Similarities in specific physical health disorder prevalence among formerly deployed Canadian forces veterans with full and subsyndromal PTSD

Clinical relevance of subthreshold PTSD versus full criteria PTSD following traumatic brain injury in U.S. service members and veterans

BACKGROUND

The purpose of this cross-sectional study was to examine the influence of subthreshold posttraumatic stress disorder (PTSD) and full PTSD on quality of life following mild traumatic brain injury (mTBI).

METHODS

Participants were 734 service members and veterans (SMV) classified into two injury groups: uncomplicated mild TBI (MTBI; n = 596) and injured controls (IC, n = 139). Participants completed a battery of neurobehavioral measures, 12-or-more months post-injury, that included the PTSD Checklist Civilian version, Neurobehavioral Symptom Inventory, and select scales from the TBI-QOL and MPAI. The MTBI group was divided into three PTSD subgroups: No-PTSD (n = 266), Subthreshold PTSD (n = 139), and Full-PTSD (n = 190).

RESULTS

There was a linear relationship between PTSD severity and neurobehavioral functioning/quality of life in the MTBI sample. As PTSD severity increased, significantly worse scores were found on 11 of the 12 measures (i.e.

, MTBI

Full-PTSD > Sub-PTSD > No-PTSD). When considering the number of clinically elevated scores, a linear relationship between PTSD severity and neurobehavioral functioning/quality of life was again observed in the MTBI sample (e.g., 3-or-more elevated scores: Full-PTSD = 92.1 %, Sub-PTSD = 61.9 %, No-PTSD = 19.9 %).

LIMITATIONS

Limitations included the use of a self-report measure to determine diagnostic status that may under/overcount or mischaracterize individuals.

CONCLUSION

PTSD symptoms, whether at the level of diagnosable PTSD, or falling short of that because of the intensity or characterization of symptoms, have a significant negative impact on one's quality of life following MTBI. Clinicians' treatment targets should focus on the symptoms that are most troubling for an individual and the individual's perception of quality of life, regardless of the diagnosis itself.

Physical health of Post-9/11 U.S. Military veterans in the context of Healthy People 2020 targeted topic areas: Results from the Comparative Health Assessment Interview Research Study

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 by veteran status. Notably, few studies have explored veteran physical health in relation to national health guidelines. Self-reported, weighted data were analyzed on post-9/11 U.S. veterans and nonveterans (n = 19,693; 6,992 women, 12,701 men; 15,160 veterans, 4,533 nonveterans). Prevalence was estimated for 24 physical health conditions classified by Healthy People 2020 targeted topic areas. Associations between physical health outcomes and veteran status were evaluated using bivariable and multivariable analyses. Back/neck pain was most reported by veterans (49.3 %), twice that of nonveterans (22.8 %)(p < 0.001). Adjusted odds ratios (AORs) for musculoskeletal and hearing disorders, traumatic brain injury, and chronic fatigue syndrome (CFS) were 3-6 times higher in veterans versus nonveterans (p < 0.001). Women versus men had the greatest adjusted odds for bladder infections (males:females, AOR = 0.08, 95 % CI:0.04-0.18)(p < 0.001), and greater odds than men for multiple sclerosis, CFS, cancer, irritable bowel syndrome/colitis, respiratory disease, some musculoskeletal disorders, and vision loss (p < 0.05). Cardiovascular-related conditions were most prominent for men (p < 0.001). Veteran status by sex interactions were found for obesity (p < 0.03; greater for male veterans) and migraine (p < 0.01; greater for females). Healthy People 2020 targeted topic areas exclude some important physical health conditions that are associated with being a veteran. National health guidelines for Americans should provide greater consideration of veterans in their design.

Illness-induced post-traumatic stress disorder among Canadian Armed Forces Members and Veterans

OBJECTIVES

There is growing recognition of illness-induced post-traumatic stress disorder (PTSD), defined by illness being the index trauma that induces PTSD symptoms. This is the first study to examine 1) the lifetime prevalence of illness-induced PTSD among military personnel and veterans, and its 2) sociodemographic, military, trauma, and physical health condition correlates.

