Shira Maguen

UCSF University of California, San Francisco | UCSF · Department of Psychiatry

Sexual assault and/or sexual harassment during military service (military sexual trauma (MST)) can have medical and mental health consequences. Most MST research has focused on reproductive-aged women, and little is known about the long-term impact of MST on menopause and aging-related health. Examine associations of MST with menopause and mental h...

Purpose of Review This review summarizes empirical studies investigating the associations between moral injury and suicide-related outcomes. Recent Findings A total of 47 studies met inclusion criteria and were reviewed. Samples included military, veteran, and civilian populations. Overall, more exposure to potentially morally injurious events (PM...

Several studies found that Black veterans demonstrate less posttraumatic stress disorder (PTSD) symptom improvement than White veterans following PTSD evidence-based psychotherapies (EBPs). We aimed to understand this disparity among veterans receiving EBPs by modeling race with demographic, clinical, and service utilization factors. Using electron...

Purpose of Review Healthcare workers (HCWs) may be exposed to potentially morally injurious events (PMIEs) while on the job and consequently experience acute, functional moral distress to prolonged, impairing moral injury. Recent Findings We reviewed 185 articles on moral distress and/or injury among HCWs. This included 91 empirical studies (appro...

Objective: The concept of moral injury resonates with impacted populations, but research has been limited by existing measures, which have primarily focused on war veterans and asked about exposure to potentially morally injurious events (PMIEs) rather than PMIE exposure outcomes. Our goal was to develop and examine the psychometric properties of...

Purpose Social determinants of health (SDoH) refer to the conditions in the environments in which people live that affect health outcomes and risks. SDoH may provide proximal, actionable targets for interventions. This study examined how SDoH are associated with posttraumatic stress disorder (PTSD) and depression symptoms among Veterans and non-Vet...

Background: Research comparing prevalence of alcohol use problems and alcohol treatment utilization between veterans and nonveterans is lacking. Whether predictors of alcohol use problems and alcohol treatment utilization differ in veterans vs. nonveterans is also unclear. Methods: Using survey data from national samples of post-9/11 veterans an...

We used the Common Sense Model to understand weight management treatment representations of diverse patients, conducting semistructured interviews with 24 veterans with obesity, recruited from multiple U.S. Veterans Health Administration facilities. We performed a directed content analysis to summarize representations and assess differences across...

Objective: Over a third of women in the United States report a lifetime history of intimate partner violence. Although a recent review found that intimate partner violence is related to poor subjective sleep, the majority of studies involved reproductive-aged women and used suboptimal measures of interpersonal violence and/or insomnia. We examined...

Objective: This study examined whether posttraumatic stress disorder (PTSD) diagnostic groups in veterans were differentiated by combat severity and specific avoidance and approach-related emotion regulation (ER) strategies. Method: In a cohort study, 725 participants (Mage = 58.39, SD = 11.27, 94.5% male, 58.2% White) recruited from VHA facilit...

Large-scale epidemiological studies suggest that veterans may have poorer physical health than nonveterans, but this has been largely unexamined in post-9/11 veterans despite research indicating their high levels of disability and healthcare utilization. Additionally, little investigation has been conducted on sex-based differences and interactions...

Objective: The current study sought to compare rates of posttraumatic stress disorder (PTSD) treatment utilization (medication and psychotherapy) among veterans and nonveterans-and to investigate which factors are associated with treatment utilization among veterans versus nonveterans. Methods: Participants were 2775 individuals (veteran, n=2508...

Background/objectives: Although studies have shown posttraumatic stress disorder (PTSD) associated with risk of suicide, the relationship in later life, especially for overdose death, remains unclear. Thus, the aim of the current study was to determine associations between PTSD, suicide, and unintended overdose death in mid- to late-life. Methods...

Studies of moral injury among non-military samples are scarce despite repeated calls to examine the prevalence and outcomes of moral injury among civilian frontline workers. The purpose of this study was to describe the prevalence of moral injury and to examine its association with psychosocial functioning among health care workers during the COVID...

Purpose of Review Veterans who kill in war are at risk of developing negative mental health problems including moral injury, PTSD, spiritual distress, and impairments in functioning. Impact of Killing (IOK) is a novel, cognitive-behaviorally based treatment designed to address the symptoms associated with killing that focuses on self-forgiveness an...

Sleep disturbance has emerged as an independent, mechanistic, and modifiable risk factor for suicide. Sexual and gender minority (SGM) people disproportionately experience sleep disturbance and are at higher risk of death by suicide relative to cisgender and/or heterosexual individuals. The present narrative review evaluates nascent research relate...

