OBJECTIVE:Behavioral health conditions are prevalent among post-9/11-era veterans with traumatic brain injury (TBI); however, little contemporary data exist on their behavioral health services use. We examined outpatient, emergency department (ED), and urgent care behavioral health services use in VA facilities and VA-purchased community care (VACC) among post-9/11 era veterans with and without clinician-confirmed TBI. SETTING:Nationwide VA facility and VACC, 2021 through 2022. PARTICIPANTS:1,374,771 veterans who were screened for deployment-related TBI and, where indicated, completed VA Comprehensive TBI Evaluation. DESIGN:Retrospective, observational study. MAIN MEASURES:VA facility reliance, measured as the percentage of VA facility and VACC behavioral health services that were delivered in VA facilities. Multivariable fractional logistic regression was used to estimate VA facility reliance by TBI history/severity and behavioral health service type (outpatient, ED, urgent care); models were adjusted for sociodemographic, military history, and clinical variables. VACC and VA facility behavioral health visits and diagnoses were examined by TBI history/severity. RESULTS:Among veterans screened for deployment-related TBI, 4.1% had a history of mild TBI and 0.6% moderate/severe TBI. Overall, 49.6% used behavioral health services during 2021 through 2022. There were differences in service use based on TBI history/severity and setting of use. Compared with veterans without TBI, greater percentages of veterans with mild or moderate/severe TBI used outpatient behavioral health services (48.7% vs. 63.3% and 68.6%, respectively). However, more than one-third of veterans with TBI did not use any of the behavioral health services we examined. In adjusted regression models, for each TBI history/severity group, VA facility reliance was the highest for outpatient behavioral health services (94.7%-95.0%) and the lowest for ED behavioral health services (65.9%-69.3%). Among veterans with moderate/severe TBI, 8 in every 10 VACC behavioral health services were for posttraumatic stress or substance use disorder. CONCLUSIONS:Findings suggest that further attention to the behavioral health needs of post-9/11 era veterans is warranted and offer targets for monitoring VACC behavioral health care quality.

INTRODUCTION:The year following military service separation is a high-risk period for suicide among reintegrating veterans, those transitioning from military service member to veteran. This randomized controlled pilot trial examined the feasibility and acceptability of health coaching, a non-clinical health behavior change modality, among reintegrating veterans and evaluated change in measures of identity coherence, reintegration functioning, and suicidal ideation. METHODS:Reintegrating veterans (n = 95) were randomized to receive either enhanced current reintegration services (eCRS) only or health coaching plus eCRS. Participants completed assessments at baseline, month 2, month 4, and month 9. Health coaching participants completed up to 12 health coaching sessions within 4 months of randomization. RESULTS:Feasibility was strong, indicated by a 23% enrollment rate, participant session completion (mean = 8), and intervention fidelity ratings ≥ 88%. Participants reported high acceptability; 95% indicated that health coaching met their approval. Significant treatment effects were observed for reintegrating functioning, with moderate-to-large effect sizes (d = 0.58 among the health coaching group and d = -0.11 among eCRS). Promising effects were observed for identity coherence measures and suicidal ideation prevalence. CONCLUSIONS:Additional research is warranted to test the efficacy of health coaching on these outcomes in a fully powered randomized controlled trial and to evaluate implementation procedures. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT05199467.

