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Utilization of mental health personnel assigned to operational military units is an area of growth for the US military. What activities they perform, how requirements may differ from workin...

Military personnel frequently report various physical and psychological complaints including somatic symptoms, bodily pain, depression, posttraumatic stress disorder, and physical role limitation. This study aimed to identify how psychological symptoms, somatic complaints, and physical role limitations are associated with each other in a sample of 207 male Air Force pararescue personnel and combat rescue officers. Results of a moderated mediation model indicated that the interaction of depression and somatic symptoms was associated with significantly more severe pain, which was, in turn, associated with greater physical role limitations. Pathways from posttraumatic stress disorder and the depression-by-somatic symptoms interaction to physical role limitation were both fully mediated by bodily pain. These findings (a) highlight the importance of assessing physical and psychological symptoms when individuals report impaired physical role limitation and (b) help to clarify the complex interplay of em...

As the construct of moral injury has gained increased conceptual and empirical attention among military personnel and veterans, preliminary attempts to operationalize and measure the construct have emerged. One such measure is the Moral Injury Event Scale (MIES). The aim of the current study was to further evaluate the MIES’s psychometric properties in two military samples: a clinical sample of Air Force personnel and a nonclinical sample of Army National Guard personnel. Exploratory and confirmatory factor analyses across both samples supported a three-factor solution: transgressions by others, transgressions by self, and betrayal. Transgressions-Others was most strongly associated with posttraumatic stress; Transgressions-Self was most strongly associated with hopelessness, pessimism, and anger; and Betrayal was most strongly associated with posttraumatic stress and anger. Results support the construct validity of the MIES, although areas for improvement are indicated and discussed.

BACKGROUND: A growing body of empirical research suggests insomnia severity is directly related to suicide ideation, attempts, and death in nonmilitary samples, even when controlling for depression and other suicide risk factors. Few studies have explored this relationship in U.S. military personnel. METHODS: The present study entailed secondary data analyses examining the associations of insomnia severity with suicide ideation and attempts in three clinical samples: Air Force psychiatric outpatients (n = 158), recently discharged Army psychiatric inpatients (n = 168), and Army psychiatric outpatients (n = 54). Participants completed the Beck Scale for Suicide Ideation, the Beck Depression Inventory-II or Patient Health Questionnaire-9, the Insomnia Severity Index, and the Posttraumatic Stress Disorder Checklist at baseline; two samples also completed these measures during follow-up. RESULTS: Sleep disturbance was associated with concurrent (β's > 0.21; P's 0.39; P's 0.200) or prospectively (β's 0.063), but depression was (β's > 0.22; P's RESULTS of a latent difference score mediation model indicated that depression mediated the relation of insomnia severity with suicide ideation. CONCLUSIONS: Across three clinical samples of military personnel, depression explained the relationship between insomnia severity and suicide risk. Language: en

Depression, posttraumatic stress (PTS), and guilt have been implicated as risk factors for suicide ideation (SI) among military personnel and veterans. Conceptual and empirical work suggests that guilt may mediate the relationship of depression and PTS with SI. The current study explored this hypothesis in two cross-sectional samples of military personnel and veterans (n = 464 and n = 158). Path analyses showed good fit for both samples [Sample 1: χ2(1) = 2.18, p = .140; CFI = 1.00; RMSEA = .05; WRMR = .23; Sample 2: χ2(2) = 1.39, p = .499; CFI = 1.00; RMSEA = .00; SRMR = .02] and indicated that depression was indirectly related to SI through guilt for both samples (ps < .038). Furthermore, guilt partially mediated the relationship of PTS with SI (p = .033) in Sample 1 and fully mediated the relationship (p = .016) in Sample 2. The present findings suggest that guilt may be a mechanism for increased risk among suicidal military personnel and veterans with depression and PTS.

Mental health problems among U.S. military personnel remain an important public health problem. However, little research exists concerning burnout, which is comprised of three interrelated experiences: emotional exhaustion, depersonalization, and (lack of) personal accomplishment (Maslach & Leiter 1997). Burnout may be especially relevant to U.S. Air Force (USAF) pararescuemen (PJs) due to their high deployment and operations tempo relative to conventional military forces. We administered the Maslach Burnout Inventory (MBI; Maslach & Jackson, 1981) to 194 male PJs from six military bases. Results of regression analyses indicated depersonalization was significantly higher among National Guard/Reserve personnel (β = .203, p = .029). Emotional exhaustion was associated with depression (β = .286, p = .004) and posttraumatic stress disorder (PTSD) symptoms (β = .194, p = .053), whereas depersonalization was associated with PTSD symptoms only (β = .353, p < .001). Greater personal accomplishment showed a nonsig...

