Residual Insomnia and Nightmares Postintervention Symptom Reduction Among Veterans Receiving Treatment for Comorbid PTSD and Depressive Symptoms

While evidence-based interventions can help the substantial number of veterans diagnosed with comorbid PTSD and depression, an emerging literature has identified sleep disturbances as predictors of treatment nonresponse. More specifically, predicting effects of residual insomnia and nightmares on postintervention PTSD and depressive symptoms among veterans with comorbid PTSD and depression has remained unclear. The present study used data from a clinical trial of Behavioral Activation and Therapeutic Exposure (BA-TE), a combined approach to address comorbid PTSD and depression, administered to veterans (N = 232) to evaluate whether residual insomnia and nightmare symptoms remained after treatment completion and, if so, whether these residual insomnia and nightmare symptoms were associated with higher levels of comorbid PTSD and depression at the end of treatment. Participants (ages 21 to 77 years old; 47.0% Black; 61.6% married) completed demographic questions, symptom assessments, and engagement-related surveys. Hierarchical multiple linear regression models demonstrated that residual insomnia was a significant predictor of PTSD and depression symptom reduction above and beyond the influence of demographic and engagement factors (e.g., therapy satisfaction). Consistent with previous research, greater residual insomnia symptoms were predictive of smaller treatment gains. Findings illustrate the potential significance of insomnia during the course of transdiagnostic treatment (e.g., PTSD and depression), leading to several important clinical assessment and treatment implications.     

Considerations Regarding Online Methods for Suicide‐Related Research and Suicide Risk Assessment

Frequent advances in technology provide new and exciting opportunities for conducting suicide research and suicide risk assessments. However, to the authors' knowledge, best practices for using technology, specifically the Internet, to conduct research protocols involving suicide risk assessments have not been examined. In research contexts, the use of technology for research on suicidal behavior and suicide risk assessment can offer benefits relative to other forms of data collection. These advantages, which include increased validity, feasibility, and efficiency, as well as improvements in data collection and management, are presented. Considerations regarding the implementation of an online system for suicide risk assessment as well as limitations and future directions are discussed.     

The Role of Attachment Styles and Interpersonal Problems in Suicide‐Related Behaviors

The relationships among adult attachment styles, interpersonal problems, and categories of suicide‐related behaviors (i.e., self‐harm, suicide attempts, and their co‐occurrence) were examined in a predominantly psychiatric sample (N = 406). Both anxious and avoidant attachment styles were associated with interpersonal problems. In turn, specific interpersonal problems differentially mediated the relations between attachment style and type of suicide‐related behaviors. These findings suggest the importance of distinguishing between these groups of behaviors in terms of etiological pathways, maintenance processes, and treatment interventions.     

Social Integration and Suicide‐Related Ideation from a Social Network Perspective: A Longitudinal Study among Inner‐City African Americans

Social network density, as measured by the extent to which network members know each other, was examined to determine whether it is associated with suicide‐related ideation and plan approximately 3 years later. Eight hundred and nineteen African Americans were interviewed at Wave 1 (1997–1999) and Wave 4 (2001–2003) of the Self‐Help In Eliminating Life‐Threatening Diseases (SHIELD) study, a HIV preventive intervention study in Baltimore, MD. Multinomial logistic regression models were used to compare risks of suicide‐related ideation and plan at Wave 4 by Wave 1 density. Even after adjusting for baseline sociodemographic characteristics and depressive symptoms, individuals with a lower level of density were three times more likely to report suicide‐related ideation and plan in the past year at Wave 4. The findings reinforce the importance of social integration among inner‐city African Americans from a social network perspective. Future research should examine the mechanisms associated with this relationship and other social network constructs.     

