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1.  Lifetime Prevalence of Respiratory Diseases and Exposures Among Veterans of Operation Enduring Freedom and Operation Iraqi Freedom Veterans 
Objective
The objective of this study was to determine the prevalence of respiratory exposures and the association between respiratory exposures and respiratory disease among veterans deployed to Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) compared with nondeployed veterans of this era.
Methods
Data come from a national health survey of 20,563 deployed and nondeployed OEF/OIF era veterans. Prevalence estimates and adjusted odds ratios were calculated. Results were weighted to represent the population.
Results
Prevalence of at least one respiratory exposure was high among both deployed and nondeployed groups (95% and 70%, respectively). In both groups, those with any respiratory exposure were at an increased risk for reporting a respiratory disease.
Conclusion
Respiratory exposures are highly prevalent and are associated with increased odds of respiratory diseases among the OEF/OIF era population.
doi:10.1097/JOM.0000000000000885
PMCID: PMC5482227  PMID: 27930474
2.  VA Suicide Prevention Applications Network 
Public Health Reports  2016;131(6):816-821.
Objectives:
The US Department of Veterans Affairs’ Suicide Prevention Applications Network (SPAN) is a national system for suicide event tracking and case management. The objective of this study was to assess data on suicide attempts among people using Veterans Health Administration (VHA) services.
Methods:
We assessed the degree of data overlap on suicide attempters reported in SPAN and the VHA’s medical records from October 1, 2010, to September 30, 2014—overall, by year, and by region. Data on suicide attempters in the VHA’s medical records consisted of diagnoses documented with E95 codes from the International Classification of Diseases, Ninth Revision.
Results:
Of 50 518 VHA patients who attempted suicide during the 4-year study period, data on fewer than half (41%) were reported in both SPAN and the medical records; nearly 65% of patients whose suicide attempt was recorded in SPAN had no data on attempted suicide in the VHA’s medical records.
Conclusion:
Evaluation of administrative data suggests that use of SPAN substantially increases the collection of data on suicide attempters as compared with the use of medical records alone, but neither SPAN nor the VHA’s medical records identify all suicide attempters. Further research is needed to better understand the strengths and limitations of both systems and how to best combine information across systems.
doi:10.1177/0033354916670133
PMCID: PMC5230828  PMID: 28123228
veterans; suicide; prevention
3.  Demographic, Military, and Health Characteristics of VA Health Care Users and Nonusers Who Served in or During Operation Enduring Freedom or Operation Iraqi Freedom, 2009-2011 
Public Health Reports  2016;131(6):839-843.
An estimated 60% of all Operation Enduring Freedom / Operation Iraqi Freedom (OEF/OIF) veterans who have left the military had used the US Department of Veterans Affairs (VA) for health care services as of March 31, 2015. What is not known, however, are the differences in demographic, military, and health characteristics between OEF/OIF veterans who use the VA for health care and OEF/OIF veterans who do not. We used data from the 2009-2011 National Health Study for a New Generation of US Veterans to explore these differences. We found that VA health care users were more likely than non-VA health care users to be non-Hispanic black, to be unmarried, to have served on active duty and in the army, to have been deployed to OEF/OIF, and to have an annual income less than $35 000. The prevalence of 21 chronic medical conditions was higher among VA health care users than among non-VA health care users. OEF/OIF veterans using the VA for health care differ from nonusers with respect to demographic, military, and health characteristics. These data may be useful for developing programs and policies to address observed health disparities and achieve maximum benefit for the VA beneficiary population.
doi:10.1177/0033354916676279
PMCID: PMC5230837  PMID: 28123232
OEF/OIF; veterans; Department of Veterans Affairs
4.  Cigarette Smoking and Sociodemographic, Military, and Health Characteristics of Operation Enduring Freedom and Operation Iraqi Freedom Veterans 
Public Health Reports  2016;131(5):714-727.
Objective:
We examined the sociodemographic, military, and health characteristics of current cigarette smokers, former smokers, and nonsmokers among Operation Enduring Freedom (OEF) / Operation Iraqi Freedom (OIF) veterans and estimated smoking prevalence to better understand cigarette use in this population.
