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Background: Peer-supported mobile health (mHealth) programs hold the promise of providing a low-burden approach to increasing access to care and improving mental health. While peer support has been shown to improve engagement in care, there is limited investigation into the impact of peers on symptom outcomes. Trauma-exposed populations frequently endure co-occurring posttraumatic stress and depressive symptoms as well as difficulties in day-to-day functioning. This study evaluated the potential benefits of a peer-supported, transdiagnostic mHealth program on symptom outcomes and functioning., Objective: This randomized controlled trial tested the effectiveness of Brief Peer-Supported (BPS) web-based Skills Training in Affective and Interpersonal Regulation (webSTAIR), a 6-module transdiagnostic digital program derived from Skills Training in Affective and Interpersonal Regulation and compared to waitlist control in a community sample of veterans who screened positive for either posttraumatic stress disorder (PTSD) or depression., Methods: A total of 178 veterans were enrolled in this study using a 2:1 randomization scheme with 117 assigned to BPS webSTAIR and 61 assigned to waitlist control. PTSD and depressive symptoms as well as emotion regulation and psychosocial functioning were assessed at pretreatment, posttreatment, and 8-week follow-up time points. Mixed-effects models were used to assess change in outcome measures across time points. Exploratory analyses were conducted to determine whether the type and number of peer interactions influenced outcomes., Results: Significant interaction effects were observed for all outcomes such that participants randomized to BPS webSTAIR reported significantly greater improvement at the posttreatment time point compared to waitlist control with moderate effect sizes for PTSD (d=0.48), depression (d=0.64), emotion regulation (d=0.61), and functional impairment (d=0.61); gains were maintained at 8-week follow-up. An initial cohort of participants who were required to engage with a peer coach to progress through the modules interacted more frequently with peers but completed fewer modules compared to a later cohort for whom peer engagement was optional. Overall, those who completed more modules reported greater improvement in all outcomes., Conclusions: BPS webSTAIR was effective in improving PTSD and depression symptoms, emotion regulation, and psychosocial functioning in community veterans. Peer-supported, transdiagnostic mHealth programs may be a particularly efficient, effective, and low-burden approach to improving mental health among trauma-exposed populations. Investigation of peer-supported programs among other populations is necessary to evaluate the generalizability of the findings. Analyses comparing peer support that was required versus optional indicated that some veterans may not need or want peer support. Future research should evaluate how best to deliver peer support and for whom it is most beneficial. If successful, peer-supported tech programs may increase the Veteran Affairs workforce as well as improve veteran mental health services and outcomes., Trial Registration: ClinicalTrials.gov NCT04286165; https://clinicaltrials.gov/study/NCT04286165., (©Laura E Ong, Sarah Speicher, Diana Villasenor, Jamie Kim, Adam Jacobs, Kathryn S Macia, Marylene Cloitre. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 02.10.2024.)

Objective: In spite of the evidence that both symptom reduction and functional improvement are important for supporting recovery from trauma, psychotherapy process research has largely focused on mechanisms of symptom reduction. A better understanding of how change occurs in treatments that emphasize functional improvement rather than trauma processing is critical for optimizing effective, patient-centered care., Method: This study involved secondary analysis of data collected in three multisite trials of a 10-module web-based version of Skills Training in Affective and Interpersonal Regulation, a skills-focused transdiagnostic intervention. The sample included 314 trauma-exposed veterans (38% male; 64% non-Hispanic White) who screened positive for elevated symptoms of posttraumatic stress disorder and/or depression. Latent change score modeling examined prospective relationships between changes from pre-to-mid and mid-to-post treatment in four potential mechanisms (emotion regulation, interpersonal problems, posttraumatic stress disorder symptoms, and depression symptoms) and the association of these changes with overall functional improvement (at posttreatment and follow-up)., Results: Emotion regulation change during the first half of treatment predicted interpersonal and symptom improvements during the second half of treatment, but not vice versa. Changes in each potential mechanism were uniquely associated with functional improvement and together statistically accounted for 78% additional variance in functional improvement beyond what was associated with baseline functioning and covariates., Conclusions: Results support emotion regulation as an early mechanism of transdiagnostic therapeutic change in web-based version of Skills Training in Affective and Interpersonal Regulation and highlight the relevance of all four potential mechanisms to functional improvement. The study contributes to an understanding of how change occurs in skills-focused interventions for trauma-exposed individuals. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: The present study examines the network structure and, using Bayesian network analysis, estimates the directional pathways among symptoms of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and levels of alcohol and cannabis use. Method: A sample of 1471 adults in the United States, who reported at least one potentially traumatic event, completed the PTSD Checklist (PCL-5), Patient Health Questionnaire (PHQ-9), and the Alcohol/Cannabis Use Disorders Identification Test (AUDIT/CUDIT). A regularized partial correlation network provided estimates of symptoms clusters and connections. Directional pathways within the network were then estimated using a directed acyclic graph (DAG). Results: Symptoms clustered in theoretically consistent ways. Risky behavior demonstrated the highest strength centrality and bridge strength. Neither alcohol nor cannabis use appeared central in the network, and DAG results suggested that MDD and PTSD symptoms are more likely to lead to substance use than the other way around. Conclusions: Results suggest that cannabis use is largely connected to alcohol use. Consistent with prior research, risky behavior appeared to be the primary bridge between substance use and PTSD. The direction of associations between substance use and psychological symptoms requires further attention.