Background Prior studies show that inaccurate disclosure of suicidal thoughts is common in health care settings. Little is known about disclosure in the context of universal suicide risk screening programs. This project sought to characterize the frequency of inaccurate disclosure of suicidal ideation during universal suicide risk screening and immediate follow-up in Veterans Health Administration (VHA) mental health settings and to identify predictors of inaccurate disclosure. Methods We conducted a national survey study with linkage to VHA electronic medical records. Analyses incorporated weighting for response and patient characteristics. Seven hundred ninety-two veterans receiving VHA mental health specialty care participated. The survey included questions inquiring about the extent to which participants had responded accurately when asked about suicidal thoughts during screening visits. Results In weighted analyses, 38.1% of screen-negative and 45.8% of screen-positive participants reported responding less than “very accurately” to screening questions. Characteristics associated with less accurate disclosure in both groups included lower beliefs that suicide is not a way out (screen-positive: OR=0.46; 95% CI=0.28-0.77; screen-negative: OR=0.40; 95% CI=0.2-0.79) and greater concern for overreaction (screen-positive: OR=2.36; 95% CI=1.35-4.11; screen-negative: OR=3.73; 95% CI=1.71-8.13). Conclusions Inaccurate disclosure during VHA universal suicide risk evaluation occurs with modest frequency. The results highlight that mental health clinicians and care systems should not overly rely on screening results and suggest that screening accuracy may be improved using a patient-centered approach including orientation of patients to the screening process.

Purpose Military Veterans and rural residents are at greater risk of firearm injury than non-Veterans and urban residents. This retrospective cohort study used administrative data and electronic health record (EHR) reviews to compare the characteristics of firearm injuries between rural and urban Veterans who presented to the Department of Veterans Affairs (VA) healthcare system.Methods A national, stratified random sample of 600 Veterans (300 rural, 300 urban) with firearm injury-related healthcare visits was identified using VA administrative data. Eligible injuries were caused by a firearm and occurred after military separation and between 2010 and 2019. Details about Veterans and firearm injuries were ascertained from administrative data and through EHR reviews. Analyses compared characteristics of firearm injuries by Veterans' rurality.Findings N = 340 firearm injuries were eligible (178 rural, 162 urban). Most were nonfatal (94.7%). Injury intent differed by rurality, where unintentional injuries comprised a higher proportion of firearm injuries for rural Veterans (55.0% rural, 34.6% urban) and assault-related injuries comprised a higher proportion for urban Veterans (16.3% rural, 37.0% urban). Initial treatment was mostly delivered at facilities outside the VA (82.8%), while follow-up care was mostly at VA facilities (75.8%). Firearm safety counseling was rarely documented (8.3%).Conclusions This study describes firearm injuries to inform healthcare-based prevention efforts for rural and urban VA facilities. Differences by rurality in Veterans' injuries suggested that intent-focused tailoring of prevention efforts is critical. Findings highlight opportunities for VA providers to deliver firearm safety counseling. Future research should examine the potential effectiveness of prevention tailored by rurality.

INTRODUCTION:Veterans who do not utilize Veterans Health Administration care are considered a high public health priority because they are disproportionately represented among veteran suicide deaths. This study focused on identifying clinical and social characteristics associated with Veterans Health Administration outpatient mental healthcare utilization among veterans after a positive suicide risk screening (e.g., reporting suicidal intent or plan within past 30 days). METHODS:This study conducted a retrospective, observational cohort study evaluating clinical and social predictors of Veterans Health Administration outpatient mental healthcare utilization 6 and 12 months after suicide risk screening within a primary care or mental health setting. Data were extracted from Veterans Health Administration's Corporate Data Warehouse, a compilation of data from electronic health records and other healthcare data sources. The sample included all veterans with a positive suicide risk screening in Veterans Health Administration Fiscal Year 2020 (October 1, 2019-September 30, 2020). Data were analyzed utilizing mixed-effects, multivariable logistic regression models controlling for age, gender, race, and Latine ethnicity. The study team conducted chart reviews in a random subsample of the analytic sample to identify potential care processes contributing to mental healthcare utilization. RESULTS:Across settings, veterans who did not utilize Veterans Health Administration outpatient mental health care after a positive suicide risk screening had fewer mental/medical comorbidities, fewer social determinants of health challenges (e.g., unemployment), and less past Veterans Health Administration mental healthcare utilization. Chart reviews showed absence of documented mental healthcare referrals as a common barrier to postscreening mental health outpatient care utilization. CONCLUSIONS:Veterans and providers may benefit from education and strategies for addressing barriers to mental healthcare utilization after a positive suicide risk screening with a particular focus on understanding referral processes. Future research should further explore modifiable processes to increase Veterans Health Administration mental health outpatient care utilization after a positive suicide risk screening.

