Carol S. Fullerton

• PhD
• Professor at Uniformed Services University of the Health Sciences

Objective: This report presents an overview of the objectives, design, and analytic strategy of the Child Maltreatment in Military Families Life Course Study, an investigation of factors associated with child maltreatment in active duty military families. Method: The study uses a case-control retrospective research design and discrete-time surviva...

Introduction Most research on suicide attempts among U.S. service members has been focused on risk factors that occur during service. There is an important gap in our understanding of premilitary factors, such as personality characteristics, that may be associated with future suicide attempt risk during service. Of particular importance is identify...

When a service member is found injured or dead, the cause is often unknown. The cause may be a medical event, an accident, suicide, or suicide attempt. Leaders and unit members may feel uncertain about what to talk about, what not to talk about, and what to do. Inside are actions to care for unit members and sustain readiness.

Background: 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. Methods: A representative sample of US Army soldiers entering service (n = 21 772) was surveyed and followed via administrative records for th...

Background: Understanding mental health predictors of imminent suicide attempt (SA; within 30 days) among soldiers with depression and no prior suicide ideation (SI) can inform prevention and treatment. The current study aimed to identify sociodemographic and service-related characteristics and mental disorder predictors associated with imminent S...

Introduction: The National Guard (NG) served as a critical component of the USA's response to the Coronavirus Disease 2019 (COVID-19) pandemic, while concurrently managing their personal responses to the pandemic. Determining whether the activation of NG service members in response to the COVID-19 pandemic was associated with a greater psychologic...

The National Guard (NG) served as a critical component of the US COVID-19 response while concurrently managing personal COVID-19 responses. Understanding pandemic-related concerns, sleep difficulties, increased substance use, and stress management strategies can promote readiness for subsequent disasters. We surveyed 3221 NG service members (75% Ar...

Objective: The purpose was to examine five types of adversity and their associations with separating from military service among a nationally representative sample of U.S. National Guard and Reserve (NGR) service members. Methods: Multivariate logistic regression analyses were conducted to examine the association between separating from the serv...

Background Emotion reactivity and risk behaviors (ERRB) are transdiagnostic dimensions associated with suicide attempt (SA). ERRB patterns may identify individuals at increased risk of future SAs. Methods A representative sample of US Army soldiers entering basic combat training ( n = 21 772) was surveyed and followed via administrative records fo...

Objective: In times of repeated disaster events, including natural disasters and pandemics, public health workers must recover rapidly to respond to subsequent events. Understanding predictors of time to recovery and developing predictive models of time to recovery can aid planning and management. Methods: We examined 681 public health workers (...

Background Although much has been learned about the physical and psychological impacts of deployment and combat injury on military service members, less is known about the effects of these experiences on military spouses. Methods The present study examined self‐reported mental health symptoms (using the Brief Symptom Inventory [BSI]‐18 and the pos...

Importance: Approximately one-third of US soldiers who attempt suicide have not received a mental health diagnosis (MH-Dx) before their suicide attempt (SA), yet little is known about risk factors for SA in those with no MH-Dx. Objective: To examine whether premilitary mental health is associated with medically documented SA among US Army soldie...

Objective: Among U.S. Army soldiers suicide attempts (SAs) are a significant public health concern, particularly early in service. We examined the association of attachment style with SA and suicide ideation (SI) among U.S. Army soldiers. Methods: We analyzed survey data from new soldiers who participated in the Army Study to Assess Risk and Res...

Stress, especially the extreme stress of traumatic events, can alter both neurobiology and behavior. Such extreme environmental situations provide a useful model for understanding environmental influences on human biology and behavior. This paper will review some of the evidence of brain alterations that occur with exposure to environmental stress....

For a limited time, full text of this article is available at: https://authors.elsevier.com/a/1epe89UUG-vl9H The DOI for published article: https://doi.org/10.1016/j.jaclp.2022.02.007

Background Bereavement has been associated with increases in immune/inflammatory and neuroendocrine reactions, cardiovascular events, non-specific physical symptoms, mental conditions, and healthcare utilization. However, little is known about bereavement effects in younger samples, multiple health effects within samples, or health changes from pre...

Coronavirus SARS-CoV-2 disease (COVID-19) has caused injury, death, and distress in millions around the globe. Adverse mental health effects are substantial, with distress, health risk behaviors, and mental disorders exacerbating the threat of morbidity and mortality related to infection itself. The unique impacts of COVID-19, as well as the measur...

Exposure to war causes a wide range of harmful mental health effects. Those working with refugees and people directly impacted in Ukraine can protect mental health by using the following evidence-based actions and other resources. Resources include: (1) Rapid Psychological First Aid: Help for You, Family, and Friends (2) Helping Others Calm an Ac...