Introduction: A substantial number of trauma-exposed veterans seen in primary care report significant symptoms of PTSD and depression. While primary care mental health integration (PCMHI) providers have been successful in delivering brief mental health treatments in primary care, few studies have evaluated interventions that combine mobile health resources with PCMHI groups. This pilot study assessed the potential benefits of webSTAIR, a 10-module transdiagnostic treatment for trauma-exposed individuals, supported by 5 biweekly group sessions delivered via telehealth. The transdiagnostic and mobile health nature of the treatment, as well as the therapist and peer support provided through group sessions, may offer an innovative approach to increasing access to patient-centered and trauma-informed treatment in primary care settings., Materials and Methods: Thirty-nine male and female veterans with trauma-related symptoms (i.e., PTSD and/or depression) participated in group webSTAIR. Mixed effects analyses were conducted to assess changes in PTSD and depression at pre-, mid-, and post-treatment. Baseline symptom severity was assessed as a predictor of module completion and group attendance. The project was part of a VHA quality improvement project, and IRB approval was waived by the affiliated university., Results: Analyses revealed significant pre-to-post improvement in both PTSD and depression outcomes with a large effect size for PTSD (Hedges' gav = 0.88) and medium to large for depression (Hedges' gav = 0.73). Of participants who completed the baseline assessment, 90% began webSTAIR; of those, 71% completed the program. Baseline symptoms of PTSD and depression did not predict group attendance or module completion., Conclusions: Good outcomes and a satisfactory retention rate suggest that group webSTAIR may provide easily accessible, high-quality, and effective treatment for patients presenting with trauma-related problems without increasing therapist or system burdens. The results suggest the value of conducting a randomized controlled trial to test the effectiveness of group webSTAIR relative to PCMHI usual care or other evidence-based, disorder-specific (e.g., PTSD) treatments for trauma-exposed individuals in PCMHI., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Many veterans seeking behavioral health services have history of criminal-legal involvement. Research on criminogenic needs of legal system involved veterans is burgeoning. However, most research has relied on cross-sectional examinations and the vast majority of prior work has focused assessment on just one criminogenic need per study., Methods: The present study evaluated seven key criminogenic needs of legal system involved veterans (N = 341) enrolled in one of three U.S. Veterans Health Administration residential behavioral health treatment programs. Criminogenic needs and legal problem severity were assessed at baseline, and at 6 months and 12 months post-baseline. Directionality of associations between participants' criminogenic needs and legal problem severity was examined using latent change score models., Results: Results revealed having more antisocial associates at a previous timepoint was associated with greater subsequent improvements in legal problem severity ($\beta $=-0.01, P < 0.02) and greater improvements in legal problem severity predicted greater subsequent improvements in alcohol problem severity ($\beta $=0.13, P < 0.01)., Conclusions: In one of the most comprehensive single-study assessments of criminogenic needs among a sample of legal system involved veterans, results highlight links between antisocial associates and alcohol problem severity with legal problem severity., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Despite the well-established link between firearm access and suicide, less is known about other variables that may influence the risk for death by self-inflicted gunshot versus other methods of suicide. As individual factors have demonstrated limited predictive ability, scholars have called for studies that consider the multifaceted relations between myriad variables. One alternative to the typical cause-and-effect approach for investigating various forms of psychopathology is network analysis. However, few studies have applied this method to suicidal outcomes, particularly in the context of a veteran population. Data from 19,234 male veteran suicide decedents (89.1% White; M age = 57.16, SD = 18.64) acquired from the National Violent Death Reporting System were used to investigate characteristics of veteran suicide decedents who died by self-inflicted gunshot (gun; 66.4%) versus alternative methods (nongun, e.g., poisoning, hanging; 33.5%). Results of the overall moderated network model indicated that veterans in the gun group were more likely to have a physical health problem that contributed to the suicide than veterans in the nongun group. Additionally, results of the moderated network model revealed several pairs of associated circumstances whose relationships were significantly moderated by method of suicide, the three strongest of which included having a physical health problem that contributed to the suicide. Overall, results suggest that public health prevention and intervention efforts aimed at reducing the overall burden of physical health problems among male veterans may mitigate the risk of firearm suicides. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: In a recent trial, moral reconation therapy (MRT)-a cognitive-behavioral intervention for criminal recidivism-was not more effective than usual care (UC) for veterans in behavioral health treatment. To determine for whom treatments of recidivism are most effective, we tested if recency of criminal history or psychopathic traits moderated MRT's effects on outcomes., Method: In a multisite trial, 341 veterans (95.3% male; 57.8% White/Non-Hispanic) with a criminal history who were admitted to behavioral health treatment programs were randomly assigned to UC or UC + MRT and followed at 6- and 12-months. Incarceration (yes/no) or criminal conviction (yes/no) in the year prior to enrollment and psychopathic traits at baseline (median split) were prespecified as moderators of treatment effects on primary (criminal thinking, criminal associations) and secondary outcomes (legal, employment, and family/social problems; substance use problems and days of use)., Results: Among veterans incarcerated in the year prior to enrollment, MRT (vs. UC) was associated with greater reductions in criminal associations (6 months) and days drinking or using drugs (12 months). Among those convicted in the year prior to enrollment, MRT (vs. UC) was associated with greater reductions in employment problems (12 months) and days drinking or using drugs at each follow-up. For those high in psychopathic traits, MRT (vs. UC) was associated with greater reductions in days drinking or using drugs at each follow-up., Conclusions: For veterans in behavioral health treatment with recent criminal histories and high in psychopathic traits, MRT may be effective for reducing risk for criminal recidivism. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Rumination is a robust vulnerability to depression and potential treatment target. However, we know relatively little about rumination in daily life. This study tested the validity of a new approach for assessing daily episodes of rumination, the Day Reconstruction Method for Rumination (DRM-R). Participants ( N = 127) who were either high or low in neuroticism completed baseline self-report measures (e.g., depression, trait rumination). Next, they completed the DRM-R by reconstructing the previous day into a series of "scenes," identifying discrete episodes of rumination, and responding to follow-up items about each episode. 78.6% of high neuroticism participants reported experiencing discrete periods of rumination, 80.0% reported constant ruminative thoughts in the back of their heads, and 68.6% reported ruminative thoughts of fluctuating intensity. Time spent ruminating was moderately correlated with trait measures of rumination and worry. Findings provide preliminary evidence that the DRM-R is a valid method for assessing discrete episodes of rumination in daily life. The DRM-R may reveal, ideographically, the relationship between specific thought content and features of ruminative episodes (e.g., length, frequency). Further research is needed to establish whether the DRM-R can detect changes in rumination across multiple days and how it corresponds with traditional daily diary methods and ecological momentary assessment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Dissociative Symptoms Scale (DSS) was developed to assess moderately severe types of dissociation (depersonalization, derealization, gaps in awareness and memory, and dissociative reexperiencing) that would be relevant to a range of clinical populations, including those experiencing trauma-related dissociation. The current study used data from 10 ethnically and racially diverse clinical and community samples ( N = 3,879) to develop a brief version of the DSS (DSS-B). Item information curves were examined to identify items with the most precision in measuring above average levels of the latent trait within each subscale. Analyses revealed that the DSS-B preserved the factor structure and content domains of the full scale, and its scores had strong reliability and validity that were comparable to those of scores on the full measure. DSS-B scores showed high levels of measurement invariance across ethnoracial groups. Results indicate that DSS-B scores are reliable and valid in the populations studied.

