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Previous research has examined risk factors associated with poorer treatment outcomes for military Veterans with PTSD. However, work has not examined risk for symptom worsening among Veterans with subthreshold PTSD. The aim of this study was to examine demographic, psychiatric, physical health, and pre-treatment PTSD symptom clusters associated with clinically significant worsening of PTSD among a nationally representative sample of United States (U.S.) Veterans with subthreshold PTSD. Participants were Veterans (weighted N = 3162; unweighted N = 236) with subthreshold PTSD entering a new episode of treatment at U.S. Veterans Affairs PTSD specialty clinics during fiscal years 2018 and 2019. Data was collected as part of the Veterans Outcome Assessment, a yearly baseline and 3-month follow-up telephone survey. Analyses used weighted calculations to support the use of VOA data to draw inferences about all eligible Veterans, and binary logistic regression was used to examine risk factors for symptom worsening. Over 1/3 (37.7%) of Veterans with subthreshold PTSD experienced clinically significant symptom worsening from baseline to follow-up. Adjusted analyses revealed several risk factors for symptom worsening, including demographic (e.g., male sex, White race), psychiatric (personality and anxiety disorders), health care utilization (e.g., more primary care encounters in the previous year), physical health disability, and specific baseline PTSD symptom clusters (negative affect and anxious arousal). Findings suggest that Veterans with subthreshold symptoms seeking treatment for PTSD are at risk for symptom worsening, and highlight the importance of assessment, prevention, and treatment in targeting veterans with PTSD symptoms below the diagnostic threshold.

Gambling and anxiety are major public health concerns in adolescents and have been linked to emotion dysregulation and mood-modulating behaviors. While previous studies have shown links between positively reinforcing excitement-motivated gambling, health and functioning measures, and gambling perceptions and behavioral correlates in adolescents, few studies have examined such relationships relative to negatively reinforcing anxiety-motivated gambling (AMG). This study systematically examined relationships between adolescents reporting gambling to relieve anxiety (compared to those who gambled but did not report AMG) and measures of health/functioning and gambling-related measures. Participants included 1,856 Connecticut high-school students. Chi-square and logistic regression models were conducted. AMG was reported by 6.41% of the sample and was associated with identifying with a minority group (Black, Asian-American, Hispanic), at-risk/problem gambling, more permissive attitudes towards gambling, and higher odds of heavy alcohol, tobacco and other drug use, and violence-related measures. Adolescents with AMG were more likely to report non-strategic gambling, and gambling to escape/relieve dysphoria and due to feeling pressure. Additional between-group differences were found for gambling types, locations, motivations, and partners. Together, AMG may represent a mood-modulating behavior indicative of multiple problematic concerns, suggesting that emotional dysregulation may be an important factor in understanding the relationship between anxiety, problem gambling, and risky behaviors in youth. Additionally, the negative reinforcing motivations to gamble to relieve anxiety may be relevant particularly to adolescents from underrepresented minority racial/ethnic groups, and the specific factors underlying this relationship warrant further investigation.

Recreational and problem gambling have been linked with adverse health and functioning outcomes among adolescents. Youth may gamble and engage in other risk-taking behaviors in casinos. There are limited data available regarding casino gambling in high-school students, and factors linked to adolescent gambling in casinos have yet to be systematically investigated. To address this gap, we analyzed cross-sectional data from 2010 Connecticut high-school students with chi-square tests and logistic regression models to examine casino gambling in relation to at-risk/problem gambling (ARPG) with respect to sociodemographic characteristics, gambling perceptions & attitudes, health/functioning measures and gambling behaviors. Approximately 11 % of adolescents acknowledged gambling in casinos. ARPG was more frequent and gambling perceptions were more permissive among adolescents endorsing casino gambling. Stronger relationships between ARPG and heavy alcohol and drug use and weaker relationships between ARPG and engagement in extracurricular activities, gambling with friends, gambling with strangers and gambling for financial reasons were observed among adolescents endorsing casino gambling. In conclusion, gambling in casinos was endorsed by a sizable minority of adolescents who gamble, and prevention efforts should consider targeting permissive attitudes towards gambling, adolescent drinking and participation in extracurricular activities when addressing underage casino gambling.

Background The items of the Patient Health Questionnaire-9 (PHQ-9) represent the criterion symptoms for DSM-IV major depression. This study evaluated the extent to which the PHQ-9 functions as a patient-reported outcome measure (PROM) specific to patients with major depressive disorder. Method Data were from the Veterans Outcome Assessment survey for 8848 patients beginning treatment in VA general mental health clinics, including 5754, re-surveyed after 3 months. The PHQ-9’s performance as a PROM was evaluated by comparing rank order correlations between both initial scores and improvements over 3 months between the PHQ-9 and several transdiagnostic PROMs across a range of diagnoses and comorbidities. Performance of PHQ-9-related patient-reported outcome-based performance measures (PROM-PM) were evaluated by comparing rates of response and remission across patient groups. Results Correlations between the PHQ-9 and transdiagnostic measures were significant and comparable in magnitude across a range of diagnoses and for cases with depression with or without comorbidities. Rates of response and remission were comparable across most patient groups. Limitations Limitations include use of clinical diagnoses as recorded in health records, and the relatively short time between assessments. Conclusions In these settings, the PHQ-9 functions more as a general measure of symptoms or distress than as a disease-specific scale. This supports its use as a PROM for patients beyond those with major depression, including those with related diagnoses and those with comorbidities, and use of related PROM-PMs in clinical settings where diagnoses may not be precise and comorbidities may be common.

Background Suicide rates are higher among veterans than non-veterans; this difference is particularly salient for females. Knowledge is sparse regarding correlates of suicidal ideation (SI) among female veterans, particularly in non-VHA samples. As such, and given that SI confers a strong risk for subsequent suicidal behavior, this study aimed to: (1) compare prevalence of recent SI by sex; and (2) determine whether deployment stressors, mental health symptoms, and recent psychosocial stressors are associated with recent SI, by sex, among post-9/11 veterans. Methods A sex-stratified analysis of cross-sectional data from 809 post-9/11, deployed veterans was conducted using the Survey of Experiences of Returning Veterans (SERV); statistical interactions between sex and correlates of interest were assessed. Results Self-reported prevalence of recent SI did not differ by sex. A statistically significant interaction between sex and combat was observed; greater combat experience was associated with increased SI for females only. While significant interactions were not observed for other correlates, differences in significant predictors and predictor effect sizes were noted across sex-stratified models. Recent housing and financial concerns were only associated with increased SI prevalence among females, whereas concern about other recent stressful life events was associated with increased SI prevalence only among males. Limitations This is a cross-sectional analysis of a national survey with limited power to detect statistical sex interactions. Conclusions While correlates of SI are relatively consistent for males and females notable differences suggest that tailored assessment and intervention based on sex may hold merit in mitigating SI among post-9/11 era Veterans.