Objective: Since 2004 increased rates of suicide have been noted in the US Armed Forces. We examined the association of social support (SS) trajectories and suicide ideation (SI) over a four-year period in Reserve Component (RC) servicemembers (National Guard and Reserve). We also examined baseline mental health measures, as predictors of the ident...

Introduction Emotion reactivity (ER) and distress intolerance (DI) may be associated with increased suicide attempt (SA) risk among U.S. Army soldiers. Method In this case–control study, 74 soldiers recently hospitalized for SA (cases) were compared with 133 control soldiers from the same Army installations selected based on either propensity scor...

Objective: The authors sought to identify predictors of imminent suicide attempt (within 30 days) among U.S. Army soldiers following their first documented suicidal ideation. Methods: Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers, the authors identified 11,178 active-duty Regular Army enlisted sold...

Background Sleep disturbances are common in individuals with post traumatic stress disorder (PTSD). However, little is known about how daily variation in sleep characteristics is related to PTSD. This study examined the night-to-night and weekday versus weekend variation in sleep duration, sleep quality, trouble falling asleep, and difficulty stayi...

Research on disaster behavioral health presents significant methodological challenges. Challenges are even more complex for research on mass violence events that involve military members, families, and communities, due to the cultural and logistical considerations of working with this population. The current article aims to inform and educate on th...

Introduction Little is known about the degree to which U.S. Army soldiers in the Reserve Components (Army National Guard and Army Reserve) and Active Component (Regular Army) differ with respect suicide attempt (SA) risk during high-stress times, such as deployment. Method Using administrative person-month records of enlisted soldiers on active du...

Objective Community characteristics, such as collective efficacy, a measure of community strength, can affect behavioral responses following disasters. We measured collective efficacy 1 month before multiple hurricanes in 2005, and assessed its association to preparedness 9 months following the hurricane season. Methods Participants were 631 Flori...

Objective: Suicide and suicide attempts among U.S. Army soldiers are a significant concern for public health. This study examined the association of parental suicide attempt prior to age 13 of the soldier with subsequent risk of pre-enlistment suicide attempt. Method: We conducted secondary analyses of survey data from new soldiers who participate...

Objective: To examine sex differences in risk for administratively documented suicide attempt (SA) among US Army soldiers during the Iraq/Afghanistan wars. Method: Using administrative person-month records of Regular Army enlisted soldiers from 2004 to 2009, we identified 9650 person-months with a first documented SA and an equal-probability con...

Objective This study examined the relationship of perceived safety and confidence in local law enforcement and government to changes in daily life activities during the Washington, DC, sniper attacks. Methods Participants were 1238 residents from the Washington, DC metropolitan area who were assessed using an Internet survey that included items re...

Returning human remains to family members after a loved one's death is thought to support grief adaptation. However, no known research has examined the effects that notifications of fragmented remains have on bereaved family members. We examined the number of notifications received, continuing questions about the death, grief severity, and posttrau...

Background Bereavement by sudden and violent deaths can lead to increased grief severity, depression, and reduced posttraumatic growth compared to those bereaved by natural causes. These outcomes can be affected by coping strategies and whether a survivor had been “prepared” for the death. The present study examined the effect of coping and conside...

Acute stress disorder (ASD) is a trauma- and stressor-related disorder characterized by exposure to a traumatic event closely followed by symptoms of intrusion, negative mood, dissociation, avoidance, arousal, and impairment in functioning. ASD’s time-limited duration (3 days to 1 month) makes it distinct from, but related to, posttraumatic stress...

Human Remains, Grief, and Posttraumatic Stress in Bereaved Family Members Fourteen Years after September 11, 2001, a forthcoming manuscript in the Journal of Traumatic Stress describes the mental health effects on 9/11-bereaved family members after being notified (often multiple times) that remains of their loved ones were identified. Although retu...

Infectious disease outbreaks, such as the novel Coronavirus (nCoV) increase fear and uncertainty. Knowing how to care for yourself and your family can reduce distress and allow people to function more effectively. These educational fact sheets provide information and recommendations for healthcare personnel, families, businesses, and communities on...

Background: Post traumatic stress disorder (PTSD) and sleep problems are highly related. The relationship between nighttime sleep characteristics and next day post traumatic stress symptoms (PTSS) is not well known. This study examined the relationship between the previous night's sleep duration, number of awakenings, sleep quality, trouble fallin...

