Abstract
Military sexual trauma (MST) has deleterious long-term psychological consequences. Among female U.S. military members, MST is associated with increased risk for future interpersonal victimization, such as experiencing intimate partner violence (IPV). Few studies have investigated the implications of the cumulative effects of IPV and MST on psychological functioning. This study examined rates of co-exposure to MST, IPV, and their cumulative impact on psychological symptoms. Data were collected from 308 female Veterans (FVets; age: M = 42, SD = 10.4) enrolled in an inpatient trauma-focused treatment program in a Veterans Administration (VA) hospital. Data were collected at program admission on symptoms of posttraumatic stress disorder (PTSD), depression, and current suicidal ideation. Lifetime trauma exposure was assessed using semi-structured interviews that identified adverse childhood events (ACEs) and combat theater deployment as well as MST and IPV. Group differences on psychological symptoms were examined among those exposed to MST, IPV, MST + IPV, and compared to FVets with ACEs or combat exposure, but no other adulthood interpersonal trauma (NAIT). Half of the sample (51%) reported experiencing both MST and IPV, approximately 29% reported MST, 10% reported IPV, and 10% reported NAIT. FVets in the MST + IPV group had worse PTSD and depression symptoms than either the MST or IPV groups. The NAIT group had the lowest scores on these measures. There were no group differences in current suicidal ideation; however, 53.5% reported at least one previous suicide attempt. FVets in this sample reported significant lifetime exposure to MST and IPV, with the majority having experienced MST + IPV. Exposure to MST + IPV was associated with greater PTSD and depression symptom severity, yet an overwhelming proportion reported current and past suicidal ideation regardless of trauma exposure history. These results demonstrate the importance of assessing for lifetime interpersonal trauma history when developing and providing mental and medical health interventions for FVets.
Introduction
Since the 60s, more than 16 million Americans have served in the U.S. military, with ~82.6% of military personnel being combat deployed and ~11.7% of those being females (NCVAS, 2021). Military service is associated with numerous physical and psychological stressors (Vogt et al., 2020), which can have chronic and long-term consequences on the quality of life and mental well-being. However, females experience disproportionately high rates of exposure to interpersonal violence and trauma prior to entering military service (i.e., adverse childhood events) as well as during their military service, including military sexual trauma (MST) and intimate partner violence (IPV), further impacting quality of life and overall functioning (Wilson, 2018). Further, exposure to MST heightens risks for later IPV exposure following military service. Consequently, female Veterans (FVets) are at an extremely heightened risk for interpersonal trauma exposure through multiple intersecting pathways that can have deleterious long-term consequences.
However, few studies have characterized exposure to both MST and IPV in FVets and the clinical impact of cumulative trauma on mental health outcomes. To address this gap, the current study examined consecutively collected baseline data from FVets voluntarily seeking admission to an inpatient trauma-focused, treatment program over the course of 5 years. Specifically, the current study first characterized adulthood interpersonal trauma history and then examined whether exposure to IPV, MST, and MST + IPV were associated with differences in mental health presentations at the beginning of treatment.
Adult Interpersonal Violence
MST is defined as sexual harassment or non-partnered sexual violence that occurred during military service (Morral et al., 2015; U.S. Government, 2011). Data from Veterans Affairs (VA) indicate that 1 in 3 FVets experienced MST during active duty or reserve service (Affairs, 2020). Independent studies show that between 15% and 49% FVets report having experienced MST (Barth et al., 2016; Haskell et al., 2010; Kimerling et al., 2010; Scott et al., 2014; Suris & Lind, 2008; Wilson, 2018).
IPV refers to physical, sexual, or psychological harm imposed by a current or former intimate partner (Basile et al., 2011; Force et al., 2018). The Department of Defense reported 16,912 incidents of IPV identified among military personnel in 2018, with >70% of victims being female (Defense, 2019). Physical abuse, as opposed to exclusively psychological abuse, accounted for the majority (73.7%) of reported IPV incidents (Defense, 2019). FVets are 1.6 times more likely to experience IPV than female civilians (Dichter et al., 2011; Kimerling et al., 2016). IPV is more frequently experienced following military service (Dichter et al., 2015; Iverson et al., 2017) and, if MST occurred during service, FVets are at a heightened risk for later IPV (Iverson et al., 2013; Mahoney et al., 2020).
