Shira Maguen

• Ph.D.
• University of California, San Francisco

Many veterans do not initiate trauma-focused evidence-based psychotherapy (TF-EBP) to treat posttraumatic stress disorder (PTSD). Instead, veterans receive other treatments prior to TF-EBP and the process of transitioning to TF-EBP is poorly understood. The goal of the current study was to understand clinicians' beliefs about and approaches to tran...

There are no reported randomized trials testing exercise versus an active comparator for Posttraumatic Stress Disorder (PTSD). This randomized clinical trial assessed the effectiveness of group exercise versus psychoeducation to improve quality of life and reduces symptomatic severity in Veterans with PTSD. Veterans who met criteria for current PTS...

Background/Objectives: While theoretical articles describing cultural considerations for post-traumatic stress disorder (PTSD) treatment in Latine/x populations exist, empirical trials are less common. The present study aimed to review the existing literature for empirically tested, trauma-focused PTSD treatments among Latine/x samples to describe...

Moral injury affects a variety of populations who make ethically complex decisions involving their own and others’ well-being, including combat veterans, healthcare workers, and first responders. Yet little is known about occupational differences in the prevalence of morally injurious exposures and outcomes in nationally representative samples of s...

Purpose of Review As evidence accumulates for the pernicious effects of exposure to potentially morally injurious events (PMIEs) on mental health, the need for improved measurement of moral injury has grown. This article summarizes the psychometric properties of scales that assess cognitive, emotional, social, and spiritual concerns linked to PMIE...

Introduction Trauma-focused evidence-based psychotherapy (EBP) is the recommended treatment for post-traumatic stress disorder (PTSD). During and after the COVID-19 pandemic, veterans began to initiate general mental health services delivered via video telehealth at high rates. Our goal in the current project was to describe the percentage as well...

Using mixed methods, we examined drivers of risk for moral injury, mental health symptoms, and burnout among frontline healthcare workers in high-risk Veterans Affairs (VA) clinical settings during the COVID-19 pandemic. Across 21 VA medical centers, 2,004 healthcare workers completed an online survey assessing potential risk factors for moral inju...

Although trauma-focused evidence-based psychotherapy (TF-EBP) is recommended for posttraumatic stress disorder (PTSD), rates of TF-EBP initiation among veterans is very low. Service delivery research has shown that other treatments are commonly provided to veterans diagnosed with PTSD, including stabilization treatments. As little is known about ho...

Objective Posttraumatic stress disorder (PTSD) has been linked with menopause symptoms (eg, vasomotor, urinary) and their sequelae (eg, sexual difficulties). However, PTSD is a heterogeneous disorder, and less is known about which aspects may be most associated with menopause-related health. Methods Using confirmatory factor analyses, we evaluated...

Purpose Understanding disease prevalence can inform treatment and resource needs across populations. This study aimed to identify the prevalence of sleep apnea (OSA) among veterans and nonveterans. Design The national Comparative Health Assessment Interview Study, cross-sectional survey using probability-based sampling frames. Setting Surveys com...

While bulimia nervosa (BN) and binge eating disorder (BED) are prevalent in military populations, an understanding of risk and protective factors is limited by a lack of longitudinal population-based epidemiological research. This study examined the prevalence of BN and BED among active duty service members and identified military and psychosocial...

Although prior research has examined the prevalence of eating disorders (EDs) such as binge eating disorder (BED) and bulimia nervosa (BN) among military personnel, less is known regarding temporal associations between EDs and other mental health conditions. Using longitudinal data from 179,694 service members and veterans from the Millennium Cohor...

Bulimia nervosa (BN) and binge eating disorder (BED) are the most prevalent eating disorders (EDs) among military personnel. Although sex differences are noted in ED prevalence in military and civilian samples, mixed findings have emerged when evaluating racial and ethnic differences. The present study examined independent associations and interact...

Binge eating disorder (BED) is a public health concern that has received little research attention in military families. Further research is needed to identify risk and protective factors to inform intervention and prevention efforts. This longitudinal study examined predictors of probable BED in a sample of U.S. military spouses (N = 5,269). Data...

Objective We aimed to explore US veteran perspectives on eating disorder screening, diagnosis, patient–provider conversations, and care in the Veterans Health Administration (VHA). Method Rapid qualitative analysis of 30–45 min phone interviews with 16 ( N = 16) veterans with an electronic health record ICD‐10 eating disorder diagnosis, who receiv...

