VA Mid-Atlantic Health Care Network

The goal of this pilot study was to describe the relationship between early psychosocial risk (i.e., adverse childhood experiences, neighborhood disadvantage, multiple relocations) and brain health outcomes among Veterans with mild TBI. Veterans (N = 76) with mild TBI participated at an outpatient VA. This cross-sectional study involved the collection and analysis of retrospective self-report data and neuropsychological tests. Interviews and surveys included the Clinician-Administered PTSD Scale for DSM-5, Mid-Atlantic MIRECC Assessment of Traumatic Brain Injury, Childhood Experiences Survey, Neurobehavioral Symptom Inventory, PTSD Checklist for DSM-5, and Patient Health Questionnaire. Neuropsychological tests included the California Verbal Learning Test-3, Controlled Oral Word Association and Animal Naming, Stroop, Trail Making Test, and WAIS-IV subtests (Digit Span, Letter Number Sequencing). Global deficit scores were calculated. Participants endorsed a wide range of psychosocial risk factors. Cognitive functioning was generally intact. There were few significant relationships between early psychosocial risk and outcomes. Early psychosocial risk was not associated with mental health or cognitive functioning.

While social support is widely viewed as a protective factor against posttraumatic stress disorder (PTSD), few studies have directly tested whether social support buffers the long-term effects of pre-existing PTSD symptoms or baseline combat exposure among Veterans (i.e., the stress-buffering hypothesis). To address this gap, the current study tested perceived social support as a moderator of the effects of baseline PTSD symptoms and combat exposure on PTSD symptoms at 10-year follow up in a sample of post-911 Veterans (N = 783). Higher levels of combat exposure and baseline PTSD symptoms predicted elevated PTSD symptoms at 10-year follow-up. Perceived social support moderated these effects, such that the impacts of baseline symptoms and combat exposure were attenuated for Veterans with high levels of perceived support. However, buffering effects were less evident at higher levels of combat exposure and were not significant at very high levels of baseline PTSD symptoms. While findings are broadly consistent with the stress-buffering hypothesis, results of the present study suggest that the benefits of perceived social support may be less evident at higher levels of combat exposure. Results also offer preliminary evidence that perceived social support is less protective for Veterans with severe pre-existing symptoms.

US veterans have a higher risk of suicide than the general civilian population. Research suggests that COVID-19 infection is associated with increased risk of suicide attempts or other forms of self-directed violence (SDV) among veterans. To identify subgroups of veterans with high risk of post-COVID-19 suicide attempts or SDV. This is a retrospective cohort study conducted using data from the Veteran Health Administration (VHA). Participants included VHA enrollees with a first case of COVID-19 between May 1, 2021, and April 30, 2022, residing in the 50 states or Washington, DC. COVID-19 infection. The main outcome was a suicide attempt or SDV 12 months after COVID-19 infection. Latent class analysis was used to identify subgroups. Outcome rates and 95% CIs per 10 000 veterans were calculated. Multinomial regressions were used to model outcome risk and marginal risk ratios with 99.5% CIs to compare outcome risk across latent classes. The cohort included 285 235 veterans with COVID-19 and was predominantly male (248 118 veterans [87.0%]) and younger than 65 years (171 636 veterans [60.2%]). Chronic pain (152 788 veterans [53.6%]), depression (98 093 veterans [34.4%]), and posttraumatic stress disorder (79 462 veterans [27.9%]) diagnoses were common. The 12-month outcome rate was 73.8 events per 10 000 (95% CI, 70.7-77.0 events per 10 000). Two latent classes with high rates of suicide attempt or SDV were identified. The first high-risk subgroup (46 693 veterans [16.4%]) was older (34 472 veterans [73.8%] aged ≥65 years) and had a high prevalence of physical conditions (43 329 veterans [92.8%] had hypertension, and 36 824 veterans [78.9%] had chronic pain); the 12-month outcome rate was 103.7 events per 10 000 (95% CI, 94.7-113.3 events per 10 000). The second high-risk subgroup (82 309 veterans [28.9%]) was generally younger (68 822 veterans [83.6%] aged <65 years) with a lower prevalence of physical conditions but high prevalence of mental health conditions (61 367 veterans [74.6%] had depression, and 50 073 veterans [60.8%] had posttraumatic stress disorder); the 12-month outcome rate was 162.9 events per 10 000 (95% CI, 154.5-171.8 events per 10 000), and compared with the lowest risk subgroup, the 12-month risk of suicide attempts or SDV was 14 times higher in this subgroup (risk ratio, 14.23; 99.5% CI, 10.22-19.80). In this cohort study of veterans with COVID-19, 2 veteran subgroups with distinct health profiles had high rates of suicide attempts and SDV, suggesting that different groups may require different approaches to suicide prevention after COVID-19.

