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Mild traumatic brain injuries (MTBIs) are common in sports, military service, and daily life. Limited data are available on the mental health needs of veterans with a history of MTBI who are seeking care in the community. The purpose of this article is to describe the mental health and psychosocial difficulties of a group of treatment-seeking veterans with a history of MTBI. The authors examined psychiatric comorbidities, psychosocial problems, and symptom burden in a cross-sectional sample of 129 treatment-seeking post-9/11 U.S. service members and veterans who reported a history of MTBI during a mental health evaluation at a nonprofit specialty outpatient clinic. The most common clinician-rated comorbid psychiatric diagnoses included posttraumatic stress disorder (N=113; 88%), major depressive disorder (N=57; 44%), alcohol use or abuse (N=56; 43%), and substance use or abuse (N=28; 22%). In addition, these service members and veterans endorsed high rates of anger and aggression, hazardous drinking, bodily pain, sleep difficulties, concentration problems, unemployment, and difficulties with family functioning. These clinical data suggest that post-9/11 service members and veterans who present with a history of MTBI represent a group of people who are highly symptomatic, have multiple comorbid conditions, and are struggling with multiple psychiatric, behavioral, and psychosocial difficulties. Clinical services designed to evaluate and treat these veterans should consider careful integration of mental health screening and services.

We investigated feared social situations in individuals with social anxiety disorder from different racial and ethnic groups in the United States. The sample included 247 African Americans, 158 Latinos, and 533 non-Latino Whites diagnosed with social anxiety disorder within the past 12 months from the integrated Collaborative Psychiatric Epidemiology Studies data set. After randomly splitting the full sample, we conducted an exploratory factor analysis with half of the sample to determine the structure of feared social situations in a more diverse sample than has been used in previous studies. We found evidence for a model consisting of three feared social domains: performance/public speaking, social interaction, and observational. We then conducted a confirmatory factor analysis on the remaining half of the sample to examine whether this factor structure varied significantly between the race-ethnic groups. Analyses revealed an adequate fit of this model across all three race-ethnic groups, suggesting invariance of the factor structure between the study groups. Broader cultural contexts within which these findings are relevant are discussed, along with important implications for comprehensive, culturally sensitive assessment of social anxiety.

Background: Few data are available on the effects of a psychiatric label on medical residents' attitudes towards an individual. Aims: To investigate the effect of a psychiatric label on the attitudes of medical residents towards an individual. Methods: Medical residents were randomly assigned to one of two vignettes describing the same apparently healthy person, differing only in the presence of a psychiatric label for one of them. Participants ( N = 322) reported their attitudes towards the described individual and their willingness to treat this person. Results: Residents allocated to the psychiatric-diagnostic label group reported being less at ease with becoming the individual's nextdoor neighbour, working in the same place, sharing a house, having him look after their children, having a member of their family date him, having their finances run by the individual, less willing to become friends with the described individual and more uneasy having to examine him the next time he visits the emergency room. Conclusion: Implementing effective programmes to combat stigma in the curriculum of medical residents appears to be needed.

The present study aimed to elucidate relations between provider perceptions of aspects of the Consolidated Framework for Implementation Research (CFIR; Damshroder et al., 2009) and provider attitudes towards the implementation of evidence-based treatments (EBTs) in an ethnically diverse community health setting. Guided by directed content analysis, we analyzed 28 semi-structured interviews that were conducted with providers during the pre-implementation phase of a larger implementation study for Cognitive Processing Therapy for Posttraumatic Stress Disorder (CPT-C for PTSD, Resick et al., 2008). Our findings extend the existing literature by also presenting provider-identified client-level factors that contribute to providers' positive and negative attitudes towards EBTs. Provider-identified client-level factors include: client motivation to engage in treatment, client openness to EBTs, support networks of family and friends, client use of community and government resources, the connection and relationship with their therapist, client treatment adherence, client immediate needs or crises, low literacy or illiteracy, low levels of education, client cognitive limitations, and misconceptions about therapy. These results highlight the relations between provider perceptions of their clients, provider engagement in EBT training, and subsequent adoption of EBTs. We present suggestions for future implementation research in this area.