BACKGROUND:Extreme risk protection order (ERPO) laws may be effective tools for preventing firearm suicide. Oregon's ERPO law allows family/household members or law enforcement officers (LEOs) to petition a civil court for an order to temporarily restrict a person's access to firearms when at imminent risk of harming themselves or others. We analysed Oregon's ERPO petitions to describe the law's utilisation for the potential prevention of suicide. METHODS:ERPO petitions were obtained from the Oregon Judicial Department. Data were abstracted for the 6-year period after the law took effect (2018-2023). A 20% random sample of records was double-coded. Inter-rater agreement was >80% for key variables. Descriptive analyses were conducted to examine petitions citing suicide risk; cross-tabulations compared suicide-related petitions to those unrelated to suicide. RESULTS:There were 835 petitions filed and 650 (78%) initially granted. Suicide risk was identified in 516 petitions (62%), 421 of which were initially granted (82%). Suicide-related petitions were more likely to be granted than non-suicide-related petitions (72%; p=0.001). Threats to others were also cited in 80% of suicide-related petitions. LEOs filed 60% and family/household members filed 29% of suicide-related petitions. Concerns cited in suicide-related petitions included substance use (56%) and mental health diagnoses (27%). Respondents were hospitalised or referred for services in 41% of suicide-related petitions. CONCLUSIONS:Oregon's ERPO law is being used to address firearm suicide risk, but implementation gaps may exist, including missed opportunities for healthcare or other services. Further research examining barriers and facilitators to ERPO use for suicide prevention is needed.

Importance:Financial strain is associated with suicide risk; however, no research has examined financial stressors in the year preceding suicide using national credit data. Objective:To assess financial stressors in the 12 months preceding suicide in a national sample of veterans by linking financial, mortality, and health care records. Design, Setting, and Participants:This case-control study of 5000 veterans who died by suicide (January 1, 2015 to December 31, 2017) used mortality data from the US Department of Veterans Affairs (VA) and the US Department of Defense. Cases were matched to 12 500 living controls on age, sex, VA health care use, and suicide index date. Analyses were conducted in December 2025. Exposures:Financial stressors in the prior 12 months were identified in TransUnion credit records provided by FinThrive. Main Outcomes and Measures:The primary outcome was death by suicide. Differences between cases and controls were analyzed using multivariable conditional logistic regression, adjusting for demographics and, among VA users, marital status and diagnoses of depression, posttraumatic stress disorder, and substance use disorder. Results:Among 17 439 veterans included in this study, the mean (SD) age was 52.9 (15.7) years, and 94.6% were male. Suicide was associated with having (vs not having) delinquent mortgage payments (odds ratio [OR], 1.4; 95% CI, 1.2-1.7), repossessions (OR, 1.9; 95% CI, 1.3-2.7), and credit card payments 30 or more days past due (OR, 1.7; 95% CI, 1.6-1.9). Lower credit score categories were associated with increasing odds of suicide. Veterans with 3 or more financial stressors had higher odds of suicide (OR, 2.4; 95% CI, 1.9-3.0) compared with those who had none. Among individuals with available data, credit score declines of 51 to 100 points (OR, 1.3; 95% CI, 1.1-1.5) and greater than 100 points (OR, 2.8; 95% CI, 2.3-3.5) over 1 year, relative to no change in score, were associated with increased odds of suicide. Cumulative financial stressors and declining credit scores had the highest ORs for suicide when adjusting for demographics and, among VA users, marital status and prior psychiatric diagnoses. ORs were lower among VA users than among non-VA users. Conclusions and Relevance:In this case-control study, suicide was associated with financial stressors in the prior 12 months. Incorporating financial stressors into clinical evaluations and safety planning may aid in identifying patients at risk for suicide. Policymakers and researchers could consider strategies to detect and mitigate financial stressors as part of comprehensive suicide prevention efforts.

