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Introduction: Difficulty controlling anger is a common postdeployment problem in military personnel. Chronic and unregulated anger can lead to inappropriate aggression and is associated with behavioral health, legal, employment, and relationship problems for military service members. Military-related betrayal (e.g., military sexual assault, insider attacks) is experienced by over a quarter of combat service members and is associated with chronic anger and aggression. The high level of physical risk involved in military deployments make interconnectedness and trust in the military organization of utmost importance for survival during missions. While this has many protective functions, it also creates a vulnerability to experiencing military-related betrayal. Betrayal is related to chronic anger and aggression. Individuals with betrayal-related injuries express overgeneralized anger, irritability, blaming others, expectations of injustice, inability to forgive others, and ruminations of revenge. Current approaches to treating anger and aggression in military populations are inadequate. Standard anger treatment is not trauma-informed and does not consider the unique cultural context of anger and aggression in military populations, therefore is not well suited for anger stemming from military-related betrayal. While trauma-informed interventions targeting anger for military personnel exist, anger outcomes are mixed, and aggression and interpersonal functioning outcomes are poor. Also, these anger interventions are designed for patients with posttraumatic stress disorder. However, not all military-related betrayal meets the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-5 definition of trauma, though it may still lead to chronic anger and aggression. As a result, these patients lack access to treatment that appropriately targets the function of their anger and aggression., Materials and Methods: This manuscript describes rationale, design, and methodology of a pilot clinical trial examining Countering Chronic Anger and Aggression Related to Trauma and Transgressions (CART). CART is a transdiagnostic, transgression-focused intervention for military personnel who have experienced military-related betrayal, targeting chronic anger and aggression, and improving interpersonal relationships. The pilot study will use an interrupted timeseries design, where participants are randomized to a 2-, 3-, or 4-week minimal contact waitlist before starting treatment. This design maximizes the sample size so that all participants receive the treatment and act as their own control, while maintaining a robust design via stepped randomization. This trial aims to (1) test the acceptability and feasibility of CART, (2) test whether CART reduces anger and aggression in military personnel with a history of military-related betrayal, and (3) test whether CART improves interpersonal functioning., Results: The primary feasibility outcome will be the successful recruitment, enrollment, and initiation of 40 participants. Primary outcome measures include the Client Satisfaction Survey-8, the State Trait Anger Expression Inventory-2, Overt Aggression Scale-Modified, and the Inventory of Interpersonal Problems-Short Version., Conclusion: If outcomes show feasibility, acceptability, and initial effectiveness, CART will demonstrate a culturally relevant treatment for chronic anger, the most frequent postdeployment problem, in a sample of active duty service members who have suffered a military betrayal. The DoD will also have an evidence-based treatment option focusing on interpersonal functioning, including relationships within the military and within families., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

People with depression often underutilize mental health care. This study was conceived as a first step toward a clinical decision support tool that helps identify patients who are at higher risk of underutilizing care. The primary goals were to (a) describe treatment utilization patterns, early termination, and return to care; (b) identify factors associated with early termination of treatment; and (c) evaluate the accuracy of regression models to predict early termination. These goals were evaluated in a retrospective cohort analysis of 108,457 U.S. veterans who received care from the Veterans Health Administration between 2001 and 2021. Our final sample was 16.5% female with an average age of 34.5. Veterans were included if they had a depression diagnosis, a positive depression screen, and received general health care services at least a year before and after their depression diagnosis. Using treatment quality guidelines, the threshold for treatment underutilization was defined as receiving fewer than four psychotherapy sessions or less than 84 days of antidepressants. Over one fifth of veterans (21.6%) received less than the minimally recommended care for depression. The odds of underutilizing treatment increased with lack of Veterans Administration benefits, male gender, racial/ethnic minority status, and having received mental health treatment in the past (adjusted OR > 1.1). Posttraumatic stress disorder comorbidity correlated with increased depression treatment utilization (adjusted OR < .9). Models with demographic and clinical information from medical records performed modestly in classifying patients who underutilized depression treatment (area under the curve = 0.595, 95% CI [0.588, 0.603]). Most veterans in this cohort received at least the minimum recommended treatment for depression. To improve the prediction of underutilization, patient factors associated with treatment underutilization likely need to be supplemented by additional clinical information. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