Though many service members will not directly seek mental health care due to stigma and other factors, they may interact with the healthcare system in other ways including contact with first responders, nurses and allied health care professionals. However, little attention has been spent in this regard on the educational needs of these professionals whose contact with service members and veterans may provide the opportunity to assist veterans in need with overcoming barriers to accessing mental health care. This qualitative study investigates the educational training needs of first responders and health care professionals in contact with military families and trauma survivors to determine whether, and what type, of additional training is needed. A sample of 42 first responders and health care professionals including emergency medical technicians, police officers, fire fighters, speech language pathologists, occupational therapists, physical therapists, and nurses, were recruited to participate in one of six focus groups. Sessions were audio-taped and transcribed verbatim. Data analysis was guided by a thematic analysis approach. Thematic analyses suggest there is a significant knowledge gap with unmet educational needs of these professionals such as information on the invisible wounds of war, military culture, and screening and referring patients who present symptoms falling outside professionals' scope of practice. Findings point to a need and desire for more robust education for first responders and health care providers around mental health concerns of military populations, including topics such as trauma, military culture, and screening tools. Efforts to develop curricula addressing these concerns are warranted.

There are well-documented associations between posttraumatic stress disorder (PTSD) symptoms and intimate relationship impairments, including dysfunctional communication at times of relationship conflict. To date, the extant research on the associations between PTSD symptom severity and conflict communication has been cross-sectional and focused on military and veteran couples. No published work has evaluated the extent to which PTSD symptom severity and communication at times of relationship conflict influence each other over time or in civilian samples. The current study examined the prospective bidirectional associations between PTSD symptom severity and dyadic conflict communication in a sample of 114 severe motor vehicle accident (MVA) survivors in a committed intimate relationship at the time of the accident. PTSD symptom severity and dyadic conflict communication were assessed at 4 and 16 weeks post-MVA, and prospective associations were examined using path analysis. Total PTSD symptom severity at 4 weeks prospectively predicted greater dysfunctional communication at 16 weeks post-MVA but not vice versa. Examination at the level of PTSD symptom clusters revealed that effortful avoidance at 4 weeks prospectively predicted greater dysfunctional communication at 16 weeks, whereas dysfunctional communication 4 weeks after the MVA predicted more severe emotional numbing at 16 weeks. Findings highlight the role of PTSD symptoms in contributing to dysfunctional communication and the importance of considering PTSD symptom clusters separately when investigating the dynamic interplay between PTSD symptoms and relationship functioning over time, particularly during the early posttrauma period. Clinical implications for the prevention of chronic PTSD and associated relationship problems are discussed.

BACKGROUND: Posttraumatic stress disorder (PTSD) has been associated with exaggerated threat processing and deficits in emotion modulation circuitry. It remains unknown how neural circuits are associated with response to evidence-based treatments for PTSD. METHOD: We examined associations between PTSD symptoms and indicators of neural response in key emotion processing and modulation regions. Fifty-six military Veterans with PTSD were randomly assigned to one of three evidence-based treatments (prolonged exposure, sertraline, and PE plus sertraline) in a randomized clinical trial ("PROGrESS"; 2018, Contemp Clin Trials, 64, 128–138). Twenty-seven combat-exposed controls (CCs) served as a comparison group at pretreatment. Before and after PTSD treatment, functional magnetic resonance imaging was used to assess brain activation and connectivity during the validated Shifted Attention Emotion Appraisal Task (2003, J Neurosci, 23, 5627–5633; 2013, Biol Psychiatry, 73, 1045–1053). RESULTS: Greater activation in emotion processing (anterior insula) and modulation (prefrontal cortex) regions and increased connectivity between attentional control (dorsolateral prefrontal cortex and superior parietal cortex) and emotion processing (amygdala) regions, at pretreatment, were associated with subsequent PTSD symptom improvement. CONCLUSIONS: This study is one of the first to examine task-based activation and functional connectivity in a PTSD treatment trial, and provides evidence to suggest that activation in and connectivity between emotion processing and modulation regions are important predictors of treatment response.