BACKGROUND:Prior research suggests that disclosure of suicidal thoughts in healthcare settings may be low. OBJECTIVES:Describe frequency of self-reported inaccurate disclosure of suicidal ideation during population-based screening and evaluation in primary care and identify patient characteristics associated with inaccurate disclosure. DESIGN:National survey study examining veteran experiences with the Veterans Health Administration's (VHA) suicide risk screening program, Risk ID. PARTICIPANTS:A national sample of 2001 veterans screened in primary care between February and October 2021 were mailed surveys. Eight-hundred sixty-eight surveys were returned, and 734 respondents recalled being screened. MAIN MEASURES:Several survey items which asked to what extent respondents had accurately responded to clinicians or nurse/medical assistants when asked about suicidal thoughts. KEY RESULTS:Fourteen percent and 18% of screen-negative participants and 40% and 48% of screen-positive participants reported responding less than very accurately to questions about suicidal thoughts when asked by nurses/medical assistants and providers, respectively. Among screen-negative participants, factors associated with inaccurate disclosure included being Black, American Indian/Alaska Native, Hispanic, Asian, or Multi-racial; higher levels of psychological distress and greater barriers to care; and lower ratings of the clinician-patient relationship. Factors associated with inaccurate disclosure in screen-positive participants included greater barriers to care, perceptions that screening questions did not make sense, perceptions that they would not be taken seriously, and lower ratings of satisfaction with the screening process. CONCLUSION:Inaccurate disclosure during VHA population-based suicide risk evaluation is not uncommon. Patients who are Black, American Indian/Alaska Native, Hispanic, Asian, or Multi-racial, are in more distress, report more barriers to care, or are less satisfied with the screening process may be less likely to disclose accurately. The results highlight that clinicians should not overly rely on screening results for clinical decision-making, and reinforce the value of strong clinician-patient treatment relationships and positive screening experiences in promoting accurate disclosure.

OBJECTIVES:The association between traumatic brain injury (TBI) and alcohol use disorder (AUD) is known, but the extent of TBI's role in developing AUD remains unclear. This study examines the association between TBI severity with subsequent AUD diagnosis, and hazard for death due to alcohol, drug overdose, or suicide. METHODS:Data from a national US military/veteran cohort (October 1999-September 2016, followed until September 2020) were analyzed using Fine-Gray competing risk models to investigate the relationships between TBI exposure, subsequent AUD, and hazards of death due to specific causes (alcohol, drug overdose, or suicide). RESULTS:TBI severity correlated with an increased likelihood of an incident AUD diagnosis: mild TBI (hazard ratio [HR]: 1.25, 95% confidence interval [CI] 1.22-1.27), moderate-severe TBI (HR: 1.34, 95% CI 1.32-1.37), and penetrating TBI (HR: 1.90, 95% CI 1.86-1.94). For those who developed AUD, TBI was associated with a higher hazard of death from specific causes such as alcohol, drug overdose, or suicide (HR: 2.47 (95% CI 2.03-3.02) for mild TBI, 4.25 (95% CI 3.49-5.17) for moderate-severe TBI, and 3.39 (95% CI 2.80-4.13) for penetrating TBI. CONCLUSIONS:Veterans with TBI were more likely to develop AUD and experience increased mortality, even after adjusting for demographic and clinical factors. Care strategies that are sensitive to the cognitive and/or emotional impairments associated with varying levels of TBI may lead to better outcomes, reducing both AUD and mortality rates. Further research is needed to develop evidence-based methods for integrating TBI and AUD care.

