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Objective: Clinicians, patients, and researchers need benchmarks to index individual-level clinically significant change (CSC) to guide decision making and inferences about treatment efficacy. Yet, there is no consensus best practice for determining CSC for posttraumatic stress disorder (PTSD) treatments. We examined criterion-related validity of the most common approach-Jacobson and Truax's (J&T; 1991) procedures for indexing CSC. We generated and compared four methods of calculating the J&T indices of CSC (two sets of sample-specific inputs, putatively norm-referenced benchmarks, and a combination of sample-specific and norm-referenced criteria) with respect to their association with a criterion index of quality of life (QoL)., Method: Participants were 91 women Veterans enrolled in a randomized clinical trial for PTSD who completed self-report measures on PTSD symptoms and various domains of QoL and functioning, pre- and posttreatment. For each of the four methods used to calculate CSC, the QoL composite was regressed onto the CSC categories., Results: All methods explained large variance in change in QoL. Across all methods, participants categorized as unchanged had smaller changes in QoL, compared with those who improved or had probable recovery. The norm-referenced benchmarks accounted for the relatively largest amount of variance in QoL, but categorized the fewest patients as having made CSC., Conclusions: The J&T methodology for indexing CSC in PTSD symptoms has criterion-related validity, and a norm-referenced benchmark appears to be the most potent. However, the norm-referenced parameters may be overly specific, potentially leading to an underestimate of improvement. Research is needed to test the generalizability of these results. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Introduction: Lesbian, gay, and bisexual (LGB) individuals and Veterans are more likely to report current smoking than the general adult population in the United States. The Minority Stress Model may explain the high prevalence of cigarette smoking among LGB individuals, who experience unique interpersonal (e.g., discrimination) and intrapersonal (e.g., identity concealment) stressors related to their minoritized sexual orientation., Aims and Methods: This study assessed whether three types of stressors (interpersonal, intrapersonal, and LGB-specific military) were associated with past-year smoking among LGB Veterans. Veterans were recruited online for a prospective cohort study. We conducted secondary data analysis of baseline surveys collected from 2019 to 2020. The study sample included cisgender, LGB Veterans (n = 463). Adjusted nested multivariable logistic regression models were used to estimate the association of each stressor with past-year cigarette smoking., Results: Participants were mostly male (54.0%), non-Hispanic white (82.1%), and at least a college graduate (58.5%). LGB Veterans who were younger, had lower levels of education, income, and healthcare coverage, higher general stressors, and post-traumatic stress disorder and depression symptoms were more likely to smoke in the past year (n = 98, 21.2%). The adjusted odds of past-year smoking were higher among those who reported higher levels of harassment (aOR = 1.13, 95% confidence interval [CI]: 1.01 to 1.26), victimization (aOR = 1.13, 95% CI: 1.02 to 1.43), and family rejection (aOR = 1.13, 95% CI: 1.08 to 1.36)., Conclusions: Multiple interpersonal stressors were associated with past-year smoking, highlighting the need to intervene on these stressors. Future interventions should aim to address policies that reduce prejudice against LGB Veterans, while helping those who smoke identify and develop positive coping skills that support cessation., Implications: Our findings contribute to the growing body of literature on tobacco use disparities among LGB individuals, particularly LGB Veterans. Results of this analysis provide some evidence for the Minority Stress Model as a conceptual model for understanding and intervening in disparities in smoking prevalence among LGB Veterans., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Women with lower extremity amputations (LEAs) tend to have poorer prosthesis-related outcomes than men, although the literature is sparse. To our knowledge, there are no prior studies examining prosthesis-related outcomes of women veterans with LEAs., Objective: To examine gender differences (overall and by type of amputation) among veterans who underwent LEAs between 2005 and 2018, received care at the Veterans Health Administration (VHA) prior to undergoing amputation, and were prescribed a prosthesis. It was hypothesized that compared to men, women would report lower satisfaction with prosthetic services, poorer prosthesis fit, lower prosthesis satisfaction, less prosthesis use, and worse self-reported mobility. Furthermore, it was hypothesized that gender differences in outcomes would be more pronounced among individuals with transfemoral than among those with transtibial amputations., Design: Cross-sectional survey. Linear regressions were used to assess overall gender differences in outcomes and gender differences based on type of amputation in a national sample of veterans., Setting: VHA medical centers., Participants: The sample consisted of 449 veterans who self-identified their gender (women = 165, men = 284) with transtibial (n = 236), transfemoral (n = 135), and bilateral LEAs (n = 68) including all amputation etiologies., Interventions: Not applicable., Main Outcome Measures: The Orthotics and Prosthetics User's Survey, Trinity Amputation and Prosthesis Experiences Scale, and Prosthetic Limb Users Survey of Mobility-Short Form were used to assess satisfaction with prosthetic services, prosthesis fit, prosthesis satisfaction, prosthesis use, and self-reported mobility., Results: Women had poorer self-reported mobility than men (d = -0.26, 95% confidence interval -0.49 to -0.02, p < .05); this difference was small. There were no statistically significant gender differences in satisfaction with prosthetic services, prosthesis fit, prosthesis satisfaction, daily hours of prosthesis use, or by amputation type., Conclusions: Contrary to the hypothesis, prosthesis-related outcomes were similar between men and women with LEAs. Minimal differences may in part be due to receiving care from the VHA's integrated Amputation System of Care., (© 2023 American Academy of Physical Medicine and Rehabilitation.)

Purpose: To examine differences across gender and sexual orientation in cigarette smoking motives and stages of change in smoking cessation among Veterans., Design: Secondary data analysis of cross-sectional baseline surveys from a prospective cohort study., Setting: United States, self-administered online survey., Participants: Cisgender Veterans who reported past-year smoking (N = 146); 66.4% identified as lesbian, gay, or bisexual and 52.1% were men., Measures: Smoking motives (i.e., social, self-confidence, boredom relief, and affect regulation), with higher scores indicating stronger motivation to smoke. Stages of change categories included precontemplation, contemplation/preparation, and action/maintenance., Analysis: Analyses were stratified by gender and sexual orientation. Age-adjusted linear regression models estimated differences in smoking motives scores and multinomial logistic regression models estimated differences in stages of change categories relative to the precontemplation stage (reference category)., Results: In this Veteran sample, gay men reported higher social smoking motives vs heterosexual men (β = 1.50 (95% CI: .04, 2.97), P -value = .045) and higher boredom relief smoking motives vs bisexual men (β = 1.53 (95% CI: .06, 2.29), P -value = .041) in age-adjusted models. Lesbian women were more likely to be in the action/maintenance stage relative to the precontemplation stage when compared to both heterosexual women (aRRR = 4.88 (95% CI: 1.00, 23.79) P -value = .050) and bisexual women (aRRR = 16.46 (95% CI: 2.12, 127.57), P -value = .007) after adjusting for age., Conclusion: Smoking cessation interventions may benefit from enhancing peer support for gay men. Given bisexual and heterosexual women were in less advance stages of change, there may be a greater need for motivational interventions to encourage quitting and additional support to assist with cessation efforts. Overall, findings highlight the diversity of cigarette use within LGB communities., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The Health for Every Veteran Study is the first Veterans Health Administration-funded, nationwide study on lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) veterans' health that relies exclusively on primary recruitment methods. This study aimed to recruit 1600 veterans with diverse sexual and gender identities to study the mental health and health risk behaviors of this population. A growing body of literature highlights the health inequities faced by LGBTQ+ veterans when compared with their heterosexual or cisgender peer groups. However, there is little to no guidance in the health disparities literature describing the recruitment of LGBTQ+ veterans., Objective: This paper provides an overview of the recruitment methodology of Health for Every Veteran Study. We describe the demographics of the enrolled cohort, challenges faced during recruitment, and considerations for recruiting LGBTQ+ veterans for health research., Methods: Recruitment for this study was conducted for 15 months, from September 2019 to December 2020, with the goal of enrolling 1600 veterans evenly split among 8 sexual orientation and gender identity subgroups: cisgender heterosexual women, cisgender lesbian women, cisgender bisexual women, cisgender heterosexual men, cisgender gay men, cisgender bisexual men, transgender women, and transgender men. Three primary recruitment methods were used: social media advertising predominantly through Facebook ads, outreach to community organizations serving veterans and LGBTQ+ individuals across the United States, and contracting with a research recruitment company, Trialfacts., Results: Of the 3535 participants screened, 1819 participants met the eligibility criteria, and 1062 completed the baseline survey to enroll. At baseline, 25.24% (268/1062) were recruited from Facebook ads, 40.49% (430/1062) from community outreach, and 34.27% (364/1062) from Trialfacts. Most subgroups neared the target enrollment goals, except for cisgender bisexual men, women, and transgender men. An exploratory group of nonbinary and genderqueer veterans and veterans with diverse gender identities was included in the study., Conclusions: All recruitment methods contributed to significant portions of the enrolled cohort, suggesting that a multipronged approach was a critical and successful strategy in our study of LGBTQ+ veterans. We discuss the strengths and challenges of all recruitment methods, including factors impacting recruitment such as the COVID-19 pandemic, negative comments on Facebook ads, congressional budget delays, and high-volume surges of heterosexual participants from community outreach. In addition, our subgroup stratification offers important disaggregated insights into the recruitment of specific LGBTQ+ subgroups. Finally, the web-based methodology offers important perspectives not only for reaching veterans outside of the Veterans Health Administration but also for research studies taking place in the COVID-19-impacted world. Overall, this study outlines useful recruitment methodologies and lessons learned to inform future research that seeks to recruit marginalized communities., International Registered Report Identifier (irrid): DERR1-10.2196/43824., (©Carolyn A Fan, Michelle Upham, Kristine Beaver, Krista Dashtestani, Malachi M Skiby, Kimberly Z Pentel, Isaac C Rhew, Michael R Kauth, Jillian C Shipherd, Debra Kaysen, Tracy Simpson, Keren Lehavot. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 02.10.2023.)