This study aimed to examine: (1) the relationship between parental psychopathology and child psychopathology in military families and (2) parenting sense of competence as a mediator of the relationship between veteran psychopathology and child psychopathology. As part of their standard clinical evaluations, 215 treatment-seeking veterans who reported having a child between the ages of 4 and 17 were assessed for psychopathology (posttraumatic stress disorder, depression, anxiety, and stress), their sense of competence as a parent, and their child's psychopathology (internalizing, externalizing, and attentional symptoms). A path analysis model examining parenting sense of competence as a mediator of the relationship between veteran psychopathology and child psychopathology showed significant indirect effects of veteran depression on all child psychopathology outcomes via parenting sense of competence. Parental sense of competence may be a critical mechanism linking veteran depression and child psychopathology, and may therefore be an important target for intervention.

BackgroundDistinguishing a disorder of persistent and impairing grief from normative grief allows clinicians to identify this often undetected and disabling condition. As four diagnostic criteria sets for a grief disorder have been proposed, their similarities and differences need to be elucidated.MethodsParticipants were family members bereaved by US military service death (N = 1732). We conducted analyses to assess the accuracy of each criteria set in identifying threshold cases (participants who endorsed baseline Inventory of Complicated Grief ⩾30 and Work and Social Adjustment Scale ⩾20) and excluding those below this threshold. We also calculated agreement among criteria sets by varying numbers of required associated symptoms.ResultsAll four criteria sets accurately excluded participants below our identified clinical threshold (i.e. correctly excluding 86-96% of those subthreshold), but they varied in identification of threshold cases (i.e. correctly identifying 47-82%). When the number of associated symptoms was held constant, criteria sets performed similarly. Accurate case identification was optimized when one or two associated symptoms were required. When employing optimized symptom numbers, pairwise agreements among criteria became correspondingly 'very good' (κ = 0.86-0.96).ConclusionsThe four proposed criteria sets describe a similar condition of persistent and impairing grief, but differ primarily in criteria restrictiveness. Diagnostic guidance for prolonged grief disorder in International Classification of Diseases, 11th Edition (ICD-11) functions well, whereas the criteria put forth in Section III of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are unnecessarily restrictive.

BACKGROUND: Complicated Grief (CG) is a bereavement-specific syndrome distinct from but commonly comorbid with posttraumatic stress disorder (PTSD). While bereavement is common among military personnel (Simon et al., 2018), there is little research on the impact of CG comorbidity on PTSD treatment outcomes. METHODS: To evaluate the impact of comorbid CG on PTSD treatment outcomes we analyzed data from a randomized trial comparing prolonged exposure (PE), sertraline, and their combination in veterans with a primary diagnosis of combat-related PTSD (n=194). Assessment of PTSD, trauma-related guilt, functional impairment, and suicidal ideation and behavior occurred at baseline and weeks 6, 12 and 24 during the 24-week trial. RESULTS: CG was associated with lower PTSD treatment response (OR=0.29, 95% CI [0.12, 0.69], p=0.005) and remission (OR=0.28, 95% CI [0.11, 0.71], p=0.007). Those with CG had greater severity of PTSD (p=.005) and trauma-related guilt (<.001) at baseline and endpoint. In addition, those with CG were more likely to experience suicidal ideation during the study (CG: 35%, 14/40 vs. no CG 15%, 20/130; OR: 3.01, 95% CI [1.29, 7.02], p=0.011). CONCLUSIONS: Comorbid CG is associated with elevated PTSD severity and independently associated with poorer endpoint treatment outcomes in veterans with combat-related PTSD, suggesting that screening and additional intervention for CG may be needed.