Association Between Clinically Meaningful Posttraumatic Stress Disorder Improvement and Risk of Type 2 Diabetes

Posttraumatic Stress Disorder and Type 2 Diabetes Outcomes in Veterans

Importance

Posttraumatic stress disorder (PTSD) symptom reduction is linked with lower risk of incident type 2 diabetes (T2D), but little is known about the association between PTSD and comorbid T2D outcomes. Whether PTSD is a modifiable risk factor for adverse T2D outcomes is unknown.

Objective

To determine whether patients with PTSD who improved and no longer met diagnostic criteria for PTSD had a lower risk of adverse T2D outcomes compared with patients with persistent PTSD.

Design, Setting, and Participants

This retrospective cohort study used deidentified data from US Veterans Health Administration (VHA) historical medical records (from October 1, 2011, to September 30, 2022) to create a cohort of patients aged 18 to 80 years with comorbid PTSD and T2D. Data analysis was performed from March 1 to June 1, 2024.

Exposures

Diagnoses of PTSD and T2D.

Main Outcomes and Measures

The main outcomes were insulin initiation, poor glycemic control, any microvascular complication, and all-cause mortality. Improvement of PTSD was defined as no longer meeting PTSD diagnostic criteria, per a PTSD Checklist score of less than 33. Entropy balancing controlled for confounding. Survival and competing risk models estimated the association between meeting PTSD criteria and T2D outcomes. Subgroup analyses examined variation by age, sex, race, PTSD severity, and comorbid depression status.

Results

The study cohort included 10 002 veterans. More than half of patients (65.3%) were aged older than 50 years and most (87.2%) were men. Patients identified as Black (31.6%), White (62.7%), or other race (5.7%). Before controlling for confounding with entropy balancing, patients who no longer met PTSD diagnostic criteria had similar incidence rates for starting insulin (22.4 vs 24.4 per 1000 person-years), poor glycemic control (137.1 vs 133.7 per 1000 person-years), any microvascular complication (108.4 vs 104.8 per 1000 person-years), and all-cause mortality (11.2 vs 11.0 per 1000 person-years) compared with patients with persistent PTSD. After controlling for confounding, no longer meeting PTSD criteria was associated with a lower risk of microvascular complications (hazard ratio [HR], 0.92 [95% CI, 0.85-0.99]). Among veterans aged 18 to 49 years, no longer meeting PTSD criteria was associated with a lower risk of insulin initiation (HR, 0.69 [95% CI, 0.53-0.88]) and all-cause mortality (HR, 0.39 [95% CI, 0.19-0.83]). Among patients without depression, no longer meeting PTSD criteria was associated with a lower risk of insulin initiation (HR, 0.73 [95% CI, 0.55-0.97]).

Conclusions and Relevance

The findings of this cohort study of patients with comorbid PTSD and T2D suggest that PTSD is a modifiable risk factor associated with a modest reduction in microvascular complications. Further research is needed to determine whether findings are similar in non-VHA health care settings.

Associations between Posttraumatic Stress Disorder and Diabetes in Vietnam-Era Women Veterans in the HealthViEWS Study

Background: Posttraumatic stress disorder (PTSD) is associated with incident diabetes. However, past studies have often included predominantly male samples, despite important sex and gender differences in diabetes. To address this limitation, this study examined the association between PTSD and diabetes in older Veteran women, a population with a high burden of PTSD. Materials and Methods: Data were collected from 4,105 women (Mage = 67.4 years), participating in the Health of Vietnam-Era Veteran Women's Study (HealthViEWS; Department of Veterans Affairs Cooperative Studies Program #579). Participants completed self-report measures of demographics, health conditions, and health behaviors. Information on military service was obtained through service records. A structured clinical interview was conducted by telephone to assess current and lifetime PTSD and other mental health disorders. Weighted descriptive and logistic regression analyses were used to examine associations between PTSD and diabetes. Results: The prevalence of diabetes was 28.4% among women with current full PTSD compared to 23.4%, 17.6%, and 17.5% for current subthreshold, remitted, and no PTSD. In unadjusted analyses, women with current full and subthreshold PTSD were 1.87 [1.49; 2.33] and 1.44 [1.11; 1.85] times more likely to have diabetes compared to women with no PTSD. Remitted PTSD was not associated with increased odds of diabetes. Effects were attenuated but remained significant after adjustment for relevant covariates. Conclusions: Vietnam-era women with current PTSD, including subthreshold symptoms, had a greater likelihood of diabetes compared to women without PTSD. These findings suggest that women with PTSD may benefit from increased diabetes prevention efforts.

Distinguishing vulnerability and resilience to posttraumatic stress disorder evaluating traumatic experiences, genetic risk and electronic health records

What distinguishes vulnerability and resilience to posttraumatic stress disorder (PTSD) remains unclear. Levering traumatic experiences reporting, genetic data, and electronic health records (EHR), we investigated and predicted the clinical comorbidities (co-phenome) of PTSD vulnerability and resilience in the UK Biobank (UKB) and All of Us Research Program (AoU), respectively. In 60,354 trauma-exposed UKB participants, we defined PTSD vulnerability and resilience considering PTSD symptoms, trauma burden, and polygenic risk scores. EHR-based phenome-wide association studies (PheWAS) were conducted to dissect the co-phenomes of PTSD vulnerability and resilience. Significant diagnostic endpoints were applied as weights, yielding a phenotypic risk score (PheRS) to conduct PheWAS of PTSD vulnerability and resilience PheRS in up to 95,761 AoU participants. EHR-based PheWAS revealed three significant phenotypes positively associated with PTSD vulnerability (top association "Sleep disorders") and five outcomes inversely associated with PTSD resilience (top association "Irritable Bowel Syndrome"). In the AoU cohort, PheRS analysis showed a partial inverse relationship between vulnerability and resilience with distinct comorbid associations. While PheRSvulnerability associations were linked to multiple phenotypes, PheRSresilience showed inverse relationships with eye conditions. Our study unveils phenotypic differences in PTSD vulnerability and resilience, highlighting that these concepts are not simply the absence and presence of PTSD.