METHODS

Participants completed the 2002 Canadian Community Health Survey-Mental Health and Well-being - Canadian Forces (N = 5155) and the 2018 Canadian Armed Forces Members and Veterans Mental Health Survey follow-up (n = 2941). A semi-structured clinical interview assessed PTSD, which we categorized as "illness-induced" or "other trauma-induced" PTSD based on the index trauma in those participating in both timepoints. To ensure representativeness of our study sample, we used baseline weights created by Statistics Canada to report weighted prevalence estimates and inferential statistics.

RESULTS

The estimated lifetime prevalence of PTSD among the full sample was 22% and 1.5% had lifetime illness-induced PTSD. Among those with lifetime PTSD, the proportion of participants with illness-induced PTSD was 8.3% (91.7% met criteria for other trauma-induced PTSD). In an unadjusted model, the prevalence of illness-induced PTSD was greater for females (13.7%) than males (7.2%), and for those who were not deployed in both 2002 (5.7%) and 2018 (7.1%; unadjusted odds ratio (OR) range: 2.05-3.72). In a multinomial model adjusting for sociodemographic and military characteristics, compared to those with other trauma-induced PTSD, those with illness-induced PTSD had elevated rates of PTSD persistence (24.1% vs. 11.9%; RRR = 6.06, 95% CI [1.21-30.25]) and lower rates of remission (7.8% vs. 19.9%).

CONCLUSION

Results highlight differences between illness-induced PTSD and other trauma-induced PTSD, primarily the potential chronicity of this manifestation. This may have implications for assessment strategies and targeted interventions.

Prevalence and Impact of Post-traumatic Stress Disorder in Gastrointestinal Conditions: A Systematic Review

Psychological distress is often observed in patients with gastrointestinal illness. To date, there has been limited research conducted to assess the prevalence and impact of post-traumatic stress disorder (PTSD) in gastrointestinal cohorts. The aim of this systematic review is to review the evidence for the prevalence of PTSD in gastrointestinal cohorts versus comparator groups (healthy controls and chronic illness groups), predictive factors associated with the development and management of PTSD and the impact on patient outcomes. Adult studies were identified through systematic searches of eight databases (MEDLINE, Embase, Emcare, PsycINFO, Ovid Nursing, CINAHL, Informit Health Collection, and Cochrane Library) in February 2020. The overall pooled prevalence rate of PTSD in GI cohorts was 36%; however, the prevalence rate in non-veteran-specific gastrointestinal cohorts of 18% across all GI classification groups is likely to be the more representative rate. The non-gastrointestinal chronic illness cohort PTSD prevalence rate was 11%. Predictors identified in the development of post-traumatic stress in gastrointestinal cohorts include: female gender, poor social support, life adversity, subjective pain, and dietary choices. Post-traumatic stress was found to exacerbate gastrointestinal symptoms in a Crohn's Disease sample, whereby disease exacerbation was four times in those who met the criteria for probable PTSD. Post-traumatic stress symptoms affect around one in five individuals (non-veteran status) with a gastrointestinal condition. Further research is needed to understand the psychological and biological mechanisms by which PTSD increases the risk of developing and exacerbating gastrointestinal symptoms.

Hospital admissions for non-communicable disease in the UK military and associations with alcohol use and mental health: a data linkage study

BACKGROUND

Since the recent conflicts in Iraq and Afghanistan, the short-term focus of military healthcare research has been on the consequences of deployment for mental health and on those wounded or injured in combat. Now that these conflicts have ended for the UK Armed Forces, it is important to consider the longer term physical and mental health consequences, and just as importantly, the links between these. The aims of this study were to determine the most common physical conditions requiring a hospital admission in UK military personnel and whether they were more common in personnel with a mental health condition, smokers, and/or those misusing alcohol compared to those without.

METHODS

Data linkage of a prospective UK military cohort study to electronic admitted patient care records for England, Wales and Scotland. Nine thousand nine hundred ninety military personnel completed phase 2 of a military cohort study (56% response rate, data collected from 2007 to 2009), with analyses restricted to 86% of whom provided consent for linkage to healthcare records (n = 8602). Ninety percent were male and the mean age at phase 2 was 36 years. The outcome was physical non communicable diseases (NCDs) requiring a hospital admission which occurred after phase 2 of the cohort when the mental health, smoking and alcohol use exposure variables had been assessed until the end of March 2014.