The negative consequences of experiencing MST on mental health are well documented (Monteith et al., 2015; Pulverman et al., 2019; Sumner et al., 2021; Suris & Lind, 2008). The National Health and Resilience study of Veterans showed that MST is associated with posttraumatic stress disorder (PTSD), major depressive disorder, generalized anxiety disorder, and current/past history of suicidal ideation (Klingensmith et al., 2014). Veterans who experience MST are 4 to 4.5 times more likely to develop PTSD than those who experienced civilian sexual assault (Himmelfarb et al., 2006; Yaeger et al., 2006). FVets with positive MST screenings had greater risk of suicidal ideation, substance use disorders, depression, and a seven-fold increased risk of PTSD compared to FVets with a negative MST screening (Gibson et al., 2020).
Like MST, individuals who experience IPV often report more frequent and severe mental health disorders compared to those with no exposure to IPV, such as depression, anxiety, substance use disorders and misuse, suicidal ideation, PTSD, and impaired cognitive functioning (Afifi et al., 2008; Brignone et al., 2018; Cancio, 2020; Carbone-López et al., 2006; Esopenko et al., 2021; Fletcher, 2010; Iovine-Wong et al., 2019; Iverson, Litwack, et al., 2013; Jones et al., 2001; Monahan, 2019; Montgomery et al., 2018; Okuda et al., 2011; Relyea et al., 2020; Zlotnick et al., 2006). In a study of FVets, those who screened positive for IPV reported higher rates of primary care and psychosocial healthcare utilization and double the rates of hospitalization when queried 6 months after screening, compared to those who had screened negative for IPV (Dichter et al., 2018). According to the WHO World Mental Health Surveys (Kessler et al., 2017), the highest conditional risk for PTSD is associated with interpersonal violence (specifically, IPV and sexual violence), compared to exposure to other types of trauma (e.g., war-related trauma, accident, witnessed trauma of another), with studies demonstrating a 2.3- to 3.74-fold increased risk of PTSD in individuals exposed to IPV (Fedovskiy et al., 2008; Golding, 1999; O’Campo et al., 2006).
In the civilian population, sexual violence and IPV victimization were found to be consistent factors in persistent suicidal ideation and predictive suicide attempts in nine countries (Devries et al., 2011), but much less is known about FVet’s suicidal ideation relative to sexual violence and IPV. Understanding the associations between trauma and mental health outcomes in FVets is of the utmost importance, given the high prevalence and revictimization risk in this population (Dardis et al., 2018; Iverson, Litwack, et al., 2013; Tirone et al., 2021).
Some studies now suggest that mental health consequences are compounded among those who experience polytrauma or multiple interpersonal traumas. For example, exposure to multiple types of interpersonal traumas is linked to high-risk behaviors, such as non-suicidal self-injury, substance abuse, and suicidality as well as comorbid depression, anxiety, and panic disorder (White et al., 2018). Further, researchers found that among combat Veterans with polytrauma (e.g., ACEs, civilian trauma, combat trauma), proximally occurring polytrauma predicted worse PTSD and depression symptom severity than distal polytrauma exposure (e.g., ACEs) (George et al., 2022). FVets with histories of cumulative trauma and multiple comorbidities are also more likely to have greater mental health symptom severity than those without cumulative trauma, and consequently, require a higher-level intervention (Davis et al., 2022; Hahn et al., 2022). These cumulative, interpersonally traumatic experiences also impact PTSD treatment outcomes and interfere with maintaining treatment gains (Baca et al., 2021). Thus, exposure to interpersonal trauma, coupled with other combat-related stresses, likely has dramatic effects on mental well-being, which can attenuate the effectiveness of treatment programs and result in worse long-term outcomes.