Symptoms of Posttraumatic Stress Disorder are Associated with Altered Glucose Parameters in Early and Late Gestation

OBJECTIVE

Posttraumatic stress disorder (PTSD) is associated with increased risk for insulin resistance and the development of diabetes outside of pregnancy. In pregnancy, emerging evidence suggests that PTSD is associated with increased risk for gestational diabetes; however, it is not yet known how PTSD is associated with disruptions in glucose processing across gestation. Therefore, the aim of the current study was to test associations between PTSD symptoms and glucose parameters in early and late gestation among pregnant people without a history of pregestational diabetes.

STUDY DESIGN

Two 34 participants were included in these analyses. PTSD symptoms were measured using the PTSD Checklist for DSM-5 (PCL-5) in early gestation. Fasting blood samples were collected at approximately 12 and 32 gestational weeks and were used to calculate β-cell function and insulin sensitivity.

RESULTS

Participants were 31 years old (standard deviation [SD] = 6) with body mass index (BMI) of 36 kg/m2 (SD = 7) at enrollment, 26% reported their ethnicity as Hispanic, 62% reported their race as White, 17% Black, 2% Asian, 3% Native American, 9% more than one race, and 11% unknown/not reported. Hierarchical linear regression analyses revealed that, after adjusting for several covariates including maternal age, race, ethnicity, BMI, apnea hypopnea index, and depressive symptoms, PTSD symptoms were positively associated with β-cell function in early (β = 0.230, p = 0.016) and late gestation (β = 0.238, p = 0.037).

CONCLUSION

Higher PTSD symptoms were associated with greater insulin secretion over pregnancy in this sample. More research is needed to replicate these findings and evaluate the effects of treatment of PTSD on mitigating the risk for gestational diabetes.

KEY POINTS

· We examined associations among symptoms of PTSD and glucose parameters over pregnancy.. · Symptoms of PTSD were positively associated with β-cell function over pregnancy.. · Symptoms of PTSD were not associated with insulin resistance over pregnancy..

Circulating cell-free mitochondrial DNA levels and glucocorticoid sensitivity in a cohort of male veterans with and without combat-related PTSD

Circulating cell-free mitochondrial DNA (ccf-mtDNA) is a biomarker of cellular injury or cellular stress and is a potential novel biomarker of psychological stress and of various brain, somatic, and psychiatric disorders. No studies have yet analyzed ccf-mtDNA levels in post-traumatic stress disorder (PTSD), despite evidence of mitochondrial dysfunction in this condition. In the current study, we compared plasma ccf-mtDNA levels in combat trauma-exposed male veterans with PTSD (n = 111) with those who did not develop PTSD (n = 121) and also investigated the relationship between ccf mt-DNA levels and glucocorticoid sensitivity. In unadjusted analyses, ccf-mtDNA levels did not differ significantly between the PTSD and non-PTSD groups (t = 1.312, p = 0.191, Cohen's d = 0.172). In a sensitivity analysis excluding participants with diabetes and those using antidepressant medication and controlling for age, the PTSD group had lower ccf-mtDNA levels than did the non-PTSD group (F(1, 179) = 5.971, p = 0.016, partial η2 = 0.033). Across the entire sample, ccf-mtDNA levels were negatively correlated with post-dexamethasone adrenocorticotropic hormone (ACTH) decline (r = -0.171, p = 0.020) and cortisol decline (r = -0.149, p = 0.034) (viz., greater ACTH and cortisol suppression was associated with lower ccf-mtDNA levels) both with and without controlling for age, antidepressant status and diabetes status. Ccf-mtDNA levels were also significantly positively associated with IC50-DEX (the concentration of dexamethasone at which 50% of lysozyme activity is inhibited), a measure of lymphocyte glucocorticoid sensitivity, after controlling for age, antidepressant status, and diabetes status (β = 0.142, p = 0.038), suggesting that increased lymphocyte glucocorticoid sensitivity is associated with lower ccf-mtDNA levels. Although no overall group differences were found in unadjusted analyses, excluding subjects with diabetes and those taking antidepressants, which may affect ccf-mtDNA levels, as well as controlling for age, revealed decreased ccf-mtDNA levels in PTSD. In both adjusted and unadjusted analyses, low ccf-mtDNA levels were associated with relatively increased glucocorticoid sensitivity, often reported in PTSD, suggesting a link between mitochondrial and glucocorticoid-related abnormalities in PTSD.

Post-traumatic stress disorder symptom remission and cognition in a large cohort of civilian women

BACKGROUND

Post-traumatic stress disorder (PTSD) is associated with cognitive impairments. It is unclear whether problems persist after PTSD symptoms remit.

METHODS

Data came from 12 270 trauma-exposed women in the Nurses' Health Study II. Trauma and PTSD symptoms were assessed using validated scales to determine PTSD status as of 2008 (trauma/no PTSD, remitted PTSD, unresolved PTSD) and symptom severity (lifetime and past-month). Starting in 2014, cognitive function was assessed using the Cogstate Brief Battery every 6 or 12 months for up to 24 months. PTSD associations with baseline cognition and longitudinal cognitive changes were estimated by covariate-adjusted linear regression and linear mixed-effects models, respectively.