RESULTS

The most common NCDs requiring a hospital admission were gastrointestinal disorders 5.62% (95% Confidence Intervals (CI) 5.04, 6.19) and joint disorders 5.60% (95% CI 5.02, 6.18). Number of NCDs requiring a hospital admission was significantly higher in those with a common mental disorder (Hazard ratio (HR) 1.40 (95% CI 1.16-1.68), post-traumatic stress disorder (HR 1.78 (95% CI 1.32-2.40)) and in current smokers (HR 1.35 (95% CI 1.12-1.64) compared to those without the disorder, and non-smokers, respectively.

CONCLUSIONS

Military personnel with a mental health problem are more likely to have an inpatient hospital admission for NCDs compared to those without, evidencing the clear links between physical and mental health in this population.

Sub-syndromal PTSD: what is important to know in military personnel and veterans?

OBJECTIVE

To assist healthcare professionals in their management of military personnel and veterans by providing information on the importance of sub-syndromal PTSD.

CONCLUSION

Sub-syndromal PTSD occurs when persons experience many of the symptoms of PTSD, with some impairment, but do not meet full diagnostic criteria. Found to be associated with a range of mental health conditions including alcohol abuse, higher rates of suicidal ideas and delayed-onset PTSD, it should be seen as 'symptoms that are predictive of later disorder'. Patients with this condition need accurate assessment, trauma-focused therapy and follow-up to address the symptoms and, potentially, prevent development of PTSD.

Factor Structure and Measurement Invariance of the Alcohol Use Disorders Identification Test (AUDIT) in a Sample of Military Veterans with and without PTSD

Background: The Alcohol Use Disorders Identification Test (AUDIT) was developed as a screening tool for problematic alcohol use and an intervention framework to aid those who drink excessively. While the AUDIT is widely used with at-risk populations, such as military veterans, major gaps exist in the research literature regarding the construct validity of the AUDIT in military samples. Objectives: This study assessed the factor structure and measurement invariance of the AUDIT in a large sample of Canadian military veterans (N = 1669; 94.94% male). Methods: Exploratory factor analysis (EFA) was conducted using a random subsample (n = 825) to assess the underlying factor structure of the AUDIT. Confirmatory factor analysis (CFA), using the second subsample (n = 844), was used to cross-validate the factor structure revealed by EFA and compare it to other model variants. Finally, multigroup CFAs were conducted using the whole sample to further cross-validate the factor structure and examine measurement invariance in military veterans with and without clinical elevations in posttraumatic stress disorder (PTSD) symptoms. Results: Factor analyses revealed that a modified two-factor model provided a statistically better fit to the data compared to all other model variants; yet, the results did not confirm measurement invariance across military veterans with and without clinically significant symptoms of PTSD. Conclusions/Importance: The findings are in line with increasing evidence suggesting that two subscale scores should be calculated for the AUDIT. Results further suggest that care should be taken in interpreting AUDIT scores when PTSD symptoms are present for military veterans.

Understanding the association between posttraumatic stress disorder characteristics and physical health conditions: A population-based study

Posttraumatic stress disorder (PTSD) is commonly comorbid with a range of physical health conditions. The aim of this study was to examine the association between index trauma and PTSD symptom clusters with physical health conditions, among individuals with PTSD in a population-based sample. Data were analyzed from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III; N = 36,309). Past-year PTSD (n = 1779) was assessed using a clinical interview in accordance with DSM-5 criteria. Multiple logistic regression models examined the associations between PTSD symptom clusters and index trauma with physical health conditions. Results of the most stringent model, adjusting for sociodemographics, other psychiatric conditions, and other PTSD symptom clusters, indicated re-experiencing symptoms were associated with cardiovascular and endocrine/metabolic conditions (adjusted odds ratio (AOR) range: 1.18-1.33) and negative alterations in mood and cognition symptoms were associated with sleep disorder (AOR = 1.16, 95% confidence interval (CI) [1.04-1.30], p = .009). Results also demonstrated significant associations between life-threatening illness with cancer, digestive, and neurologic conditions (AOR range: 2.10-3.42) and life-threatening injury with musculoskeletal and neurologic conditions (AOR range: 1.76-2.04). Finally, significant associations emerged between psychological trauma with musculoskeletal and neurologic conditions (AOR range: 0.48-0.66), and other trauma with digestive conditions and anemia (AOR range: 0.38-0.47). Results suggest PTSD symptomatology and index trauma play a differential role in their association with variable physical health conditions. Results may inform screening practices and targeted interventions to mitigate risk of PTSD and physical health conditions.