Background There is mixed evidence regarding the direction of a potential association between post-traumatic stress disorder (PTSD) and suicide mortality. Aims This is the first population-based study to account for both PTSD diagnosis and PTSD symptom severity simultaneously in the examination of suicide mortality. Method Retrospective study tha...

Objective: The current studies explored associations between exposure to potentially morally injurious events (PMIEs) and mental health outcomes among frontline workers affected by the coronavirus pandemic. Method: We administered online self-report surveys to emergency responders (N = 473) and hospital personnel (N = 854) in the Rocky Mountain...

Background Questions persist about how often potentially morally injurious events (PMIEs) are associated with posttraumatic stress disorder (PTSD) and depression. Methods This study examined the overlap of morally injurious events with probable PTSD and depression in a nationally representative sample of U.S. combat veterans (n = 1,321, mean age 5...

Background Prior research has examined how the post-military health and well-being of both the larger veteran population and earlier veteran cohorts differs from non-veterans. However, no study has yet to provide a holistic examination of how the health, vocational, financial, and social well-being of the newest generation of post-9/11 U.S. militar...

Posttraumatic stress disorder (PTSD) and chronic pain are highly prevalent and co-morbid among veterans. Moral injury (MI), which results from traumatic experiences that conflict with deeply held moral beliefs, is also associated with pain. However, relationships between different types of exposures to potentially morally injurious events (PMIEs) a...

Purpose of Review Due to the unique characteristics of posttraumatic stress disorder (PTSD), considering the contextual factors that influence the development, maintenance, and treatment of PTSD is particularly important. Social determinants of health (SDoH) provide a transdiagnostic, comprehensive, and actionable approach to studying and accountin...

Background Approximately 1 in 3 women veterans endorse military sexual trauma (MST) during Veterans Health Administration (VHA) screening. Higher rates have been reported in anonymous surveys. Objective We compared MST identified by VHA screening to survey-reported MST within the same sample and identified participant characteristics associated wi...

Reports an error in "Development and validation of a brief warfare exposure measure among U.S. Iraq and Afghanistan war veterans: The Deployment Risk and Resilience Inventory-2 Warfare Exposure-Short Form (DRRI-2 WE-SF)" by Michelle J. Bovin, Aaron Schneiderman, Paul A. Bernhard, Shira Maguen, Claire A. Hoffmire, John R. Blosnich, Brian N. Smith, R...

Rationale: Posttraumatic stress disorder (PTSD) is highly prevalent among veterans. Many veterans with PTSD respond well to serotonin reuptake inhibitors (SRIs). Nonresponders may be prescribed augmenting medications, which are not as well-studied in PTSD. Aims and objectives: We used Veterans Health Administration electronic records to compare...

Objective: It is important to assess warfare experiences beyond direct combat exposure, as these exposures can negatively impact military veterans' health. Although two validated scales from the Deployment Risk and Resilience Inventory-2 [DRRI-2] together capture a broad range of stressful warfare experiences, the length of this combined measure (...

Rates of adherence to positive airway pressure (PAP) for sleep apnea are suboptimal. Though previous studies have identified individual factors associated with PAP nonadherence, few projects have investigated a wide range of possible barriers directly from the patient perspective. We examined the range of factors that patients identify as barriers...

Objective: Veterans with posttraumatic stress disorder (PTSD) initiate and complete cognitive processing therapy (CPT) and prolonged exposure (PE) at low rates within Veterans Health Administration (VHA) despite substantial dissemination and training. This study investigated how trauma-informed, skills-based treatment ("stabilization") administere...

Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) are effective psychotherapies for post-traumatic stress disorder (PTSD). However, these treatments also have high rates of dropout and non-response. Therefore, patients may need a second course of treatment. We compared outcomes for patients who switched between CPT/PE and those...

Although it is well-established that sexual assault results in variable and long-lasting negative impacts on emotional well-being, perceptions of physical health, and relationship functioning, these “psychosocial” outcomes may vary based on the type(s) of sexual trauma experienced. To identify the differential impact of sexual trauma type(s) on psy...

Study objectives: Trauma-related nightmares are highly prevalent among veterans and are associated with higher severity insomnia and PTSD. Cognitive behavioral therapy for insomnia (CBT-I, typically 6-8 sessions) has been shown to reduce trauma-related nightmares. Brief behavioral treatment for insomnia (BBTI, 4 sessions) has been found to be comp...

