Improvement has been anecdotally observed in patients with persistent postconcussion symptoms (PCS) after mild traumatic brain injury following treatment with hyperbaric oxygen (HBO). The effectiveness of HBO as an adjunctive treatment for PCS is unknown to date. OBJECTIVES To compare the safety of and to estimate the efficacy for symptomatic outcomes from standard PCS care alone, care supplemented with HBO, or a sham procedure. DESIGN, SETTING, AND PARTICIPANTS Multicenter, double-blind, sham-controlled clinical trial of 72 military service members with ongoing symptoms at least 4 months after mild traumatic brain injury enrolled at military hospitals in Colorado, North Carolina, California, and Georgia between April 26, 2011, and August 24, 2012. Assessments occurred before randomization, at the midpoint, and within 1 month after completing the interventions. INTERVENTIONS Routine PCS care was provided in specialized clinics. In addition, participants were randomized 1:1:1 to 40 HBO sessions administered at 1.5 atmospheres absolute (ATA), 40 sham sessions consisting of room air at 1.2 ATA, or no supplemental chamber procedures. MAIN OUTCOMES AND MEASURES The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) served as the primary outcome measure. A change score of at least 2 points on the RPQ-3 subscale (range, 0-12) was defined as clinically significant. Change scores from baseline were calculated for the RPQ-3 and for the total RPQ. Secondary measures included additional patient-reported outcomes and automated neuropsychometric testing. RESULTS On average, participants had sustained 3 lifetime mild traumatic brain injuries; the most recent occurred 23 months before enrollment. No differences were observed between groups for improvement of at least 2 points on the RPQ-3 subscale (25% in the no intervention group, 52% in the HBO group, and 33% in the sham group; P = .24). Compared with the no intervention group (mean change score, 0.5; 95% CI, −4.8 to 5.8; P = .91), both groups undergoing supplemental chamber procedures showed improvement in symptoms on the RPQ (mean change score, 5.4; 95% CI, −0.5 to 11.3; P = .008 in the HBO group and 7.0; 95% CI, 1.0-12.9; P = .02 in the sham group). No difference between the HBO group and the sham group was observed (P = .70). Chamber sessions were well tolerated. CONCLUSIONS AND RELEVANCE Among service members with persistent PCS, HBO showed no benefits over sham compressions. Both intervention groups demonstrated improved outcomes compared with PCS care alone. This finding suggests that the observed improvements were not oxygen mediated but may reflect nonspecific improvements related to placebo effects. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01306968

Perceptions regarding institutional betrayal appear to be highly relevant to MST and its sequelae. These findings underscore the importance of Veterans' perceptions of the military institution's efforts to prevent and respond to MST to individual recovery from sexual trauma. Additional research regarding the association between institutional betrayal and health-related outcomes is needed.

According to the interpersonal-psychological theory of attempted and completed suicide (Joiner, 2005) suicide-related behavior is contingent upon three factors: acquired ability, burdensomeness, and failed belongingness. Qualitative research methodology was employed to explore these concepts among a group of returning Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) combat veterans. A sample of 16 individuals participated in interviews. Themes emerged regarding combat as a context for exposure to pain, subsequent coping strategies, and perceptions of burdensomeness, failed belongingness, and increased pain tolerance. Suicidal behavior was also articulated as a means of coping with risk factors outlined by Joiner. These results highlight the potential utility of this theory for OEF/OIF veterans. Interventions aimed at decreasing emotional dysregulation, and lessening perceptions of burdensomeness and failed belongingness may reduce risk for suicidal behavior.

Reliance on self-report limits clinicians' ability to accurately predict suicidal behavior. In this study the predictive validity of an objective measure, the death/suicide Implicit Association Test (d/sIAT), was tested among psychiatrically hospitalized veterans. Following acute stabilization, 176 participants completed the d/sIAT and traditional suicide risk assessments. Participants had similar d/sIAT scores regardless of whether they had recently attempted suicide. However, d/sIAT scores significantly predicted suicide attempts during the 6-month follow-up above and beyond other known risk factors for suicidal behavior (OR = 1.89; 95% CI: 1.15-3.12; based on 1SD increase). The d/sIAT may augment the accuracy of suicide risk assessment.