RESULTS

Compared to women with trauma/no PTSD, women with remitted PTSD symptoms had a similar cognitive function at baseline, while women with unresolved PTSD symptoms had worse psychomotor speed/attention and learning/working memory. In women with unresolved PTSD symptoms, past-month PTSD symptom severity was inversely associated with baseline cognition. Over follow-up, both women with remitted and unresolved PTSD symptoms in 2008, especially those with high levels of symptoms, had a faster decline in learning/working memory than women with trauma/no PTSD. In women with remitted PTSD symptoms, higher lifetime PTSD symptom severity was associated with a faster decline in learning/working memory. Results were robust to the adjustment for sociodemographic, biobehavioral, and health factors and were partially attenuated when adjusted for depression.

CONCLUSION

Unresolved but not remitted PTSD was associated with worse cognitive function assessed six years later. Accelerated cognitive decline was observed among women with either unresolved or remitted PTSD symptoms.

Severity of posttraumatic stress disorder, type 2 diabetes outcomes and all-cause mortality: A retrospective cohort study

BACKGROUND

Some evidence suggests patients with comorbid PTSD and type 2 diabetes (T2D) have worse T2D outcomes than those with T2D alone. However, there is no evidence regarding PTSD severity and risk for starting insulin, hyperglycemia, microvascular complications, and all-cause mortality.

METHODS

In this retrospective cohort study, Veterans Health Affairs (VHA) medical record data from fiscal year (FY) 2012 to FY2022 were used to identify eligible patients (n = 23,161) who had a PTSD diagnosis, ≥1 PTSD Checklist score, controlled T2D (HbA1c ≤ 7.5) without microvascular complications at baseline. PTSD Checklist for DSM-5 (PCL-5) scores defined mild, moderate, and severe PTSD. Competing risk and survival models estimated the association between PTSD severity and T2D outcomes before and after controlling for confounding.

RESULTS

Most (70%) patients were ≥ 50 years of age, 88% were male, 64.2% were of white race and 17.1% had mild, 67.4% moderate and 15.5% severe PTSD. After control for confounding, as compared to mild PTSD, moderate (HR = 1.05; 95% CI:1.01-1.11) and severe PTSD (HR = 1.15; 95%CI:1.07-1.23) were significantly associated with increased risk for microvascular complication. Hyperarousal was associated with a 42% lower risk of starting insulin. Negative mood was associated with a 16% increased risk for any microvascular complication. Severe PTSD was associated with a lower risk for all-cause mortality (HR = 0.76; 95%CI:0.63-0.91).

CONCLUSIONS

Patients with comorbid PTSD and T2D have an increased risk for microvascular complications. However, they have lower mortality risk perhaps due to more health care use and earlier chronic disease detection. PTSD screening among patients with T2D may be warranted.

Efficacy of Repetitive Transcranial Magnetic Stimulation (rTMS) Combined with Psychological Interventions: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

(1) Background: Psychological interventions are effective in alleviating neuropsychiatric symptoms, though results can vary between patients. Repetitive transcranial magnetic stimulation (rTMS) has been proven to improve clinical symptoms and cognition. It remains unclear whether rTMS can augment the efficacy of psychological interventions. (2) Methods: We examined the effects of rTMS combined with psychological interventions on clinical, functional, and cognitive outcomes from randomized controlled trials conducted in healthy and clinical populations. We searched PubMed, EMBASE, Cochrane Library, and PsycINFO databases up to April 2023. (3) Results: Twenty-seven studies were ultimately included. Compared to sham rTMS combined with psychological interventions, active rTMS combined with psychological interventions significantly improved overall clinical symptoms (k = 16, SMD  =  0.31, CIs 0.08 to 0.54, p  <  0.01). We found that 10 or more sessions of rTMS combined with cognitive behavioural therapy significantly improved clinical outcomes overall (k = 3, SMD  =  0.21, CIs  0.05 to 0.36, Z = 2.49, p  <  0.01). RTMS combined with cognitive training (CT) significantly improved cognition overall compared to sham rTMS combined with CT (k = 13, SMD  =  0.28, CIs 0.15 to 0.42, p  <  0.01), with a significant effect on global cognition (k = 11, SMD  =  0.45, CIs 0.21 to 0.68, p  < 0.01), but not on the other cognitive domains. (4) Conclusion: The current results provide preliminary support for the augmentation effects of active rTMS on clinical and cognitive outcomes across diverse populations. Future clinical trials are required to confirm these augmentation effects for specific psychological interventions in specific clinical populations.

Metabolic and immune dysfunctions in post-traumatic stress disorder: what can we learn from animal models?

Highly stressful experiences such as terrorist attacks, domestic and sexual violence may lead to persistent pathological symptoms such as those seen in posttraumatic stress disorder (PTSD). There is growing evidence of multiple metabolic and immune disorders underlying the etiology and maintenance of PTSD. However, changes in the functioning of various systems and organs associated with PTSD are not well understood. Studies of reliable animal models is one of the effective scientific tools that can be used to gain insight into the role of metabolism and immunity in the comorbidity associated with PTSD. Since much progress has been made using animal models to understand mechanisms of PTSD, we summarized metabolic and immune dysfunction in mice and humans to compare certain outcomes associated with PTSD. The systemic effects of PTSD include chronic activation of the sympathetic nervous system (psycho-emotional stress), that leads to impairment of the function of the immune system, increased release of stress hormones, and metabolic changes. We discuss PTSD as a multisystem disease with its neurological, immunological, and metabolic components.

The impact of forced displacement: trauma, increased levels of inflammation and early presentation of diabetes in women Syrian refugees

BACKGROUND

Forced displacement and war trauma cause high rates of post-traumatic stress, anxiety disorders and depression in refugee populations. We investigated the impact of forced displacement on mental health status, gender, presentation of type 2 diabetes (T2D) and associated inflammatory markers among Syrian refugees in Lebanon.

METHODS

Mental health status was assessed using the Harvard Trauma Questionnaire (HTQ) and the Hopkins Symptom Checklist-25 (HSCL-25). Additional metabolic and inflammatory markers were analyzed.