Cognitive behavioral therapy for insomnia (CBTi) is the standard of care for treating insomnia disorder, but access is limited. Alternative approaches are needed to expand access to the standard of care. To examine the effectiveness of a nurse-supported, self-directed behavioral insomnia intervention for decreasing insomnia severity and improving sleep outcomes among veterans, a population with considerable mental health comorbidity. This randomized clinical trial included 178 patients with insomnia disorder who were recruited from a Veterans Affairs hospital (Durham VA Healthcare System) from September 2019 to April 2022 and randomized following baseline assessment; follow-ups were conducted at 8 weeks (primary end point) and 6 months. Data analysis was primarily conducted during the summer of 2023 and concluded in May 2024. Six weekly phone calls from a nurse interventionist plus assigned treatment manual readings covering CBTi treatment components. The health education manual focused on health topics but not sleep. The primary outcome was the Insomnia Severity Index (score range, 0-28; remission <8; differential improvement of 3 points targeted) score assessed at 8 weeks postrandomization. Secondary outcomes were sleep outcomes, depression, fatigue, treatment response, and remission. Of 178 study participants, the mean (SD) age was 55.1 (13.2) years, and 128 (71.9%) identified as men. At 8 weeks, Insomnia Severity Index scores decreased by an estimated mean (SE) of 5.7 (0.51) points in the intervention group and 2.0 (0.47) points in the control group, a differential mean improvement of 3.7 points (95% CI, -5.0 to -2.4; P < .001). Differences were sustained at 6 months (mean, -2.8; 95% CI, -4.4 to -1.3; P < .001). The intervention also resulted in greater improvements at 8 weeks postrandomization in diary sleep onset latency, wake after sleep onset, and sleep efficiency and actigraphy sleep efficiency; these differences were sustained at 6 months. At 8 weeks, depression and fatigue were significantly reduced, and the odds of treatment response and remission were greater in the intervention group compared with controls. This randomized clinical trial found that despite greater prevalence of mental health conditions and sleep difficulties among veterans, a nurse-supported self-directed CBTi was more effective than health education control for reducing insomnia severity and improving sleep outcomes. Although less effective than therapist-delivered CBTi, findings were comparable with other trials using modified CBTi protocols. ClinicalTrials.gov Identifier: NCT03727438.

This cross-sectional study examines the association of protective psychological characteristics with mental, psychosocial, cognitive, and physical functioning in military veterans.

Background: Substance use disorders (SUDs) negatively impact veterans and their relationships with others. Although there are several evidence-based treatments for SUD symptoms, there is less research on whether reduction in SUD symptoms coincides with reduction in interpersonal difficulties. Methods: In this study we examined the relationship between SUD and relationships in a national sample of 458 veterans who received approximately 12 sessions of Cognitive Behavioral Therapy for Substance Use Disorders (CBT-SUD) through the Veterans Health Administration (VHA). Results: Parallel latent growth curve modeling (LGCM) indicated that self-reported alcohol use, drug use, and interpersonal difficulties decreased over the course of treatment. Alcohol and drug use were positively associated with each other and with interpersonal difficulties at each time point, and baseline alcohol and drug use were negatively associated with the reduction of use over time. However, there was little evidence that reductions in substance use led to a reduction in interpersonal difficulties (or vice-versa). Conclusions: Findings highlight promising strategies to further understand how CBT-SUD may enhance reductions in substance use as well as improve relationships with family and friends.

