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Interleukin (IL)-18 generates T helper 1-type immunity and inhibits human immunodeficiency virus type 1 (HIV-1) in primary cells in vitro. Because IL-18 may participate in HIV-1 containment, whole-blood IL-18 levels were measured in 20 healthy control subjects and longitudinally in 28 subjects with early HIV-1 infection. Compared with those in control subjects, IL-18 levels were higher during early HIV-1 infection, and IL-18 levels predicted reduced CXCR4 HIV-1 coreceptor expression and diminished interferon (IFN)- gamma levels. By contrast, a direct association between IL-18 and IFN- gamma levels was observed in blood stimulated with lipopolysaccharide. During early HIV-1 infection, IL-18 may regulate HIV-1 coreceptor expression and have antiretroviral activity. Copyright © 2007 Infectious Diseases Society of America [ABSTRACT FROM AUTHOR]

Abstract Background Despite declines over recent years, youth tobacco and other substance use rates remain high. Latino youth are at equal or increased risk for lifetime tobacco, alcohol, marijuana, and other illicit drug use compared with their white peers. Family plays an important and influential role in the lives of youth, and longitudinal research suggests that improving parenting skills may reduce youth substance use. However, few interventions are oriented towards immigrant Latino families, and none have been developed and evaluated using a community-based participatory research (CBPR) process that may increase the effectiveness and sustainability of such projects. Therefore, using CBPR principles, we developed a randomized clinical trial to assess the efficacy of a family-skills training intervention to prevent tobacco and other substance use intentions in Latino youth. Methods/Design In collaboration with seven Latino community-serving agencies, we will recruit and randomize 336 immigrant families, into intervention or delayed treatment conditions. The primary outcome is youth intention to smoke 6 months post intervention. The intervention consists of eight parent and four youth sessions targeting parenting skills and parent–youth relational factors associated with lower smoking and other substance use in youth. Discussion We present the study protocol for a family intervention using a CBPR randomized clinical trial to prevent smoking among Latino youth. The results of this trial will contribute to the limited information on effective and sustainable primary prevention programs for tobacco and other substance use directed at the growing US Latino communities. Trial registration ClinicalTrials.gov: NCT01442753

Improving public health approaches to suicide prevention requires scalable evidence-based interventions that can be easily disseminated. Given empirical data supporting the association between insomnia and suicide risk, internet-delivered insomnia interventions are promising candidates to meet this need. The purpose of this study was to examine whether an unguided internet-delivered cognitive-behavioral therapy for insomnia (iCBT-I) improved insomnia severity, suicidal ideation (SI), and suicide risk correlates (depression, post-traumatic stress disorder, anxiety, hostility, belongingness, hopelessness, agitation, irritability, concentration) in a sample of veterans. Secondary data analysis of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (n = 50) with clinically significant insomnia and elevated SI drawn from a larger randomized controlled trial (RCT) of an iCBT-I, Sleep Healthy Using the Internet (SHUTi). Two-sample t-tests or Wilcoxon rank sum tests were used to evaluate between-group differences (SHUTi vs. Insomnia Education Website control) in symptom improvement from baseline to post-intervention. SHUTi participants experienced a significant improvement in insomnia severity (P < .001; d = -1.08) and a non-significant with small (subthreshold medium) effect size reduction of SI (P = .17, d = 0.40), compared to control participants. Significant improvement in hopelessness was observed (medium effect size), with non-significant small to medium effect size reductions in most remaining suicide risk correlates. Self-administered iCBT-I was associated with improvements in insomnia severity in veterans at elevated risk for suicide. These preliminary findings suggest that SI and suicide risk correlates may improve following an iCBT-I intervention, demonstrating the need for future well-powered iCBT-I RCTs targeted for populations at elevated suicide risk., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society of Behavioral Medicine.)

Objective: The authors sought to investigate whether utilization of inpatient occupational therapy (OT) was associated with reduced risk for 30-day psychiatric readmission in the Veterans Health Administration (VHA)., Methods: The authors conducted a secondary analysis of VHA medical record data for veterans who received inpatient psychiatric care from 2015 to 2020 (N=176,889). Mixed-effects logistic regression was used to model psychiatric readmission within 30 days of discharge (yes or no) as a function of inpatient psychiatric OT utilization (none, one, two, three, or four or more encounters) and other care utilization (e.g., previous psychiatric hospitalization), as well as clinical (e.g., primary diagnosis), sociodemographic (e.g., race-ethnicity), and facility (e.g., complexity) characteristics. Sensitivity analyses were conducted to evaluate the robustness of findings (e.g., stratification by discharge disposition)., Results: Relatively few veterans received inpatient psychiatric OT (26.2%), and 8.4% were readmitted within 30 days. Compared with veterans who did not receive inpatient psychiatric OT, those with one (OR=0.76), two (OR=0.64), three (OR=0.67), or four or more encounters (OR=0.64) were significantly (p<0.001) less likely to be readmitted within 30 days. These findings were consistent across all sensitivity analyses., Conclusions: Veterans who received inpatient OT services were less likely to experience psychiatric readmission. A clear dose-response relationship between inpatient psychiatric OT and readmission risk was not identified. These findings suggest that OT services may facilitate high-value inpatient psychiatric care in the VHA by preventing readmissions that stymie recovery and incur high costs. Future research may establish the causality of this relationship, informing policy regarding increased access to inpatient psychiatric OT., Competing Interests: Dr. Brenner reports editorial remuneration from Wolters Kluwer and RAND, royalties from the American Psychological Association and Oxford University Press, and consulting for sports leagues. The other authors report no financial relationships with commercial interests.

