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Importance: Social and economic inequities can have a profound impact on human health. The inequities could result in alterations to the gut microbiome, an important factor that may have profound abilities to alter health outcomes. Moreover, the strong correlations between social and economic inequities have been long understood. However, to date, limited research regarding the microbiome and mental health within the context of socioeconomic inequities exists. One particular inequity that may influence both mental health and the gut microbiome is living in a food desert. Persons living in food deserts may lack access to sufficient and/or nutritious food and often experience other inequities, such as increased exposure to air pollution and poor access to healthcare. Together, these factors may confer a unique risk for microbial perturbation. Indeed, external factors beyond a food desert might compound over time to have a lasting effect on an individual's gut microbiome. Therefore, adoption of a life-course approach is expected to increase the ecological validity of research related to social inequities, the gut microbiome, and physical and mental health., Competing Interests: Dr. Brenner reports grants from the VA, DOD, NIH, and the State of Colorado; editorial remuneration from Wolters Kluwer and the Rand Corporation; and royalties from the American Psychological Association and Oxford University Press. Dr. Lowry reports grants from the NIH; serves on the Scientific Advisory Board of Immodulon Therapeutics, Ltd.; is cofounder, board member, and chief scientific officer of Mycobacteria Therapeutics Corporation; and is a member of the faculty of the Integrative Psychiatry Institute, Boulder, CO.

Objective: The aim of the study is to increase understanding regarding healthcare provider experiences with psychological trauma, moral injury, and institutional betrayal, both over the lifetime and during the COVID-19 pandemic., Methods: The study employed a cross-sectional design to understand traumatic experiences, moral injury, and institutional betrayal among medical and mental health providers. Participants were asked to identify an index trauma, and experiences were coded qualitatively using categories for traumatic events, moral injury, and institutional betrayal., Results: Results revealed that experiences of trauma, moral injury, and institutional betrayal were common in relation to the pandemic, as were prepandemic histories of traumatic exposures. Findings indicate that trauma exposure was a work hazard for healthcare providers during the pandemic, which could result in negative long-term mental health outcomes., Conclusions: Future research is needed to explore potential long-term negative outcomes among healthcare providers., Competing Interests: Conflicts of interest: B.B.D. reports grants from the US Department of Veterans Affairs (VA) and PCORI. She also has received remuneration from the state of Colorado, the University of Massachusetts Boston, and the American Congress of Rehabilitation Medicine for speaking engagements. J.M. reports grants from the VA. N.B. reports grants from the VA and editorial remuneration from Wolters Kluwer. L.A.B. reports grants from the VA, Department of Defense, National Institutes of Health, and the State of Colorado, editorial remuneration from Wolters Kluwer and the Rand Corporation, and royalties from the American Psychological Association and Oxford University Press. In addition, she consults with sports leagues via her university affiliation. The other authors report no conflicts of interest., (Copyright © 2023 American College of Occupational and Environmental Medicine.)

Mild traumatic brain injury (mTBI) is one of the most common injuries experienced by Veterans and can frequently result in a variety of post-concussive symptoms. Post-concussive headaches (PCH), one of the most common symptoms, can persist for years after the injury occurred. The long-lasting impacts of PCH can be extremely distressing for Veterans, thus necessitating the need to find reliable biomarkers that directly relate to subjective feelings of distress. Yoga-based interventions have been shown to improve both subjective and objective markers of stress. Techniques used in yoga, such as the focus on releasing muscular tension, are also recommended as strategies for treating PCH. Thus, yoga-based interventions provide a unique context for the comparison of subjective and objective measures of distress in Veterans with PCH. In this secondary, exploratory analysis, we examined the relationship between perceived distress and cortisol in sixteen Veterans with mTBI and long-term PCH within the context of a yoga intervention feasibility study. The Visual Analogue Scale (VAS), a validated tool for measuring subjective distress, was administered to participants immediately before and after 75-min yoga classes, which occurred twice weekly over eight weeks. Participants also provided salivary cortisol (pre- and post-yoga) at in-person sessions (eight) to compare to changes in VAS scores. We found that VAS scores were significantly reduced within five of the eight assessed yoga classes, but there were no significant changes in cortisol levels. No significant correlations were found between VAS scores and salivary cortisol levels. When looking at how cortisol levels changed over time (i.e., over the series of eight yoga sessions), there was a significant downward trajectory in post-yoga cortisol, but not after taking pre-class cortisol into account (i.e., within yoga session cortisol change over time). Taken together, we found that subjective distress, but not cortisol was reduced by yoga classes. These data suggest that salivary cortisol did not match changes in perceived distress, thus emphasizing the ongoing challenges of relating subjective and objective measures.

