Association of mental health problems with gastrointestinal disorders in Iraq and Afghanistan veterans

Exposome Signatures of Gastrointestinal Disorders Among Active Duty Service Members

INTRODUCTION

We evaluated the risk factors associated with gastrointestinal disorders (GD) among the soldiers of the Army and Marine Aviation community (AMAC) using an exposomic approach. Specifically, we aimed to determine the medical and operational factors associated with reported GD in the Military Health System.

METHODS

Longitudinal data were obtained from the Medical Assessment and Readiness System (MARS) housed at Womack Army Medical Center, Fort Liberty, NC, for a retrospective cohort study that included 79,249 active duty United States AMAC active duty service members (ADSMs) from October 2015 to December 2019. Multivariable mixed-effects logistic regression was used to assess the relationship between the incidence occurrence of GD and variables including rank, service time, deployment, Armed Forces Qualification Test score, education, tobacco use, alcohol use, age, gender, race, ethnicity, body mass index (BMI), and marital status.

RESULTS

The incidence of GD included 22,813 person-years of observations with a rate of 2.2 per 100 person-years and a period prevalence of 3.2%. GD was independently associated with rank, service time, and deployment (all P < 0.05).

CONCLUSION

The high-risk categories associated with GD in the AMAC included age, BMI, race (not ethnicity), marital status, and service time. Our data also show that deployment time, not geographical location, was associated with a higher risk of GD. Together, these analyses suggest that White ADSMs older than 33 years of age who have experienced marriage, longer service time, and deployments appear to have a higher risk of GDs. Our assessment shows the utility of using an exposomic approach to create a member-specific, big data-informed personalized clinical algorithm of health outcomes.

The relationship between post-traumatic stress disorder and gastrointestinal disease in United States Military Veterans

Background

This study examined the relationship between gastrointestinal disease and post-traumatic stress disorder in U.S. military Veterans. Based on literature and clinical practice data sources from the U.S. Veterans Administration, gastrointestinal disease and post-traumatic stress disorder were hypothesized to be positively correlated in Veterans.

Objectives

This study aimed to determine the frequency with which gastrointestinal disease and post-traumatic stress disorder are diagnosed comorbidities, a diagnosis of gastrointestinal disease accompanies a diagnosis of post-traumatic stress disorder, and a diagnosis of post-traumatic stress disorder accompanies a diagnosis of a gastrointestinal disease.

Methods

The methodology was a retrospective, correlational design using data collected from the U.S. Department of Veterans Affairs patient database.

Results

The results were that post-traumatic stress disorder is bi-directionally correlated with the gastrointestinal diseases of gastroesophageal reflux disease, peptic ulcer disease, functional dyspepsia, Crohn's disease, diverticular disease, irritable bowel syndrome, and the symptoms of constipation and nausea/vomiting within Veterans who served during wartime periods. The study also found that post-traumatic stress disorder is not correlated with ulcerative colitis in Veterans.

Conclusions

The conclusions are that clinicians who see a presentation of post-traumatic stress disorder should be screening for gastrointestinal disease, while primary care and gastroenterology providers treating gastrointestinal disease should be screening for a history of trauma, as improved diagnosis rates may lead to improved treatment.

Enduring association between irritable bowel syndrome and war trauma during the Nicaragua civil war period: A population-based study

BACKGROUND

Psychosocial and physical trauma are known risk factors for irritable bowel syndrome (IBS), including in war veterans, whereas war exposure in civilians is unclear. Nicaragua experienced two wars, 1970-1990: The Sandinistas Revolution (1970s) and The Contra War (1980s). Our aim was to investigate the role of exposure to war trauma in the subsequent development of IBS in the context of an established health surveillance system (11000 households).

AIM

To investigate in a civilian population the relationship between exposure to war trauma and events and the subsequent development of IBS in the context of an established public health and demographic surveillance system in western Nicaragua.

METHODS

We conducted a nested population-based, cross-sectional study focused on functional gastrointestinal disorders based on Rome II criteria. 1617 adults were randomly selected. The Spanish Rome II Modular Questionnaire and Harvard Trauma Questionnaire were validated in Nicaragua. War exposure was assessed with 10 measures of direct and indirect war trauma and post-war effects. Multiple exposures were defined by ≥ 3 measures.

RESULTS

The prevalence of IBS was 15.2% [Female (F) 17.1%, Male (M) 12.0%], war exposure 19.3% (F 9.3%, M 36.7%), and post-traumatic stress disorder (PTSD) 5.6% (F 6.4%, M 4.3%). Significant associations with IBS in the civilian population were observed (adjusted by gender, age, socioeconomic status, education): physical and psychological abuse [adjusted odds ratio (aOR): 2.25; 95% confidence interval: 1.1-4.5], witnessed execution (aOR: 2.4; 1.1-5.2), family member death (aOR: 2.2; 1.2-4.2), and multiple exposures (aOR: 2.7; 1.4-5.1). PTSD was independently associated with IBS (aOR: 2.6; 1.2-5.7).

CONCLUSION

An enduring association was observed in the Nicaragua civilian population between specific civil war-related events and subsequent IBS. Civilian populations in regions with extended armed conflict may warrant provider education and targeted interventions for patients.

Association of mental health conditions and functional gastrointestinal disorders among Vietnamese new-entry medical students

BACKGROUND

Functional gastrointestinal disorders (FGIDs), also known as disorders of gut-brain interaction, occur not only in the elderly but also in young adults. This study aimed to evaluate the association between mental health conditions and FGIDs among Vietnamese new-entry medical students.

METHODS

This cross-sectional study was conducted in February 2022 among new-entry medical students in Ho Chi Minh City, Vietnam. A printed questionnaire was distributed to all students on the day of freshmen health screening. Their urine samples were collected to screen for Helicobacter pylori infection using rapid urinary test. FGIDs were diagnosed using ROME IV criteria. Gastroesophageal reflux disease (GERD) was defined as the presence of typical reflux symptoms at least twice a week. Mental health conditions, including generalized anxiety disorder (GAD) and major depressive disorder (MDD), were identified using Generalized Anxiety Disorder Assessment-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) scales, respectively.

