BACKGROUND Research among military personnel and veterans indicates that subjective appraisal of warzone stressors explains the relation of combat exposure to posttraumatic stress disorder (PTSD), but not the relation of exposure to injury and death to PTSD. Studies have primarily been limited to conventional forces using aggregate measures of warzone stressor exposure. Threat appraisal may play a different role in the emergence of PTSD among military personnel for whom dangerous deployment experiences are more closely associated with exposure to injury and death, such as US Air Force Pararescuemen and Combat Rescue officers. MATERIALS AND METHODS In a sample of 207 rescue personnel, correlations among various types of warzone stressor exposure, threat appraisal, and postdeployment PTSD symptoms were examined. RESULTS The relative strongest correlates of threat appraisal were stressors related to injury, death, and human remains. Although exposure to these stressors was also correlated with PTSD symptom severity, partial correlations of stressor exposure and PTSD symptoms were no longer significant when adjusting for threat appraisal. CONCLUSION Results support the contributing role of threat appraisal to PTSD among military personnel whose primary duties entail exposure to injury and death under hostile and dangerous conditions.

Utilization of mental health personnel assigned to operational military units is an area of growth for the US military. What activities they perform, how requirements may differ from working in clinical settings, and how to select and train for these types of positions is still poorly understood. A job analysis was conducted of Air Force mental health providers and enlisted technicians embedded in special operations, intelligence, and high-risk training units. Participants rated 27 tasks on frequency, importance, difficulty, and risks, as well as the importance of 37 knowledge, skills, and abilities (KSAs), with differentiation between KSAs that may be trained versus those that must be present to be assigned to the embedded position. Tasks reflected 4 areas of activity: unit embedding/engagement, behavioral health consultation and support, performance optimization activities, and operational mission tasks. Tasks varied by professional training (psychologist, social worker, enlisted technician) and unit type. The KSAs rated as most important were ethical judgment and ability to manage complex relationships and boundaries while working outside of a clinic, strong interpersonal skills with appropriate assertiveness to advocate for safe, effective courses of action, and understanding of unit missions and organizational dynamics. Results have implications for job design, selection criteria, professional disciplines with KSAs necessary to unit-specific tasks, and training of personnel for integrated operational support positions.

Military personnel frequently report various physical and psychological complaints including somatic symptoms, bodily pain, depression, posttraumatic stress disorder, and physical role limitation. This study aimed to identify how psychological symptoms, somatic complaints, and physical role limitations are associated with each other in a sample of 207 male Air Force pararescue personnel and combat rescue officers. Results of a moderated mediation model indicated that the interaction of depression and somatic symptoms was associated with significantly more severe pain, which was, in turn, associated with greater physical role limitations. Pathways from posttraumatic stress disorder and the depression-by-somatic symptoms interaction to physical role limitation were both fully mediated by bodily pain. These findings (a) highlight the importance of assessing physical and psychological symptoms when individuals report impaired physical role limitation and (b) help to clarify the complex interplay of emotional and physical health conditions among elite military personnel.

As the construct of moral injury has gained increased conceptual and empirical attention among military personnel and veterans, preliminary attempts to operationalize and measure the construct have emerged. One such measure is the Moral Injury Event Scale (MIES). The aim of the current study was to further evaluate the MIES's psychometric properties in two military samples: a clinical sample of Air Force personnel and a nonclinical sample of Army National Guard personnel. Exploratory and confirmatory factor analyses across both samples supported a three-factor solution: transgressions by others, transgressions by self, and betrayal. Transgressions-Others was most strongly associated with posttraumatic stress; Transgressions-Self was most strongly associated with hopelessness, pessimism, and anger; and Betrayal was most strongly associated with posttraumatic stress and anger. Results support the construct validity of the MIES, although areas for improvement are indicated and discussed.

Mental health problems among U.S. military personnel remain an important public health problem. However, little research exists concerning burnout, which is comprised of three interrelated experiences: emotional exhaustion, depersonalization, and (lack of) personal accomplishment (Maslach & Leiter 1997). Burnout may be especially relevant to U.S. Air Force (USAF) pararescuemen (PJs) due to their high deployment and operations tempo relative to conventional military forces. We administered the Maslach Burnout Inventory (MBI; Maslach & Jackson, 1981) to 194 male PJs from six military bases. Results of regression analyses indicated depersonalization was significantly higher among National Guard/Reserve personnel (β = .203, p = .029). Emotional exhaustion was associated with depression (β = .286, p = .004) and posttraumatic stress disorder (PTSD) symptoms (β = .194, p = .053), whereas depersonalization was associated with PTSD symptoms only (β = .353, p < .001). Greater personal accomplishment showed a nonsignificant inverse relationship with depression (β = −.205, p = .064). Results suggest that different dimensions of burnout are associated with different types of psychological distress among PJs and may be related to mental health problems in this population. Burnout warrants further attention among researchers.