Comparing Japanese International College Students' and U.S. College Students' Mental‐Health‐Related Stigmatizing Attitudes

This study examined differences between Japanese international college students and U.S. college students on stigma toward people with psychological disorders, stigma tolerance in help seeking, and self‐concealment. Japanese international students had greater stigma toward individuals with psychological disorders than did their U.S. counterparts. No interrelationships between these variables, however, were found in the Japanese international student group. Este estudio examinó las diferencias entre estudiantes universitarios internacionales japoneses y estudiantes universitarios estadounidenses en lo concerniente al estigma hacia las personas con trastornos psicológicos, la tolerancia del estigma al buscar ayuda y la auto‐ocultación. Los estudiantes internacionales japoneses mostraron un mayor estigma hacia los individuos con trastornos psicológicos que sus homólogos estadounidenses. Sin embargo, no se encontró ninguna interrelación entre estas variables en el grupo de estudiantes internacionales japoneses.     

Interaction of Combat Exposure and Unit Cohesion in Predicting Suicide‐Related Ideation Among Post‐Deployment Soldiers

Suicide is one of the leading causes of death among U.S. Army soldiers. Suicide‐related ideation, which is associated with suicide attempts and suicide, can cause considerable distress. In a sample of 1,663 recently redeployed soldiers, we used factor analysis and structural equation modeling to test the associations between combat exposure, unit cohesion, and their interaction in predicting suicide‐related ideation. We found that combat exposure was a significant risk factor for suicide‐related ideation, while unit cohesion was a significant protective factor. The significant interaction between the two factors indicated that soldiers who experienced greater combat exposure but also had higher levels of unit cohesion had relatively lower levels of suicide‐related ideation. In addition, those who had higher levels of combat exposure and lower unit cohesion were most at risk for suicide‐related ideation. Our findings indicate the importance of unit cohesion in protecting soldiers from suicide‐related ideation and suggest a higher risk group of soldiers who should be targeted for interventions.     

Demographic,Clinical, and Service Utilization Factors Associated with Suicide‐Related Visits among Alaska Native and American Indian Adults

Alaska Native and American Indian people (AN/AIs) are disproportionately affected by suicide. Within a large AN/AI health service organization, demographic, clinical, and service utilization factors were compared between those with a suicide‐related health visit and those without. Cases had higher odds of a behavioral health diagnosis, treatment for an injury, behavioral health specialty care visits, and opioid medication dispensation in the year prior to a suicide‐related visit compared to gender‐, age‐, and residence‐ (urban versus rural) matched controls. Odds of a suicide‐related visit were lower among those with private insurance and those with non‐primary care ambulatory clinic visits.     

Precipitating Circumstances of Suicide among Active Duty U.S. Army Personnel Versus U.S. Civilians, 2005–2010

To help understand suicide among soldiers, we compared suicide events between active duty U.S. Army versus civilian decedents to identify differences and inform military prevention efforts. We linked 141 Army suicide records from 2005 to 2010 to National Violent Death Reporting System (NVDRS) data. We described the decedents’ military background and compared their precipitators of death captured in NVDRS to those of demographically matched civilian suicide decedents. Both groups commonly had mental health and intimate partner precipitating circumstances, but soldier decedents less commonly disclosed suicide intent.     

Characteristics and Correlates of Cigarette Use Among Recent U.S. Veterans

Little is known about the smoking habits and cessation efforts of veterans returning from Iraq and Afghanistan, many of whom will seek health care services in the public sector. This project documents rates of smoking and quit attempts among veterans receiving Veteran's Health Administration (VHA) health care and describes the relationship between current smoking use/cessation and demographic characteristics, quality of life, and potential alcohol misuse.