Methods:
We analyzed data from the US Department of Veterans Affairs (VA) 2009-2011 National Health Study for a New Generation of US Veterans. On the basis of a stratified random sample of 60 000 OEF/OIF veterans, we sought responses to a 72-item questionnaire via mail, telephone, or Internet. Cigarette smoking status was based on self-reported cigarette use in the past year. We used multinomial logistic regression to evaluate associations between smoking status and sociodemographic, military, and health characteristics.
Results:
Among 19 911 veterans who provided information on cigarette smoking, 5581 were current smokers (weighted percentage: 32.5%, 95% confidence interval [CI]: 31.7-33.2). Current smokers were more likely than nonsmokers or former smokers to be younger, to have less education or income, to be separated/divorced or never married/single, and to have served on active duty or in the army. Comparing current smokers and nonsmokers, some significant associations from adjusted analyses included the following: having a Mental Component Summary score (a measure of overall mental health) above the mean of the US population relative to below the mean (adjusted odds ratio [aOR] = 0.81, 95% CI: 0.73-0.90); having physician-diagnosed depression (aOR = 1.52, 95% CI: 1.33-1.74), respiratory conditions (aOR = 1.16, 95% CI: 1.04-1.30), or repeated seizures/blackouts/convulsions (aOR = 1.80, 95% CI: 1.22-2.67); heavy alcohol use vs never use (aOR = 5.49, 95% CI: 4.57-6.59); a poor vs excellent perception of overall health (aOR = 3.79, 95% CI: 2.60-5.52); and being deployed vs nondeployed (aOR = 0.87, 95% CI: 0.78-0.96). Using health care services from the VA protected against current smoking.
Conclusion:
Mental and physical health, substance use, and military service characteristics shape cigarette-smoking patterns in OEF/OIF veterans.
doi:10.1177/0033354916664864
PMCID: PMC5230820  PMID: 28123213
veterans; cigarettes; smoking; OEF/OIF; Operation Iraqi Freedom; Operation Enduring Freedom; health; Afghanistan; Iraq
6.  Predicting suicides after outpatient mental health visits in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
Molecular psychiatry  2016;10.1038/mp.2016.110.
The 2013 U.S. Veterans Administration/Department of Defense Clinical Practice Guidelines (VA/DoD CPG) require comprehensive suicide risk assessments for VA/DoD patients with mental disorders but provide minimal guidance on how to carry out these assessments. Given that clinician-based assessments are known not to be strong predictors of suicide, we investigated whether a precision medicine model using administrative data after outpatient mental health specialty visits could be developed to predict suicides among outpatients. We focused on male non-deployed Regular U.S. Army soldiers because they account for the vast majority of such suicides. Four machine learning classifiers (naïve Bayes, random forests, support vector regression, elastic net penalized regression) were explored. 41.5% of Army suicides in 2004-2009 occurred among the 12.0% of soldiers seen as outpatient by mental health specialists, with risk especially high within 26 weeks of visits. An elastic net classifier with 10-14 predictors optimized sensitivity (45.6% of suicide deaths occurring after the 15% of visits with highest predicted risk). Good model stability was found for a model using 2004-2007 data to predict 2008-2009 suicides, although stability decreased in a model using 2008-2009 data to predict 2010-2012 suicides. The 5% of visits with highest risk included only 0.1% of soldiers (1047.1 suicides/100,000 person-years in the 5 weeks after the visit). This is a high enough concentration of risk to have implications for targeting preventive interventions. An even better model might be developed in the future by including the enriched information on clinician-evaluated suicide risk mandated by the VA/DoD CPG to be recorded.
doi:10.1038/mp.2016.110
PMCID: PMC5247428  PMID: 27431294
Army; machine learning; military; predictive modeling; risk assessment; suicide
7.  The effect of depression on the association between military service and life satisfaction 
Purpose
The purpose of this study was to examine the effect of depression on the association between a history of military service and life satisfaction among a nationally representative sample of US males.