Post-9/11 veterans frequently experience diminished mental health following military service. Life meaning is related to better mental health in veterans, yet its mechanism of action is unknown. A meaning-making model suggests that life meaning can reduce perceived stress, thus enhancing mental health. The present study tested this meaning-making model by predicting multiple dimensions of mental health (i.e., symptoms of posttraumatic stress disorder, anxiety, insomnia, and depression, and mental health quality of life) from life meaning as mediated by perceived stress.The present study was a secondary analysis of a 12-month observational study of 367 post-9/11 veterans. Participants completed demographic and health surveys at baseline, 6-month, and 12-month follow-ups. A multivariate mediation model was created predicting changes in dimensions of mental health from 6 months to 12 months.Higher life meaning at baseline predicted changes in all dimensions of mental health between 6 and 12 months, an effect mediated by changes in perceived stress between baseline and 6 months.Across dimensions of mental health, the meaning-making model was supported. Understanding post-9/11 veteran mental health from this theoretical perspective may help better tailor healthcare efforts and enhance veteran health overall.

Objective Justice-involved veteran research remains largely limited to men and those using Veterans Health Administration (VHA) services. Research inclusive of women and those not using VHA care is critical to understanding mental health and suicide risk among justice-involved veterans. This study examined whether lifetime justice involvement was associated with symptoms of posttraumatic stress disorder (PTSD) and depression, recent suicidal ideation, and lifetime suicide attempt. Method We conducted a secondary analysis of 812 post-9/11 male and female veterans. The sample included veterans eligible and not eligible for VHA care. Participants were administered the PTSD Checklist for DSM-IV, the Patient Health Questionnaire-8, and the Columbia-Suicide Severity Rating Scale. Additional questions assessed justice involvement, military characteristics, demographics, and recent use of VHA mental health care. Results History of justice involvement was associated with more severe PTSD and depression symptoms as well as suicidal ideation and suicide attempt. Associations were maintained after adjusting for sex, combat exposure, service branch, recent use of VHA mental health care, and education. Sex-stratified exploratory analyses revealed consistent findings among males; justice involvement was associated with suicide attempt among females. Current probation or parole was particularly related to depressive symptoms, suicidal ideation, and suicide attempt. Conclusions Justice-involved veterans appear to be a vulnerable population experiencing heightened psychiatric symptoms and increased risk for recent suicidal ideation and lifetime suicide attempt. Programs within VHA and the community are important for connecting justice-involved veterans to mental health services and mitigating suicide risk. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Gaming is popular among youth and gaming disorders have been introduced recently into psychiatric nomenclature systems. Motivations underlying gaming may include involvement to reduce negative emotional states and thus may link to psychiatric and overall health. Thus, the extent to which adolescents engage in gaming to relieve anxiety warrants additional investigation. Data from 2005 Connecticut high-school students were used to examine how adolescents who reported gaming to relieve tension or anxiety differed from those who reported gaming but not to relieve tension or anxiety on measures of demographics, academic performance, general health, extracurricular activities, dysphoria/depression symptoms, substance use, and aggressive or violent behaviors. Chi-square analyses and binomial and multinomial logistic regression models were conducted. Gaming to relieve anxiety was more prevalent in boys and Hispanic and Asian adolescents and associated with less extracurricular involvement, poorer academic performance, increased cigarette and other drug use, problematic internet use, and depression. Participants with gaming to relieve tension or anxiety were also more likely to report weapon-carrying, missing school because they felt unsafe, having been threatened with a weapon, having engaged in physical fights, and having experienced injuries from fights. As gaming to relieve anxiety was related to mental-health- and functioning-related measures, additional research is needed to examine the precise natures of these relationships and to translate the information into improved intervention strategies.

Background Religiousness/spirituality (R/S) has been associated with greater mental wellbeing in US military veterans, but this work has been conducted primarily with older veterans, cross-sectionally, using a constrained set of R/S and mental health constructs, and lacking consideration of the influence of sex and race/ethnicity. Further, few studies have focused on associations of R/S with veterans’ physical health. Method We investigated the relationship of R/S to mental and physical health in a sample of 410 Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn veterans within five years of military separation and one year later. Results In the full sample, R/S coping, R/S organized practices and private prayer minimally related to mental or physical wellbeing, yet R/S struggle related inversely to concurrent and subsequent mental and physical health. For women only, higher baseline organized R/S was associated with lower subsequent stress, anxiety, and insomnia. For men only, baseline R/S coping predicted subsequent poorer physical quality of life and baseline R/S struggle predicted subsequent increased pain. For minority race but not white veterans, higher baseline private prayer predicted increased current pain level at 12 months; for Latinx ethnicity only, higher baseline R/S coping predicted increased quality of life a year later and higher baseline R/S struggle predicted higher subsequent levels of anxiety. Conclusions R/S, broadly conceptualized, may relate to wellbeing in military veterans in different ways depending on sex and race/ethnicity, with implications for the role of R/S and R/S struggle in personalizing mental and physical health services.

Objective Post-9/11 military deployment is commonly reported as stressful and is often followed by psychological distress after returning home. Yet veterans also frequently report experiencing meaningful military engagement (MME) that may buffer detrimental effects of military stressors. Focusing on the under-investigated topic of association of MME with post-deployment psychological adjustment, this study tests gender differences in MME and post-deployment outcomes. Method This cross-sectional study examined the relationship of MME with deployment stressors, subsequent psychological distress (posttraumatic stress symptoms (PTSS) and depression), and gender among 850 recent-era U.S. veterans (41.4% female). Results On average, both male and female veterans reported high MME. Greater MME was associated with less PTSS and depression following combat and general harassment, and more depression after sexual harassment. For men only, MME associated with less PTSS after sexual harassment. Conclusions MME is high among post-9/11 veterans, but its stress-buffering effects depend on gender and specific stressor exposure.

PURPOSE: Gambling on the lottery is a prevalent behavior, and lottery products are increasingly available in online and electronic formats. As lottery-purchasing is prevalent in adolescents, this study systematically examined relationships between lottery-purchasing and problem-gambling severity and gambling perceptions and attitudes, and differences in the relationships between problem-gambling severity and measures of health/functioning and gambling characteristics among lottery-purchasing groups. METHODS: Participants were 1,517 Connecticut high-school adolescents with past-year gambling. Chi-square and logistic regression models were conducted, and interactions between problem-gambling severity and lottery-purchasing status on multiple outcomes were determined. RESULTS: Lottery-purchasing, compared to non-lottery-purchasing, adolescents had greater problem-gambling severity and reported more permissive gambling attitudes and greater parental approval of gambling. Significant between-group differences were observed, with at-risk/problem-gambling more strongly associated with having friends and adult gambling partners among non-lottery-purchasing adolescents, and machine and online gambling, and gambling alone more strongly associated among lottery-purchasing adolescents. CONCLUSIONS: Greater problem-gambling severity, permissive gambling attitudes, and parental approval of gambling in lottery-purchasing adolescents suggest that parenting contexts are important considerations in prevention efforts targeting problem gambling in youths. Between-group differences in associations between problem-gambling severity and gambling types and partners may identify high-risk groups associated with more solitary gambling behaviors for whom targeted interventions may be adapted.

