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BACKGROUND: Video telehealth offers a mechanism to help Veterans Health Administration (VHA) patients overcome health care access barriers; however, many veterans lack a suitable device and sufficient internet connectivity. To address disparities in technology access, VHA established a Connected Device Program that offers veterans loaned video-capable tablets and internet service. In 2020, VHA introduced a national Digital Divide Consult to facilitate and standardize referrals for this resource. OBJECTIVE: We sought to evaluate the reach and impact of VHA's Connected Device Program, leveraging Digital Divide Consult data to determine whether resources are supporting veterans with health care needs and access barriers. METHODS: We examined the reach of VHA's Connected Device Program using national secondary data from VHA's electronic health records among 119,926 tablet recipients who received a tablet (April 1, 2020, to February 28, 2023) and 683,219 veterans from the general VHA population. We assessed changes in tablet recipients' demographic and clinical characteristics before and after implementation of the Digital Divide Consult compared with the general VHA population. We examined the impact of tablets and the consult on adoption of telehealth (ie, video visit use and number of visits) adjusting for differences between tablet recipients and the general VHA population. Finally, we evaluated consult implementation by assessing the use of video-based services by tablet referral reason. RESULTS: Common reasons for tablet referral included mental health diagnoses (50,367/79,230, 63.9%), distance from a VHA facility >30 miles (17,228/79,230, 21.7%), and social isolation (16,161/79,230, 20.4%). Moreover, 63.0% (49,925/79,230) of individuals who received a tablet after implementation of the Digital Divide Consult had a video visit in the first 6 months of tablet receipt. Some consult reasons were associated with a higher-than-average percentage of video telehealth use, including enrollment in evidence-based mental health programs (74.8% [830/1100] with video use), living >30 miles from a VHA facility (68.3% [10,557/17,228] with video use), and having a mental health diagnosis (68.1% [34,301/50,367] with video use). Tablet recipients had nearly 3 times the likelihood of having a video visit within a month once provided a tablet compared to the general VHA population, with an adjusted risk ratio of 2.95 (95% CI 2.91-2.99) before consult implementation and 2.73 (95% CI 2.70-2.76) after consult implementation. Analyses of telehealth adoption suggested that veterans receiving tablets for mental health care and evidence-based programs have higher rates of video visits, while those who are homebound or receiving tablets for hospice have higher rates of nonuse. CONCLUSIONS: This evaluation of VHA's Connected Device Program suggests that tablets are facilitating video-based care among veterans with complex needs. Standardization of referrals through the Digital Divide Consult has created opportunities to identify groups of tablet recipients with lower telehealth adoption rates who might benefit from a targeted intervention.

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Tobacco-related deaths remain the leading cause of preventable death in the United States. Veterans suffering from posttraumatic stress disorder (PTSD)-about 11% of those receiving care from the Department of Veterans Affairs (VA)-have triple the risk of developing tobacco use disorder (TUD). The most efficacious strategies being used at the VA for smoking cessation only result in a 23% abstinence rate, and veterans with PTSD only achieve a 4.5% abstinence rate. Therefore, there is a critical need to develop more effective treatments for smoking cessation. Recent studies suggest the insula is integrally involved in the neurocircuitry of TUD. Thus, we propose a feasibility phase II randomized controlled trial (RCT) to study a form of repetitive transcranial magnetic stimulation (rTMS) called intermittent theta burst stimulation (iTBS). iTBS has the advantage of allowing for a patterned form of stimulation delivery that we will administer at 90% of the subject's resting motor threshold (rMT) applied over a region in the right post-central gyrus most functionally connected to the right posterior insula. We hypothesize that by increasing functional connectivity between the right post-central gyrus and the right posterior insula, withdrawal symptoms and short-term smoking cessation outcomes will improve. Fifty eligible veterans with comorbid TUD and PTSD will be randomly assigned to active-iTBS + cognitive behavioral therapy (CBT) + nicotine replacement therapy (NRT) (n = 25) or sham-iTBS + CBT + NRT (n = 25). The primary outcome, feasibility, will be determined by achieving a recruitment of 50 participants and retention rate of 80%. The success of iTBS will be evaluated through self-reported nicotine use, cravings, withdrawal symptoms, and abstinence following quit date (confirmed by bioverification) along with evaluation for target engagement through neuroimaging changes, specifically connectivity differences between the insula and other regions of interest.

