The temporal relationship between mental health and disability after injury

[Psychosocial Care in the Intensive Care Unit]

The improvement of intensive care treatment options leads to an increasing number of patients being treated in this setting. For the majority of those affected and their relatives, this treatment is associated with tremendous stress, but also subsequent physical, psychological and cognitive impairments, the post-intensive care syndrome. The aim of psychosocial support in the intensive care unit is to stabilise and minimise the acute stress. This is done through care services oriented towards trauma therapy interventions and emergency psychology. Equally central are the needs of the patient's relatives and ways to stabilise and relieve them. The third pillar of psychosocial work in the intensive care unit is the support of the treatment team. Finally, an outlook is given for the specialised aftercare of these complex patients in PICS outpatient clinics.

Cohort profile: The Trauma Outcomes Project, a prospective study of New Zealanders experiencing major trauma

PURPOSE

Patient-reported outcome measures (PROMs) are useful for trauma registries interested in monitoring patient outcomes and trauma care quality. PROMs had not previously been collected by the New Zealand Trauma Registry (NZTR). More than 2500 New Zealanders are admitted to hospital for major trauma annually. The Trauma Outcomes Project (TOP) collected PROMs postinjury from three of New Zealand's (NZ's) major trauma regions. This cohort profile paper aims to provide a thorough description of preinjury and 6 month postinjury characteristics of the TOP cohort, including specifically for Māori (Indigenous population in Aotearoa me Te Waipounamu/NZ).

PARTICIPANTS

Between July 2019 and June 2020, 2533 NZ trauma patients were admitted to one of 22 hospitals nationwide for major trauma and included on the NZTR. TOP invited trauma patients (aged ≥16 years) to be interviewed from three regions; one region (Midlands) declined to participate. Interviews included questions about health-related quality of life, disability, injury recovery, healthcare access and household income adequacy.

FINDINGS TO DATE

TOP recruited 870 participants, including 119 Māori. At 6 months postinjury, most (85%) reported that the injury still affected them, 88% reported problems with≥1 of five EQ-5D-5L dimensions (eg, 75% reported problems with pain or discomfort, 71% reported problems with usual activities and 52% reported problems with mobility). Considerable disability (World Health Organization Disability Assessment Schedule, WHODAS II, score ≥10) was reported by 45% of participants. The prevalence of disability among Māori participants was 53%; for non-Māori it was 44%. Over a quarter of participants (28%) reported trouble accessing healthcare services for their injury. Participation in paid work decreased from 63% preinjury to 45% 6 months postinjury.

FUTURE PLANS

The 12 and 24 month postinjury data collection has recently been completed; analyses of 12 month outcomes are underway. There is potential for longer-term follow-up interviews with the existing cohort in future. TOP findings are intended to inform the National Trauma Network's quality improvement processes. TOP will identify key aspects that aid in improving postinjury outcomes for people experiencing serious injury, including importantly for Māori.

Differences in suicide risk correlates and history of suicide ideation and attempts as a function of disability type

BACKGROUND

Disability status is associated with correlates of suicide risk (perceived burdensomeness, thwarted belongingness, negative future disposition, felt stigma, suicidal ideation, and suicide attempts).

AIMS

This study aimed to examine whether suicide-related correlates differ significantly as a function of disability type.

METHODS

Individuals with mobility and vision disabilities (N = 102) completed semistructured interviews and online-based questionnaires. Analysis of variance/analysis of covaiance and Fisher's exact tests were conducted to examine whether mean levels of suicide-related correlates differed significantly between individuals with blindness/low vision (n = 63) versus mobility-related (n = 39) disabilities.

RESULTS

No significant between-group differences were observed for most outcomes; however, individuals with vision disabilities reported higher mean levels of felt stigma and positive future disposition than those with mobility-related disabilities.

LIMITATIONS

The limited representation of disabilities among participants precludes generalization to individuals with other forms of disability and the cross-sectional design prevents inference about causality.

CONCLUSIONS

Interventions targeting cognitive processes that underlie suicide risk may be applicable to people with mobility and vision disabilities.

Temporal Associations Between Posttraumatic Stress Symptoms and Depression in Response to Online Expressive Writing Interventions in a Hispanic Sample

Some expressive writing (EW) interventions targeting posttraumatic stress symptoms (PTSS) may reduce both PTSS and comorbid depression symptoms. The temporal associations between PTSS and depression symptom levels in response to EW interventions are unknown. This study examined the directionality of PTSS and depression symptom levels from baseline to 1-week, 1-month, and 3-month follow-ups of two online EW interventions in a Hispanic sample with diverse trauma experiences. Participants (n = 70) completed either emotion-focused or fact-focused writing for 3 consecutive days online. A manifest autoregressive model with cross-lagged effects and treatment condition was analyzed. All but one first-order autoregressive path were statistically significant, with later PTSS and depression scores significantly predicted by those scores at preceding time points. The cross-lagged effects findings suggest that earlier PTSS levels influenced later depression levels, but earlier depression did not influence later PTSS, demonstrating a unidirectional temporal association. Severe PTSS may hinder EW treatment gains in depression. Superior outcomes for emotion-focused writing relative to fact-focused writing were also found.

Occupational posttraumatic stress disorder and workplace violence in workers' compensation claims

Acts of violence are the fifth leading cause of nonfatal occupational injuries in the United States. Experiencing a traumatic event at work can have serious mental health consequences, including the development of posttraumatic stress disorder (PTSD). This study aimed to quantify the prevalence of PTSD caused by workplace violence (WPV) in a statewide workers' compensation system and compare the outcomes and treatment of WPV cases versus those caused by other traumatic events. Using a retrospective cohort study design, workers who reported PTSD as the primary reason for a workers' compensation claim and had no coexisting physical injuries were found in California during 2009-2018. A total of 3,772 PTSD cases were identified, 48.9% of which were attributed to WPV. Demographic risk factors associated with WPV PTSD included lower income, younger age, female gender, and employment in retail or finance, p < .001-p = .007. For individuals who returned to work, claims due to WPV resulted in longer medically approved time away from work than non-WPV causes (Mdn = 132.5 days vs. Mdn = 91 days, respectively), p < .001. Three of the top 10 most frequently prescribed medications were administered against evidence-based guidelines. This study found that many treatments prescribed to PTSD patients are based on insufficient evidence, and the provision of existing empirically supported treatments is needed, particularly in generalized populations. The findings support the need for additional recognition of the cause of workplace PTSD to facilitate appropriate referrals to WPV or PTSD specialists to support return-to-work efforts.