Objective: MDMA/Ecstasy motives differ from those of other substances such as alcohol, cannabis, and methamphetamine. Previous literature on alcohol and cannabis use identified social, expansion, enhancement, coping, and conformism as primary motives for use. MDMA/Ecstasy users also report using the drug for increases in self-awareness and energy. The development of an MDMA/Ecstasy use motives assessment has potential to inform treatment interventions and public policy on harm reduction., Method: An MDMA/Ecstasy use motives assessment was developed from alcohol and cannabis motives measures and qualitative feedback from MDMA/Ecstasy users. Participants included an international sample of adults (N = 1754) who completed an online questionnaire regarding their motives for using recreational MDMA/Ecstasy., Results: Exploratory and confirmatory factor analysis supported a 4-factor MDMA/Ecstasy motives scale. The four motive scales showed good internal consistency reliabilitySocial (α = 0.88) Expansion (α = 0.81), Coping (α = 0.82), and Energy (α = 0.75). Conformity and Enhancement did not emerge as significant factors. Analyses demonstrated convergent and discriminant validity with relevant constructs including quantity/frequency of use, MDMA use disorder, sensation seeking personality, and positive and negative consequences of use., Conclusions: MDMA/Ecstasy use motives differ from those of other substances due to the distinctly stimulating, emotional, and empathic effects sought by users. By identifying salient MDMA/Ecstasy motives, this study highlights the unique aspects of recreational MDMA/Ecstasy use. This research has utility for informing clinical practice and contributing to public health harm reduction efforts., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Rationale: Mental health and substance use disorders are strong risk factors for homelessness. Understanding the role of transdiagnostic factors could help inform efforts to reduce homelessness among veterans with a range of disorders. Homeless veterans have high rates of trauma exposure, which can result in the depletion of social and emotional resources that may contribute to housing and employment stability. In this study, we evaluated the role of problems with emotional lability and interpersonal closeness as transdiagnostic socio-emotional factors that might interfere with efforts to achieve housing and employment stability., Methods: The sample consisted of 346 homeless veterans with co-occurring disorders that were admitted to a U.S. Department of Veterans Affairs (VA) residential treatment program between 2004 and 2009. Assessments were conducted at treatment entry (baseline) and two follow-up timepoints (6- and 12-months). Variables used in the current analyses included history of interpersonal trauma exposure, emotional lability and interpersonal closeness at baseline and 6-months, and homelessness and employment problems during follow-up. Data were analyzed using structural equation modeling and counterfactually-defined mediation effects., Results: Veterans exposed to more trauma types experienced more baseline impairment and less improvement during treatment in emotional lability and interpersonal closeness. Problems with interpersonal closeness mediated 73% of the relationship between exposure to multiple traumas and homelessness, and 32%-61% of the relationship between trauma exposure and employment problems. Emotional lability mediated 36% of the relationship between exposure to multiple traumas and employment problems. Decomposition of indirect pathways revealed that indirect effects were primarily transmitted through changes during treatment, and not baseline levels., Conclusion: Findings support a cumulative effect of trauma on persistence of socio-emotional deficits across treatment, which increased risk of homelessness and employment problems during follow-up. Greater attention and more targeted efforts should be directed at helping trauma-exposed veterans build socio-emotional resources during treatment., (Published by Elsevier Ltd.)