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Objective: To develop an evidence and consensus-based clinical recommendation (CR) regarding primary care management of insufficient and disturbed sleep associated with concussion/mild traumatic brain injury (mTBI) in service members and veterans.Participants: A multidisciplinary expert working group (EWG) of 23 subject matter experts was selected by the Defense Health Agency (DHA) Traumatic Brain Injury Center of Excellence (TBICoE), based on relevant expertise and experience, from candidates nominated by DHA communities of interest.Evidence: The TBICoE core working group (CWG) conducted a literature search using PubMed and Google Scholar databases for articles relevant to sleep and mTBI from 2014 to 2018. Resulting studies were reviewed by the CWG, and questions addressing gaps in the literature were formulated.Consensus Process: Questions addressing gaps in the literature were distributed to the EWG, and consensus was achieved over the course of 5 online meetings. Based on the available evidence and EWG consensus, TBICoE developed a draft of the clinical recommendations and submitted it to the EWG for review and feedback. Feedback was adjudicated by TBICoE, and areas of nonconsensus were addressed via email utilizing a modified Delphi method.Conclusion: The evidence and EWG agree that addressing sleep early following mTBI is imperative to promoting recovery and preventing chronic mTBI symptoms, maladaptive sleep behaviors, and chronic sleep disorders.Prim Care Companion CNS Disord 2024;26(5):23nr03691. Author affiliations are listed at the end of this article.

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Importance: Open burn pits have commonly been used for waste disposal by the US military but have not been systematically investigated as an independent risk factor for headache disorders. Objective: To evaluate the association between exposure to open burn pits and incidence of headache and migraine. Design, Setting, and Participants: This retrospective cohort study used data from the Veterans Health Administration Headache Cohort along with data from the US Department of Defense and the Airborne Hazards and Open Burn Pit (AH&OBP) Registry to assess registry participants with potential exposure to open burn pits in the Veterans Health Administration from April 1, 2014, through October 31, 2022. Participants were included by linking data from the AH&OBP Registry to their US Department of Defense and Veterans Health Administration electronic health records. Those with preexisting headache were removed from the analytic sample. The analysis was conducted between November 1, 2022, and January 31, 2024. Exposure: Open burn pit exposure composite variables based on the registry questionnaire were examined, specifically being near open burn pits, days near open burn pits, and having open burn pit duties. Main Outcomes and Measures: Primary incident outcomes included medically diagnosed headache disorders and medically diagnosed migraine. Results: The analytic sample included 247 583 veterans (mean [SD] age, 27.9 [7.7] years; 222 498 [89.9%] male). After covariates were controlled for at baseline, participants who were near an open burn pit with open burn pit duties had the highest adjusted odds of medically diagnosed headache disorders (adjusted odds ratio [AOR], 1.59; 95% CI, 1.46-1.74), migraine (AOR, 1.60; 95% CI, 1.43-1.79), and self-reported disabling migraine (AOR, 1.93; 95% CI, 1.69-2.20) compared with those without exposure. The 2 highest quartiles of cumulative burn pit exposure (290-448 days and >448 days) had significantly higher adjusted odds of medically diagnosed headache (290-448 days: AOR, 1.20; 95% CI, 1.09-1.31; >448 days: AOR, 1.55; 95% CI, 1.41-1.70) and migraine (290-448 days: AOR, 1.19; 95% CI, 1.07-1.34; >448 days: AOR, 1.48; 95% CI, 1.32-1.65). Conclusions and Relevance: In this cohort study, a dose-dependent association existed between open burn pit exposure and medically diagnosed headache and migraine. These new data identify potentially important associations between open burn bit exposure and new-onset headache among service personnel as well as a possible health condition that may be encountered more frequently in Veterans Health Administration facilities during mandatory screening for military exposures.