What can we learn about polytrauma typologies by comparing population-representative to trauma-exposed samples: A Nepali example

BACKGROUND

Potentially traumatic events (PTEs) are common and associated with detrimental outcomes over the life-course. Previous studies exploring the causes and consequences of PTE-exposure profiles are often from high-income settings and fail to explore the implications of sample selection (i.e., population-representative versus PTE-restricted).

METHODS

Among individuals in the Nepal Chitwan Valley Family Study, latent class analyses (LCA) were performed on 11 self-reported PTEs collected by the Nepali version of the World Mental Health Consortium's Composite International Diagnostic Interview 3.0 from 2016 to 2018, in a population-representative sample (N = 10,714), including a PTE-restricted subsample (N = 9183). Multinomial logistic regressions explored relationships between sociodemographic factors and class membership. Logistic regressions assessed relationships between class membership and psychiatric outcomes.

RESULTS

On average, individuals were exposed to 2 PTEs in their lifetime. A five-class solution showed optimal fit for both samples; however, specific classes were distinct. No single sociodemographic factor was universally associated with PTE class membership in the population-representative sample; while several factors (e.g., age, age at incident PTE, education, marital status, and migration) were consistently associated with class membership in the PTE-subsample. PTE class membership differentiated psychiatric outcomes in the population-representative sample more than the PTE-subsample.

LIMITATIONS

Primary limitations are related to the generalizability to high-income settings, debate on LCA model fit statistic usage for final class selection, and cross-sectional nature of data collection.

CONCLUSIONS

Although population-representative samples provide information applicable to large-scale, population-based programming and policy, PTE-subsample analyses may provide additional nuance in PTE profiles and their consequences, important for specialized prevention efforts.

Association between functional disability type and suicide-related outcomes among U.S. adults with disabilities in the National Survey on Drug Use and Health, 2015-2019

While research on suicidal behavior for people with disability (PWD) suggests they experience higher risk than people without disability, less is known about variations among individuals with different disability types. This nationally representative, cross-sectional study compared differences in suicide-related outcomes (ideation, planning, attempts) among PWD by functional disability type (hearing, vision, cognitive, mobility, complex activity) and number. Secondary analysis of adult PWD in the 2015-2019 National Survey on Drug Use and Health (unweighted N = 35,544; representing 47,723,378 PWD, weighted) was used to estimate relationships between suicide-related outcomes and disability type and number. Most respondents were female (55.9%), and 36.0% were aged ≥65 years. Adjusted odds ratios (AORs) from multivariable logistic regression indicated that suicidal ideation and suicide attempt, respectively, were significantly more likely among individuals with cognitive (AOR = 1.71, 95% CI = 1.24-2.35; AOR = 2.54, 95% CI = 1.31-4.91), complex activity (AOR = 1.96, 95% CI = 1.37-2.81; AOR = 2.67, 95% CI = 1.32-5.41), and ≥2 limitations (AOR = 2.02, 95% CI = 1.52-2.69; AOR = 3.46, 95% CI = 1.84-6.50) than hearing limitation. Also, relative to other disability types, suicide-related outcomes were significantly more likely among individuals with cognitive limitation and complex activity limitation (p < 0.001). Additionally, suicide-related outcomes elevated in likelihood as the number of limitations increased, with the largest associations among those with ≥5 limitations for suicidal ideation (AOR = 2.31, 95% CI = 1.46-3.66), suicide planning (AOR = 3.34, 95% CI = 1.97-5.68), and suicide attempt (AOR = 6.37, 95% CI = 3.76-10.79). Subgroup analyses showed that presence of cognitive limitation and multiple limitations differentiated between suicidal ideators and suicide attempters. Further research is needed to identify causes of these risks and develop suicide prevention efforts for these particularly vulnerable groups.

AAOS/Major Extremity Trauma and Rehabilitation Consortium Clinical Practice Guideline Summary for Evaluation of Psychosocial Factors Influencing Recovery From Orthopaedic Trauma

The Clinical Practice Guideline for Evaluation of Psychosocial Factors Influencing Recovery from Adult Orthopaedic Trauma is based on a systematic review of current scientific and clinical research. The purpose of this clinical practice guideline is to improve outcomes after adult orthopaedic trauma by evaluating, and addressing, the psychosocial factors that affect recovery. This guideline contains one recommendation to address eight psychosocial factors after military and civilian adult orthopaedic trauma that may influence clinical, functional, and quality of life recovery. Furthermore, it addresses additional factors that may be associated with greater biopsychosocial symptom intensity, limitations, and/or diminished health-related quality of life. However, this guideline did not evaluate effective treatment strategies for the treatment or prevention of psychosocial factors. This guideline cannot be fully extrapolated to the treatment of children or adolescents. In addition, the work group highlighted the need for additional research because studies of general traumatic injuries do not always generalize to specific orthopaedic populations.

Systematic Review of the Association Between Trauma Severity and Postinjury Symptoms of Depression

BACKGROUND

Greater symptoms of depression are associated with greater symptom intensity during recovery from musculoskeletal injury. It is not clear that more severe trauma is associated with greater symptoms of depression as one might expect. The goal of this study was to systematically review the existing evidence regarding the association of Injury Severity Score (ISS) with symptoms of depression during recovery from musculoskeletal injury.

METHODS

Two independent reviewers used PubMed and Embase to identify studies that measured both ISS and symptoms of depression. Among the 17 studies satisfying inclusion criteria, 5 studies assessed the correlation of symptoms of depression and ISS on their continuum; 3 studies compared the mean of symptoms of depression for people above and below a specific ISS level; five compared mean ISS above and below a threshold level of symptoms of depression; and four compared dichotomized ISS and dichotomized depression. Four of the 17 evaluated factors associated with symptoms of depression in multivariable analysis.