RESULTS

Among 400 new-entry medical students who participated in the study, the overall prevalence of FGIDs was 10.3% (functional dyspepsia 6.5%, irritable bowel disease 5.5%). The overlap syndrome (OS) of GERD-FGIDs or different FGIDs was present in 3.0% of participants. The prevalences of GAD and MDD were 6.8% and 10.2%, respectively. The urinary test was positive in 180 (45.0%) participants. In the multivariable logistic regression analysis, MDD was significantly associated with not only the risk of FGIDs (OR = 5.599, 95%CI: 2.173-14.430, p<0.001) but also the risk of OS (OR = 10.076, 95CI%: 2.243-45.266, p = 0.003).

CONCLUSIONS

MDD is associated with FGIDs and OS among new-entry medical students.

Self-reported gastrointestinal disorders among veterans with gulf war illness with and without posttraumatic stress disorder

BACKGROUND

Gulf War Illness (GWI) is a chronic, multi-symptom disorder affecting 25%-32% of Gulf War veterans. Veterans with GWI disproportionately suffer from gastrointestinal (GI) disorders. Given the increasing evidence supporting a gut-brain axis, we explore the relationship between post-traumatic stress disorder (PTSD), GWI, and self-reported GI disorders among GW veterans.

METHODS

Veterans from the Gulf War Era Cohort and Biorepository responded to a mail-based survey (N = 1058). They were stratified by GWI (Centers for Disease Control definition) and PTSD status. This yielded three groups: GWI-, GWI+/PTSD-, and GWI+/PTSD+. Multivariable logistic regression adjusting for demographic and military characteristics examined associations between GWI/PTSD groups and GI disorders. Results were expressed as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI).

KEY RESULTS

The most frequently reported GI disorders were irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), and colon polyps (CP). The GWI+/PTSD+ group had a higher odds of these disorders than the GWI+/PTSD- group (aOR_IBS  = 3.12, 95% CI: 1.93-5.05; aOR_GERD  = 2.04, 95% CI: 1.44-2.90; aOR_CP  = 1.85, 95% CI: 1.23-2.80), which had a higher odds of these disorders than the GWI- group (aOR_IBS  = 4.38, 95% CI: 1.55-12.36; aOR_GERD  = 2.51 95% CI: 1.63-3.87; aOR_CP  = 2.57, 95% CI: 1.53-4.32).

CONCLUSIONS & INFERENCES

GW veterans with GWI and PTSD have significantly higher odds of specific self-reported GI disorders than the other groups. Given the known bidirectional influences of the gut and brain, these veterans may benefit from a holistic healthcare approach that considers biopsychosocial contributors to the assessment and management of disease.

Assessment of Post-traumatic Stress Disorder Among Objective Esophageal Motility and Reflux Phenotypes in Symptomatic Veterans

Prior research suggests post-traumatic stress disorder (PTSD) is associated with the development of esophageal symptoms. We aimed to evaluate the prevalence of PTSD in veterans with esophageal symptoms, and assess for differences in objective esophageal motility and reflux classifications. Consecutive veterans reporting esophageal symptoms (e.g., dysphagia and reflux) underwent clinical evaluation with standard reflux and motility testing. Relevant demographic, mental health, and clinical esophageal information was gathered. Patients were classified into "PTSD" and "Non-PTSD" groups based on the documentation of a clinician-confirmed diagnosis of PTSD in the medical chart. Of the 273 consecutive veterans (89% men, mean age: 62 years) that met inclusion criteria for the study, 34% had a clinician-confirmed diagnosis of PTSD. Differences existed between PTSD and non-PTSD groups on smoking, bipolar disorder, depression, ADHD, and opiate use. However, no differences existed in objectively determined motility or reflux phenotypes. While PTSD was highly prevalent among our sample of symptomatic veterans, the presence of PTSD was not associated with differences in motility classifications and reflux phenotypes. These findings are consistent with recent research in psychogastroenterology, which suggests psychological processes are important to consider across esophageal classifications.

Prevalence of Gastrointestinal Symptoms and Irritable Bowel Syndrome Among Individuals With Symptomatic Posttraumatic Stress Disorder

GOALS

Our aim was to describe the prevalence of irritable bowel syndrome (IBS) and other gastrointestinal symptoms in a sample of veterans with posttraumatic stress disorder (PTSD) and to examine the relationship between gastrointestinal symptoms, PTSD severity, depression severity, and number of prior traumatic events reported.

BACKGROUND

IBS and PTSD can co-occur; yet, little research has focused on describing the gastrointestinal symptoms and prevalence of IBS among veterans with PTSD.

MATERIALS AND METHODS

We examined baseline data from a randomized clinical trial of behavioral interventions for veterans with PTSD. Veterans completed questionnaires assessing gastrointestinal symptoms (Gastrointestinal Patient-Reported Outcome Measures Information Systems; PROMIS) and lifetime traumatic events. Multivariable regression analyses were performed to examine associations between gastrointestinal symptoms and the number of prior traumas reported PTSD severity, and depression symptom severity.

RESULTS

One hundred eighty-four veterans with a diagnosis of PTSD were included. Twenty-five percent met the Rome III criteria for IBS. Veterans reported gastrointestinal symptoms including abdominal/belly pain (36%), diarrhea (21%), constipation (18%), and bloating/gas (17%). In multivariable analyses, greater PTSD severity was associated with worse constipation ( P =0.008), diarrhea ( P =0.005), and gas/bloating ( P =0.001) when controlling for age and sex. Higher levels of depressive symptoms severity were associated with greater abdominal/belly pain ( P =0.04).