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Importance: Robotic exoskeletons leverage technology that assists people with spinal cord injury (SCI) to walk. The efficacy of home and community exoskeletal use has not been studied in a randomized clinical trial (RCT). Objective: To examine whether use of a wheelchair plus an exoskeleton compared with use of only a wheelchair led to clinically meaningful net improvements in patient-reported outcomes for mental and physical health. Design, Setting, and Participants: This RCT of veterans with SCI was conducted at 15 Veterans Affairs medical centers in the US from September 6, 2016, to September 27, 2021. Data analysis was performed from March 10, 2022, to June 20, 2024. Interventions: Participants were randomized (1:1) to standard of care (SOC) wheelchair use or SOC plus at-will use of a US Food and Drug Administration (FDA)-cleared exoskeletal-assisted walking (EAW) device for 4 months in the home and community. Main Outcomes and Measures: Two primary outcomes were studied: 4.0-point or greater improvement in the mental component summary score on the Veterans RAND 36-Item Health Survey (MCS/VR-36) and 10% improvement in the total T score of the Spinal Cord Injury-Quality of Life (SCI-QOL) physical and medical health domain and reported as the proportion who achieved clinically meaningful changes. The primary outcomes were measured at baseline, post randomization after advanced EAW training sessions, and at 2 months and 4 months (primary end point) in the intervention period. Device usage, reasons for not using, and adverse events were collected. Results: A total of 161 veterans with SCI were randomized to the EAW (n = 78) or SOC (n = 83) group; 151 (94%) were male, the median age was 47 (IQR, 35-56) years, and median time since SCI was 7.3 (IQR, 0.5 to 46.5) years. The difference in proportion of successes between the EAW and SOC groups on the MCS/VR-36 (12 of 78 [15.4%] vs 14 of 83 [16.9%]; relative risk, 0.91; 95% CI, 0.45-1.85) and SCI-QOL physical and medical health domain (10 of 78 [12.8%] vs 11 of 83 [13.3%]; relative risk, 0.97; 95% CI, 0.44-2.15) was not statistically different. Device use was lower than expected (mean [SD] distance, 1.53 [0.02] miles per month), primarily due to the FDA-mandated companion being unavailable 43.9% of the time (177 of 403 instances). Two EAW-related foot fractures and 9 unrelated fractures (mostly during wheelchair transfers) were reported. Conclusions and Relevance: In this RCT of veterans with SCI, the lack of improved outcomes with EAW device use may have been related to the relatively low device usage. Solutions for companion requirements and user-friendly technological adaptations should be considered for improved personal use of these devices. Trial Registration: ClinicalTrials.gov Identifier: NCT02658656.

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AIMS: We conducted a proof-of-concept randomized controlled trial of the mu-opioid receptor antagonist, naltrexone, augmented with the alpha-1 adrenergic receptor antagonist, prazosin, for alcohol use disorder in veterans. We sought a signal that the naltrexone plus prazosin combination regimen would be superior to naltrexone alone. METHODS: Thirty-one actively drinking veterans with alcohol use disorder were randomized 1:1:1:1 to naltrexone plus prazosin (NAL-PRAZ [n = 8]), naltrexone plus placebo (NAL-PLAC [n = 7]), prazosin plus placebo (PRAZ-PLAC [n = 7]), or placebo plus placebo (PLAC-PLAC [n = 9]) for 6 weeks. Prazosin was titrated over 2 weeks to a target dose of 4 mg QAM, 4 mg QPM, and 8 mg QHS. Naltrexone was administered at 50 mg QD. Primary outcomes were the Penn Alcohol Craving Scale (PACS), % drinking days (PDD), and % heavy drinking days (PHDD). RESULTS: In the NAL-PRAZ condition, % reductions from baseline for all three primary outcome measures exceeded 50% and were at least twice as large as % reductions in the NAL-PLAC condition (PACS: 57% vs. 26%; PDD: 51% vs. 22%; PHDD: 69% vs. 15%) and in the other two comparator conditions. Standardized effect sizes between NAL-PRAZ and NAL-PLAC for each primary outcome measure were >0.8. All but one participant assigned to the two prazosin containing conditions achieved the target prazosin dose of 16 mg/day and maintained that dose for the duration of the trial. CONCLUSION: These results suggest that prazosin augmentation of naltrexone enhances naltrexone benefit for alcohol use disorder. These results strengthen rationale for an adequately powered definitive randomized controlled trial.