Military psychologists from all services play a significant role in providing behavioral health care throughout the deployment cycle. These professionals offer a broad range of preventative, consultative, and clinical services throughout multiple phases of military operations including offensive, defensive, and stabilizing activities (i.e., humanitarian and peacekeeping missions). This chapter provides a brief overview of the history and capabilities of American military psychologists in the Navy, Air Force, and Army who are engaged in deployed military operations. And this chapter also provides recommendations for enhancing military behavioral health doctrine, organization, training, materiel, leadership, personnel, and facilities that may also be applicable to foreign and international forces.

Moral injury entails emotional distress associated with perceived violations of one’s moral code and has been proposed to be a possible contributor to self-injurious thoughts and behaviors (SITB) among military personnel. Three dimensions of moral injury have previously been empirically derived: transgressions committed by others (Transgressions-Others), transgressions committed by oneself (Transgressions-Self), and perceived betrayal by others (Betrayal). The current study examined the relationship of these dimensions of moral injury with SITB in a clinical sample of 151 active duty military personnel. Transgressions-Other and Transgressions-Self were significantly higher among personnel with a history of suicide attempt relative to history of suicidal ideation and no suicidality (Hedge’s g’s .64). Transgressions-Self was associated with significantly more severe suicidal ideation during the past week (p .018).

Objective Past self-injurious thoughts and behaviors (SITB) are robust predictors of future suicide risk, but no studies have explored the prevalence of SITB occurring prior to military service among military personnel and veterans, or the association of premilitary SITB with suicidal ideation and suicide attempts during or after military service. The current study explores these issues in two separate samples. Method Self-report data were collected from 374 college student veterans via anonymous only survey (Study 1) and from 151 military personnel receiving outpatient mental health treatment (Study 2). Results Across both studies, premilitary suicide attempts were among the most prominent predictor of subsequent suicide attempts that occurred after joining the military, even when controlling for demographics and more recent emotional distress. Among military personnel who made a suicide attempt during or after military service, approximately 50% across both samples experienced suicidal ideation and up to 25% made a suicide attempt prior to joining the military. Military personnel and veterans who made suicide attempts prior to joining the military were over six times more likely to make a later suicide attempt after joining the military. In Study 2, significantly more severe current suicidal ideation was reported by participants with histories of premilitary suicide risk, even when controlling for SITB occurring while in the military. Conclusions Military personnel and veterans who experienced SITB, especially suicide attempts, prior to joining the military are more likely to attempt suicide while in the military and/or as a veteran, and experience more severe suicidal crises.

Background: Newer approaches for understanding suicidal behavior suggest the assessment of suicidespecific beliefs and cognitions may improve the detection and prediction of suicidal thoughts and behaviors. The Suicide Cognitions Scale (SCS) was developed to measure suicide-specific beliefs, but it has not been tested in a military setting. Methods: Data were analyzed from two separate studies conducted at three military mental health clinics (one U.S. Army, two U.S. Air Force). Participants included 175 active duty Army personnel with acute suicidal ideation and/or a recent suicide attempt referred for a treatment study (Sample 1) and 151 active duty Air Force personnel receiving routine outpatient mental health care (Sample 2). In both samples, participants completed self-report measures and clinician-administered interviews. Follow-up suicide attempts were assessed via clinician-administered interview for Sample 1. Statistical analyses included confirmatory factor analysis, between-group comparisons by history of suicidality, and generalized regression modeling. Results: Two latent factors were confirmed for the SCS: Unloveability and Unbearability. Each demonstrated good internal consistency, convergent validity, and divergent validity. Both scales significantly predicted current suicidal ideation ( βs 40.316, ps o0.002) and significantly differentiated suicide attempts from nonsuicidal self-injury and control groups (F(6, 286) ¼9.801, po0.001). Both scales significantly predicted future suicide attempts (AORs41.07, ps o0.050) better than other risk factors. Limitations: Self-report methodology, small sample sizes, predominantly male samples. Conclusions: The SCS is a reliable and valid measure that predicts suicidal ideation and suicide attempts among military personnel better than other well-established risk factors.