Despite evidence-based interventions for the treatment of PTSD secondary to MST, some Veterans continue to meet full criteria for full PTSD at discharge from services (Menefee et al., 2016). The high degree of cumulative trauma exposure (MST + IPV) in FVets may require a more integrative approach targeting this cumulative effect. However, few studies have characterized exposure to both MST and IPV in FVets, or investigated how lifetime cumulative trauma impacts mental health (e.g., PTSD, depression). The current study addresses this gap by first characterizing adulthood interpersonal trauma history among FVets seeking intensive, inpatient treatment for PTSD and comorbid mental health presentations. We then examined whether exposure to IPV, MST, and MST + IPV were associated with differences in PTSD symptoms, depression symptoms, and suicidal ideation among FVets seeking inpatient psychiatric care.
Methods
Participants
Data in the present study were collected as part of a larger study evaluating clinical outcomes of trauma-focused care program housed within a VA-based acute psychiatric setting. FVets, primarily from the southern United States, were enrolled between December 2009 and March 2013 (see, Menefee et al., 2016). This 4-week, female-only inpatient program integrated multiple evidence-based treatments to address a wide range of psychiatric comorbidities presented by this subset of Veterans. For all participants, criteria for elective admission into the program included a current PTSD diagnosis and documentation of limited progress in less intensive, outpatient treatment for PTSD. Veterans were not excluded for history, or current presentation, of depression, alcohol/substance use disorders (AUD/SUDs), and suicidality. Among the 333 patients admitted to this inpatient program, 5% chose not to participate in the study. In the current sample, FVets ranged in age from 20 to 70 years (N = 308; M = 42.0, SD = 10.5), with ~50% having served in military operations in Iraq (Operation Iraqi Freedom/Operation New Dawn) or Operation Enduring Freedom, Afghanistan. Approximately 40% of the sample (n = 126) reported deployment to combat theaters and 38.5% (n = 95) reported both combat trauma and MST. In 80% of the sample, MST was cited as the primary reason for seeking inpatient treatment.
Procedures
During orientation to the inpatient program, treatment staff told Veterans that a research coordinator would discuss opportunities to participate in research. Given that these were vulnerable patients in a psychiatric setting, treatment staff made explicit efforts to assure them that their provision, refusal, or withdrawal of consent, at any time, would not alter the standard of care delivered. The study research coordinator approached patients at a time when no other treatment activities were occurring, provided information about the study and, when warranted, obtained informed consent. Participants completed structured interviews and self-report clinical assessments within the first 24 to 48 hr of admission. The study protocol was approved by the VA-affiliated medical school’s Institutional Review Board and VA Research and Development. All participants provided written informed consent within 24 hr of admission to have their clinical assessment data used in this study.
Measures
Demographic and socioeconomic information was collected from each participant, including age, race, level of education, relationship status, and employment. All Veterans reported their primary military branch, highest rank, deployment history, and time served.
Lifetime exposure to trauma
The Lifetime Events Checklist (LEC; Gray et al., 2004) is a 16-item questionnaire that assesses participant’s exposure to natural, accidental, or workplace trauma as well as physical violence, assault with a weapon, and sexual assault across the lifespan. The LEC was originally developed to accompany semi-structured interviews for confirmation of traumatic events that met criterion A in the Diagnostic and Statistical Manual—4th edition Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000) PTSD diagnosis. Typically given in a self-report format, respondents indicated whether the traumatic event happened to them, they witnessed the event, or learned about the event. In the current study, the LEC was conducted as a semi-structured clinical interview to inquire about adverse childhood sexual assault or physical abuse, IPV, adult rape versus MST, and witnessing family-related violence. Data were collected with yes or no responses for each of the 16 LEC items as well as these additional items. Supplemental interviews were conducted to characterize exposure to MST based on the VA two-item screener (i.e., “During your military service, did you have unwanted sexual experiences forced on you, including rape?”). The LEC inquires about combat exposure. We further addressed combat deployment status by asking FVets “Were you deployed to Iraq/Afghanistan post 9/11 or to Kuwait (U.S. Gulf War I) during an active combat theatre operation?” to ensure that peace-keeping deployments outside the period of combat were excluded (Sullivan et al., 2020).