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Subjective cognitive decline (SCD) is one of the most important early onset symptoms of Alzheimer's Disease. Previous studies consistently reported that SCD is associated with quality of life, socio-economic factors, and related health comorbidities. However, the impact of veteran status on SCD has been little investigated. This study conducted a cross-sectional study to address disproportionate effects in subjective cognitive decline between veterans and non-veterans in the United States. Propensity score matching (PSM) was applied in this observational study to achieve covariate balancing and reduce selection bias, providing a more accurate estimate of the isolated effect of veteran status on SCD. Our study utilized 32,431 forty-five years or older non-institutionalized White, Black or African-American, and Hispanic or Latin-American male population from the 2019 Behavioral Risk Factor Surveillance System data. We first identified 10,685 paired PSM samples for the binary veteran status using the preselected covariates. Next, we performed a logistic regression for modeling the relationship between the veteran status and the SCD status using the PSM samples along with the covariates selected by a BIC-based stepwise selection. Our analyses revealed a statistically significant causal association between veteran status and SCD after PSM (odds ratio (OR): 1.16 and 95% confidence interval (CI): 1.06-1.27). We obtained a similar result before PSM with an OR of 1.20 and 95% CI of 1.10-1.31. When we focused on a minority group (Black or African-American males), we found a significantly increased veterans' risk of SCD, especially after propensity score matching (OR: 1.69, 95% CI: 1.16-2.45). We also found several factors such as employment status, difficulty dressing/walking/running errands, general health status, physical health status, unaffordability of medical costs, mental health status, and comorbid conditions including stroke, blindness, high cholesterol, and arthritis as statistically significantly associated with SCD (P-value < 0.05). Similar to post-traumatic stress disorder and traumatic brain injury, our study demonstrated a causal association between SCD and military-related activities in the United States, which has a disproportionate impact on the minority population. This study sets the groundwork to further research in this domain to diagnose neurological diseases early among veterans.

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Importance: Adults experiencing homelessness in the US face numerous challenges, including the management of chronic kidney disease (CKD). The extent of a potentially greater risk of adverse health outcomes in the population with CKD experiencing homelessness has not been adequately explored. Objective: To evaluate the association between a history of homelessness and the risk of end-stage kidney disease (ESKD) and death among veterans with incident CKD. Design, Setting, and Participants: This retrospective cohort study was conducted between January 1, 2005, and December 31, 2017. Participants included veterans aged 18 years and older with incident stage 3 to 5 CKD utilizing the Veterans Health Administration health care network in the US. Patients were followed-up through December 31, 2018, for the occurrence of ESKD and death. Analyses were performed from September 2022 to October 2023. Exposure: History of homelessness, based on utilization of homeless services in the Veterans Health Administration or International Classification of Diseases, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Homelessness was measured during the 2-year baseline period prior to the index date of incident CKD. Main Outcomes and Measures: The primary outcomes were ESKD, based on initiation of kidney replacement therapy, and all-cause death. Adjusted hazard ratios (HRs) were calculated to compare veterans with a history of homelessness with those without a history of homelessness. Results: Among 836 361 veterans, the largest proportion were aged 65 to 74 years (274 371 veterans [32.8%]) or 75 to 84 years (270 890 veterans [32.4%]), and 809 584 (96.8%) were male. A total of 26 037 veterans (3.1%) developed ESKD, and 359 991 (43.0%) died. Compared with veterans who had not experienced homelessness, those with a history of homelessness showed a significantly greater risk of ESKD (adjusted HR, 1.15; 95% CI, 1.10-1.20). A greater risk of all-cause death was also observed (HR, 1.48; 95% CI, 1.46-1.50). After further adjustment for body mass index, comorbidities, and medication use, results were attenuated for all-cause death (HR, 1.09; 95% CI, 1.07-1.11) and were no longer significant for ESKD (HR, 1.04; 95% CI, 0.99-1.09). Conclusions and Relevance: In this cohort study of veterans with incident stage 3 to 5 CKD, a history of homelessness was significantly associated with a greater risk of ESKD and death, underscoring the role of housing as a social determinant of health.