The Behavioral Health Measure (BHM) is a brief self-report measure of general psychological distress and functioning developed for the tracking of mental health outcomes in outpatient psychotherapy settings (Kopta & Lowry, 2002). Although the BHM is used in integrated primary care behavioral health clinics, the scale's psychometric properties have not been evaluated in these settings. The current study investigated the BHM's psychometric properties, including its factor structure and reliability, and presents normative data from 3 large integrated primary care clinics. Mean scores for each of the BHM's 4 scales were significantly lower (i.e., more distress) for women than men, with scores being stable across the 3 primary care samples. Confirmatory factor analysis demonstrated adequate fit for the 3-factor and 1-factor models, with fit improving when 3 items were omitted. Internal consistency estimates for the BHM's 4 scales ranged from adequate to very good (α range: .72-.93). The 4 scales were highly intercorrelated, suggesting they measure similar constructs. Results suggest a revised, 17-item version of the BHM has adequate structure and reliability estimates, and is appropriate for use in primary care settings.

Few studies have examined rates of mental health problems among special duty military personnel, who often have frequent deployments and high exposure to operational stressors and trauma. The curre...

Suicide risk among U.S. military personnel has been increasing over the past decade. Fluid vulnerability theory (FVT; Rudd, 2006) posits that acute suicidal episodes increase in severity when trait-based (e.g., shame) and state-based (e.g., hopelessness) risk factors interact, especially among individuals who have been previously suicidal. In contrast, trait-based protective factors (e.g., pride) should buffer the deleterious effects of risk factors.77 active duty military personnel (95% Air Force; 58.4% male, 39.0% female; 67.5% Caucasian, 19.5% African-American, 1.3% Native American, 1.3% Native Hawaiian/Pacific Islander, 1.3% Asian, and 5.2% other) engaged in outpatient mental health treatment completed self-report surveys of shame, hopelessness, pride, and suicidal ideation. Multiple generalized regression was utilized to test the associations and interactive effects of shame, hopelessness, and worst-point past suicidal ideation on severity of current suicidal ideation.Shame significantly interacted with hopelessness (B=-0.013, SE=0.004, p0.001) and worst-point suicidal ideation (B=0.027, SE=0.010, p=0.010), augmenting each variable's effect on severity of current suicidal ideation. A significant three-way interaction among shame, worst-point suicidal ideation, and pride was also observed (B=-0.010, SE=0.0043, p=0.021), indicating that pride buffered the interactive effects of shame with worst-point suicidal ideation.Small sample size, cross-sectional design, and primarily Air Force sample.Among military outpatients with histories of severe suicidal episodes, pride buffers the effects of hopelessness on current suicidal ideation. Results are consistent with FVT.

BACKGROUND: Suicide rates in the U.S. military have been rising rapidly in the past decade. Research suggests guilt is a significant predictor of suicidal ideation among military personnel, and may be especially pronounced among those who have been exposure to combat-related traumas. The current study explored the interactive effect of direct combat exposure and guilt on suicidal ideation in a clinical sample of military personnel. METHODS: Ninety-seven active duty U.S. Air Force personnel receiving outpatient mental health treatment at two military clinics completed self-report symptom measures of guilt, depression, hopelessness, perceived burdensomeness, posttraumatic stress disorder, and suicidal ideation. RESULTS: Generalized multiple regression analyses indicated a significant interaction of guilt and direct combat exposure (B=.124, SE=.053, p=.020), suggesting a stronger relationship of guilt with suicidal ideation among participants who had direct combat exposure as compared to those who had not. The interactions of direct combat exposure with depression (B=.004, SE=.040, p=.926), PTSD symptoms (B=.016, SE=.018, p=.382), perceived burdensomeness (B=.159, SE=.152, p=.300) and hopelessness (B=.069, SE=.036, p=.057) were nonsignificant. CONCLUSIONS: Although guilt is associated with more severe suicidal ideation in general among military personnel, it is especially pronounced among those who have had direct combat exposure. Language: en

Suicide risk is an issue of increasing concern among military personnel. To date, most studies have focused on identifying risk factors for suicide in military personnel, but have by and large overlooked possible protective factors that reduce suicide risk, such as optimism. In a clinical sample of 97 treatment-seeking active duty Air Force personnel, the protective effects of optimism on suicidal ideation was investigated by considering the direct effect of optimism on suicidal ideation as well as the possible moderating effects of optimism on several suicide risk factors: depression, posttraumatic stress, and hopelessness. When adjusting for demographic and clinical covariates, results of multiple regression indicated that optimism was significantly associated with less severe depression, hopelessness, and suicidal ideation, but not posttraumatic stress symptoms. The interaction of optimism with hopelessness was also significant, and indicated that severe hopelessness contributed to more severe suicidal ideation only among participants with low levels of optimism. Results suggest that optimism is associated with less severe suicidal ideation, and buffer the effects of hopelessness among military patients.