A growing body of empirical research suggests insomnia severity is directly related to suicide ideation, attempts, and death in nonmilitary samples, even when controlling for depression and other suicide risk factors. Few studies have explored this relationship in U.S. military personnel.The present study entailed secondary data analyses examining the associations of insomnia severity with suicide ideation and attempts in three clinical samples: Air Force psychiatric outpatients (n = 158), recently discharged Army psychiatric inpatients (n = 168), and Army psychiatric outpatients (n = 54). Participants completed the Beck Scale for Suicide Ideation, the Beck Depression Inventory-II or Patient Health Questionnaire-9, the Insomnia Severity Index, and the Posttraumatic Stress Disorder Checklist at baseline; two samples also completed these measures during follow-up.Sleep disturbance was associated with concurrent (β's > 0.21; P's < 0.059) and prospective (β's > 0.39; P's < 0.001) suicide ideation in all three samples. When adjusting for age, gender, depression, and posttraumatic stress, insomnia severity was no longer directly associated with suicide ideation either concurrently (β's < 0.19; P's > 0.200) or prospectively (β's < 0.26; P's > 0.063), but depression was (β's > 0.22; P's < 0.012). Results of a latent difference score mediation model indicated that depression mediated the relation of insomnia severity with suicide ideation.Across three clinical samples of military personnel, depression explained the relationship between insomnia severity and suicide risk.

BACKGROUNDCaffeine, tobacco, and alcohol are the most widely used substances globally, but the majority of research on the associations among legal substance use and physical health has focused on the general population, not elite military personnel. The purpose of the current study was to describe patterns of tobacco, alcohol, and caffeine use and to examine the relationship of legal substance use with self-reported physical health complaints among US Air Force Pararescuemen (PJs) and Combat Rescue Officers (CROs).METHODSParticipants were 196 US PJs and CROs. Participants completed self-report measures of legal drug use and somatic symptoms. Generalized linear modeling with robust maximum likelihood estimation was used for multivariate regression analyses. Chi-square analyses were conducted for univariate comparisons of categorical variables.RESULTSReported rates of tobacco use (28.2%), alcohol consumption (83.2%), and regular caffeine consumption (88.8%) were similar to the general population. Daily caffeine intake was significantly higher among participants reporting they were bothered a lot by back pain [Wald χ2(2)=11.39; ρ=.003] and extremity pain [Wald χ2(2)=11.39; ρ=.003], even when controlling for age and deployment history. Participants with severe extremity pain also reported drinking approximately twice as many alcoholic beverages per week (mean, 5.46; standard error [SE], 0.91) than participants who were bothered a little (mean, 2.88; SE, 0.54) or not bothered at all (mean, 2.88; SE, 0.52) by extremity pain.CONCLUSIONBack and extremity pain is associated with greater caffeine and alcohol consumption among PJs.

Depression, posttraumatic stress (PTS), and guilt have been implicated as risk factors for suicide ideation (SI) among military personnel and veterans. Conceptual and empirical work suggests that guilt may mediate the relationship of depression and PTS with SI. The current study explored this hypothesis in two cross-sectional samples of military personnel and veterans (n = 464 and n = 158). Path analyses showed good fit for both samples [Sample 1:chi(2)(1) = 2.18, p = .140; CFI = 1.00; RMSEA = .05; WRMR = .23; Sample 2:chi(2)(2) = 1.39, p = .499; CFI = 1.00; RMSEA = .00; SRMR = .02] and indicated that depression was indirectly related to SI through guilt for both samples (ps < .038). Furthermore, guilt partially mediated the relationship of PTS with SI (p = .033) in Sample 1 and fully mediated the relationship (p = .016) in Sample 2. The present findings suggest that guilt may be a mechanism for increased risk among suicidal military personnel and veterans with depression and PTS.