Objective: To examine whether co-morbid insomnia, post-traumatic stress disorder (PTSD), depression, and chronic pain mediate the relationship between traumatic brain injury (TBI) and positive airway pressure (PAP) treatment adherence., Setting: One Veterans Health Administration (VHA) sleep medicine site., Participants: Veterans (n = 8836) who were prescribed a modem-enabled PAP device., Design: Secondary analysis of clinical data. We used path analysis to examine: (1) whether Veterans with a history of TBI were more likely to experience insomnia, PTSD, depression, and chronic pain; (2) in turn, whether Veterans with these co-morbid conditions exhibited lesser PAP adherence; and (3) whether Veterans with a history of TBI will exhibit lesser PAP adherence, even while accounting for such co-morbid conditions. Model estimates were adjusted for sociodemographic (eg, race/ethnicity) and clinical characteristics (eg, mask leakage)., Main Measures: Health conditions were abstracted from the VHA medical record. PAP adherence was measured using average nightly use (hours)., Results: Among 8836 Veterans, 12% had a history of TBI. TBI history was not associated with PAP adherence when accounting for the presence of insomnia, PTSD, depression, and chronic pain. Indirect effect estimates indicated that a history of mild, moderate-severe, or unclassified TBI was associated with lesser PAP adherence, as mediated by the presence of co-morbid insomnia and chronic pain. Generally, TBI was associated with an increased likelihood of co-morbid insomnia, PTSD, depression, and chronic pain. In turn, insomnia and chronic pain, but not PTSD or depression, were associated with lesser PAP adherence., Conclusions: Our study offers empirical support for insomnia and chronic pain as potential explanatory mechanisms underlying the relationship between TBI history and suboptimal PAP adherence. While additional research is needed to confirm causality, findings offer preliminary evidence that can inform the development of tailored PAP adherence interventions for Veterans with TBI and obstructive sleep apnea., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Although recent work has highlighted high rates of suicide among American Indian and Alaska Native individuals who served in the US military, to date, a comprehensive evaluation of age-specific suicide rates, over time, has yet to be conducted., Methods: Population-based retrospective cohort study. Average annual suicide rates (2005-2020) were computed. The cohort included 207,955 Native Veterans who were alive as of January 1, 2005, and separated from military service on or before December 31, 2020. Suicide was identified via National Death Index codes., Results: Between 2005 and 2020, average annual, age-specific suicide rates among Native Veterans ranged from 16.32/100,000 (55+ y) to 64.49/100,000 (18-34 y). Compared with other age-related cohorts, the rate among those in the youngest age cohort (18-34y) was the highest between 2005 and 2018. The 2019-2020 average annual rate for 18- to 34-year-olds (41.86/100,000) dropped below that of the middle-aged cohort (35-45 y; 44.66/100,000). Across all age cohorts, firearms were the most used method of suicide [57.2% (18-34 and 35-54 y) to 66.17% (55+y)]; however, a notable percentage of Veterans died by suffocation, 16.54% (55 y and older), 26.71% (35-54 y), and 33.21% (18-34 y)., Conclusions: Findings highlight differences in suicide rates by age groups overtime for Native Veterans irrespective of Veterans Health Administration use and across service eras, as well as means of suicide, which also differed across groups. Increased efforts are needed to identify culturally and age-relevant intervention strategies, as well as factors associated with risk, to reduce deaths among Native Veterans., Competing Interests: L.A.B. reports grants from the VA, DOD, NIH, and the State of Colorado, editorial remuneration from Wolters Kluwer and the Rand Corporation, and royalties from the American Psychological Association and Oxford University Press. In addition, she consults with sports leagues via her university affiliation. J.E.F. reports grants from the VA, DOD, NIH, and the State of Colorado. The remaining authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Individuals with unilateral hip osteoarthritis walk with kinematic and spatiotemporal compensations compared to healthy individuals. Our purpose was to determine associations between gait, pain, and functional performance during the six-minute walk test., Methods: Trunk and hip kinematics and spatiotemporal gait outcomes were recorded from individuals with unilateral hip osteoarthritis using inertial sensors (Xsens Technologies). Pain was collected prior to and at the end of the six-minute walk test. Paired t-tests were conducted to evaluate gait between limbs and between the first and final minutes of walking. Correlations were conducted between gait, pain, and six-minute walk test performance., Findings: Nineteen participants (8 females, age: 63 ± 5 yrs., , Bmi: 29.0 ± 4.5 kg/m 2 ) completed the study. Between-limb differences in hip flexion, hip extension, and trunk forward flexion peak angles were observed during the six-minute walk test (P < .05). Participants demonstrated an increase in trunk forward flexion of the osteoarthritis side (t = -2.34, P = .031) and a bilateral decrease in stride length (osteoarthritis limb: t = 2.98, P = .008, non- osteoarthritis limb: t = 3.17, P = .006) from the first to the final minute of walking. Greater pain was associated with greater osteoarthritis limb hip extension (first minute: r = -0.506, P = .027, final minute: r = -0.53, P = .020) and greater hip abduction (r = 0.46, P = .046) during the final minute of walking., Interpretations: Gait compensations increase throughout the six-minute walk test, and pain associates with hip kinematics during the six-minute walk test. Wearable technology may allow for more accurate clinical movement assessments., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Comparing self-reported symptom scores across time requires longitudinal measurement invariance (LMI), a psychometric property that means the measure is functioning identically across all time points. Despite its prominence as a measure of depression symptom severity in both research and health care, LMI has yet to be firmly established for the Patient Health Questionnaire-9 depression module (PHQ-9), particularly over the course of antidepressant pharmacotherapy. Accordingly, the objective of this study was to assess for LMI of the PHQ-9 during pharmacotherapy for major depressive disorder. This was a secondary analysis of data collected during a randomized controlled trial. A total of 1,944 veterans began antidepressant monotherapy and completed the PHQ-9 six times over 24 weeks of treatment. LMI was assessed using a series of four confirmatory factor analysis models that included all six time points, with estimated parameters increasingly constrained across models to test for different aspects of invariance. Root-mean-square error of approximation of the chi-square difference test values below 0.06 indicated the presence of LMI. Exploratory LMI analyses were also performed for separate sex, age, and race subgroups. Root-mean-square error of approximation of the chi-square difference test showed minimal change in model fits during invariance testing (≤ 0.06 for all steps), supporting full LMI for the PHQ-9. LMI was also supported for all tested veteran subgroups. As such, PHQ-9 sum scores can be compared across extended pharmacotherapy treatment durations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: To assess injured military veterans' experiences, beliefs, and daily physical and psychosocial functioning in relation to food and nutrition., Design: We used a convergent mixed-methods study design and the International Classification of Functioning, Disability, and Health to operationalize the core constructs and influencing factors related to physical and psychosocial functioning, food, and nutrition., Setting: Three Veterans Affairs polytrauma rehabilitation centers., Participants: Veterans who served in the United States military on or after September 11, 2001, and whose medical diagnoses met the criteria for polytrauma; at least 1 mild traumatic brain injury and at least 1 associated comorbidity (eg, posttraumatic stress disorder, chronic musculoskeletal pain, vestibular disturbances), for a total N of 43., Interventions: None., Main Outcome Measures: Themes from survey responses and semistructured interview data were pooled into core constructs and influencing factors., Results: Thirty-seven veterans completed all surveys and participated in recorded interviews. Based on qualitative and quantitative data, veterans' relation to food and nutrition (ie, nutritional functioning) was found to be characterized by 5 core constructs, including food background, nutrition knowledge, meal aptitude, resource navigation, and navigation to/of food spaces. Nutritional functioning was found to be shaped by 5 influencing factors, including injuries and health conditions, ideological and cultural exposures, relations, current beliefs, and current behaviors., Conclusions: Nutritional functioning (food background, nutrition knowledge, meal aptitude, resource navigation, navigation to/of food spaces) among injured veterans is complex and shaped by multiple physical, psychosocial, economic, and cultural factors., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Research has focused on developing ways to prevent death by suicide, such as 24-hr crisis lines. The purpose of the study was to examine health-related outcomes among individuals using Veterans Crisis Line services who were evaluated to be at increased risk. Among those with identifying information, records were linked with electronic medical record and death data. 36,133 contacts were coded, and 9,010 Veteran contacts were linked to external data. For 3,331 contacts (37.0%), responders initiated a facility transport plan (FTP; self-transport). For 5,325 contacts (59.1%) responders contacted police department (PD) or emergency medical services (EMS) to facilitate transport. Among those with FTPs, 2,876 Veterans (86.3% of arranged FTPs, and 32.0% of all Veteran callers) were noted as arriving at a health care facility, versus 3,324 Veterans (62.9% of PD/EMS contacts and 36.9% of all Veteran callers) involving PD/EMS dispatch. Over 90% of Veterans in the cohort had a Veterans Health Administration (VHA) health encounter in the year prior to their first contact. Of the 769 previously unengaged Veterans, 765 lived for at least 3 months following their first contact, and 639 (83.5%) had a VHA encounter. Among identified Veterans, the age- and sex-adjusted rates for death by suicide, unintentional drug overdoses, and all causes were 370.8, 456.8, and 3,018.4 per 100,000, respectively. Among members of this high-risk cohort, self-transport resulted in arrival at health care facilities more frequently than PD/EMS transport. Although many engaged in some treatment posttransport, death rates remained high. Ongoing efforts are needed to identify novel ways to prevent suicide among this group of Veterans. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: We sought to elicit key informant (KI) perspectives regarding decisional needs of Veterans with mild traumatic brain injury (mTBI) who are initiating insomnia disorder and obstructive sleep apnea (OSA) treatment within the Veterans Health Administration (VHA) Polytrauma/TBI System of Care (PSC). Specifically, we sought to understand: (1) information regarding treatment options that Veterans with mTBI require in order to make an informed decision; and (2) values used to guide decision-making (ie, personally meaningful aspects of the decision used to compare treatment options)., Setting: Nationwide VHA PSC sites., Participants: Clinicians included VHA providers and policymakers involved in the management of mTBI and/or sleep disorders in the VHA PSC (n = 29). Veterans included those with a clinician-confirmed mTBI who received care for insomnia disorder and/or OSA within the past year (n = 20)., Design: Semi-structured interviews with the 49 KIs were recorded and transcribed verbatim. Themes were identified using a descriptive and interpretive approach to qualitative analysis., Main Measures: Not applicable., Results: Informational needs identified by both KI groups included information regarding outcomes and downsides of treatment, accessible delivery, treatment candidates, description of diagnosis, and level of commitment. Values used to guide decision-making for both insomnia disorder and OSA treatment included benefits, downsides, and availability of treatments. Values used to decide on insomnia treatments alone included time commitment, intrinsic management of sleep, beliefs regarding mental health treatment, and time course of benefit. Values used to decide on OSA treatment alone included intrusiveness of the treatment, appearance, and impact on bed partners., Conclusions: The current study revealed the decisional needs of Veterans with mTBI who are initiating sleep disorder treatment. Findings can inform the development of decision aids and other efforts aimed at promoting patient-centered management of comorbid mTBI and sleep disorders, thereby improving care quality and clinical outcomes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Veterans receiving inpatient psychiatric services with limitations in activities of daily living (ADLs) benefit from occupational therapy, yet disparities in access are unknown., Objective: To investigate whether ADL limitations, an indicator of occupational therapy need, was associated with inpatient psychiatric occupational therapy utilization in the Veterans Health Administration (VHA) and whether this relationship differs by facility characteristics., Design: Secondary analysis of VHA data. Modified Poisson regression modeled occupational therapy utilization as a function of ADL limitations, facility characteristics, and covariates. Interactions estimated whether the relationship between ADL limitations and occupational therapy utilization differed across facility characteristics., Setting: VHA inpatient psychiatric setting., Participants: Veterans receiving VHA inpatient psychiatric care from 2015 to 2020 (N = 133,844)., Outcomes and Measures: Occupational therapy utilization., Results: Veterans with ADL limitations were more likely to receive occupational therapy. Veterans receiving care in facilities with higher complexity and greater inpatient psychiatric care quality were more likely to receive occupational therapy. Additionally, Black veterans were less likely to receive occupational therapy relative to their White, non-Hispanic counterparts. Interactions indicated that the extent to which ADL limitations drove access to occupational therapy utilization was weaker within facilities with higher complexity and care quality., Conclusions and Relevance: Veterans with ADL limitations were more likely to access inpatient psychiatric occupational therapy, suggesting that such services are generally allocated to veterans in need. However, findings indicate disparities in access across patient-level (e.g., Black race) and facility-level (e.g., facility complexity) factors, informing efforts to eliminate barriers to accessing these valuable services. Plain-Language Summary: This is the first study, to our knowledge, to examine disparities in access to inpatient psychiatric occupational therapy in the Veterans Health Administration (VHA). The study findings show that access to inpatient psychiatric occupational therapy is partly driven by the needs of the patient. However, nonclinical factors, such as a patient's race and the characteristics of the facility at which they receive care (complexity, number of psychiatric beds available, and the quality of psychiatric care), are also important drivers of access. Identifying factors influencing access to these valuable services is the first step in developing strategies that reduce barriers to access for veterans in need., (Copyright © 2024 by the American Occupational Therapy Association, Inc.)