RESULTS

In bivariate analysis, 12 of 17 studies (71%) found no association between ISS level and symptoms of depression. Three studies found a bivariate association that did not persist in multivariable analysis. Two studies reported slight associations in bivariate analysis, but did not perform multivariable analysis.

CONCLUSIONS

The knowledge that symptoms of depression are common during recovery, in combination with the finding of this review that they have little or no relationship with injury severity, directs clinicians to anticipate and address mental health during recovery from physical trauma of any severity.

Association Between Disability and Suicide-Related Outcomes Among U.S. Adults

INTRODUCTION

Although research has analyzed the sociodemographic and socioeconomic risks for suicide, only recently has suicide risk for people with disabilities been examined. This study investigates the associations between disability and distinct suicide-related outcomes, including suicidal ideation, suicide planning, and suicide attempt.

METHODS

This nationally representative, cross-sectional study comprised secondary analyses of the 2015-2019 National Survey on Drug Use and Health conducted in 2020 (N=198,640, representing 229,556,289 U.S. adults). Disability status comprised the presence of any disability; hearing, vision, mobility, cognitive, complex activity, or ≥2 limitations; and 1, 2, 3, 4, or ≥5 limitations. Suicide-related outcomes in the past year included none, suicidal ideation only, suicide planning, and suicide attempt. Multivariable logistic regression was applied to estimate the AORs.

RESULTS

Overall, 19.8% reported any disability. Results showed that people with disabilities were significantly more likely than those without disabilities to report suicidal ideation (AOR=2.13, 95% CI=1.93, 2.36), suicide planning (AOR=2.66, 95% CI=2.27, 3.11), and suicide attempt (AOR=2.47, 95% CI=2.05, 2.98). Furthermore, individuals within each limitation count group were significantly more likely than people without disabilities to report suicide-related outcomes (p<0.001), with the largest magnitudes among those with ≥5 limitations for suicidal ideation (AOR=3.80, 95% CI=2.32, 6.23), suicide planning (AOR=6.45, 95% CI=3.52, 11.80), and suicide attempt (AOR=8.19, 95% CI=4.45, 15.07).

CONCLUSIONS

People with various types of functional disabilities had an elevated risk for suicide-related outcomes, compared with people without disabilities. The more limitations a person had progressively increased their risk. These findings call for focused attention to the mental health of people with disabilities, including suicide prevention efforts that accommodate their needs.

Genetic Differences between Physical Injury Patients With and Without Post-traumatic Syndrome: Focus on Secondary Findings and Potential Variants Revealed by Whole Exome Sequencing

Objective

Sudden traumatic physical injuries often cause psychological distress, which may be associated with chronic disability. Although considerable effort has been expended to identify genetic predictors of post-traumatic stress disorder (PTSD) after traumatic events, genetic predictors of psychological distress in response to severe physical injuries have been yet to be elucidated using whole exome sequencing (WES). Here, the genetic architecture of post-traumatic syndrome (PTS), which encompasses a broad range of psychiatric disorders after traumatic events including depression, anxiety disorder, acute stress disorder, and PTSD, was explored using WES in severely physically injured patients, focusing on secondary findings and potential PTS-related variants.

Methods

In total, 141 severely physically injured patients were consecutively recruited, and PTS was evaluated within 1 month of the injury. Secondary findings were analyzed according to PTS status. To identify PTS-related variants, genome-wide association analyses and the optimal sequencing kernel association test were performed.

Results

Of the 141 patients, 88 (62%) experienced PTS. There were 108 disease-causing variants in severely physically injured patients. As secondary findings, the stress- and inflammation-related signaling pathways were enriched in the PTS patients, while the glucose metabolism pathway was enriched in those without PTS. However, no significant PTS-related variants were identified.

Conclusion

Our findings suggest that genetic alterations in stress and inflammatory pathways might increase the likelihood of PTS immediately after severe physical injury. Future studies with larger samples and longitudinal designs are needed.

Examining the role of stigma and disability-related factors in suicide risk through the lens of the Interpersonal Theory of Suicide

Research has largely not identified processes contributing to the relationship between physical disability and suicide risk. This cross-sectional research is aimed at examining the associations among felt stigma, perceived burdensomeness, disability severity, and perceptions about future suicidal ideation and attempts. Adults (N = 127) with physical disabilities recruited through online and printed advertisements completed self-report measures and semi-structured interviews. We anticipated that felt stigma would be associated with individuals' perceived likelihood of future suicidal ideation and attempts indirectly through perceived burdensomeness, and that these relationships would be moderated by the impact of disability on three important life domains. Results from a series of moderated mediation analyses partially supported study hypotheses and indicated indirect relationships of stigma to suicide-related perceptions. However, disability severity in the three examined domains did not moderate these indirect relationships. Felt stigma and perceived burdensomeness may contribute to self-perceptions of suicide risk among individuals with physical disabilities.

Rehabilitation Needs, Service Provision, and Costs in the First Year Following Traumatic Injuries: Protocol for a Prospective Cohort Study

BACKGROUND

Traumatic injuries, defined as physical injuries with sudden onset, are a major public health problem worldwide. There is a paucity of knowledge regarding rehabilitation needs and service provision for patients with moderate and major trauma, even if rehabilitation research on a spectrum of specific injuries is available.

OBJECTIVE

This study aims to describe the prevalence of rehabilitation needs, the provided services, and functional outcomes across all age groups, levels of injury severity, and geographical regions in the first year after trauma. Direct and indirect costs of rehabilitation provision will also be assessed. The overarching aim is to better understand where to target future efforts.

METHODS

This is a population-based prospective follow-up study. It encompasses patients of all ages with moderate and severe acute traumatic injury (New Injury Severity Score >9) admitted to the regional trauma centers in southeastern and northern Norway over a 1-year period (2020). Sociodemographic and injury data will be collected. Upon hospital discharge, rehabilitation physicians estimate rehabilitation needs. Rehabilitation needs are assessed by the Rehabilitation Complexity Scale Extended-Trauma (RCS E-Trauma; specialized inpatient rehabilitation), Needs and Provision Complexity Scale (NPCS; community-based rehabilitation and health care service delivery), and Family Needs Questionnaire-Pediatric Version (FNQ-P). Patients, family caregivers, or both will complete questionnaires at 6- and 12-month follow-ups, which are supplemented by telephone interviews. Data on functioning and disability, mental health, health-related quality of life measured by the EuroQol Questionnaire (EQ-5D), and needs and provision of rehabilitation and health care services are collected by validated outcome measures. Unmet needs are represented by the discrepancies between the estimates of the RCS E-Trauma and NPCS at the time of a patient's discharge and the rehabilitation services the patient has actually received. Formal service provision (including admission to inpatient- or outpatient-based rehabilitation), informal care, and associated costs will be collected.