U.S. Service members and Veterans (SM/V) experience elevated rates of traumatic brain injury (TBI), chronic pain, and other non-pain symptoms. However, the role of non-pain factors on pain interference levels remains unclear among SM/Vs, particularly those with a history of TBI. The primary objective of this study was to identify factors that differentiate high/low pain interference, given equivalent pain intensity among U.S. SM/V participating in the ongoing Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) national multi-center prospective longitudinal observational study. An explainable machine learning was used to identify key predictors of pain interference conditioned on equivalent pain intensity. The final sample consisted of n = 1,577 SM/Vs who were predominantly male (87%), and 83.6% had a history of mild TBI(s) (mTBI), while 16.4% were TBI negative controls. The sample was categorized according to pain interference level (Low: 19.9%, Moderate: 52.5%, and High: 27.6%). Both pain intensity scores and pain interference scores increased with the number of mTBIs ( p < 0.001), and there was evidence of a dose response between the number of injuries and pain scores. Machine learning models identified fatigue and anxiety as the most important predictors of pain interference, whereas emotional control was protective. Partial dependence plots identified that marginal effects of fatigue and anxiety were associated with pain interference ( p < 0.001), but the marginal effect of mTBI was not significant in models considering all variables ( p > 0.05). Non-pain factors are associated with functional limitations and disability experience among SM/V with an mTBI history. The functional effects of pain may be mediated through multiple other factors. Pain is a multi-dimensional experience that may benefit most from holistic treatment approaches that target comorbidities and build supports that promote recovery.

This study evaluates the use of the crosswalk between the PTSD Checklist-Civilian (PCL-C) and PTSD Checklist for DSM-5 (PCL-5) designed by Moshier et al. (2019) in a sample of service members and veterans (SM/V; N = 298) who had sustained a traumatic brain injury (TBI) and were receiving inpatient rehabilitation. The PCL-C and PCL-5 were completed at the same time. Predicted PCL-5 scores for the sample were obtained according to the crosswalk developed by Moshier et al. We used three measures of agreement: intraclass correlation coefficient (ICC), mean difference between predicted and observed scores, and Cohen's κ to determine the performance of the crosswalk in this sample. Subgroups relevant to those who have sustained a TBI, such as TBI severity, were also examined. There was strong agreement between the predicted and observed PCL-5 scores (ICC = .95). The overall mean difference between predicted and observed PCL-5 scores was 0.07 and not statistically significant (SD = 8.29, p = .89). Significant mean differences between predicted and observed PCL-5 scores calculated between subgroups were seen in Black participants (MD = -4.09, SD = 8.41, p = .01) and those in the Year 5 follow-up group (MD = 1.77, SD = 7.14, p = .03). Cohen's κ across subgroups had a mean of κ = 0.76 (.57-1.0), suggesting that there was moderate to almost perfect diagnostic agreement. Our results suggest the crosswalk created by Moshier et al. can be applied to SM/V who have suffered a TBI. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Background: Depression is prevalent among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans, yet rates of Veteran mental health care utilization remain modest. The current study examined: factors in electronic health records (EHR) associated with lack of treatment initiation and treatment delay; the accuracy of regression and machine learning models to predict initiation of treatment., Methods: We obtained data from the VA Corporate Data Warehouse (CDW). EHR data were extracted for 127,423 Veterans who deployed to Iraq/Afghanistan after 9/11 with a positive depression screen and a first depression diagnosis between 2001 and 2021. We also obtained 12-month pre-diagnosis and post-diagnosis patient data. Retrospective cohort analysis was employed to test if predictors can reliably differentiate patients who initiated, delayed, or received no mental health treatment associated with their depression diagnosis., Results: 108,457 Veterans with depression, initiated depression-related care (55,492 Veterans delayed treatment beyond one month). Those who were male, without VA disability benefits, with a mild depression diagnosis, and had a history of psychotherapy were less likely to initiate treatment. Among those who initiated care, those with single and mild depression episodes at baseline, with either PTSD or who lacked comorbidities were more likely to delay treatment for depression. A history of mental health treatment, of an anxiety disorder, and a positive depression screen were each related to faster treatment initiation. Classification of patients was modest (ROC AUC = 0.59 95%CI = 0.586-0.602; machine learning F-measure = 0.46)., Conclusions: Having VA disability benefits was the strongest predictor of treatment initiation after a depression diagnosis and a history of mental health treatment was the strongest predictor of delayed initiation