Objective: To identify distinct subgroups of veterans with mild traumatic brain injury (mTBI) based on configurations of postconcussive symptom (PCS) endorsement, and to examine predictors of subgroup membership., Setting: Outpatient Veterans Health Administration (VHA)., Participants: Veterans with clinician-confirmed mTBI who completed the Neurobehavioral Symptom Inventory (NSI), determined using the Comprehensive Traumatic Brain Injury Evaluation database. Individuals who tended to overreport symptoms were excluded via an embedded symptom validity scale., Design: Retrospective cohort study leveraging national VHA clinical data from 2012 to 2020. Latent class analysis (LCA) with a split-sample cross-validation procedure was used to identify subgroups of veterans. Multinomial logistic regression was used to examine predictors of subgroup membership., Main Measures: Latent classes identified using NSI items., Results: The study included 72 252 eligible veterans, who were primarily White (73%) and male (94%). The LCA supported 7 distinct subgroups of veterans with mTBI, characterized by diverging patterns of risk for specific PCS across vestibular (eg, dizziness), somatosensory (eg, headache), cognitive (eg, forgetfulness), and mood domains (eg, anxiety). The most prevalent subgroup was Global (20.7%), followed by Cognitive-Mood (16.3%), Headache-Cognitive-Mood (H-C-M; 16.3%), Headache-Mood (14.2%), Anxiety (13.8%), Headache-Sleep (10.3%), and Minimal (8.5%). The Global class was used as the reference class for multinomial logistic regression because it was distinguished from others based on elevated risk for PCS across all domains. Female (vs male), Black (vs White), and Hispanic veterans (vs non-Hispanic) were less likely to be members of most subgroups characterized by lesser PCS endorsement relative to the Global class (excluding Headache-Mood)., Conclusion: The 7 distinct groups identified in this study distill heterogenous patterns of PCS endorsement into clinically actionable phenotypes that can be used to tailor clinical management of veterans with mTBI. Findings reveal empirical support for potential racial, ethnic, and sex-based disparities in PCS among veterans, informing efforts aimed at promoting equitable recovery from mTBI in this population., Competing Interests: The authors declare no conflicts of interest.

Objective: To understand factors influencing adherence to recommended treatment for insomnia and obstructive sleep apnea (OSA) among Veterans with mild traumatic brain injury (mTBI)., Method: Semi-structured interviews ( n  = 49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach., Results: Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., cognitive challenges), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support)., Conclusions: Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population.

Objective: The purpose of this study will be to determine the efficacy of low intensity lower extremity resistance training with and without blood flow restriction (BFR) on quadriceps muscle strength and thickness in veterans with advanced multiple sclerosis (MS)., Methods: This will be an assessor-blinded, 2-group (1 to 1 allocation) randomized controlled trial targeting an enrollment of 58 participants with advanced MS as defined by Patient-Determined Disease Steps scale levels 4 to 7. Both groups will complete 10 weeks of twice weekly low-load resistance training (20%-30% of 1-repetition max) targeting knee and hip extension, knee flexion, and ankle plantarflexion. The intervention group will perform all training using BFR, with limb occlusion pressures between 60% and 80% of maximal limb occlusion pressure. Primary outcomes will be quadriceps muscle strength and thickness. Secondary outcomes will include knee flexion and ankle plantarflexion strength, functional mobility, physical activity, and patient-reported measures. All outcomes will be assessed at baseline before the intervention, immediately after the intervention, and at a 2-month follow-up assessment. The change between groups postintervention and after the 2-month follow-up will be reported for all outcomes. All analyses will assume a 2-sided test of hypothesis (α = .05)., Impact: There is very little evidence for the efficacy of exercise interventions in people with MS who have advanced mobility disability. Resistance training with BFR may be an important approach for people with advanced MS who may not tolerate more conventional, moderate-to-high intensity resistance training. The results of this study will inform clinicians regarding exercise decisions for people with advanced MS and future investigations on the role of BFR in people with MS., (© Published by Oxford University Press on behalf of the American Physical Therapy Association 2024.)

Background: Individuals with a history of moderate-severe traumatic brain injury (TBI) experience a significantly higher prevalence of insomnia compared to the general population. While individuals living with TBI have been shown to benefit from traditional insomnia interventions (e.g., face-to-face [F2F]), such as Cognitive Behavioral Therapy for Insomnia (CBTI), many barriers exist that limit access to F2F evidence-based treatments. Although computerized CBT-I (CCBT-I) is efficacious in terms of reducing insomnia symptoms, individuals with moderate-severe TBI may require support to engage in such treatment. Here we describe the rationale, design, and methods of a randomized controlled trial (RCT) assessing the efficacy of a guided CCBT-I program for reducing insomnia symptoms for participants with a history of moderate-severe TBI., Methods: This is an RCT of a guided CCBT-I intervention for individuals with a history of moderate-severe TBI and insomnia. The primary outcome is self-reported insomnia severity, pre- to post-intervention. Exploratory outcomes include changes in sleep misperception following CCBT-I and describing the nature of guidance needed by the Study Clinician during the intervention., Conclusion: This study represents an innovative approach to facilitating broader engagement with an evidence-based online treatment for insomnia among those with a history of moderate-severe TBI. Findings will provide evidence for the level and nature of support needed to implement guided CCBT-I. Should findings be positive, this study would provide support for a strategy by which to deliver guided CCBT-I to individuals with a history of moderate-severe TBI., Competing Interests: Declaration of competing interest Dr. Brenner reports grants from the VA, DOD, NIH, and the State of Colorado, editorial renumeration from Wolters Kluwer, and royalties from the American Psychological Association and Oxford University Press. In addition, she consults with sports leagues via her university affiliation. Dr. Forster reports grants from the VA, DOD and NIH., (Copyright © 2023. Published by Elsevier Inc.)

Study Objectives: We elicited perspectives of clinical stakeholders and Veterans regarding barriers and facilitators to implementing shared decision-making (SDM) for comorbid mild traumatic brain injury (mTBI) and sleep disorders in the Veterans Health Administration. We also compared the perspectives of clinical stakeholders and Veterans regarding determinants of SDM., Methods: Semistructured interviews were conducted with 29 clinical stakeholders and 20 Veterans (n = 49). Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders (insomnia disorder, obstructive sleep apnea). Veterans included those with a clinician-confirmed mTBI who received care for insomnia disorder and/or obstructive sleep apnea within the past year. Themes were identified using a descriptive and interpretive approach to qualitative analysis. We compared results across clinical stakeholders and Veterans., Results: Barriers to implementing SDM were identified by both groups at the patient (eg, mTBI sequalae), provider (eg, deprioritization of Veteran preferences), encounter (eg, time constraints), and facility levels (eg, reduced care access). Similarly, both groups identified facilitators at the patient (eg, enhanced trust), provider (eg, effective communication), encounter (eg, decision support), and facility levels (eg, mitigating access barriers). Integrated services and provider discontinuity were factors identified by clinical stakeholders and Veterans alone, respectively., Conclusions: Our study revealed factors shaping the implementation of SDM at the levels of the patient, provider, encounter, and facility. Findings can inform the development of strategies aimed at implementing SDM for comorbid mTBI and sleep disorders, promoting patient-centered care and enhancing clinical outcomes., Citation: Kinney AR, Brenner LA, Nance M, et al. Factors influencing shared decision-making for insomnia and obstructive sleep apnea treatment among Veterans with mild traumatic brain injury. J Clin Sleep Med . 2024;20(5):801-812., (© 2024 American Academy of Sleep Medicine.)

Background: Bright light therapy (BLT) is efficacious for seasonal and non-seasonal depression. However, the current state of BLT use in practice is unknown, impeding efforts to identify and address utilization gaps. This study's objective was to investigate BLT delivery in a nationwide U.S. healthcare system., Methods: This was a retrospective observational study of electronic medical records from all veterans who received outpatient mood disorder-related care in the Veterans Health Administration (VHA) from October 2008 through September 2020. BLT delivery was measured through the placement of light box consults., Results: Of the 3,442,826 veterans who received outpatient mood disorder care, only 57,908 (1.68 %) received a light box consult. Consults increased by 548.44 % (99.9 % credible interval: 467.36 %, 638.74 %) over the timeframe and displayed a robust yearly cycle that peaked on either December 21st or December 22nd. Past mental health treatment for a mood disorder was associated with a higher probability of a consult (relative risk = 4.79, 99.9 % CI: 4.21, 5.60). There was low representation related to veteran age, gender, race, and ethnicity., Limitations: No information on patients who declined light boxes or actual light box use following consult placement., Conclusions: Outpatient BLT delivery for mood disorders in the VHA remains low, despite significant growth over the past decade. It also displays a strong seasonal rhythm that peaks on the winter solstice, suggesting a limited focus on seasonal depression and a suboptimal reactive approach to changing sunlight. Overall, there exists ample opportunity for novel implementation efforts aimed at increasing utilization of BLT., Competing Interests: Declaration of competing interest The authors have no known conflicts of interest to disclose., (Published by Elsevier B.V.)