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BACKGROUND: Veteran residents in Northern Ireland (NI) are an under-researched population. Little is known about their experiences of trauma and mental health management. The overall mental well-being of veterans living in NI may be poorer than other veteran populations, due to the challenges presented by the unique landscape. Understanding their experiences is crucial for providing appropriate, targeted support. METHOD: Six male veterans, who had received a mental health diagnosis, living in NI and all aged > 40 years participated. Semi-structured interviews, using open-ended questions, were conducted over the telephone. Interpretative phenomenological analysis was used to explore their experiences. RESULTS: Two experiential themes were identified each containing three experiential statements. Statements for 'an extreme lack of' included: lack of mental health literacy/awareness; lack of expectations of official support; lack of a sense of perceived appreciation. Statements for 'an extreme abundance of' included: exacerbated exposure to a range of extreme environments; high levels of ruled-based living; high levels of engaging with informal/local level support. CONCLUSIONS: Several experiential statements aligned with existing literature, including having poor mental health literacy and problem recognition, and heavily utilising social support versus formal help-seeking. Some novel findings included bouncing between extreme positive and negative environments which could be as detrimental to mental health as experiencing conflict trauma. Heavy alcohol use was just another rule soldiers followed. Positive help-seeking experiences failed to improve poor opinions of support organisations. Finally, poor self-perceptions connected to military status are pertinent in NI, which seems to fuel self-marginalisation and distrust. A combination of factors likely contributes to many veterans living in NI having poorer mental well-being. Novel findings would benefit from further exploration as understanding how NI veterans interpret their experiences is key to providing adequate healthcare.

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BACKGROUND: National initiatives such as 'Joining Forces' and the 'Have you ever served in the military?' campaign increased awareness of the needs of the military and veteran population. Yet, empirical evidence suggests that nurses and other healthcare providers continue to report insufficient cultural competency, as well as knowledge and awareness of unique healthcare needs to provide optimal care to this population. PURPOSES: The study purposes were to explore nurses' and nursing students' knowledge, attitudes, confidence, and comfort levels to care for veterans and their family, identify potential factors associated with these outcome measures, and examine the relationships between knowledge, attitudes, confidence, and comfort. METHOD: A quantitative, cross-sectional study design guided an online survey of 153 respondents. The military and veteran family cultural competency model provided a theoretical foundation. FINDINGS: Overall, the confidence in skills and abilities, and comfort levels on addressing military culture, providing care, and discussing health issues increases as participants' gain knowledge and awareness of the military. Having an immediate family member(s) who served in the military was a significant factor related to confidence. IMPLICATIONS: Nursing students and nurses in practice need education aimed at addressing the veteran care competencies, specifically military/veteran culture.

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BACKGROUND: The military is a male-dominated environment and culture in which women veterans can experience significant institutional prejudice. Transition can be confusing and isolating for women veterans. Group programs are an important source of transition support. However, we know little about the specific group program needs of women veterans. OBJECTIVES: To examine mental health and well-being support group programs delivered to women veterans, to understand what they value and find most helpful. ELIGIBILITY CRITERIA: Women military veterans (all types); empirical studies using any design; published between 1990 and 2022; group programs focused on transition issues (such as housing, employment, education, physical health, mental health). SOURCES OF EVIDENCE: Peer-reviewed journals and theses. CHARTING METHODS: Six databases searched: Medline (via Ovid SP), PsycINFO (via Ovid SP), EmCare (via Ovid SP), CINAHL, Scopus, and ProQuest. RESULTS: There was significant heterogeneity across 35 included studies in type of groups, program content and structure, length of sessions, measurement of impact, follow-up, and so forth. Most programs were delivered face to face. Physical health and preventative healthcare were important topics for women veterans, particularly reproductive health, mental health, and chronic pain. Groups that included physical activity, creative arts, and alternative therapies were beneficial to women's physical and mental health. Strengths-based women-only groups, facilitated by women, that created safe spaces for women veterans to share their experiences, enhanced self-expression, agency, and self-empowerment. This was particularly important for women who had experience military sexual trauma. CONCLUSION: This review found a small but diverse range of group programs available for women veterans. Many program evaluations were of moderate or low quality and lacked sufficient information to determine whether benefits were sustained over time. No studies involved Australian women veterans. Despite these concerns, this review highlighted several useful lessons that could help inform improved design, delivery, and evaluation of group programs for women veterans.