Twenty-one states, the District of Columbia, and the U.S. Virgin Islands have passed Extreme Risk Protection Order (ERPO) laws, risk-based firearm removal policies intended to reduce firearm violence. Oregon’s ERPO law, which went into effect in 2018, allows family/household members and law enforcement officers (LEOs) to petition a civil court for an order to temporarily restrict one’s access to firearms if the individual is at imminent risk of harming themselves or others. To examine current knowledge and perceptions of Oregon’s ERPO law, and experiences with its use, we interviewed professionals involved in ERPO implementation. We conducted 33 semi-structured interviews with 35 professionals, including LEOs, judges, representatives from district and city attorneys’ offices, and prevention professionals (ie, suicide, substance abuse, and domestic violence prevention). We used rapid qualitative analysis to distil key themes from interview recordings. Interviewees indicated an overall low level of public knowledge about the ERPO law, both among professionals in their fields and among the public more broadly. To increase knowledge and support, interviewees highlighted a need for more professional training, especially for LEOs, and public education on ERPOs. Most interviewees saw ERPOs as effective tools for reducing firearm violence, but some noted a need to incorporate more trauma-informed practices and connections to services for ERPOs to be viewed as a suicide prevention tool. Professionals involved in ERPO implementation in Oregon identified a need for more professional training and public education on ERPOs. Our findings may help inform the development of this messaging and training.

PURPOSE:The primary objective of this observational study was to describe the population of Veterans who did and did not receive a hearing aid following an incident hearing loss diagnosis during the 12-year study period. We also sought to measure the relationship between hearing loss severity and hearing aid acquisition and explore how this association differs according to Veterans' urban/rural residential status. Understanding associations of clinical or demographic characteristics with hearing aid acquisition by US Veteran health care users may contribute to more effective treatment of hearing loss. METHOD:We examined all Veteran electronic health records to identify participants with an incident (new) hearing loss diagnosis between January 2011 and June 2023. Hearing loss was identified using International Classification of Diseases diagnosis codes and audiogram results. Hearing aid fittings were identified using Current Procedural Terminology codes. Poisson regression models were used to compute rate ratios and 95% confidence intervals of hearing aid acquisition. RESULTS:Among 256,409 Veterans with an incident hearing loss diagnosis, the prevalence of hearing aid acquisition was 81% (n = 206,438) during the study period. Among Veterans who received hearing aids, a greater proportion were older, male, White, non-Hispanic, married, and from higher income groups. The average number of days between hearing loss diagnosis and hearing aid fitting was less than 1 year (M = 200 days; SD = 502 days). The association between hearing loss severity and hearing aid acquisition was stronger among urban Veterans compared to rural Veterans, and there was a significant interaction between hearing loss severity and urban/rural status (p < .0001). CONCLUSIONS:This large, national cohort study provides the first description of hearing aid acquisition patterns among Veterans using VA health care. Hearing aid uptake was high overall but varied by demographic and geographic factors. The observed differences may reflect structural challenges or variations in perceived need. These findings can help inform targeted VA programs aimed at improving timely uptake of hearing care, particularly among rural Veteran populations.

BACKGROUND:Post-traumatic stress disorder (PTSD) significantly impacts US Veterans' well-being by potentially exacerbating health-related social needs (HRSN). This study investigated short- and long-term associations between PTSD diagnosis and nine HRSN indicators. METHODS:Utilizing national Veterans Health Administration (VHA) electronic health record (EHR) data, we employed dual designs. A cross-sectional analysis included 62,298 Veterans (PTSD diagnosed in fiscal year [FY] 2012 vs. non-PTSD), matched on key demographic and comorbidity factors. A retrospective cohort followed 11,758 propensity-matched Veterans (no baseline HRSN at FY2012) from FY2013-FY2023. Outcomes were nine HRSN indicators identified via codes and natural language processing in EHRs. RESULTS:Cross-sectionally (N = 62,298), PTSD was linked to higher prevalent HRSN odds at baseline, including violence (adjusted odds ratio [aOR] = 3.98; 95% CI: 3.77-4.20), social problems (aOR = 2.87; 95% CI: 2.73-3.01), and legal issues (aOR = 1.75; 95% CI: 1.64-1.87). In the cohort study (N = 11,758), baseline PTSD strongly predicted incident HRSN across all nine indicators in the first year (e.g., violence: adjusted hazard ratio [aHR] = 3.05; 95% CI: 2.68-3.47). Though strongest initially, these associations attenuated but remained significant up to 10 years post-diagnosis. CONCLUSIONS:US Veterans diagnosed with PTSD face substantially elevated short- and long-term risks for diverse HRSN, including critical social, financial, housing, and legal problems. These persistent vulnerabilities demand integrated healthcare with routine screening, monitoring, and targeted interventions to address complex needs and improve Veteran well-being.