Purpose: Accidental death is a leading cause of mortality among military members and Veterans; however, knowledge is limited regarding time-dependent risk following deployment and if there are differences by type of accidental death., Methods: Longitudinal cohort study (N = 860,930) of soldiers returning from Afghanistan/Iraq deployments in fiscal years 2008-2014. Accidental deaths (i.e., motor vehicle accidents [MVA], accidental overdose, other accidental deaths), were identified through 2018. Crude and age-adjusted mortality rates, rate ratios, time-dependent hazard rates and trends postdeployment were compared across demographic and military characteristics., Results: During the postdeployment observation period, over one-third of deaths were accidental; most were MVA (46.0 %) or overdoses (37.9 %). Across accidental mortality categories (all, MVA, overdose), younger soldiers (18-24, 25-29) were at higher risk compared to older soldiers (40+), and females at lower risk than males. MVA death rates were highest immediately postdeployment, with a significant decreasing hazard rate over time (annual percent change [APC]: -6.5 %). Conversely, accidental overdose death rates were lowest immediately following deployment, with a significant increasing hazard rate over time (APC: 9.9 %)., Conclusions: Observed divergent trends in risk for the most common types of accidental deaths provide essential information to inform prevention and intervention planning for the immediate postdeployment transition and long-term., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Rachel Sayko Adams, PhD, MPH reports financial support was provided by grants from NIH, Henry Jackson Foundation, and a VA IPA. Jeri Forster, PhD reports financial support was provided by grants from the VA, DoD and NIH. Claire Hoffmire, PhD reports financial support was provided by grants from the VA and NIH. Colin Walsh, MD reports financial support was provided by grants from NIH, and US Food and Drug Admin. Mary Jo Larson, PhD reports financial support was provided by grants from the NIH, USU and DoD. Jaimie Gradus, PhD reports financial support was provided by grants from the VA, DoD, and NIH. Lisa A. Brenner, PhD reports financial support was provided by VA, DoD, NIH, and the State of Colorado. Colin Walsh MD reports financial support was provided by the Military Suicide Research Consortium, Wellcome Leap, Selby Stead Fund, Vanderbilt Univ. Medical Center, TN Department of Health, Southeastern Home Office Underwriters Ass., Hannover Re., and holding equity in Sage AI outside the submitted work. Lisa Brenner, PhD reports financial support was provided by Editorial renumeration from Wolters Kluwer, royalties from the American Psychological Association and Oxford Unv., and financial support was provided by Consults with sports leagues via her university affiliation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Total hip arthroplasty (THA) is a common orthopedic procedure that alleviates pain for millions of individuals. Yet, persistent physical function deficits, perhaps associated with movement compensations, are observed after THA. These deficits negatively affect quality of life and health for many individuals. Functional strength integration (FSI) techniques combine muscle strength training with specific movement retraining to improve physical function. This study aimed to determine if FSI would improve functional performance through remediation of movement compensations for individuals after THA., Methods: A double-blind randomized controlled trial was conducted. Ninety-five participants were randomized to either the FSI or control (CON) group for an 8-week intervention. The FSI protocol included exercise to improve muscular control and stability around the hip to minimize movement compensation during daily activity. The CON protocol included low-load resistance exercise, range-of-motion activities, and patient education. Functional performance, muscle strength, and self-reported outcomes were measured preoperatively, midway and after intervention, and 6 months after THA. Change from preoperative assessment to each time point was measured, and between-group differences were assessed., Results: There were minimal differences in outcomes between groups at the first postoperative assessment. There were no statistically significant between-group differences in the later assessments, including the primary endpoint. Both groups improved functional outcomes throughout the study period., Conclusion: The FSI intervention did not result in greater improvements in function after THA compared to the CON intervention. Future work should further investigate additional biomechanical outcomes, timing of the FSI protocol, effective dosing, and patient characteristics predictive of success with FSI., Impact: Recovery after THA is complex, and individuals after THA are affected by persistent movement deficits that affect morbidity and quality of life. The present study suggests that either approach to THA rehabilitation could improve outcomes for patients, and that structured rehabilitation programs may benefit individuals after THA., (Published by Oxford University Press on behalf of American Physical Therapy Association 2023.)

Despite efforts to identify risk factors associated with suicidal ideation (SI), less work has been conducted to highlight protective factors to promote prevention. Perceived social support has been shown to positively impact a wide range of psychological outcomes; however, prior efforts exploring whether perceived social support moderates the relationship between mental health (MH) symptoms and current SI among men and women have been hampered by limitations. To address knowledge gaps, data from the Comparative Health Assessment Interview Research Study was used to evaluate whether (a) perceived social support moderates the relationship between mental health symptoms (posttraumatic stress, anxiety, alcohol use, depressive) and current SI among veterans and nonveterans; (b) the strength of this moderating effect varies by gender and veteran status; and (c) the strength of this moderating effect varies by social support source (significant other, friend, family). Results suggest that perceived social support is more protective against SI for those with lower levels of mental health symptoms (≤ 25th percentile) than for those with higher symptom levels (≥ 75th percentile). Findings were largely consistent across study groups, support sources, and mental health symptoms examined; however, a significant moderating effect on the alcohol use-SI relationship was only observed for veteran men. Those with a lower mental health symptom severity may receive more benefit from strategies aimed at increasing perceived social support compared to those with higher symptom severity. Research is needed to match protective factors to individual phenotypes, with the goal of engaging those living with SI in more effective interventions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Military veterans account for 8% of homeless individuals living in the United States. To highlight associations between history of homelessness and the gut microbiome, we compared the gut microbiome of veterans who reported having a previous experience of homelessness to those from individuals who reported never having experienced a period of homelessness. Moreover, we examined the impact of the cumulative exposure of prior and current homelessness to understand possible associations between these experiences and the gut microbiome. Microbiome samples underwent genomic sequencing and were analyzed based on alpha diversity, beta diversity, and taxonomic differences. Additionally, demographic information, dietary data, and mental health history were collected. A lifetime history of homelessness was found to be associated with alcohol use disorder, substance use disorder, and healthy eating index compared to those without such a history. In terms of differences in gut microbiota, beta diversity was significantly different between veterans who had experienced homelessness and veterans who had never been homeless ( P = 0.047, weighted UniFrac), while alpha diversity was similar. The microbial community differences were, in part, driven by a lower relative abundance of Akkermansia in veterans who had experienced homelessness (mean; range [in percentages], 1.07; 0-33.9) compared to veterans who had never been homeless (2.02; 0-36.8) ( P = 0.014, ancom-bc2). Additional research is required to facilitate understanding regarding the complex associations between homelessness, the gut microbiome, and mental and physical health conditions, with a focus on increasing understanding regarding the longitudinal impact of housing instability throughout the lifespan.IMPORTANCEAlthough there are known stressors related to homelessness as well as chronic health conditions experienced by those without stable housing, there has been limited work evaluating the associations between microbial community composition and homelessness. We analyzed, for the first time, bacterial gut microbiome associations among those with experiences of homelessness on alpha diversity, beta diversity, and taxonomic differences. Additionally, we characterized the influences of diet, demographic characteristics, military service history, and mental health conditions on the microbiome of veterans with and without any lifetime history of homelessness. Future longitudinal research to evaluate the complex relationships between homelessness, the gut microbiome, and mental health outcomes is recommended. Ultimately, differences in the gut microbiome of individuals experiencing and not experiencing homelessness could assist in identification of treatment targets to improve health outcomes., Competing Interests: Dr. Hoisington reports grants from the VA, DOD, and NIH. Dr. Holliday reports grants from the VA, DOD, American Psychological Association, and NIH. Dr. Forster reports grants from the VA, DOD, NIH, and the state of Colorado. Dr. Postolache reports current support from the VA and NIH and the DC Department of Behavioral Health, Washington, DC. In the past, he was also funded by the American Foundation for Suicide Prevention, NARSAD, and FDA. Dr. Lowry is a member of the faculty of the Integrative Psychiatry Institute, Boulder, CO, USA; the Institute for Brain Potential, Los Banos, CA, USA; and Intelligent Health, Ltd., Reading, UK, and reports grants from the VA, NIH, NSF, and Institute for Cannabis Research. Dr. Brenner reports grants from the VA, DOD, NIH, and the state of Colorado; editorial renumeration from Wolters Kluwer; and royalties from the American Psychological Association, Oxford University Press, and the Rand Corporation. In addition, she consults with sports leagues via her university affiliation.

More than half of older adults are frail or prefrail in the United States, and hospital-associated deconditioning likely increases this risk. However, the impact of frailty on potential functional improvements after hospital discharge is poorly understood. We sought to identify the influence of baseline frailty on gait speed change in older adults receiving home health physical therapy (PT) after hospital discharge. The severity of frailty was assessed using Cardiovascular Health Study frailty criteria (weakness, slowness, weight loss, physical inactivity, and exhaustion). Gait speed was measured at baseline and 60-days post-hospital discharge. Upon admission to home health rehabilitation services, half of older adults (total N=250) were considered frail, with slowness (90%) and weakness (75%) being the most common characteristics. Older adults, whether pre-frail or frail, demonstrated similar and clinically meaningful improvements in gait speed after receiving home health rehabilitation for 60 days following hospital discharge. These results suggest that clinicians caring for older adults in the hospital can counsel both pre-frail and frail patients that, with home health rehabilitation, clinically significant improvements in function can be expected over the 2 months following discharge. Furthermore, we observed encouraging gait speed improvement with physical therapy following hospitalization in older adults. Results can inform anticipatory guidance on hospital discharge., Competing Interests: R.E. Burke is an Advisory Board Member, Mighty Health.

Background: Despite the common practice of intraarticular corticosteroid injections (ICSIs) for peripheral joint disease, little is known about their systemic effects on the hypothalamic-pituitary-gonadal axis., Objective: To assess the short-term effects of ICSIs on serum testosterone (T), luteinizing hormone (LH), and follicle stimulating hormone (FSH) levels together with changes in Shoulder Pain and Disability Index (SPADI) scores in a veteran population., Design: Prospective pilot study., Setting: Outpatient musculoskeletal clinic., Participants: Thirty male veterans, median age 50 (range 30-69) years., Interventions: Ultrasound-guided glenohumeral joint injection using 3 mL of 1% lidocaine HCl and 1 mL of 40 mg triamcinolone acetonide (Kenalog)., Outcome Measure(s): Serum T, FSH, and LH levels, Quantitative Androgen Deficiency in the Aging Male (qADAM), and SPADI questionnaires at baseline, 1, and 4 week(s) post procedure., Results: At 1 week post injection, serum T levels decreased by 56.8 ng/dL (95% confidence interval (CI): 91.8, 21.7, p = .002) compared with baseline. Between 1 and 4 weeks post injection, serum T levels increased by 63.9 ng/dL (95% CI: 26.5, 101.2, p = .001), recovering to near baseline levels. SPADI scores were reduced at 1 week (-18.3, 95% CI: -24.4, -12.1, p < .001) and 4 weeks (-14.5, 95% CI -21.1, -7.9, p < .001)., Conclusions: A single ICSI can temporarily suppress the male gonadal axis. Future studies are needed to evaluate for long-term effects of multiple injections at a single setting and/or higher corticosteroid doses on male reproductive axis function., (© 2023 American Academy of Physical Medicine and Rehabilitation.)