of treatment. The complexity of the relationship between VA benefits and history of mental health care with treatment initiation after a depression diagnosis is further discussed. Modest classification accuracy with currently known predictors suggests the need to identify additional predictors of successful depression management., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Behavioral dyscontrol occurs commonly in the general population and in United States service members and Veterans (SM/V). This condition merits special attention in SM/V, particularly in the aftermath of deployments. Military deployments frequently give rise to posttraumatic stress disorder (PTSD) and deployment-related mild TBI traumatic brain injury (TBI), potentially leading to manifestations of behavioral dyscontrol., Objective: Examine associations among PTSD symptom severity, deployment-related mild traumatic brain injury, and behavioral dyscontrol among SM/V., Design: Secondary cross-sectional data analysis from the Long-Term Impact of Military-Relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium prospective longitudinal study among SM/V ( N  = 1,808)., Methods: Univariable and multivariable linear regression models assessed the association and interaction effects between PTSD symptom severity, as assessed by the PTSD Checklist for the Diagnostic and Statistical Manual, 5th edition (PCL-5), and deployment-related mild TBI on behavioral dyscontrol, adjusting for demographics, pain, social support, resilience, and general self-efficacy., Results: Among the 1,808 individuals in our sample, PTSD symptom severity ( B  = 0.23, 95% CI: 0.22, 0.25, p  < 0.001) and deployment-related mild TBI ( B  = 3.27, 95% CI: 2.63, 3.90, p  < 0.001) were significantly associated with behavioral dyscontrol in univariable analysis. Interaction effects were significant between PTSD symptom severity and deployment mild TBI ( B  = -0.03, 95% CI: -0.06, -0.01, p  = 0.029) in multivariable analysis, indicating that the effect of mild TBI on behavioral dyscontrol is no longer significant among those with a PCL-5 score > 22.96., Conclusion: Results indicated an association between PTSD symptom severity, deployment-related mild TBI, and behavioral dyscontrol among SM/V. Notably, the effect of deployment-related mild TBI was pronounced for individuals with lower PTSD symptom severity. Higher social support scores were associated with lower dyscontrol, emphasizing the potential for social support to be a protective factor. General self-efficacy was also associated with reduced behavioral dyscontrol., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Stromberg, Martindale, Walker, Ou, Pogoda, Miles, Dismuke-Greer, Carlson, Rowland, O’Neil and Pugh.)

Background: Traumatic brain injury (TBI) is a complex health problem in military veterans and service members (V/SM) that often involves comorbid vestibular impairment. Sleep apnea is another comorbidity that may exacerbate, and/or be exacerbated by, vestibular dysfunction., Objective: To examine the relationship between sleep apnea and vestibular symptoms in V/SM diagnosed with TBI of any severity., Design: Multicenter cohort study; cross-sectional sample., Setting: In-patient TBI rehabilitation units within five Veterans Affairs (VA) Polytrauma Rehabilitation Centers., Participants: V/SM with a diagnosis of TBI (N = 630) enrolled in the VA TBI Model Systems study., Intervention: Not applicable., Methods: A multivariable regression model was used to evaluate the association between sleep apnea and vestibular symptom severity while controlling for relevant covariates, for example, posttraumatic stress disorder (PTSD)., Main Outcome Measures: Lifetime history of sleep apnea was determined via best source reporting. Vestibular disturbances were measured with the 3-item Vestibular subscale of the Neurobehavioral Symptom Inventory (NSI)., Results: One third (30.6%) of the sample had a self-reported sleep apnea diagnosis. Initial analysis showed that participants who had sleep apnea had more severe vestibular symptoms (M = 3.84, SD = 2.86) than those without sleep apnea (M = 2.88, SD = 2.67, p < .001). However, when the data was analyzed via a multiple regression model, sleep apnea no longer reached the threshold of significance as a factor associated with vestibular symptoms. PTSD severity was shown to be significantly associated with vestibular symptoms within this sample (p < .001)., Conclusion: Analysis of these data revealed a relationship between sleep apnea and vestibular symptoms in V/SM with TBI. The significance of this relationship was affected when PTSD symptoms were factored into a multivariable regression model. However, given that the mechanisms and directionality of these relationships are not yet well understood, we assert that in terms of clinical relevance, providers should emphasize screening for each of the three studied comorbidities (sleep apnea, vestibular symptoms, and PTSD)., (© 2023 American Academy of Physical Medicine and Rehabilitation. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Objective: Evidence-based psychotherapies are efficacious at reducing posttraumatic stress disorder (PTSD) symptoms, but military and veteran samples improve less than civilians. The objective of this secondary analysis of two clinical trials of cognitive processing therapy (CPT) was to determine if hyperarousal symptoms were more resistant to change compared with other PTSD symptom clusters in active duty service members., Method: Service members completed the PTSD Checklist for the DSM-5 (PCL-5) pre- and post-CPT. Symptoms were coded present if rated 2 ( moderate ) or higher on a 0-4 scale. Cutoffs for reliable and clinically significant change classified 21%, 18%, and 61% of participants as recovered, improved, and suboptimal responders, respectively. Data analyses focused on the posttreatment status of symptoms that were present at baseline to determine their persistence as a function of treatment outcome. Generalized linear mixed effects models with items treated as a repeated measure estimated the proportions who continued to endorse each symptom and compared hyperarousal symptoms with symptoms in other clusters., Results: Among improved participants, the average hyperarousal symptom was present in 69% compared with 49% for symptoms in other clusters ( p < .0001). Among recovered patients, hyperarousal symptoms were present for 26%, while symptoms in the reexperiencing (2%), avoidance (3%), and negative alterations (4%) clusters were almost nonexistent ( p < .0001)., Conclusions: Even among service members who recovered from PTSD after CPT, a significant minority continue to report hyperarousal symptoms while other symptoms remit. Hyperarousal symptoms may require additional treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Introduction: Veterans and service members (V/SM) may have more risk factors for arrest and felony incarceration (e.g., posttraumatic stress disorder and at-risk substance use) but also more protective factors (e.g., access to health care) to mitigate behaviors that may lead to arrest. As such, understanding which factors are associated with criminal justice involvement among V/SM could inform prevention and treatment efforts. The current study examined relationships between lifetime history of arrests and felony incarceration and sociodemographic, psychological, and brain injury characteristics factors among combat V/SM., Materials and Methods: The current study was a secondary data analysis from the Chronic Effects of Neurotrauma Consortium multicenter cohort study, approved by local institutional review boards at each study site. Participants were V/SM (N = 1,540) with combat exposure (19% active duty at time of enrollment) who were recruited from eight Department of Veterans Affairs and DoD medical centers and completed a baseline assessment. Participants were predominantly male (87%) and white (72%), with a mean age of 40 years (SD = 9.7). Most (81%) reported a history of at least one mild traumatic brain injury, with one-third of those experiencing three or more mild traumatic brain injuries (33%). Participants completed a self-report measure of lifetime arrest and felony incarceration history, a structured interview for all potential concussive events, the post-traumatic stress disorder checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and the Alcohol Use Disorders Identification Test-Consumption. Three groups were compared on self-reported level of lifetime history of criminal justice system involvement: (1) no history of arrest or incarceration (65%); (2) history of arrest but no felony incarceration (32%); and (3) history of felony incarceration (3%)., Results: Ordinal regression analyses revealed that hazardous alcohol consumption (β = .44, P < .001; odds ratio = 1.56) was positively associated with increased criminal justice involvement after adjusting for all other variables. Being married or partnered (β = -.44, P < .001; odds ratio = 0.64) was negatively associated with decreased criminal justice involvement., Conclusions: The rate of lifetime arrest (35%) in this V/SM sample was consistent with rates of arrests in the U.S. general population. One modifiable characteristic associated with lifetime arrest and felony incarceration was hazardous alcohol consumption. Alcohol use should be a top treatment target for V/SM at risk for arrest and those with history of criminal justice involvement., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objective: To explore the factor structure of the Rehabilitation Needs Survey (RNS)., Design: Secondary analysis of observational cohort study who were 5-years post-traumatic brain injury (TBI)., Setting: Five Inpatient Rehabilitation Facilities., Participants: Veterans enrolled in the TBI Model Systems longitudinal study who completed the RNS at 5-year follow-up (N=378)., Main Outcome Measure(s): RNS., Results: RNS factor structure was examined with exploratory factor analysis (EFA) with oblique rotation. Analyses returned 2- and 3-factor solutions with Cronbach alphas ranging from 0.715 to 0.905 and corrected item-total correlations that ranged from 0.279 to 0.732. The 2-factor solution accounted for 61.7% of the variance with ≥3 exclusively loading items on each factor with acceptable internal consistency metrics and was selected as the most parsimonious and clinically applicable model. Ad hoc analysis found the RNS structure per the EFA corresponded with elements of the International Classification of Functioning, Disability and Health (ICF) conceptual framework. All factors had adequate internal consistency (α≥0.70) and 20 of the 21 demonstrated good discrimination (corrected item-total correlations≥0.40)., Conclusions: The 2-factor solution of the RNS appears to be a useful model for enhancing its clinical interpretability. Although there were cross-loading items, they refer to complex rehabilitation needs that are likely influenced by multiple factors. Alternatively, there are items that may require alteration and redundant items that should be considered for elimination., (Published by Elsevier Inc.)