CONCLUSIONS

Among a sample of veterans with PTSD, rates of IBS and abdominal/belly pain are greater than general US population reference values. Although levels of constipation and bloating/gas are lower than general US population reference values, increased severity of PTSD was associated with increased gastrointestinal symptoms.

Symptom clusters in chronic kidney disease and their association with people's ability to perform usual activities

Background

People living with a long-term condition, such as chronic kidney disease (CKD), often suffer from multiple symptoms simultaneously, making symptom management challenging. This study aimed to identify symptom clusters in adults with CKD across treatment groups and investigate their association with people’s ability to perform their usual activities.

Methods

We conducted a secondary analysis of both cross-sectional and longitudinal data collected as part of a national service improvement programme in 14 kidney centres in England, UK. This data included symptom severity (17 items, POS-S Renal) and the extent to which people had problems performing their usual activities (single item, EQ-5D-5L). We categorised data by treatment group: haemodialysis (n = 1,462), transplantation (n = 866), peritoneal dialysis (n = 127), or CKD without kidney replacement therapy (CKD non-KRT; n = 684). We used principal component analysis to identify symptom clusters per treatment group, and proportional odds models to assess the association between clusters and usual activities.

Results

Overall, clusters related to: lack of energy and mobility; gastrointestinal; skin; and mental health. Across groups, the ‘lack of energy and mobility’ clusters were associated with having problems with usual activities, with odds ratios (OR) ranging between 1.24 (95% confidence interval [CI], 1.21–1.57) for haemodialysis and 1.56 for peritoneal dialysis (95% CI, 1.28–1.90). This association was confirmed longitudinally in haemodialysis (n = 399) and transplant (n = 249) subgroups.

Implications

Our findings suggest that healthcare professionals should consider routinely assessing symptoms in the ‘lack of energy & mobility’ cluster in all people with CKD, regardless of whether they volunteer this information; not addressing these symptoms is likely to be related to them having problems with performing usual activities. Future studies should explore why symptoms within clusters commonly co-occur and how they interrelate. This will inform the development of cluster-level symptom management interventions with enhanced potential to improve outcomes for people with CKD.

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.

The Relationship between Functional Constipation and Major Dietary Patterns in Iranian Adults: Findings from the Large Cross-Sectional Population-Based SEPAHAN Study

Although associations between dietary patterns and risk of chronic conditions have recently received increased attention, few studies have examined the relationship between major dietary patterns and risk of constipation. We collected dietary data using a validated dish-based, 106-item semi-quantitative Food Frequency Questionnaire on 4,763 adults aged 18∼55 years. Data on anthropometric measures were collected through self-administered questionnaires. Functional constipation was defined based on the Iranian validated version of Rome III. Factor analysis followed by a varimax rotation was applied to derive major dietary patterns from 39 predefined food groups, and logistic regression was used for association analysis. Three major dietary patterns were extracted: traditional (TD), fruit and vegetables dominant (FVD), and Western (WD). The association between TD and constipation was not significant for both genders and for the total sample. However, in the crude model and the fully adjusted model, poor adherence to the FVD was associated with a higher risk of constipation in men and in the total sample. In addition, we observed a significantly lower risk of constipation in the total sample and in female participants with low adherence to WD; however, this was not significant for male participants. Further studies in other populations, and future prospective studies, are required to reiterate these results.

Gastrointestinal Symptoms During Depressive Episodes in 3256 Patients with Major Depressive Disorders: Findings from the NSSD

BACKGROUND

Little is known how often depressive episodes are accompanied by gastrointestinal symptoms in major depressive disorders (MDD). The authors sought to determine the frequency and clinical correlates of gastrointestinal symptoms during episodes of depressive disorder.

METHODS

3,256 MDD patients from the National Survey on Symptomatology of Depression (NSSD), which was designed to investigate the magnitude of symptoms of current major depressive episodes in China, were enrolled and assessed for gastrointestinal symptoms in this study. Illness characteristics were compared in patients with a different frequency of gastrointestinal symptoms. Pearson correlation analysis and multiple linear regression analysis were employed to investigate the associations between gastrointestinal symptoms and psychological characteristics in the patients.

RESULTS

More than 70% of the subjects with depressive episodes had concomitant gastrointestinal symptoms. A higher frequency of gastrointestinal symptoms was associated with an increased risk of suicide ideation, suicide attempts, anxious mood, depressed mood, insomnia, feeling a failure, poor concentration, body pain, hopelessness, anger, and irritability. Pearson correlation analysis indicated moderate but significant associations between gastrointestinal symptoms and psychological characteristics (p<0.001). Multiple linear regression analysis showed that suicide ideation (β=0.161, p<0.001), anxiety mood (β=0.166, p = 0.006), insomnia (β =0.262, p<0.001), anger (β=0.144, p<0.001), feeling a failure (β =0.365, p<0.001), and body pain (β=0.581 p<0.001) were independently associated with gastrointestinal symptoms in MDD patients.

CONCLUSION

Gastrointestinal symptoms were one of the most prevalent clinical presentations of MDD. The associations between gastrointestinal symptoms and psychological characteristics may prove useful in expanding our understanding of how gastrointestinal symptoms contributes to MDD.