BACKGROUND: Increased suicide risk among US military personnel is a growing concern. Research has linked trauma exposure, including exposure to combat-related injuries, death, and atrocities to suicidal ideation among combat veterans. Guilt (feeling bad about what you did to another) and shame (feeling bad about who you are) have been proposed as potential contributors to suicidal ideation among military personnel, but have not yet received much empirical attention. METHODS: Sixty-nine active duty military personnel receiving outpatient mental health treatment at a military clinic completed self-report symptom measures of guilt, shame, depression, posttraumatic stress disorder, and suicidal ideation while engaged in treatment. Generalized linear regression modeling was utilized to test the association of guilt and shame with suicidal ideation. RESULTS: Mean levels of guilt and shame were significantly higher among military personnel with a history of suicidal ideation. Guilt (B = 0.203, SE = .046, P Language: en

There is a clear relationship between suicide risk and chronic pain conditions. However, the exact nature of this link has been poorly understood, with risk attribution often limited to comorbid depression. Perceived burdensomeness has already been confirmed as a risk factor for suicidal ideation (SI) and suicide attempt in the general population. Self-perceived burden, studied among medically and terminally ill medical populations, has begun to receive a great deal of attention as a suicide risk factor. However, this risk has not been considered in an outpatient chronic pain population, a group likely to experience perceived burdensomeness as a particular problem. Guidelines recommend routine suicide risk screening in medical settings, but many questionnaires are time-consuming and do not allow for the assessment of the presence of newly identified risk constructs, such as perceived burdensomeness. This retrospective study examined the relationship between depression, perceived burdensomeness, and SI in a patient sample seeking behavioral treatment for chronic pain management. A logistic regression model was developed, with preliminary results indicating perceived burdensomeness was the sole predictor of SI, even in the presence of other well-established risk factors such as age, gender, depressive symptoms, and pain severity. Findings highlight the potential utility of a single-item screening question in routine clinical care as an incrementally superior predictor of SI in a chronic pain population.

Objective: To model typical trajectories for improvement among patients treated in an integrated primary care behavioral health service, multilevel models were used to explore the relationship between baseline mental health impairment level and eventual mental health functioning across follow-up appointments. Method: Data from 495 primary care patients (61.1% female, 60.7% Caucasian, 37.141 12.21 years of age) who completed the Behavioral Health Measure (Kopta & Lowry, 2002) at each primary care appointment were used for the analysis. Three separate models were constructed to identify clinical improvement in terms of number of appointments attended, baseline impairment severity level, and the interaction of these 2 variables. Results: The data showed that 71.5% of patients improved across appointments, 56.8% of which (40.5% of the entire sample) was clinically meaningful and reliable. Number of appointments and baseline severity of impairment significantly accounted for variability in clinical outcome, with trajectories of change varying across appointments as a function of baseline severity. Patients with more severe impairment at baseline improved faster than patients with less severe baseline impairment. Conclusions: Patients treated within an integrated primary care behavioral health service demonstrate significant improvements in clinical status, even those with the most severe levels of distress at baseline.

Despite considerable efforts on the part of the Department of Defense, Department of Veterans Affairs, andthe wider mental health community, mental health stigma continues to be a significant barrier to seeking helpbyservicemembers,highlightingtheneedfornewermodesofthought.Asignificantfactorcontributingtothisstigma is the fundamental difference between traditional mental health approaches and the warrior culture. Asa mental health prevention initiative, the Defender’s Edge (DEFED) program was specifically developed tofit within the United States Air Force Security Forces (SF) charged with ground combat operations whiledeployed to Iraq. DEFED adopted a strengths-based philosophy and integrated a psychologist into the SFculture. Evaluative feedback from 192 program participants is presented, demonstrating high programmaticacceptability and feasibility suggestive of success in circumventing mental health stigma.Keywords: mental health stigma, military, OEF/OIF, deployment