Healthcare workers face numerous occupational stressors, including some that may challenge personal and shared morals and values. This is particularly true during disasters and crises such as the COVID-19 pandemic, which require critical decisions to be made with little time and information often under personal distress and situational constraints....

Background: The Common Sense Model provides a framework to understand health beliefs and behaviors. It includes illness representations comprised of five domains (identity, cause, consequences, timeline, and control/cure). While widely used, it is rarely applied to obesity, yet could explain self-management decisions and inform treatments. This st...

Objective: Racial/ethnic disparities in menopause symptoms and hormone therapy management remain understudied among women served by the Veteran's Health Administration, despite the unique racial/ethnic diversity of this population. Thus, we determined racial/ethnic disparities in medical record-documented menopause symptoms and prescribed menopaus...

The number of racial/ethnic and women minorities entering the military continues to grow and more research is needed to properly assess, conceptualize, and treat posttraumatic stress disorder (PTSD) in diverse women. Recently, typological approaches have been useful in revealing distinct PTSD symptom presentations; however, existing research has no...

Background: Although the transition out of military service is a high-risk time for suicidal ideation (SI), a paucity of research examines the development of SI during this transition process and veteran subgroups at risk for SI as they readjust to civilian life. Methods: A population-based, longitudinal post-9/11 veteran cohort reported SI freq...

Background Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans. Methods A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injuri...

Background Exposure to potentially morally injurious events (PMIEs) is associated with increased risk for substance use disorders (SUDs), although population-based studies remain limited. The goal of this study was to better understand the relationships between PMIE exposure and lifetime and past-year alcohol use disorder (AUD), drug use disorder (...

Objective Several vulnerability factors for suicidal behavior in U.S. veterans have been identified. However, little is known about factors that differentiate veterans who contemplate suicide from those who attempt suicide. This study examined sociodemographic and clinical characteristics that distinguish veterans who think about suicide from those...

Background The coronavirus-2019 (COVID-19) pandemic is associated with increased potential for morally injurious events, during which individuals may experience, witness, or learn about situations that violate deeply held moral beliefs. However, it is unknown how pandemic risk and resilience factors are associated with COVID-related moral injury....

OBJECTIVE Veterans with a history of multiple suicide attempts are at increased risk for suicide mortality relative to those with a single attempt. However, little is known about factors that differentiate veterans who attempt suicide once compared to more than once. This study examined factors that distinguish single suicide attempters (SSA) from...

Background While evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) is a first-line treatment, its real-world effectiveness is unknown. We compared cognitive processing therapy (CPT) and prolonged exposure (PE) each to an individual psychotherapy comparator group, and CPT to PE in a large national healthcare system. Method...

Objective: To evaluate longitudinal prescription practice trends for patients diagnosed with posttraumatic stress disorder (PTSD) using a national cohort of veterans who engaged in Veterans Health Administration (VHA) care from 2009 to 2018. Methods: Using ICD-9 and ICD-10 codes to determine diagnoses, 1,353,416 patients diagnosed with PTSD in V...

Rationale aims and objectives: As quality measurement becomes increasingly reliant on the availability of structured electronic medical record (EMR) data, clinicians are asked to perform documentation using tools that facilitate data capture. These tools may not be available, feasible, or acceptable in all clinical scenarios. Alternative methods o...

Introduction Although posttraumatic stress disorder (PTSD) may increase risk of suicide in mid- to late-life, findings have been controversial, in large part, because studies have not accounted for comorbid disorders. Moreover, little is known about association between mid- to late-life PTSD and apparent accidental death by overdose, which could be...

Objective This study examined whether expressive suppression (ES), a maladaptive regulation strategy, was more strongly associated with PTSD diagnosis and symptom clusters in veterans than cognitive reappraisal (CR), an adaptive regulation strategy. Method In a cohort study, 746 participants recruited from VHA facilities completed Clinician Admini...

Objective Little is known about prevalence estimates of new and revised DSM‐5 eating disorders diagnoses in general, and especially among high‐risk, underserved and diverse eating disorder populations. The aim of the current study was to determine prevalence, gender differences and correlates of DSM‐5 eating disorders in veterans. Method Iraq and...

Background: Rising US suicide rates are particularly notable among military veterans, especially women. It is unknown whether these differences extend to suicidal ideation (SI) and suicide attempts (SA), which are major predictors of suicide. Literature comparing SI and SA prevalence and timing of onset between veterans and nonveterans is limited....

Aims To examine whether cognitive behavioral therapy for insomnia (CBT-I), delivered by telephone, improves sleep and non-sleep symptoms of Gulf War Illness (GWI). Main methods Eighty-five Gulf War veterans (21 women, mean age: 54 years, range 46–72 years) who met the Kansas GWI case definition, the Centers for Disease Control and Prevention (CDC)...