Importance of Non-pharmacological Approaches for Treating Irritable Bowel Syndrome: Mechanisms and Clinical Relevance

Chronic visceral pain represents a major unmet clinical need with the severity of pain ranging from mild to so severe as to prevent individuals from participating in day-to-day activities and detrimentally affecting their quality of life. Although chronic visceral pain can be multifactorial with many different biological and psychological systems contributing to the onset and severity of symptoms, one of the major triggers for visceral pain is the exposure to emotional and physical stress. Chronic visceral pain that is worsened by stress is a hallmark feature of functional gastrointestinal disorders such as irritable bowel syndrome (IBS). Current pharmacological interventions for patients with chronic visceral pain generally lack efficacy and many are fraught with unwanted side effects. Cognitive behavioral therapy (CBT) has emerged as a psychotherapy that shows efficacy at ameliorating stress-induced chronic visceral pain; however, the molecular mechanisms underlying CBT remain incompletely understood. Preclinical studies in experimental models of stress-induced visceral pain employing environmental enrichment (EE) as an animal model surrogate for CBT are unraveling the mechanism by which environmental signals can lead to long-lasting changes in gene expression and behavior. Evidence suggests that EE signaling interacts with stress and nociceptive signaling. This review will (1) critically evaluate the behavioral and molecular changes that lead to chronic pain in IBS, (2) summarize the pharmacological and non-pharmacological approaches used to treat IBS patients, and (3) provide experimental evidence supporting the potential mechanisms by which CBT ameliorates stress-induced visceral pain.

Clinical Complexity in Women Veterans: A Systematic Review of the Recent Evidence on Mental Health and Physical Health Comorbidities

A recent evidence map focused on women veterans underscored the limited number of articles published on mental health comorbid with physical health conditions in this population. The quality of this small body of research has yet to be evaluated. The aim of this systematic review was to evaluate and synthesize research published between 2008 and 2015 and identified in the Women Veterans' Health Research Evidence Map as related to mental and physical health comorbidities among women veterans. Following PRISMA guidelines, 23 published studies were identified and 21 were included in the review. In general, significant associations between several mental health conditions (e.g., depression, posttraumatic stress disorder, substance use disorders) and physical health disorders (e.g., cardiovascular disease, diabetes, gastrointestinal disorders, hypertension, obesity, pain, and urinary symptoms) and health behaviors (e.g., preventative care and treatment adherence) were noted. The majority of studies were rated as low risk of bias, with selection and detection bias most frequently observed across studies. Additionally, gaps in the recent literature were observed, including the need for further investigation of the role of medical conditions in complicating mental health symptoms and care provision. Results underscore the importance of healthcare providers attending to women veterans' mental and physical health simultaneously and irrespective of setting. Further, while the Department of Veterans Affairs continues to make sizable gains in its focus on women veterans' health, continued research on several health domains is needed to ensure adequate understanding of the health needs of women veterans.

Evaluation of an Immunomodulatory Probiotic Intervention for Veterans With Co-occurring Mild Traumatic Brain Injury and Posttraumatic Stress Disorder: A Pilot Study

Background: US military Veterans returned from Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) with symptoms associated with mild traumatic brain injury [mTBI; i.e., persistent post-concussive (PPC) symptoms] and posttraumatic stress disorder (PTSD). Interventions aimed at addressing symptoms associated with both physical and psychological stressors (e.g., PPC and PTSD symptoms) are needed. This study was conducted to assess the feasibility, acceptability, and safety of a probiotic intervention, as well as to begin the process of evaluating potential biological outcomes.

Methods: A pilot randomized controlled trial was implemented among US military Veterans from recent conflicts in Iraq and Afghanistan. Those enrolled had clinically significant PPC and PTSD symptoms. Participants were randomized to intervention (Lactobacillus reuteri DSM 17938) or placebo supplementation (daily for 8 weeks +/- 2 weeks) at a 1:1 ratio, stratified by irritable bowel syndrome status. Thirty-one Veterans were enrolled and randomized (15 to the placebo condition and 16 to the probiotic condition).

Results: Thresholds for feasibility, acceptability, and safety were met. Probiotic supplementation resulted in a decrease in plasma C-reactive protein (CRP) concentrations relative to the placebo group that approached statistical significance (p = 0.056). Although during the Trier Social Stress Test (TSST; administered post-supplementation) no between-group differences were found on a subjective measure of stress responsivity (Visual Analog Scale), there was a significantly larger increase in mean heart beats per minute between baseline and the math task for the placebo group as compared with the probiotic group (estimated mean change, probiotic 5.3 [95% Confidence Interval: −0.55, 11.0], placebo 16.9 [11.0, 22.7], p = 0.006).

Conclusions: Findings from this trial support the feasibility, acceptability, and safety of supplementation with an anti-inflammatory/immunoregulatory probiotic, L. reuteri DSM 17938, among Veterans with PPC and PTSD symptoms. Moreover, results suggest that CRP may be a viable inflammatory marker of interest. A larger randomized controlled trial aimed at measuring both biological and clinical outcomes is indicated.

Clinical Trial Registration:ClinicalTrials.gov, Identifier NCT02723344.

Depression and Structural Factors Are Associated With Symptoms in Patients of Irritable Bowel Syndrome With Diarrhea

Background/Aims

A strong correlation between depression and irritable bowel syndrome with diarrhea (IBS-D) has been identified. The aim of this study is to identify the correlations among depression, structural factors, gastrointestinal (GI) and extra-GI symptoms, and efficacy of neuromodulators in patients with IBS-D.

Methods

Patients meeting the Rome III Diagnostic Criteria for IBS-D were enrolled. The intestinal symptoms and psychological states were evaluated using IBS-specific symptom questionnaires and Hamilton Depression Rating Scale.

Results

In total, 410 patients with IBS-D were enrolled, 28.8% (118/410) had comorbid depression. Patients with depression did not readily experience improvement in abdominal pain/discomfort after defecation, and had a higher prevalence of passing mucus, overlapping functional dyspepsia, and extra-GI symptoms. The structural factor “mental disorders” significantly correlated with main bowel symptom score and degree of pre-defecation abdominal pain/discomfort. No structural factor significantly correlated with bowel movements or stool form. Patients who had passing mucus, overlapping functional dyspepsia and extra-GI painful symptoms have higher score of “anxiety/somatization.” Patients with sexual dysfunction have higher score of “retardation symptoms.” In total, 28.3% of patients with IBS-D were prescribed neuromodulators. Baseline scores of “anxiety/somatization” and “retardation symptoms” positively correlated with improvement of diarrhea after paroxetine, and “sleep disturbances” positively correlated with improvement of abdominal pain/discomfort and diarrhea after mirtazapine.