Dysregulated anger can result in devastating health and interpersonal consequences for individuals, families, and communities. Compared to civilians, combat veterans and service members (C-V/SM) report higher levels of anger and often have risk factors for anger including posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), pain, alcohol use, and impaired sleep. The current study examined the relative contributions of established variables associated with anger (e.g., combat exposure, current PTSD symptoms, history of TBI, pain interference, and hazardous alcohol use) in 1263 C-V/SM. Sleep impairments, represented by poor sleep quality and obstructive sleep apnea (OSA) risk, were also evaluated as potential mediators of the relationships between established risk factors and anger, and therefore potential modifiable treatment targets. Multiple regression model results revealed that PTSD symptoms (β = 0.517, p < .001), OSA risk (β = 0.057, p = .016), pain interference (β = 0.214, p < .001), and hazardous alcohol use (β = 0.054, p = .009) were significantly associated with anger. Results of the mediation models revealed that OSA risk accounted for the association between PTSD and anger, in addition to the association between pain interference and anger. The current study extends previous literature by simultaneously examining factors associated with anger using a multivariable model in a large sample of C-V/SM. Additionally, treating OSA may be a novel way to reduce anger in C-V/SM who have PTSD and/or pain interference., Competing Interests: Declaration of competing interest None., (Published by Elsevier Ltd.)

Objective: While outcome from mild traumatic brain injury (mTBI) is generally favorable, concern remains over potential negative long-term effects, including impaired cognition. This study examined the link between cognitive performance and remote mTBIs within the Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) multicenter, observational study of Veterans and service members (SMs) with combat exposure., Method: Baseline data of the participants passing all cognitive performance validity tests ( n = 1,310) were used to conduct a cross-sectional analysis. Using multivariable regression models that adjusted for covariates, including age and estimated preexposure intellectual function, positive mTBI history groups, 1-2 lifetime mTBIs (nonrepetitive, n = 614), and 3 + lifetime mTBIs (repetitive; n = 440) were compared to TBI negative controls ( n = 256) on each of the seven cognitive domains computed by averaging Z scores of prespecified component tests. Significance levels were adjusted for multiple comparisons., Results: Neither of the mTBI positive groups differed from the mTBI negative control group on any of the cognitive domains in multivariable analyses. Findings were also consistently negative across sensitivity analyses (e.g., mTBIs as a continuous variable, number of blast-related mTBIs, or years since the first and last mTBI)., Conclusions: Our findings demonstrate that the average veteran or SM who experienced one or more mTBIs does not have postacute objective cognitive deficits due to mTBIs alone. A holistic health care approach including comorbidity assessment is indicated for patients reporting chronic cognitive difficulties after mTBI(s), and strategies for addressing misattribution may be beneficial. Future study is recommended with longitudinal designs to assess within-subjects decline from potential neurodegeneration. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Veterans Health Administration (VHA) screens veterans who deployed in support of the wars in Afghanistan and Iraq for traumatic brain injury (TBI) and mental health (MH) disorders. Chronic symptoms after mild TBI overlap with MH symptoms, for which there are already established screens within the VHA. It is unclear whether the TBI screen facilitates treatment for appropriate specialty care over and beyond the MH screens. Our primary objective was to determine whether TBI screening is associated with different types (MH, Physical Medicine & Rehabilitation [PM&R], and Neurology) and frequency of specialty services compared with the MH screens. A retrospective cohort design examined veterans receiving VHA care who were screened for both TBI and MH disorders between Fiscal Year (FY) 2007 and FY 2018 (N = 241,136). We calculated service utilization counts in MH, PM&R, and Neurology in the six months after the screens. Zero-inflated negative binomial regression models of encounters (counts) were fit separately by specialty care type and for a total count of specialty services. We found that screening positive for TBI resulted in 2.38 times more specialty service encounters than screening negative for TBI. Compared with screening positive for MH only, screening positive for both MH and TBI resulted in 1.78 times more specialty service encounters and 1.33 times more MH encounters. The TBI screen appears to increase use of MH, PM&R, and Neurology services for veterans with post-deployment health concerns, even in those also identified as having a possible MH disorder.