PTSD symptoms
The PTSD Checklist-Civilian (PCL-C) (Weathers et al., 1994) is a widely accepted 17-item, self-report measure of participants’ experiences of trauma reexperiencing, avoidance, and hyperarousal symptoms. Participants indicated how much they have been bothered by each of the 17 symptoms of the DSM-IV-TR (APA, 2000) criteria for PTSD in the past 1 month. A total score ranging from 17 to 85 is calculated using a Likert-type scale, with higher scores indicating greater perceptions of disturbance. Evidence supports severity cut scores ranging from 37 to 44 (Karstoft et al., 2014). The PCL-C is used extensively within the VA system and it demonstrates excellent psychometric properties for male and FVets (Dobie et al., 2002; Keen et al., 2008). Given the concerns that the PCL-C overestimates the prevalence of PTSD without anchoring symptoms to a traumatic event, clinical interviews were used to ascertain PTSD diagnoses (Wilkins et al., 2011). PCL-C responses were missing from 21 participants.
Depressive symptoms
The Beck Depression Inventory-II (BDI-II) (Beck et al., 1996) is a 21-item self-report inventory used to measure the respondent’s perception of the severity of depression for the 2 weeks prior to survey administration. Participants are asked to respond to each item using unique indicators for each question ranging from 0 (indicating absence of symptom) to 3 (severe symptom interference). The total score is created by summing-up the item responses and total scores range from 0 to 63. Cutoff scores are provided for mild, moderate, and severe (>21) depression. BDI-II responses were missing in 34 participants.
Suicidality
The Beck Scale for Suicidal Ideation (BSSI) (Beck & Steer, 1991) was used to evaluate the presence and intensity of suicidality occurring in the past 1 week prior to admission. The BSSI has a screening component with a hard stop after the first five items. Specifically, only participants who endorse current suicidality complete the remaining questions. In the current study, responses from participants with current suicidal ideation (n = 142) were included in the analyses. Participants respond on an ordinal scale of 0 (none) to 2 (indicating greater severity) for 19 items (includes screening items) with a summed up score ranging from 1 to 38. Two additional questions are provided that ask participants to indicate the number of times they have attempted suicide and, if an attempt was made, to rate the intensity of the wish to die during the last attempt. Suicidal behavior history was assessed for all participants whether or not they were currently suicidal. Past suicidal attempts were identified in 165 (54%) participants of the total sample. BSSI responses were missing in three participants.
Data Analysis
Means and standard deviations were computed for standard demographic information and participant characteristics (Table 1). The frequency of trauma exposure was calculated by type to define the trauma exposure groups resulting in: (a) MST: history of MST and any ACE; (b) IPV: history of IPV and any ACE; (c) MST + IPV: history of both MST, IPV, and any ACE; and (d) No Adulthood Interpersonal Trauma (NAIT): characterized by those who only experienced ACEs or combat deployment. Chi-square analyses were used to examine categorical differences and ANOVA was used to examine differences for continuous demographic variables by trauma type. General linear modeling (GLM) with covariates was used to examine the group on the PCL-C, BDI-II, and BSSI scores at program intake. Combat deployment experiences were included as a covariate in the GLMs for each mental health outcome variable to control for the effect of combat exposure (i.e., combat-related trauma) regardless of interpersonal trauma type. ACEs were included in ANCOVAs to control for childhood-related trauma exposure. Post hoc analyses using Bonferroni to correct for multiple comparisons were computed as part of the GLM in SPSS (corrected p = .05). All analyses were performed in IBM SPSS Statistics, Version 28 (IBM Corp., Armonk, NY, USA).
Sample Demographics and Military Service Characteristics by Period Served.
Note. M = Mean; SD = Standard Deviation; MST = Military Sexual Trauma; IPV = Intimate Partner Violence; NAIT = No Adulthood Interpersonal Trauma.
Bold = Tests of statistical within group differences p < .01.
