Patients with posttraumatic stress disorder (PTSD) exhibit smaller regional brain volumes in commonly reported regions including the amygdala and hippocampus, regions associated with fear and memory processing. In the current study, we have conducted a voxel-based morphometry (VBM) meta-analysis using whole-brain statistical maps with neuroimaging data from the ENIGMA-PGC PTSD working group.

T1-weighted structural neuroimaging scans from 36 cohorts (PTSD n = 1309; controls n = 2198) were processed using a standardized VBM pipeline (ENIGMA-VBM tool). We meta-analyzed the resulting statistical maps for voxel-wise differences in gray matter (GM) and white matter (WM) volumes between PTSD patients and controls, performed subgroup analyses considering the trauma exposure of the controls, and examined associations between regional brain volumes and clinical variables including PTSD (CAPS-4/5, PCL-5) and depression severity (BDI-II, PHQ-9).

PTSD patients exhibited smaller GM volumes across the frontal and temporal lobes, and cerebellum, with the most significant effect in the left cerebellum (Hedges’ g = 0.22, pcorrected = .001), and smaller cerebellar WM volume (peak Hedges’ g = 0.14, pcorrected = .008). We observed similar regional differences when comparing patients to trauma-exposed controls, suggesting these structural abnormalities may be specific to PTSD. Regression analyses revealed PTSD severity was negatively associated with GM volumes within the cerebellum (pcorrected = .003), while depression severity was negatively associated with GM volumes within the cerebellum and superior frontal gyrus in patients (pcorrected = .001).

PTSD patients exhibited widespread, regional differences in brain volumes where greater regional deficits appeared to reflect more severe symptoms. Our findings add to the growing literature implicating the cerebellum in PTSD psychopathology.

Posttraumatic stress disorder (PTSD) has been associated with advanced epigenetic age cross-sectionally, but the association between these variables over time is unclear. This study conducted meta-analyses to test whether new-onset PTSD diagnosis and changes in PTSD symptom severity over time were associated with changes in two metrics of epigenetic aging over two time points.

We conducted meta-analyses of the association between change in PTSD diagnosis and symptom severity and change in epigenetic age acceleration/deceleration (age-adjusted DNA methylation age residuals as per the Horvath and GrimAge metrics) using data from 7 military and civilian cohorts participating in the Psychiatric Genomics Consortium PTSD Epigenetics Workgroup (total N = 1,367).

Meta-analysis revealed that the interaction between Time 1 (T1) Horvath age residuals and new-onset PTSD over time was significantly associated with Horvath age residuals at T2 (meta β = 0.16, meta p = 0.02, p-adj = 0.03). The interaction between T1 Horvath age residuals and changes in PTSD symptom severity over time was significantly related to Horvath age residuals at T2 (meta β = 0.24, meta p = 0.05). No associations were observed for GrimAge residuals.

Results indicated that individuals who developed new-onset PTSD or showed increased PTSD symptom severity over time evidenced greater epigenetic age acceleration at follow-up than would be expected based on baseline age acceleration. This suggests that PTSD may accelerate biological aging over time and highlights the need for intervention studies to determine if PTSD treatment has a beneficial effect on the aging methylome.

Epidemiological evidence shows a concerning rise in youth mental health difficulties over the past three decades. Most evidence, however, comes from countries in Europe or North America, with far less known about changes in other global regions. This study aimed to compare adolescent mental health across two population-based cohorts in the UK, and two population-based cohorts in Pelotas, Brazil.

Four population-based cohorts with identical mental health measures were compared. In Brazil, these included the 1993 Pelotas Birth Cohort and the 2004 Pelotas Birth Cohort. In the UK, cohorts included the Avon Longitudinal Study of Parents and Children, and the Millennium Cohort Study. Mental health was measured in all cohorts using identical, parent-rated scores from the Strengths and Difficulties Questionnaire (SDQ). This was assessed in both countries over approximately the same time periods, when adolescents were aged 11 (2004 vs 2015 in Brazil, and 2003 vs 2012 in the UK), with follow-up analyses focused on outcomes in later adolescence.

Mental health problems were higher in the UK for adolescents born in the early 2000s compared to those born in the early 1990s. In Pelotas, the opposite was found, whereby problems were lower for adolescents born in the early 2000s compared to those born in the early 1990s. Despite these promising reductions in mental health problems in Pelotas over time, SDQ scores remained higher in Pelotas compared to the UK.