Methods
Data from 57,905 men were obtained from the 2006 Behavioral Risk Factor Surveillance (BRFSS) survey that assessed depression, history of military service, and life satisfaction. Multivariable logistic regression was conducted, controlling for demographics and physical health characteristics.
Results
In non-depressed men, a history of military service was associated with higher odds of life satisfaction, OR (95%CI) = 1.39 (1.07, 1.81). However, the interaction between depression and a history of military service was significant, OR (95%CI) = 0.56 (0.38–0.84), such that a history of military service was associated with equivalent odds of satisfaction in depressed men, OR (95%CI) = 0.78 (0.56–1.09).
Conclusions
Intervention efforts targeting depression in men with a history of military service may have a significant impact on their well being. Future research should replicate these findings, examine potential mechanisms of the effects, and study the utility of life satisfaction measures in this population.
doi:10.1007/s11136-011-0104-4
PMCID: PMC5064428  PMID: 22286221
8.  Veterans Crisis Line Callers With and Without Prior VHA Service Use 
This study examines differences between Veterans with and without prior Veterans Health Administration service use who received a clinical referral from the Veterans' Crisis Line. Approximately 91% of Veterans had a history of service use and 9% did not. Callers with prior service use were older, had more mental health disorders, made in-person contact more quickly, and used more outpatient mental healthcare. Those without prior service use were younger, had more mental health problems, and presented for care later. Callers with suicide-related diagnoses had high rates of service contact. These groups represent different subpopulations with unique healthcare needs and practices.
doi:10.1080/13811118.2015.1017681
PMCID: PMC5064429  PMID: 26649615
Veterans; suicide; telephone counseling
9.  Prevalence, Correlates, and Symptom Profiles of Depression among Men with a History of Military Service 
Purpose
The purpose of this study was to examine the prevalence, correlates, and symptom profiles of depressive disorders in men with a history of military service.
Methods
Data was obtained from the 2006 Behavioral Risk Factor Surveillance System (BRFSS) survey. Multivariable logistic regressions were used to identify correlates of lifetime and current depression. Regularly occurring symptom profiles were identified via cluster analysis.
Results
Prevalence of lifetime and current depression was similar in men with and without a history of military service. Lifetime diagnosis was positively associated with younger age and negatively associated with black minority status, married or cohabitation, and self-reported good health. Current depression was positively associated with other minority status (non-Hispanic non-black) and negatively associated with older age, some college, being in a relationship, and self-reported good health. A cluster of younger men who experience significant depressive symptoms but may not report depressed mood or anhedonia was identified.
Conclusions
Depression is as prevalent in men with a history of military service as it is in men without a history. Research should examine subpopulations of men with a history of military service in which depression may be more prevalent or burdensome. Younger men with significant depressive symptoms may be missed by standard depression screens and still be at elevated risk for negative outcomes associated with depressive disorders.
doi:10.1007/s00127-010-0226-y
PMCID: PMC5064430  PMID: 20652680
Depression; Prevalence; Military Personnel; Veterans
10.  Influences on call outcomes among Veteran callers to the National Veterans Crisis Line 
This evaluation examined the association of caller and call characteristics with proximal outcomes of Veterans Crisis Line calls. From October 1-7, 2010, 665 Veterans with recent suicidal ideation or a history of attempted suicide called the Veterans Crisis Line, 646 had complete data and were included in the analyses. A multivariable multinomial logistic regression was conducted to identify correlates of a favorable outcome, either a resolution or a referral, when compared to an unfavorable outcome, no resolution or referral. A multivariable logistic regression was used to identify correlates of responder-rated caller risk in a subset of calls. Approximately 84% of calls ended with a favorable outcome, 25% with a resolution and 59% with a referral to a local health care provider. Calls from high-risk callers had greater odds of ending with a referral than without a resolution or referral, as did weekday calls (6:00 am to 5:59 pm EST, Monday through Friday). Responders used caller intent to die and the absence of future plans to determine caller risk. Findings suggest that the Veterans Crisis Line is a useful mechanism for generating referrals for high-risk Veteran callers. Responders appeared to use known risk and protective factors to determine caller risk.
doi:10.1111/sltb.12033
PMCID: PMC5064431  PMID: 23611446
11.  Mental Health and Self-directed Violence Among Student Service Members/Veterans in Postsecondary Education 
Objectives
Using a sample of student service members/veterans, the current study aimed to examine the prevalence of psychiatric diagnoses and suicide-related outcomes and the association of hazardous duty with mental health.