RESULTS

The project was funded in December 2018 and approved by the Regional Committee for Medical and Health Research Ethics in October 2019. Inclusion of patients began at Oslo University Hospital on January 1, 2020, and at the University Hospital of North Norway on February 1, 2020. As of February 2021, we have enrolled 612 patients, and for 286 patients the 6-month follow-up has been completed. Papers will be drafted for publication throughout 2021 and 2022.

CONCLUSIONS

This study will improve our understanding of existing service provision, the gaps between needs and services, and the associated costs for treating patients with moderate and major trauma. This may guide the improvement of rehabilitation and health care resource planning and allocation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/25980.

Predictors of Outcome of Acute Partial Hospitalization: An Exploratory Study

To identify predictors of outcome of acute partial hospital (PH) treatment, patients admitted during a 15-month period were studied. Outcomes were change in the Behavior and Symptom Identification Scale and readmission within 30 days. Predictors were clinical and demographic variables obtained on all patients. Most patients (92%) improved during acute PH treatment, only 5% were readmitted, and average changes were moderate to large. However, many patients still had significant symptoms and behavioral problems at discharge, 56.5% missed at least 1 day, and 16.5% dropped out. Less acute improvement was associated with greater long-term impairment, worse treatment attendance, more previous treatment episodes, and fewer medication changes. Readmission was associated with less acute improvement and its predictors, and with nonattendance. In summary, acute outcome in PH was predicted by functioning more generally. Factors that affect patients' acute PH responses may also affect functioning in other areas. These findings suggest possible modifications of PH practices and programs.

An observational study on risk factors for prolonged opioid prescription after severe trauma

Background and aims:

Trauma is one of the most common causes of morbidity and mortality in people of working age. Following surgery, approximately 10% of patients develop persistent postsurgical pain. Chronic pain is a complex phenomenon that can adversely affect quality of life and is associated with psychiatric conditions such as anxiety and depression. Pharmacological treatment is normally insufficient to fully alleviate chronic pain and improve functional capacity, especially in the long term. The appropriateness of opioid treatment in chronic non-cancer pain has become increasingly examined with high numbers of serious side effects including drug dependency and death. The present study was based on clinical observations suggesting that a problematic opioid use can be initiated during trauma care, which implies the importance of evaluating opioid therapy and its effect on trauma patients. Specific attention is given to patients with known psychiatric conditions which may render them more vulnerable to develop problematic opioid use. The aim of this observational study was to broadly characterize patients referred to a pain specialist after severe trauma regarding their trauma type, psychiatric co-morbidity, and opioid prescription pattern. This was done to tentatively investigate possible risk factors for long-term opioid use following trauma.

Methods:

Trauma patients referred to the Pain Center at Karolinska University Hospital, Sweden (n=29) were recruited for the study over a period of 2 years. Demographic information, trauma-related data as well as psychiatric diagnoses and pharmacological prescriptions were retrieved from the registry SweTrau and electronic medical records.

Results:

Among the 29 participants (age range 21–55 years, median=34; 76% male), 14 (48%) were prescribed opioids at least once during the 6-months period preceding the trauma. For 21 patients (72%) opioids were prescribed 6 months after the trauma. One year after the trauma, 18 patients (62%) still had prescriptions for opioids corresponding to daily use or more, and two other patients used opioids intermittently. Twenty patients (69%) had psychiatric diagnoses before the trauma. According to the medical records, 17 patients (59%) received pharmacological treatment for psychiatric conditions in the six months period preceding the trauma. During the follow-up period, psychiatric pharmacological treatment was prescribed for 27 (93%) of the patients.

Conclusion and implications:

For most of the participants opioids were still being prescribed one year after trauma. The majority presented with psychiatric co-morbidity before trauma and were also prescribed psychiatric medication. Findings support the notion that patients with a complex pain situation in the acute phase following trauma are at risk for prolonged opioid prescription. These results, although tentative, point at psychiatric co-morbidity, opioid use before trauma, high injury severity, extensive surgery and extended hospital stay as risk factors for prolonged opioid prescription after severe trauma. This study is purely observational, with a small sample and non-controlled design. However, these data further emphasize the need to identify patients at risk for developing problematic long-term opioid use following trauma and to ensure appropriate pain treatment.

The Hong Kong Survey on the Epidemiology of Trauma Exposure and Posttraumatic Stress Disorder

This study examined the epidemiology of trauma exposure (TE) and posttraumatic stress disorder (PTSD) among community-dwelling Chinese adults in Hong Kong. Multistage stratification sampling design was used, and 5,377 participants were included. In Phase 1, TE, probable PTSD (p-PTSD), and psychiatric comorbid conditions were examined. In Phase 2, the Structured Clinical Interview for the DSM-IV (SCID-I) was used to determine the weighted diagnostic prevalence of lifetime full PTSD. Disability level and health service utilization were studied. The findings showed that the weighted prevalence of TE was 64.8%, and increased to 88.7% when indirect TE types were included, with transportation accidents (50.8%) reported as the most common TE. The prevalence of current p-PTSD among participants with TE was 2.9%. Results of logistic regression suggested that nine specific trauma types were significantly associated with p-PTSD; among this group, severe human suffering, sexual assault, unwanted or uncomfortable sexual experience, captivity, and sudden and violent death carried the greatest risks for developing PTSD, odds ratio (OR) = 2.32-2.69. The occurrence of p-PTSD was associated with more mental health burdens, including (a) sixfold higher rates for any past-week common mental disorder, OR = 28.4, (b) more mental health service utilization, p < .001, (c) poorer mental health indexes in level of symptomatology, suicide ideation and functioning, p < .001, and (d) more disability, ps < .001-p = .014. The associations found among TE, PTSD, and health service utilization suggest that both TE and PTSD should be considered public health concerns.