RESULTS

Although symptomatic stress scores were observed in both men and women, women consistently displayed higher symptomatic anxiety/depression scores with the HSCL-25 (2.13 ± 0.58 versus 1.95 ± 0.63). With the HTQ, however, only women aged 35-55 years displayed symptomatic post-traumatic stress disorder (PTSD) scores (2.18 ± 0.43). Furthermore, a significantly higher prevalence of obesity, prediabetes and undiagnosed T2D were observed in women participants (23.43, 14.91 and 15.18%, respectively). Significantly high levels of the inflammatory marker serum amyloid A were observed in women (11.90 ± 11.27 versus 9.28 ± 6.93, P = 0.036).

CONCLUSIONS

Symptomatic PTSD, anxiety/depression coupled with higher levels of inflammatory marker and T2D were found in refugee women aged between 35 and 55 years favoring the strong need for psychosocial therapeutic interventions in moderating stress-related immune dysfunction and development of diabetes in this subset of female Syrian refugees.

360-Degree Perspectives on Obesity

Alarming statistics show that the number of people affected by excessive weight has surpassed 2 billion, representing approximately 30% of the world's population. The aim of this review is to provide a comprehensive overview of one of the most serious public health problems, considering that obesity requires an integrative approach that takes into account its complex etiology, including genetic, environmental, and lifestyle factors. Only an understanding of the connections between the many contributors to obesity and the synergy between treatment interventions can ensure satisfactory outcomes in reducing obesity. Mechanisms such as oxidative stress, chronic inflammation, and dysbiosis play a crucial role in the pathogenesis of obesity and its associated complications. Compounding factors such as the deleterious effects of stress, the novel challenge posed by the obesogenic digital (food) environment, and the stigma associated with obesity should not be overlooked. Preclinical research in animal models has been instrumental in elucidating these mechanisms, and translation into clinical practice has provided promising therapeutic options, including epigenetic approaches, pharmacotherapy, and bariatric surgery. However, more studies are necessary to discover new compounds that target key metabolic pathways, innovative ways to deliver the drugs, the optimal combinations of lifestyle interventions with allopathic treatments, and, last but not least, emerging biological markers for effective monitoring. With each passing day, the obesity crisis tightens its grip, threatening not only individual lives but also burdening healthcare systems and societies at large. It is high time we took action as we confront the urgent imperative to address this escalating global health challenge head-on.

Posttraumatic Stress Disorder (PTSD) as a Risk Factor for Cardiovascular Disease: Implications for Future Research and Clinical Care

PURPOSE OF REVIEW

Posttraumatic stress disorder (PTSD) may be an important risk factor for cardiovascular disease (CVD). We explore the literature linking PTSD to CVD, potential mechanisms, interventions, and clinical implications. We outline gaps in current literature and highlight necessary future research.

RECENT FINDINGS

PTSD has been independently associated with deleterious effects on cardiovascular health through biological, behavioral, and societal pathways. There are evidence-based psychotherapeutic interventions and pharmacotherapies for PTSD that may mitigate its impact on CVD. However, there are limited studies that rigorously analyze the impact of treating PTSD on cardiovascular outcomes. Trauma-informed CVD risk stratification, education, and treatment offer opportunities to improve patient care. These approaches can include a brief validated screening tool for PTSD identification and treatment. Pragmatic trials are needed to test PTSD interventions among people with CVD and evaluate for improved outcomes.

The role of mental disorders in precision medicine for diabetes: a narrative review

This narrative review aims to examine the value of addressing mental disorders as part of the care of people with type 1 and type 2 diabetes in terms of four components of precision medicine. First, we review the empirical literature on the role of common mental disorders in the development and outcomes of diabetes (precision prevention and prognostics). We then review interventions that can address mental disorders in individuals with diabetes or at risk of diabetes (precision treatment) and highlight recent studies that have used novel methods to individualise interventions, in person and through applications, based on mental disorders. Additionally, we discuss the use of detailed assessment of mental disorders using, for example, mobile health technologies (precision monitoring). Finally, we discuss future directions in research and practice and challenges to addressing mental disorders as a factor in precision medicine for diabetes. This review shows that several mental disorders are associated with a higher risk of type 2 diabetes and its complications, while there is suggestive evidence indicating that treating some mental disorders could contribute to the prevention of diabetes and improve diabetes outcomes. Using technologically enabled solutions to identify mental disorders could help individuals who stand to benefit from particular treatments. However, there are considerable gaps in knowledge and several challenges to be met before we can stratify treatment recommendations based on mental disorders. Overall, this review demonstrates that addressing mental disorders as a facet of precision medicine could have considerable value for routine diabetes care and has the potential to improve diabetes outcomes.

Adiponectin gene polymorphisms and posttraumatic stress disorder symptoms among female rape survivors: an exploratory study