Background and aimsSelf-injurious behaviors (SIBs) and problematic shopping (PS) are both prevalent in adolescents. These behaviors have been proposed as behavioral addictions and linked to impulsivity (Imp) and sensation-seeking (SS). They are also associated with negative mental health and psychosocial measures. This study examined relationships between PS and SIB in adolescents. It also examined how PS and SIB relate to Imp and SS, and interactions between PS and SIB in relation to health/functioning measures.MethodsSurvey data from 2,624 Connecticut high-school students were evaluated using chi-square analyses. Next, logistic regression models were used to assess relationships between PS and measures of SIB. T-tests compared Imp and SS in adolescents with and without PS and SIB. Interaction analyses assessed effects of PS on relationships between SIB and health/functioning measures.ResultsAdolescents with PS had 3.43-fold higher odds of endorsing lifetime SIB than those without PS, and were more likely to exhibit severe SIB and disruption due to SIB. PS and SIB were associated with elevated Imp and SS. Interaction analyses revealed that in adolescents with PS, the relationships between SIB and substance use was weaker than in adolescents without PS. This suggests PS accounts for variance in relationships between SIB and substance use.Discussion and conclusionsPS is strongly related to SIB prevalence, severity, and impairment in adolescents, and weakens associations between SIB and substance use. PS should therefore be considered for prevention efforts for SIB. Further research should investigate mechanisms connecting PS and SIB and explore possible interventions targeting associated features like Imp and SS.

More than 50% of individuals who enter treatment for posttraumatic stress disorder (PTSD) are prescribed a psychotropic medication. To date, however, data are limited regarding the prevalence and determinants of discontinuation of psychotropic medication in this population. To address this gap, we analyzed data from 154,953 veterans newly diagnosed with PTSD who were seeking VA treatment and followed them for one year to identify the prevalence and determinants of medication discontinuation. A hazard analysis was conducted to identify factors associated with discontinuation of antidepressant, anxiolytic/hypnotic and antipsychotic medications. Binomial regressions examined the role of these factors in early discontinuation (within 30 days). Results revealed that 71.8% of veterans discontinued medication treatment within 180 days, and 34.6% within 30 days. The strongest risk factors associated with discontinuing medication were no engagement in adjunctive psychotherapy and prescription of a single medication. Older veterans were less likely than younger veterans to discontinue treatment. Similar risk factors were associated with medication discontinuation in the first 30 days. These results suggest that psychiatric comorbidities, age, and race are key risk factors for poor medication adherence, and underscore the importance of early intervention and patient education in promoting adherence to pharmacotherapy for PTSD.

The desire to escape from pressures/anxiety represents an important motivation for problematic engagement with short-term rewarding behaviors that could contribute to the development of recognized and candidate behavioral addictions, including problematic shopping, a prevalent condition among youth in the U.S.A. characterized by excessive shopping cognitions/behaviors that lead to distress/impairment. However, to date, the specific correlates of shopping to relieve anxiety or tension have yet to be evaluated. We aimed at addressing this gap by analyzing data (N = 2556) from a high-school survey from Connecticut in an exploratory fashion. Adolescents who acknowledged experiencing a growing tension or anxiety that could only be relieved by shopping were classified as having negative-reinforcement shopping and compared to the remaining students. Data were analyzed in chi-square and logistic regression models to examine negative-reinforcement shopping in relation to socio-demographics, health correlates, gambling-related perceptions/attitudes, and problem-gambling severity/gambling behaviors. Negative-reinforcement shopping was more frequent in female and Hispanic students, was linked to more permissive gambling attitudes and at-risk/problematic gambling, and was associated with the use of alcohol, tobacco, marijuana, and other drugs, dysphoria/depression, and weapon-carrying and physical fighting. Taken together, these findings highlight adverse measures of health and functioning linked to negative-reinforcement shopping that may be particularly relevant to girls and Hispanic youth. Additional efforts to prevent negative outcomes are warranted.

This special issue highlights new research in psychological assessment and measurement-based care. Psychological assessment has historically been central to the field of psychology. Measurement-based care, considered an evidence-based practice, is a special type of applied psychological assessment in which patient-reported outcome measures are used to track progress in care as part of a clinical process. We discuss how the knowledge from these two distinct but related fields can synergistically advance mental health treatment. The articles in this special issue demonstrate ways to practically implement measurement-based care, the application of measurement-based care in special populations, as well as feature advances in psychological assessment that support the practice of measurement-based care. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

In 2016, the Department of Veterans Affairs (VA) began the Measurement-Based Care in Mental Health Initiative to implement measurement-based care (MBC) across all mental health programs with the goal of making MBC the national standard of care. Phase 1 of this initiative, beginning in fall 2016 through fall 2017, was carefully designed to meet the ambitious goals of the organization while minimizing implementation barriers. Phase 1 participants reported an increase in MBC implementation across mental health programs with a simultaneous increase in the proportion of patient-reported outcome measures among veterans new to mental health care. The initiative adopted a broad range of strategies informed by implementation science to facilitate implementation at the organizational, provider, and patient level which are described here. The initiative was successful, but use of patient-reported outcome measures across VA mental health remains proportionally low. Technology, VA's hierarchical structure, and competition from other VA mental health initiatives may have slowed national implementation efforts. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Motivational characteristics such as excitement-seeking are key components of models of addiction, including problem gambling. Previous studies have established associations between excitement-seeking and problem gambling in youth. However, these studies have employed dimensional psychological assessments which are unlikely to be routinely administered. Other approaches to conceptualize excitement-seeking could be of value. In the present study, we employed a single question (What are the reasons that you gamble?) to identify adolescents who reported excitement-seeking motivation for gambling. Cross-sectional data from 2030 adolescent gamblers who participated in a Connecticut high-school survey were examined. Gambling perceptions and correlates of problem-gambling severity were examined relative to excitement-seeking and non-excitement-seeking gambling. Gambling perceptions were more permissive and at-risk/problem gambling was more frequent among adolescents with excitement-seeking gambling versus non-excitement-seeking gambling. A weaker relationship between problem-gambling severity and moderate and heavy alcohol use was observed for excitement-seeking versus non-excitement-seeking gambling. Excitement-seeking gambling is associated with more permissive gambling-related attitudes and riskier gambling behaviors and may account for some variance in adolescent risk of heavy alcohol use. A single question may provide important information for identifying adolescents who are at elevated risk of problem gambling and associated negative outcomes, although the utility of the question in specific settings warrants direct examination, especially given the observed high prevalence of excitement-seeking motivations for gambling.