Our study represents the first to compare two population-based cohorts in the UK, and two population-based cohorts in Pelotas, Brazil, to understand how mental health problems have changed over time across the two settings. Our findings provide the most up-to-date insight into population-level rates of youth mental health problems in Pelotas, and shed novel insight into how these have changed over the last two decades in comparison to the UK. In doing so, our study provides a tentative first step towards understanding youth mental health over time at a more global scale, and presents a valuable opportunity to examine putative contributors to differences across time.

Cannabis use and familial vulnerability to psychosis have been associated with social cognition deficits. This study examined the potential relationship between cannabis use and cognitive biases underlying social cognition and functioning in patients with first episode psychosis (FEP), their siblings, and controls.

We analyzed a sample of 543 participants with FEP, 203 siblings, and 1168 controls from the EU-GEI study using a correlational design. We used logistic regression analyses to examine the influence of clinical group, lifetime cannabis use frequency, and potency of cannabis use on cognitive biases, accounting for demographic and cognitive variables.

FEP patients showed increased odds of facial recognition processing (FRP) deficits (OR = 1.642, CI 1.123–2.402) relative to controls but not of speech illusions (SI) or jumping to conclusions (JTC) bias, with no statistically significant differences relative to siblings. Daily and occasional lifetime cannabis use were associated with decreased odds of SI (OR = 0.605, CI 0.368–0.997 and OR = 0.646, CI 0.457–0.913 respectively) and JTC bias (OR = 0.625, CI 0.422–0.925 and OR = 0.602, CI 0.460–0.787 respectively) compared with lifetime abstinence, but not with FRP deficits, in the whole sample. Within the cannabis user group, low-potency cannabis use was associated with increased odds of SI (OR = 1.829, CI 1.297–2.578, FRP deficits (OR = 1.393, CI 1.031–1.882, and JTC (OR = 1.661, CI 1.271–2.171) relative to high-potency cannabis use, with comparable effects in the three clinical groups.

Our findings suggest increased odds of cognitive biases in FEP patients who have never used cannabis and in low-potency users. Future studies should elucidate this association and its potential implications.

Neuropsychological assessment of preschool children is essential for early detection of delays and referral for intervention prior to school entry. This is especially pertinent in low- and middle-income countries (LMICs), which are disproportionately impacted by micronutrient deficiencies and teratogenic exposures. The Grenada Learning and Memory Scale (GLAMS) was created for use in limited resource settings and includes a shopping list and face-name association test. Here, we present psychometric and normative data for the GLAMS in a Grenadian preschool sample.

Typically developing children between 36 and 72 months of age, primarily English speaking, were recruited from public preschools in Grenada. Trained Early Childhood Assessors administered the GLAMS and NEPSY-II in schools, homes, and clinics. GLAMS score distributions, reliability, and convergent/divergent validity against NEPSY-II were evaluated.

The sample consisted of 400 children (190 males, 210 females). GLAMS internal consistency, inter-rater agreement, and test-retest reliability were acceptable. Principal components analysis revealed two latent factors, aligned with expected verbal/visual memory constructs. A female advantage was observed in verbal memory. Moderate age effects were observed on list learning/recall and small age effects on face-name learning/recall. All GLAMS subtests were correlated with NEPSY-II Sentence Repetition, supporting convergent validity with a measure of verbal working memory.

The GLAMS is a psychometrically sound measure of learning and memory in Grenadian preschool children. Further adaptation and scale-up to global LMICs are recommended.

While previous studies have reported high rates of documented suicide attempts (SAs) in the U.S. Army, the extent to which soldiers make SAs that are not identified in the healthcare system is unknown. Understanding undetected suicidal behavior is important in broadening prevention and intervention efforts.

Representative survey of U.S. Regular Army enlisted soldiers (n = 24 475). Reported SAs during service were compared with SAs documented in administrative medical records. Logistic regression analyses examined sociodemographic characteristics differentiating soldiers with an undetected SA v. documented SA. Among those with an undetected SA, chi-square tests examined characteristics associated with receiving a mental health diagnosis (MH-Dx) prior to SA. Discrete-time survival analysis estimated risk of undetected SA by time in service.