Conclusions

Comorbid depression and higher scores of structural factors might aggravate GI and extra-GI symptoms other than bowel movements and stool form. Structural factors of Hamilton Depression Rating Scale correlated with efficacy of paroxetine and mirtazapine in patients with IBS-D.

Examining physical health conditions and associations of pain, obesity, and function of UK Veterans diagnosed with PTSD and other mental health conditions

Introduction: Little is known about the physical health conditions experienced by United Kingdom (UK) military Veterans with posttraumatic stress disorder (PTSD) or other mental health diagnoses. We aimed to explore the prevalence of self-reported physical health complaints and health behaviours in a patient sample of UK Veterans who had engaged with mental health services. Methods: This study used questionnaire data from a cross-sectional study that sampled Veterans engaged in a UK national Veteran’s mental health charity ( N = 403). Prevalence rates of reported physical health complaints were ranked, and health behaviours were described. Adjusted multivariate logistic regression models were fitted to examine associations between the top five physical health complaints and socio-demographic factors, mental health outcomes, and health-related behaviours. Results: We observed that chronic pain (41.2%, n = 166) and poor mobility (34.2%, n = 138) were the most prevalent conditions reported. Participants with PTSD were more than twice as likely to report chronic pain (AOR = 2.25, 95% CI, 1.16–4.37, P ≤ 0.05). Of 384 Veterans in the sample, the majority had a calculated body mass index (BMI) deemed overweight or obese (76.5%, n = 294). Obese participants were 2–4 times more likely to report prevalent physical health complaints. Discussion: Veterans with complex mental health problems experience a high burden of physical health complaints. Of most concern are the associations between PTSD, obesity, pain, impairment, and the potential difficulties in recovery and treatment. These findings are important for the way health services assess and treat individuals presenting with complex mental health problems.

Impact of occupational stress on irritable bowel syndrome pathophysiology and potential management in active duty noncombat Greek military personnel: a multicenter prospective survey

INTRODUCTION

Irritable bowel syndrome (IBS) is one of the gut-brain axis interaction disorders. It has global distribution with varying prevalence and particular financial and psychological consequences. IBS has been associated with stress and anxiety, conditions that are usually prevalent in the army. There are scarce data investigating the impact of IBS on noncombat active duty military without reports of Greek military or stress in the occupational environment.

MATERIALS AND METHODS

The main exclusion criteria in our noncombat military multicenter prospective survey were gastrointestinal pathologies, malignancies, hematochezia, recent infections and antibiotics prescription, and pregnancy. Questionnaires included a synthesis of baseline information, lifestyle, and diet, psychological and stress-investigating scales and the IBS diagnosis checklist. Hospital Anxiety and Depression Scale and Rome IV criteria were utilized.

RESULTS

Among 1605 participants included finally, the prevalence of IBS was 8% and 131 cases were identified. Women were more vulnerable to IBS, although male sex was prevalent at a ratio of 3.5 : 1 (male:female) in the entire sample. The mean age of all participants was 23.85 years; most of the IBS patients were older than thirty. Abnormal anxiety scores and high levels of occupational stress were related to an IBS diagnosis.

DISCUSSION

This prospective multicenter survey showed, for the first time, the potential impact of occupational stress on IBS in active duty noncombat Greek Military personnel. The diagnosis of IBS by questionnaire is a quick, affordable way that can upgrade, by its management, the quality of life and relieve from the military burden. Our results are comparable with previous studies, although large-scale epidemiological studies are required for the confirmation of a possible causative relationship.

Gut Microbiota Disorder, Gut Epithelial and Blood-Brain Barrier Dysfunctions in Etiopathogenesis of Dementia: Molecular Mechanisms and Signaling Pathways

Emerging evidences indicate a critical role of the gut microbiota in etiopathogenesis of dementia, a debilitating multifactorial disorder characterized by progressive deterioration of cognition and behavior that interferes with the social and professional functions of the sufferer. Available data suggest that gut microbiota disorder that triggers development of dementia is characterized by substantial reduction in specific species belonging to the Firmicutes and Bacteroidetes phyla and presence of pathogenic species, predominantly, pro-inflammatory bacteria of the Proteobacteria phylum. These changes in gut microbiota microecology promote the production of toxic metabolites and pro-inflammatory cytokines, and reduction in beneficial substances such as short chain fatty acids and other anti-inflammatory factors, thereby, enhancing destruction of the gut epithelial barrier with concomitant activation of local and distant immune cells as well as dysregulation of enteric neurons and glia. This subsequently leads to blood-brain barrier dysfunctions that trigger neuroinflammatory reactions and predisposes to apoptotic neuronal and glial cell death, particularly in the hippocampus and cerebral cortex, which underlie the development of dementia. However, the molecular switches that control these processes in the histo-hematic barriers of the gut and brain are not exactly known. This review integrates very recent data on the molecular mechanisms that link gut microbiota disorder to gut epithelial and blood-brain barrier dysfunctions, underlying the development of dementia. The signaling pathways that link gut microbiota disorder with impairment in cognition and behavior are also discussed. The review also highlights potential therapeutic options for dementia.

The Relation between Dietary Patterns and Functional Gastrointestinal Disorders among Iranian Military Men

Background

Assessing the relation between dietary habits and functional gastrointestinal disorders (FGIDs) is less investigated among military personnel. In this study, we aimed to evaluate the association of certain eating patterns and FGIDs in Iranian army men.

Materials and Methods

This cross-sectional study was performed on 600 army personnel working in Kerman ground forces military station number 05, Iran. Participants were asked to define their weekly breakfast consumption, lunch intake time, and chewing efficiency. FGIDs were categorized as four groups including functional dyspepsia (FD), irritable bowel syndrome (IBS), functional constipation (FC) and functional diarrhea (FDi) diagnosed by Rome Ш criteria. Relation between variables was assessed through crude and multiple stepwise adjusted models.