Few studies have focused on homelessness among Operations Iraqi Freedom, Enduring Freedom and New Dawn (OEF/OIF/OND) veterans, especially female veterans. An explanatory model of homelessness was constructed and tested for each gender. Data collected in the United States from 833 OEF/OIF/OND veterans (41.5% female; Mage = 35.22, SD = 8.86) who completed the baseline assessment of the Survey of the Experiences of Returning Veterans between September 2011 and July 2014 were analysed. Path analysis was used to examine associations between risk factors and any lifetime homelessness, stratified by gender. Adverse childhood events (ACEs) and low social support were significantly associated with lifetime homelessness for both genders. Social support mediated associations between ACEs and homelessness, after controlling for sociodemographic factors. While sociodemographic risk factors are often considered in homeless prevention, these findings highlight the importance of social support among male and female OEF/OIF/OND veterans, underscoring the need to target this life domain in preventing homelessness.

Introduction Previous research has demonstrated an association between military sexual trauma and risk for suicide; however, risk for self-directed violence such as suicide attempt or nonsuicidal self-injury following military sexual trauma is understudied. This study examines the relationship between military sexual trauma and serious self-directed violence resulting in hospitalization, as well as whether this relationship differs by sex. Methods Participants were 750,176 Operations Enduring Freedom/Iraqi Freedom/New Dawn veterans who were enrolled in Veterans Health Administration care during the period of October 1, 2001–September 30, 2014 and who were screened for military sexual trauma. Data were analyzed in 2019. Bivariate analyses and Cox proportional hazards regression models were employed. Results Women veterans were more likely to screen positive for military sexual trauma (21.33% vs 1.63%), and women and men were equally likely to experience serious self-directed violence (1.19% women vs 1.18% men). Controlling for demographic variables and psychiatric morbidity, military sexual trauma predicted serious self-directed violence for both men and women. Further, men with military sexual trauma were 15% less likely to experience self-directed violence compared with women with military sexual trauma (hazard ratio=0.85, 95% CI=0.74, 0.98). Conclusions Military sexual trauma is associated with risk for serious self-directed violence for both men and women veterans, and the relationship may be pronounced among women. Results underscore the importance of incorporating military sexual trauma into treatment and preventative efforts for self-directed violence.

Cannabis use and related disorders are common in adults and frequently co-occur with subsyndromal and pathological gambling. However, understanding how cannabis use may moderate relationships between problem-gambling severity and psychiatric disorders remains poorly understood. Data from the National Epidemiological Survey on Alcohol and Related Conditions (N = 43,093 adults) were examined to investigate how cannabis use moderated associations between problem-gambling severity (with gambling groups based on the 10 Diagnostic and Statistical Manual [DSM-IV] inclusionary criteria for pathological gambling) and Axis I and Axis II psychiatric disorders. Problem-gambling severity groups included low frequency/nongambling, low-risk gambling, at-risk gambling, and problem/pathological gambling (PPG). Among both the group with lifetime cannabis use and that which never used cannabis, greater problem-gambling severity was associated with more psychopathology across mood, anxiety, substance-use and Axis II disorders. Significant Cannabis Use × Problem-Gambling Severity Group interactions were observed between PPG and major depression (OR = 0.35, 95% CI = [0.14-0.85]), cluster A personality disorders (OR = 0.37, 95% CI = [0.16-0.86])-especially paranoid personality disorder (OR = 0.34, 95% CI = [0.14-0.81])-and cluster B personality disorders (OR = 0.36, 95% CI = [0.18-0.75])-especially antisocial personality disorder (OR = 0.25, 95% CI = [0.11-0.60]). In all cases, associations between problem-gambling severity and psychopathologies were weaker among the lifetime-cannabis-using group as compared to the never-using group. Cannabis use moderates the relationships between problem-gambling severity and psychiatric disorders, with cannabis use appearing to account for some of the variance in the associations between greater problem-gambling severity and specific forms of psychopathology. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Introduction Sending sexually explicit text messages (“sexting”) is prevalent among US adults; however, the mental health correlates of this behavior among adults have not been studied adequately. Furthermore, there are few studies examining the related but distinct behavior of posting sexually explicit photos or videos of oneself online (posting sexual images [PSI]) and the mental health correlates of this behavior. Aim To examine associations between sexting, PSI, impulsivity, hypersexuality, and measures of psychopathology. Methods Using a national convenience sample of 283 US post-deployment, post-9/11 military veterans, we evaluated the prevalence of 2 behaviors: sexting and PSI and the associations of these behaviors with psychopathology, suicidal ideation, sexual behaviors, hypersexuality, sexually transmitted infections, trauma history, and measures of impulsivity. Main Outcome Measure Measures of psychopathology including depression, anxiety, post-traumatic stress disorder, insomnia, substance dependence, hypersexuality, and suicidal ideation, as well as measures of impulsivity, sexual behavior, and trauma. Results Sexting was found to be common among post-9/11 veterans (68.9%). A smaller number of veterans engaged in PSI (16.3%). PSI veterans were more likely to be younger, male, less educated, and unemployed. After adjusting for covariates, no associations were detected between PSI or sexting and the examined measures of psychopathology. However, PSI was associated with higher levels of impulsivity and hypersexuality, whereas sexting was not associated with these measures. Clinical Implications Results from this study suggest that not all digital sexual behaviors are associated with psychopathology. However, PSI was associated with hypersexuality and impulsivity. Those who engage with PSI may benefit from guidance on how to manage their impulsivity to prevent ego-dystonic sexual behaviors. Strengths & Limitations The strengths of this study include differentiating PSI from sexting broadly, highlighting that digital sexual behaviors are heterogeneous. Limitations include the study's cross-sectional design, which limits causal interpretations. More research is also needed in civilian populations. Conclusion PSI was less prevalent than sexting in our sample. This behavior was associated with impulsivity and hypersexuality but not with elevated levels of psychopathology. Sexting was not associated with any of these measures.

We report on studies conducted to develop outcome-based performance measures (PROM-PMs) based on generic patient-reported outcome measures (PROMs) that could support strategies for quality improvement applicable to all patients in a mental health system. Data were from the Veterans Outcome Assessment Survey at baseline and three months for the Mental Component Score (MCS-12), a widely used measure of mental health-related quality of life, for 15,540 outpatients beginning treatment in General Mental Health clinics in 140 Veterans Affairs (VA) facilities. Mental health diagnoses from medical records were coded using hierarchical categories. Mental health staffing levels and quality measures were from administrative data. Changes in MCS-12 scores were associated with demographics, baseline scores, and diagnostic categories; in fully adjusted models, differences between facilities accounted for only 0.5% of the total variance between patients. There were small but significant associations of both baseline and changes in MCS-12 scores with staffing levels and administrative measures of the quality of care that support the potential value of adjusted measures of changes in MCS-12 as a PROM-PM. Remaining issues include the low proportion of variability that can be attributed to differences between facilities and the associations of staffing and quality with possible case-mix adjustment variables.