Objective: Determine anxiety trajectories and predictors up to 10 years posttraumatic brain injury (TBI)., Design: Prospective longitudinal, observational study., Setting: Inpatient rehabilitation centers., Participants: 2836 participants with moderate to severe TBI enrolled in the TBI Model Systems National Database who had ≥2 anxiety data collection points (N=2836)., Main Outcome Measure: Generalized Anxiety Disorder-7 (GAD-7) at 1, 2, 5, and 10-year follow-ups., Results: Linear mixed models showed higher GAD-7 scores were associated with Black race (P<.001), public insurance (P<.001), pre-injury mental health treatment (P<.001), 2 additional TBIs with loss of consciousness (P=.003), violent injury (P=.047), and more years post-TBI (P=.023). An interaction between follow-up year and age was also related to GAD-7 scores (P=.006). A latent class mixed model identified 3 anxiety trajectories: low-stable (n=2195), high-increasing (n=289), and high-decreasing (n=352). The high-increasing and high-decreasing groups had mild or higher GAD-7 scores up to 10 years. Compared to the low-stable group, the high-decreasing group was more likely to be Black (OR=2.25), have public insurance (OR=2.13), have had pre-injury mental health treatment (OR=1.77), and have had 2 prior TBIs (OR=3.16)., Conclusions: A substantial minority of participants had anxiety symptoms that either increased (10%) or decreased (13%) over 10 years but never decreased below mild anxiety. Risk factors of anxiety included indicators of socioeconomic disadvantage (public insurance) and racial inequities (Black race) as well as having had pre-injury mental health treatment and 2 prior TBIs. Awareness of these risk factors may lead to identifying and proactively referring susceptible individuals to mental health services., (Copyright © 2022 American Congress of Rehabilitation Medicine. All rights reserved.)

Introduction: Special Operations Forces (SOF) personnel are at increased risk for traumatic brain injury (TBI), when compared with conventional forces (CF). Prior studies of TBI in military samples have not typically investigated SOF vs. CF as specific subgroups, despite documented differences in premorbid resilience and post-injury comorbidity burden. The aim of the current study was to compare SOF vs. CF on the presence of neurobehavioral symptoms after TBI, as well as factors influencing perception of symptom intensity., Materials and Methods: This study conducted an analysis of the prospective veterans affairs (VA) TBI Model Systems Cohort, which includes service members and veterans (SM/V) who received inpatient rehabilitation for TBI at one of the five VA Polytrauma Rehabilitation Centers. Of those with known SOF status (N = 342), 129 participants identified as SOF (average age = 43 years, 98% male) and 213 identified as CF (average age = 38.7 years, 91% male). SOF vs. CF were compared on demographics, injury characteristics, and psychological and behavioral health symptoms. These variables were then used to predict neurobehavioral symptom severity in univariable and multivariable analyses., Results: SOF personnel reported significantly greater posttraumatic stress disorder (PTSD) symptoms but less alcohol and drug use than the CF. SOF also reported greater neurobehavioral symptoms. When examining those with TBIs of all severities, SOF status was not associated with neurobehavioral symptom severity, while race, mechanism of TBI, and PTSD symptoms were. When examining only those with mTBI, SOF status was associated with lower neurobehavioral symptoms, while PTSD severity, white race, and certain mechanisms of injury were associated with greater neurobehavioral symptoms., Conclusions: Among those receiving inpatient treatment for TBI, SOF SM/V reported higher neurobehavioral and symptom severity. PTSD was the strongest predictor of neurobehavioral symptoms and should be considered an important treatment target in both SOF and CF with co-morbid PTSD/TBI. A proactive human performance approach