Background: Rape is a common traumatic event which may result in the development of posttraumatic stress disorder (PTSD), yet few studies have investigated risk biomarkers in sexually traumatised individuals. Adiponectin is a novel cytokine within inflammatory and cardiometabolic pathways with evidence of involvement in PTSD. Objective: This prospective exploratory study in a sample of female rape survivors investigated the association of single nucleotide polymorphisms (SNPs) in the adiponectin gene (ADIPOQ) and posttraumatic stress symptom (PTSS) severity, and the interaction of these SNPs of interest with childhood trauma in modifying the association with PTSS severity. Method: The study involved 455 rape-exposed black South African women (mean age (SD), 25.3 years (±5.5)) recruited within 20 days of being raped. PTSS was assessed using the Davidson Trauma Scale (DTS) and childhood trauma was assessed using a modified version of the Childhood Trauma Scale-Short Form Questionnaire. Eight ADIPOQ SNPs (rs17300539, rs16861194, rs16861205, rs2241766, rs6444174, rs822395, rs1501299, rs1403697) were genotyped using KASP. Mixed linear regression models were used to test additive associations of ADIPOQ SNPs and PTSS severity at baseline, 3 and 6 months following rape. Results: The mean DTS score post-sexual assault was high (71.3 ± 31.5), with a decrease in PTSS severity shown over time for all genotypes. rs6444174TT genotype was inversely associated with baseline PTSS in the unadjusted model (β = -13.6, 95% CI [-25.1; -2.1], p = .021). However, no genotype was shown to be significantly associated with change in PTSS severity over time and therefore ADIPOQ SNP x childhood trauma interaction was not further investigated. Conclusion: None of the ADIPOQ SNPs selected for investigation in this population were shown to be associated with change in PTSS severity over a 6-month period and therefore their clinical utility as risk biomarkers for rape-related PTSD appears limited. These SNPs should be further investigated in possible gene-gene and gene-environment interactions.

Safety of psychological interventions for adult post-traumatic stress disorder: meta-analysis on the incidence and relative risk of deterioration, adverse events and serious adverse events

BACKGROUND

Attention on harmful effects of psychological interventions for adult post-traumatic stress disorder (PTSD) has increased, yet a comprehensive meta-analysis is lacking.

AIMS

To summarise incidences and relative risks of deterioration, adverse events (AEs) and serious adverse events (SAEs) in trials of psychological interventions for adult PTSD.

METHOD

We searched MEDLINE, PsycInfo, Web of Science and PTSDpubs from inception to 21 April 2022 for sufficiently large (n ≥ 20) randomised controlled trials (RCTs) reporting on the incidence of harms.

RESULTS

We included 56 RCTs (4230 patients). Incidences of harms were generally low (0-5%). Psychological interventions were associated with decreased risk of deterioration relative to passive (RR = 0.21, 95% CI 0.15-0.28) and active control conditions (RR = 0.36, 95% CI 0.14-0.92). Decreased risk was even more pronounced in sensitivity analyses on trials exclusively delivering treatments face to face. When compared with other psychological interventions, trauma-focused cognitive-behavioural therapy (TF-CBT) was associated with decreased risk of SAEs (RR = 0.54, 95% CI 0.31-0.95) and with no differential risk of deterioration and AEs.

CONCLUSIONS

The current evidence base suggests that psychological interventions are safe for most adults with PTSD. In none of the analyses were psychological interventions associated with an increased risk of harm compared with control conditions. TF-CBT was found at least as safe as other psychological interventions. Individual face-to-face delivery might be the safest delivery format. However, more data are needed to draw firmer conclusions. We encourage research teams to routinely and thoroughly assess and report the incidence of harms and their causes.

How does PTSD treatment affect cardiovascular, diabetes and metabolic disease risk factors and outcomes? A systematic review

OBJECTIVE

Prior research indicates PTSD is associated with cardiovascular and metabolic disease. A number of different treatments for PTSD can be effective in reducing PTSD symptoms. The aim of this study is to systematically review studies which determine whether treatment for PTSD is associated with better cardiovascular and metabolic outcomes.

METHOD

Five different databases were searched in a systematic manner, and 11 relevant studies were recovered and analyzed.

FINDINGS

Treatments associated with PTSD improvement and found to be effective in improving cardiovascular or metabolic outcomes among individuals with PTSD include cognitive behavioral therapy (heart rate variability and blood pressure), prolonged exposure (heart rate and heart rate variability) and SSRIs (blood pressure).

CONCLUSIONS

Multiple PTSD treatment modalities were associated with improved cardiovascular health and reduced risk of cardiovascular-related mortality. Given the small sample sizes, lack of follow-up studies and the extensive use of military populations in studies on PTSD and chronic diseases, these results should be interpreted with caution. More studies are needed that assess and verify whether PTSD treatments mitigate the risk for metabolic, diabetic and cardiovascular disease.

THE FEATURES OF POSTTRAUMATIC STRESS DISORDER DEVELOPMENT IN PATIENTS WITH DIABETES MELLITUS 2 TYPE

OBJECTIVE

The aim: The revealing of the development of stress-related disorders in patients with type 2 diabetes mellitus (DM 2) to: identify the prevalence of stress-related disorders, particularly, posttraumatic stress disorder (PTSD); study the influence of psychosocial factors on the occurrence and course of stress-related disorders and increase the effectiveness of treatment in DM 2.

PATIENTS AND METHODS

Materials and methods: Research papers have been found by searching the PubMed database using the keywords ``ptsd and diabetes 2 type" with the result of 74 studies. Totally 25 of selected publications were analysed based on our criteria about the mechanisms through which the influence of psychosocial factors, permanent stressful or traumatic events on the probable risk of PTSD development and their analysis and relationships for the improvement of treatment effectiveness in DM 2 patients who have not been the veterans.

CONCLUSION

Conclusions: Given the complex neurophysiological relationships between the long-term stress and pathophysiological mechanisms of DM 2 - this group of patients has the higher risk of developing stress-related disorders, including PTSD.

Knowledge, Attitudes, and Screening for Obstructive Sleep Apnea and Diabetes Mellitus among War Veterans Seeking Treatment of Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is one of the most common psychiatric disorders. However, we should not neglect the somatic aspects of PTSD. Associations with cardiovascular diseases (CVD) are particularly concerning because PTSD was associated with an even 53% higher risk for CVD. This study aimed to analyze the prevalence of several CVD risk factors, especially diabetes mellitus among PTSD patients divided into three groups according to obstructive sleep apnea (OSA) risk stratification (low, intermediate, and high). This cross-sectional study included one hundred male PTSD veterans. The mean age was 53 (40-67) years. The estimated OSA risk was 95% for the whole cohort, and 53% were in the high-risk group. Median HbA1c was 5.6 (4.6-10)%. The hemoglobin A1c (HbA1c) levels showed that 34 patients were in the prediabetes group, and 20 of them fulfilled the criteria for diabetes. However, only 13 of them were aware of their previous diagnosis of diabetes mellitus. In testing knowledge about diabetes, 62% and only 23% of patients knew the correct definition of HbA1c and level of fasting plasma glucose, respectively. Diabetic patients had insufficient knowledge about diabetic complications and treatment. A higher level of PTSD symptoms in veterans was associated with a higher prevalence of OSA. The results strongly support further research and education into early detection of CVD risk factors associated with PTSD.