Longitudinal depressive and anxiety symptoms of adult injury patients in Kenya and their risk factors

Background: Injuries account for a significant proportion of the health and economic burden for populations in low- and middle-income countries. However, little is known about psychological distress trajectories amongst injury survivors in low- and middle-income countries.Methods: Adult injury patients (n = 644) admitted to Kenyatta National Hospital in Nairobi, Kenya, were enrolled and interviewed in the hospital, and at 1, 2-3, and 4-7 months after hospital discharge through phone to assess depressive and anxiety symptoms and level of disability. Growth mixture modeling was applied to identify latent trajectories of depressive and anxiety symptoms.Results: Elevated depressive and moderate-level anxiety symptoms (13%) and low depressive and anxiety symptoms (87%) trajectories were found between hospitalization and up to seven months after hospital discharge. Being female, prior trauma experience, longer hospitalization, worse self-rated health status while in the hospital, and lack of monetary assistance during hospitalization were associated with the elevated symptoms trajectory. The higher symptoms trajectory associated with higher disability levels after hospital discharge and significantly lower proportion of resuming daily activities and work.Conclusion: The persistence of elevated depressive symptoms and associated reduced functioning several months after physical injury underscores the importance of identifying populations at risk for preventive and early interventions.Implications for RehabilitationHealth providers following up with injury survivors should screen for depressive and anxiety symptomsSpecial attention to women and people with a potential traumatic exposure historyIncorporation of evidence-based culturally adapted psychosocial interventions in rehabilitation and outpatient clinics.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Persons injured in the 2011 terror attacks in Norway - Relationship between post-traumatic stress symptoms, emotional distress, fatigue, sleep, and pain outcomes, and medical and psychosocial factors

Purpose: The main aim was to assess long-term post-traumatic stress symptoms, emotional distress, fatigue, sleep disturbances and pain in individuals hospitalized with physical injuries after two terror attacks in Oslo in 2011, approximately three years after the events. A secondary aim was to explore the relationship between these outcomes and medical and psychosocial factors.Materials and methods: Thirty of 43 potential persons participated. Injury characteristics were collected from medical charts. Level of post-traumatic stress, emotional distress, fatigue, sleep disturbances and pain was assessed and the association with injury severity, resilience, optimism, neuroticism and extroversion, and perceived access to social support was explored.Results: Nine of 30 met criteria for full or partial PTSD, and 14 of 30 displayed clinical levels of emotional distress. Fifteen reported moderate to severe fatigue, and 16 said sleep disturbances affected their daily life. Twelve indicated that pain affected daily activities and work ability, and 15 that pain affected their quality of life. I Resilience, optimism, neuroticism, and perceived social support, were associated with outcomes, but injury severity was not. When controlling for pain, many of the psychosocial variables failed to reach significance.Conclusions: Injury severity was not associated with outcomes. On the other hand, psychosocial factors were, but seemed to be influenced by pain.Implications for rehabilitationPersons who have obtained physical injuries under extreme psychological conditions such as terror, are at high risk of poor long-term outcomes, and will often be in need of comprehensive interdisciplinary rehabilitation services.Psychological outcomes are not associated with severity of physical injury, but premorbid and current psychological variables such as resilience, optimism, personality, and access to social support are highly associated with long-term outcome.Longstanding pain seems to diminish or weaken the role of protective psychological factors and should be addressed in the rehabilitation context.

Tinnitus, Depression, Anxiety, and Suicide in Recent Veterans: A Retrospective Analysis

OBJECTIVES

The purpose of this project was to investigate whether there is an association between tinnitus diagnosis and suicide and whether depression and anxiety strengthen that association. Given that tinnitus is the top service-connected disability among U.S. Veterans () and that suicide among Veterans has been occurring at a higher frequency as compared with community suicide rates (), the possible associations between tinnitus and suicide will be explored. Co-occurring physical conditions also will be examined to determine if they increase the risk of suicide in the context of tinnitus.

DESIGN

Administrative health care data related to Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) were used to identify Veterans who accessed the Veterans Administration (VA) health care system from January 1, 2002, to December 31, 2011. Veterans who were deceased as of December 2011 were identified using the National Death Index (NDI) files. Tinnitus cases were followed until either they were deceased or to the end of the study period. The International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) codes were used to identify all conditions and diseases. As per mortality research standards, International Classification of Diseases 10th Revision (ICD-10) codes were used to identify cause of death.

RESULTS

Of 769,934 OEF/OIF/OND Veterans receiving VA care January 2002 to December 2011, 15% (n =116,358) were diagnosed with tinnitus. Of these Veterans diagnosed with tinnitus, 21% were also diagnosed with depression, another 8% with anxiety, and another 17% with both depression and anxiety. Fifty-four percentage were identified as having tinnitus without depression or anxiety. Among individuals with tinnitus, 41.9% had co-occurring hearing loss. Suicide rates were lower among Veterans with tinnitus than Veterans without tinnitus. Co-occurring diagnoses of mental-health conditions did not significantly increase the risk of suicide.

CONCLUSIONS

The study results do not confirm clinical and anecdotal reports that tinnitus could be related to suicide among Veterans. However, tenets from rehabilitation psychology suggest that the onset of chronic impairment or disability does not predict an individual's subsequent psychological states; other personal attributes may be more influential. Health care professionals, such as audiologists and psychologists, should be cognizant of the associations between tinnitus and mental health issues and be prepared to address the psychological needs of individuals who have tinnitus.