Background Risk for suicide attempt (SA) versus suicide ideation (SI) is clinically important and difficult to differentiate. We examined whether a history of self‐injurious thoughts and behaviors (SITBs) differentiates soldiers with a recent SA from nonattempting soldiers with current/recent SI. Methods Using a unique case‐control design, we admi...

Objective: We examined the association of U.S. Reserve Component (RC) personnel separating from military service with the risk of mental health problems at three time periods. Methods: Structured interviews were conducted with a nationally representative sample of 1,582 RC personnel at baseline and three follow-up waves from 2010 to 2013. Multivari...

Importance Understanding suicide ideation (SI) during combat deployment can inform prevention and treatment during and after deployment. Objective To examine associations of sociodemographic characteristics, lifetime and past-year stressors, and mental disorders with 30-day SI among a representative sample of US Army soldiers deployed in Afghanist...

Cytokines, including chemokines, are small secreted proteins, which specifically effect on the interactions and communications between cells. Pro-inflammatory cytokines are produced predominantly by activated macrophages and are involved in the upregulation of inflammatory reactions. Dysregulation of cytokines is associated with post-traumatic stre...

Background: Bereavement is associated with cognitive difficulties, but it is unclear whether these difficulties are associated with normative and/or complicated grief (CG) and how comorbid depression and anxiety contribute to them. Self-reported "minor errors in thinking" (i.e., cognitive failures) may manifest following bereavement and be differe...

Post-traumatic stress disorder (PTSD) is a debilitating mental disorder with a prevalence of more than 7% in the US population and 12% in the military. An interaction of childhood trauma with FKBP5 (a glucocorticoid-regulated immunophilin) has been reported to be associated with PTSD in the general population. However, there are few reports on the...

Background: Deployment-related experiences might be risk factors for soldier suicides, in which case identification of vulnerable soldiers before deployment could inform preventive efforts. We investigated this possibility by using pre-deployment survey and administrative data in a sample of US Army soldiers to develop a risk model for suicide att...

Background/objectives: Bereavement is associated with increases in prevalence of mental health conditions and in healthcare utilization. Due to younger age and bereavement by sudden and violent deaths, military widows may be vulnerable to poorer outcomes. No systematic research has examined these effects. Method: Using outpatient medical records...

Objective: During the wars in Afghanistan and Iraq, suicidal behaviors increased among U.S. Army soldiers. Although Reserve Component (RC) soldiers (National Guard and Army Reserve) comprise approximately one third of those deployed in support of the wars, few studies have examined suicidal behaviors among these "citizen-soldiers". The objective of...

Objective: We examined early first deployment and subsequent suicide attempt among U.S. Army soldiers. Method: Using 2004-2009 administrative data and person-month records of first-term, Regular Army, enlisted soldiers with one deployment (89.2% male), we identified 1,704 soldiers with a documented suicide attempt during or after first deploymen...

Studies of terrorism-related deaths are few and mostly focus on short-term effects. To characterize long-term bereavement outcomes, including resilience/recovery and patterns of comorbidity, following the September 11, 2001 (9/11), terrorist attacks, we report mental health conditions and grief-related impairment in 454 9/11 bereaved family members...

Objective This study examined the relationship of sniper-related television viewing (TV) and perceived safety to posttraumatic stress (PTS) and depressive symptoms during the Washington, DC sniper attacks. Methods Participants were 1238 Washington, DC area residents assessed using an internet survey including the Impact of Event Scale-Revised, Pat...

Hostility is a common form of emotionally charged anger which can lead to maladaptive and unhealthy behaviors. Significant association between shortened telomeres and greater levels of hostility has been observed in civilian populations, but has not yet been comprehensively studied in military populations. Our study investigates the relationship be...

Background Distinguishing a disorder of persistent and impairing grief from normative grief allows clinicians to identify this often undetected and disabling condition. As four diagnostic criteria sets for a grief disorder have been proposed, their similarities and differences need to be elucidated. Methods Participants were family members bereave...

Objective: Suicide is one of the ten leading causes of death in United States and the suicide rate in the military population has increased since the start of the Iraq and Afghanistan wars. However, few biomarkers for current suicidal ideation (CSI) have been identified. The current study examined the association of four candidate genes with CSI i...

Objective US Army soldiers and military veterans experience high rates of post-traumatic stress disorder (PTSD). However, PTSD risk factors are not fully understood. Sensitivity to blood, injury, and mutilation (SBIM), which includes fear of being injured, seeing another person injured, and exposure to mutilation-relevant stimuli (e.g., blood, woun...

Background Little is known about the extent to which post traumatic stress symptoms (PTSS) vary from day to day in individuals with post traumatic stress disorder (PTSD). This study examined the variation of PTSS by day of the week, and whether daily or day of week variation differs between individuals with and without probable PTSD. Methods Subje...