Objective Veterans are disproportionately affected by firearm injury (FAI). Beyond the human toll of FAIs, they also strain healthcare systems. This study examined excess costs from FAIs incurred by the Veterans Affairs (VA) Healthcare System among a cohort of VA-using Veterans. Methods Using International Classification of Diseases external cause-of-injury codes from VA administrative data, we identified Veterans with non-fatal FAI visits between 2010 and 2019 (‘cases’). We matched cases to two uninjured Veterans ‘controls’ by cost-relevant characteristics (eg, a prediction score of future healthcare costs). Average VA healthcare costs were calculated for all Veterans 1 year post-index date and were compared between cases and controls and by Veteran and injury characteristics. Sensitivity analyses examined characteristics and costs for cases who were not matched to controls. Results The sample (N=30 624) consisted of cases (n=10 208) and their matched controls (n=20 416). Average healthcare costs for cases were 2.1 times higher than for controls (US$31 049 vs US$14 685), resulting in mean excess healthcare costs of US$16 364 per case in the year following their index date. Injuries categorised as intentional were associated with two times the excess cost of injuries categorised as unintentional (US$23 049 vs US$11 190). Conclusion The cost of providing care for Veterans in the year following an FAI was over two times as high as for similar Veterans without an FAI. Costs varied by intent. The excess costs reported in this study are conservative estimates of the true costs that the VA paid in the year post-injury. Policy implications are discussed.

[This corrects the article DOI: 10.1016/j.dadr.2024.100311.].

Firearm violence is a critical public health issue in the United States. Extreme Risk Protection Order (ERPO) laws have been enacted in many states to prevent firearm violence, including mass violence. Oregon’s ERPO law allows family/household members or law enforcement officers to petition a civil court for an order to temporarily restrict a person’s access to firearms when at imminent risk of harming themselves or others. This study examined the characteristics of ERPO petitions filed in Oregon that involved mass violence threats. ERPO court records for petitions filed from January 1, 2018 to December 31, 2023 were obtained through the Oregon Judicial Case Information Network and abstracted; double coding was completed to assess interrater reliability. Descriptive analyses were conducted to examine characteristics of ERPO petitions filed to prevent mass violence. These petitions were compared to those without mass violence threats using Fisher’s exact tests and the Wilcoxon rank sum test. From 2018 to 2023, 835 ERPO petitions were filed, of which 92 (11.0