A large representative sample of Iraq/Afghanistan era veterans was surveyed using the VA Survey of Healthcare Experiences of Patients (Wright, Craig, Campbell, Schafer, &; Humble, 2006 Wright, S. M., Craig, T., Campbell, S., Schaefer, J. and Humble, C. 2006. Patient satisfaction of female and male users of Veterans Health Administration services. Journal of General Internal Medicine, 21(Suppl. 3): S26–S32. [Crossref], [PubMed] , [Google Scholar]). One third of respondents reported smoking during the past year and 24% reported currently smoking. Current smoking status was more prevalent among those who reported less education and lower household income. Current smoking status was also related to lower mental and physical health quality of life and higher potential alcohol misuse scores. Quit attempts were significantly less common among reserve component veterans and quitters reported higher incomes and were slightly older. The frequency of cigarette smoking among recent veterans underscores the importance of addressing smoking cessation efforts within this population. Individual characteristics associated with current smoking, cessation efforts, and relapse may help tailor cessation treatment for this growing cohort of new veterans.     

Measurement Error-Corrected Estimation of Clinically Significant Change Trajectories for Interventions Targeting Comorbid PTSD and Substance Use Disorders in OEF/OIF Veterans

In randomized control trials (RCTs), a focus on average differences between treatment arms often limits our understanding of whether individuals show clinically significant improvement or deterioration. The present study examined differences in individual-level clinical significance trajectories between Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) and Relapse Prevention (RP). Eighty-one treatment-seeking veterans with a comorbid PTSD/SUD diagnosis were randomized to COPE or RP; data from an additional n = 48 patients who did not meet criteria for both disorders was used to establish a normative threshold. A newly developed, modernized approach to the Jacobson and Truax (1991) clinically significant change framework, using (a) moderated nonlinear factor analysis (MNLFA) scale scoring and (b) measurement error-corrected multilevel modeling (MEC-MLM) was used; this approach was compared to other approaches using conventional total scores and/or assuming no measurement error. Using a conventional approach to estimating the Reliable Change Index (RCI) yielded no differences between COPE and RP in the percentage of patients achieving statistically significant improvement (SSI; 88.9% for both groups). However, under MNLFA/MEC-MLM, higher percentages of patients receiving COPE (75.0%) achieved SSI compared to RP (40.7%). Findings suggest that, even though COPE and RP appear to reduce the same number of PTSD symptoms, MNLFA scoring of outcome measures gives greater weight to interventions that target and reduce “hallmark” PTSD symptoms.     

Parental Predictors of Adolescent Alcohol Use and Alcohol‐Related Consequences

This study examined parental predictors of alcohol use and alcohol‐related consequences among 9th‐grade students (N = 296). Parental disapproval of teen drinking and quality of parent–child general communication were significant predictors of drinking behaviors. Implications for counselors are discussed.     

Prevalence of Suicide Risk Factors and Suicide‐Related Outcomes in the National Mental Health Study,Colombia

A community survey in 4,426 adults was undertaken as part of the World Mental Health Survey Initiative reporting the prevalence and risk factors for suicide‐related outcomes in Colombia. Lifetime prevalence estimates of suicide ideation, plans, attempts, and risk factors for suicide‐related outcomes were assessed. Retrospective reports of disorders age‐of‐onset were used to study associations between primary mental disorders and first onset of suicide‐related outcomes. Risks of plans and attempts were highest with ideation early age‐of‐onset and within the first year. The highest risk for ideation and attempt among ideators occurred in the 18–29 age group. After first employment (defined as the first paid job accepted by the respondent) and presence of mental disorders constituted risk factors. Impulse‐control disorders were strongest diagnostic predictors.     

Firearm Storage Practices and Risk Perceptions Among a Nationally Representative Sample of U.S. Veterans With and Without Self‐Harm Risk Factors

Despite the disproportionate use of firearms in Veteran suicides and the well‐established link between firearm access and suicide, little is known about how Veterans store their firearms or what they think about the relationship between firearm access and suicide risk. Using data from 2015 nationally representative online survey (response rate 60.9%), we compare characteristics of Veteran firearm owners with and without self‐harm risk factors with respect to how they store their firearms and their beliefs about suicide risk related to firearms. Overall, one in three U.S. Veteran firearm owners store household firearms loaded and unlocked, one in twenty believe that a firearm increases household suicide risk, and one in four consider their loaded and unlocked firearm to be inaccessible to suicidal household members. Storage practices and risk perceptions are similar among those with and without self‐reported suicide risk factors. Affecting risk perceptions may be a critical aspect of interventions addressing lethal means safety among U.S. Veterans.     