Suicidal because I don't feel connected or vice versa? A longitudinal study of suicidal ideation and connectedness among child welfare youth

Suicide is a major public health problem among youth involved with the child welfare system. Although social connectedness rests at the core of many prevention approaches, we know little about this relationship over time in this vulnerable population. This study tested the hypotheses that inverse relationships would exist between connectedness in three social domains (i.e., caregiver, peers, and school) and suicidal ideation over time. The current study used baseline and 18-month follow-up data from 995 youth who participated in the National Survey of Child and Adolescent Well-Being (NSCAW II)-a nationally representative study of children and families investigated by a child welfare agency conducted from 2008 to 2011. A cross-lagged path model was used for the analysis. There were significant main effects of suicidal ideation at Time 1 on peer connectedness (β= -.17, p < .01) and caregiver connectedness (β= -.12, p < .05) at Time 2, but not on school connectedness (β= -.05, ns). There was no main effect of any of the connectedness variables at Time 1 on suicidal ideation at Time 2. Screening for suicidal ideation is important for managing immediate risk but our findings suggest that such ideation also foreshadows disconnectedness from their primary caregiver and peers in the future. These findings demonstrate that there is clinical value in engaging child-welfare-involved youth and their social systems about how their suicide-related experiences may affect vital social ties. Therefore, there may be merit to designing and exploring the effects of pilot programming focused on mitigating social distancing that suicide-related experiences engender.

Subjective Age as a Moderator in the Reciprocal Effects Between Posttraumatic Stress Disorder Symptoms and Self-Rated Physical Functioning

It is now widely acknowledged that physical decline may increase among middle-aged and older adults who suffer from posttraumatic stress disorder (PTSD). Much less is known about the temporal sequencing of PTSD and physical decline relationship over time. While PTSD can lead to physical decline, physical decline may preserve or augment existing PTSD symptoms. Both problems can also mutually affect each other forming a vicious cycle. Additionally, it is important to address variables that can mitigate these longitudinal effects. Following the recovery capital framework, we consider how the existence or lack of capital in the form of young age identity may affect the recovery process. Therefore, the current study aimed to examine the reciprocal effects of PTSD symptoms and self-rated physical functioning and further test whether one's subjective age moderates these effects. Using in-region random digit dialing, we collected a stratified sample of community dwelling older adult residing in south Israel. Of that sample (N at T1 = 339), 132 older adults (age range = 51-88, mean age = 66.90, SD = 9.14) were interviewed 4 months after the 2014 Israel-Gaza conflict (T2) and 1 year later (T3). Participants responded to PTSD symptoms scale, and reported their physical functioning and subjective age. PTSD symptoms and self-rated physical functioning were tested as both predictors and outcomes in a cross-lagged model. The moderating effect of subjective age was assessed by examining whether T2 variables interacted with subjective age in predicting T3 outcomes. Results showed that higher PTSD symptoms at T2 were associated with subsequent lower self-rated physical functioning at T3, yet self-rated physical functioning at T2 did not predict PTSD symptoms at T3, thereby highlighting the PTSD self-rated physical function direction. Moreover, subjective age moderated this latter association, so that this relationship was significant only for those who felt relatively older. In addition to clarifying the temporal sequencing of the PTSD self-rated physical functioning association, the study further suggests that an older subjective age (i.e., lack of recovery capital) could render middle-aged and older adults more susceptible to physical decline following PTSD symptoms. We therefore propose to develop interventions aimed at coping with an older age identity and facilitating a younger age identity among traumatized older individuals.

Acute stress and subsequent health outcomes: A systematic review

OBJECTIVE

To systematically review the relationship between acute posttraumatic stress symptoms (<1 month) and subsequent physical and mental health outcomes other than posttraumatic stress disorder (PTSD).

METHODS

A systematic search of electronic databases (PubMed, PsycINFO, CINAHL, and Web of Science) was conducted to identify longitudinal studies examining the link between acute posttraumatic stress and physical and mental health. Inclusion criteria required assessment of acute posttraumatic stress (<1 month post-event) and at least one follow-up assessment of a physical or mental health outcome (not PTSD).

RESULTS

1,051 articles were screened; 22 met inclusion criteria. Fourteen studies examined physical health outcomes and 12 examined non-PTSD mental health outcomes. Early psychological responses to trauma were associated with a variety of short- (<1 year) and long- (≥1 year) term physical and mental health outcomes. Physical health outcomes included poor general physical health, increased pain and disability, lower quality of life, and higher risk of all-cause mortality. Significant psychological outcomes included more cumulative psychiatric disorders, depression, and anxiety. Significant psychosocial outcomes included increased family conflict.

CONCLUSIONS

Methodologically rigorous longitudinal studies support the utility of measuring acute psychological responses to traumatic events as they may be an important marker of preventable trauma-related morbidity and mortality that warrants long-term monitoring and/or early intervention.

Mental Disorder, Psychological Distress, and Functional Status in Canadian Military Personnel

OBJECTIVE

We examined the overlap between mood and anxiety disorders and psychological distress and their associations with functional status in Canadian Armed Forces (CAF) personnel.

METHOD

Data on Regular Forces personnel ( N = 6700) were derived from the 2013 Canadian Forces Mental Health Survey, a nationally representative survey of the CAF personnel. Current psychological distress was assessed using the Kessler K10 scale. Past-month mood and anxiety disorders were assessed using the World Health Organization World Mental Health Composite Diagnostic Interview.

RESULTS

The prevalence of psychological distress was the same as that of any past-month mood or anxiety disorder (7.1% for each). A total of 3.8% had both distress and past-month mood or anxiety disorder, 3.3% had past-month disorder without psychological distress, while another 3.3% had psychological distress in the absence of a past-month mood or anxiety disorder. After adjusting for age, sex, marital, education, income, language, element, rank, and alcohol use disorder, individuals with both psychological distress and past-month mood and anxiety disorders exhibited the highest levels of disability, days out of role, and work absenteeism relative to those with neither mental disorders nor psychological distress. Relative to individuals with both disorder and distress, those who endured distress in the absence of mental disorder exhibited lower, but meaningful, levels of disability compared with those with neither disorder nor distress.

CONCLUSIONS

Disability is most severe among CAF personnel with both distress and past-month mood and anxiety disorders. Nevertheless, distress in the absence of disorder is prevalent and is associated with meaningful levels of disability.

Comparison of the performance of mental health, drug and alcohol comorbidities based on ICD-10-AM and medical records for predicting 12-month outcomes in trauma patients

Background

Many outcome studies capture the presence of mental health, drug and alcohol comorbidities from administrative datasets and medical records. How these sources compare as predictors of patient outcomes has not been determined. The purpose of the present study was to compare mental health, drug and alcohol comorbidities based on ICD-10-AM coding and medical record documentation for predicting longer-term outcomes in injured patients.