Prior research suggests that personality traits change during substance use disorder (SUD) treatment. However, the extent to which changes in traits during SUD treatment are associated with subsequent improvements in treatment outcomes remains untested. Among U.S. military veterans (n = 200) enrolled in SUD residential treatment, we examined whether changes in the personality factors of positive emotionality (PEM), negative emotionality (NEM), and constraint (CON) during treatment were associated with subsequent changes in abstinence self-efficacy and SUD symptoms. We analyzed data at treatment entry, discharge, and 12-months post-discharge via univariate and bivariate latent change score models. During treatment, PEM, CON, and abstinence self-efficacy increased, while NEM decreased, on average. Changes in NEM and CON were largely sustained, whereas PEM and abstinence self-efficacy significantly decreased post-treatment. SUD symptoms decreased from pre- to post-treatment. In bivariate models, higher levels of NEM at baseline were associated with less improvement in both abstinence self-efficacy during treatment and SUD symptoms pre- to post-treatment. Higher levels of CON at baseline were associated with greater improvement in SUD symptoms pre- to post-treatment, and increases in CON during treatment were associated with greater retention of treatment gains in abstinence self-efficacy post-treatment. Greater improvements in CON during treatment were also associated with greater improvements in SUD symptoms pre- to post-treatment in unadjusted (p = 0.041) but not adjusted models (p = 0.089). Our findings suggest that personality changes marked by improvements in impulse control over the course of SUD treatment may be linked to subsequent improvements in treatment outcomes and may have value as a proximal treatment target among SUD patients during residential care., (Published by Elsevier Inc.)