Objectives: Many older adults are discharged from skilled nursing facilities (SNFs) at functional levels below those needed for safe, independent home and community mobility. There is limited evidence explaining this insufficient recovery. The purpose of this secondary analysis was to determine predictors of physical function change following SNF rehabilitation., Design: Secondary analysis of a prospective observational cohort study., Setting and Participants: Across 4 SNFs, data were collected from 698 adults admitted for physical rehabilitation following an acute hospitalization., Methods: Physical function recovery was evaluated as change from admission to discharge in Short Physical Performance Battery (SPPB) scores (N = 698) and gait speed (n = 444). Demographic and clinical characteristics collected at admission served as potential predictors of physical function change. Following imputation, a standardized model selection estimator was calculated for predictors per physical function outcome. Predictor estimates and 95% CIs were calculated for each outcome model., Results: Higher cognitive scores [standardized β (β STD ) = 0.11, 95% CI: 0.0004, 0.20] and higher activities of daily living (ADL) independence at admission (β STD  = 0.22, 95% CI: 0.05, 0.34) predicted greater SPPB change; higher SPPB scores at admission (β STD  = -0.26, 95% CI: -0.35, -0.14) predicted smaller SPPB change. Higher ADL independence at admission (β STD  = 0.17, 95% CI: 0.01, 0.37) predicted greater gait speed change; faster gait speed at admission (β STD  = -0.30, 95% CI: -0.44, -0.15) predicted smaller gait speed change., Conclusions and Implications: Admission cognition, ADL independence, and physical function predicted physical function change following post-hospitalization rehabilitation. Inverse findings for admission physical function and ADL independence predictors suggest independence with ADL is not necessarily aligned with mobility-related function. Findings highlight that functional recovery is multifactorial and requires comprehensive assessment throughout SNF rehabilitation., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2023 AMDA – The Society for Post-Acute and Long-Term Care Medicine. All rights reserved.)

Background: Despite a growing evidence base that internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) is associated with decreased insomnia severity, its efficacy has been minimally examined in veterans., Objective: The objective of this study was to evaluate the efficacy of an unguided iCBT-I (Sleep Healthy Using the Internet [SHUTi]) among veterans., Methods: We conducted a single-blind, randomized controlled trial in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans eligible for Veterans Health Administration care. Participants were randomly assigned (1:1) to receive SHUTi (a self-guided and interactive program) or an Insomnia Education Website (IEW) that provided nontailored and fixed insomnia information. Web-based assessments were administered at baseline, postintervention, 6 months postintervention, and 1 year postintervention. The primary outcome was self-reported insomnia severity (Insomnia Severity Index [ISI]). Secondary outcomes were self-reported mental and physical health functioning (Veterans RAND 36-item Health Survey). Exploratory outcomes comprised sleep diary parameters., Results: Of the 231 randomized participants (mean age 39.3, SD 7.8 years; 170/231, 73.5% male sex; 26/231, 11.3% Black; 172/231, 74.5% White; 10/231, 4.3% multiracial; and 17/231, 7.4% other; 36/231, 15.6% Hispanic) randomized between April 2018 and January 2019, a total of 116 (50.2%) were randomly assigned to SHUTi and 115 (49.8%) to the IEW. In intent-to-treat analyses, SHUTi participants experienced significantly larger ISI decreases compared with IEW participants at all time points (generalized η 2 values of 0.13, 0.12, and 0.10, respectively; all P<.0001). These corresponded to estimated larger differences in changes of -3.47 (95% CI -4.78 to -2.16), -3.80 (95% CI -5.34 to -2.27), and -3.42 (95% CI -4.97 to 1.88) points on the ISI for the SHUTi group. SHUTi participants experienced significant improvements in physical (6-month generalized η 2 =0.04; P=.004) and mental health functioning (6-month and 1-year generalized η 2 =0.04; P=.009 and P=.005, respectively). Significant sleep parameter improvements were noted for SHUTi (all P<.05), though the pattern and magnitude of these reductions varied by parameter. No adverse events were reported., Conclusions: Self-administered iCBT-I was associated with immediate and long-term improvements in insomnia severity. Findings suggest that leveraging technology to meet insomnia treatment demands among veterans may be a promising approach., Trial Registration: ClinicalTrials.gov NCT03366870; https://clinicaltrials.gov/ct2/show/NCT03366870., (©Sarra Nazem, Sean M Barnes, Jeri E Forster, Trisha A Hostetter, Lindsey L Monteith, Emily B Kramer, Laurel A Gaeddert, Lisa A Brenner. Originally published in JMIR Mental Health (https://mental.jmir.org), 24.11.2023.)

Objective: To investigate whether participation restrictions, an indicator of need for occupational therapy (OT), was associated with outpatient OT utilization in the Veterans Health Administration (VHA) among Veterans with mild traumatic brain injury (mTBI), and whether this relation differs by facility characteristics., Design: In a secondary analysis of national VHA data, we used modified Poisson regression to model OT utilization (yes/no) as a function of participation restrictions (Mayo-Portland Adaptability Inventory Participation Index [M2PI]), facility characteristics, and covariates. Facility characteristics included complexity, geographic region, and self-reported access to specialty care. Covariates included prior OT utilization, sociodemographic factors, injury characteristics, and spatial access (eg, drive time). Interactions estimated whether the relation between participation restrictions and OT utilization differed across facility characteristics., Setting: Outpatient setting in the VHA., Participants: 8684 Veterans with a clinician-confirmed mTBI who received outpatient VHA care between 2012 and 2020 (N=8684)., Interventions: None., Main Outcome Measure(s): OT utilization was measured within a year of M2PI administration using VHA administrative data., Results: Many Veterans who did not receive OT reported participation limitations, indicating unmet need for OT (eg, 67% with leisure restrictions). Participation restrictions were associated with increased likelihood of receiving OT (risk ratio [RR]=1.01; 95% confidence interval [CI]=1.006-1.019), suggesting a tendency for Veterans' OT-related needs to be satisfied. However, interactions indicated that this was not the case among Veterans receiving care in lower complexity facilities, and those in the South. Veterans with longer drive times were less likely to receive OT (RR=0.82; 95% CI=0.744-0.904)., Conclusions: Participation restrictions were associated with OT utilization, yet many Veterans with mTBI who may have benefited did not receive such care. Specific barriers to accessing OT (eg, OT practitioner supply) should be investigated. Novel care models can ensure access to OT services among Veterans seeking care at less-resourced and/or geographically distant VHA facilities., (Published by Elsevier Inc.)

Objective: Skilled nursing facility rehabilitation is commonly required to address hospital-associated deconditioning among older adults with medical complexity. In skilled nursing facilities, standard-of-care rehabilitation focuses on low-intensity interventions, which are not designed to sufficiently challenge skeletal muscle and impart functional improvements. In contrast, a high-intensity resistance training approach (IntenSive Therapeutic Rehabilitation for Older NursinG homE Residents; i-STRONGER) in a single-site pilot study resulted in better physical function among patients in skilled nursing facilities. To extend this work, an effectiveness-implementation hybrid type 1 design, cluster-randomized trial will be conducted to compare patient outcomes between 16 skilled nursing facilities utilizing i-STRONGER principles and 16 Usual Care sites., Methods: Clinicians at i-STRONGER sites will be trained to deliver i-STRONGER as a standard of care using an implementation package that includes a clinician training program. Clinicians at Usual Care sites will continue to provide usual care. Posttraining, changes in physical performance (eg, gait speed, Short Physical Performance Battery scores) from patients' admission to discharge will be collected over a period of 12 months. The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework will be used to evaluate i-STRONGER effectiveness and factors underlying successful i-STRONGER implementation. Effectiveness will be evaluated by comparing changes in physical function between study arms. Reach (proportion of patients treated with i-STRONGER), adoption (proportion of clinicians utilizing i-STRONGER), implementation (i-STRONGER fidelity), and maintenance (i-STRONGER sustainment) will be concurrently quantified and informed by clinician surveys and focus groups., Impact: This effectiveness-implementation hybrid type 1 cluster-randomized trial has the potential to shift rehabilitation care paradigms in a nationwide network of skilled nursing facilities, resulting in improved patient outcomes and functional independence. Furthermore, evaluation of the facilitators of, and barriers to, implementation of i-STRONGER in real-world clinical settings will critically inform future work evaluating and implementing best rehabilitation practices in skilled nursing facilities., (Published by Oxford University Press on behalf of American Physical Therapy Association 2023.)