Results
Trauma exposure in FVets
Participant demographic characteristics are presented in Table 1. Over half of the participants reported exposure to MST + IPV (51.3%), followed by MST (29.9%), and then IPV (10.1%); 9.4% of the sample reported NAIT. Significant variance was found for mean age of participants by trauma group, with older participants (Mage = 44.8, SD = 10.0) endorsing MST + IPV and younger participants (Mage = 35.5, SD = 9.1) reporting no adult interpersonal trauma, F (3, 304) = 8.9, p < .001. Relationship status differed among participants by trauma type, X2 (15, 293) = 30.8, p = .009 with those in the NAIT group listing status in the single, never married category and were less likely to be married or divorced. The rates of divorce and separation were higher for groups with Adulthood Interpersonal Trauma (see Table 1). Trauma type group differences were not significant (p > .05) on measures of race/ethnicity, education, military branch, or years of military service. Rates of childhood physical abuse (71.8%) were high in the sample and group differences were found for trauma type. The physical abuse rates were higher in the MST + IPV group (80.4%) but were also greater than half (55.2%) for the NAIT group X2 (3, 305) = 16.4, p < .001. Childhood sexual abuse occurred for half of the sample (54.2%) and groups differed by trauma type, X2 (3, 305) = 20.8, p < .001.
Differences in psychiatric symptoms across trauma groups
PTSD
The PCL-C total scale scores (M = 63.9, SD = 13.8) were well above diagnostic cut scores, indicating that participants reported strong symptoms of hypervigilance, avoidance, and hyperarousal in the weeks prior to entering the inpatient program. PCL-C scores by trauma type are presented in Table 2. While controlling for ACEs and combat deployment, a significant effect of trauma type was found for PCL-C scores, F (3, 281) = 5.42, p = .001. As illustrated in Figure 1, FVets who reported both MST and IPV showed greater PCL-C scores (M = 65.6, SD = 12.8) compared to participants who reported IPV only (M = 57.4, SD = 18.0; p = .019) or NAIT (M = 58.7, SD = 12.6; p = .017). Group differences found for ACEs or deployment by trauma types did not significantly (p > .05) predict variance in the model of PCL-C scores.
PCL, BDI, and BSSI by Trauma Type at Baseline.
Note. M = Mean; SD = Standard Deviation; PCL-C = Posttraumatic Stress Disorders Checklist-Civilian total scale score range 17 to 85; BDI-II = Beck Depression Inventory-II; BSSI = Beck Scale of Suicidal Ideation; MST = Military Sexual Trauma; IPV = Intimate Partner Violence; NAIT = No Adulthood Interpersonal Trauma.
Differences in PTSD and depression symptoms by trauma type. Panel A represents the marginal means for the PCL-C by trauma type. Panel B represents the marginal means for the BDI-II by trauma type. Line and ** depict group differences, significant at p < .05, when accounting for covariates (deployment and ACEs).
Depression
Depression scores were positively correlated with PTSD scores, r = .51, p < .001. In this sample, BDI-II total scale scores were indicative of severe depression (M = 35.5, SD = 12.2). A significant effect of trauma type was found for BDI-II scores, F (3, 268) = 3.81, p = .011, such that FVets who reported both MST and IPV showed greater BDI-II scores (mean = 37.2, SD = 12.1) compared to participants who reported NAIT (mean = 30.3, SD = 11.5; p = .013). Figure 1 illustrates the BDI-II mean scores by trauma type. ACEs and combat deployment did not contribute variance to the models for trauma type and depression (p > .05). BDI-II scores by trauma type are also presented in Table 2.
Suicidality
In the total sample of participants with past suicide attempts (n = 165), 54.1% of the overall sample had reported previously attempting suicide, while 30.8% reported attempting more than once. Of those with at least one past suicide attempt, 20.6% reported a moderate wish to die, while 57.6% reported a high wish to die. Using the BSSI, we first screened for current suicidal ideation within the past 1 week. Among Veterans who screened positive for current suicide ideation, there were no differences in BSSI scores by interpersonal trauma type (p = .082) or between those who were and were not deployed (p = .77). Suicidality was positively correlated with PTSD symptom scores, r = .34, p < .001, and depressive symptom scores, r = .49, p < .001. BSSI scores by trauma type are presented in Table 2.
The psychiatric admission history of participants was also examined. There were no group differences (p > .05) regarding psychiatric hospitalization while in the military (n = 47) for those with MST (n = 13), IPV (n = 5), MST + IPV (n = 25), or NAIT (n = 4). Eighty participants (25.9%) in the total sample reported admission for general psychiatric hospitalization within the past year.