Purpose: Drinking is common among young adult veterans. Previous research has established that veterans' drinking is more strongly associated with veteran versus civilian drinking norms. The present research extends these findings by examining the influence of self-identification both with other veterans and with civilians as moderators of the association between perceived norms and drinking., Methods: Veterans aged 18-34 ( N  = 1015; 88.7% male; M  = 28.23, SD  = 3.44) were recruited via Facebook to participate. Measures included same-gender veterans/same-gender civilians self-identification, same-gender veterans/same gender-civilians perceived drinking norms, and own drinking., Results: Pairwise comparisons revealed both male and female veterans identified more with other veterans than civilians and perceived drinking to be more prevalent among other veterans than civilians. However, males overestimated male veteran drinking norms to a greater degree than male civilian norms whereas the opposite was true for females. Negative binomial analysis examining a three-way interaction between veteran identification, civilian identification, and civilian norms revealed civilian drinking norms were positively associated with drinking, particularly for veterans who strongly identified with both veterans and civilians. Conversely, civilian drinking norms were also found to be negatively associated with drinking, particularly for those who did not identify strongly with civilians but identified strongly with veterans., Implications: This study represented a preliminary step for understanding how identity plays a role in terms of veterans' drinking. Given that veterans drank at differing levels of identification, it may be important to consider identities that are most salient when designing interventions targeting individual veterans.

Veterans with mental health problems and a history of interpersonal and military trauma exposure are at increased risk for chronic homelessness. Although studies have examined posttraumatic stress disorder (PTSD) as a predictor of homelessness, there is limited understanding of specific mechanisms related to cumulative trauma exposure. We sought to elucidate how cumulative interpersonal and military trauma exposure may be linked to homelessness chronicity by examining the role of factors that influence trauma recovery and functional impairment. Specifically, we examined the indirect association of cumulative trauma exposure with homelessness chronicity through distress and responses to trauma-related intrusions and emotion regulation problems in a sample of 239 veterans in community-based homeless programs. Participants completed measures of trauma exposure, responses to intrusions, intrusion distress, difficulties with emotion regulation, and duration and episodes of homelessness. Structural equation modeling was used to test a serial indirect effect model in which cumulative trauma exposure was indirectly associated with homelessness chronicity through distress from and responses to intrusions as well as emotion regulation problems. The results supported the hypothesized sequential indirect effect for episodes of homelessness, indirect effect odds ratio (IE ORs) = 1.12-1.13, but not for current episode duration, IE OR = 1.05. Overall, the present findings elucidate specific trauma-related factors that may be particularly relevant to episodic patterns of homelessness and interfere with efforts to remain housed. These findings represent an important step toward shaping policy and program development to better meet mental health care needs and improve housing outcomes among homeless veterans., (© 2020 International Society for Traumatic Stress Studies.)

Background: Network analysis has become popular among PTSD researchers for studying causal structure or interrelationships among symptoms. However, some have noted that results do not seem to be consistent across studies. Preliminary evidence suggests that trauma type may be one source of variability., Methods: The current study sought to examine the PTSD networks of veterans with combat versus non-combat index trauma. Participants included 944 veterans who completed the PTSD Checklist for DSM-5 at intake at two VA PTSD clinics., Results: There were many similarities between the combat and non-combat trauma networks, including strong edges between symptoms that were theoretically related or similar (e.g., avoidance) and negative emotion being a highly central symptom. However, correlations of edge weights (0.509) and node centrality (0.418) across networks suggested moderate correspondence, and there appeared to be some differences associated with certain symptoms. Detachment was relatively more central and the connections of negative emotion with blame and lack of positive emotion with reckless behavior were stronger for veterans with combat-related index trauma., Limitations: The data were cross-sectional, which limits the ability to infer directional relationships between symptoms. In addition, the sample was likely not large enough to directly test for differences between networks via network comparison tests., Conclusions: Although there were many similarities, results also suggested some variability in PTSD networks associated with combat versus non-combat index trauma that could have implications for conceptualizing and treating PTSD among veterans., (Copyright © 2020. Published by Elsevier B.V.)