Religion in Public Health‐Care Institutions: U.S. and U.K. Perspectives

In this article, we consider the role that religion plays in the health‐care institutions of the United States and the United Kingdom. Religion has played a significant role in the development of health‐care institutions in both countries and continues to be present in them in important ways. To capture the range of involvement of religious groups in various sectors of the health‐care institution, we propose a continuum for their relationship, from completely merged identities at one end (“faith‐saturated”) to entirely separate ones at the other (“faith‐secular partnerships”). Versions of this scheme have appeared in both U.S. and U.K. reports that describe the faith component of faith‐based organizations that work in global contexts. We apply this framework to identify specific U.S. and U.K. exemplars, finding that examples of all types exist in both societies, despite the more secular nature of the United Kingdom. Accurately characterizing the relationship between religion and public health‐care institutions can inform future policy and research.     

Clinical Effectiveness of an Intensive Outpatient Program for Integrated Treatment of Comorbid Substance Abuse and Mental Health Disorders

Comorbid substance use disorders (SUDs) and mental health disorders are a pervasive problem among post-9/11 veterans and service members. Treatment of SUD and comorbid disorders has historically occurred separately and sequentially, and when treated concurrently has been primarily done in a weekly outpatient setting, which has high rates of dropout. The current study describes an integrated 2-week intensive outpatient treatment (IOP) using cognitive-behavioral therapy, including prolonged exposure for posttraumatic stress disorder (PTSD), unified protocol for anxiety and mood disorders, and relapse prevention for SUD. Forty-two patients completed the comorbid treatment program. Results indicated that self-reported substance use, PTSD, and depression symptoms significantly decreased following treatment, while satisfaction with participation in social roles increased. These preliminary effectiveness data indicate that comorbid SUD and mental health disorders can be effectively treated in a 2-week intensive outpatient program.     

A Cross‐Cultural Comparison of U.S. and Japanese Trainees’ Emotion‐Recognition Ability

This study investigated the ability of non‐Hispanic White U.S. counseling psychology trainees and Japanese clinical psychology trainees to recognize facially expressed emotions. Researchers proposed that an in‐group advantage for emotion recognition would occur, women would have higher emotion‐recognition accuracy than men, and participants would vary in their emotion‐intensity ratings. Sixty White U.S. students and 60 Japanese students viewed photographs of non‐Hispanic White U.S. and Japanese individuals expressing emotions and completed a survey assessing emotion‐recognition ability and emotion‐intensity ratings. Two four‐way mixed‐factor analyses of variance were performed, examining effects of participant nationality/race, participant gender, poser nationality/race, and poser gender on emotion‐recognition accuracy scores and intensity ratings. Results did not support the in‐group advantage hypothesis, rather, U.S. participants had higher accuracy rates than Japanese trainees overall. No gender differences in accuracy were found. However, respondents varied in their intensity ratings across gender and nationality. Implications for training applied psychology students and for future research are presented.     

Rates of Subthreshold PTSD Among U.S. Military Veterans and Service Members: A Literature Review

The current study’s goal was to provide a comprehensive review of current subthreshold posttraumatic stress disorder (PTSD) rates among U.S. military veterans and service members. PubMed, PsycInfo, ProQuest, Web of Knowledge, Google Scholar, and any relevant articles’ reference lists identified studies of subthreshold PTSD in the U.S. military. Search terms included PTSD in combination with partial, subthreshold or sub-threshold, subsyndromal or sub-syndromal, subclinical or sub-clinical, and military or veteran. Sixteen articles met criteria for review. Current subthreshold PTSD rates ranged from 2.3% to 22.3%, with a weighted mean rate of 7.6%. Definitional variation within and across the “below threshold” terms produced some variability in rates reported. Few studies consistently reported on impairment and comorbidity in the subthreshold PTSD population. Variability of current subthreshold PTSD rates may be due to methodological issues such as sampling methods, sample sizes, and how below threshold PTSD was assessed and defined. Based on our findings, we provide a number of recommendations that can be used to inform future research of subthreshold PTSD among U.S. military veterans and service members. These recommendations include having a standardized term and definition, determining how to more properly assess subthreshold PTSD symptomatology, clarifying subthreshold PTSD diagnostic stability, and identifying appropriate sampling methods.     