Methods

A random sample of patients (n = 500) captured by the Victorian State Trauma Registry was selected for the study. Retrospective medical record reviews were conducted to collect data about documented mental health, drug and alcohol comorbidities while ICD-10-AM codes were obtained from routinely collected hospital data. Outcomes at 12-months post-injury were the Glasgow Outcome Scale – Extended (GOS-E), European Quality of Life Five Dimensions (EQ-5D-3L), and return to work. Linear and logistic regression models, adjusted for age and gender, using medical record derived comorbidity and ICD-10-AM were compared using measures of calibration (Hosmer-Lemeshow statistic) and discrimination (C-statistic and R²).

Results

There was no demonstrable difference in predictive performance between the medical record and ICD-10-AM models for predicting the GOS-E, EQ-5D-3L utility sore and EQ-5D-3L mobility, self-care, usual activities and pain/discomfort items. The area under the receiver operating characteristic (AUC) for models using medical record derived comorbidity (AUC 0.68, 95% CI: 0.63, 0.73) was higher than the model using ICD-10-AM data (AUC 0.62, 95% CI: 0.57, 0.67) for predicting the EQ-5D-3L anxiety/depression item. The discrimination of the model for predicting return to work was higher with inclusion of the medical record data (AUC 0.69, 95% CI: 0.63, 0.76) than the ICD-10-AM data (AUC 0.59, 95% CL: 0.52, 0.65).

Conclusions

Mental health, drug and alcohol comorbidity information derived from medical record review was not clearly superior for predicting the majority of the outcomes assessed when compared to ICD-10-AM. While information available in medical records may be more comprehensive than in the ICD-10-AM, there appears to be little difference in the discriminative capacity of comorbidities coded in the two sources.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3248-x) contains supplementary material, which is available to authorized users.

PTSD Latent Classes and Class Transitions Predicted by Distress and Fear Disorders in Disaster-Exposed Adolescents

This study aimed to determine the population-based typologies of posttraumatic stress disorder (PTSD) symptomatology, the longitudinal patterns of transitions across these typologies, and the predictive effects of distress and fear disorder symptoms on these transitions in a frequently referred but scantly studied population of traumatized youth. A sample of 1,278 Chinese adolescents (54.0% girls) with a mean age of 13.4 years (SD = 0.8, range = 12-16) completed 2-wave surveys 2.5 and 3.5 years after a major disaster. Psychopathological symptoms were assessed with the UCLA PTSD Reaction Index for DSM-IV, the Depression Self-Rating Scale for Children, and the Screen for Child Anxiety Related Emotional Disorders. Latent class analyses identified 4 classes characterized by high, reexperiencing/hypervigilance, dysphoria, and low symptoms, respectively at each time point. Latent transition analyses revealed relatively high levels of temporal stability within low symptom and dysphoria classes but relatively high probabilities of migration from re-experiencing/hypervigilance and high symptom classes into lower symptom classes. Multinomial logistic regression analyses found that some of the between-class movements during the year were predicted by baseline distress or fear disorders. This study provides an initial depiction of both quantitative and qualitative changes in youth's long-term PTSD symptom patterns over time and gives a further elucidation of other forms of posttrauma psychopathology's impacts on PTSD course. These findings carry implications for ongoing evaluation and adjustable intervention individually tailored to youth's PTSD manifestations and comorbidities in the long-term disaster aftermath.

Association of physical injury and mental health: Results from the national comorbidity survey- adolescent supplement

Nonfatal injury is common among adolescents in the U.S., but little is known about the bi-directional associations between injury and mental health. Utilizing a nationally representative sample of U.S. adolescents, we examined 1) associations between lifetime mental health history and subsequent injury; 2) concurrent associations between injury and mental health; and 3) associations between injury and subsequent mental disorders. Data were drawn from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A), a national survey of adolescents aged 13 through 17 years (N = 10,123). Twelve-month prevalence of nonfatal injury requiring medical attention was assessed along with lifetime, 12-month, and 30-day prevalence of DSM-IV depressive, anxiety, behavior, substance use, and bipolar disorders. We used Poisson regression to examine associations between 1) lifetime history of mental disorders and 12-month exposure to injury; 2) concurrent associations between 12-month exposure to injury and 12-month prevalence of mental disorders; and 3) 12-month exposure to injury and 30-day prevalence of mental disorders. A total of 11.6% of adolescents experienced an injury requiring medical attention in the year before the survey. Lifetime history of mental disorders was not associated with past-year injury. Behavior and bipolar disorders were concurrently associated with past-year injury. Past-year injury occurrence predicted increased risk for past-month anxiety disorders and decreased risk of past-month depressive disorders. Our findings reveal reciprocal associations between injury and mental disorders and highlight the need for systematic assessment, prevention, and treatment of mental disorders among injured youth.

Examination of polytrauma typologies: A latent class analysis approach

Potentially traumatizing events (PTE) are highly prevalent, and are associated with detrimental effects on psychological health, including increased risk of posttraumatic stress disorder (PTSD). Multiple endorsed PTEs (polytraumatization) may have even greater effects on a person's health than the impact of a single index event. To better understand patterns of polytraumatization, person-centered analytic techniques such as Latent class analysis (LCA) are recommended. The current study used LCA to explore latent subgroupings of people based on their endorsement of PTEs, thus defining patterns in PTE exposure. The sample included 850 participants who endorsed at least one PTE on a web-administered Trauma History Questionnaire (THQ). Results indicated a best-fitting 3-class solution: (1) a class with a greater probability of experiencing interpersonal PTEs and other PTEs, (2) a class with moderate PTE exposure and higher probability of mugging and accidents, and (3) a class with low PTE exposure. Differences in age, gender, and PTSD symptom severity accounted for class membership. Results suggest the experience of interpersonal PTEs may be a risk factor for additional lifetime PTE exposure, and is associated with increased PTSD severity. Additional findings underscore the heterogenity of trauma experiences, highlighting the importance of examining such patterns in future research.