Prevalence of comorbid chronic pain and mental health conditions in Canadian Armed Forces active personnel: analysis of a cross-sectional survey

BACKGROUND

Chronic pain conditions and mental disorders have high prevalence rates in military populations. However, few investigations have examined the comorbidity between chronic pain conditions and specific mental disorders among Canadian active military personnel.

METHODS

We conducted a secondary analysis of data from the 2013 Canadian Forces Mental Health Survey (CFMHS) concerning the population of regular members. Diagnostic interviews assessed the presence of mental disorders, and participants self-reported chronic pain conditions (i.e., arthritis, back problems, musculoskeletal conditions, migraines) and indicators of pain severity. We used multiple logistic regressions to assess associations between chronic pain conditions and mental disorders. We used cross-tabulations to assess the prevalence of pain severity indicators in comorbid relationships compared with the chronic pain condition alone. We used moderation analyses to examine the interactions between pain condition by pain severity, and pain condition by activity limitation, respectively, on mental disorders.

RESULTS

The CFMHS included data from 6696 regular members and had a response rate of 79.8%. About one-quarter (n = 1761) of military personnel reported having chronic pain. In the fully adjusted model, all assessed pain conditions were significantly associated with posttraumatic stress disorder (PTSD) (odds ratio [OR] range 1.86-2.55), and several pain conditions were associated with major depressive episode, generalized anxiety disorder and panic disorder. Back problems were significantly associated with all mental disorders apart from alcohol use disorders (OR range 1.40-2.17). Cross-tabulations showed higher prevalence estimates of endorsement for pain severity indicators among pain conditions and comorbid mental disorders, compared with pain conditions alone. Formal moderation analyses showed a significant relationship between migraine and activity limitation on PTSD.

INTERPRETATION

Chronic pain conditions are prevalent and co-occur with mental disorders among Canadian regular force members. Greater understanding of these chronic pain conditions and mental disorders and their impact on people's abilities to adapt to both military and civilian life is needed.

Number and Type of Post-Traumatic Stress Disorder Symptom Domains Are Associated With Patient-Reported Outcomes in Patients With Chronic Pain

Post-traumatic stress disorder (PTSD) commonly accompanies complex chronic pain, yet PTSD is often overlooked in chronic pain management. Using the 4-item Primary Care (PC)-PTSD screening tool, we evaluated the relationship between the number and type of PC-PTSD symptoms endorsed and a set of patient-reported outcomes, including: pain intensity and interference, function, mood, quality of life, and substance abuse risk in a consecutive sample of patients with chronic pain (n = 4,402). Patients completed PainTracker, a Web-based patient-reported outcome tool that provides a multidimensional evaluation of chronic pain, as part of their intake evaluation at a specialty pain clinic in a community setting. Twenty-seven percent of the sample met PC-PTSD screening criteria for PTSD by endorsing 3 of the 4 symptom domains. Significant ordinal trends were observed between increasing number of PTSD symptoms and all outcomes evaluated. The occurrence of even 1 PTSD symptom was associated with overall poorer outcomes, suggesting that subsyndromal PTSD is clinically significant in the context of chronic pain. Among the 4 PTSD domains assessed, "numbness/detachment" was most strongly associated with negative pain outcomes in relative weight analysis. Results from this cross-sectional study suggest that a range of pain-related outcomes may be significantly related to comorbid PTSD.

PERSPECTIVE

We present evidence that PTSD symptoms are significantly related to a broad set of pain-related patient-reported outcomes. These findings highlight the need to evaluate for PTSD symptoms in patients with chronic pain, especially feelings of numbness or detachment from others, to improve understanding and management of chronic pain.