Veterans in treatment for substance use disorders (SUD) often report past criminal offending. However, the rate of criminal recidivism in this population is unknown. Further, prior research in veterans has not examined personality factors as predictors of recidivism, despite the prominence of such factors in leading models of recidivism risk management. We examined these issues in a secondary data analysis of 197 military veterans with a history of criminal offending who were enrolled in an SUD residential treatment program. Participants were interviewed using several measurement instruments at treatment entry, one month into treatment, treatment discharge, and 12 months post-discharge. Most veterans (94%) had a history of multiple charges, and 53% had recent involvement in the criminal justice system at the time of treatment entry. In the 12 months post-discharge, 22% reported reoffending. In addition, 30% of patients who had been recently involved in the criminal justice system at treatment entry reoffended during follow-up. Higher friend relationship quality (OR = 2.32, 95% CI [1.03, 5.21]) at treatment entry and higher staff ratings of patients' relationship quality with other residents during treatment (OR = 2.76, 95% CI [1.40, 5.41]) predicted lower odds of recidivism post-discharge. After accounting for these factors, smaller reductions during treatment in the personality trait of Negative Emotionality predicted an increased risk for criminal recidivism post-discharge (OR = 1.13, 95% CI [1.01, 1.26]). Results support augmenting the curriculum of SUD programs for veterans with services aimed at reducing risk for criminal recidivism, with a focus on interventions that directly target patients' social support networks and tendencies towards negative emotionality., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

The actor-partner interdependence (APIM) and common-fate (CFM) models for dyadic data are well understood and widely applied. The actor and partner coefficients estimated in the APIM reflect the associations between individual-level variance components, whereas the CFM coefficient describes the association between dyad-level variance components. Additionally, both models assume that the theoretically relevant and/or empirically dominant component of variability resides at the same level (individual or dyad) across the predictor and outcome variables. The present work recasts the APIM and CFM in terms of dyadic nonindependence, or the extent to which a given variable reflects dyad- versus individual-level processes, and describes a pair of hybrid actor-partner and common-fate models that connect variance components residing at different levels. A series of didactic examples illustrate how the traditional APIM and CFM can be combined with the hybrid models to describe mediational processes that span the individual and dyad levels.

Mixture analysis of count data has become increasingly popular among researchers of substance use, behavioral analysis, and program evaluation. However, this increase in popularity seems to have occurred along with adoption of some conventions in model specification based on arbitrary heuristics that may impact the validity of results. Findings from a systematic review of recent drug and alcohol publications suggested count variables are often dichotomized or misspecified as continuous normal indicators in mixture analysis. Prior research suggests that misspecifying skewed distributions of continuous indicators in mixture analysis introduces bias, though the consequences of this practice when applied to count indicators has not been studied. The present work describes results from a simulation study examining bias in mixture recovery when count indicators are dichotomized (median split; presence vs. absence), ordinalized, or the distribution is misspecified (continuous normal; incorrect count distribution). All distributional misspecifications and methods of categorizing resulted in greater bias in parameter estimates and recovery of class membership relative to specifying the true distribution, though dichotomization appeared to improve class enumeration accuracy relative to all other specifications. Overall, results demonstrate the importance of accurately modeling count indicators in mixture analysis, as misspecification and categorizing data can distort study outcomes.

The Dissociative Symptoms Scale (DSS) was developed to assess moderately severe levels of depersonalization, derealization, gaps in awareness or memory, and dissociative reexperiencing that would be relevant to a wide range of clinical populations. Structural analyses of data from four clinical and five nonclinical samples ( N = 1,600) yielded four factors that reflected the domains of interest and showed good fit with the data. Sample scores were consistent with expectations and showed very good internal consistency and temporal stability. Analyses showed consistent evidence of convergent and divergent validity, and posttrauma elevations in scores and in patients with posttraumatic stress disorder provided additional evidence of construct validity. Item response theory analyses indicated that the items assessed moderately severe dissociative experiences. Overall, the results provide support for the reliability and validity of DSS total and subscale scores in the populations studied. Further work is needed to evaluate the performance of the DSS relative to structured interview measures and in samples of patients with other psychological disorders.