Reports an error in "Observations from the national implementation of Measurement Based Care in Mental Health in the Department of Veterans Affairs" by Sandra G. Resnick and Rani A. Hoff (Psychological Services, 2020[Aug], Vol 17[3], 238-246). In the original article, the data reported in Figure 1 are incorrect. The baseline data point (FY16Q3) is 16.8% for Champion Sites, and 16.6% for non-Champion Sites. The final data point (FY18Q3) is 28.8% for Champion Sites, and 26.1% for non-Champion Sites. The corrected Figure 1 is present in the erratum. (The following abstract of the original article appeared in record 2019-24508-001). In 2016, the Department of Veterans Affairs (VA) began the Measurement-Based Care in Mental Health Initiative to implement measurement-based care (MBC) across all mental health programs with the goal of making MBC the national standard of care. Phase 1 of this initiative, beginning in fall 2016 through fall 2017, was carefully designed to meet the ambitious goals of the organization while minimizing implementation barriers. Phase 1 participants reported an increase in MBC implementation across mental health programs with a simultaneous increase in the proportion of patient-reported outcome measures among veterans new to mental health care. The initiative adopted a broad range of strategies informed by implementation science to facilitate implementation at the organizational, provider, and patient level which are described here. The initiative was successful, but use of patient-reported outcome measures across VA mental health remains proportionally low. Technology, VA's hierarchical structure, and competition from other VA mental health initiatives may have slowed national implementation efforts. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Racial disparities across various domains of health care are a long-standing public health issue that affect a variety of clinical services and health outcomes. Mental health research has shown that prevalence rates of posttraumatic stress disorder (PTSD) are high for Black veterans compared with White veterans, and some studies suggest poorer clinical outcomes for Black veterans with PTSD. The aim of this study was to examine the impact of racial disparities longitudinally in the U.S. Department of Veterans Affairs (VA) residential rehabilitation treatment programs (RRTPs).Participants included 2,870 veterans treated nationally in VA PTSD RRTPs in fiscal year 2017. Veterans provided demographic data upon admission to the program. Symptoms of PTSD and depression were collected at admission, discharge, and 4-month follow-up. Hierarchical linear modeling was used to examine symptom change throughout and after treatment.Black veterans experienced attenuated PTSD symptom reduction during treatment as well as greater depression symptom recurrence 4 months after discharge, relative to White veterans.This study adds to the body of literature that has documented poorer treatment outcomes for Black compared with White veterans with PTSD. Although both Black and White veterans had an overall reduction in symptoms, future research should focus on understanding the causes, mechanisms, and potential solutions to reduce racial disparities in mental health treatment.

Problematic video gaming (PVG) and problematic shopping (PS) are addictive behaviors prevalent in adolescents, characterized by positive and negative reinforcement, and associated with psychosocial impairment. This study examined how PS and PVG relate in adolescents. It also examined how PS interacts with PVG in relation to health/functioning measures. Survey data from 3,657 Connecticut high-school students were evaluated. Chi-square analyses and logistic regression models were used to assess relationships between PS and measures of PVG. Interaction analyses measured effects of PS on relationships between PVG and health/functioning measures. Relative to adolescents without PS, those with PS had 8.79-fold higher odds of exhibiting PVG and were more likely to endorse gaming to relieve anxiety and impairment due to gaming. Interaction analyses revealed that in adolescents with PS, the relationships between PVG and aggressive behaviors, including fighting, serious fighting leading to physical injury, and weapon-carrying, were stronger than in adolescents without PS. PS strongly relates to PVG, and among youth reporting PS, there are stronger associations between PVG and aggressive behaviors. Prevention efforts for adolescents should consider the co-occurrence of PS and PVG. PS and PVG may be linked by negative reinforcement and propensities for aggressive and addictive behaviors, suggesting that further research should explore possible interventions targeting stress management and maladaptive coping.

Recreational and problem gambling have been linked with adverse health and functioning outcomes among adolescents. Youth may gamble and engage in other risk-taking behaviors in casinos. There are limited data available regarding casino gambling in high-school students, and factors linked to adolescent gambling in casinos have yet to be systematically investigated. To address this gap, we analyzed cross-sectional data from 2010 Connecticut high-school students with chi-square tests and logistic regression models to examine casino gambling in relation to at-risk/problem gambling (ARPG) with respect to sociodemographic characteristics, gambling perceptionsattitudes, health/functioning measures and gambling behaviors. Approximately 11 % of adolescents acknowledged gambling in casinos. ARPG was more frequent and gambling perceptions were more permissive among adolescents endorsing casino gambling. Stronger relationships between ARPG and heavy alcohol and drug use and weaker relationships between ARPG and engagement in extracurricular activities, gambling with friends, gambling with strangers and gambling for financial reasons were observed among adolescents endorsing casino gambling. In conclusion, gambling in casinos was endorsed by a sizable minority of adolescents who gamble, and prevention efforts should consider targeting permissive attitudes towards gambling, adolescent drinking and participation in extracurricular activities when addressing underage casino gambling.

Emotion dysregulation, a risk factor for suicide ideation and attempts, has not been studied in U.S. veterans of Operations Enduring and Iraqi Freedom and New Dawn (OEF/OIF/OND). Data were collected through standardized telephone interviews and computer-based surveys from 278 OEF/OIF/OND veterans (70.6% male, 29.4% female). Bivariate analyses indicated that emotion dysregulation was associated with suicidal ideation during the past-three-months (r = 0.30, p < 0.05) and lifetime suicide attempts (r = 0.21, p < 0.05). When PTSD and depression symptoms were added to a sequential logistic regression model, emotion dysregulation was no longer significantly associated with ideation or attempt. Emotion dysregulation was associated with suicidal ideation and attempt; however, current distress had greater associations. Dysregulation is one of several factors in veteran suicide risk.