Introduction Veterans with traumatic brain injuries (TBIs) may have a heightened risk of neurocognitive impairment and early onset of neurodegenerative diseases. Exposure to opioid analgesics may also be associated with a reduction in neurocognitive function. To understand the potential interplay between TBI and opioid exposure on neurocognitive performance, we measured associations between lifetime opioid exposure and neurocognitive performance and examined potential interaction/effect measure modification by Veterans' mild TBI (mTBI) history.Materials and Methods Participants included combat Veterans enrolled at the Veterans Affairs Portland Health Care System site of the Long-term Impact of Military-Relevant Brain Injury Consortium/Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) prospective longitudinal study. Lifetime opioid exposure was measured using survey responses and prescription data and was categorized as moderate/high versus low/no. Neurocognitive performance was measured using 9 neuropsychological component test scores. Associations between lifetime opioid exposure and neurocognitive performance were estimated using bivariable and multivariable linear regression models; multivariable models controlled for demographic, military, and clinical characteristics. Stratified analyses were performed to examine associations by mTBI history.Results Of 282 participants, 84 (29.8%) had moderate or high lifetime opioid exposure and 198 (70.2%) had low or no lifetime opioid exposure; 31.3% had deployment-related mTBI history, 45.7% non-deployment-related mTBI, and 33.0% no mTBI. There were no associations between lifetime opioid exposure and neurocognitive performance. However, among participants with deployment-related mTBI, those with moderate or high lifetime opioid exposure demonstrated improved performance on executive functioning neuropsychological component tests compared to those with low or no lifetime opioid exposure.Conclusions Although lifetime opioid exposure did not appear to be significantly associated with neurocognitive performance among this sample of Veterans, there are indications that the relationship between opioid exposure and neurocognitive function is modified by deployment-related mTBI history. Continued research exploring the interplay between mTBI and opioid exposure on neurocognitive performance is needed.

OBJECTIVE:To describe how Oregon's Extreme Risk Protection Order (ERPO) law has been used to address risks of harm to children. METHODS:ERPO petitions were obtained from the Oregon Judicial Department. Data were abstracted from 2018 to 2023. A 20% random sample of records was double-coded. Interrater agreement was >80% for key variables. Descriptive analyses compared petitions with versus without cited risks to children and adolescents. RESULTS:Of the 835 ERPO petitions filed, 143 (17%) cited risks of harm to children. Petitions citing risks of harm to children were less likely to be granted (63%) compared to those without such risks (81%). Ex-spouses/ex-intimate partners, who do not have standing under Oregon's law, made up a larger proportion of petitioners for petitions citing risks to children (16%) than those that did not involve children (5%). Petitions involving risks to children more commonly included threats to schools or universities (17%), mass violence threats (22%), and domestic violence (64%) than petitions without risks to children (1%, 9%, and 33%; respectively). CONCLUSIONS:Oregon's ERPO law is being used to try to avert harm to children, including threats of mass violence, school shootings, and domestic violence, but gaps may remain in individuals' or families' needs. Pediatricians and other health care professionals may be in a unique position to identify and address risks to children and their caregivers. Understanding how ERPOs can successfully address these risks to children-and how they are failing-may raise awareness of the tool among health care professionals, informing both clinical practice and policy advocacy.

Extreme Risk Protection Order (ERPO) laws are a promising strategy for preventing firearm violence through risk-based firearm restrictions, but effectiveness hinges on implementation. Oregon's ERPO law went into effect in 2018, but utilization has varied across the state. We interviewed professionals involved in ERPO implementation to understand barriers and facilitators to the use of ERPOs for violence prevention in Oregon. Semi-structured interviews were conducted with 35 professionals involved in ERPO implementation in Oregon, including law enforcement officers (LEOs), judges, representatives from district and city attorneys' offices, and those working in suicide, substance use, and domestic violence prevention. Rapid qualitative analysis was used to analyze interview data. Implementation challenges identified by professionals included insufficient funding and resources, time constraints on petitioning, safety and timeliness of ERPO service, and limited enforcement mechanisms. While professionals shared the strategies they use to overcome these barriers, such as conducting risk assessments and using a non-confrontational approach to increase safety of ERPO service, they also identified potential policy and practice changes that may bolster implementation. Such changes included cautiously expanding petitioner eligibility, allowing LEOs to petition at any time of the day or week, and requiring ERPO respondents to file a declaration of firearm surrender form with the court and attend compliance hearings. This work helps to increase knowledge about the implementation and use of Oregon's ERPO law and identify potential gaps in current practices. This work may inform policy and practice changes needed to improve implementation of risk-based laws like ERPOs.