Results

The prevalence of FD, IBS, FC, and FDi in our study was 20%, 32.3%, 3%, and 53.2%, respectively. After adjustment of all potential confounding variables, more weekly breakfast consumption was associated with decreased FDi prevalence (odds ratio [OR]: 0.57, 95% confidence interval [CI] = 0.38-0.84, P = 0.005). Slowly lunch consumption declined prevalence of IBS (OR: 0.33, 95% CI = 0.13-0.84, P = 0.02). Individuals chewing their meals well had a lower percentage of IBS, FC, and FDi (OR: 0.53, 95% CI = 0.33-0.83, P = 0.006; OR: 0.24, 95% CI = 0.06-0.89, P = 0.03; and OR: 0.52, 95% CI = 0.34-0.79, P = 0.003, respectively).

Conclusions

This study suggested that increasing breakfast intake, slowly lunch consumption, and better food chewing could be effective decreasing FGIDs' prevalence and increasing army crews' quality of lives and work efficiency. Further studies required to confirm this relationship and define accurate pathophysiological mechanisms.

Systematic review with meta-analysis: The association between post-traumatic stress disorder and irritable bowel syndrome

BACKGROUND AND AIM

Post-traumatic stress disorder (PTSD) is a psychiatric condition characterized by symptoms of hyperarousal and hypervigilance. Increasing research on the "gut-brain" axis (bidirectional signaling between the gut and the brain) has drawn links between PTSD and irritable bowel syndrome (IBS), an exceedingly common yet incompletely understood gastrointestinal condition. This meta-analysis thus aimed to examine the body of evidence and extent of association of PTSD with IBS.

METHODS

Using the keywords [early abuse OR childhood abuse OR violence OR trauma OR PTSD] AND [irritable bowel syndrome or IBS], a preliminary search on the PubMed, Medline, Embase, ScienceDirect, PsychINFO, Web of Science, and Google Scholar databases yielded 11,257 papers published in English between January 1, 1988, and May 1, 2018. Of these, only eight studies were included in the final meta-analysis.

RESULTS

The eight studies (four cross-sectional and four cohort) contained a total of 648,375 subjects. Most studies were from the USA and conducted on army veterans. The funnel plot revealed a roughly symmetrical distribution of studies, and Egger test was not significant for publication bias (P = 0.583). Random-effects meta-analysis found PTSD to be a significant risk factor for IBS (pooled odds ratio 2.80, 95% confidence interval: 2.06 to 3.54, P < 0.001).

CONCLUSIONS

Overall, PTSD is associated with an increased likelihood of IBS. This is the first meta-analysis to specifically examine the association between PTSD and IBS, and it provides insights into the probable (patho)physiology and management of IBS, supporting a holistic consideration of the psychosocial aspects of IBS and further research into effective multi-modal therapeutics.

The Association Between Military Sexual Trauma and Use of VA and Non-VA Health Care Services Among Female Veterans With Military Service in Iraq or Afghanistan

Military sexual trauma (MST) has been linked with increased rates of mental health disorders among veterans. Few studies have addressed how MST is related to use of VA and non-VA health care. The purpose of the current study was to (a) examine the association between MST, combat experiences, and mental health outcomes (i.e., posttraumatic stress disorder [PTSD] and depression) and (b) examine the association of MST and use of VA and non-VA health care services among female veterans who served in Iraq and Afghanistan. Female respondents to a survey assessing Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) veterans' needs and health ( N = 185) completed measures of demographic variables, military history, combat exposure, MST, PTSD, and depression symptoms, and use of VA and non-VA health care. Overall, 70% of the sample experienced one or more combat-related experiences and 15.7% endorsed MST during deployment to Iraq or Afghanistan. MST and combat exposure were both positively associated with PTSD and depression symptoms even after controlling for the effects of demographic and military history variables. MST was associated with increased use of VA mental health services in bivariate results but was not independently related to VA service utilization after accounting for PTSD and depression symptoms. Approximately half of the women who reported MST had not used VA health care. Continued outreach and education initiatives may be needed to ensure veterans understand the resources available to address MST-related mental and physical health problems through the VA.

Posttraumatic Stress Disorder and Gastrointestinal Disorders in the Danish Population

BACKGROUND

Evidence for the association between posttraumatic stress disorder (PTSD) and gastrointestinal (GI) disorders is mixed, owing in part to methodologic differences across studies. Furthermore, studies which have combined GI disorders or symptoms for examination as one overall category may potentially obscure associations between PTSD and individual GI diagnoses.

METHODS

This nationwide cohort study examined the incidence of all major nonmalignant GI disorders in patients with a prior PTSD diagnosis (n = 4,076), compared with the general population incidence from 1995 to 2013, using Danish medical registry data. We examined differences by sex, age, marital status, psychiatric and somatic comorbidity, and follow-up time. Risks, standardized incidence rates (SIRs), and confidence intervals (95% CIs) were calculated.

RESULTS

Risk of any GI disorder among PTSD patients was 25% (95% CI: 21%, 29%); the SIR for any GI disorder was 1.8 (95% CI: 1.7, 2.0). Risk and SIRs varied by disorder (e.g., no association with diverticula of the intestines [SIR: 1.1, 95% CI: 0.83, 1.5]; stronger association with peptic ulcer, site unspecified [SIR: 3.3, 95% CI: 1.8, 5.5]). Stratified analyses revealed that some associations were stronger for persons ages 16-39 or unmarried at PTSD diagnosis, persons with comorbid psychiatric diagnoses, and in the year following PTSD diagnosis.