Participants
Data are from the Fall 2011 National College Health Assessment (n=27,774).
Methods
Logistic regression was used to examine (1) the association of student service member/veteran status with mental health outcomes and (2) the association of hazardous duty with mental health outcomes among student service members/veterans (n=706).
Results
Student service members/veterans had higher odds of self-harm than students without military experience. Among student service members/veterans, hazardous duty was positively associated (OR=2.00, 95% CI: 1.30–3.07) with having a psychiatric diagnosis but negatively associated (OR=0.41, 95% CI: 0.20–0.85) with suicidal ideation.
Conclusions
Self-harm may be a unique phenomenon among service members/veterans. Suicide prevention with this population should include information about self-harm, and future research should explore whether suicidal intent underlies self-harm.
doi:10.1080/07448481.2014.931282
PMCID: PMC4263812  PMID: 24918517
veterans health; mental health; suicidal ideation; attempted suicide; self injurious behavior
12.  Improving National Data Systems for Surveillance of Suicide-related Events 
American journal of preventive medicine  2014;47(3 Suppl 2):S122-S129.
Background
Describing the characteristics and patterns of suicidal behavior is an essential component in developing successful prevention efforts. The Data and Surveillance Task Force (DSTF) of the National Action Alliance for Suicide Prevention was charged with making recommendations for improving national data systems for public health surveillance of suicide-related problems, including suicidal thoughts, suicide attempts and deaths due to suicide. Data from the national systems can be used to draw attention to the magnitude of the problem and are useful for establishing national health priorities. National data can also be used to examine differences in rates across groups (e.g., sex, racial/ethnic, and age groups) and geographic regions, and are useful in identifying patterns in the mechanism of suicide, including those that rarely occur.
Methods
Using evaluation criteria from the Centers for Disease Control and Prevention, the World Health Organization, and the U.S.-based Safe States Alliance, the DSTF reviewed 28 national data systems for feasibility of use in the surveillance of suicidal behavior, including deaths, non-fatal attempts and suicidal thoughts. The review criteria included such attributes as the aspects of the suicide-related spectrum (e.g., thoughts, attempts, deaths) covered by the system, how the data are collected (e.g., census, sample, survey, administrative data files, self-report, reporting by care providers), and the strengths and limitations of the survey or data system.
Results
The DSTF identified common strengths and challenges among the data systems based on the underlying data source (e.g., death records, health care provider records, population-based surveys, health insurance claims). From these findings, the DSTF proposed several recommendations for improving existing data systems, such as using standard language and definitions, adding new variables to existing surveys, expanding the geographic scope of surveys to include areas where data are not currently collected, oversampling of underrepresented groups, and improving the completeness and quality of information on death certificates.
Conclusions
Some of the DSTF recommendations are potentially achievable in the short term (<1–3 years) within existing data systems, while others involve more extensive changes and will require longer term efforts (4–10 years). Implementing these recommendations would assist in the development of a national coordinated program of fatal and nonfatal suicide surveillance to facilitate evidence-based action to reduce the incidence of suicide and suicidal behavior in all populations.
doi:10.1016/j.amepre.2014.05.026
PMCID: PMC4959537  PMID: 25145729
13.  Testing a machine-learning algorithm to predict the persistence and severity of major depressive disorder from baseline self-reports 
Molecular psychiatry  2016;21(10):1366-1371.