BACKGROUND:Newer approaches for understanding suicidal behavior suggest the assessment of suicide-specific beliefs and cognitions may improve the detection and prediction of suicidal thoughts and behaviors. The Suicide Cognitions Scale (SCS) was developed to measure suicide-specific beliefs, but it has not been tested in a military setting. METHODS:Data were analyzed from two separate studies conducted at three military mental health clinics (one U.S. Army, two U.S. Air Force). Participants included 175 active duty Army personnel with acute suicidal ideation and/or a recent suicide attempt referred for a treatment study (Sample 1) and 151 active duty Air Force personnel receiving routine outpatient mental health care (Sample 2). In both samples, participants completed self-report measures and clinician-administered interviews. Follow-up suicide attempts were assessed via clinician-administered interview for Sample 1. Statistical analyses included confirmatory factor analysis, between-group comparisons by history of suicidality, and generalized regression modeling. RESULTS:Two latent factors were confirmed for the SCS: Unloveability and Unbearability. Each demonstrated good internal consistency, convergent validity, and divergent validity. Both scales significantly predicted current suicidal ideation (βs >0.316, ps <0.002) and significantly differentiated suicide attempts from nonsuicidal self-injury and control groups (F(6, 286)=9.801, p<0.001). Both scales significantly predicted future suicide attempts (AORs>1.07, ps <0.050) better than other risk factors. LIMITATIONS:Self-report methodology, small sample sizes, predominantly male samples. CONCLUSIONS:The SCS is a reliable and valid measure that predicts suicidal ideation and suicide attempts among military personnel better than other well-established risk factors.

Research has established clear links among posttraumatic stress disorder (PTSD), somatic symptoms, and general health among conventional force military personnel. It is possible that the same relationships exist among Special Operations Force (SOF) personnel, but there are very few, if any, studies that examine these relationships. This study investigated correlates of general health and medical visits among SOF personnel and found that the interaction of somatic and PTSD symptoms was associated with worse health and more frequent medical visits. Follow-up analyses indicated that the interaction of avoidance symptoms with somatic symptoms was significantly associated with worse health, whereas the interaction of emotional numbing with somatic symptoms significantly contributed to increased medical visits. In addition, the results suggest that a sense of accomplishment among SOF personnel may serve as a protective factor against poor health. The results suggest developing interactions among SOF personnel that promote a sense of achievement to ultimately improve the health of the force.

The Behavioral Health Measure (BHM) is a brief self-report measure of general psychological distress and functioning developed for the tracking of mental health outcomes in outpatient psychotherapy settings (Kopta & Lowry, 2002). Although the BHM is used in integrated primary care behavioral health clinics, the scale's psychometric properties have not been evaluated in these settings. The current study investigated the BHM's psychometric properties, including its factor structure and reliability, and presents normative data from 3 large integrated primary care clinics. Mean scores for each of the BHM's 4 scales were significantly lower (i.e., more distress) for women than men, with scores being stable across the 3 primary care samples. Confirmatory factor analysis demonstrated adequate fit for the 3-factor and 1-factor models, with fit improving when 3 items were omitted. Internal consistency estimates for the BHM's 4 scales ranged from adequate to very good (α range: .72-.93). The 4 scales were highly intercorrelated, suggesting they measure similar constructs. Results suggest a revised, 17-item version of the BHM has adequate structure and reliability estimates, and is appropriate for use in primary care settings.

OBJECTIVES:Combat exposure is associated with increased mental health symptom severity among military personnel, whereas unit support is associated with decreased severity. However, to date no studies have examined these relationships among U.S. Air Force pararescuemen (PJs), who have a unique and specialized career field that serves in both medical and combatant capacities. DESIGN:Cross-sectional self-report survey. METHODS:Self-reported survey data regarding depression symptoms, posttraumatic stress disorder (PTSD) symptoms, perceived unit support, and exposure to traditional combat experiences (e.g., firefights) and medical consequences of combat (e.g., injuries and human remains) were collected from 194 PJs in seven rescue squadrons. RESULTS:Levels of combat exposure were compared with previously published findings from combat units, and levels of medical exposure were compared with previously published findings among military medical professionals. Medical exposure intensity showed a stronger relationship with PTSD severity (?=.365, p=.018) than with combat exposure intensity (?=.136, p=.373), but neither combat nor medical exposure was associated with depression severity (?s<.296, ps>.164). Unit support was associated with less severe PTSD (?=?.402, p<.001) and depression (?=?.259, p=.062) symptoms and did not moderate the effects of combat or medical exposure. CONCLUSIONS:Medical stressors contribute more to PTSD among PJs than do traditional combat stressors. Unit support is associated with reduced PTSD and depression severity regardless of intensity of warzone exposure among PJs.