Review of women veteran transition mental health and well-being support group programsWomen veterans learn to become soldiers, sailors and aviators in a male-dominated environment and culture in which their presence is highly visible, challenged and often subject to institutional prejudice. Transition can be confusing and isolating for women veterans. We know little about the specific needs of women veterans to support them to transition successfully to civilian life. Group programs are an important source of transition and post-transition support for veterans. The aim of this review was to examine the existing literature on mental health and well-being support group programs delivered to women veterans to understand what women veterans value and find most helpful in the design and delivery of such programs. Thirty-five studies were included in this review; 33 of these were conducted in the United States. They were of mixed quality and diverse design. Women only groups were favored. Strengths-based Programs that help to build emotional strengths, agency and empowered women were valued by them. Physical health and preventative healthcare are important topics for group programs for women veterans, as are creative arts and alternative therapies that facilitate self-expression and self-empowerment.

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Posttraumatic stress disorder (PTSD) is a burdensome disorder associated with lower quality of life and increased morbidity and mortality. Veterans are particularly at risk for PTSD resulting from experiencing traumatic events during military service. Current treatments for PTSD often fail to remediate symptoms and are associated with high dropout rates; therefore, complementary and integrative health approaches, such as yoga, are being considered to treat PTSD-related symptoms. The present study investigated the feasibility of a 12-week, 1-hour/week, in-person, trauma-informed mindful resilience yoga intervention for improving PTSD symptom severity and secondary psychological outcomes (e.g., physical and mental health, sleep, mindfulness, and self-efficacy), physiological health-related fitness outcomes (e.g., body composition and muscular strength), and physical activity outcomes (e.g., accelerometry) in a sample of veterans with PTSD. Results demonstrated the intervention to be feasible, with 12 participants (9 male, 3 female; mean age 50.3) completing the program (10 participants completed ≥ 75% of the 12 sessions). Statistically significant improvement was demonstrated in the "nonjudging of inner experience" aspect of mindfulness (p = 0.005, d = 1.280). Although not considered statistically significant (p > 0.008), the majority of outcomes demonstrated trending improvement from pre- to postintervention, with small to large Cohen's d effect sizes. The novelty of this study is represented by the trending improvements in physiological health-related fitness outcomes, with lean mass and handgrip strength demonstrating small effect sizes (d = 0.243 and d = 0.267, respectively). Our results extend the existing literature on the feasibility and potential effectiveness of yoga as a complementary or integrative therapy for PTSD in the veteran population.

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INTRODUCTION: Intraindividual variability across a battery of neuropsychological tests (IIV-dispersion) can reflect normal variation in scores or arise from cognitive impairment. An alternate interpretation is IIV-dispersion reflects reduced engagement/invalid test data, although extant research addressing this interpretation is significantly limited. METHOD: We used a sample of 97 older adult (mean age: 69.92), predominantly White (57%) or Black/African American (34%), and predominantly cis-gender male (87%) veterans. Examinees completed a comprehensive neuropsychological battery, including measures of reduced engagement/invalid test data (a symptom validity test [SVT], multiple performance validity tests [PVTs]), as part of a clinical evaluation. IIV-dispersion was indexed using the coefficient of variance (CoV). We tested 1) the relationships of raw scores and "failures" on SVT/PVTs with IIV-dispersion, 2) the relationship between IIV-dispersion and validity/neurocognitive disorder status, and 3) whether IIV-dispersion discriminated the validity/neurocognitive disorder groups using receiver operating characteristic (ROC) curves. RESULTS: IIV-dispersion was significantly and independently associated with a selection of PVTs, with small to very large effect sizes. Participants with invalid profiles and cognitively impaired participants with valid profiles exhibited medium to large (d = .55-1.09) elevations in IIV-dispersion compared to cognitively unimpaired participants with valid profiles. A non-significant but small to medium (d = .35-.60) elevation in IIV-dispersion was observed for participants with invalid profiles compared to those with a neurocognitive disorder. IIV-dispersion was largely accurate at differentiating participants without a neurocognitive disorder from invalid participants and those with a neurocognitive disorder (areas under the Curve [AUCs]=.69-.83), while accuracy was low for differentiating invalid participants from those with a neurocognitive disorder (AUCs=.58-.65). CONCLUSIONS: These preliminary data suggest IIV-dispersion may be sensitive to both neurocognitive disorders and compromised engagement. Clinicians and researchers should exercise due diligence and consider test validity (e.g. PVTs, behavioral signs of engagement) as an alternate explanation prior to interpretation of intraindividual variability as an indicator of cognitive impairment.