Chronic Medical Conditions as Predictors of the Likelihood of PTSD among Black Adults: Preparing for the Aftermath of COVID-19

The relationship between chronic medical conditions and PTSD within-race in Black adults is not well understood and there exists a dearth of empirical research investigating the gender differences. Cross-sectional data from the National Survey of American Life were used to examine the relationship between PTSD and obesity, hypertension, diabetes, heart disease, and asthma (five of the most commonly identified COVID-19 underlying medical conditions) among Black adults in the United States. Results from modified Poisson regression analyses revealed that Black adults across all three groups (overall, male, and female samples) who reported two or more chronic medical conditions had a higher prevalence of PTSD than those who reported zero or one. Black men with obesity, diabetes, or heart disease and Black women with asthma had a higher prevalence of PTSD than those who did not report obesity, diabetes, heart disease, or asthma. Findings from this study underscore the need to alert social workers to the potential relationship between obesity, diabetes, or heart disease and PTSD for Black men and asthma and PTSD for Black women to help develop culturally appropriate biopsychosocial-spiritual assessments, with a measured focus on Black men based on their comparatively worse health status.

Increased Smoking Cessation among Veterans with Large Decreases in Posttraumatic Stress Disorder Severity

BACKGROUND

Improvement in posttraumatic stress disorder (PTSD) is associated with better health behavior such as better medication adherence and greater use of nutrition and weight loss programs. However, it is not known if reducing PTSD severity is associated with smoking cessation, a poor health behavior common in patients with PTSD.

METHODS

Veterans Health Affairs (VHA) medical record data (2008 to 2015) were used to identify patients with PTSD diagnosed in specialty care. Clinically meaningful PTSD improvement, was defined as ≥20 point PTSD Checklist (PCL) decrease from the first PCL ≥ 50 and the last available PCL within 12 months and at least 8 weeks later. The association between clinically meaningful PTSD improvement and smoking cessation within 2-years after baseline among 449 smokers was estimated in Cox proportional hazard models. Entropy balancing controlled for confounding.

RESULTS

On average, patients were 39.4 (SD=12.9) years of age, 86.6% were male and 71.5% were white. We observed clinically meaningful PTSD improvement in 19.8% of participants. Overall, 19.4% quit smoking in year 1 and 16.6% in year 2. More patients with vs. without clinically meaningful PTSD improvement stopped smoking (n=36, cumulative incidence=40.5% vs. 111, cumulative incidence=30.8%; respectively). After controlling for confounding, patients with vs. without clinically meaningful PTSD improvement were more likely to stop smoking within 2-years (HR=1.57; 95%CI:1.04-2.36).

CONCLUSIONS

Patients with clinically meaningful PTSD improvement were significantly more likely to stop smoking. Further research should determine if targeted interventions are needed or whether improvement in PTSD symptoms is sufficient to enable smoking cessation.

IMPLICATIONS

Patients with PTSD are more likely to develop chronic health conditions such as heart disease and diabetes. Poor health behaviors, including smoking, partly explain the risk for chronic disease in this patient population. Our results demonstrate that clinically meaningful PTSD improvement is followed by greater likelihood of smoking cessation. Thus, PTSD treatment may enable healthier behaviors and reduce risk for smoking related disease.

High prevalence of somatisation in ICD-11 complex PTSD: A cross sectional cohort study

BACKGROUND

While research demonstrates that somatisation is highly correlated with post-traumatic stress disorder (PTSD), the relationship between International Classification of Diseases 11th edition (ICD-11) PTSD, complex PTSD (CPTSD) and somatisation has not previously been determined.

OBJECTIVE

To determine the relationship between frequency and severity of somatisation and ICD-11 PTSD/CPTSD.

METHOD

This cross-sectional study included 222 individuals recruited to the National Centre for Mental Health (NCMH) PTSD cohort. We assessed rates of Patient Health Questionnaire 15 (PHQ-15) somatisation stratified by ICD-11 PTSD/CPTSD status. Path analysis was used to explore the relationship between PTSD/CPTSD and somatisation, including number of traumatic events, age, and gender as controls.

RESULTS

70% (58/83) of individuals with CPTSD had high PHQ-15 somatisation symptom severity compared with 48% (12/25) of those with PTSD (chi-square: 95.1, p value <0.001). Path analysis demonstrated that core PTSD symptoms and not disturbances in self organisation (DSO) symptoms were associated with somatisation (unstandardised coefficients: 0.616 (p-value 0.017) and - 0.012 (p-value 0.962) respectively.

CONCLUSIONS

Individuals with CPTSD have higher somatisation than those with PTSD. The core features of PTSD, not the DSO, characteristic of CPTSD, were associated with somatisation.

Novel, Neuroscience-Informed Approaches to Trauma Care in Community Clinical Settings

Trauma exposure, a highly prevalent condition in the United States, results in the development of chronic physical and mental health disabilities, such as diabetes, cardiovascular disease and posttraumatic stress disorder. Bench science advances in neurobiology and neuroscience have been translated into exciting clinical interventions, which have been shown to improve mental functioning and stress response. This article highlights three such interventions in hospital, primary care and community settings.