Parents as Partners: A U.K. Trial of a U.S. Couples‐Based Parenting Intervention For At‐Risk Low‐Income Families

Despite the well‐established links between couple relationship quality and healthy family functioning, and burgeoning evidence from the international intervention field, there is little or no evidence of the efficacy of couples‐based interventions from the United Kingdom (U.K.). This study explored whether the Parents as Partners (PasP) program, a group‐based intervention developed in the United States, brought about the same benefits in the U.K. The evaluation is based on 97 couples with children from communities with high levels of need, recruited to PasP because they are at high risk for parent and child psychopathology. Both mothers and fathers completed self‐report questionnaires assessing parents’ psychological distress, parenting stress, couple relationship quality and conflict, fathers’ involvement in child care and, importantly, children's adjustment. Multilevel modeling analysis comparing parents’ responses pre‐ and postintervention not only showed substantial improvements for both parents on multiple measures of couple relationship quality, but also improvements in parent and child psychopathology. Analyses also indicated most substantial benefits for couples displaying poorest functioning at baseline. The findings provide initial evidence for the successful implementation of PasP, an American‐origin program, in the U.K., and add support for the concept of the couple relationship as a resource by which to strengthen families.     

Examining Compulsive Sexual Behavior and Psychopathology Among a Sample of Postdeployment U.S. Male and Female Military Veterans

Compulsive sexual behavior (CSB) is defined as difficulties in controlling inappropriate or excessive sexual fantasies, urges, or behaviors that cause subjective distress or impairment in important areas of daily functioning. Using data from a baseline telephone interview, we examined the prevalence of CSB in a convenience sample of 820 postdeployed U.S. military male and female veterans and investigated correlates of CSB with sociodemographics and other mental health and sexual history characteristics. More men (13.8%) than women (4.3%) endorsed CSB-related symptoms. Given the limited sample size of women reporting CSB, correlational analyses were conducted only with men. After adjusting for significant sociodemographics, results indicated that gambling, suicidality, and sexually transmitted infections were significantly associated with male CSB. Current results suggest that CSB may be prevalent among U.S. military veterans post deployment and associated with significant negative health indices in men. CSB warrants attention regarding screening and intervention.     

Predictors of Cognitive Behavioral Therapy for Insomnia (CBTi) Outcomes in Active-Duty U.S. Army Personnel

Cognitive behavioral therapy for insomnia (CBTi) is well established as the first-line treatment for the management of chronic insomnia. Identifying predictors of response to CBTi should enable the field to efficiently utilize resources to treat those who are likely to respond and to personalize treatment approaches to optimize outcomes for those who are less likely to respond to traditional CBTi. Although a range of studies have been conducted, no clear pattern of predictors of response to CBTi has emerged. The purpose of this study was to examine the impact and relative importance of a comprehensive group of pretreatment predictors of insomnia outcomes in 99 active-duty service members who received in-person CBTi in a randomized clinical trial. Results indicated that higher levels of baseline insomnia severity and total sleep time predicted greater improvements on the Insomnia Severity Index (ISI) following treatment. Higher depression symptoms and a history of head injury predicted a worse response to treatment (i.e., smaller improvements on the ISI). Clinically meaningful improvements, as measured by the reliable change index (RCI), were found in 59% of the sample. Over and above baseline insomnia severity, only depressive symptoms predicted this outcome. Future studies should examine if modifications to CBTi based on these predictors of response can improve outcomes.