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Abstract. Background and Aim: The Suicide Cognitions Scale (SCS) was developed to assess a broad range of suicide-related cognitions. Research to date supports the scale's factor structure, internal consistency, and construct validity. The present study tested the scale's prospective validity for suicide attempts among 97 military personnel presenting to an emergency department or psychiatric outpatient clinic for an unscheduled walk-in evaluation. Method: Cox regression and receiver operator characteristic analyses were conducted to test the prospective validity of the SCS. Results: Results supported the prospective validity of the SCS (area under the curve [AUC] = 0.69) and indicate the scale's performance is comparable to an empirically supported measure of suicide ideation (AUC = 0.75). The SCS performance was not reduced by removing items containing the word suicide. Limitations: Homogeneous sample comprised of US soldiers, predominantly male, with recent suicidal ideation. Conclusion: Results support the SCS as an indicator of subsequent risk for suicidal behavior when used in acute care settings, and suggest the scale's performance is similar to more traditional suicide risk screening methods that depend on honest self-disclosure of suicidal thoughts.

Suicides within the U.S. Armed Forces remain elevated. Brief cognitive behavioral therapy for suicide prevention (BCBT) has demonstrated preliminary efficacy as a psychotherapeutic intervention that reduces suicide attempts among U.S. Army Soldiers. The generalizability of BCBT's effects in other military groups and its underlying mechanisms of action remain unknown, however. The Marine Suicide Prevention and Intervention REsearch (M-SPIRE) study is designed to test the efficacy of BCBT for the prevention of suicide attempts among active duty U.S. Marines with recent suicidal ideation or attempts and to identify potential mechanisms of change contributing to BCBT's effects. In this protocol paper, we describe M-SPIRE's rationale and methods with a particular emphasis on measuring treatment fidelity and BCBT's hypothesized mechanisms of action.

Background: Successful psychotherapy for posttraumatic stress disorder (PTSD) necessitates initial and sustained engagement. However, treatment dropout is common, with rates of 50–70% depending on the setting, type of treatment and how dropout is calculated. Dropout from residential treatment is less understood and could be impacted by participation of more symptomatic patient populations and reduced day-to-day barriers to engagement. Gaining insight into predictors of treatment dropout is critical given that individuals with greater symptoms are the most in need of successful treatments but also at higher risk of unsuccessful psychotherapy episodes. Aim: The aim of the current study was to examine predictors of treatment dropout among veterans receiving residential treatment for PTSD. Methods: The study included 3,965 veterans who initiated residential PTSD treatment within a Department of Veterans Affairs program during Fiscal Year 2015 and completed self-report measures of demographics and psychiatric symptoms at admission. Results: In our sample (N = 3,965, 86.5% male, mean age = 45.5), 27.5% did not complete the residential program (n = 1,091). Controlling for age, marital status, combat/non-combat trauma, and facility, generalized estimating equation modeling analysis indicated greater PTSD symptoms and physical functioning at admission were associated with reduced likelihood of completing the residential program. There were significant differences in trauma-focused psychotherapy received by individuals who dropped out of residential treatment and those who did not. Among veterans who dropped out, 43.6% did not get any trauma-focused psychotherapy; 22.3% got some, but less than 8 sessions; and 34.1% got at least 8 sessions; compared to 37.3%, 4.8%, and 57.9%, respectively, among program completers. Conclusion: Dropout rates from residential PTSD programs indicate that at least one in four veterans do not complete residential treatment, with more symptomatic individuals and those who do not receive ...

Background: It has been suggested that current frontline posttraumatic stress disorder (PTSD) treatments are not effective for the treatment of moral injury and that individuals who have experienced morally injurious events may respond differently to treatment than those who have not. However, these claims have yet to be empirically tested. Objective: This study evaluated the rates of morally injurious event exposure and morally injurious index trauma and their impact on PTSD (PCL-5) and depression symptom (PHQ-9) reductions during intensive PTSD treatment. Method: Data from 161 USA military combat service members and veterans (91.3% male; mean age=39.94years) who participated in a 3-week Cognitive Processing Therapy (CPT)-based intensive PTSD treatment programme (ITP) was utilized. Morally injurious event exposure was established via the Moral Injury Event Scale (MIES). Index traumas were also coded by the treating clinician. Linear mixed effects regression analyses were conducted to examine if differences in average effects or trends over the course of treatment existed between veterans with morally injurious event exposure or index trauma and those without. Results: Rates of morally injurious event exposure in this treatment sample were high (59.0%-75.2%). Morally injurious event exposure and the type of index trauma did not predict changes in symptom outcomes from the ITP and veterans reported large reductions in PTSD (d =1.35-1.96) and depression symptoms (d =0.95-1.24) from pre- to post-treatment. Non-inferiority analyses also demonstrated equivalence across those with and without morally injurious event exposure and index events. There were no significant gender differences. Conclusions: The present study suggests that PTSD and depression in military veterans with morally injurious event exposure histories may be successfully treated via a 3-week CPT-based ITP.

BACKGROUND: Suicidal thoughts are common among veterans with posttraumatic stress disorder (PTSD). The aim of this study was to examine the prevalence and correlates of four courses of suicidal ideation (SI) among veterans receiving residential PTSD treatment. METHODS: 1807 veterans receiving residential PTSD treatment at Department of Veterans Affairs medical facilities who completed self-report measures at admission and discharge were included. RESULTS: The prevalence of SI courses were No SI (33.6%), Remitted SI (23.0%), SI Onset (6.0%), and Chronic SI (37.4%). There were group differences between the four SI courses in PTSD symptoms at baseline, magnitude of PTSD symptom change during treatment, race/ethnicity and baseline depression, substance use, physical functioning, and pain. Chronic SI was associated with highest baseline PTSD, depression, substance use, pain and worse physical functioning. Remitted SI course was associated with greatest pre-post-treatment PTSD improvement, followed by No SI, Chronic SI, and SI Onset. Multinomial logistic regressions revealed that PTSD symptom improvement and baseline PTSD symptoms most consistently related to symptomatic SI courses compared to less symptomatic or No SI courses. Receipt of trauma-focused psychotherapy (none, some, or adequate) and length of stay were not related to SI courses and did not differ between groups. CONCLUSIONS: Findings indicate that treating PTSD symptoms could be impactful for reducing suicidal thoughts. Although many veterans had remitted or reduced severity of SI at discharge, a significant proportion of veterans reported SI at discharge (43.4%), potentially highlighting the need for suicide specific treatment interventions within the context of PTSD treatment.

Identifying predictors of suicide attempts is critical in intervention and prevention efforts, yet finding predictors has proven difficult due to the low base rate and underpowered statistical approaches. The objective of the current study was to use machine learning to examine predictors of suicidal behaviors among high-risk suicidal Soldiers who received outpatient mental health services in a randomized controlled trial of Brief Cognitive Behavioral Therapy for Suicide Prevention (BCBT) compared to treatment as usual (TAU). Self-report measures of clinical and demographic variables, administered prior to the start of outpatient treatment to 152 participants with recent suicidal thoughts and/or behaviors were analyzed using machine learning software to identify the best combination of variables for predicting suicide attempts during or after treatment. Worst-point suicidal ideation, history of multiple suicide attempts, treatment group (i.e., BCBT or TAU), suicidogenic cognitions, and male sex were found, in combination, correctly classified 30.8% of patients who attempted suicide during the two-year follow-up period. This combination has higher sensitivity than many models that have previously been used to predict suicidal behavior. Overall, this study provides a combination of variables that can be assessed clinical to help identify high-risk suicidal individuals.