CONCLUSIONS

This study documents associations between clinician-diagnosed PTSD and all major nonmalignant GI disorders in an unselected nationwide cohort with long follow-up. Differences in associations across GI disorders and important modifiers may account for previous conflicting research findings.

Mechanisms of Stress-induced Visceral Pain

Evidence suggests that long-term stress facilitates visceral pain through sensitization of pain pathways and promotes chronic visceral pain disorders such as the irritable bowel syndrome (IBS). This review will describe the importance of stress in exacerbating IBS-induced abdominal pain. Additionally, we will briefly review our understanding of the activation of the hypothalamic-pituitary-adrenal axis by both chronic adult stress and following early life stress in the pathogenesis of IBS. The review will focus on the glucocorticoid receptor and corticotropin-releasing hormone-mediated mechanisms in the amygdala involved in stress-induced visceral hypersensitivity. One potential mechanism underlying persistent effects of stress on visceral sensitivity could be epigenetic modulation of gene expression. While there are relatively few studies examining epigenetically mediated mechanisms involved in stress-induced visceral nociception, alterations in DNA methylation and histone acetylation patterns within the brain, have been linked to alterations in nociceptive signaling via increased expression of pro-nociceptive neurotransmitters. This review will discuss the latest studies investigating the long-term effects of stress on visceral sensitivity. Additionally, we will critically review the importance of experimental models of adult stress and early life stress in enhancing our understanding of the basic molecular mechanisms of nociceptive processing.

An Evidence Map of the Women Veterans' Health Research Literature (2008-2015)

BACKGROUND

Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning.

METHODS

The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps.

RESULTS

We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials.

CONCLUSIONS

Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.

Prevalence and prognosis of stress disorders: a review of the epidemiologic literature

Given the ubiquity of traumatic events, it is not surprising that posttraumatic stress disorder (PTSD) - a common diagnosis following one of these experiences - is characterized as conferring a large burden for individuals and society. Although there is recognition of the importance of PTSD diagnoses throughout psychiatry, the literature on other diagnoses one may receive following a stressful or traumatic event is scant. This review summarizes the literature on stress disorders (classified according to the International Classification of Diseases, 10th Edition [ICD-10]), including acute stress reaction, PTSD, adjustment disorder and unspecified stress reactions. This review focuses on the literature related to common psychiatric and somatic consequences of these disorders. The prevalence and incidence of each disorder are described. A review of epidemiologic studies on comorbid mental health conditions, including depression, anxiety and substance abuse, is included, as well as a review of epidemiologic studies on somatic outcomes, including cancer, cardiovascular disease and gastrointestinal disorders. Finally, the current literature on all-cause mortality and suicide following stress disorder diagnoses is reviewed. Stress disorders are a critical public health issue with potentially deleterious outcomes that have a significant impact on those living with these disorders, the health care system and society. It is only through an awareness of the impact of stress disorders that appropriate resources can be allocated to prevention and treatment. Future research should expand the work done to date beyond the examination of PTSD, so that the field may obtain a more complete picture of the impact all stress disorders have on the many people living with these diagnoses.

Irritable Bowel Syndrome and Female Patients

Irritable bowel syndrome is probably the most common functional gastrointestinal disorder and is characterized by abdominal pain along with altered bowel function. It is a disorder of female predominance. This article focuses on how being female influences the pathophysiology, diagnosis, management, and treatment of this common disorder and discusses the evidence and important controversies related to these areas.

Age, Gender and Women's Health and the Patient

Patients with functional gastrointestinal disorders (FGIDs) often experience distress, reduced quality of life, a perceived lack of validation, and an unsatisfactory experience with health care providers. A health care provider can provide the patient with a framework in which to understand and legitimize their symptoms, remove self-doubt or blame, and identify factors that contribute to symptoms that the patient can influence or control. This framework is implemented with the consideration of important factors that impact FGIDs, such as gender, age, society, and the patient's perspective. Although the majority of FGIDs, including globus, rumination syndrome, IBS, bloating, constipation, functional abdominal pain, sphincter of Oddi dyskinesia, pelvic floor dysfunction, and extra-intestinal manifestations, are more prevalent in women than men, functional chest pain, dyspepsia, vomiting, and anorectal pain do not appear to vary by gender. Studies suggest sex differences in somatic but not visceral pain perception, motility, and central processing of visceral pain; although further research is required in autonomic nervous system dysfunction, genetics and immunologic/microbiome. Gender differences in response to psychological treatments, antidepressants, fiber, probiotics, and anticholinergics have not been adequately studied. However, a greater clinical response to 5-HT3 antagonists but not 5-HT4 agonists has been reported in women compared with men.

The Epidemiology of Irritable Bowel Syndrome in the US Military: Findings from the Millennium Cohort Study

OBJECTIVES

Functional gastrointestinal disorders occur more frequently among deployed veterans, although studies evaluating the relative impact of risk factors, including stress and antecedent infectious gastroenteritis (IGE), are limited. We examined risk factors for new-onset irritable bowel syndrome (IBS) among active duty participants in the military's Millennium Cohort Study.

METHODS

Medical encounter data from 2001 to 2009, limited to Cohort members on active duty, were used to identify incident IBS cases (any and highly probable). IGE was identified using medical encounter or self-report. Covariate data were obtained from the Millennium Cohort Study surveys and analyzed using Cox proportional hazards methods.

RESULTS

Overall, 41,175 Cohort members met the eligibility criteria for inclusion and 314 new-onset cases of IBS were identified among these. Significant risk factors (adjusted hazard ratio, 95% confidence interval) included antecedent IGE (2.05, 1.53-2.75), female gender (1.96, 1.53-2.52), number of life stressors (1: 1.82, 1.37-2.41; 2: 2.86, 2.01-4.06; 3+: 6.69, 4.59-9.77), and anxiety syndrome (1.74, 1.17-2.58). Limited to highly probable IBS, a stronger association with antecedent IGE was observed, particularly when based on medical encounter records (any IGE: 2.20, 1.10-4.43; medical encounter IGE only: 2.84, 1.33-6.09). Precedent anxiety or depression and IGE interacted with increased IBS risk compared with IGE alone.