Discussion
This 5-year study was one of the first to prospectively collect data through consecutive admissions to a VA inpatient treatment program that covered a large geographic catchment area including racially diverse and representative populations using integrated evidence-based practices that specifically addressed trauma exposure and psychological functioning. In our sample of FVets seeking inpatient treatment for mental health concerns, we found a higher incidence of exposure to MST + IPV than what has been previously reported. The majority of the sample (51%) reported exposure to both MST and IPV, while the smallest proportion of the sample was represented in the NAIT. Moreover, close to 30% of the sample reported MST exposure and 10% reported IPV exposure independently. The prevalence of exposure to both MST and IPV in this sample was unexpected and is higher than what has been previously reported. Furthermore, those Veterans who reported exposure to MST + IPV showed greater symptoms of PTSD and depression than those with NAIT. However, current suicidal ideation and past suicide attempts did not differ by interpersonal trauma types. The alarming rates of trauma in this sample of inpatient care-seeking FVets whose psychiatric symptoms have been intractable, reflects grave consequences of cumulative lifetime trauma. Given the devastating psychiatric sequelae these findings highlight the need for future studies to assess for MST, IPV, and combined MST/IPV exposure in other samples of FVets, including those who do not seek care.
Consistent with past studies, our results also demonstrated that interpersonal trauma exposure has differential effects on the severity of mental health outcomes (Afifi et al., 2008; Baca et al., 2021; Carbone-López et al., 2006; Golding, 1999; Okuda et al., 2011). Our results demonstrate that poly-interpersonal trauma is more likely to result in more severe PTSD and depression symptoms relative to experiencing MST and IPV on their own. Similarly, FVets who reported exposure to both MST and IPV had more severe depression symptoms relative to the NAIT group, but there were no differences for other interpersonal trauma types. As such, our results found that exposure to poly-interpersonal trauma in FVets seeking treatment was high for mental health burden, which might explain the ineffectiveness of prior outpatient treatment, as well as the ability to maintain treatment gains. In FVets who are seeking treatment for MST-related outcomes, providers may lack the knowledge of the high incidence of IPV exposure and thus do not screen for IPV or include it in treatment plans. In the Veterans health administration, screening for IPV was not enacted until recently, nor were there mental health services available for those who experienced IPV. Importantly, we intend to conduct follow-up studies to examine how interpersonal trauma affects treatment outcomes in this and other samples.
We also examined the degree of suicidal ideation reported in this sample and whether the severity of ideation, including suicide attempts, differed dependent on interpersonal trauma type. Almost half (46%) of our sample screened positive for current suicidal ideation; however, the severity of suicidal ideation did not differ depending on trauma type. These results are consistent with past work demonstrating high prevalence rates of suicidal ideation and attempts in Veterans (Kachadourian et al., 2022; Lemle, 2020; Nichter et al., 2021). Thus, although interpersonal trauma may increase severity of PTSD and depression symptoms which is related to suicidal ideation (Arenson et al., 2018; Forehand et al., 2019; Herzog et al., 2022), suicide screening should occur in all FVets who have experienced trauma in general.
These results have important implications for future research, treatment program implementation, and policy. In particular, it is important to assess all FVets for lifetime trauma exposure and poly-interpersonal trauma history as exposure affects PTSD and depression symptom severity. Although this sample is restricted to FVets voluntarily enrolling in an inpatient treatment program, the proportion of FVets with exposure to MST, IPV, and both MST and IPV do not differ markedly from those reported in the general FVet population (Holliday et al., 2020), including those not receiving treatment but may still struggling in daily life. Screening for interpersonal trauma may also help identify Veterans who are not currently receiving treatment, but would benefit from support services. Future studies are needed to understand the temporal and possibly bidirectional relationships between IPV and MST, that is, whether one increases the risk of the other, and how they independently and interactively affect mental health and treatment. Understanding this relationship will inform targeted screening efforts, deploy timely treatments, and enable us to develop more efficacious treatment programs for those who have experienced interpersonal trauma. These results also suggest that all FVets should be screened for current and past suicidal ideation, particularly those who have any trauma exposure (ACEs, combat, interpersonal) as they may be at risk for attempting and completing suicide. However, assessing for interpersonal trauma could also help identify those who may be at risk for worse mental health outcomes and related comorbidities and address needs for additional referral and care coordination.