Background: Older adult Veterans are at high risk for adverse health outcomes following hospitalization. Since physical function is one of the largest potentially modifiable risk factors for adverse health outcomes, our purpose was to determine if progressive, high-intensity resistance training in home health physical therapy (PT) improves physical function in Veterans more than standardized home health PT and to determine if the high-intensity program was comparably safe, defined as having a similar number of adverse events., Methods: We enrolled Veterans and their spouses during an acute hospitalization who were recommended to receive home health care on discharge because of physical deconditioning. We excluded individuals who had contraindications to high-intensity resistance training. A total of 150 participants were randomized 1:1 to either (1) a progressive, high-intensity (PHIT) PT intervention or (2) a standardized PT intervention (comparison group). All participants in both groups were assigned to receive 12 visits (3 visits/week over 30 days) in their home. The primary outcome was gait speed at 60 days. Secondary outcomes included adverse events (rehospitalizations, emergency department visits, falls and deaths after 30 and 60-days), gait speed, Modified Physical Performance Test, Timed Up-and-Go, Short Physical Performance Battery, muscle strength, Life-Space Mobility assessment, Veterans RAND 12-item Health Survey, Saint Louis University Mental Status exam, and step counts at 30, 60, 90, 180 days post-randomization., Results: There were no differences between groups in gait speed at 60 days, and no significant differences in adverse events between groups at either time point. Similarly, physical performance measures and patient reported outcomes were not different at any time point. Notably, participants in both groups experienced increases in gait speed that met or exceeded established clinically important thresholds., Conclusions: Among older adult Veterans with hospital-associated deconditioning and multimorbidity, high-intensity home health PT was safe and effective in improving physical function, but not found to be more effective than a standardized PT program., (© 2023 The American Geriatrics Society. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Veterans accessing Department of Veterans Affairs (VA) Veterans Justice Program (VJP) services have high rates of depression, substance misuse, and posttraumatic stress disorder. Although factors that may confer risk for mental health sequelae among these Veterans have been identified (e.g., childhood abuse, combat exposure), limited research has examined report of military sexual trauma (MST) among Veterans accessing VJP services. As survivors of MST experience myriad chronic health conditions which necessitate identification and referral to evidence-based care, identifying MST survivors among those accessing VJP services may facilitate referral to appropriate services. We examined whether MST prevalence differed between Veterans with and without a history of VJP service use. Sex-stratified analyses were conducted with 1,300,252 male (13.34% accessing VJP) and 106,680 female (10.14% accessing VJP) Veterans. In crude models, male and female Veterans accessing VJP services were significantly more likely to screen positive for MST (PR = 3.35 and 1.82 respectively). Significance was maintained in models that adjusted for age, race/ethnicity, VA service use, and VA mental health use. VJP service settings may serve as a critical intercept for identifying male and female survivors of MST. Using a trauma-informed approach to screen for MST in VJP settings is likely warranted. Moreover, integration of MST programing into VJP settings may be beneficial., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Importance: Research to identify the direct and indirect associations of military-related traumatic brain injury (TBI) with suicide has been complicated by a range of data-related challenges., Objective: To identify differences in rates of new-onset mental health conditions (ie, anxiety, mood, posttraumatic stress, adjustment, alcohol use, and substance use disorders) among soldiers with and without a history of military-related TBI and to explore the direct and indirect (through new-onset mental health disorders) associations of TBI with suicide., Design, Setting, and Participants: This retrospective cohort study used data from the Substance Use and Psychological Injury Combat Study (SUPIC) database. Demographic, military, and health data from the Department of Defense within SUPIC were compiled and linked with National Death Index records to identify deaths by suicide. Participants included US Army soldiers who returned from an Afghanistan or Iraq deployment. Data were analyzed from September to December 2022., Exposures: Military-related TBI., Main Outcomes and Measures: The outcome of interest was suicide. Secondary outcomes were incidence of new-onset mental health conditions. Mediation analyses consisted of accelerated failure time (AFT) models in conjunction with the product of coefficients method. The 6 new-onset mental health diagnosis categories and the 2 or more categories variable were each considered separately as potential mediators; therefore, a total of 14 models plus the overall AFT model estimating the total effect associated with TBI in suicide risk were fit., Results: The study included 860 892 soldiers (320 539 soldiers [37.2%] aged 18-24 at end of index deployment; 766 454 [89.0%] male), with 108 785 soldiers (12.6%) with at least 1 documented TBI on their military health record. Larger increases in mental health diagnoses were observed for all conditions from before to after documented TBI, compared with the matched dates for those without a history of TBI, with increases observed for mood (67.7% vs 37.5%) and substance use (100% vs 14.5%). Time-to-suicide direct effect estimates for soldiers with a history of TBI were similar across mediators. For example, considering new-onset adjustment disorders, time-to-suicide was 16.7% faster (deceleration factor, 0.833; 95% CI, 0.756-0.912) than for soldiers without a history of TBI. Indirect effect estimates of associations with TBI were substantial and varied across mediators. The largest indirect effect estimate was observed through the association with new-onset substance use disorder, with a time to suicide 63.8% faster (deceleration factor, 0.372; 95% CI, 0.322-0.433) for soldiers with a history of TBI., Conclusions and Relevance: In this longitudinal cohort study of soldiers, rates of new-onset mental health conditions were higher among individuals with a history of TBI compared with those without. Moreover, risk for suicide was both directly and indirectly associated with history of TBI. These findings suggest that increased efforts are needed to conceptualize the accumulation of risk associated with multiple military-related exposures and identify evidence-based interventions that address mechanisms associated with frequently co-occurring conditions.