Objective Following exposure to events that transgress moral beliefs and expectations rooted in cultural, organizational, and group-based ethical rules, veterans can experience psychological, social, and spiritual problems referred to as Moral Injury (MI). We examined patterns of exposure to potentially morally injurious events (PMIEs) among Israel...

Adverse childhood experiences (ACEs) are robustly associated with physical and mental health problems over the life span. Relatively limited research has examined the breadth of ACEs among military veteran populations, for whom ACEs may be premilitary traumas associated with suicidal ideation and attempt. Using data from the Comparative Health Asse...

Objective: Although behavioral treatments are recommended for treating insomnia disorder, these treatments are not the most commonly provided treatments due to numerous barriers (e.g., treatment length, time limitations). Brief Behavioral Treatment for Insomnia (BBTI) was developed, in part, to help overcome these barriers. The purpose of the curre...

Background The Whole Health model of the U.S. Department of Veterans Affairs (VA) emphasizes holistic self-care and multimodal approaches to improve pain, functioning, and quality of life. wHOPE (Whole Health Options and Pain Education) seeks to be the first multisite pragmatic trial to establish evidence for the VA Whole Health model for chronic p...

Background Although research has shown that exposure to potentially traumatic and morally injurious events is associated with psychological symptoms among veterans, knowledge regarding functioning impacts remains limited. Methods A population-based sample of post-9/11 veterans completed measures of intimate relationship, health, and work functioni...

Introduction The United States Department of Veterans Affairs (VA) has invested in implementation of evidence-based psychotherapy (EBP) for post-traumatic stress disorder (PTSD) for over a decade, resulting in slow but steady uptake of these treatments nationally. However, no prior research has investigated the geographic variation in initiation of...

Prolonged exposure therapy (PE) is an effective treatment for posttraumatic stress disorder (PTSD). Identifying metrics of treatment response can guide treatment delivery. The median effective dose represents the number of sessions at which there is a 50% probability of clinically meaningful improvement (i.e., 10-point reduction in PTSD checklist)....

Study Objectives Our goal was to compare Brief Behavioral Treatment for Insomnia (BBTI) to a Progressive Muscle Relaxation Training (PMRT) control condition among veterans with insomnia, examining psychosocial functioning as a primary outcome and sleep-related outcomes, mood, cognition, and pain as secondary outcomes. Methods Veterans were randoml...

Objective Cognitive Processing Therapy (CPT) has been disseminated in the Veterans Health Administration (VHA) to treat posttraumatic stress disorder (PTSD). Identifying the median effective dose (MED) of CPT, the number of sessions at which the probability of experiencing clinically meaningful improvement (CMI) is 50%, can assist with treatment....

The original version of this article unfortunately contained a mistake. The co-author name was incorrectly published with the middle initial in the author list.

Our goal was to identify gender differences in the prevalence and outcomes of exposure to potentially morally injurious events (PMIEs) in a sample of U.S. military veterans. In a national sample of post-9/11 veterans (n = 7,200) weighted to reflect the larger population of newly separated U.S. veterans, we conducted gender-stratified analyses of th...

Objective Evidence-based psychotherapy (EBP) for PTSD effectiveness can vary based on gender and trauma type, with poorer outcomes for men and sexual traumas. Among veterans receiving EBPs for PTSD, the effects of the interaction between gender and military sexual trauma (MST) on treatment outcome are unclear. This study examined how gender and MST...

Moral injury is a helpful lens through which we can better understand and prepare for the downstream psychosocial impact faced by health care providers during the coronavirus pandemic. Moral injury is psychological weight caused by a transgression of one's own or shared morals and values and can manifest as guilt, shame, inability to self-forgive,...

Introduction Brief behavioral treatment for insomnia (BBTI) is efficacious for insomnia symptoms. Here we examine whether BBTI reduces sleep and daily rhythm variability and whether reductions in variability result in improved functioning and quality of life. Methods Ninety-one Veterans with insomnia (49.3±18.7yrs; 18.7% female) were randomized to...

We sought to develop a quality standard for the delivery of psychotherapy for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting psychotherapy as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified psychotherapy receipt during the initial year of PTSD treat...

Background : Despite availability of evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), not all veterans who initiate EBPs experience benefit. Better understanding factors associated with clinically significant improvement can help ameliorate care. Methods : A cohort of Iraq and Afghanistan War veterans who initiated a...