Blast-related head injuries are one of the most prevalent injuries among military personnel deployed in service of Operation Iraqi Freedom. Although several studies have evaluated symptoms after blast injury in military personnel, few studies compared them to nonblast injuries or measured symptoms within the acute stage after traumatic brain injury (TBI). Knowledge of acute symptoms will help deployed clinicians make important decisions regarding recommendations for treatment and return to duty. Furthermore, differences more apparent during the acute stage might suggest important predictors of the long-term trajectory of recovery. This study evaluated concussive, psychological, and cognitive symptoms in military personnel and civilian contractors (N = 82) diagnosed with mild TBI (mTBI) at a combat support hospital in Iraq. Participants completed a clinical interview, the Automated Neuropsychological Assessment Metric (ANAM), PTSD Checklist-Military Version (PCL-M), Behavioral Health Measure (BHM), and Insomnia Severity Index (ISI) within 72 hr of injury. Results suggest that there are few differences in concussive symptoms, psychological symptoms, and neurocognitive performance between blast and nonblast mTBIs, although clinically significant impairment in cognitive reaction time for both blast and nonblast groups is observed. Reductions in ANAM accuracy were related to duration of loss of consciousness, not injury mechanism. (JINS, 2011, 17, 000–000)

Rising suicide rates are an increasing concern among military personnel. The interpersonal-psychological theory of suicide proposes that three necessary factors are needed to die by suicide: feelings that one does not belong with other people, feelings that one is a burden on others or society, and an acquired capability to overcome the fear and pain associated with suicide. The current study tests the theory's proposal that acquired capability may be particularly influenced by military experience, because combat exposure may cause habituation to fear of painful experiences such as suicide. Utilizing clinical and nonclinical samples of military personnel deployed to Iraq, results of the current study indicate that a greater range of combat experiences predicts acquired capability above and beyond depression and post-traumatic stress disorder symptoms, previous suicidality, and other common risk factors for suicide. Combat experiences did not, however, predict perceived burdensomeness or thwarted belongingness. The authors discuss how combat experiences might serve as a mechanism for elevating suicide risk and implications for clinical interventions and suicide prevention efforts.

Suicide in the military is a growing concern. The interpersonal-psychological theory of suicidal behavior proposes that an individual will not die by suicide unless he or she experiences a combined disconnection from others, feelings that one is a burden on others, and the ability to do so, but this theory has not yet been rigorously tested with military samples. The current study tested the theory’s hypotheses in predicting history of suicide in a sample of 88 active duty US Air Force personnel, which was compared to a non-military undergraduate sample (n = 309) and a non-military clinical sample (n = 228). Active duty personnel demonstrated higher acquired capability when compared to a clinical non-military sample. As compared to non-military undergraduates, active duty personnel demonstrated less perceived burdensomeness, but did not differ in terms of thwarted belongingness. The interaction of burdensomeness and acquired capability significantly predicted suicidal history, but the three-way interaction between burdensomeness, belongingness, and acquired capability did not, providing partial support for the theory in a military sample.

Active-duty military personnel face deterrents to seeking outpatient mental health treatment despite the high prevalence of posttraumatic stress disorder (PTSD) in this population. The Behavioral Health Consultation (BHC) model may be the answer for those presenting subthreshold PTSD symptoms, at high risk for PTSD due to their occupation, not interested in outpatient mental health treatment, or unable to seek such treatment due to occupational limitations. Three empirically based interventions that have been effective in managing symptoms of PTSD are summarized and then integrated into the established BHC model as suggested treatments for managing PTSD symptoms in an integrated primary care setting. Pilot data and recommendations for future research and practice are provided.

Patterns of symptomatic and functional change associated with behavioral health consultant (BHC) intervention in an integrated family medicine clinic were investigated among 338 primary care patients under routine conditions without exclusion. Patients were referred to the BHC by primary care providers (PCPs) and participated in one to four brief, behaviorally oriented appointments in primary care. The Behavioral Health Measure-20 (BHM) was completed at each appointment. Results indicated that higher levels of distress at baseline were associated with more follow-up appointments, and that patients demonstrated simultaneous, clinically meaningful improvement in well-being, symptoms, and functioning in as few as two to three BHC appointments. Patterns of clinical improvement support the effectiveness of BHC interventions, but contradict the phase model of psychotherapy (Howard, Lueger, Maling, & Martinovich, 1993).