Prevalence of undetected SA (unweighted n = 259) was 1.3%. Annual incidence was 255.6 per 100 000 soldiers, suggesting one in three SAs are undetected. In multivariable analysis, rank ⩾E5 (OR = 3.1[95%CI 1.6–5.7]) was associated with increased odds of undetected v. documented SA. Females were more likely to have a MH-Dx prior to their undetected SA (Rao-Scott χ 21 = 6.1, p = .01). Over one-fifth of undetected SAs resulted in at least moderate injury. Risk of undetected SA was greater during the first four years of service.

Findings suggest that substantially more soldiers make SAs than indicated by estimates based on documented attempts. A sizable minority of undetected SAs result in significant injury. Soldiers reporting an undetected SA tend to be higher ranking than those with documented SAs. Undetected SAs require additional approaches to identifying individuals at risk.

Forensic psychiatric services serve a dual purpose: treatment of mental disorders and prevention of associated violent reoffending. Progression along the secure care pathway is often impeded by impaired insight, mainly as a result of treatment-resistant psychoses.

We assessed levels of insight among patients in Ireland’s National Forensic Mental Health Service before and after its relocation from the historic 1850 campus in Dundrum to a modern facility in Portrane, Dublin.

The VAGUS insight scale was used in this repeated measures study before and after the relocation at two time points 42 months apart. All inpatients were invited to participate in completing the self-report (VAGUS-SR) and clinician-rated (VAGUS-CR) versions on both occasions. Total scores of both versions were averaged to obtain a combined VAGUS insight score. Corresponding Positive and Negative Syndrome Scale (PANSS) scores were used to ascertain correlations between the insight and symptomatology scales. This study is part of the Dundrum Forensic Redevelopment Evaluation Study (D-FOREST)

40 pairs of observations were available for legal capacity to consent to medication, combined VAGUS-CR and VAGUS-SR assessments of insight (Cronbach’s alpha=0.927), and PANSS. VAGUS-CR insight and PANSS scores were progressively better from admission and high dependency wards through medium-term medium secure wards to rehabilitation and pre-discharge wards. Mean scores did not change significantly over this time interval. Those legally certified fit to give or withhold consent by their treating consultant psychiatrists scored significantly better on the VAGUS combined insight scale: 8.3 (SD 1.7) v 5.3 (2.2) at baseline, paired t=25.9, p<0.001; and also 42 months later: 8.2 (1.4) v 5.7 (3.9), paired t=5.2, p=0.022. PANSS subscales were all significantly better for those assessed as being capacitous. Change in combined VAGUS score correlated with change in all PANSS subscales. Binary logistic regression with legal capacity as the dependent variable yielded a model in which combined VAGUS score and PANSS positive symptom score were independent determinants of assessed capacity status. Receiver operating characteristic area under the curve was 0.873, 95% CI 0.760-0.986, at baseline and 0.856, 95% CI 0.720-0.991, at 42 months. A score of 7.3 yielded a sensitivity of 0.8 and a specificity of 0.8.

The combined VAGUS score is a reliable and valid measure of insight relevant to functional mental capacity to consent to treatment with sensitivity and specificity sufficient to guide but not bind clinical decision-making. It measures a quality that varies with symptom severity but is also partly independent of symptom severity; the constructive inclusion of self-reported insight is notable.

None Declared

As evidence has converged on the feasibility and effectiveness of focused, non-specialized, manualized interventions for treating mental distress in humanitarian settings, challenges persist in how to promote implementation fidelity and rigorously evaluate interventions designed to be more preventive or promotive in addressing risk and protective factors for poor mental health. One such intervention, Baby Friendly Spaces (BFS), is a psychosocial support program implemented for Rohingya mothers and their malnourished children living in refugee camps of Cox’s Bazar, Bangladesh. That follows a place-based intervention model in which various activities may be offered either individually or in groups with no specified sequence.

This presentation describes the process of establishing standards for implementing optimal mental health and psychosocial support (MHPSS) interventions, training BFS workers, and building monitoring and supervision systems to promote implementation fidelity within this flexible support program.

As BFS services were already being offered as part of Action Against Hunger programming, we first conducted an audit of current services, determining that there was limited current standardization or support for implementation. Therefore, a manualized protocol was designed and covered the program curricula and self-care using didactic and practice-based learning. A series of online training sessions were conducted for 13 psychosocial workers and psychologists at centers delivering the enhanced intervention. Following the training, a baseline evaluation of attitudes, confidence, and knowledge for delivering BFS services was administered. We also collaboratively designed a systematic supervision process to meet the staff’s needs with a focus on capacity building and self-care.