Heterogeneity of major depressive disorder (MDD) illness course complicates clinical decision-making. While efforts to use symptom profiles or biomarkers to develop clinically useful prognostic subtypes have had limited success, a recent report showed that machine learning (ML) models developed from self-reports about incident episode characteristics and comorbidities among respondents with lifetime MDD in the World Health Organization World Mental Health (WMH) Surveys predicted MDD persistence, chronicity, and severity with good accuracy. We report results of model validation in an independent prospective national household sample of 1,056 respondents with lifetime MDD at baseline. The WMH ML models were applied to these baseline data to generate predicted outcome scores that were compared to observed scores assessed 10–12 years after baseline. ML model prediction accuracy was also compared to that of conventional logistic regression models. Area under the receiver operating characteristic curve (AUC) based on ML (.63 for high chronicity and .71–.76 for the other prospective outcomes) was consistently higher than for the logistic models (.62–.70) despite the latter models including more predictors. 34.6–38.1% of respondents with subsequent high persistence-chronicity and 40.8–55.8% with the severity indicators were in the top 20% of the baseline ML predicted risk distribution, while only 0.9% of respondents with subsequent hospitalizations and 1.5% with suicide attempts were in the lowest 20% of the ML predicted risk distribution. These results confirm that clinically useful MDD risk stratification models can be generated from baseline patient self-reports and that ML methods improve on conventional methods in developing such models.
doi:10.1038/mp.2015.198
PMCID: PMC4935654  PMID: 26728563
14.  Correlates of Suicide Among Veterans Treated in Primary Care: Case–Control Study of a Nationally Representative Sample 
Journal of General Internal Medicine  2014;29(Suppl 4):853-860.
ABSTRACT
BACKGROUND
Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death.
OBJECTIVE
Our aim was to describe characteristics of veterans who received VA primary care in the 6 months prior to suicide; and to compare these to characteristics of control patients who also received VA primary care.
DESIGN
This was a retrospective case–control study.
SUBJECTS
The investigators partnered with VA operations leaders to obtain death certificate data from 11 states for veterans who died by suicide in 2009. Cases were matched 1:2 to controls based on age, sex, and clinician.
MAIN MEASURES
Demographic, diagnosis, and utilization data were obtained from VA’s Corporate Data Warehouse. Additional clinical and psychosocial context data were collected using manual medical record review. Multivariate conditional logistic regression was used to examine associations between potential predictor variables and suicide.
KEY RESULTS
Two hundred and sixty-nine veteran cases were matched to 538 controls. Average subject age was 63 years; 97 % were male. Rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors were all significantly greater in cases compared to controls. In the final model describing men in the sample, non-white race (OR = 0.51; 95 % CI = 0.27–0.98) and VA service-connected disability (OR = 0.54; 95 % CI = 0.36–0.80) were associated with decreased odds of suicide, while anxiety disorder (OR = 3.52; 95 % CI = 1.79–6.92), functional decline (OR = 2.52; 95 % CI = 1.55–4.10), depression (OR = 1.82; 95 % CI = 1.07–3.10), and endorsement of suicidal ideation (OR = 2.27; 95 % CI = 1.07–4.83) were associated with greater odds of suicide.
CONCLUSIONS
Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.
doi:10.1007/s11606-014-3028-1
PMCID: PMC4239287  PMID: 25355088
mental health; veterans; primary care; health services research
15.  Associations Between the Department of Veterans Affairs' Suicide Prevention Campaign and Calls to Related Crisis Lines 
Public Health Reports  2014;129(6):516-525.
Objective
The Transit Authority Suicide Prevention (TASP) campaign was launched by the Department of Veterans Affairs (VA) in a limited number of U.S. cities to promote the use of crisis lines among veterans of military service.
Methods
We obtained the daily number of calls to the VCL and National Suicide Prevention Lifeline (NSPL) for six implementation cities (where the campaign was active) and four control cities (where there was no TASP campaign messaging) for a 14-month period. To identify changes in call volume associated with campaign implementation, VCL and NSPL daily call counts for three time periods of equal length (pre-campaign, during campaign, and post-campaign) were modeled using a Poisson log-linear regression with inference based on the generalized estimating equations.