Objective: There is inconclusive evidence regarding sexual identity and race/ethnicity differences in outcomes in evidence-based psychological treatments. Although dialectical behavior therapy (DBT) is well-studied, little is known about the extent to which its efficacy generalizes to sexual minority and racial/ethnic minority people. This study examined sexual identity, race/ethnicity, and their interaction as predictors of treatment outcome and retention in DBT., Method: Data were from five clinical trials conducted in research and community settings with a variety of adult populations ( N = 269) engaged in standard DBT, augmented DBT, or DBT components. Longitudinal mixed-effects models evaluated sexual identity and racial/ethnic differences in clinical outcomes (suicide attempts, nonsuicidal self-injury [NSSI], global functioning, psychiatric hospitalizations) and retention., Results: Sexual identity, race/ethnicity, and their interaction did not predict the average severity or the rate of change in any clinical outcome over time. Sexual minority identity was associated with decreased risk of treatment dropout ( OR = .44, p < .001). However, this effect was moderated by race/ethnicity, such that non-Hispanic White sexual minority participants had the lowest rates of dropout. Exploratory analyses suggested potential differences related to NSSI for certain sexual and racial/ethnic minority subgroups., Conclusions: Findings suggest no significant differences in DBT treatment outcomes when comparing between sexual minority and heterosexual individuals and between non-Hispanic White and racial/ethnic minority individuals. Sexual minority identity interacted with race/ethnicity to predict dropout, such that non-Hispanic sexual minority people were more likely to complete DBT compared to sexual minority people of color and heterosexual individuals. Further research is needed to clarify potential subgroup and intersectional differences. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Objective: To evaluate whether prosthetic prescription differed by gender and the extent to which differences were mediated by measured factors., Design: Retrospective longitudinal cohort study using data from Veterans Health Administration (VHA) administrative databases., Setting: VHA patients throughout the United States., Participants: The sample included 20,889 men and 324 women who had an incident transtibial or transfemoral amputation between 2005 and 2018., Interventions: Not applicable., Main Outcome Measures: Time to prosthetic prescription (up to 1 year). We used parametric survival analysis (an accelerated failure time model) to assess gender differences. We estimated mediation effects of amputation level, pain comorbidity burden, medical comorbidities, depression, and marital status on time to prescription., Results: In the 1 year after amputation, the proportion of women (54.3%) and men (55.7%) prescribed a prosthesis was similar. However, after we controlled for age, race, ethnicity, enrollment priority, VHA region, and service-connected disability, the time to prosthetic prescription was significantly faster among men compared with women (acceleration factor=0.73; 95% confidence interval, 0.61-0.87). The difference in time to prosthetic prescription between men and women was significantly mediated by amputation level (23%), pain comorbidity burden (-14%), and marital status (5%) but not medical comorbidities or depression., Conclusions: Although the proportion of patients with prosthetic prescription at 1-year postamputation was similar between men and women, women received prosthetic prescriptions more slowly than men, suggesting that more work is needed to understand barriers to timely prosthetic prescriptions among women, and how to intervene to reduce those barriers., (Published by Elsevier Inc.)

Purpose: Data on heterogeneity in cancer screening and diagnosis rates among lesbians/gays and bisexuals (LGBs) is lacking. Recent studies showed that LGBs have decreased healthcare utilization compared to heterosexual counterparts. Few studies have examined how sexual orientation impacts cancer screening and prevalence. We, therefore, investigated the association between sexual orientation and prevalent sex-specific cancer including prostate (PCa), breast (BC), and cervical (CC) cancer., Methods: This was a cross-sectional survey-based US study, including men and women aged 18 + from the Health Information National Trends Survey (HINTS) database between 2017 and 2019. The primary endpoint was individual-reported prostate, breast, and cervical cancer screening and prevalence rates among heterosexual and LGB men and women. Multivariable logistic regression analyses assessed association of various covariates with undergoing screening and diagnosis of these cancers., Results: Overall, 4,441 and 6,333 heterosexual men and women, respectively, were compared to 225 and 213 LGB men and women, respectively. LGBs were younger and less likely to be screened for PCa, BC, and CC than heterosexuals. A higher proportion of heterosexual women than lesbian and bisexual women were screened for CC with pap smears (95.36% vs. 90.48% and 86.11%, p ≤ 0.001) and BC with mammograms (80.74% vs. 63.81% and 45.37%, p ≤ 0.001). Similarly, a higher proportion of heterosexual men than gay and bisexual men were screened for PCa with PSA blood tests (41.27% vs. 30.53% and 27.58%, p ≤ 0.001)., Conclusion: There were more heterosexuals than LGBs screened for CC, BC, and PCa. However, no association between sexual orientation and cancer diagnosis was found. Healthcare professionals should be encouraged to improve cancer screening among LGBs., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Purpose: This study examined differences in mental health and health risk behaviors across sexual orientation and gender identity among U.S. veterans. Methods: Veterans were recruited through targeted social media advertising, community organizations, and listservs to complete an online survey ( N  = 1062). Generalized linear regression was used to evaluate differences in outcomes between subgroups, which included cisgender heterosexual men and women, lesbian women, gay men, bisexual men and women, transgender men and women, and veterans with other gender identities. Results: Transgender men and women reported a significantly higher prevalence of lifetime suicide plans and attempts compared to all other subgroups within the respective genders. Beyond this finding, patterns of all outcomes varied by gender. Compared to other subgroups of men, transgender men reported higher prevalence of posttraumatic stress disorder, whereas cisgender gay men reported higher prevalence of lifetime cocaine use and positive human immunodeficiency virus (HIV) status. Within the women subgroups, all LGBT subgroups reported higher prevalence of lifetime smoking and past-year marijuana use compared to heterosexual women. Cisgender lesbian women also reported higher prevalence of past-month heavy episodic drinking, and cisgender bisexual women reported higher prevalence of lifetime cocaine and stimulant use compared to other groups. Conclusion: Transgender women and men reported significantly higher prevalence of lifetime suicide plans and attempts than other groups, highlighting this as an area in need of urgent public health attention. Other disparity patterns indicated the importance of examining subgroups within the LGBT veteran community.