ABSTRACT Background Historically, resilience has often been conceptualized as the sustained lack of symptoms following trauma exposure. In line with a novel conceptualization of resilience as being dynamic over lifespan, determined by interacting biological and environmental factors, we examined the VA Mid-Atlantic Post Deployment Mental Health Repository (PDMH) comprised of 3876 US Military Veterans with and without PTSD diagnoses. Methods We performed regression modelling to study the relationship between resilience (measured with Connor Davidson Resilience Scale; CD-RISC), posttraumatic stress disorder (PTSD) severity (Davidson Trauma Scale; DTS), social support (Medical Outcome Study Social Support Survey; MOSSS), combat exposure (Combat Exposure Scale; CES), childhood trauma (Trauma Life Events Questionnaire; TLEQ), and demographic factors. CD-RISC was positively correlated with years of education and negatively correlated with DTS, CES and TLEQ scores. Results We found an interaction between CD-RISC and CES in predicting PTSD severity (Davidson Trauma Scale). Specifically, high resilience predicted lower PTSD symptom severity than low resilience, this relationship was amplified with increasing levels of combat exposure. Structural equation modelling (SEM) identified an optimal latent variable that represents resilience and relationships between latent variables for resilience, trauma, and illness. We derived a resilience latent variable composed of age, education level, MOSSS and race. Conclusions Our results support a conceptualization of resilience as a multifactorial determinant that coexists with PTSD, a state rather than trait variable, and can be quantified by biological and behavioural metrics. HIGHLIGHTS • Historically, resilience has often been conceptualized as the sustained lack of symptoms following trauma exposure. • We examined the VA Mid-Atlantic Post Deployment Mental Health Repository (PDMH) comprised of 3876 US Military Veterans. • We found an interaction effect between CD-RISC and CES in predicting PTSD severity (Davidson Trauma Scale)

Abstract Genome-wide association studies (GWAS) identify genetic variants underlying complex traits but are limited by stringent genome-wide significance thresholds. Here we dramatically relax GWAS stringency by orders of magnitude and apply GRIN (Gene set Refinement through Interacting Networks), which increases confidence in the expanded gene set by retaining genes strongly connected by biological networks from diverse lines of evidence. From multiple GWAS summary statistics of suicide attempt, a complex psychiatric phenotype, GRIN identified additional genes that replicated across independent cohorts and retained genes that were more biologically interrelated despite a relaxed significance threshold. We present a conceptual model of how these retained genes interact through neurobiological pathways to influence suicidal behavior and identify existing drugs associated with these pathways that would not have been identified under traditional GWAS thresholds. We demonstrate that GRIN is a useful community resource for improving the signal to noise ratio of GWAS results.

BACKGROUND Rural, primary care providers face particular challenges with adapting the delivery of care in the setting of the Coronavirus Disease of 2019 (COVID-19) pandemic. Project ECHO® is a virtual, case-based platform centered on collective learning. As a regional Area Health Education Center (AHEC), we developed two Project ECHO® series aimed at disseminating best practices and creating a community of shared experiences for rural providers.METHODS On March 30, 2020, we launched two Project ECHO® series pertaining to COVID-19: the Primary Care COVID-19 Collaborative series and the Practice Support for COVID-19 Preparedness series. These series each occurred twice weekly, concluding in February 2021, and were free to attend. Topics include COVID-19-specific management as well as strategies for adapting the delivery of care during the pandemic. We assessed engagement per county as well as attendee evaluations.RESULTS In the first month, we hosted 19 sessions with 283 participants from 37 counties in North Carolina. Providers felt the most impactful aspects of the sessions were the changes to their practice and the lateral learning from peers in the region.LIMITATIONS In review of our survey responses, a small percentage of our participants do not appear to have direct patient care roles, so we believe this impacted our survey results particularly in regard to relevance to clinical practice and change to clinical practice.CONCLUSIONS Project ECHO® is an effective platform for quickly disseminating information and creating a sense of community in the midst of the social distancing required during the pandemic.