Objective: The purpose of the study was to compare lesbian, gay, bisexual, transgender, queer+ (LGBTQ+) veterans’ and nonveterans’ prevalence of potentially traumatic events (PTEs) and other stressor exposures, mental health concerns, and mental health treatment. Method: A subsample of veterans and nonveterans who identified as LGBTQ+ (N = 1,291; 8...

The present study sought to investigate whether gender moderates the relationship between military sexual trauma (MST) and posttraumatic stress disorder (PTSD) treatment utilization, among veterans with clinically significant PTSD symptoms. Participants were 2,664 veterans with probable PTSD from a nationwide, population-based survey. Participants...

There are no reported randomized trials testing exercise versus an active comparator for Posttraumatic Stress Disorder (PTSD). This randomized clinical trial assessed the effectiveness of group exercise versus psychoeducation to improve quality of life and reduces symptomatic severity in Veterans with PTSD. Veterans who met criteria for current PTS...

Despite theory suggesting that self‐forgiveness facilitates recovery from moral injury, no measure of self‐forgiveness has been validated with individuals exposed to potentially morally injurious events (PMIEs). Military veterans, healthcare workers, and first responders who reported PMIE exposure ( n = 924) completed the Self‐Forgiveness Dual‐Proc...

Despite the proliferation of moral injury studies, a remaining gap is distinguishing moral injury from normative distress following exposure to potentially morally injurious events (PMIEs). Our goal was to leverage mental health and functional measures to identify clinically meaningful and functionally impairing moral injury using the Moral Injury...

The Veterans Health Administration (VHA) currently employs over 1,300 peer specialists—veterans with lived experience of mental illness who are in recovery and have been trained to provide support to other veterans experiencing these issues. VHA peer specialists have largely been employed in behavioral health settings. In 2014, VHA began to employ...

Food and/or housing instability (FHI) has been minimally examined in post-9/11 US veterans. A randomly selected nationally representative sample of men and women veterans (n = 38,633) from the post-9/11 US veteran population were mailed invitation letters to complete a survey on health and well-being. Principal component analysis and multivariable...

Objective: This is a randomized controlled trial (NCT03056157) of an enhanced adaptive disclosure (AD) psychotherapy compared to present-centered therapy (PCT; each 12 sessions) in 174 veterans with posttraumatic stress disorder (PTSD) related to traumatic loss (TL) and moral injury (MI). AD employs different strategies for different trauma types....

Background: Military sexual trauma (MST) and moral injury (MI) are associated with adverse psychiatric and health outcomes among military veterans. However, no known population-based studies have examined the incremental burden associated with the co-occurrence of these experiences relative to either alone. Method: Cross-sectional data were an...

Despite efforts to identify risk factors associated with suicidal ideation (SI), less work has been conducted to highlight protective factors to promote prevention. Perceived social support has been shown to positively impact a wide range of psychological outcomes; however, prior efforts exploring whether perceived social support moderates the rela...

Sexual minority veterans are at heightened risk for mental health conditions compared with their heterosexual peers. Subpopulations of the sexual minority community, including veterans, are at even greater risk for mental health conditions. Despite this heightened risk, little is known about mental health treatment seeking among sexual minority vet...

Objective We examined the impact of healthcare workers’ (HCWs) adjustment to the COVID-19 pandemic on their work-related attitudes and behaviors. Methods: HCWs (N = 1,468) participated in an observational longitudinal study in which they completed surveys of anxiety and occupational health between 2020 and 2021. Results: Most HCWs reported anxiety...

Alternative models of traumatic stress and broader psychopathology have been proposed to address issues of heterogeneity, comorbidity, clinical utility, and equitable representation. However, systematic and practical methods and guidelines to organize and apply these models remain scarce. The Middle‐Out Approach is a novel, integrative, contextuall...

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 t...

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 nonmilitary 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 (3...

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”) administered...

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...

This study reviews current literature regarding referral to evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) within U.S. Veterans Affairs (VA). The referral process for EBPs for PTSD impacts care, but this process has not been the focus of much research. The current literature suggests that patient, provider, and struc...

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....

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...

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...

Given the devastation caused by disasters and mass violence, it is critical that intervention policy be based on the most updated research findings. However, to date, no evidence-based consensus has been reached supporting a clear set of recommendations for intervention during the immediate and the mid-term post mass trauma phases. Because it is un...

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...

Background Recent research suggests that exposure to potentially morally injurious experiences (PMIEs) may be associated with increased risk for suicidal behavior among US combat veterans, but population‐based data on these associations are scarce. This study examined the association between PMIEs with current suicidal ideation (SI), lifetime suici...

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...