Frequent utilization of emergency department (ED) services contributes substantially to the cost of healthcare nationally and is often driven by psychiatric factors. Using national-level data from the Veterans Health Administration (VHA), the present study examined patient-level factors associated with ED use among veteran psychiatric patients. Veterans who had at least one ED visit with a psychiatric diagnosis in fiscal years 2011-2012 (n = 226,122) were identified in VHA administrative records. Andersen's behavioral model of healthcare utilization was used to identify need, enabling, and predisposing factors associated with frequency of ED use (primary outcome) in multivariate regression models. Greater ED use was primarily linked with need (psychotic, anxiety, personality, substance use, and bipolar disorders) and enabling (detoxification-related service utilization and homelessness) factors. Chronic medical conditions, receipt of an opioid prescription, and predisposing factors (e.g., younger age) were also linked to greater ED use; however, the effect sizes for these factors were markedly lower than those of most psychiatric and psychosocial factors. The findings suggest that intensive case management programs aimed reducing frequent ED use among psychiatric patients may require greater emphasis on homelessness and other psychosocial deficits that are common among these patients, and future research should explore cost-effective approaches to implementing these programs.

Objective: Traumatic experiences cause considerable suffering and place a burden on society due to lost productivity, increases in suicidality, violence, criminal behavior, and psychological disorder. The impact of traumatic experiences is complicated because many factors affect individuals' responses. By employing several methodological improvements, we sought to identify risk factors that would account for a greater proportion of variance in later disorder than prior studies., Method: In a sample of 129 traumatically injured hospital patients and family members of injured patients, we studied pre-trauma, time of trauma, and post-trauma psychosocial risk and protective factors hypothesized to influence responses to traumatic experiences and posttraumatic (PT) symptoms (including symptoms of PTSD, depression, negative thinking, and dissociation) two months after trauma., Results: The risk factors were all significantly correlated with later PT symptoms, with post-trauma life stress, post-trauma social support, and acute stress symptoms showing the strongest relationships. A hierarchical regression, in which the risk factors were entered in 6 steps based on their occurrence in time, showed the risks accounted for 72% of the variance in later symptoms. Most of the variance in PT symptoms was shared among many risk factors, and pre-trauma and post-trauma risk factors accounted for the most variance., Conclusions: Collectively, the risk factors accounted for more variance in later PT symptoms than in previous studies. These risk factors may identify individuals at risk for PT psychological disorders and targets for treatment., (Published by Elsevier Inc.)

Purpose: Family members of intensive care unit (ICU) patients are sometimes highly distressed and report lower satisfaction with communication and emotional support from staff. Within a study of emotional responses to traumatic stress, associations between family distress and satisfaction with aspects of ICU care were investigated., Materials and Methods: In 29 family members of trauma patients who stayed in an ICU, we assessed symptoms of depression and posttraumatic stress disorder (PTSD) during ICU care. Later, family members rated staff communication, support, and skills and their overall satisfaction with ICU care., Results: Ratings of staff competence and skills were significantly higher than ratings of frequency of communication, information needs being met, and support. Frequency of communication and information needs being met were strongly related to ratings of support (rs = .75-.77) and staff skills (rs = .77-.85), and aspects of satisfaction and communication showed negative relationships with symptoms of depression (rs = -.31 to -.55) and PTSD (rs = -.17 to -.43)., Conclusions: Although satisfaction was fairly high, family member distress was negatively associated with several satisfaction variables. Increased understanding of the effects of traumatic stress on family members may help staff improve communication and increase satisfaction of highly distressed family members., (Published by Elsevier Inc.)

Objectives: To better understand potential risk factors for post-traumatic stress disorder (PTSD) and homelessness in veterans, we studied trauma exposure and responses in archival data on 115 homeless veterans., Methods: Rates of exposure to military and a variety of civilian high magnitude stressor (HMS) and persistent post-traumatic distress (PPD) events and symptoms of post-traumatic stress were assessed. The relationships between frequency of different trauma types and symptoms of post-traumatic stress were examined., Results: Exposure to both HMS and PPD events were extremely high in this sample, with particularly high exposure to adult (82%) and childhood (62%) interpersonal violence HMS events and HMS events during military service (53%). Exposure to both military and civilian PPD events was associated with significantly higher levels of PTSD symptoms than exposure to no PPD events or only civilian PPD events, and almost all HMS event types were significantly correlated with both PTSD and dissociation symptoms., Conclusions: Post-traumatic symptoms and military and civilian traumatic stressors of all types should be assessed in homeless veterans because they may be contributing to poor social and occupational functioning., (Reprint & Copyright © 2013 Association of Military Surgeons of the U.S.)