Objective: Military veterans who interpret their own or others' actions as moral transgressions are theorized to experience moral distress. The purpose of this study was to explore patterns of moral distress and associated psychological, social, and religious or spiritual problems among student veterans. Method: Student veterans (N = 498) retros...

Objective: The goal was to examine psychiatric diagnosis rates among a national cohort of primary care patients with and without obesity. Methods: The cohort was derived from national Veterans Health Administration data (women, N=342,262; men, N=4,524,787). Sex-stratified descriptive statistics characterized psychiatric diagnosis rates. Chi-squa...

Background: Although evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) were implemented starting in 2005 in the veterans health administration (VHA), the largest national healthcare system in the U.S., the rate of initiation (uptake) and prevalence of these treatments in each calendar year have not been determined. We...

The Department of Veterans Affairs (VA) has implemented initiatives to promote veterans' recovery from the health sequelae of military sexual trauma (MST), including posttraumatic stress disorder (PTSD). MST can impact emotion regulation, interpersonal functioning, and perceptions of trust and safety, as well as increase risk for psychiatric comorb...

Background Recent attention has highlighted the common occurrence and health consequences of military sexual trauma (MST) in younger women veterans. However, almost nothing is known about MST in older veterans. Objective To describe MST among older women veterans, including prevalence and common comorbidities. Design Cross-sectional observational...

Background Eating disorders affect upwards of 30 million people worldwide and often go undertreated and underdiagnosed. The purpose of this systematic review and meta-analysis was to evaluate the diagnostic accuracy of the Sick, Control, One, Fat and Food (SCOFF) questionnaire for DSM-5 eating disorders in the general population. Method The Prefer...

Objective: Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) were widely disseminated to treat posttraumatic stress disorder (PTSD) in the Veterans Health Administration (VHA). However, few Iraq and Afghanistan war veterans (Operation Enduring Freedom [OEF], Operation Iraqi Freedom [OIF], Operation New Dawn [OND]) diagnosed wi...

Rationale Identifying predictors of improvement amongst patients receiving routine treatment for post‐traumatic stress disorder (PTSD) could provide information about factors that influence the clinical effectiveness of guideline‐concordant care. This study builds on prior work by accounting for delivery of specific evidence‐based treatments (EBTs)...

Suicide rates amongst women veterans are significantly higher than rates for their civilian counterparts. However, risk factors for suicide among women veterans remain unclear. The current study examined the impact of exposure to a number of military stressors (e.g., perceived life threat, killing in combat, military sexual trauma) on suicidal idea...

Little is known about predictors of initiation and completion of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD), with most data coming from small cohort studies and post-hoc analyses of clinical trials. We examined patient and treatment factors associated with initiation and completion of EBP for PTSD in a large longitu...

Low relationship satisfaction is associated with mental health disorders in service members/veterans (SM/Vs), yet eating disordered behavior (EDB) and sexual function and satisfaction in SM/Vs are understudied. Those with EDB may experience bodily discomfort that may be associated with low relationship satisfaction because of avoidance of physical...

Individuals who are exposed to traumatic events that violate their moral values may experience severe distress and functional impairments known as "moral injuries." Over the last decade, moral injury has captured the attention of mental health care providers, spiritual and faith communities, media outlets, and the general public. Research about mor...

Objective: To determine whether diagnoses of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and depression, alone or in combination, increase dementia risk among older female veterans. Methods: This cohort study included data from 109,140 female veterans ≥55 years of age receiving care from Veterans Health Administration med...

Progress in the scientific study of self-forgiveness reveals a need for (a) integration of the extant self-forgiveness literature with general psychological theory, (b) development of measures that reflect nuanced conceptualizations of self-forgiveness, (c) better understanding of the impact of self-forgiveness on personal and interpersonal functio...

For military veterans struggling with moral injury, forgiveness can become both an animating concern and a potential path to healing. In this perspective piece, we draw on our clinical work and research findings to examine why forgiveness matters to veterans who feel guilt and shame about their actions in war, what type of forgiveness is attainable...

Objective We assessed whether treatment providers specializing in evidence‐based treatment for posttraumatic stress disorder found the Impact of Killing (IOK), a novel treatment for moral injury among combat veterans, acceptable, and feasible. Methods Ten providers from a large veterans administration (VA) medical center were provided with materia...

Objective: Fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine have consistently shown efficacy for posttraumatic stress disorder (PTSD) in meta-analyses of randomized controlled trials. However, no study has compared the effectiveness of these agents in routine clinical practice. We conducted a retrospective comparative effectiveness...