Although little is known about moral injury in nonmilitary populations, the COVID-19 pandemic has made it clear that moral injury's relevance extends beyond the battlefield. Health care providers are experiencing potentially morally injurious events that may violate their moral code or values, yet almost no research has been conducted on moral injury among health care providers to date. The purpose of this commentary is to describe the relevance of moral injury to health care providers and to spark a dialogue that motivates future research, prevention, and intervention.

Although the Veterans Health Administration (VHA) provides free health care related to military sexual trauma (MST), many veterans forgo or delay such care, underscoring the need for research aimed at understanding MST survivors' perceptions and concerns regarding VHA care. This study employed a qualitative phenomenological approach to describe MST survivors': (a) perceptions of VHA care, (b) concerns about VHA care, and (c) suggestions for how VHA can facilitate recovery from MST. Fifty veterans (32 women, 18 men) with histories of MST participated in semistructured interviews. Transcripts were analyzed using thematic analysis. The pattern of themes was examined by gender and MST type. The majority of participants described neutral or positive perceptions of VHA care; however, a subset of participants described negative perceptions and reservations about using VHA care. Participants expressed concerns regarding distrust, provider compassion, privacy, stigma, shame, and continuity of care. Some women, particularly those who experienced military sexual assault, also described genderrelated distress (e.g., feeling anxious or out of place, desire for separate facilities). Both men and women described wanting nonspecific support, improved continuity of care, and the ability to choose from a variety of treatment options (e.g., holistic, gender-specific). Further research is needed to examine if these findings are replicated in other samples.

Traumatic brain injury (TBI) is prevalent among many populations and existing data suggest that those with TBI are at increased risk for death by suicide. This systematic review serves as an update to a previous review, with the aim of evaluating the current state of evidence regarding prevalence and risk of suicide deaths, post-TBI suicidal ideation and suicide attempts, and treatments to reduce suicide-related outcomes among TBI survivors. Review procedures followed the PRISMA statement guidelines. In all, 1014 abstracts and 83 full-text articles were reviewed to identify 16 studies meeting inclusion criteria. Risk of bias for individual studies ranged from low to high, and very few studies were designed to examine a priori hypotheses related to suicide outcomes of interest. Overall, findings from this systematic review supported an increased risk of suicide among TBI survivors compared to those with no history of TBI. Evidence pertaining to suicidal thoughts and attempts was less clear, mainly due to heterogeneity of methodological quality across studies. One small randomised controlled trial was identified that targeted suicide prevention in TBI survivors. Further research is needed to identify the prevalence of post-TBI ideation and attempts, and to establish evidence-based suicide prevention practices among TBI survivors.

Medical leaders have warned of the potential public health burden of a “parallel pandemic” faced by healthcare workers during the COVID-19 pandemic. These individuals may have experienced scenarios in which their moral code was violated resulting in potentially morally injurious events (PMIEs). In the present study, hierarchical linear modeling was utilized to examine the role of PMIEs on COVID-19 pandemic-related difficulties in psychosocial functioning among 211 healthcare providers (83% female, 89% White, and an average of 11.30 years in their healthcare profession [9.31]) over a 10-month span (May 2020 –March 2021). Reported exposure to PMIEs was associated with statistically significant poorer self-reported psychosocial functioning at baseline and over the course of 10-months of data collection. Within exploratory examinations of PMIE type, perceptions of transgressions by self or others (e.g., “I acted in ways that violated my own moral code or values”), but not perceived betrayal (e.g., “I feel betrayed by leaders who I once trusted”), was associated with poorer COVID-19 related psychosocial functioning (e.g., feeling connected to others, relationship with spouse or partner). Findings from this study speak to the importance of investing in intervention and prevention efforts to mitigate the consequences of exposure to PMIEs among healthcare providers. Interventions for healthcare providers targeting psychosocial functioning in the context of moral injury is an important area for future research.