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BACKGROUND: Distress related to systemic racism in the public service and healthcare systems is linked to adverse mental health sequelae in racial and ethnic minority populations. Emerging research has found that distress related to racism may impact military veterans, an increasingly racially and ethnically diverse segment of the US population who are at increased risk of mental health problems relative to non-veterans. To date, however, no known study has examined longitudinal trends in distress related to systemic racism in this population. METHODS: A nationally representative sample of 2361 US military veterans completed a baseline assessment in 2020 and a 2-year follow-up in 2022. A multinomial logistic regression analysis was conducted to examine longitudinal courses and baseline predictors of systemic racism-related distress. RESULTS: Relative to the veterans with no racism-related distress, those who reported racism-related distress across the 2-year study period were older, more likely to be female, Black, or Hispanic, and to have completed college or higher education, and reported more lifetime traumas and stressors. Nearly 4-of-5 of Black veterans endorsed distress related to systemic racism over the 2-year study period. LIMITATIONS: Use of self-report and abbreviated measures of distress related to systemic racism. CONCLUSIONS: Results suggest that distress related to systemic racism may pose a significant emotional burden on subgroups of US veterans. They further underscore the importance of training clinicians to provide culturally-informed assessments and treatments for Black and other racial and ethnic minority veterans who bear the weight of racial discrimination.

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BACKGROUND: Veterans with substance use disorder (SUD) are at high risk for cognitive problems due to neurotoxic effects of chronic drug and alcohol use coupled in many cases with histories of traumatic brain injury (TBI). These problems may in turn result in proneness to SUD relapse and reduced adherence to medical self-care regimens and therefore reliance on health care systems. However, the direct relationship between cognitive function and utilization of Veterans Health Administration (VHA) SUD and other VHA health care services has not been evaluated. We sought initial evidence as to whether neurocognitive performance relates to repeated health care engagement in Veterans as indexed by estimated VHA care costs. METHODS: Neurocognitive performance in 76 Veterans being treated for SUD was assessed using CNS-Vital Signs, a commercial computerized cognitive testing battery, and related to histories of outpatient and inpatient/residential care costs as estimated by the VHA Health Economics Resource Center. RESULTS: After controlling for age, an aggregate metric of overall neurocognitive performance (Neurocognition Index) correlated negatively with total VHA health care costs, particularly with SUD-related outpatient care costs but also with non-mental health-related care costs. Barratt Impulsiveness Scale scores also correlated positively with total VHA care costs. CONCLUSIONS: In Veterans receiving SUD care, higher impulsivity and lower cognitive performance were associated with greater health care utilization within the VHA system. This suggests that veterans with SUD who show lower neurocognitive performance are at greater risk for continued health problems that require healthcare engagement. Cognitive rehabilitation programs developed for brain injury and other neurological conditions could be tried in Veterans with SUD to improve their health outcomes.

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Homelessness and suicide are top priorities in the U.S. Department of Veterans Affairs (VA). This study examined the various pathways involving homelessness, substance use, and mental health disorders in relation to suicide deaths among veterans in the VA healthcare system. A retrospective cohort study was conducted among 6,128,921 veterans-399,125 homeless and 5,729,796 non-homeless-followed-up between 2017 and 2021 using VA/Department of Defense linked databases. Multivariable Cox regression was applied for homelessness and psychiatric disorders as predictor of suicide deaths, sequentially controlling for demographic, clinical, substance use, and mental health characteristics. Four-way decomposition analysis was used to calculate proportions of suicide deaths mediated and/or moderated by homelessness, substance use, and mental health disorders. The relationship between homelessness and suicide-specific mortality risk was reduced from 40 % greater risk in unadjusted to 9 % greater risk in fully-adjusted models. Nearly 26 % of the total effect of homelessness on suicide-specific mortality risk was mediated by substance use disorders, whereas 49 % was mediated and 36 % was moderated by mental health disorders. In conclusion, excess suicide-specific mortality risk in homeless veterans is partly explained by substance use and mental health disorders, highlighting the importance of wrap-around health and social services for homeless veterans in mitigating suicide risk.