Physical disability and suicide: recent advancements in understanding and future directions for consideration

Recent research indicates a heightened risk of suicide in this population, a concern given that suicide may be more accepted for those with physical disabilities than for those without such disabilities. The relationship between physical disability and suicide has begun to be examined within empirically supported frameworks of suicide and indicates that interpersonal factors (e.g. perceived burdensomeness) and pain are mechanisms contributing to this heightened risk of suicide. The suicide rate after acquiring a physical disability, such as a spinal cord injury, and the greater odds of suicide after reporting having a disability further support the association between physical disability and suicide. The multifaceted nature of physical disability is reflected in its relationship with suicidal ideation and behaviors.

Development of a Biomarker-Based Diagnostic Algorithm for Posttraumatic Syndrome after Physical Injury: Design of the BioPTS Study

Severe physical injury is a leading cause of posttraumatic syndrome (PTS). This is to develop a biomarker-based diagnostic algorithm for posttraumatic syndrome (BioPTS) study. This is a 2-year longitudinal cohort study assessing patients who were hospitalized beginning in 2015 at Chonnam National University Hospital in Gwangju, Korea, after experiencing severe physical injuries. Baseline evaluations were made during the acute phase (within 1 month) of the physical injury and included extensive information on sociodemographic and clinical variables as well as a list of biomarkers. All participants will be followed up for 2 years, and the diagnostic and predictive validities of various biomarkers for PTS will be estimated. The BioPTS study will develop the most accurate models for the diagnosis and prediction of PTS, and will contribute to existing research regarding the complex relationships between severe physical injury and psychological issues.

Return to Work After Traumatic Injury: Increased Work-Related Disability in Injured Persons Receiving Financial Compensation is Mediated by Perceived Injustice

Purpose Traumatic injury is a leading cause of work disability. Receiving compensation post-injury has been consistently found to be associated with poorer return to work. This study investigated whether the relationship between receiving compensation and return to work was associated with elevated symptoms of psychological distress (i.e., anxiety, depression, and posttraumatic stress disorder) and perceived injustice. Methods Injured persons, who were employed at the time of injury (n = 364), were recruited from the Victorian State Trauma Registry, and Victorian Orthopaedic Trauma Outcomes Registry. Participants completed the Hospital Anxiety and Depression Scale, Posttraumatic Stress Disorder Checklist, Injustice Experience Questionnaire, and appraisals of pain and work status 12-months following traumatic injury. Results Greater financial worry and indicators of actual/perceived injustice (e.g., consulting a lawyer, attributing fault to another, perceived injustice, sustaining compensable injury), trauma severity (e.g., days in hospital and intensive care, discharge to rehabilitation), and distress symptoms (i.e., anxiety, depression, PTSD) led to a twofold to sevenfold increase in the risk of failing to return to work. Anxiety, post-traumatic stress and perceived injustice were elevated following compensable injury compared with non-compensable injury. Perceived injustice uniquely mediated the association between compensation and return to work after adjusting for age at injury, trauma severity (length of hospital, admission to intensive, and discharge location) and pain severity. Conclusions Given  that perceived injustice is associated with poor return to work after compensable injury, we recommend greater attention be given to appropriately addressing psychological distress and perceived injustice in injured workers to facilitate a smoother transition of return to work.

World Health Organization disability assessment schedule 2.0: An international systematic review

PURPOSE

This systematic review examines research and practical applications of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a basis for establishing specific criteria for evaluating relevant international scientific literature. The aims were to establish the extent of international dissemination and use of WHODAS 2.0 and analyze psychometric research on its various translations and adaptations. In particular, we wanted to highlight which psychometric features have been investigated, focusing on the factor structure, reliability, and validity of this instrument.

METHOD

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a search for publications focused on "whodas" using the ProQuest, PubMed, and Google Scholar electronic databases.

RESULTS

We identified 810 studies from 94 countries published between 1999 and 2015. WHODAS 2.0 has been translated into 47 languages and dialects and used in 27 areas of research (40% in psychiatry).

CONCLUSIONS

The growing number of studies indicates increasing interest in the WHODAS 2.0 for assessing individual functioning and disability in different settings and individual health conditions. The WHODAS 2.0 shows strong correlations with several other measures of activity limitations; probably due to the fact that it shares the same disability latent variable with them. Implications for Rehabilitation WHODAS 2.0 seems to be a valid, reliable self-report instrument for the assessment of disability. The increasing interest in use of the WHODAS 2.0 extends to rehabilitation and life sciences rather than being limited to psychiatry. WHODAS 2.0 is suitable for assessing health status and disability in a variety of settings and populations. A critical issue for rehabilitation is that a single "minimal clinically important .difference" score for the WHODAS 2.0 has not yet been established.

Disability and Mental Disorders in the Canadian Armed Forces

OBJECTIVES

The initial goal was to validate the use of a self-report measure of disability in the Canadian Armed Forces (CAF). The main goal was to document the extent of disability in personnel with and without mental disorders.

METHODS

Data were obtained from the 2013 Canadian Forces Mental Health Survey; the sample included 6700 Regular Forces personnel. Disability was measured with the 12-item version of the World Health Organization Disability Assessment Schedule (WHODAS-2); established cut points were used to demarcate severe, moderate, minimal, and no disability. The following recent (past-year) and remote (lifetime but not past-year) disorders were assessed with diagnostic interviews: posttraumatic stress disorder, major depressive episode, generalized anxiety disorder, panic disorder, and alcohol use disorder.

RESULTS

The WHODAS-2 showed good internal consistency (α = 0.89) and a 1-factor structure. Most personnel had no disability (59.2%) or minimal disability (30.8%). However, an important minority had moderate or severe disability (8.4% and 1.6%, respectively). Individuals with recent disorders reported greater disability than those without lifetime disorders, although many had minimal or no disability (41.2% and 24.7%, respectively). Disability increased with the number of recent disorders. Relative to those without lifetime disorders, individuals with remote disorders showed slightly greater disability, but most had no disabilty (57.1%) or minimal disability (35.0%).

CONCLUSIONS

The 12-item WHODAS-2 is a valid measure of disability in the CAF. Mental disorders may be important drivers of disability in this population, although limited residual disability is seen in individuals with remote disorders.