A growing body of empirical research suggests insomnia severity is directly related to suicide ideation, attempts, and death in nonmilitary samples, even when controlling for depression and other suicide risk factors. Few studies have explored this relationship in U.S. military personnel.The present study entailed secondary data analyses examining the associations of insomnia severity with suicide ideation and attempts in three clinical samples: Air Force psychiatric outpatients (n = 158), recently discharged Army psychiatric inpatients (n = 168), and Army psychiatric outpatients (n = 54). Participants completed the Beck Scale for Suicide Ideation, the Beck Depression Inventory-II or Patient Health Questionnaire-9, the Insomnia Severity Index, and the Posttraumatic Stress Disorder Checklist at baseline; two samples also completed these measures during follow-up.Sleep disturbance was associated with concurrent (β's0.21; P's0.059) and prospective (β's0.39; P's0.001) suicide ideation in all three samples. When adjusting for age, gender, depression, and posttraumatic stress, insomnia severity was no longer directly associated with suicide ideation either concurrently (β's0.19; P's0.200) or prospectively (β's0.26; P's0.063), but depression was (β's0.22; P's0.012). Results of a latent difference score mediation model indicated that depression mediated the relation of insomnia severity with suicide ideation.Across three clinical samples of military personnel, depression explained the relationship between insomnia severity and suicide risk.

Research has established clear links among posttraumatic stress disorder (PTSD), somatic symptoms, and general health among conventional force military personnel. It is possible that the same relationships exist among Special Operations Force (SOF) personnel, but there are very few, if any, studies that examine these relationships. This study investigated correlates of general health and medical visits among SOF personnel and found that the interaction of somatic and PTSD symptoms was associated with worse health and more frequent medical visits. Follow-up analyses indicated that the interaction of avoidance symptoms with somatic symptoms was significantly associated with worse health, whereas the interaction of emotional numbing with somatic symptoms significantly contributed to increased medical visits. In addition, the results suggest that a sense of accomplishment among SOF personnel may serve as a protective factor against poor health. The results suggest developing interactions among SOF personnel that promote a sense of achievement to ultimately improve the health of the force.

A strong therapeutic alliance is considered to be an essential factor for the effective assessment and management of suicidal patients; however, to date this has received little empirical attention. The current study evaluated the association of future change in suicidal ideation with therapeutic alliance during first appointments with primary care behavioral health consultants. The Behavioral Health Measure (BHM; Kopta & Lowery, 2002) and Therapeutic Bond Scale (TBS; CelestHealth Solutions, 2006) were completed by 497 primary care patients who kept 2 to 8 appointments with the integrated behavioral health consultant. Results indicated that suicidal ideation generally improved over the course of several behavioral health appointments and that therapeutic alliance was rated very high by patients. Therapeutic alliance during the first appointment was not associated with eventual change in suicidal ideation.

Increased suicide risk among US military personnel is a growing concern. Research has linked trauma exposure, including exposure to combat-related injuries, death, and atrocities to suicidal ideation among combat veterans. Guilt (feeling bad about what you did to another) and shame (feeling bad about who you are) have been proposed as potential contributors to suicidal ideation among military personnel, but have not yet received much empirical attention.Sixty-nine active duty military personnel receiving outpatient mental health treatment at a military clinic completed self-report symptom measures of guilt, shame, depression, posttraumatic stress disorder, and suicidal ideation while engaged in treatment. Generalized linear regression modeling was utilized to test the association of guilt and shame with suicidal ideation.Mean levels of guilt and shame were significantly higher among military personnel with a history of suicidal ideation. Guilt (B = 0.203, SE = .046, P.001) and shame (B = 0.111, SE = .037, P = .002) were independently associated with severity of current suicidal ideation above and beyond the effects of depression, PTSD symptoms, and the depression-by-PTSD interaction, and fully mediated the relationships of depression and PTSD symptom severity with suicidal ideation. When considered simultaneously, only guilt (B = 0.167, SE = .053, P = .001) was significantly associated with increased suicidal ideation.Guilt and shame are associated with increased severity of suicidal ideation in military mental health outpatients. Guilt has a particularly strong relationship with suicidal ideation.