Following the initial training, BFS workers receiving the re-training showed similar levels of knowledge, but greater confidence (p=0.01) than MHPSS workers proceeding as usual. Participants reported that the training was useful for their field of work and for improving the quality of their work, and acknowledged they would be able to integrate the new learnings into their work and daily life. The follow-up with the supervision process confirmed their capacity to deliver the services and highlighted the need for workspace improvements, the lack of continuous motivation, their ability to identify specific issues for which they requested additional trainings.

There is a particular need for careful attention to implementation supports and supervision when offering flexible, place-based mental health and psychosocial support interventions. In that process, ensuring a continuity between the training and the supervision is essential for the quality of both the program and the research project.

None Declared

Develop and implement a system in the Veterans Health Administration (VA) to alert local medical center personnel in real time when an acute- or long-term care patient/resident is admitted to their facility with a history of colonization or infection with a multidrug-resistant organism (MDRO) previously identified at any VA facility across the nation.

An algorithm was developed to extract clinical microbiology and local facility census data from the VA Corporate Data Warehouse initially targeting carbapenem-resistant Enterobacterales (CRE) and methicillin-resistant Staphylococcus aureus (MRSA). The algorithm was validated with chart review of CRE cases from 2010-2018, trialed and refined in 24 VA healthcare systems over two years, expanded to other MDROs and implemented nationwide on 4/2022 as “VA Bug Alert” (VABA). Use through 8/2023 was assessed.

VABA performed well for CRE with recall of 96.3%, precision of 99.8%, and F1 score of 98.0%. At the 24 trial sites, feedback was recorded for 1,011 admissions with a history of CRE (130), MRSA (814), or both (67). Among Infection Preventionists and MDRO Prevention Coordinators, 338 (33%) reported being previously unaware of the information, and of these, 271 (80%) reported they would not have otherwise known this information. By fourteen months after nationwide implementation, 113/130 (87%) VA healthcare systems had at least one VABA subscriber.

A national system for alerting facilities in real-time of patients admitted with an MDRO history was successfully developed and implemented in VA. Next steps include understanding facilitators and barriers to use and coordination with non-VA facilities nationwide.

We examined whether cannabis use contributes to the increased risk of psychotic disorder for non-western minorities in Europe.

We used data from the EU-GEI study (collected at sites in Spain, Italy, France, the United Kingdom, and the Netherlands) on 825 first-episode patients and 1026 controls. We estimated the odds ratio (OR) of psychotic disorder for several groups of migrants compared with the local reference population, without and with adjustment for measures of cannabis use.

The OR of psychotic disorder for non-western minorities, adjusted for age, sex, and recruitment area, was 1.80 (95% CI 1.39–2.33). Further adjustment of this OR for frequency of cannabis use had a minimal effect: OR = 1.81 (95% CI 1.38–2.37). The same applied to adjustment for frequency of use of high-potency cannabis. Likewise, adjustments of ORs for most sub-groups of non-western countries had a minimal effect. There were two exceptions. For the Black Caribbean group in London, after adjustment for frequency of use of high-potency cannabis the OR decreased from 2.45 (95% CI 1.25–4.79) to 1.61 (95% CI 0.74–3.51). Similarly, the OR for Surinamese and Dutch Antillean individuals in Amsterdam decreased after adjustment for daily use: from 2.57 (95% CI 1.07–6.15) to 1.67 (95% CI 0.62–4.53).

The contribution of cannabis use to the excess risk of psychotic disorder for non-western minorities was small. However, some evidence of an effect was found for people of Black Caribbean heritage in London and for those of Surinamese and Dutch Antillean heritage in Amsterdam.

To determine whether poorer performance on the Boston Naming Test (BNT) in individuals with transactive response DNA-binding protein 43 pathology (TDP-43+) is due to greater loss of word knowledge compared to retrieval-based deficits.