Introduction: This study investigated whether health disparities exist among lesbian, gay, and bisexual individuals serving in the U.S. military by examining the associations of sexual orientation with mental, physical, and behavioral health among a population-based sample of service members and veterans., Methods: Sexual orientation and health outcomes were self-reported on the 2016 Millennium Cohort Study follow-up questionnaire (N=96,930). Health outcomes were assessed across 3 domains: mental health (post-traumatic stress disorder, depression, anxiety, binge eating, problematic anger), physical health (multiple somatic symptoms, physical functioning, BMI), and behavioral health (smoking, problem and risky drinking, insomnia). Adjusted logistic regression models conducted between 2019 and 2022 estimated the associations between sexual orientation and each health outcome., Results: Lesbian, gay, and bisexual individuals (3.6% of the sample) were more likely to screen positive for post-traumatic stress disorder, depression, anxiety, binge eating, problematic anger, multiple somatic symptoms, and insomnia than heterosexual individuals. Gay/lesbian and bisexual women reported more adverse health outcomes (overweight and obesity, smoking, problem/risky drinking) than heterosexual women. Gay and bisexual men reported some adverse health outcomes (e.g., smoking and problem drinking) but better physical health (e.g., less overweight/obesity) than heterosexual men., Conclusions: Lesbian, gay, and bisexual service members reported poorer mental, physical, and behavioral health than heterosexual peers, most notably among gay/lesbian women and bisexual individuals. Findings suggest that lesbian, gay, and bisexual service members experience health disparities, despite many having equal eligibility for health care, highlighting the need for improved equity initiatives that promote cultural responsiveness, acceptance, and approaches to support the healthcare needs of lesbian, gay, and bisexual military members., (Copyright © 2022 American Journal of Preventive Medicine. All rights reserved.)

Objective: Evaluate suicide attempt prevalence and potentially related sociodemographic and psychiatric factors among racial and ethnic groups., Methods: Between 2012 and 2013, the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) conducted semi-structured interviews with 36,309 adults in the USA. We identified lifetime suicide attempt prevalence and significant predictors for each racial/ethnic group using stratified logistic regressions. Analyses were exploratory without a priori hypotheses., Results: Asian/Native Hawaiian/other Pacific Islander and Black individuals had the lowest prevalence of suicide attempts while Alaska Native/American Indian and White individuals had the highest prevalence. Identifying as female and meeting criteria for psychiatric diagnoses featuring mood regulation difficulties (depression, borderline personality disorder, bipolar I disorder) were consistently related to a suicide attempt history across racial and ethnic groups, whereas substance abuse disorders and other sociodemographic factors differed between racial and ethnic groups in their associations with suicide attempt history., Conclusions: Although several factors were consistently related to suicide risk across racial and ethnic groups, the prevalence of suicide attempts and overall pattern of related factors were not uniform between racial and ethnic groups., Policy Implications: Study findings highlight the importance of considering suicide risk within the context of race and ethnicity both regarding the overall prevalence of risk and in determining personal factors associated with elevated risk. A failure to appreciate experiences related to race and ethnicity may adversely impact suicide risk assessment and treatment, ultimately contributing to health disparities. Results suggest that additional research is warranted., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Despite substantial efforts to counter sexual assault and harassment in the military, both remain persistent in the Armed Services. In February 2021, President Biden directed the U.S. Department of Defense to establish a 90-day Independent Review Commission on Sexual Assault in the Military (IRC) to assess the department's efforts and make actionable recommendations. As servicemembers discharge from the military, effects of military sexual trauma (MST) are often seen in the Veterans Health Administration (VA). In response to an IRC inquiry about VA MST research, we organized an overview on prevalence, adverse consequences, and evidence-based treatments targeting the sequelae of MST. Women are significantly more likely to experience MST than their male counterparts. Other groups with low societal and institutional power (e.g., lower rank) are also at increased risk. Although not all MST survivors experience long-term adverse consequences, for many, they can be significant, chronic, and enduring and span mental and physical health outcomes, as well as cumulative impairments in functioning. Adverse consequences of MST come with commonalities shared with sexual trauma in other settings (e.g., interpersonal betrayal, victim-blaming) as well as unique aspects of the military context, where experiences of interpersonal betrayal may be compounded by perceptions of institutional betrayal (e.g., fear of reprisal or ostracism, having to work/live alongside a perpetrator). MST's most common mental health impact is posttraumatic stress disorder, which rarely occurs in isolation, and may coincide with major depression, anxiety, eating disorders, substance use disorders, and increased suicidality. Physical health impacts include greater chronic disease burden (e.g., hypertension), and impaired reproductive health and sexual functioning. Advances in treatment include evidence-based psychotherapies and novel approaches relying on mind-body interventions and peer support. Nonetheless, much work is needed to enhance detection, access, care, and support or even the best interventions will not be effective., (© 2022. The Author(s).)

Background: Women Veterans with amputation are a group with unique needs whose numbers have grown over the last 5 years, accounting for nearly 3% of all Veterans with amputation in 2019. Although identified as a national priority by the Veterans Health Administration, the needs of this population have remained largely underrepresented in amputation research., Objective: To describe the experiences of women Veterans with lower extremity amputation (LEA) related to prosthetic care provision and devices., Design: National qualitative study using semi-structured individual interviews., Participants: Thirty women Veterans with LEA who had been prescribed a prosthesis at least 12 months prior., Approach: Inductive content analysis., Key Results: Four key themes emerged: (1) a sense of "feeling invisible" and lacking a connection with other women Veterans with amputation; (2) the desire for prosthetic devices that meet their biological and social needs; (3) the need for individualized assessment and a prosthetic limb prescription process that is tailored to women Veterans; the current process was often perceived as biased and either dismissive of women's concerns or failing to adequately solicit them; and (4) the desire for prosthetists who listen to and understand women's needs., Conclusions: Women Veterans with LEA articulated themes reminiscent of those previously reported by male Veterans with LEA, such as the importance of prostheses and the central role of the provider-patient relationship. However, they also articulated unique needs that could translate into specific strategies to improve prosthetic care, such as integrating formal opportunities for social support and peer interaction for women Veterans with LEA, advocating for administrative changes and research efforts to expand available prosthetic component options, and ensuring that clinical interactions are gender-sensitive and free of bias., (© 2022. The Author(s).)

Introduction: Opioid use disorder (OUD), a chronic illness associated with substantial morbidity and mortality, is common in veterans. Despite several national Department of Veteran Affairs (VA) initiatives over the last 15 years to increase access to medications to treat OUD (MOUD), MOUD remain underutilized. Women and veterans with mental health comorbidities are less likely to receive MOUD. The current study evaluated associations between military sexual trauma (MST), one common comorbidity among veterans, and receipt of MOUD among VA outpatients. We also evaluated whether gender moderated the MST-MOUD association and whether mental health conditions were associated with lower rates of MOUD across MST status., Methods: In a cross-sectional study using a national sample of 80,845 veterans with OUD who sought care at VA facilities from 2009 to 2017, we fit mixed-effects logistic regression models to assess the association between MST and MOUD, adjusting for demographic and clinical characteristics, and with facility modeled as a random effect. Secondary analyses added interaction terms of MST x gender and MST x mental health diagnoses and compared average predicted probabilities to evaluate whether the MST and MOUD association varied by gender or mental health diagnoses. The study used a p-value threshold of .001 to determine significance due to multiple comparisons and large sample size., Results: Overall, 35% of veterans with OUD received MOUD. MST (8.1% overall; 5.2% of men, 48.8% of women) was not significantly associated with receipt of MOUD in a fully adjusted model (OR = 1.08; 99% CI 1.00, 1.17). No significant MST x gender interaction (p = .377) and no significant MST x mental health interaction (p = .722) occurred., Conclusions: Both men and women veterans with and without a history of MST received MOUD treatment at similar rates. Room for improvement exists in MOUD receipt and future research should continue to assess barriers to MOUD receipt., (Published by Elsevier Inc.)

Introduction: Opioid use disorder and high-risk opioid prescription increase the risks for overdose and death. In Veterans, military sexual trauma is associated with increased risk for assorted health conditions. This study evaluates the association of military sexual trauma with opioid use disorder and high-risk opioid prescription and potential moderation by gender., Methods: In a national sample of Veterans Health Administration outpatients receiving care from October 1, 2009 to August 1, 2017, logistic regression models were fit to evaluate the associations between military sexual trauma and opioid use disorder and high-risk opioid prescription, adjusting for demographic and clinical covariates. A second set of models included a gender X military sexual trauma interaction. Analyses were conducted in 2020-2021., Results: Patients with history of military sexual trauma (n=327,193) had 50% higher odds of opioid use disorder diagnosis (AOR=1.50, 95% CI=1.45, 1.54, p<0.001) and 5% higher odds of high-risk opioid prescription (AOR=1.05, 95% CI=1.04, 1.07, p<0.001) than those without history of military sexual trauma (n=7,738,665). The effect of military sexual trauma on opioid use disorder was stronger in men than in women . The predicted probability of opioid use disorder among men with history of military sexual trauma (1.5%) was nearly double that of women with history of military sexual trauma (0.8%)., Conclusions: Military sexual trauma was a significant risk factor for opioid use disorder and high-risk opioid prescription, with the former association particularly strong in men. Clinical care for Veterans with military sexual trauma should consider elevated risk of opioid use disorder and high-risk opioid prescription., (Copyright © 2021 American Journal of Preventive Medicine. All rights reserved.)