Background and aims A recent call to action highlighted the need to understand the relationship between problem gambling, violence, and health/functioning. As weapon-carrying and gambling behaviors are prevalent in adolescents, this study systematically examined relationships between weapon-carrying status and measures of problem gambling severity and gambling perceptions and attitudes, as well as how weapon-carrying status moderated relationships between problem gambling severity and measures of health/functioning and gambling behavior. Methods Participants were 2,301 Connecticut high-school adolescents. χ2 and logistic regression models were conducted. Results Weapon-carriers reported greater problem gambling severity, more permissive gambling perceptions, greater parental approval of gambling, and more family gambling concerns, compared to non-weapon-carriers. At-risk/problem gambling was more strongly associated with family, peers, and adult gambling partners among non-weapon-carriers (vs. weapon-carriers) and with machine gambling among weapon-carriers (vs. non-weapon-carriers). Discussion and conclusions Greater problem gambling severity and more permissive gambling perceptions and perceived parental approval of gambling in weapon-carrying adolescents suggest that parent–child relationships are important to be considered in prevention efforts. The moderated relationship by weapon-carrying status between problem gambling severity and gambling partners suggests a problem gambling risk group that may be less linked to gambling with traditional social support groups, and this group may benefit from targeted interventions.

Objective To evaluate the associations of self-reports of suicidal ideation and behavior using the Columbia-Suicide Severity Rating Scale (C-SSRS) in a survey of patients receiving mental health services in the Veterans Health Administration (VHA) with reports of attempts documented in medical records and administrative data. Method The C-SSRS was administered to 15,373 Veterans in the Veterans Outcome Assessment (VOA) survey. Concurrent validity was evaluated by comparing self-reports from the past 3 months with VHA records. Predictive validity was evaluated by logistic regression models using attempts over the subsequent 3 months as the outcome. Results Tests of concurrent validity found strong associations between self-reports and attempts documented in VHA records, but there were substantial numbers of discordant responses. In tests of predictive validity, area under the ROC curve for predicting future attempts was >0.8. There were differences in the distribution of responses and of psychometric properties across VHA mental health programs. Conclusions Findings support the value of screening and the validity of the self-reports based on the C-SSRS, but limitations in concordance with medical records and variability across programs suggest the need for clinical judgment in interpreting responses.

Deployment sexual trauma (DST; i.e., sexual harassment or assault during deployment in the military) is associated with physical and mental health consequences, including posttraumatic stress disorder (PTSD), depression, and suicidal ideation (SI). Less attention has been placed on factors that may offer protection from deleterious mental health outcomes following DST. Global meaning in life (i.e., purpose, beliefs, goals, and subjective feelings) has been shown to be a protective factor against PTSD, depression, and SI following combat trauma; however, the extent to which meaning in life may affect outcomes following DST has not been investigated. Cross-sectional associations and Hayes mediation models were examined using baseline interview data from the Survey of Experiences of Returning Veterans sample (SERV; 850 recently returned veterans, 352 women). DST was associated with post-deployment posttraumatic stress symptoms (PTSS), depressive symptoms, and SI severity, and with decreased sense of meaning in life. Further, meaning in life was a significant mediator between DST and each of the three outcomes, even after controlling for demographic variables and combat experiences. The mediation models did not differ by gender. Findings suggest meaning in life may be an important clinical factor, both for the identification of risk and as a point of intervention.

Nationally representative data on mental health disorder prevalence are critical to set informed mental health priorities and policies. Data indicating mental health diagnoses within our nation's veteran population treated at the Veterans Health Administration (VHA) are available, but have yet to be examined for changing trends to inform both VHA and community care. We use VHA national program evaluation data from a time of increasing military enrollment (2007) to troop draw down (2013) to examine changes over time in the number of diagnoses in veterans receiving VHA services. The number of veterans in all diagnostic categories increased during our study period with the smallest increase in psychotic disorders (8%) and the largest in posttraumatic stress disorder (71%). Trends in behavioral health diagnoses among veterans have important implications for policy and clinician competencies within VHA and community providers as veteran mental health care needs change.

Suicide is a significant public health problem associated with numerous health factors such as insomnia. Suicidal ideation is common among veterans, who often present with multiple comorbidities. The present study examined direct and indirect relationships among suicidal ideation, insomnia, depression, and alcohol use. U.S. veterans (n = 850) recently separated from military service completed phone-based interviews covering multiple domains. Tests of indirect effects and bias-corrected confidence intervals were used to conduct a cross-sectional analysis of baseline data from a larger parent study examining relationships among the latent variables of suicidal ideation, insomnia, alcohol use, and depression. In this analysis insomnia did not have direct associations with suicidal ideation (Β = 0.06, t = 0.29, p = .772) or alcohol use (Β = 0.07, t = 1.73, p = .084). Insomnia severity was, however, significantly and positively related to depression severity (Β = 0.58, t = 21.70, p .001). Additionally, more severe depression was associated with greater intensity of suicidal ideation (Β = 0.59, t = 3.64, p .001). Notably, insomnia's indirect effect on suicidal ideation was driven by depression. In this sample of returning veterans, insomnia appears to indirectly impact suicidal ideation through its relationship with depression. This finding suggests the potential utility of addressing insomnia as part of an overall approach to reducing depressive symptomatology and indirectly, suicidal ideation.

From 2005 to 2016, the Veteran suicide rate increased 25.9%. Reducing this rate is a top priority for the Department of Veterans Affairs. In 2017, a policy change expanded emergent mental health services to include previously ineligible Veterans discharged under other than honorable conditions. To date, research examining the relationship between military discharge type and suicide risk has been limited.This study aimed to examine the association between discharge type (honorable versus administrative) and active suicide ideation among Veterans participating in the Survey of Experiences of Returning Veterans (N=850, data collection 2012-2015 and data analysis 2017-2018) using logistic regression. Stratified analyses explored whether gender, time since military separation, or recent mental health service use moderated this relationship.The prevalence of suicide ideation was significantly higher (p0.01) among Veterans reporting administrative discharge (23.1%, 95% CI=12.8, 33.3 vs 10.6%, 95% CI=8.4, 12.8). However, after accounting for lifetime suicide attempt history, combat experiences, posttraumatic stress disorder symptoms, depression, and drug dependence, discharge was no longer associated with suicide ideation. Recent mental health service use and time since separation significantly modified this relationship. The relationship was only significant among Veterans not using mental health services (OR=4.8, 95% CI=1.3, 18.2) and among transitioning Veterans2years from separation (OR=3.6, 95% CI=1.4, 9.2).These findings suggest that recognized risk factors for suicide, such as a history of mental health conditions, account for the increased prevalence of suicide ideation among Veterans with administrative discharges and that mental health services may have the potential to mitigate such risk in this high-risk Veteran population.

Objective Although several treatments for PTSD have demonstrated efficacy, a substantial portion of patients do not experience clinically significant improvement. Predictors of treatment response are poorly understood. The current study was designed to investigate predictors of PTSD symptom change in a large national sample of treatment-seeking Veterans with PTSD. Method We analyzed predictors of treatment response among Veterans engaged in residential PTSD treatment from 2012 to 2013 (N = 2715). Multilevel modeling was used to assess the association between individual-level factors and symptom improvement from treatment entry to post-discharge. Guided by the theory of Resources, Life Events and Changes in Psychological States, we hypothesized that individuals with greater psychological, social/contextual, material, and physical health resources would exhibit better treatment response. Results In adjusted analyses, accounting for facility, factors that predicted better treatment response included female gender, more psychological and social/contextual protective factors, and more years of education. Factors that predicted worse treatment response included Black race, comorbid personality disorder, greater pain severity, and current application for disability-related compensation. Conclusions These findings highlight factors that place individuals at risk of poor treatment response. Treatment modifications may be needed in order to optimize response for subgroups who are less likely to benefit from residential PTSD treatment.

