Posttraumatic stress disorder (PTSD), depression, alcohol use disorders (AUD), traumatic brain injury, and chronic pain frequently co-occur among post-9/11 war Veterans and are associated with functional impairment and suicide risk. Yet, no treatment exists [that was specifically designed] to promote functional recovery in Veterans experiencing any combination of these most common mental and physical wounds of war. This is the re-submitted proposal for a second competitive renewal to fund Phase 3 of Project SERVE (Study Evaluating Returning Veterans? Experiences). In Phase 1 (RX000304-01A1), we identified risk and resilience factors for deployment-related mental health conditions regardless of whether those factors were modifiable. In Phase 2 (RX000304-04A1), we refined our approach by focusing on modifiable predictors drawn from the treatment outcomes literature. The over-arching aim of this programmatic line of research is to inform the development of evidence-based prevention and treatment programs designed to assist returning Veterans with achieving optimal functioning upon reintegrating into civilian life. This vision comes to fruition in the proposed Phase 3, which proposes both to extend the longitudinal study (Aim 1) and to adapt, refine, and pilot test an intervention to promote functional recovery (Aim 2). The 2-year longitudinal study (N = 500) will examine novel factors (e.g., mindfulness, perceived burdensomeness, thwarted belongingness, moral injury) and established treatment targets (psychological flexibility, self-compassion, emotion regulation) in relation to latent class trajectories of functional impairment, and as predictors of risk for self-directed violence (SDV; i.e., suicide risk), which is a top priority for VA and RR&D. In the prior Phases, we established psychological inflexibility as a robust risk factor for mental health problems, functional impairment, and SDV. Thus, in Aim 2, using a Successive Cohort Design, we will adapt, refine [based on Veterans? feedback], and pilot-test an adapted evidence-based intervention, Acceptance and Commitment Therapy (ACT) that targets psychological flexibility to promote functional recovery (ACT-FX). We previously demonstrated the promise of ACT, a transdiagnostic, mindfulness and acceptance-based behavior therapy aimed at improving functioning by increasing psychological flexibility with Veterans with co-occurring PTSD-AUD. We will test the feasibility and acceptability of ACT-FX, [an individually-tailored intervention to promote functional recovery related to these commonly co-occurring conditions as compared to mental health treatment as usual (TAU) in 60] Veterans with moderate-to-severe functional impairment. Our ultimate goal is to help shift chronically impaired Veterans to a recovery trajectory. Integrating data from the longitudinal study (Aim 1) with data from the treatment study (Aim 2), we will conduct a preliminary test of whether ACT-FX is associated with functionally impaired Veterans moving to a latent class trajectory characterized by long-term recovery (Aim 3; Exploratory).

Public Health Relevance

While resilience is the norm, many of our nation?s post-9/11 Iraq and Afghanistan war Veterans struggle with impaired social and occupational functioning related to posttraumatic stress disorder, depression, alcohol use disorders, traumatic brain injury, and chronic pain, conditions that frequently co-occur. Crucially, these conditions also increase risk for suicide. We plan to continue following a cohort of post-9/11 Veterans for two additional years to identify novel, modifiable predictors of long-term functional impairment and suicide risk. In addition, we will use what we have learned in our prior research phases to adapt, refine based on Veterans? feedback, and pilot test a psychological treatment specifically designed to promote long-term functional recovery among Veterans experiencing any combination of these mental and physical wounds of war.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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Behavioral Health & Social Reintegration (RRD4)
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Olin Teague Veterans Center
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Frankfurt, Sheila B; DeBeer, Bryann B; Morissette, Sandra B et al. (2018) Mechanisms of Moral Injury Following Military Sexual Trauma and Combat in Post-9/11 U.S. War Veterans. Front Psychiatry 9:520
Kimbrel, Nathan A; Meyer, Eric C; DeBeer, Bryann B et al. (2018) The Impact of Cannabis Use Disorder on Suicidal and Nonsuicidal Self-Injury in Iraq/Afghanistan-Era Veterans with and without Mental Health Disorders. Suicide Life Threat Behav 48:140-148
Kimbrel, Nathan A; Wilson, Laura C; Mitchell, John T et al. (2017) ADHD and nonsuicidal self-injury in male veterans with and without PTSD. Psychiatry Res 252:161-163
DeBeer, Bryann B; Davidson, Dena; Meyer, Eric C et al. (2017) The Association Between Toxic Exposures and Chronic Multisymptom Illness in Veterans of the Wars of Iraq and Afghanistan. J Occup Environ Med 59:54-60
Elliott, Timothy R; Hsiao, Yu-Yu; Kimbrel, Nathan A et al. (2017) Resilience and Traumatic Brain Injury Among Iraq/Afghanistan War Veterans: Differential Patterns of Adjustment and Quality of Life. J Clin Psychol 73:1160-1178
DeBeer, Bryann B; Kimbrel, Nathan A; Mendoza, Corina et al. (2017) Traumatic Brain Injury, Sleep Quality, and Suicidal Ideation in Iraq/Afghanistan Era Veterans. J Nerv Ment Dis 205:512-516
Martindale, Sarah L; Morissette, Sandra B; Kimbrel, Nathan A et al. (2016) Neuropsychological functioning, coping, and quality of life among returning war veterans. Rehabil Psychol 61:231-9
Kimbrel, Nathan A; Meyer, Eric C; DeBeer, Bryann B et al. (2016) A 12-Month prospective study of the effects of PTSD-depression comorbidity on suicidal behavior in Iraq/Afghanistan-era veterans. Psychiatry Res 243:97-9
Konecky, Brian; Meyer, Eric C; Kimbrel, Nathan A et al. (2016) The structure of DSM-5 posttraumatic stress disorder symptoms in war veterans. Anxiety Stress Coping 29:497-506
Kittel, Julie A; DeBeer, Bryann B; Kimbrel, Nathan A et al. (2016) Does body mass index moderate the association between posttraumatic stress disorder symptoms and suicidal ideation in Iraq/Afghanistan veterans? Psychiatry Res 244:123-9

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