Retrospective clinical-pathologic study of 282 participants with Alzheimer’s disease neuropathologic changes (ADNC) and known TDP-43 status. We evaluated item-level performance on the 60-item BNT for first and last available assessment. We fit cross-sectional negative binomial count models that assessed total number of incorrect items, number correct of responses with phonemic cue (reflecting retrieval difficulties), and number of “I don’t know” (IDK) responses (suggestive of loss of word knowledge) at both assessments. Models included TDP-43 status and adjusted for sex, age, education, years from test to death, and ADNC severity. Models that evaluated the last assessment adjusted for number of prior BNT exposures.

43% were TDP-43+. The TDP-43+ group had worse performance on BNT total score at first (p = .01) and last assessments (p = .01). At first assessment, TDP-43+ individuals had an estimated 29% (CI: 7%–56%) higher mean number of incorrect items after adjusting for covariates, and a 51% (CI: 15%–98%) higher number of IDK responses compared to TDP-43−. At last assessment, compared to TDP-43−, the TDP-43+ group on average missed 31% (CI: 6%–62%; p = .01) more items and had 33% more IDK responses (CI: 1% fewer to 78% more; p = .06).

An important component of poorer performance on the BNT in participants who are TDP-43+ is having loss of word knowledge versus retrieval difficulties.

Evidence development for medical devices is often focused on satisfying regulatory requirements with the result that health professional and payer expectations may not be met, despite considerable investment in clinical trials. Early engagement with payers and health professionals could allow companies to understand these expectations and reflect them in clinical study design, increasing chances of positive coverage determination and adoption into clinical practice.

An example of early engagement through the EXCITE International model using an early technology review (ETR) is described which includes engagement with payers and health professionals to better inform companies to develop data that meet their expectations. ETR is based on an early evidence review, a framework of expectations that guides the process and identified gaps in evidence. The first fourteen ETRs were reviewed for examples of advice to companies that provided additional information from payers and health professionals that was thought likely to impact on downstream outcomes or strategic direction. Given that limitations were imposed by confidentiality, examples were genericized.

Advice through early engagement can inform evidence development that coincides with expectations of payers and health professionals through a structured, objective, evidence-based approach. This could reduce the risk of business-related adverse outcomes such as failure to secure a positive coverage determination and/or acceptance by expert health professionals.

Early engagement with key stakeholders exemplified by the ETR approach offers an alternative to the current approach of focusing on regulatory expectations. This could reduce the time to reimbursement and clinical adoption and benefit patient outcomes and/or health system efficiencies.

Neuropsychological assessment of preschool children is essential for early detection of delays and referral for intervention prior to school entry. This is especially relevant in low-and middle-income countries (LMICs), which are disproportionately impacted by micronutrient deficiencies and teratogenic exposures. There are limited options for assessment of preschool learning and memory, developed and validated in resource-limited regions. The Grenada Learning and Memory Scale (GLAMS) was created for use in the Caribbean using an indigenous “ground-up” approach, with feedback from regional stakeholders at various stages of development. The GLAMS contains two subtests - a verbal list-learning task, which imagines a trip to the shop to buy culturally familiar items, and a face-name associative learning task using locally-drawn faces of Caribbean children. There are two versions: a 4-item version for 3-year-olds and a 6-item version for 4 and 5-year-olds. Here we present descriptive data and psychometric features for the GLAMS from an initial preschool sample.

Participants were recruited from a social-emotional intervention study (SGU IRB#14099) in Grenada between 2019-2021. Children were between 36 and 72 months of age, primarily English-speaking, and had no known history of neurodevelopmental disorders. Trained Early Childhood Assessors administered the GLAMS and NEPSY-II in public preschools and homes across Grenada. Exploratory descriptive statistics characterized participant sociodemographics and test score distributions. Spearman correlations, MannWhitney U, and Kruskal-Wallis tests examined the impact of sociodemographics on test scores. Internal reliability was assessed with coefficient alpha. NEPSY-II subtests were used to assess convergent validity, with the prediction that the highest correlations would be observed for NEPSY-II Sentence Repetition. Test engagement (as reflected by “zero-learning”, “some learning”, and “positive learning curves”) was assessed across each age bracket (in 6-month increments). We assessed and summarized barriers to engagement qualitatively.