Results
Statistically significant increases in calls to both the VCL and the NSPL were reported during the TASP campaign in implementation cities, but were not reported in control cities during or following the campaign. Secondary outcome measures were also reported for the VCL and included the percentage of callers who are veterans, and calls resulting in a rescue during the study period.
Conclusions
Results from this study reveal some promise for suicide prevention messaging to promote the use of telephone crisis services and contribute to an emerging area of research examining the effects of campaigns on help seeking.
PMCID: PMC4187294  PMID: 25364053
16.  Parent and Child Psychopathology and Suicide Attempts among Children of Parents with Alcohol Use Disorder 
Parents with psychopathology such as alcohol use disorder (AUD) that confers risk for suicide attempt (SA) may have children who are more likely to develop such psychopathology and to attempt suicide, suggesting that risk may be “transmitted” from parents to children. We examined this phenomenon during the transition from childhood to adolescence, when risk for SA increases dramatically. A cohort of 418 children were examined at average age 9.4 (range 7–14) years at enrollment (Time 1, childhood) and approximately five years later, prior to reaching age 18 (Time 2, adolescence). One or both biological parents, oversampled for AUD, were also interviewed. Structural equation models (SEM) examined father-child, mother-child, and either/both parent-child associations. The primary outcome was SA over follow-up among offspring, assessed at Time 2. As hypothesized, parental antisocial personality disorder predicted conduct disorder symptoms in offspring both during childhood and adolescence (parent-child model, father-child model) and maternal AUD predicted conduct disorder symptoms during childhood (mother-child model). However, we did not find evidence to support transmission of depression from parents to offspring either during childhood or adolescence, and parent psychopathology did not show statistically significant associations with SA during adolescence. In conclusion, we conducted a rare study of parent-to-child “transmission” of risk for SA that used a prospective research design, included diagnostic interviews with both parents and offspring, and examined the transition from childhood to adolescence, and the first such study in children of parents with AUD. Results provided mixed support for hypothesized parent-child associations.
doi:10.1080/13811118.2013.826154
PMCID: PMC4059391  PMID: 24716789
adolescent; parent; suicide attempt; alcohol use disorder; risk factor
17.  Health Care Utilization and Health Indicators Among a National Sample of U.S. Veterans in Same-Sex Partnerships 
Military medicine  2013;178(2):207-212.
Objectives
To examine health indicators of same-sex partnered veterans as compared with their opposite-sex partnered veteran and nonveteran peers.
Methods
Same-sex partner status was derived by self-reported same-sex partnerships in data from the 2004 Behavioral Risk Factor Surveillance System. Outcome variables included health risk disparities associated with sexual minority status (e.g., frequent mental distress) and veteran status (e.g., firearm ownership). Stratified multiple logistic regression models were used to examine the association of same-sex partnered veteran status with health indicators.
Results
Same-sex partnered veterans had higher odds of being overweight and keeping firearms in the house compared with same-sex partnered nonveterans. Same-sex partnered veterans were less likely than opposite-sex partnered veterans to be overweight, and they were more than twice as likely to be current smokers when compared with opposite-sex partnered nonveterans.
Conclusions
Findings suggest both that some health disparities patterns identified by same-sex partnership status among the general population also exist among veteran populations, and that some unique distinctions may exist, particularly related to BMI and firearm ownership. Collection of information about sexual minority status within Department of Veterans Affairs data sources is needed to more accurately assess the health of this minority population.
PMCID: PMC3725588  PMID: 23495467
18.  Suicide acceptability among U.S. Veterans with active duty experience: Results from the 2010 General Social Survey 
Objectives
To examine whether U.S. Veterans more frequently indicate suicide acceptability than non-Veterans.
Methods
The 2010 General Social Survey, which employed a probability-based sample of U.S. adults, was analyzed by self-reported Veteran status on suicide acceptability in four, separate hypothetical situations regarding ending one’s life (i.e., incurable illness, bankruptcy, bringing dishonor/shame upon family; tired of living and ready to die).
Results
Veterans were no more likely to endorse suicide as acceptable than their non-Veteran counterparts.