Background: The well-being of lesbian, gay, and bisexual (LGB) individuals is a topic of increasing concern within the military where significant institutional barriers, targeted aggression, and differential organizational policies such as "Don't Ask Don't Tell" have historically contributed to experiences of exclusion and discrimination. However, limited research has examined specific military and post-separation experiences among LGB service members and veterans. The goal of this study was to examine differences in military and service separation experiences by sexual orientation among a large representative sample of United States service members and veterans., Methods: Survey data from the 2016 Millennium Cohort Study follow-up questionnaire were used to assess sexual orientation and multiple outcomes of interest: military experiences (morale, feelings about the military, missed workdays) and service separation experiences (reasons for separation, post-separation employment). The associations between sexual orientation (LGB versus heterosexual) and each of these outcomes were evaluated in a series of adjusted logistic regression models, stratified by sex when interactions were observed., Results: Of the 99,599 participants, 3.4% identified as LGB. In adjusted models, LGB service members had significantly higher odds than heterosexual service members of feeling: unimpressed by the quality of unit leadership, unsupported by the military, and negative about the military overall. Bisexual women were more likely than heterosexual women to feel less unit camaraderie; both gay and bisexual men felt less camaraderie than heterosexual men. LGB veterans were more likely than heterosexual peers of the same sex to separate from service due to unplanned administrative reasons. Compared to heterosexual women, lesbian and bisexual women were more likely to separate from service due to dissatisfaction with promotions/pay and disability/medical reasons, while bisexual women specifically separated due to dissatisfaction with leadership and incompatibility with the military. Gay and bisexual men also reported separating due to incompatibility with the military, but only bisexual men were more likely to report separating due to disability/medical reasons compared to heterosexual men., Conclusions: Less positive military- and separation-specific experiences disproportionately affected LGB service members in this study. Promoting inclusion and increasing support for LGB service members may improve satisfaction with military service and retention., (© 2022. The Author(s).)

Background/objective: Evidence-based alcohol-related care-brief intervention for all patients with unhealthy alcohol use and specialty addictions treatment and/or pharmacotherapy for patients with alcohol use disorder (AUD)-should be routinely offered. Transgender persons may be particularly in need of alcohol-related care, given common experiences of social and economic hardship that may compound the adverse effects of unhealthy alcohol use. We examined receipt of alcohol-related care among transgender patients compared to non-transgender patients in a large national sample of Veterans Health Administration (VA) outpatients with unhealthy alcohol use., Methods: We extracted electronic health record data for patients from all VA facilities who had an outpatient visit 10/1/09-7/31/17 and a documented positive screen for unhealthy alcohol use (AUDIT-C ≥ 5). We identified transgender patients with a validated approach using transgender-related diagnostic codes. We fit modified Poisson models, adjusted for demographics and comorbidities, to estimate the average predicted prevalence of brief intervention (documented 0-14 days following most recent positive screening), specialty addictions treatment for AUD (documented 0-365 days following screening), and filled prescriptions for medications to treat AUD (documented 0-365 days following screening) for transgender patients, and compared to that of non-transgender patients., Results: Among transgender Veterans with unhealthy alcohol use (N = 1392), the adjusted prevalence of receiving brief intervention was 75.4% (95% CI 72.2-78.5), specialty addictions treatment for AUD was 15.7% (95% CI 13.7-17.7), and any AUD pharmacotherapy was 19.0% (95% CI 17.1-20.8). Receipt of brief intervention did not differ for transgender relative to non-transgender patients (Prevalence Ratio [PR] 1.01, 95% CI 0.98-1.04, p = 0.574). However, transgender patients were more likely to receive specialty addictions treatment (PR 1.24, 95% CI 1.12-1.37, p < 0.001) and pharmacotherapy (PR 1.16, 95% CI 1.06-1.28, p = 0.002)., Conclusions: Findings suggest the majority of transgender VHA patients with unhealthy alcohol use receive brief intervention, though a quarter still do not. Nonetheless, rates of specialty addictions treatment and pharmacotherapy are low overall, although transgender patients may be receiving this care at greater rates than non-transgender patients. Further research is needed to investigate these findings and to increase receipt of evidence-based care overall., (Copyright © 2021. Published by Elsevier Inc.)

Over the past 20 years, numerous treatments addressing comorbid Posttraumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD) have been developed and tested. The current meta-analysis examined the efficacy and acceptability of the two central treatment types- trauma-focused and non-trauma-focused - compared with all comparators and with cognitive-behavioral manualized SUD treatments immediately post-treatment and at longest follow-up. Twenty-eight randomized clinical trials (N = 3247) were included. There were small to large within-group effects for all forms of active treatment (gs = 0.30-1.11). Trauma-focused but not non-trauma-focused treatments outperformed all comparators on PTSD outcomes at post-treatment. Neither trauma-focused nor non-trauma-focused treatment outperformed all comparators on SUD outcomes at post-treatment. Neither trauma- nor non-trauma-focused treatment outperformed manualized SUD treatments on PTSD outcomes at either time point. Manualized SUD treatments outperformed trauma-focused treatments on SUD outcomes at post-treatment and non-trauma-focused treatments on PTSD outcomes at follow-up. Regarding treatment retention, neither trauma-focused nor non-trauma-focused treatments significantly differed from all comparators or from manualized SUD treatments. Between-group results were largely unchanged in trim-and-fill analyses, but were not robust to fail-safe N. Few moderators were detected. Taken together, results suggest that trauma-focused, non-trauma-focused, and manualized SUD interventions are sound options for individuals with comorbid PTSD/SUD., (Published by Elsevier Ltd.)