Abstract Background Although the majority of active duty U.S. Army soldiers are full-time personnel in the Active Component (AC), a substantial minority of soldiers on active duty are in the Reserve Components (RCs). These “citizen-soldiers” (Army National Guard and Army Reserve) represent a force available for rapid activation in times of national...

Objective Community characteristics, such as perceived collective efficacy, a measure of community strength, can affect mental health outcomes following disasters. We examined the association of perceived collective efficacy with posttraumatic stress disorder (PTSD) and frequent mental distress (14 or more mentally unhealthy days in the past month)...

Background Most people with suicide ideation (SI) do not attempt suicide (SA). Understanding the transition from current/recent SI to SA is important for mental health care. Our objective was to identify characteristics that differentiate SA from 30‐day SI among representative U.S. Army soldiers. Methods Using a unique case–control design, soldier...

Recent theory and empirical research suggest that child neglect is a heterogeneous phenomenon characterized by various types. This study examined family risk factors associated with five neglect types including failure to provide physical needs, lack of supervision, emotional neglect, moral-legal neglect, and educational neglect in 390 substantiate...

Importance The US Army suicide attempt rate increased sharply during the wars in Afghanistan and Iraq. Although soldiers with a prior mental health diagnosis (MH-Dx) are known to be at risk, little is known about risk among those with no history of diagnosis. Objective To examine risk factors for suicide attempt among soldiers without a previous M...

Responding to an unprecedented increase in the suicide rate among soldiers, in 2008 the US Army and US National Institute of Mental Health funded the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), a multicomponent epidemiological and neurobiological study of risk and resilience factors for suicidal thoughts and behaviors,...

Objective: The U.S. Army suicide rate increased sharply during the wars in Iraq and Afghanistan. There is limited information about medically documented, nonfatal suicidal behaviors among soldiers in the Army's Reserve Component (RC), which is composed of the Army National Guard and Army Reserve. Here we examine trends and sociodemographic correla...

Objective: A series of sniper attacks in the Washington, DC, area left 10 people dead and three wounded. The authors examined the relationship of sniper-related television (TV) viewing, identification with victims, and peritraumatic dissociation to post-traumatic stress symptoms. Methods: Participants were 1,238 DC residents (ages 18-90, M = 41....

Importance There has been limited systematic examination of whether risk of suicide attempt (SA) among US Army soldiers is associated with time-related deployment variables, such as time in service before first deployment, duration of first deployment, and dwell time (DT) (ie, length of time between deployments). Objective To examine the associati...

Over the past decade, suicide rates in the US Armed Forces have increased substantially, prompting considerable efforts to address this devastating public health concern. The effects of a suicide can echo through families, unit members, and the military community. Better understanding of the epidemiology of suicidality among soldiers, and increased...

Background Given the greater prevalence of post-deployment mental health concerns among reservists, the higher likelihood of deploying without their regular unit, and potentially lower rates of deployment preparedness, we examined associations between deploying with or without one’s regular unit (individual augmentee status, IAS), deployment prepar...

Violent behavior is an important problem for military service members and veterans. A representative cohort of U.S. Reserve and National Guard personnel (N = 1,293) were interviewed to assess self-reported problems controlling violent behavior, deployment traumas, posttraumatic stress disorder (PTSD), alcohol abuse, and social support. Poisson regr...

Suicide attempt (SA) rates in the U.S. Army increased substantially during the wars in Afghanistan and Iraq. This study examined associations of family violence (FV) history with SA risk among soldiers. Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), we identified person-month records of...

Objective A series of sniper attacks in the Washington, DC, area left 10 people dead and 3 wounded. We developed and tested a model that examined the unique and interdependent relationships of sniper-related television viewing, prior life-threatening events, and parental status to identification with attack victims. Methods Participants were 1238...

Suicide is a global public health problem with particular resonance for the US military. Genetic risk factors for suicidality are of interest as indicators of susceptibility and potential targets for intervention. We utilized population-based nonclinical cohorts of US military personnel (discovery: N = 473 cases and N = 9778 control subjects; repli...

Importance Mental health of soldiers is adversely affected by the death and injury of other unit members, but whether risk of suicide attempt is influenced by previous suicide attempts in a soldier’s unit is unknown. Objective To examine whether a soldier’s risk of suicide attempt is influenced by previous suicide attempts in that soldier’s unit....

Increases in combat deployments have been associated with rises in rates of child neglect in U.S. military families. Although various types of child neglect have been described in military families, it is unknown whether deployment status is associated with specific types of child neglect and whether other factors, such as substance misuse, play a...