The Need to Take a Staging Approach to the Biological Mechanisms of PTSD and its Treatment

Despite the substantial body of neurobiological research, no specific drug target has been developed to treat PTSD and there are substantial limitations with the available interventions. We propose that advances are likely to depend on the development of better classification of the heterogeneity of PTSD using a staging approach of disease. A primary rationale for staging is to highlight the probability that distinct therapeutic approaches need to be utilised according to the degree of biological progression of the disorder. Prospective studies, particularly of military populations, provide substantial evidence about the emerging biological abnormalities that precede the full-blown disorder. These need to be targeted with tailored interventions to prevent disease progression. Equally, the neurobiology of chronic unremitting PTSD needs to be differentiated from the acute disorder which emerges across a spectrum of severity, and this range of presentations correspondingly needs to be addressed with differing therapeutic strategies. The staging approach also needs to take account of the range of somatic pathological outcomes that are being identified as a consequence of traumatic stress exposure. PTSD should be conceptualised as a systemic disorder underpinned a range of biological dysregulation, including metabolic and altered immune function, reflected in the increased rates of cardiovascular and autoimmune disease. The effectiveness of novel treatments needs to be judged across their effectiveness in addressing the spectrum of trauma-related pathology.

Comorbidity and functional correlates of anxiety and physical conditions in Canadian Veterans

Introduction: Little is known about the relationship between anxiety disorders and physical conditions in Canadian Veterans. The purpose of this investigation was to examine the comorbidity of anxiety and physical conditions and their relation to physical and mental health–related quality of life and activity limitations in a nationally representative sample of Canadian Veterans. Methods: Participants were selected from the cross-sectional 2010 Survey on Transition to Civilian Life ( N = 3,154, response rate = 71.0%). The sample consisted of former Canadian Armed Forces Regular Force personnel who were released from 1998 to 2007. Multivariate logistic and linear regression models evaluated associations between several commonly occurring chronic physical conditions and any anxiety disorder and correlates (i.e., quality of life and activity limitations) of comorbidity. Results: Any anxiety disorder was associated with significantly elevated rates of cardiovascular, gastrointestinal, respiratory, and musculoskeletal conditions; diabetes; and chronic pain after controlling for sociodemographics, military characteristics, any mood disorder, and heavy drinking. However, when additionally controlling for number of physical conditions, any anxiety disorder remained significantly associated with gastrointestinal conditions (adjusted odds ratio [AOR] = 1.63, 99% confidence interval [CI] = 1.07–2.50) and chronic pain (AOR = 1.79, 99% CI = 1.15–2.78). Co-occurring anxiety disorders and musculoskeletal conditions were associated with poorer physical health–related quality of life and activity limitations than musculoskeletal conditions alone. Conclusion: Anxiety disorders and physical health problems co-occur at high rates among Canadian Veterans, and this comorbidity is linked to poorer physical health–related quality of life and activity limitations. These findings have implications for supporting at-risk personnel with the transition to civilian life and for informing health promotion and prevention efforts.

Trauma exposure and health: the role of depressive and hyperarousal symptoms

Posttraumatic stress disorder (PTSD) and depressive symptoms have been theorized to mediate the relationship between trauma exposure and physical health symptoms. Although empirical evidence supports this premise, studies conducted to date have employed statistical mediation analyses that are now broadly criticized. Furthermore, the mediating roles of both PTSD and depressive symptoms have seldom been examined concurrently, and it remains unclear which PTSD symptom clusters uniquely mediate this relationship. The aim of the present study was to examine the mediating role of reexperiencing, avoidance/numbing, hyperarousal, and depressive symptoms in the relationship between trauma exposure and physical health symptoms. Participants were 516 Spanish female undergraduate students. Physical health symptoms were compared between those who reported trauma exposure (n = 266) and those who did not (n = 250). Data from trauma-exposed participants were analyzed using regression models with bootstrapping to test mediation. Results of the analyses showed that the trauma-exposed group reported significantly more physical health symptoms (r(2) = .035). Hyperarousal and depressive symptoms uniquely mediated the relationship between trauma exposure and physical health symptoms. Our findings clarify some of the mechanisms by which negative health consequences occur subsequent to trauma exposure.