To validate the Computerized Adaptive Test Suicide Scale (CAT-SS), Veterans completed measures at baseline (n = 305), and 6- (n = 249), and 12-months (n = 185), including the CAT-SS (median items 11, duration of administration 107 seconds) and the Columbia-Suicide Severity Rating Scale (C-SSRS). Logistic regression was used to relate CAT-SS scores (baseline) to C-SSRS assessed outcomes (active ideation with plan and intent; attempt; interrupted, aborted or self-interrupted attempt, or preparatory acts or behaviors; all outcomes combined). A mixed-effects logistic regression model was used to evaluate the relationship between the lagged CAT-SS scores and outcomes (6- and 12-months). The baseline CAT-SS demonstrated predictive accuracy for all outcomes at 6-months, and similar results were found for baseline and all outcomes at and through 12-months. Longitudinal analysis revealed for every 10-point change in the CAT-SS there was a 50-77% increase in the likelihood of suicide-related outcomes. The CAT-SS demonstrated added value when compared to current suicide risk prediction practices., Competing Interests: The views, opinions, and/or findings contained in this article are those of the author(s) and should not be construed as an official Department of Veterans Affairs position, policy, or decision unless so designated by other documentation. Dr. Brenner has received royalties from American Psychological Association Publishing and Oxford University Press. Dr. Gibbons has been an expert witness for the US Department of Justice, Merck, Glaxo-Smith-Kline, Pfizer and Wyeth and is a founder of Adaptive Testing Technologies, which distributes the CAT-MH™ battery of adaptive tests in which the CAT-SS is included. The terms of this arrangement have been reviewed and approved by the University of Chicago in accordance with its conflict of interest policies.

Importance: Veterans from recent and past conflicts have high rates of posttraumatic stress disorder (PTSD). Adaptive testing strategies can increase accuracy of diagnostic screening and symptom severity measurement while decreasing patient and clinician burden., Objective: To develop and validate a computerized adaptive diagnostic (CAD) screener and computerized adaptive test (CAT) for PTSD symptom severity., Design, Setting, and Participants: A diagnostic study of measure development and validation was conducted at a Veterans Health Administration facility. A total of 713 US military veterans were included. The study was conducted from April 25, 2017, to November 10, 2019., Main Outcomes and Measures: The participants completed a PTSD-symptom questionnaire from the item bank and provided responses on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (PCL-5). A subsample of 304 participants were interviewed using the Clinician-Administered Scale for PTSD for DSM-5., Results: Of the 713 participants, 585 were men; mean (SD) age was 52.8 (15.0) years. The CAD-PTSD reproduced the Clinician-Administered Scale for PTSD for DSM-5 PTSD diagnosis with high sensitivity and specificity as evidenced by an area under the curve of 0.91 (95% CI, 0.87-0.95). The CAT-PTSD demonstrated convergent validity with the PCL-5 (r = 0.88) and also tracked PTSD diagnosis (area under the curve = 0.85; 95% CI, 0.79-0.89). The CAT-PTSD reproduced the final 203-item bank score with a correlation of r = 0.95 with a mean of only 10 adaptively administered items, a 95% reduction in patient burden., Conclusions and Relevance: Using a maximum of only 6 items, the CAD-PTSD developed in this study was shown to have excellent diagnostic screening accuracy. Similarly, using a mean of 10 items, the CAT-PTSD provided valid severity ratings with excellent convergent validity with an extant scale containing twice the number of items. The 10-item CAT-PTSD also outperformed the 20-item PCL-5 in terms of diagnostic accuracy. The results suggest that scalable, valid, and rapid PTSD diagnostic screening and severity measurement are possible.

Background: Mild traumatic brain injury (mTBI) is a signature injury sustained by Veterans during recent conflicts. For some, mTBI/concussion is associated with disabling symptoms, including post-concussive headaches (PCH). However, there are limited evidence-based treatments for persistent PCH., Objective: Investigators assessed the feasibility of design elements of a yoga-based interventional trial for PCH among Veterans, as well as the acceptability of the intervention., Methods: This randomized controlled acceptability and feasibility trial was implemented using a waitlist-control design. Design elements of interest included: an exercise run-in class; recruitment and retention strategies; and, ecological momentary assessment (EMA) modalities to track headaches and yoga practice. Veteran satisfaction regarding the intervention was also evaluated. A descriptive analysis was conducted on candidate outcomes including PCH, post-concussive symptoms, pain, and daily functioning., Results: Twenty-seven participants (out of 70 consented and eligible after Study Visit 1) completed each evaluation timepoint and regularly attended yoga sessions, with 89% of these Veterans reporting moderate to high levels of satisfaction with the intervention at study completion. Qualitatively, participants endorsed improvements in headaches, chronic pain, and mood. Feasibility results were mixed. Initial feasibility criterion regarding yoga attendance was not met; however, modifications, such as expansion to an additional clinic site and reduction of in-person yoga sessions with increased encouragement to use study-created online yoga videos improved feasibility of the study design. Participants most frequently used mobile and web-based EMA modalities to track yoga practice., Conclusions: Although challenges with feasibility of the study design elements were noted, results suggested acceptability of the yoga-based intervention for Veterans with persistent PCH. Additional exploration regarding the frequency and modality of yoga delivery (e.g., in-person, telehealth) is warranted., Impact: Veterans found the yoga-based intervention acceptable, however exploration of novel modalities of intervention delivery will likely be necessary to enhance the feasibility of intervention implementation during future trials., Competing Interests: 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., (© 2021 Published by Elsevier Inc.)