Knowledge about the effect of a US service member's death on surviving family members is limited. In order to identify their grief-related health care needs, a first step is to identify the characteristics of persistent and elevated grief in a military family sample. The present study identified military family members (n = 232) bereaved more than...

Pandemics have a global reach of mass destruction and historically have been more devastating than any other type of disaster. Over many centuries, only the human- made disasters of war and the intentional extermination of ethnic groups have competed with the lethality of infectious disease outbreaks. Th e history of the infl uenza pandemic – occur...

Covering both natural and man-made scenarios including war and terrorism, the Textbook of Disaster Psychiatry is a vital international reference for medical professionals, community leaders and disaster responders a decade after its initial publication. Spanning a decade of advances in disaster psychiatry, this new and updated second edition brings...

BACKGROUND: The U.S. Army suicide attempt rate increased sharply during the wars in Iraq and Afghanistan. Risk may vary according to occupation, which significantly influences the stressors that soldiers experience. METHODS: Using administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), we identified p...

This study examined the relationship of on- and off-post resources to perceived residential neighborhood quality in 432 soldiers and their spouses from the four largest U.S. Army installations. Participants completed a questionnaire that measured one important element of perceived neighborhood quality (social cohesion/interrelatedness) and the exte...

Covering both natural and man-made scenarios including war and terrorism, the Textbook of Disaster Psychiatry is a vital international reference for medical professionals, community leaders and disaster responders a decade after its initial publication. Spanning a decade of advances in disaster psychiatry, this new and updated second edition brings...

Disaster exposure influences community-level characteristics, such as community strength, and the mental health of residents. Collective efficacy, a measure of community strength, is associated with reduction in adverse outcomes, including lower levels of depressive symptoms and reduced rates of post-traumatic stress disorder following a natural di...

BACKGROUND: Improvised explosive devices (IEDs) were a prominent and initially new threat in the Iraq and Afghanistan war which raised concerns and anticipatory fear in and out of theater. This study examined the association of monthly IED rates with risk of soldier suicide attempt among those deployed and nondeployed. METHODS: Person-month records...

BACKGROUND: U.S. military service members die from a variety of causes (i.e., accidents, combat, illnesses, homicide, suicide, and terrorism) while on duty and in greater numbers during times of war, leaving behind bereaved dependent family members. Identifying characteristics of these dependent families improves our understanding of their unique n...

Background: Preventing child maltreatment fatalities is a critical goal of the U.S. society and the military services. Fatality review boards further this goal through the analysis of circumstances of child deaths, making recommendations for improvements in practices and policies, and promoting increased cooperation among the many systems that ser...

This volume focuses on the culture of the U.S. Army. Many of the major points also apply to other military services. The concepts are important for those who desire to understand U.S. Army culture for research - particularly those early in their careers. We hope that this book helps those interested in conducting research in the Army to better navi...

U.S. Army mortuary affairs (MA) soldiers experience stressors of deployment and exposure to the dead, increasing risk for post-traumatic stress and depression. This study examines Troop Education for Army Morale, a postdeployment early intervention based on Psychological First Aid. MA soldiers (N = 126) were randomized to intervention or comparison...

This prospective cohort study used administrative data from the Army Study to Assess Risk and Resilience in Servicemembers to examine associations between neurocognitive functioning and subsequent suicidal events among Regular Army enlisted soldiers during the years 2004-2009. Cases were all soldiers who completed the Army's Automated Neuropsycholo...

TO THE EDITOR: Smid and Boelen rightfully highlight the importance of identifying standards for diagnosing clinically impairing grief. This issue has been of clinical interest within the United States and internationally, leading to the proposed DSM-5 persistent complex bereavement disorder criteria, as well as newly defined ICD-11 criteria for a s...

We used administrative data to examine predictors of medically documented suicide ideation (SI) among Regular Army soldiers from 2006 through 2009 (N = 10,466 ideators, 124,959 control person-months). Enlisted ideators (97.8% of all cases) were more likely than controls to be female, younger, older when entering service, less educated, never or pre...

Objectives: We documented the prevalence of post-traumatic stress disorder (PTSD), depression, and binge drinking in U.S. Reserve and National Guard (Reserve Component [RC]) personnel for each service and branch by rank, gender, and deployment status. Methods: Structured interviews were conducted with a nationally representative sample of RC perso...

U.S. Army soldiers with mental disorders report a variety of barriers to initiating and continuing treatment. Improved understanding of these barriers can help direct mental health services to soldiers in need. A representative sample of 5,428 nondeployed Regular Army soldiers participating in the Army Study to Assess Risk and Resilience in Service...