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BACKGROUND: Research suggests an association between COVID-19 infection and certain financial hardships in the shorter term and among single-state and privately insured samples. Whether COVID-19 is associated with financial hardship in the longer-term or among socially vulnerable populations is unknown. Therefore, we examined whether COVID-19 was associated with a range of financial hardships 18 months after initial infection among a national cohort of Veterans enrolled in the Veterans Health Administration (VHA)-the largest national integrated health system in the US. We additionally explored the association between Veteran characteristics and financial hardship during the pandemic, irrespective of COVID-19. METHODS: We conducted a prospective, telephone-based survey. Out of 600 Veterans with COVID-19 from October 2020 through April 2021 who were invited to participate, 194 Veterans with COVID-19 and 194 matched comparators without a history of infection participated. Financial hardship outcomes included overall health-related financial strain, two behavioral financial hardships (e.g., taking less medication than prescribed due to cost), and seven material financial hardships (e.g., using up most or all savings). Weighted generalized estimating equations were used to estimate risk ratios (RR) and 95% confidence intervals (CI) of financial hardship by COVID-19 status, and to assess the relationship between infection and Veteran age, VHA copay status, and comorbidity score, irrespective of COVID-19 status. RESULTS: Among 388 respondents, 67% reported at least one type of financial hardship since March 2020, with 21% reporting behavioral hardships and 64% material hardships; 8% reported severe-to-extreme health-related financial strain. Compared with uninfected matched comparators, Veterans with a history of COVID-19 had greater risks of severe-to-extreme health-related financial strain (RR: 4.0, CI: 1.4-11.2), taking less medication due to cost (RR: 2.9, 95% CI: 1.0-8.6), and having a loved one take time off work to care for them (RR: 1.9, CI: 1.1-3.6). Irrespective of COVID-19 status, Veterans aged < 65 years had a greater risk of most financial hardships compared with Veterans aged ≥ 65 years. CONCLUSIONS: Health-related financial hardships such as taking less medication due to cost and severe-to-extreme health-related financial strain were more common among Veterans with a history of COVID-19 than among matched comparators. Strategies are needed to address health-related financial hardship after COVID-19. TRIAL REGISTRATION: NCT05394025, registered 05-27-2022.

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BACKGROUND: Deployment-related neurotoxicant exposures are implicated in the etiology of Gulf War illness (GWI), the multisymptom condition associated with military service in the 1990-1991 Gulf War (GW). A Q/R polymorphism at position 192 of the paraoxonase (PON)-1 enzyme produce PON1192 variants with different capacities for neutralizing specific chemicals, including certain acetylcholinesterase inhibitors. METHODS: We evaluated PON1192 status and GW exposures in 295 GWI cases and 103 GW veteran controls. Multivariable logistic regression determined independent associations of GWI with GW exposures overall and in PON1192 subgroups. Exact logistic regression explored effects of exposure combinations in PON1192 subgroups. RESULTS: Hearing chemical alarms (proxy for possible nerve agent exposure) was associated with GWI only among RR status veterans (OR = 8.60, p = 0.014). Deployment-related skin pesticide use was associated with GWI only among QQ (OR = 3.30, p = 0.010) and QR (OR = 4.22, p < 0.001) status veterans. Exploratory assessments indicated that chemical alarms were associated with GWI in the subgroup of RR status veterans who took pyridostigmine bromide (PB) (exact OR = 19.02, p = 0.009) but not RR veterans who did not take PB (exact OR = 0.97, p = 1.00). Similarly, skin pesticide use was associated with GWI among QQ status veterans who took PB (exact OR = 6.34, p = 0.001) but not QQ veterans who did not take PB (exact OR = 0.59, p = 0.782). CONCLUSION: Study results suggest a complex pattern of PON1192 exposures and exposure-exposure interactions in the development of GWI.

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