The current study investigated therapeutic alliance and clinical improvement within an integrated primary care behavioral health model. Participants included 542 primary care patients seen in two large family medicine clinics. Mental health symptoms and functioning were assessed using the 20-item Behavioral Health Measure (Kopta & Lowery, 2002) at the beginning of each patient appointment. Therapeutic alliance was measured with the Therapeutic Bond Scale (CelestHealth Solutions, 2008) following an initial appointment with one of 22 behavioral health consultants (BHCs). Primary care patients rated their therapeutic alliance following a first appointment with a BHC as statistically stronger than alliance ratings from a previously reported sample of outpatient psychotherapy patients after the second, third, and fourth psychotherapy sessions (Kopta, Saunders, Lutz, Kadison, & Hirsch, 2009). Results of a bootstrapped linear regression analysis indicated that therapeutic alliance assessed after the first primary care behavioral health appointment was not associated with eventual clinical change in mental health symptoms and functioning. A strong therapeutic alliance was able to be formed in a primary care behavioral health modality. This exceeded the magnitude found in outpatient psychotherapy alliance ratings. Early therapeutic alliance was unrelated to overall clinical improvement in primary care.

There is a clear relationship between suicide risk and chronic pain conditions. However, the exact nature of this link has been poorly understood, with risk attribution often limited to comorbid depression. Perceived burdensomeness has already been confirmed as a risk factor for suicidal ideation (SI) and suicide attempt in the general population. Self-perceived burden, studied among medically and terminally ill medical populations, has begun to receive a great deal of attention as a suicide risk factor. However, this risk has not been considered in an outpatient chronic pain population, a group likely to experience perceived burdensomeness as a particular problem. Guidelines recommend routine suicide risk screening in medical settings, but many questionnaires are time-consuming and do not allow for the assessment of the presence of newly identified risk constructs, such as perceived burdensomeness. This retrospective study examined the relationship between depression, perceived burdensomeness, and SI in a patient sample seeking behavioral treatment for chronic pain management. A logistic regression model was developed, with preliminary results indicating perceived burdensomeness was the sole predictor of SI, even in the presence of other well-established risk factors such as age, gender, depressive symptoms, and pain severity. Findings highlight the potential utility of a single-item screening question in routine clinical care as an incrementally superior predictor of SI in a chronic pain population.

The primary aim of the current study was to obtain information about the longitudinal clinical functioning of primary care patients who had received care from behavioral health consultants (BHCs) integrated into a large family medicine clinic. Global mental health functioning was measured with the 20-item self-report Behavioral Health Measure (BHM), which was completed by patients at all appointments with the BHC. The BHM was then mailed to 664 patients 1.5 to 3 years after receipt of intervention from BHCs in primary care, of which 70 (10.5%) were completed and returned (62.9% female; mean age 43.1 ± 12.7 years; 48.6% Caucasian, 12.9% African American, 21.4% Hispanic/Latino, 2.9% Asian/Pacific Islander, 10.0% Other, 4.3% no response). Mixed effects modeling revealed that patients improved from their first to last BHC appointment, with gains being maintained an average of 2 years after intervention. Patterns of results remained significant even when accounting for the receipt of additional mental health treatment subsequent to BHC intervention. Findings suggest that clinical gains achieved by this subset of primary care patients that were associated with brief BHC intervention were maintained approximately 2 years after the final appointment.

Caffeine, tobacco, and alcohol are the most widely used substances globally, but the majority of research on the associations among legal substance use and physical health has focused on the general population, not elite military personnel. The purpose of the current study was to describe patterns of tobacco, alcohol, and caffeine use and to examine the relationship of legal substance use with self-reported physical health complaints among US Air Force Pararescuemen (PJs) and Combat Rescue Officers (CROs).Participants were 196 US PJs and CROs. Participants completed self-report measures of legal drug use and somatic symptoms. Generalized linear modeling with robust maximum likelihood estimation was used for multivariate regression analyses. Chi-square analyses were conducted for univariate comparisons of categorical variables.Reported rates of tobacco use (28.2%), alcohol consumption (83.2%), and regular caffeine consumption (88.8%) were similar to the general population. Daily caffeine intake was significantly higher among participants reporting they were bothered a lot by back pain [Wald χ2(2)=11.39; ρ=.003] and extremity pain [Wald χ2(2)=11.39; ρ=.003], even when controlling for age and deployment history. Participants with severe extremity pain also reported drinking approximately twice as many alcoholic beverages per week (mean, 5.46; standard error [SE], 0.91) than participants who were bothered a little (mean, 2.88; SE, 0.54) or not bothered at all (mean, 2.88; SE, 0.52) by extremity pain.Back and extremity pain is associated with greater caffeine and alcohol consumption among PJs.