Conclusions
Results suggest that attitudes approving of suicide are not different among Veterans in general and non-Veterans. However, future research may need to examine if subpopulations of Veterans with elevated risk for suicide may report differential attitudes about suicide.
doi:10.1080/13811118.2013.748415
PMCID: PMC3601790  PMID: 23387403
suicide; veterans health
19.  Co-Occurring Physical Fighting and Suicide Attempts among U.S. High School Students: Examining Patterns of Early Alcohol Use Initiation and Current Binge Drinking 
Introduction: A growing body of empirical research documents a significant co-occurrence of suicide attempts and interpersonal violence among youth. However, the potential role of early alcohol use initiation and current heavy alcohol use as correlates of this comorbidity has not been examined in a nationally representative sample of high school students.
Methods: We based our analyses on cross-sectional data from the 2009 Youth Risk Behavior Survey, which includes a nationally representative sample (n=16,410) of high school students in grades 9 through 12 in the United States. Multinomial logistic regression analyses were conducted to test the associations between measures of alcohol use (early alcohol use initiation and heavy drinking) and comorbid suicidal and violent behavior while controlling for potential confounders.
Results: Among high school students, 3.6% reported comorbid physical fighting and suicide attempt in the past year. Early alcohol use (prior to age 13) and heavy drinking (5 or more drinks in a row) were strongly associated with comorbid reports of physical fighting and suicide attempts (Adj. odds ratio [OR]=3.12; 95% confidence interval [CI]:2.49–3.89) and (Adj. OR=3.45; 95%CI:2.63–4.52).
Conclusion: These findings underscore the importance of both early alcohol use initiation and heavy drinking as statistically significant correlates of comorbid fighting and suicide attempts among youth. While future research is needed to determine the temporal ordering between problem drinking and violent or suicidal behaviors, existing prevention programs may benefit from including components aimed at reducing and delaying alcohol use.
doi:10.5811/westjem.2013.3.15705
PMCID: PMC3735381  PMID: 23930147
20.  Drivers of Disparity: Differences in Socially-Based Risk Factors of Self-injurious and Suicidal Behaviors Among Sexual Minority College Students 
Lesbian, gay, and bisexual (i.e., sexual minority) populations have increased prevalence of both self-injurious and suicidal behaviors, but reasons for these disparities are poorly understood.
Objective
To test the association between socially-based stressors (e.g., victimization, discrimination) and self-injurious behavior, suicide ideation, and suicide attempt.
Participants
A national sample of college-attending 18- to 24-year-olds.
Methods
Random or census samples from post-secondary educational institutions that administered the National College Health Assessment during the Fall 2008 and Spring 2009 semesters.
Results
Sexual minorities reported more socially-based stressors than heterosexuals. Bisexuals exhibited greatest prevalence of self-injurious and suicidal behaviors. In adjusted models, intimate partner violence was most consistently associated with self-injurious behaviros.
Conclusions
Sexual minorities' elevated risks of self-injurious and suicidal behaviors may stem from higher exposure to socially-based stressors. Within-group differences among sexual minorities offer insight to specific risk factors that may contribute to elevated self-injurious and suicidal behaviors in sexual minority populations.
doi:10.1080/07448481.2011.623332
PMCID: PMC3340564  PMID: 22316411
Community Health; Health Education; Mental Health
21.  Self-Harm and Suicide Attempts among High-Risk, Urban Youth in the U.S.: Shared and Unique Risk and Protective Factors 
The extent to which self-harm and suicidal behavior overlap in community samples of vulnerable youth is not well known. Secondary analyses were conducted of the “linkages study” (N = 4,131), a cross-sectional survey of students enrolled in grades 7, 9, 11/12 in a high-risk community in the U.S. in 2004. Analyses were conducted to determine the risk and protective factors (i.e., academic grades, binge drinking, illicit drug use, weapon carrying, child maltreatment, social support, depression, impulsivity, self-efficacy, parental support, and parental monitoring) associated with both self-harm and suicide attempt. Findings show that 7.5% of participants reported both self-harm and suicide attempt, 2.2% of participants reported suicide attempt only, and 12.4% of participants reported self-harm only. Shared risk factors for co-occurring self-harm and suicide attempt include depression, binge drinking, weapon carrying, child maltreatment, and impulsivity. There were also important differences by sex, grade level, and race/ethnicity that should be considered for future research. The findings show that there is significant overlap in the modifiable risk factors associated with self-harm and suicide attempt that can be targeted for future research and prevention strategies.