Shared decision making is an important implementation "pull" strategy for increasing uptake of evidence-based mental health practices. In this qualitative study, we explored provider perspectives on implementing shared decision making at the point of mental health treatment initiation using a publicly available, patient-facing decision support tool for post-traumatic stress disorder (PTSD). We conducted semi-structured interviews with 22 mental health providers (psychiatrists, nurses, psychologists, and social workers) working in one of five VA primary care clinics. Interviewed were analyzed using thematic analysis. Provider were enthusiastic about using decision aids as a source of high quality information that could improve patient experience and confidence in treatment. However, providers had concerns about decision aid accessibility, time constraints to conduct shared decision making in-session, and patient motivation to engage in shared decision making. Providers stated they would prefer to use shared decision making with patients that they felt were most likely to follow through with treatment. While providers believed that shared decision making could improve PTSD treatment planning, they thought it most appropriate for patients with the highest levels of motivation and fewest barriers to care. These beliefs may limit widespread adoption and reflect missed opportunities to reach difficult-to-engage patients., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Objectives: To evaluate feasibility and acceptability of a group-based nature recreation intervention (nature hiking) and control condition (urban hiking) for military Veterans with post-traumatic stress disorder (PTSD)., Design and Setting: A pilot randomised controlled trial conducted in the US Pacific Northwest., Participants: Veterans with PTSD due to any cause., Interventions: Twenty-six participants were randomised to a 12-week intervention involving either six nature hikes (n=13) or six urban hikes (n=13)., Primary and Secondary Outcome Measures: Feasibility was assessed based on recruitment, retention and attendance. Questionnaires and postintervention qualitative interviews were conducted to explore intervention acceptability. Questionnaires assessing acceptability and outcomes planned for the future trial (eg, PTSD symptoms) were collected at baseline, 6 weeks, 12 weeks (immediately after the final hike) and 24 weeks follow-up., Results: Of 415 people assessed for eligibility/interest, 97 were interested and passed preliminary eligibility screening, and 26 were randomised. Mean completion of all questionnaires was 91% among those in the nature hiking group and 68% in those in the urban hiking group. Over the course of the intervention, participants in the nature and urban groups attended an average of 56% and 58%, respectively, of scheduled hikes. Acceptability of both urban and nature hikes was high; over 70% reported a positive rating (ie, good/excellent) for the study communication, as well as hike locations, distance and pace. Median PTSD symptom scores (PTSD Checklist-5) improved more at 12 weeks and 24 weeks among those in the nature versus urban hiking group., Conclusions: This pilot study largely confirmed the feasibility and acceptability of nature hiking as a potential treatment for Veterans with PTSD. Adaptations will be needed to improve recruitment and increase hike attendance for a future randomised controlled trial to effectively test and isolate the ways in which nature contact, physical activity and social support conferred by the group impact outcomes., Trial Registration Number: NCT03997344., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Transgender people-those whose gender identity differs from their sex assigned at birth-are at risk for health disparities resulting from stressors such as discrimination and violence. Transgender people report more drug use than cisgender people; however, it is unclear whether they have higher likelihood of drug use disorders. We examined whether transgender patients have increased likelihood of documented drug use disorders relative to cisgender patients in the national Veterans Health Administration (VA)., Methods: Electronic health record data were extracted for VA outpatients from 10/1/09 to 7/31/17. Transgender status and past-year documentation of drug use disorders (any, opioid, amphetamine, cocaine, cannabis, sedative, hallucinogen) were measured using diagnostic codes. Logistic regression models estimated odds ratios for drug use disorders among transgender compared to cisgender patients, adjusted for age, race/ethnicity and year. Effect modification by presence of ≥1 mental health condition was tested using multiplicative interaction., Results: Among 8,872,793 patients, 8619 (0.1%) were transgender. Transgender patients were more likely than cisgender patients to have any drug use disorder (Adjusted Odds Ratio [aOR] 1.67, 95% confidence interval [CI] 1.53-1.83), amphetamine (aOR 2.22, 95% CI 1.82-2.70), cocaine (aOR 1.59, 95% CI 1.29-1.95), and cannabis (aOR 1.82, 95% CI 1.62-2.05) use disorders. There was no significant interaction by presence of ≥1 mental health condition., Conclusions: Transgender VA patients may have higher likelihood of certain drug use disorders than cisgender VA patients, particularly amphetamine use disorder. Future research should explore mechanisms underlying disparities and potential barriers to accessing treatment and harm reduction services faced by transgender people., Competing Interests: The authors report no conflicts of interest.

Objective: Proportionally more women use online alcohol interventions but also report less robust treatment outcomes compared to men. Less is known about outcome disparities among veteran women, who are a growing demographic nationally. The current study examined gender differences among returning veteran men and women who used VetChange, a web-based intervention for hazardous drinking and posttraumatic stress symptoms (PTSS)., Method: Using data from a nationwide implementation study of returning combat veterans (n = 222), we performed hierarchical linear modeling to examine gender differences in alcohol and PTSS outcomes over six months following VetChange registration. Additional analyses examined gender differences in proportional changes in hazardous drinking and at each assessment point., Results: Returning veterans reported significant decreases in alcohol use and PTSS over time, yet men evidenced significantly greater reduction in average weekly drinks and drinks per drinking day compared to women. Follow up analyses indicated that women were significantly less likely than men to achieve low-risk drinking by one month post-registration. Proportional change in alcohol use yielded marginal and non-significant trends that were, nonetheless, consistent with the overall pattern of gender differences., Conclusion: These results contribute to emerging literature suggesting that women use online alcohol use interventions at proportionately higher rates than do men, but do not reduce their drinking as much as men. There are a number of potential content changes that could improve outcomes for returning veteran women using online interventions, and data-driven adaptations based on stakeholder input are recommended., (Published by Elsevier B.V.)

Objective: Scalable, efficiently delivered treatments are needed to address the needs of women Veterans with PTSD. This randomized clinical trial compared an online, coach-assisted cognitive behavioral intervention tailored for women Veterans with PTSD to phone monitoring only., Method: Women Veterans who met diagnostic criteria for PTSD were randomized to an 8-week web-based intervention, called DElivery of Self TRaining and Education for Stressful Situations (DESTRESS)-Women Veterans version (WV), or to phone monitoring only (N = 102). DESTRESS-WV consisted of online sessions and 15-min weekly phone calls from a study coach. Phone monitoring included 15-min weekly phone calls from a study coach to offer general support. PTSD symptom severity (PTSD Symptom-Checklist-Version 5 [PCL-5]) was evaluated pre and posttreatment, and at 3 and 6 months posttreatment., Results: More participants completed phone monitoring than DESTRESS-WV (96% vs. 76%, p = 0.01), although treatment satisfaction was significantly greater in the DESTRESS-WV condition. We failed to confirm the superiority of DESTRESS-WV in intent-to-treat slope changes in PTSD symptom severity. Both treatments were associated with significant reductions in PTSD symptom severity over time. However, post hoc analyses of treatment completers and of those with baseline PCL ≥ 33 revealed that the DESTRESS-WV group had greater improvement in PTSD symptom severity relative to phone monitoring with significant differences at the 3-month follow-up assessment., Conclusions: Both DESTRESS-WV and phone monitoring resulted in significant improvements in women Veterans' PTSD symptoms. DESTRESS-WV may be an appropriate care model for women Veterans who can engage in the demands of the treatment and have higher baseline symptoms. Future research should explore characteristics of and the methods of reliably identifying women Veterans who are most likely to benefit. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Objective: Alcohol use is understudied among transgender persons--persons whose sex differs from their gender identity. We compare patterns of alcohol use between Veterans Health Administration (VA) transgender and nontransgender outpatients., Method: National VA electronic health record data were used to identify all patients' last documented Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screen (October 1, 2009-July 31, 2017). Transgender patients were identified using diagnostic codes. Logistic regression models estimated four past-year primary outcomes: (a) alcohol use (AUDIT-C > 0); (b) unhealthy alcohol use (AUDIT-C ≥ 5); (c) high-risk alcohol use (AUDIT-C ≥ 8); and (d) heavy episodic drinking (HED; ≥6 drinks on ≥1 occasion). Two secondary diagnostic-based outcomes, alcohol use disorder (AUD) and alcohol-specific conditions, were also examined., Results: Among 8,872,793 patients, 8,619 (0.10%) were transgender. For transgender patients, unadjusted prevalence estimates were as follows: 52.8% for any alcohol use, 6.6% unhealthy alcohol use, 2.8% high-risk use, 10.4% HED, 8.6% AUD, and 1.3% alcohol-specific conditions. After adjustment for demographic characteristics, transgender patients had lower odds of patient-reported alcohol use but higher odds of alcohol-related diagnoses compared with nontransgender patients. Differences in alcohol-related diagnoses were attenuated after adjustment for comorbid conditions and utilization., Conclusions: This is the largest study of patterns of alcohol use among transgender persons and among the first to directly compare patterns to nontransgender persons. Findings suggest nuanced associations with patterns of alcohol use and provide a base for further disparities research to explore alcohol use within the diverse transgender community. Research with self-reported measures of gender identity and sex-at-birth and structured assessment of alcohol use and disorders is needed.

A recent evidence map focused on women veterans underscored the limited number of articles published on mental health comorbid with physical health conditions in this population. The quality of this small body of research has yet to be evaluated. The aim of this systematic review was to evaluate and synthesize research published between 2008 and 2015 and identified in the Women Veterans' Health Research Evidence Map as related to mental and physical health comorbidities among women veterans. Following PRISMA guidelines, 23 published studies were identified and 21 were included in the review. In general, significant associations between several mental health conditions (e.g., depression, posttraumatic stress disorder, substance use disorders) and physical health disorders (e.g., cardiovascular disease, diabetes, gastrointestinal disorders, hypertension, obesity, pain, and urinary symptoms) and health behaviors (e.g., preventative care and treatment adherence) were noted. The majority of studies were rated as low risk of bias, with selection and detection bias most frequently observed across studies. Additionally, gaps in the recent literature were observed, including the need for further investigation of the role of medical conditions in complicating mental health symptoms and care provision. Results underscore the importance of healthcare providers attending to women veterans' mental and physical health simultaneously and irrespective of setting. Further, while the Department of Veterans Affairs continues to make sizable gains in its focus on women veterans' health, continued research on several health domains is needed to ensure adequate understanding of the health needs of women veterans.