Limitations
This study provides important information on how interpersonal trauma impacts mental health; however, there are some limitations that warrant consideration. The current sample is homogeneous in mental health diagnoses, which may limit generalizability of current findings to FVets from underrepresented groups, those who have not sought mental health care, and those who have sought care outside the VA system. A limitation of this study was the inability to examine differences in outcome measures dependent on racial background between the interpersonal violence groups due to sample size. Similarly, an inclusive assessment of sexual orientation was not included in this sample. Therefore, it is also important to address it in future research; and in particular, focusing on the intersection of sexual orientation in gender diverse individuals exposed to interpersonal violence.
This sample size and composition is also a strength in that it allows us to examine the implications of past interpersonal trauma in a high-priority group whose psychological functioning has not improved secondary to standard mental health care. These questions need to be addressed in samples of FVets who have not sought mental health care, and who have sought and benefitted from outpatient care. Associations of psychiatric symptoms with types of lifetime trauma may differ in samples with an unrestricted range of scores on key outcome measures. For example, our study would have benefitted from inclusion of an anxiety measure. Furthermore, given the nature of data available, we were unable to investigate causal or temporal associations between MST and IPV. In the future, it would be helpful to understand the effect of age at time of exposures to MST or IPV on mental health symptom severity. Furthermore, research examining the role of physical and sexual assault in childhood and their long-term ramifications is needed.
There has been an increased and long-overdue focus in the IPV literature on the high prevalence of head trauma (e.g., being punched, shaken violently) and nonfatal strangulation (NFS), which often results in focal and diffuse or anoxic/hypoxic brain injury, respectively (Valera & Berenbaum, 2003; Valera & Kucyi, 2017). In fact, recent reviews examining IPV related head trauma in Veterans and the general population demonstrated that a high proportion of respondents in these samples (up to 92% [Jackson et al., 2002]) reported probable traumatic brain injury or exposure to NFS (Haag et al., 2022; Campbell et al., 2022). In the current study, brain injury exposure was not assessed as an outcome of interpersonal trauma as the researchers were not anticipating the prevalence of IPV in this sample. It is highly probable that many of our participants have experienced head trauma and probable brain injury which may further impact the severity of psychosocial symptoms and ability to benefit from treatment. It is critical to screen for a history of head trauma and strangulation in individuals with exposure to interpersonal trauma.
Conclusion
The current study sought to characterize exposure to interpersonal trauma and its effects on PTSD and depression symptoms as well as suicidal ideation in a sample of FVets seeking inpatient treatment for mental health problems. A large proportion of our sample reported experiencing both MST and IPV, with fewer reporting experiencing MST or IPV independently. We found that exposure to both MST and IPV was associated with more severe PTSD and depression symptoms. Furthermore, almost half of our participants screened positive for suicidal ideation, yet severity of suicidal ideation did not differ depending on interpersonal trauma type. Together, these results demonstrate that interpersonal trauma has signficant effects on severity of mental health outcomes, but suicidal ideation is problematic regardless of trauma history in this treatment-seeking sample. Thus, all FVets returning from deployment should be screened for exposure to interpersonal trauma history and suicide risk to identify those in need of further mental health services. Future research should assess how interpersonal and general trauma (ACEs, combat) impact the effectiveness of existing mental health treatment programs and how the incorporation of additional treatment components may enhance care.
Footnotes
Author’s Note
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S government. Statistical support is provided by the South Central MIRECC.
Elisabeth A. Wilde is also affiliated to Baylor College of Medicine, Houston, TX, USA.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: CE and EAW are supported by the National Institutes of Neurological Disorders and Stroke (NINDS; R01NS115957/R01NS115957-02S1). KDOC is supported by the NIH/NINDS (1RF1NS115268-01). ET is supported by a VA Rehabilitation Research and Development grant (1I21RX003863-01A).