The sample consisted of 304 children (152 males,152 females). Participants were predominantly Afro-Caribbean and Indo-Caribbean. Parent education and household income (Mdn=$370-740 USD per month) were consistent with the general population. GLAMS internal consistency was reliable (a=0.713). There were age effects on list-learning (rs=0.51; p<0.001), list recall (rs=0.51; p<0.001), face-name learning (rs=0.30;p<0.001), and face-name recall (rs=0.25; p<0.001). There were gender effects on list-learning (p=0.02) and list recall (p=0.01) but not face-name learning or recall. All GLAMS subtests were correlated with NEPSY Sentence Repetition (rs=0.22-0.34; p<0.001). There was sufficient sampling of males and females across all 6 age brackets. As age increased, a higher proportion of children showed a positive learning curve (and fewer “zero-scores”) on verbal learning (X2 =30.88, p<0.001) and face-name learning (X2=22.19, p=0.014), demonstrating increased task engagement as children mature. There were various qualitative observations of why children showed “zero-scores”, ranging from environmental distractions to anxiety and inattention.

As far as we know, the GLAMS is the first preschool measure of learning and memory developed indigenously from within the Caribbean. It shows reliable internal consistency, expected age and gender effects and convergent validity. These initial results are encouraging and support continued efforts to establish test-retest and inter-rater reliability. Plans include validation in clinical samples, scale-up to other Caribbean countries, and eventual adaptation across global LMICs.

Neuroticism is a significant predictor of adverse psychological outcomes in patients with cancer. Less is known about how this relationship manifests in those with noncancer illness at the end-of-life (EOL). The objective of this study was to examine the impact of neuroticism as a moderator of physical symptoms and development of depression in patients with amyotrophic lateral sclerosis (ALS), chronic obstructive pulmonary disease (COPD), end-stage renal disease (ESRD), and frailty in the last 6 months of life.

We met this objective using secondary data collected in the Dignity and Distress across End-of-Life Populations study. The data included N = 404 patients with ALS (N = 101), COPD (N = 100), ESRD (N = 101), and frailty (N = 102) in the estimated last 6 months of life, with a range of illness-related symptoms, assessed longitudinally at 2 time points. We examined neuroticism as a moderator of illness-related symptoms at Time 1 (∼6 months before death) and depression at Time 2 (∼3 months before death) using ordinary least squares regression.

Results revealed that neuroticism significantly moderated the relationship between the following symptoms and depression measured 3 months later: drowsiness, fatigue, shortness of breath, wellbeing (ALS); drowsiness, trouble sleeping, will to live, activity (COPD); constipation (ESRD); and weakness and will to live (frailty).

These findings suggest that neuroticism represents a vulnerability factor that either attenuates or amplifies the relationship of specific illness and depressive symptoms in these noncancer illness groups at the EOL. Identifying those high in neuroticism may provide insight into patient populations that require special care at the EOL.

Insecure attachment styles are associated with retrospectively reported suicide attempts (SAs). It is not known if attachment styles are prospectively associated with medically documented SAs.

A representative sample of US Army soldiers entering service (n = 21 772) was surveyed and followed via administrative records for their first 48 months of service. Attachment style (secure, preoccupied, fearful, dismissing) was assessed at baseline. Administrative medical records identified SAs. Discrete-time survival analysis examined associations of attachment style with future SA during service, adjusting for time in service, socio-demographics, service-related variables, and mental health diagnosis (MH-Dx). We examined whether associations of attachment style with SA differed based on sex and MH-Dx.

In total, 253 respondents attempted suicide. Endorsed attachment styles included secure (46.8%), preoccupied (9.1%), fearful (15.7%), and dismissing (19.2%). Examined separately, insecure attachment styles were associated with increased odds of SA: preoccupied [OR 2.5 (95% CI 1.7–3.4)], fearful [OR 1.6 (95% CI 1.1–2.3)], dismissing [OR 1.8 (95% CI 1.3–2.6)]. Examining attachment styles simultaneously along with other covariates, preoccupied [OR 1.9 (95% CI 1.4–2.7)] and dismissing [OR 1.7 (95% CI 1.2–2.4)] remained significant. The dismissing attachment and MH-Dx interaction was significant. In stratified analyses, dismissing attachment was associated with SA only among soldiers without MH-Dx. Other interactions were non-significant. Soldiers endorsing any insecure attachment style had elevated SA risk across the first 48 months in service, particularly during the first 12 months.

Insecure attachment styles, particularly preoccupied and dismissing, are associated with increased future SA risk among soldiers. Elevated risk is most substantial during first year of service but persists through the first 48 months. Dismissing attachment may indicate risk specifically among soldiers not identified by the mental healthcare system.