Objective: Brief intervention (BI) for unhealthy alcohol use is a top prevention priority for adults in the U.S, but rates of BI receipt vary across patients. We examine BI receipt across race/ethnicity and gender in a national cohort of patients from the Department of Veterans Affairs (VA)-the largest U.S. integrated healthcare system and a leader in implementing preventive care for unhealthy alcohol use., Methods: Among 779,041 VA patients with documented race/ethnicity and gender who screened positive for unhealthy alcohol use (AUDIT-C score ≥ 5) between 10/1/09 and 5/30/13, we fit Poisson regression models to estimate the predicted prevalence of BI (EHR-documented advice to reduce or abstain from drinking) across race/ethnicity and gender., Results: Rates of BI were lowest among Black women (67%), Black men (68%), and Asian/Pacific Islander women (68%), and highest among white men (75%), Hispanic men (75%), and Asian/Pacific Islander men (75%). A significant race/ethnicity by gender interaction indicated that the associations between race/ethnicity and gender with BI depended on the other factor. Gender differences were largest among Asian/Pacific Islander patients and were nonsignificant among American Indian/Alaska Native patients. Adjustment for covariates not expected to be on the causal pathway (e.g., age, year of AUDIT-C screen) slightly attenuated but did not change the direction of results., Conclusions: Receipt of BI for unhealthy alcohol use varied by race/ethnicity and gender, and the impact of one factor depended on the other. Black women, Black men, and Asian/Pacific Islander women had the lowest rates of receiving recommended alcohol-related care. We found these disparities in a healthcare system that has implemented universal alcohol screening and incentivized BI for all patients with unhealthy alcohol use, suggesting that reducing disparities in alcohol-related care may require targeted interventions., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To determine latent classes of treatment receipt among people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) and describe each class by demographics, disease characteristics, and psychiatric diagnoses., Method: Participants were National Epidemiologic Survey on Alcohol and Related Conditions-III respondents with lifetime PTSD and SUD (n = 1,349; mean age 40.3; 62.5% female; 30.9% non-White or Hispanic-White). Cross-sectional data were collected using the DSM-5 Alcohol Use Disorder and Associated Disabilities Interview Schedule. Latent class analysis was used to identify subgroups of participants with different patterns of treatment receipt., Results: Of the patients, 36% received at least 1 SUD treatment while 84% received at least 1 mental health (MH) treatment. Six latent classes were identified: no treatment (17.3%), outpatient MH (34.0%), outpatient + inpatient MH (17.9%), SUD (7.3%), SUD + outpatient MH (15.7%), and SUD + outpatient MH + inpatient MH (7.7%). The SUD treatment classes evidenced greater social instability, had higher alcohol use disorder symptom severity, and used more drug types than the non-SUD classes. Classes receiving inpatient MH treatment had a greater incidence of additional comorbid conditions and suicidal behaviors. Across all 6 classes, most respondents met diagnostic criteria for chronic PTSD (overall: 68.9%) while fewer met diagnostic criteria for chronic SUD (overall: 38.7%)., Conclusions: Most people with lifetime PTSD and SUD have sought either SUD or MH treatment or both, with substantially greater receipt of MH treatment. This comorbid group has complex clinical presentations that differ depending upon treatment subgroup, and for most, their PTSD persisted despite high rates of treatment engagement. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

People in need of mental health treatment do not access care at high rates or in a timely manner, inclusive of Veterans at Department of Veteran's Affairs (VA) medical centers. Barriers to care have been identified, and one potential solution is the use of technology-based interventions within primary care. This study evaluated the Cognitive Anxiety Sensitivity Treatment (CAST), a previously developed computerized treatment that has shown efficacy in community samples for mental health symptoms including: anxiety, depression, post-traumatic stress, and suicidal ideation. VA primary care patients with elevated anxiety sensitivity (N = 25) were recruited to participate in a mixed-method open pilot to examine acceptability, usability, and preliminary effectiveness in a VA primary care setting. Participants completed an initial visit, that included the intervention, and a one-month follow-up. Veterans found CAST to be generally acceptable, with strong usability ratings. Qualitative analyses identified areas of strength and areas for improvement for use with VA primary care Veterans. Repeated measures ANCOVAs revealed significant effects for symptoms of anxiety, depression, traumatic-stress, and suicidal ideation. CAST could potentially have a large public health impact if deployed across VA medical centers as a first-step intervention for a range of mental health presenting concerns., (Published by Elsevier B.V.)

Background: When hysterectomy is used to treat uterine fibroids, a minimally invasive versus open abdominal approach is preferred. Depression and post-traumatic stress disorder (PTSD) may be associated with surgical mode. We sought to examine whether depression and PTSD are associated with minimally invasive hysterectomy (MIH)., Methods: This was a cross-sectional study of veterans with uterine fibroids undergoing hysterectomy in the Department of Veterans Affairs between 2012 and 2014. Diagnoses and procedures were identified by International Classification of Disease, Ninth Revision, codes. MIH was defined as laparoscopic, vaginal, or robotic-assisted versus open abdominal. A dichotomous variable indicated presence of depression or PTSD. Clinical variables, including uterine size, were abstracted from the medical record. We employed generalized linear models to estimate adjusted percentages and 95% confidence intervals (CIs) of MIH by presence of depression or PTSD and sequentially adjusted for sociodemographic variables and health indicators (model 1), and then gynecologic and reproductive history variables, including uterine size (model 2)., Results: We included 770 veterans in our analytic sample. Veterans with depression or PTSD were more likely than those without such diagnoses to have a MIH (49% vs. 42%). Differences were attenuated in model 1 (47% [95% CI, 37%-57%] vs. 43% [95% CI, 34%-52%]) and no longer detectable in model 2 (45% [95% CI, 36%-54%] vs. 44% [95% CI, 36%-52%])., Conclusions: Veterans with depression or PTSD were more likely that those without to have a MIH, possibly owing to smaller uterine size, suggesting that they may be undergoing hysterectomy earlier in the disease process. Further research is needed to understand whether this reflects high-quality, patient-centered care., (Published by Elsevier Inc.)

Objective: To remedy the notable gap in evidence-based treatments for sexual minority women, this study tested the efficacy of a minority-stress-focused cognitive-behavioral treatment intended to improve this population's mental and behavioral health., Method: The intervention, EQuIP (Empowering Queer Identities in Psychotherapy), was adapted from a transdiagnostic cognitive-behavioral treatment as also recently adapted for sexual minority men. Sexual minority women at risk of mental and behavioral health problems ( n = 19) and expert providers with this population ( n = 12) shaped the treatment's development, including by supporting its primary focus on universal and minority-stress-focused processes underlying this population's disproportionately poor mental and behavioral health. The resulting treatment was then delivered to young adult sexual minority women ( n = 60; M age = 25.58; 41.67% racial/ethnic minority; 43.33% transgender/nonbinary) experiencing depression/anxiety and past 90-day heavy alcohol use., Results: Compared to waitlist ( n = 30), participants randomized to immediately receive EQuIP ( n = 30) experienced significantly reduced depression and anxiety ( d = 0.85, 0.86, respectively); effects for alcohol use problems were smaller ( d = 0.29) and marginally significant. In pre- to post-intervention pooled analyses, effect sizes for minority stress processes (mean d = .25) and universal risk factors (mean d = .48), through which the treatment was expected to work, were small and moderate, respectively, and in the expected direction., Conclusions: This study provides initial support for a minority-stress-focused transdiagnostic cognitive-behavioral treatment for sexual minority women. These first results can launch exploration of other mechanisms and modalities through which to equip this population with evidence-based support. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

We aimed to evaluate whether military service and access to veteran heath care coverage attenuates racial/ethnic disparities in time to mental health treatment initiation for posttraumatic stress disorder (PTSD), major depressive disorder, and/or alcohol-use disorder. Results are based on 13,528 civilians and 1392 veterans from NESARC-III. Among civilians, racial/ethnic minorities reported longer time to PTSD and depression treatment initiation than non-Hispanic whites. Among veterans, racial/ethnic minorities did not differ from whites in time to PTSD and depression treatment initiation, and showed shorter time to treatment initiation for alcohol-use disorder treatment. Racial/ethnic minorities with past year veteran health care coverage showed the strongest evidence for attenuated disparities.