ObjectiveExamine the association between military blast exposure and functional status among veterans with a focus on functional disability as a proxy for quality of life and explore the potential modifying effect of hearing loss on this association.Study DesignProspective cohort.SettingMulti-institutional tertiary referral centers.Patients540 veterans.ExposureSelf-reported military blast exposure with and without tinnitus; high-frequency hearing loss (yes/no).Main Outcome MeasureWHO Disability Assessment Schedule 2.0 questionnaires at baseline and annually over 5 years. The odds of membership into three functional disability trajectory groups: low functional disability, moderate functional disability, and high functional disability.ResultsOf 540 veterans, 197 (36.5%) self-reported a blast exposure history, and 106 of 197 (53.8%) reported tinnitus as a direct result of the blast. Blast exposure without tinnitus increased the odds of moderate functional disability compared with low functional disability (odds ratio [OR] = 1.5; 95% confidence interval [CI], 0.92-2.51), which strengthened among those with blast with tinnitus (OR, 3.6; 95% CI, 2.1-6.1). Blast exposure without tinnitus also increased the odds of membership to high functional disability versus low functional disability (OR, 2.2; 95% CI, 1.1-4.8). Hearing loss further increased the odds of reporting functional disability. The probability of low functional disability was approximately 60% if there was no history of blast or hearing loss, dropping to 20% if there was blast, tinnitus, and hearing loss history.ConclusionsBlast exposure negatively affects the quality of life of veterans, especially when compounded with tinnitus and hearing loss.

INTRODUCTION:Military Service Members, Veterans, and other patient populations who experience traumatic brain injury (TBI) may have increased risk of early neurodegenerative diseases relative to those without TBI history. Some evidence suggests that exposure to psychotropic medications may play a role in this association. The Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) prospective longitudinal study provides an ideal setting to examine the effects of psychotropic medication exposure on long-term neurological health of those with and without mild TBI history. In this study, we sought to develop and pilot test a self-report electronic survey instrument to measure participants' psychotropic medication histories for use across LIMBIC-CENC study sites. MATERIALS AND METHODS:We developed a new survey instrument measuring psychotropic medication history and fielded it among Service Members and Veterans enrolled in a single site of the LIMBIC-CENC study to evaluate response rates and patterns, and to compare survey responses to prescription data extracted from participants' Veterans Affair (VA) records. Descriptive statistics estimated survey respondents' lifetime psychotropic medication exposures by their TBI history and other demographic and clinical characteristics of interest. We also compared survey responses to participants' VA outpatient prescription records to estimate sensitivity and negative predictive values (NPVs) for participants' self-reported medication exposures relative to this single prescription data source. RESULTS:Among 310 Veterans enrolled at the study site, 249 completed the survey (response rate = 80%), of whom 248 also had VA health records and were included in the analysis. Most (69%) had a history of mild TBI. Over three-fourths of survey respondents (78%) reported ever having used prescription opioids, 26% reported benzodiazepines, 50% reported muscle relaxants, 42% reported antidepressants, 13% reported non-benzodiazepine sedative-hypnotics, 15% reported stimulants, 7% reported mood stabilizers, and 6% reported antipsychotics. Veterans with, versus without, a history of mild TBI were more likely to self-report psychotropic medication history as well as have confirmed receipt of VA prescriptions for each medication class. Using VA records as a criterion standard, the sensitivity of the survey for detecting VA prescriptions ranged from 19% to 84%, while the NPVs ranged from 64% to 97%. Sensitivity and NPVs were similar for participants with, versus without, mild TBI history. CONCLUSIONS:Service Members and Veterans may receive psychotropic medications from multiple sources over their lifetimes. Valid methods to examine and quantify these exposures among those with a history of TBI are important, particularly as we evaluate causes of neurodegenerative disorders in this population over time. The measurement of Veterans' lifetime psychotropic medication exposures using a self-report survey, in combination with health care records, holds promise as a valid approach, but further testing and refinement are needed.