Disturbed Sleep Connects Symptoms of Posttraumatic Stress Disorder and Somatization: A Network Analysis Approach

Posttraumatic stress disorder (PTSD) and physical health problems, particularly somatic symptom disorder, are highly comorbid. Studies have only examined this co-occurrence at the disorder level rather than assessing the associations between specific symptoms. Using network analysis to identify symptoms that act as bridges between these disorders may allow for the development of interventions to specifically target this comorbidity. We examined the association between somatization and PTSD symptoms via network analysis. This included 349 trauma-exposed individuals recruited through the National Centre for Mental Health PTSD cohort who completed the Clinician-Administered PTSD Scale for DSM-5 and the Patient Health Questionnaire-15. A total of 215 (61.6%) individuals met the DSM-5 diagnostic criteria for PTSD. An exploratory graph analysis identified four clusters of densely connected symptoms within the overall network: PTSD, chronic pain, gastrointestinal issues, and more general somatic complaints. Sleep difficulties played a key role in bridging PTSD and somatic symptoms. Our network analysis demonstrates the distinct nature of PTSD and somatization symptoms, with this association connected by disturbed sleep.

PTSD improvement and substance use disorder treatment utilization in veterans: Evidence from medical record data

BACKGROUND

Clinical trials reveal posttraumatic stress disorder (PTSD) improvement leads to decreased substance use among patients with comorbid substance use disorder (SUD). Using administrative medical record data, we determined whether clinically meaningful PTSD Checklist (PCL) (≥20 points) score decreases were positively associated with SUD treatment utilization.

METHODS

We used a retrospective cohort of Veterans Health Affairs (VHA) medical record data (2008-2015). PTSD Checklist (PCL) scores were used to categorize patients into those with a clinically meaningful PTSD improvement (≥20 point decrease) or not (<20 point decrease or increase). PTSD and SUD were measured by ICD-9 codes. Propensity score weighting controlled for confounding in logistic and negative binomial models that estimated the association between clinically meaningful PTSD improvement and use of SUD treatment and number of SUD clinic visits.

RESULTS

The 699 eligible patients were, on average, 40.4 (±13.2) years old, 66.2% white and 33.1% were married. After controlling for confounding, there was a 56% increased odds of any SUD treatment utilization among those with a PCL decrease ≥20 vs < 20 (OR = 1.56; 95%CI = 1.04-2.33) but there was no association with number of SUD treatment visits.

CONCLUSIONS

Clinically meaningful reductions in PTSD symptoms were associated with any SUD treatment utilization but not amount of utilization. Improvement in PTSD symptoms, independent of the treatment modality, may enable SUD treatment seeking.

Resting high frequency heart rate variability and PTSD symptomatology in Veterans: Effects of respiration, role in elevated heart rate, and extension to spouses

Heart rate variability (HRV) associated with parasympathetic activity (i.e., cardiac vagal tone) is reduced in posttraumatic stress disorder (PTSD), but possible confounding effects of respiration have not been studied sufficiently. Further, reduced parasympathetic inhibition might contribute to elevated heart rate (HR) in PTSD. Finally, reduced HRV in PTSD might extend to intimate partners, given their chronic stress exposure. In 65 couples (male Veterans, female partners), elevated PTSD symptomatology (n = 32; 28 met full DSM IV criteria, 4 fell slightly short) was documented by structured interview and self-reports. Baseline HR, high-frequency HRV (HF-HRV), cardiac pre-ejection period (PEP), and respiration rate and depth were measured via impedance cardiography. Veterans with PTSD symptoms displayed reduced lnHF-HRV, even when adjusting for respiration, but their partners did not. In mediational analyses, elevated resting HR in PTSD was accounted for by lnHF-HRV but not PEP. Results strengthen evidence regarding HF-HRV and elevated HR in PTSD.

PTSD improvement and incident cardiovascular disease in more than 1000 veterans

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiovascular disease (CVD). Whether clinically meaningful PTSD improvement is associated with lowering CVD risk is unknown.

METHODS

Eligible patients (n = 1079), were 30-70 years old, diagnosed with PTSD and used Veterans Health Affairs PTSD specialty clinics. Patients had a PTSD Checklist score (PCL) ≥ 50 between Fiscal Year (FY) 2008 and FY2012 and a second PCL score within 12 months and at least 8 weeks after the first PCL ≥ 50. Clinically meaningful PTSD improvement was defined by ≥20 point PCL decrease between the first and second PCL score. Patients were free of CVD diagnoses for 1 year prior to index. Index date was 12 months following the first PCL. Follow-up continued to FY2015. Cox proportional hazard models estimated the association between clinically meaningful PTSD improvement and incident CVD and incident ischemic heart disease (IHD). Sensitivity analysis stratified by age group (30-49 vs. 50-70 years) and depression. Confounding was controlled using propensity scores and inverse probability of exposure weighting.

RESULTS

Patients were 48.9 ± 10.9 years of age on average, 83.3% male, 60.1% white, and 29.5% black. After controlling for confounding, patients with vs. without PTSD improvement did not differ in CVD risk (HR = 1.08; 95%CI: 0.72-1.63). Results did not change after stratifying by age group or depression status. Results were similar for incident IHD.

CONCLUSIONS

Over a 2-7 year follow-up, we did not find an association between clinically meaningful PTSD improvement and incident CVD. Additional research is needed using longer follow-up.

Predicting and Managing Treatment Non-Response in Posttraumatic Stress Disorder

PURPOSE OF REVIEW

This review aims to synthesize existing research regarding the definition of treatment resistance in posttraumatic stress disorder (PTSD), predictors of treatment non-response to first-line interventions, and emerging second-line PTSD treatment options into an accessible resource for the practicing clinician.