towards identification and treatment of psychological and neurobehavioral symptoms is recommended for SOF., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objective: To examine traumatic brain injury (TBI) characteristics and comorbid medical profiles of Special Operations Forces (SOF) Active Duty Service Member/Veterans (ADSM/Vs) and contrast them with conventional military personnel., Setting: The 5 Veterans Affairs (VA) Polytrauma Rehabilitation Centers., Participants: A subset of participants in the VA TBI Model Systems multicenter longitudinal study with known SOF status. These included 157 participants who identified as SOF personnel (average age = 41.8 years; 96% male, 81% active duty), and 365 who identified as Conventional Forces personnel (average age = 37.4 years; 92% male, 30% active duty)., Design: Retrospective analysis of prospective cohort, cross-sectional., Main Measures: The Health Comorbidities Interview., Results: SOF personnel were more likely to have deployed to a combat zone, had more years of active duty service, and were more likely active duty at time of TBI. SOF personnel were more likely to have had mild TBI (vs moderate/severe) and their TBI caused by violent mechanism. SOF personnel had a higher number of comorbidities, with more diagnoses of chronic pain, osteoarthritis, hyperlipidemia, hip fractures, and obstructive sleep apnea., Conclusion: SOF personnel are at a higher risk for multimorbidity after TBI. Current rehabilitation practices should incorporate early screening and treatment of common conditions in this population, while future practices may benefit from a focus on prevention., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Objectives: Characterize associations between sleep impairments and posttraumatic stress disorder (PTSD) symptoms, including anger, in service members seeking treatment for PTSD., Methods: Ninety-three US Army personnel recruited into a PTSD treatment study completed the baseline assessment. State-of-the-science sleep measurements included 1) retrospective, self-reported insomnia, 2) prospective sleep diaries assessing sleep patterns and nightmares, and 3) polysomnography measured sleep architecture and obstructive sleep apnea-hypopnea severity. Dependent variables included self-report measures of PTSD severity and anger severity. Pearson correlations and multiple linear regression analyses examined if sleep symptoms, not generally measured in PTSD populations, were associated with PTSD and anger severity., Results: All participants met PTSD, insomnia, and nightmare diagnostic criteria. Mean sleep efficiency = 70%, total sleep time = 5.5 hours, obstructive sleep apnea/hypopnea (obstructive sleep apnea-hypopnea index ≥ 5 events/h) = 53%, and clinically significant anger = 85%. PTSD severity was associated with insomnia severity (β = .58), nightmare severity (β = .24), nightmare frequency (β = .31), and time spent in Stage 1 sleep (β = .27, all P < .05). Anger severity was associated with insomnia severity (β = .37), nightmare severity (β = .28), and obstructive sleep apnea-hypopnea during rapid eye movement sleep (β = .31, all P < .05)., Conclusions: Insomnia and nightmares were related to PTSD and anger severity, and obstructive sleep apnea-hypopnea was related to anger. Better assessment and evidence-based treatment of these comorbid sleep impairments in service members with PTSD and significant anger should result in better PTSD, anger, and quality-of-life outcomes., Clinical Trials Registration: Registry: ClinicalTrials.gov; Name: Treatment of Comorbid Sleep Disorders and Post Traumatic Stress Disorder; Identifier: NCT02773693; URL: https://clinicaltrials.gov/ct2/show/NCT02773693., Citation: Miles SR, Pruiksma KE, Slavis D, et al. Sleep disorder symptoms are associated with greater posttraumatic stress and anger symptoms in US Army service members seeking treatment for posttraumatic stress disorder. J Clin Sleep Med . 2022;18(6):1617-1627., (© 2022 American Academy of Sleep Medicine.)