CONCLUSIONS

These results confirm previous studies on the association between sociodemographic or life stressors and IBS. IGE was significantly associated with IBS risk. Whether deployed or not, US service members often encounter repeated exposure to high levels of stress, which, combined with other environmental factors such as IGE, may result in long-term debilitating functional gastrointestinal disorders.

Chronic multisymptom illness among female Veterans deployed to Iraq and Afghanistan

BACKGROUND

Chronic multisymptom illness (CMI) may be more prevalent among female Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) deployed Veterans due to deployment-related experiences.

OBJECTIVES

To investigate CMI-related diagnoses among female OEF/OIF/OND Veterans.

RESEARCH DESIGN

We estimated the prevalence of the International Classification of Disease-9th edition-Clinical Modification coded CMI-related diagnoses of chronic fatigue syndrome, fibromyalgia (FM), and irritable bowel syndrome (IBS) among female OEF/OIF/OND Veterans with Veterans Health Administration (VHA) visits, FY2002-2012 (n=78,435). We described the characteristics of female Veterans with and without CMI-related diagnoses and VHA settings of first CMI-related diagnoses.

RESULTS

The prevalence of CMI-related diagnoses among female OEF/OIF/OND Veterans was 6397 (8.2%), over twice as high as the prevalence 95,424 (3.9%) among the totality of female Veterans currently accessing VHA (P<0.01). There were statistically significant differences in age, education, marital status, military component, service branch, and proportions of those with depression and/or post-traumatic stress disorder diagnoses across females with and without CMI-related diagnoses. Diagnoses were mainly from primary care, women's health, and physical medicine and rehabilitation clinics.

CONCLUSIONS

CMI-related diagnoses were more prevalent among female OEF/OIF/OND Veterans compared with all female Veterans who currently access VHA. Future studies of the role of mental health diagnoses as confounders or mediators of the association of OEF/OIF/OND deployment and CMI are warranted. These and other factors associated with CMI may provide a basis for enhanced screening to facilitate recognition of these conditions. Further work should evaluate models of care and healthcare utilization related to CMI in female Veterans.

Prevalence of, risk factors for, and consequences of posttraumatic stress disorder and other mental health problems in military populations deployed to Iraq and Afghanistan

This review summarizes the epidemiology of posttraumatic stress disorder (PTSD) and related mental health problems among persons who served in the armed forces during the Iraq and Afghanistan conflicts, as reflected in the literature published between 2009 and 2014. One-hundred and sixteen research studies are reviewed, most of which are among non-treatment-seeking US service members or treatment-seeking US veterans. Evidence is provided for demographic, military, and deployment-related risk factors for PTSD, though most derive from cross-sectional studies and few control for combat exposure, which is a primary risk factor for mental health problems in this cohort. Evidence is also provided linking PTSD with outcomes in the following domains: physical health, suicide, housing and homelessness, employment and economic well-being, social well-being, and aggression, violence, and criminality. Also included is evidence about the prevalence of mental health service use in this cohort. In many instances, the current suite of studies replicates findings observed in civilian samples, but new findings emerge of relevance to both military and civilian populations, such as the link between PTSD and suicide. Future research should make effort to control for combat exposure and use longitudinal study designs; promising areas for investigation are in non-treatment-seeking samples of US veterans and the role of social support in preventing or mitigating mental health problems in this group.

The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans: a meta-analysis

Literature on posttraumatic stress disorder (PTSD) prevalence among Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans report estimates ranging from 1.4% to 60%. A more precise estimate is necessary for projecting healthcare needs and informing public policy. This meta-analysis examined 33 studies published between 2007 and 2013 involving 4,945,897 OEF/OIF veterans, and PTSD prevalence was estimated at 23%. Publication year and percentage of Caucasian participants and formerly active duty participants explained significant variability in prevalence across studies. PTSD remains a concern for a substantial percentage of OEF/OIF veterans. To date, most studies have estimated prevalence among OEF/OIF veterans using VA medical chart review. Thus, results generalize primarily to the prevalence of PTSD in medical records of OEF/OIF veterans who use VA services. Additional research is needed with randomly selected, representative samples administered diagnostic interviews. Significant financial and mental health resources are needed to promote recovery from PTSD.

Efficacy of tandospirone in patients with irritable bowel syndrome-diarrhea and anxiety

AIM: To investigate the efficacy of tandospirone in patients with irritable bowel syndrome-diarrhea (IBS-D) and anxiety in a prospective, randomized, controlled study.

METHODS: Two hundred patients with IBS-D and moderate anxiety were randomized to receive pinaverium and tandospirone (arm A) or pinaverium and placebo (arm B). Tandospirone or placebo was given thrice daily at a fixed dose of 10 mg and pinaverium was given thrice daily at a fixed dose of 50 mg. The duration of treatment was 8 wk. Patients were assessed for abdominal pain and diarrhea. Anxiety was evaluated using the Hamilton Rating Scale for Anxiety (HAM-A). The primary study endpoints were response rates for abdominal pain and diarrhea. The secondary study endpoints were response rates for anxiety. Adverse events were also evaluated.

RESULTS: One hundred and seventy of 200 patients (82 patients in arm A and 88 patients in arm B) completed the study. Demographic and baseline characteristics of the 200 participants were comparable in the two arms. At week 8, the overall response rate for abdominal pain and diarrhea was 52.0% for arm A and 37.0% for arm B (P < 0.05). The HAM-A score showed that the response rate was 61.0% for arm A and 21.0% for arm B (P < 0.01). The treatments were well tolerated and no significant adverse events were reported.

CONCLUSION: Tandospirone is effective and can be combined with pinaverium in IBS-D patients with anxiety.