Knowledge regarding deaths due to suicide or alcohol- or drug-related causes may be limited by inconsistent and/or restrictive case definitions, resulting in concerns regarding validity of findings and underestimates of burden. In this proof-of-concept study, we assessed varying case definitions (suicide, alcohol-related, and drug-related mortality using underlying-cause-of-death (UCOD) versus multiple-cause-of-death (MCOD) International Classification of Diseases, Tenth Revision (ICD-10) codes) on the basis of counts and rates among Colorado veterans who died (2009-2020). Suicide, alcohol-related, or drug-related ICD-10 codes were identified, and 2 case definitions were compared: UCOD (qualifying ICD-10 code listed as the UCOD) and MCOD (qualifying ICD-10 code in any cause-of-death field). Of 109,314 decedents, the number of deaths and the age-adjusted mortality rate (per 100,000 persons) significantly increased when MCOD codes were included: n = 4,930 (110.3 deaths/100,000 persons) for UCOD versus n = 6,954 (138.4 deaths/100,000 persons) for MCOD. While rates of suicide mortality did not change, rates of alcohol-related mortality doubled with the more inclusive case definition: 1,752 (27.3 deaths/100,000 persons) for UCOD versus 3,847 (59.8 deaths/100,000 persons) for MCOD. Alcohol-use disorder codes accounted for 71% of additional alcohol-related deaths captured with the MCOD definition. Studies that rely on UCOD codes may be underestimating the burden of deaths, especially alcohol-related deaths. Increased effort is required to reevaluate current classifications of deaths associated with suicide, alcohol use, or drug use., (Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objective: Examine the association between insomnia symptom severity and suicidal ideation (SI), after adjusting for clinical comorbidity in veterans meeting diagnostic criteria for insomnia disorder., Methods: Secondary data analyses of psychometrically validated baseline assessments of depression, posttraumatic stress disorder (PTSD), and anxiety symptoms from two online insomnia intervention randomized clinical trials (n = 232; n = 80) were conducted. Multiple linear regression was used to determine the association between insomnia symptom severity and SI, after controlling for clinical comorbidity and demographics., Results: Insomnia symptom severity was significantly correlated with comorbid depression, PTSD, and anxiety symptoms in both cohorts and significantly correlated with SI in one. After controlling for demographics and clinical comorbidity, insomnia symptom severity was not significantly associated with SI in linear regression models., Conclusion: Findings extend insomnia-suicide research by providing evidence that insomnia symptom severity may not confer a unique risk for SI above comorbid mental health symptoms in veterans meeting diagnostic criteria for insomnia disorder., (© 2023 Wiley Periodicals LLC. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Background: Justice-involved Veterans experience notable risk for psychosocial stressors (e.g., homelessness) and psychiatric multimorbidity, which can result in complex clinical presentations. However, research examining how such factors coalesce to impact risk for suicide remains limited., Methods: We conducted a latent class analysis of 180,454 Veterans accessing Veterans Health Administration (VHA) justice-related services from 2005 to 2018., Results: A four-model class membership solution was identified. Among these classes, risk for suicide was highest among Veterans with greater psychiatric burden, with risk most notable among those with high VA service use. Veterans seeking healthcare primarily focused on substance use disorders or with low psychiatric burden and service use had a lower risk for suicide., Conclusions: Psychiatric multimorbidity is salient as it relates to suicide among Veterans accessing VHA justice-related services. Further evaluation of existing VHA services for this population and methods of augmenting and enhancing care for justice-involved Veterans with histories of co-occurring psychiatric conditions may be beneficial in facilitating suicide prevention efforts., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: To examine racial and ethnic differences in suicide and drug and opioid-related overdose deaths among a population-based cohort of military service members who were diagnosed with a mild traumatic brain injury (mTBI) during military service., Design: Retrospective cohort., Setting: Military personnel receiving care within the Military Health System between 1999 and 2019., Participants: In total, 356 514 military members aged 18 to 64 years, who received an mTBI diagnosis as their index TBI between 1999 and 2019, while on active duty or activated., Main Measures: Death by suicide, death by drug overdose, and death by opioid overdose were identified using International Classification of Diseases, Tenth Revision (ICD-10) codes within the National Death Index. Race and ethnicity were captured from the Military Health System Data Repository., Results: Overall crude rates were 38.67 per 100 000 person-years for suicide; 31.01 per 100 000 person-years for drug overdose death; and 20.82 per 100 000 person-years for opioid overdose death. Crude and age-specific rates for military members who self-identified as Other were higher than all other racial/ethnic groups for all 3 mortality outcomes. Adjusting for age, suicide rates for those classified as Other were up to 5 times that of other racial/ethnic groups for suicide, and up to 11 and 3.5 times that of other race/ethnicity groups for drug and opioid overdose death, respectively., Conclusion: Findings extend previous knowledge regarding risk for suicide and deaths by drug overdose among those with mTBI and highlight new important areas for understanding the impact of race and ethnicity on mortality. Methodological limitations regarding classification of race and ethnicity must be addressed to ensure that future research provides a better understanding of racial and ethnic disparities in suicide and drug overdose mortality among military members with TBI., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Efforts were focused on identifying differences in suicide rates and time-dependent hazard rate trends, overall and within age groups, by race and ethnicity among United States Army members who returned from an index deployment (October 2007 to September 2014). This retrospective cohort study was conducted using an existing longitudinal database, the Substance Use and Psychological Injury Combat Study (SUPIC). Demographic (e.g., race and ethnicity) and military data from the Department of Defense compiled within SUPIC, as well as Department of Veterans Affairs data were linked with National Death Index records (through 2018) to identify deaths by suicide including those that occurred after military service. The cohort included 860,930 Army Service members (Active Duty, National Guard, and Reserve). Age-adjusted (using the direct standardization method) and age-specific suicide rates per 100,000 person years were calculated and rate ratios (RR) were used for comparisons. Trends were evaluated using hazard rates over time since the end of individuals' index deployments. Among those aged 18-29 at the end of their index deployment, the suicide rate for American Indian/Alaskan Native (AI/AN) individuals was 1.51 times higher (95% confidence interval [CI]: 1.03, 2.14) compared to White non-Hispanic individuals (WNH), and lower for Hispanic and Black non-Hispanic (BNH) than for WNH individuals (RR = 0.65 [95% CI: 0.55, 0.77] and RR = 0.71 [95% CI: 0.61, 0.82], respectively). However, analyses revealed increasing trends in hazard rates post-deployment (≤ 6.5 years) within groups of Hispanic and BNH individuals (Average Annual Percent Change [APC]: 12.1% [95% CI: 1.3%, 24.1%] and 11.4% [95% CI: 6.9%, 16.0%], respectively) with a smaller, increase for WNH individuals (APC: 3.1%; 95% CI: 0.1%, 6.1%). Findings highlight key subgroups at risk for post-deployment suicide (i.e., WNH, AI/AN and younger individuals), as well as heterogeneous trends overtime, with rates and trends varying within race and ethnic groups by age groups. Post-deployment suicide prevention efforts that address culturally relevant factors and social determinants of health associated with health inequities are needed., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Objective: Bayesian meta-analyses offer several advantages over traditional approaches, including improved accuracy when using a small number of studies and enhanced estimation of heterogeneity. However, psychological trauma research has yet to see widespread adoption of these statistical methods, potentially due to researchers' unfamiliarity with the processes involved. The purpose of this article is to provide a practical tutorial for conducting random-effects Bayesian meta-analyses., Method: Explanations and recommendations are provided for completing the primary steps of a Bayesian meta-analysis, ranging from model specification to interpretation of results. Furthermore, an illustrative example is used to demonstrate the application of each step. In the example, results are synthesized from six studies included in a previously published systematic review (Holliday et al., 2020), with a combined sample size of 21,244,109, examining the association between posttraumatic stress disorder and risk of suicide in veterans and military personnel., Results: The posterior distributions for each model estimate, such as the pooled effect size and the heterogeneity parameter, are discussed and interpreted with regard to the probability of increased suicide risk., Conclusions: Our hope is that this tutorial, along with the provided data and code, facilitate the use of Bayesian meta-analyses in the study of psychological trauma. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Objective: Psychosocial factors, including combat-related distress (e.g., posttraumatic stress disorder [PTSD]), contribute to postconcussive symptoms (PCS) among veterans with mild traumatic brain injury (mTBI). However, research on risk factors for PCS has focused solely on life-threatening combat experiences, neglecting the morally injurious dimension of combat-related trauma and associated implications for treatment. Morally injurious events (MIEs) are associated with PTSD symptoms among veterans, a robust risk factor of PCS. Nonetheless, the interplay between MIEs, PTSD symptoms, and PCS remains poorly understood. We sought to investigate MIEs as an indirect risk factor for PCS among Veterans with mTBI., Method: This cross-sectional study of 145 veterans with mTBI used path analysis to investigate whether PTSD symptoms mediated the relationship between MIEs (transgressions and betrayals) and PCS (mood-behavioral, vestibular-sensory, and cognitive domains) among 145 veterans with mTBI. We used the Moral Injury Event Scale, PTSD Checklist-Civilian Version, and Neurobehavioral Symptom Inventory to measure MIEs, PTSD, and PCS, respectively., Results: Perceived transgressions were indirectly associated with mood-behavioral (β = .21, p = .005), vestibular-sensory (β = .17, p = .005), and cognitive PCS (β = .20, p = .005), as mediated by PTSD. Greater transgressions were associated with more severe PTSD (β = .27, p = .003), and greater PTSD was associated with more severe mood-behavioral (β = .79, p < .001), vestibular-sensory (β = .64, p < .001), and cognitive PCS (β = .73, p < .001). Betrayals were not indirectly associated with PCS., Conclusions: Findings offer preliminary support for responses to MIEs being a modifiable risk factor for PCS among veterans. Interventions designed to foster veterans' recovery by targeting the unique emotions and beliefs associated with MIEs may be indicated. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Objective: Kibler et al. (2009) reported that hypertension was related to PTSD independent of depression. These two conditions have significant diagnostic overlap. The present study sought to conceptually replicate this work with a veteran sample, using Bayesian estimation to directly update past results, as well as examine symptom severity scores in relation to hypertension., Method: This was a secondary analysis of data obtained from the United States-Veteran Microbiome Project. Lifetime diagnoses of PTSD and major depressive disorder (MDD) were obtained from a structured clinical interview and hypertension diagnoses were extracted from electronic medical records. PTSD and depressive symptom severity were obtained from self-report measures. Logistic regressions with Bayesian estimation were used to estimate the associations between hypertension and (a) psychiatric diagnostic history and (b) symptom severity scores., Results: Compared with veterans without lifetime diagnoses of either disorder, the PTSD-only group was estimated to have a 29% increase in hypertension risk, and the PTSD + MDD group was estimated to have a 66% increase in hypertension risk. Additionally, higher levels of PTSD symptom severity were associated with a higher risk of hypertension., Conclusion: PTSD diagnosis and symptom severity are uniquely associated with hypertension, independent of MDD or depressive symptom severity. These results support previous findings that PTSD might be a modifiable risk factor for the prevention and treatment of hypertension. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Introduction: Among women Veterans, firearms are the leading suicide means. This has prompted efforts to elucidate factors associated with women Veterans' firearm ownership. This cross-sectional study examined if deployment experiences were associated with firearm ownership among women Veterans and if safety-related beliefs mediated these associations., Methods: 492 previously deployed post-9/11 women Veterans participated in a national survey that included the Deployment Risk and Resilience Inventory-2, subscales of the Posttraumatic Cognitions Inventory and Posttraumatic Maladaptive Beliefs Scale, and firearm ownership questions. Path analysis was used., Results: Perceived threat during deployment was associated with firearm ownership, irrespective of safety-related beliefs. Indirect effects did not support that safety-related beliefs mediated relations between deployment experiences and firearm ownership. The other deployment experiences (sexual harassment, sexual assault, general harassment, combat experiences) were not indirectly associated with firearm ownership, nor were safety-related beliefs (negative cognitions about the world, threat of harm, beliefs about others' reliability and trustworthiness) directly associated with firearm ownership. In an exploratory serial mediation analysis, perceived threat during deployment mediated the association between combat experiences and firearm ownership. In a sensitivity analysis examining firearm acquisition following military service, results were similar, except the indirect effect of combat experiences upon firearm acquisition through perceived threat was not significant., Conclusion: Post-9/11 women Veterans' firearm acquisition and ownership may relate to specific deployment experiences, such as perceived threat; however, longitudinal studies are needed to fully ascertain this. Efforts to address firearm access among post-9/11 women Veterans may benefit from assessing heightened sense of danger during deployment., Competing Interests: Declaration of competing interest The authors report grant funding from the Department of Veterans Affairs (Monteith, Kinney, Holliday, Miller, Schneider, Hoffmire, Simonetti, Brenner, Forster), Department of Defense (Monteith, Hoffmire, Brenner, Holliday, Forster), National Institutes of Health (Brenner, Hoffmire, Forster), American Psychological Association (Monteith), and State of Colorado (Brenner). Dr. Brenner also reports editorial renumeration from Wolters Kluwer, and royalties from the American Psychological Association and Oxford University Press. In addition, she consults with sports leagues via her university affiliation., (Copyright © 2022. Published by Elsevier Ltd.)

Background: To date, knowledge is limited regarding time-dependent suicide risk in the years following return from deployment and whether such rates vary by military rank (i.e., enlisted, officer) or component (i.e., active duty, National Guard, reserve). To address these gaps in knowledge, the objectives of this study were to determine and compare postdeployment suicide rates and trends (percent change over time), and hazard rates for Army soldiers, by rank and component (measured at the end of the deployment)., Methods: Longitudinal cohort study of 860,930 Army soldiers returning from Afghanistan/Iraq deployment in fiscal years 2008-2014 from the Substance Use and Psychological Injury Combat study. Death by suicide was observed from the end of the first deployment in the study period through 2018 (i.e., the most recently available mortality data) for up to 11 years of follow-up. Analyses were conducted in 2021-2022., Results: Adjusting for age, lowest-ranking Junior Enlisted (E1-E4) soldiers had a suicide rate 1.58 times higher than Senior Enlisted (E5-E9)/Warrant Officers (95% CI [1.24, 2.01]) and 2.41 times higher than Officers (95% CI [1.78, 3.29]). Suicide rates among lower-ranking enlisted soldiers remained elevated for 11 years postdeployment. Overall and annual postdeployment suicide rates did not differ significantly across components. Comparisons across rank and component for females were generally consistent with the full cohort results., Conclusions: Lower-ranking enlisted soldiers had the highest rate of suicide, underscoring the importance of understanding rank as it relates to social determinants of health. For over a decade following Afghanistan/Iraq deployment, lower-enlisted rank during deployment was associated with an elevated rate of suicide; thereby suggesting that postdeployment prevention interventions targeting lower-ranking military members are warranted., (© 2022. The Author(s).)