Deployment sexual trauma is associated with post-deployment suicidal ideation. No studies have examined the role of social support in this association. The present study examined if perceived unit support and post-deployment support influenced the association between deployment sexual trauma and suicidal ideation. 824 post-9/11 veterans (480 men, 344 women) from the Survey of Experiences of Returning Veterans completed the Deployment Risk and Resilience Inventory-2 and Columbia-Suicide Severity Rating Scale. Age, possible depression, posttraumatic stress disorder symptoms, and lifetime suicide attempt were covaried. Among men, post-deployment support moderated the association between deployment sexual trauma and suicidal ideation; deployment sexual trauma predicted suicidal ideation only for men reporting low post-deployment support. Among women, post-deployment support mediated the association between deployment sexual trauma and suicidal ideation. Unit support neither moderated nor mediated the association between deployment sexual trauma and suicidal ideation. Among men who experience deployment sexual trauma, those with low perceived post-deployment support may be at particularly elevated risk for suicidal ideation and may benefit from more intensive monitoring and interventions that bolster social support. Increasing perceived post-deployment support for women who experience deployment sexual trauma is also warranted. Determining optimal ways to strengthen post-deployment support for sexual trauma survivors is essential.

Objectives US military veterans face many challenges in transitioning to civilian life; little information is available regarding veterans' reintegration experiences over time. The current study characterized veterans' postdeployment stressful life events and concurrent psychosocial wellbeing over one year and determined how stressors and wellbeing differ by demographic factors. Methods Recent Post-911 veterans (n = 402) were assessed approximately every three months for 1 year. Participants were 60% men, primarily White (78%), and 12% Latinx; the average age was 36 years. Results The frequency of stressful events decreased over time but was higher for men and minority-race veterans (independent of time since separation). Veterans reported high mean levels of posttraumatic stress disorder, anxiety, and insomnia symptoms, which improved slightly over time. Minority-race and Latinx veterans had higher symptom levels and slower rates of symptom reduction. Conclusion Veterans remain distressed in their overall transition to civilian life. Interventions to promote resilience and help veterans manage readjustment to civilian life appear urgently needed.

Studies have examined relationships between suicidality and problem gambling and suicidality and Axis I psychiatric disorders. However, questions remain regarding how suicidality may influence relationships between problem-gambling severity and Axis I disorders. Using a sample of 13,543 participants with mood symptomatology from Wave 1 of the National Epidemiologic Survey of Alcohol and Related Conditions study (NESARC), we examined the relationship between different levels of problem-gambling severity and DSM-IV Axis I psychiatric disorders according to suicidality level. Bivariate analyses were conducted to examine the association between problem-gambling severity, sociodemographic characteristics, and presence or absence of past-year Axis I disorders according to suicidality status. Next, a series of adjusted logistic regression analyses evaluated the relationships between problem-gambling severity and psychopathology according to suicidality level. The relationships between Axis I psychiatric disorders and problem-gambling severity were largely not moderated by suicidal ideation or attempt. A possible exception was observed with panic disorder in which a stronger relationship was observed in the relationship between low-risk gambling (vs low-frequency/non-gambling) in the group with suicide attempts as compared with that without attempt or ideation, suggesting the importance of considering subsyndromal gambling behaviors, particularly among individuals with panic disorder and suicidal tendencies.

This study addressed ongoing questions about the meaning of patients' perceptions of change during treatment. The study used data from the Veterans Outcome Assessment survey for patients with a depressive disorder, without mental health comorbidities, treated in Department of Veterans Affairs general mental health clinics (n = 694). Perceived changes in problems/symptoms, other domains, and the quality of communication with providers were evaluated with items from the Experience of CareHealth Outcomes (ECHO) survey. Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9). Linear regression models evaluated associations of perceived change at 3-months post-baseline with observed change in PHQ-9 scores, scores on other patient-reported outcome measures (PROMs), and ratings of communication with providers. Patients' reports of their clinical condition at follow-up together with ratings of communication accounted for approximately one-third of the variance in patients' perceptions of change. Adding change-scores based on baseline and follow-up scores on the PHQ-9 and other PROMs did not improve model fit. The findings suggest that patient reports of perceived change during treatment reflect their current clinical state and their experience of care more closely than actual changes in the PHQ-9 or other PROMs.

Background Patient-centeredness is a cornerstone of substance use disorder (SUD) treatment. Patient-experience measures are potential tools for the routine assessment of patient-centered SUD care and may be valuable measures to inform quality monitoring improvement efforts. Little research exists on the predictive validity of patient-experience measures in SUD care. Purpose We report on findings from the Veterans Outcome Assessment (VOA) survey that provides information on Veterans Health Administration SUD specialty care at treatment initiation and approximately 3-months post-initiation. Methods The VOA includes patient-reported outcomes across multiple domains, including the Brief Addiction Monitor (BAM-R), the Short-Form-12 (SF-12) and the Experience of Care and Health Outcome Survey (ECHO), and provides patient reports of the quality of provider communication and overall quality of SUD care. Results Nearly 40% of veterans in SUD care gave the highest possible ratings for communication and quality at both baseline and follow-up. Ratings of communication at 3-months were associated with treatment discontinuation and both ratings of communication and quality at 3-months and were independently associated with SUD symptoms and with mental well-being at 3-months. Conclusions This study provides preliminary support for the inclusion of patient experience measures, particularly ratings of provider communication, as part of routine assessment in SUD care. However, further work on the validity of ratings of provider communication using additional methodologies is likely important before piloting the inclusion of such measures in routine assessment, such as in measurement base care.

Advancements in technologies and their mass-scale adoption throughout the United States create rapid changes in how people interact with the environment and each other and how they live and work. As technologies become commonplace in society through increased availability and affordability, several problems may emerge, including disparate use among groups, which creates divides in attainment of the beneficial aspects of a technology’s use and coinciding mental health issues. This chapter briefly overviews new technologies and associated emerging applications in information communication technologies, social media networks, video games and massively multiplayer online role-playing games, and online gambling, then examines the prevalence of use among the general population and its subgroups and further discusses potential links between mental health issues associated with each technology and implications of overuse.