RECENT FINDINGS

The concept of treatment resistance in PTSD is currently poorly defined and operationalized. There are no well-established predictors of treatment non-response utilized in routine clinical care, but existing research identifies several potential candidate markers, including male gender, low social support, chronic and early life trauma exposure, comorbid psychiatric disorders, severe PTSD symptoms, and poor physical health. The most promising available treatment options for PTSD patients non-responsive to first-line psychotherapies and antidepressants include transcranial magnetic stimulation and ketamine infusion. Methylenedioxymethamphetamine-assisted psychotherapy also appears promising but is only available in a research context. These options require careful consideration of risks and benefits for a particular patient.

SUMMARY

More research is required to develop a robust, clinically-useful definition of treatment resistance in PTSD; identify reliable, readily assessable, and generalizable predictors of PTSD treatment non-response; and implement measurement and prediction in clinical settings to identify individuals unlikely to respond to first-line treatments and direct them to appropriate second-line treatments.

Clinically meaningful posttraumatic stress disorder (PTSD) improvement and incident hypertension, hyperlipidemia, and weight loss

OBJECTIVE

Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiometabolic disease. Clinically meaningful PTSD improvement is associated with a lower risk for diabetes, but it is not known if similar associations exist for incident hypertension, hyperlipidemia, and clinically relevant weight loss (i.e., ≥5% loss).

METHOD

Medical record data from Veterans Health Affairs patients with clinic encounters between fiscal year (FY) 2008 to 2015 were used to identify patients with worsening or no PTSD improvement (i.e., PTSD checklist (PCL) score decrease <10), small (10-19 point PCL decrease), and large (≥20 point PCL decrease) PTSD improvement. To estimate the association between degree of PTSD improvement and incident hypertension (n = 979), incident hyperlipidemia (n = 1,139) and incident ≥5% weight loss (1,330), we computed Cox proportional hazard models, controlling for confounding using inverse probability of exposure weighting (IPEW).

RESULTS

Overall, patients were about 40 years of age, 80% male and 65% White. Worsening or no PCL change occurred in about 60%, small improvement in 20%, and large improvement in 20%. After weighting data, compared with worsening or no change, both small and large PTSD improvements were associated, albeit not significantly, with lower risks for hypertension (HR = 0.68; 95% confidence interval, CI [0.46, 1.01] and HR = 0.79; 95% CI [0.53, 1.18], respectively). In weighted data, PTSD improvement was not associated with incident hyperlipidemia or ≥5% weight loss.

CONCLUSIONS

We observed limited evidence for an association between PTSD improvement and decreased hypertension risk. PCL decreases were not associated with hyperlipidemia or ≥5% weight loss. Further studies that measure potential physical health benefits of change in specific PTSD symptoms are needed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Trauma exposure and stress-related disorders in African-American women with diabetes mellitus

OBJECTIVE

The purpose of the study was to assess demographic features, rates of trauma exposure, prevalence of post-traumatic stress and depressive symptoms in a group of urban, low-income, African-American women with type 1 or type 2 diabetes mellitus.

RESEARCH DESIGN AND METHODS

We conducted a survey of (n = 290) low-income, African-American women seeking care in the diabetes clinic of an urban hospital and collected data on the demographic characteristics, childhood and nonchildhood abuse trauma exposure, and the severity of post-traumatic stress and depressive symptoms using the Post-traumatic Stress Disorder (PTSD) Symptom Scale (PSS) and the Beck Depression Inventory (BDI). In a subset of women with type 2 diabetes (n = 96), we assessed haemoglobin A1c to examine the relationship between psychopathology and glycaemic control.

RESULTS

Of the overall sample, 61.7% reported exposure to trauma in their lifetime, and 30.4% and 29.3% had current PTSD and MDD, respectively. Exposure to both childhood and nonchildhood abuse trauma was associated with an increased PTSD and depressive symptom severity (P's < .05). PTSD diagnosis, but not depression, was associated with increased haemoglobin A1c (P = .002).

CONCLUSIONS

These data document high levels of trauma exposure, PTSD and depressive symptoms in diabetic African-American women treated in a specialty clinic of an urban hospital setting. Furthermore, these data indicate that the presence of PTSD is negatively associated with glycaemic control.

PTSD symptom decrease and use of weight loss programs

OBJECTIVE

Posttraumatic stress disorder (PTSD) is associated with poor health behaviors, including low utilization of Veteran Health Affairs (VHA) weight loss programs. It is not known if clinically meaningful PTSD improvement is associated with increased use of weight loss programs.

METHODS

Medical record data was obtained from VHA patients who received PTSD specialty care between Fiscal Year (FY) 2008 to FY2012. Clinically meaningful PTSD improvement was defined as ≥20 point PTSD Checklist (PCL) decrease between the first PCL ≥ 50 and a second PCL at least 8 weeks later and within 12 months of the first PCL. Eligible patients, n = 993, were followed through FY2015. Propensity scores and inverse probability of exposure weighting controlled confounding. Cox proportional hazard models estimated the association between clinically meaningful PCL decrease and weight loss clinic utilization. Supplemental analysis compared both PTSD groups vs. no PTSD.

RESULTS

Patients were 44.8 (SD ±14) years of age, 88.9% male and 66.8% white. Patients with vs. without a clinically meaningful PCL decrease were more likely to use a weight loss clinic (HR = 1.37; 95%CI:1.02-1.85). Among those with a weight loss encounter, PCL decrease was not associated with the number of encounters (RR = 1.13; 95%CI:0.70-1.81). Compared to no PTSD, patients with PTSD improvement had more weight loss encounters.

CONCLUSIONS

Large improvements in PTSD are associated with increased utilization of weight loss programs, and PTSD is not a barrier to seeking weight loss counseling. Research to understand why improvement in PTSD is not related to better weight loss outcomes is needed.