Military sexual trauma (MST) is a significant public health issue associated with adverse psychiatric outcomes, including heightened risk for suicide, posttraumatic stress disorder, depression, and substance use disorders. Recently, research has begun exploring gender-linked disparities in mental health outcomes for individuals who experience MST. The current study assessed whether women who screened positive for MST were at disproportionately higher risk for diagnoses of alcohol-use disorder (AUD) or drug-use disorder (DUD) relative to men. Veterans Health Administration (VHA) clinical data were extracted for 435,690 military veterans who separated from the military between 2004 and 2011 and had at least 5 years of follow-up data after their initial VHA visit until the end of fiscal year 2014. Logistic regression models examined the main and interactive effects of gender and screening positively for MST as predictors of AUD and DUD. MST positive screens were associated with increased rates of both AUD and DUD across genders. Although rates of both AUD and DUD were higher among men, the increased rate of diagnosis associated with MST positive screens was proportionally higher for women than men (interaction adjusted odds ratios = 1.43 and 1.17 for AUD and DUD, respectively), indicating the presence of a gender-linked health risk disparity. This disparity was more pronounced for AUD than DUD ( p < .01). The current study adds to previous literature documenting increased risk for women exposed to MST. These findings support efforts to reduce the occurrence of MST and continued use of MST screening measures within the VHA. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Aims: To compare individuals with comorbid life-time post-traumatic stress disorder (PTSD) and alcohol use disorders [AUD; i.e. no drug use disorders (DUD)] with those with comorbid PTSD and DUD on past-year prevalence of these disorders, social functioning, life-time psychiatric comorbidities, and treatment receipt. The comorbid groups were also compared with their single diagnosis counterparts., Design and Setting: Cross-sectional cohort study using data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC-III)., Participants: The total sample size was 36 309. Six groups were established: PTSD/AUD, PTSD/DUD, AUD, DUD, PTSD, and neither PTSD nor AUD/DUD. Life-time prevalence of AUD among those with PTSD/DUD was 80.2% and among those with DUD was 73.8%., Measurements: The Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-5 version assessed life-time and past-year psychiatric disorders and treatment receipt. Demographics and social stability indicators were queried. Group characteristics were summarized using weighted means. Prevalences and estimates for adjusted differences in means and adjusted odds ratios (aORs) were derived from multiple linear regression and logistic regression models, respectively. Analyses were conducted in R and accounted for the NESARC-III's complex survey design, clustering, and non-response., Findings: Compared with those with life-time PTSD/AUD, those with life-time PTSD/DUD were significantly less likely to have neither disorder in the past year (PTSD/AUD = 16.1%; PTSD/DUD = 8.5%; aOR = 0.54), and were more likely to report worse social and psychiatric functioning, and to have received both addiction and mental health treatment (PTSD/AUD = 18.4%; PTSD/DUD = 43.2%; aOR = 3.88). Compared with their single disorder counterparts, those with PTSD/DUD reported greater impairment than both groups, whereas the comorbid PTSD/AUD group differed more from the AUD than the PTSD group., Conclusions: People with comorbid PTSD and drug use disorder have greater social and psychiatric impairment and may require different types and intensity of intervention than people with comorbid post-traumatic stress disorder and alcohol use disorder., (© 2019 Society for the Study of Addiction.)

Objective: The study compared delay of treatment for posttraumatic stress disorder (PTSD), major depressive disorder, and alcohol use disorder among post-9/11 veterans versus pre-9/11 veterans and civilians., Methods: The 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a nationally representative survey of U.S. noninstitutionalized adults, was used. Participants included 13,528 civilians, 1,130 pre-9/11 veterans, and 258 post-9/11 veterans with lifetime diagnoses of PTSD, major depression, or alcohol use disorder. Cox proportional hazard models, controlling for relevant demographic characteristics, were used to estimate differences in treatment delay (i.e., time between diagnosis and treatment)., Results: Post-9/11 veterans were less likely to delay treatment for PTSD and depression than pre-9/11 veterans (adjusted hazard ratios [AHRs]=0.69 and 0.74, respectively) and civilians (AHRs=0.60 and 0.67, respectively). No differences in treatment delay were observed between post-9/11 veterans and pre-9/11 veterans or civilians for alcohol use disorder. In an exploratory analysis, post-9/11 veterans with past-year military health care coverage (e.g., Veterans Health Administration) had shorter delays for depression treatment compared with post-9/11 veterans without military coverage, pre-9/11 veterans regardless of health care coverage, and civilians, although past-year coverage did not predict treatment delay for PTSD or alcohol use disorder., Conclusions: Post-9/11 veterans were less likely to delay treatment for some common psychiatric conditions compared with pre-9/11 veterans or civilians, which may reflect efforts to engage recent veterans in mental health care. All groups exhibited low initiation of treatment for alcohol use disorder, highlighting the need for further engagement efforts.

Research suggests the prevalence of suicide ideation and suicide attempts in the transgender veteran community may be upwards of 20 times higher than nontransgender veterans, who are known to be at increased risk than the general US population. This study aimed to understand the potential influence of external and internal minority stress experienced during and after military service on past-year and recent suicide ideation in a sample of 201 transgender veterans. Nonparametric bootstrapping analyses indicated past-year transgender-specific discrimination and rejection (external minority stress) indirectly predicted frequency of both past-year and past 2-week suicide ideation through past-year shame related to gender identity (internal minority stress). This result was significant when controlling for symptoms of depression and demographics. Similar patterns emerged when examining relationships among military external and internal minority stress on suicide outcomes. These results suggest that attempts to reduce both the experience and impact of minority stressors related to gender identity during and after military service may be an important avenue for suicide prevention., (© 2018 The American Association of Suicidology.)

Purpose: The aim was to examine social support and community connection as moderators of the relationship between discrimination and suicidal ideation (SI) in transgender veterans., Methods: A national convenience sample of 298 transgender veterans completed an online cross-sectional survey from February to May 2014. Hierarchical regressions using nonparametric bootstrapping assessed associations among gender-related discrimination within the past year, two aspects of social support (social support, social connection) from four sources (family, friends, transgender/LGBT friends, and veterans), and SI in the past 2 weeks., Results: Discrimination was positively associated with SI. Social support from transgender friends and social connection with LGBT and veteran communities moderated the relationship between discrimination and SI. At high and average levels of social support and connection, discrimination was associated with greater SI, whereas at low levels of these variables, SI was consistently elevated and unrelated to discrimination., Conclusion: Given that SI was consistently elevated when discrimination was high, these findings emphasize the need for additional research on how to mitigate the detrimental effects of discrimination, with consideration given to interventions targeting discrimination or responses to discrimination. In addition, given that high and average transgender social support and LGBT social connection were associated with reduced SI when discrimination was low, research would benefit from continued exploration of the potential protective elements of social support from a shared stigmatized community.

Objective: To identify patterns of risk and resilience by the intersections of race/ethnicity and sexual orientation in mental health symptom severity, sexism, and social support among U.S. women veterans., Methods: A national sample of women veterans ( n = 648, 38% sexual minority, 15% racial/ethnic minority) was recruited online in 2013 using social networking websites and listservs. Using cross-sectional survey data, we evaluated main and interactive associations between race/ethnicity and sexual orientation on depression, anxiety, posttraumatic stress, unhealthy alcohol use, sexism, and social support. Models were adjusted for other demographic characteristics., Results: Across depression, anxiety, and sexism, White heterosexual women reported the least distress and racial/ethnic minority heterosexual women the most distress (race/ethnicity x sexual orientation interactions p < .05). Among White women, sexual minority women reported greater levels of depression, anxiety, and sexism than heterosexual women. The effects were the opposite among racial/ethnic minority women, where heterosexual women reported similar or worse depression, anxiety, and sexism than sexual minority women. There were no race/ethnicity or sexual orientation interaction effects on posttraumatic stress symptoms or unhealthy alcohol use and marginally significant effects on social support., Conclusions: Among women veterans, race/ethnicity and sexual orientation were associated with mental health and sexism, alone and in combination. Findings suggest that those who were both racial/ethnic and sexual minorities may develop resilience from their lived experience. On the other hand, women veterans with a minority race/ethnicity or a minority sexual orientation appeared more vulnerable to adverse outcomes and may need targeted care.