For mental health, evidence linking the patients' experiences of care with treatment outcomes is limited. We report findings from the Veterans Outcome Assessment (VOA) survey of Veterans beginning treatment in Veterans Health Administration (VHA) mental health programs with follow-up after approximately 3 months. In addition to assessments of symptoms and functioning, it includes key components of the Experience of Care and Health Outcomes (ECHO) survey including patient reports of communication with clinicians and of the overall quality of mental health care. For Veterans treated in VHA general mental health clinics, significant associations between ratings of communication and quality at baseline, and both retention in treatment and patient-reported outcomes assessed at follow-up demonstrate that better patient experience predicts more favorable outcomes. Further research is necessary to determine whether including them in measurement-based care could improve outcomes by facilitating the early identification of problems in providing care.

The Veterans Outcomes Assessment (VOA) program surveys Veteran Health Administration (VHA) patients when they begin mental health treatment and at follow-up at three months to obtain patient-reported outcomes measures (PROM). It complements VA's evolving program in measurement-based care by providing additional data that can be useful for program evaluation including assessments of patients who have not been seen for ongoing mental health care. In principle, it provides data on intention-to-treat outcomes for program evaluation to complement the outcomes for patients who are receiving ongoing treatment that can be derived from measurement-based care. VOA findings confirm differences in outcomes between patients who have continued to be seen for treatment and those who have not. Patients in general mental health clinics with no encounters between the baseline and follow-up assessments who reported discontinuing care because they did not want or need treatment improved more, and those who discontinued due to problems improved less than those who remained in treatment. Experience with VOA has identified a number of issues that must be addressed before it is possible to use intention-to-treat outcomes for program evaluation.

Background Suicidal thoughts are common among veterans with posttraumatic stress disorder (PTSD). The aim of this study was to examine the prevalence and correlates of four courses of suicidal (SI) among veterans receiving residential PTSD treatment. Methods A total of 1,807 veterans receiving residential PTSD treatment at Department of Veterans Affairs medical facilities who completed self-report measures at admission and discharge were included. Results The prevalence of SI courses were No SI (33.6%), Remitted SI (23.0%), SI onset (6.0%), and Chronic SI (37.4%). There were group differences between the four SI courses in PTSD symptoms at baseline, magnitude of PTSD symptom change during treatment, race/ethnicity and baseline depression, substance use, physical functioning, and pain. Chronic SI was associated with highest baseline PTSD, depression, substance use, pain and worse physical functioning. Remitted SI course was associated with greatest pre-posttreatment PTSD improvement, followed by No SI, Chronic SI, and SI Onset. Multinomial logistic regressions revealed that PTSD symptom improvement and baseline PTSD symptoms most consistently related to symptomatic SI courses compared to less symptomatic or No SI courses. Receipt of trauma-focused psychotherapy (none, some, or adequate) and length of stay were not related to SI courses and did not differ between groups. Conclusions Findings indicate that treating PTSD symptoms could be impactful for reducing suicidal thoughts. Although many veterans had remitted or reduced severity of SI at discharge, a significant proportion of veterans reported SI at discharge (43.4%), potentially highlighting the need for suicide specific treatment interventions within the context of PTSD treatment.

Deaths of despair, a composite outcome including suicide and drug- and alcohol-related deaths, have been increasing, especially in subpopulations and geographic areas sensitive to economic and social hardships. The Veterans Health Administration (VHA) has begun evaluating the utility of this concept to guide planning and evaluations of clinical and preventive services for Veterans. In this study, mortality rates for middle-aged American men for 2013 to 2017 were from CDC WONDER, and rates for all Veterans, those using VHA healthcare services (VHA-utilizers), and other (non-VHA) Veterans were derived from National Death Index data. Findings demonstrated that rates for the composite were higher in VHA-utilizers and lower in non-VHA Veterans than middle-aged American men, consistent with use of VHA services by Veterans with the greatest needs. State rates in Veteran men were significantly and positively correlated with state rates for American men, and both were correlated with other characteristics of the social environment. The lack of correlation between rates for suicide and drug-related deaths indicates that deaths of despair cannot be modeled by assuming parallel paths from reactions to community-based stressors to the component outcomes; models should allow for an impact of community characteristics on partitioning between outcomes.

Gambling is prevalent among adolescents and adolescents are vulnerable to experiencing gambling-related problems. Although problem gambling and suicidal behavior have been linked in adults and self-injurious behaviors may predict future suicidality, prior studies have not investigated relationships between problem-gambling severity and self-injurious behavior in adolescents. Data from 2234 Connecticut high-school students were analyzed in chi-square tests and logistic regression models to examine self-injurious behaviors in relation to at-risk/problem gambling with respect to sociodemographic characteristics, gambling attitudes and perceptions, and extracurricular and health measures. Individuals who engaged in self-injurious behavior (versus those who did not) reported more permissive views towards gambling and were more likely to exhibit at-risk/problem gambling. Stronger relationships between problem-gambling severity and gambling in casinos (OR 4.85, 95%CI 1.94, 12.12) and non-strategic gambling (1.92, 95%CI 1.01, 3.66) were observed in adolescents who acknowledged engagement in self-injurious behavior versus those who did not. Links between self-injurious behaviors and more permissive gambling attitudes and perceptions and at-risk/problem gambling suggest the need for improved interventions targeting co-occurring self-injurious behaviors and gambling. Stronger relationships between problem-gambling severity and casino and non-strategic gambling among adolescents with self-injurious behaviors suggest adolescents with self-injurious behavior may engage in specific forms of gambling as maladaptive coping strategies to alleviate suffering. Prevention and treatment approaches targeting distress management and improving adaptive coping skills may be important for targeting self-injurious behaviors in adolescents with at-risk/problem gambling.

Although the link between posttraumatic stress disorder (PTSD) and aggression has been repeatedly demonstrated, to our knowledge no research has examined whether PTSD symptom reductions are linked to less aggression after treatment. The current study aimed to address this gap in the literature by examining the association between reductions in PTSD symptoms and posttreatment aggression among 2,275 veterans in residential treatment for PTSD across 35 Veterans Health Administration sites. We estimated a multilevel model that examined the effect of clinically significant PTSD symptom change on aggression at 4-month posttreatment follow-up, and found significant within-site and between-site contextual effects of clinically significant changes in PTSD symptoms on follow-up aggression. Findings revealed that veterans who reported clinically significant changes in their PTSD symptoms had lower levels of aggression at follow-up than veterans at the same treatment site who did not report clinically significant PTSD change. After we controlled for individual clinically significant PTSD change, participants in treatment sites where the rates of clinically significant PTSD change were higher overall had lower levels of aggression at follow-up. The model explained over one-fourth of the variability in aggression, R2 = .26. Findings from the current study extend previous research that has shown associations between PTSD and aggression, by revealing that clinically significant change in PTSD during residential treatment is associated with less aggression at follow-up. These findings suggest that interventions that effectively reduce PTSD symptoms may also help reduce risk for aggression.