doi:10.3390/ijerph9010178
PMCID: PMC3315085  PMID: 22470286
self-harm; suicide attempt; youth; adolescents; U.S.; high-risk; school; cross-sectional
23.  The Associations between Area of Residence, Sexual Violence Victimization, and Asthma Episodes among US Adult Women in 14 States and Territories, 2005–2007 
Gaps in understanding of how area-based differences in exposure to violence are associated with asthma prevalence may limit the development of effective prevention programs and the identification of risk for asthma episodes. The current investigation examines the associations between sexual violence victimization and asthma episodes among US adult women across three different metropolitan settings. The association between sexual assault victimizations and asthma attacks in the past year was examined using data from the 2005, 2006, and 2007 Behavioral Risk Factor Surveillance System surveys. Cross-sectional analyses were based on adult women with current asthma (n = 4,099). Multivariate logistic regression models were used to identify associations between four categories of sexual violence victimization and asthma episodes across three categories of metropolitan and non-metropolitan settings. Our findings show that unwanted touching, attempted unwanted intercourse, forced unwanted intercourse, and any sexual violence victimization (touching, attempted intercourse, or forced intercourse) were significantly associated with asthma episodes (ORadj. = 3.67, 95% CI, 1.76–7.69; ORadj. = 1.77, 95% CI, 1.32–2.37; ORadj. = 2.24, 95% CI, 1.64–3.05, and ORadj. = 1.93, 95% CI, 1.47–2.53, respectively). While no significant differences in the associations between asthma episodes and metropolitan status were found, a significant interaction between non-metropolitan areas and attempted sexual intercourse was identified (ORadj = 0.53, 95% CI, 0.29–0.96). Sexual victimization appears to be an important, but understudied, correlate of asthma morbidity among adult women in the USA, suggesting that additional research is needed to better understand the associations between sexual violence, psychological distress, and asthma.
doi:10.1007/s11524-008-9340-5
PMCID: PMC2648886  PMID: 19096937
Metropolitan; Sexual violence; Asthma; Prevention
24.  Assessing and Quantifying High Risk: Comparing Risky Behaviors by Youth in an Urban, Disadvantaged Community with Nationally Representative Youth 
Public Health Reports  2009;124(2):224-233.
SYNOPSIS
Objective
This study examined whether youth who live in an urban, disadvantaged community are significantly more likely than youth representing the nation to engage in a range of health-compromising behaviors.
Methods
Analyses were based on the Youth Violence Survey conducted in 2004 and administered to students (n=4,131) in a high-risk school district. Students in ninth grade (n=1,114) were compared with ninth-grade students in the 2003 national Youth Risk Behavior Survey (n=3,674) and the National Longitudinal Study of Adolescent Health conducted in 1995/1996 (n=3,523). Analyses assessed the differences in prevalence of risk and protective factors among ninth-grade students from the three studies using Chi-square tests.
Results
The results showed that youth in this urban, disadvantaged community were significantly more likely than their peers across the country to report vandalism, theft, violence, and selling drugs. Youth in this community also reported significantly less support from their homes and schools, and less monitoring by their parents. Moreover, youth in this community were significantly less likely to binge drink or initiate alcohol use prior to age 13 than youth across the U.S.
Conclusions
Youth who live in this urban, disadvantaged community reported significantly higher prevalence of some, but not all, risky behaviors than nationally representative U.S. youth. These findings highlight that some caution is justified when defining what might constitute high risk and that demographic and other characteristics need to be carefully considered when targeting certain high-risk behaviors.
PMCID: PMC2646479  PMID: 19320364

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