Background: Independently, veterans and individuals with Parkinson's Disease (PD) are at increased risk for suicide. To our knowledge, the risk of suicide among veterans with PD has yet to be evaluated. This study aimed to examine the associations between PD and risk of suicide, as well as suicide means among those using Veteran Health Administration (VHA) services., Methods: Retrospective cohort study of individuals who used VHA services between 1/1/2001-12/31/2019. Cox proportional hazard models were used to estimate the hazard of suicide for those with PD relative to those without. A nested-case control study was carried out among the suicide decedents where logistic regression was used to assess the relationship between PD and suicide by firearms versus suicide by any other means., Results: The unadjusted hazard of death by suicide for those with a PD diagnosis, relative to those without, was 1.51 (95% CI: 1.32-1.72, p < 0.0001), and was still significant after controlling for age/gender, and psychiatric/chronic physical health diagnoses (HR: 1.50; 95% CI: 1.32-1.72, p < 0.0001; HR:1.21, 95% CI:1.06-1.38, p = 0.006, respectively). Compared to the non-PD cohort, the PD group also had higher rates of mood, anxiety, and psychotic disorders. There was no significant difference between the method of suicide for those with PD versus those without PD (p = 0.60). Most suicide deaths among both cohorts were firearm-related (PD = 78.9%, No-PD = 80.3%)., Conclusions: PD is associated with an elevated risk for suicide. Based on the high rate of deaths by firearm, increased efforts to facilitate lethal means safety among veterans is warranted., Competing Interests: Declaration of competing interest Dr. Brenner reports grants from the VA, DOD, NIH, and the State of Colorado, editorial renumeration from Wolters Kluwer and the Rand Corporation, and royalties from the American Psychological Association and Oxford University Press. In addition, she consults with sports leagues via her university affiliation. Dr. Forster reports grants from the VA, DOD, and NIH., (Published by Elsevier Ltd.)

Objective: Understand barriers and facilitators of implementing recommended practices for postconcussive sleep disturbance and headache, as outlined in the Veterans Administration/Department of Defense 2016 Clinical Practice Guideline (CPG) for mild traumatic brain injury (mTBI)., Design: Convergent parallel mixed methods., Setting: Ten national Veterans Health Administration (VHA) facilities., Participants: Twenty VHA stakeholders (14 clinicians; 4 researchers; 2 policymakers), 55% of whom were affiliated with a VHA polytrauma rehabilitation center (N=20)., Interventions: None., Main Outcome Measures: Stakeholders rated the quality of recommendations for sleep disturbance and headache using the Appraisal of Guidelines Research and Evaluation-Recommendations Excellence instrument. A descriptive analysis of item scores was performed to understand the following features of the recommendations: (1) clinical credibility (eg, evidence quality), (2) alignment with stakeholder values, and (3) implementability. We conducted semistructured interviews with stakeholders and used descriptive and interpretive analyses to reveal emergent themes. After analyzing the Appraisal of Guidelines Research and Evaluation-Recommendations Excellence and qualitative interview data, we synthesized the results into coherent conclusions (ie, meta-inferences) by comparing and contrasting respective findings., Results: Stakeholders highlighted that the mTBI CPG includes features that reflect clinical priorities (eg, alignment with veteran preferences), making it an appropriate standard of care and facilitating its implementation. However, stakeholders also identified that the design of the mTBI CPG, along with provider-level (eg, knowledge) and facility-level (eg, resources) factors, may create barriers for implementation. In addition to these potential barriers, stakeholders noted a lack of comprehensive and systematic efforts designed to promote the uptake of these recommendations. Findings also revealed stakeholder recommendations for addressing potential barriers (eg, decision support)., Conclusions: With the recent release of the 2021 mTBI CPG, decision makers are encouraged to incorporate information gathered from previous implementation efforts to promote adherence to updated recommendations. Study findings, including recommended changes suggested by stakeholders, offer information that can be leveraged to design such efforts and promote care quality and associated outcomes for veterans with mTBI., (Published by Elsevier Inc.)

Objective: Challenges associated with case ascertainment of traumatic brain injuries (TBIs) sustained during the Afghanistan/Iraq military operations have been widespread. This study was designed to examine how the prevalence and severity of TBI among military members who served during the conflicts were impacted when a more precise classification of TBI diagnosis codes was compared with the Department of Defense Standard Surveillance Case-Definition (DoD-Case-Definition)., Setting: Identification of TBI diagnoses in the Department of Defense's Military Health System from October 7, 2001, until December 31, 2019., Participants: Military members with a TBI diagnosis on an encounter record during the study window., Design: Descriptive observational study to evaluate the prevalence and severity of TBI with regard to each code set (ie, the DoD-Case-Definition and the more precise set of TBI diagnosis codes). The frequencies of index TBI severity were compared over time and further evaluated against policy changes., Main Measures: The more precise TBI diagnosis code set excludes the following: (1) DoD-only extender codes, which are not used in other healthcare settings; and (2) nonprecise TBI codes, which include injuries that do not necessarily meet TBI diagnostic criteria., Results: When comparing the 2 TBI classifications, the DoD-Case-Definition captured a higher prevalence of TBIs; 38.5% were classified by the DoD-Case-Definition only (>164 000 military members). 73% of those identified by the DoD-Case-Definition only were diagnosed with nonprecise TBI codes only, with questionable specificity as to whether a TBI occurred., Conclusion: We encourage the field to reflect on decisions made pertaining to TBI case ascertainment during the height of the conflicts. Efforts focused on achieving consensus regarding TBI case ascertainment are recommended. Doing so will allow the field to be better prepared for future conflicts, and improve surveillance, screening, and diagnosis in noncombat settings, as well as our ability to understand the long-term effects of TBI., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Homeless Veterans are at substantially elevated risk for suicide mortality; however, understanding of drivers of suicide in this population remains limited., Method: Building upon prior work, we conducted a retrospective chart review, comprised of a latent class analysis of 724,752 Veterans with use of Veterans Health Administration (VHA) homeless services 2005-2018., Results: A five-model class membership solution was identified. Among these classes, risk for suicide mortality was greatest among Veterans with the highest psychiatric burden and high VHA service use. Those experiencing moderate psychiatric burden or primarily experiencing substance use disorders also experienced elevated risk for suicide mortality relative to those with low burden and service use., Limitations: Models were specific to Veterans accessing VHA homeless services and may not generalize to those not using such services outside VHA care., Conclusions: Continued research and programing remain necessary to determine how to address mental health conditions and engage homeless Veterans in services to facilitate suicide prevention., (Published by Elsevier B.V.)

Background: Sleep problems are common among Veterans with mild traumatic brain injury (mTBI) and may contribute to participation restrictions. However, explanatory mechanisms underlying this relationship are poorly understood. Sleep problems are associated with post-concussive symptoms (e.g., headaches). In turn, post-concussive symptoms contribute to participation restrictions. We hypothesized that post-concussive symptom severity mediates the purported relationship between sleep problems and participation restrictions among Veterans with mTBI., Materials and Methods: This study was a retrospective analysis of clinical data among 8,733 Veterans with mTBI receiving Veterans Health Administration outpatient care. Sleep problems (yes/no) were identified using the sleep-related item from the Neurobehavioral Symptom Inventory (NSI). Post-concussive symptoms were measured using remaining NSI items. Participation restrictions were measured using the Mayo-Portland Adaptability Inventory Participation Index. We specified a latent variable path model to estimate relationships between: (1) sleep problems and three latent indicators of post-concussive symptoms [vestibular-sensory (e.g., headache)]; mood-behavioral [e.g., anxiety]; cognitive [e.g., forgetfulness]); and, (2) the three latent indicators of post-concussive symptoms and two latent indicators of participation restrictions (social and community participation [e.g., leisure activities]; productivity [e.g., financial management]). We examined the indirect effects of sleep problems upon participation restrictions, as mediated by post-concussive symptoms. Estimates were adjusted for sociodemographic factors (e.g., age), injury characteristics (e.g., blast), and co-morbid conditions (e.g., depression)., Results: 87% of Veterans reported sleep problems. Sleep problems were associated with greater social and community participation restrictions, as mediated by mood-behavioral ( β  = 0.41, p  < 0.001) and cognitive symptoms ( β  = 0.13, p  < 0.001). There was no evidence that vestibular-sensory symptoms mediated this relationship ( β  = -0.01, p  = 0.48). Sleep problems were associated with greater productivity restrictions, as mediated by vestibular-sensory ( β  = 0.16, p  < 0.001) and cognitive symptoms ( β  = 0.14, p  < 0.001). There was no evidence that mood-behavioral symptoms mediated this relationship ( β  = 0.02, p  = 0.37)., Discussion: Findings suggest that evidence-based sleep treatment should occupy a prominent role in the rehabilitation of Veterans with mTBI. Indirect effects of sleep problems differed when considering impact on social and community participation vs. productivity, informing individualized rehabilitative care for Veterans with mTBI., 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., (This work is authored by Adam R. Kinney, Xiang-Dong Yan, Alexandra Lindsay Schneider, Samuel King, Jeri E. Forster, Nazanin Bahraini and Lisa Anne Brenner on behalf of the U.S. Government and as regards Dr. Kinney, Dr. Yan, Dr. Schneider, Dr. King, Dr. Forster, Dr. Bahraini and Dr. Brenner, and the U.S. Government, is not subject to copyright protection in the United States. Foreign and other copyrights may apply.)