COVID-19, mental health, psychology, social determinants of health, utilization of health services. Individuals in rural communities are at increased risk for suicide. 1,2 While the impact of Coronavirus Disease 2019 (COVID-19) continues to unfold, 3 it is likely that suicide risk factors among individuals residing in rural areas will be exacerbated and suicide rates may subsequently increase. 4 Awareness of these factors is essential to ensure that appropriate steps are taken to prevent suicide in rural communities, both during and in the aftermath of this pandemic. In this commentary, we delineate key considerations for doing so, with potential solutions summarized in Table 1.

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.

Background/Objective Male veterans ages 55-74 comprise a disproportionate number of suicide deaths among United States veterans, for whom a majority of suicides are firearm-related. Little is known about the firearm-related experiences and beliefs of veterans, which could be informative for firearm-related lethal means safety interventions. The aim of this qualitative study was to identify themes relevant to developing such interventions among older male veterans. Methods We conducted semi-structured qualitative interviews with seventeen United States male veterans, ages 50-70, who were eligible to receive Veterans Health Administration services, and were current or former firearm owners or users. Transcripts were analyzed via thematic analysis using an inductive approach. Results Six themes were identified: 1) Firearm experiences were usually facilitated by male family members and occurred at an early age; 2) Safety lessons during early firearm encounters focused on preventing unintentional injuries through safe firearm handling and using "common sense;" 3) Firearms serve an important social function across veterans' lifespans (e.g., hunting with friends); 4) Veterans perceive firearms as useful for protection; 5) Veterans believe that not everyone should have access to firearms, and some described scenarios in

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.

Rates of suicide and posttraumatic stress disorder remain high among United States military personnel and veterans. Building upon prior work, we conducted a systematic review of research published from 2010 to 2018 regarding: (1) the prevalence of suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans diagnosed with posttraumatic stress disorder; (2) whether posttraumatic stress disorder was associated with suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans. 2,106 titles and abstracts were screened, with 48 articles included. Overall risk of bias was generally high for studies on suicidal ideation or suicide attempt and low for studies on suicide. Across studies, rates of suicidal ideation, suicide attempt, and suicide widely varied based on study methodology and assessment approaches. Findings regarding the association between posttraumatic stress disorder diagnosis with suicidal ideation and suicide were generally mixed, and some studies reported that posttraumatic stress disorder was associated with lower risk for suicide. In contrast, most studies reported significant associations between posttraumatic stress disorder and suicide attempt. These findings suggest complex associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, which are likely influenced by other factors (e.g., psychiatric comorbidity). In addition, most samples were comprised of veterans, rather than military personnel. Further research is warranted to elucidate associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, including identification of moderators and mediators of this relationship. Addressing this among United States military personnel, by gender, and in relation to different trauma types is also necessary.

This article traces the history of classification systems for mental illness and then reviews the history of the American diagnostic system for mental disorders. The steps leading up to each publication of the Diagnostic and Statistical Manual (DSM) are described including leaders, timelines, pre-publication meetings, and field trials. Important changes in the purpose of the manuals are described with a focus on events leading to the manual’s third edition (DSM-III), which represented a paradigm shift in how we think about, and use, the classification system for mental illness. For the first time, DSM-III emphasized empirically-based, atheoretical and agnostic diagnostic criteria. New criticisms of the DSM-III and subsequent editions have arisen with a call for a new paradigm shift to replace diagnostic categories with continuous dimensional systems of classification, returning to etiologically-based definitions and incorporating findings from neurobiological science into systems of diagnosis. In the foreseeable future, however, psychiatric diagnosis must continue to be accomplished by taking a history and assessing the currently established criteria. This is necessary for communication about diseases and education of clinicians and scientists in medical fields, as well as advancement of research needed to further advance the diagnostic criteria of psychiatry.

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