Background: Access to transition-related medical interventions (TRMIs) for transgender veterans has been the subject of substantial public interest and debate. To better inform these important conversations, the current study investigated whether undergoing hormone or surgical transition intervention(s) relates to the frequency of recent suicidal ideation (SI) and symptoms of depression in transgender veterans., Methods: This study included a cross-sectional, national sample of 206 self-identified transgender veterans. They self-reported basic demographics, TRMI history, recent SI, and symptoms of depression through an online survey., Results: Significantly lower levels of SI experienced in the past year and 2-weeks were seen in veterans with a history of both hormone intervention and surgery on both the chest and genitals in comparison with those who endorsed a history of no medical intervention, history of hormone therapy but no surgical intervention, and those with a history of hormone therapy and surgery on either (but not both) the chest or genitals when controlling for sample demographics (e.g., gender identity and annual income). Indirect effect analyses indicated that lower depressive symptoms experienced in the last 2-weeks mediated the relationship between the history of surgery on both chest and genitals and SI in the last 2-weeks., Conclusions: Results indicate the potential protective effect that TRMI may have on symptoms of depression and SI in transgender veterans, particularly when both genitals and chest are affirmed with one's gender identity. Implications for policymakers, providers, and researchers are discussed.

Objectives: To examine factors that account for women veterans' higher prevalence of past-year DSM-5 posttraumatic stress disorder (PTSD) compared to women civilians and men veterans., Methods: Cross-sectional analyses of the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). Face-to-face interviews with 379 women veterans, 20,007 women civilians, and 2740 men veterans were conducted. Trauma type (child abuse, interpersonal violence, combat or war zone, and other), number of trauma types, past-year stressful life events, current social support, and DSM-5 PTSD were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5. Generalized linear models were used that accounted for the complex survey design., Results: Women veterans had a higher unadjusted prevalence of past-year PTSD (11.40%) compared to their civilian (5.96%) and male (5.19%) counterparts. Individual predictor models indicated that the difference between women veterans' and civilians' prevalence of PTSD was attenuated when adjusting for number of trauma types, whereas the difference between men and women veterans was attenuated when adjusting for child abuse, interpersonal violence, and stressful life events. Nonetheless, while full adjustment in a multiple predictor model accounted for the difference in PTSD between women veterans and civilians, gender differences between men and women veterans remained., Conclusions: Number of trauma types, type of trauma, and social factors may together help explain women veterans' higher PTSD prevalence compared to women civilians, but do not fully account for differences between men and women veterans. Results highlight a need to explore additional explanatory factors and evaluate associations with longitudinal data.

Introduction: This study sought to describe the prevalence of regular past year cannabis use (i.e., at least monthly use) in women veterans, to characterize women veterans reporting this level of use, and to examine the independent contributions of sexual trauma across the lifespan on regular past year cannabis use., Methods: A national online survey on women veterans' health, with targeted oversampling of lesbian and bisexual women, collected data from US armed forces women veterans, 18 or older, living in the US (N = 636)., Results: Eleven percent of women reported regular cannabis use (5% heterosexual women; 21% lesbian/bisexual women). In bivariate analysis, identifying as a sexual and/or racial ethnic minority, younger age, being unmarried, reporting lower income, receiving VA services, smoking tobacco, and screening positive for alcohol misuse were positively associated with regular cannabis use. Additionally, a greater percentage of cannabis users reported experiencing childhood and adult sexual trauma and screened positive for posttraumatic stress disorder (PTSD) when compared to peers who did not use any drugs. In a multivariate model, the number of life eras women endorsed experiencing sexual trauma was significantly associated with regular cannabis use even when adjusting for demographic variables and PTSD symptoms., Conclusions: Among women veterans, regular cannabis use is fairly common among those who are sexual and racial/ethnic minorities, younger, unmarried, receiving VA services, and reporting alcohol or tobacco use, PTSD symptoms, and/or multiple sexual traumas across the lifespan. Screening and assessment may be important to consider in healthcare settings serving this veteran population., (Published by Elsevier Ltd.)

There is limited understanding about the frequency of military sexual assault (MSA) in transgender veterans, characteristics associated with MSA, or subsequent mental and behavioral health problems. To address this gap, we used an online national survey of 221 transgender veterans to identify prevalence of MSA and to assess its association with demographic characteristics, past history of sexual victimization, and stigma-related factors. We also evaluated the association between MSA and several mental and behavioral health problems. Overall, 17.2% of transgender veterans experienced MSA, but rates differed significantly between transgender women (15.2%) and transgender men (30.0%). Using adjusted regression models, MSA was associated with adult sexual assault prior to military service, odds ratio (OR) = 4.05, 95% CI [1.62, 10.08], and distal minority stress during military service, OR = 2.98, 95% CI [1.28, 6.91]. With respect to health outcomes, MSA was associated with past-month posttraumatic stress disorder (PTSD) symptom severity, B = 10.18, 95% CI [3.45, 16.91]; current depression symptom severity, B = 3.71, 95% CI [1.11, 6.30]; and past-year drug use, OR = 3.17, 95% CI [1.36, 7.40]. Results highlight the vulnerability of transgender veterans to MSA, and the need for military prevention programs that acknowledge transgender individuals' heightened risk. Furthermore, clinicians should consider clinical screening for PTSD, depression, and drug use in transgender veterans who have a history of MSA., (Published 2018. This article is a U.S. Government work and is in the public domain in the USA.)

Sexual minority women (SMW) are at high risk of trauma exposure and, subsequently, the development of posttraumatic stress disorder (PTSD). The authors extended a theoretical model explaining the higher risk of mental disorders in minority populations to the maintenance and exacerbation of PTSD symptoms among young adult SMW specifically. This study used observational longitudinal data from a sample of 348 trauma-exposed 18- to 25-year-old individuals assigned female sex at birth who identified as either bisexual (60.1%) or lesbian (39.9%) and met screening criteria for PTSD. Participants identified as White (82.8%), Hispanic/Latina (12.4%), American Indian/Alaska Native (13.5%), Black/African American (13.8%), and/or Asian/Asian American (4.9%). The authors investigated whether distal stressors (i.e., criterion A traumatic events, daily experiences of heterosexism) produced proximal stressors (i.e., trauma-related cognitions, internalized heterosexism) that maintained or exacerbated PTSD symptoms. Findings indicated that daily heterosexism longitudinally predicted trauma-related cognitions (i.e., cognitions related to the self, world, and self-blame). Internalized heterosexism and cognitions about the self longitudinally predicted PTSD symptom severity. In addition, a significant indirect effect was identified between daily heterosexism and PTSD symptoms via self-related posttraumatic cognitions. These findings suggest that exposure to minority-specific distal stressors appears to promote nonminority-specific cognitive processes that, in turn, may maintain or exacerbate PTSD among young adult SMW exposed to trauma. Clinicians should consider addressing daily heterosexism in young adult SMW presenting with PTSD and evaluate how these experiences might promote clients' global, negative views regarding themselves. (PsycINFO Database Record, ((c) 2018 APA, all rights reserved).)

Severe mental illness (SMI) and substance use disorders (SUD) are among the more chronic and costly mental health conditions treated in the Department of Veterans Affairs (VA). Service use patterns of returning veterans with SMI and SUD have received little attention. We examined gender differences in the utilization of VA services among a national sample of Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND) VA patients with SMI, SUD, and their comorbidity (SMI/SUD) in their first year of established VA care (N = 24,166). Outpatient services and acute-residential stays were modeled using negative binomial and logistic regression, respectively. Among all diagnostic categories, men used outpatient services less often than did women, including primary care (adjusted rate ratio [ARR] = .71, 95% confidence interval CI [.68, .74]), mental health (ARR = .85, 95% CI [.80, .91]), and addiction (ARR = .91, 95% CI [.83, .99]) services. For emergency department (ED) and psychiatric inpatient services, gender interacted significantly with diagnosis. The combination of SMI/SUD compared to either SMI or SUD conferred greater risk of ED utilization among men than women (adjusted odds ratio [AOR] = 2.09, 95% CI [1.24, 3.51], and 1.95, 95% CI [1.17, 3.26], respectively). SMI versus SUD conferred greater risk of psychiatric inpatient utilization among men than women (AOR = 1.83, 95% CI [1.43, 2.34]). Our findings point to gender differences in outpatient and acute service utilization among OEF/OIF/OND VA patients with some of the more chronic and costly mental health conditions. Further investigation of health care utilization patterns is needed to understand factors driving these gender differences to ensure that veterans have appropriate access to the services they need. (PsycINFO Database Record, ((c) 2018 APA, all rights reserved).)