Sensitivity of the SF-36 to PTSD symptom change in veterans

Mediterranean Diet Adherence, Physical Activity, and Advanced Glycation End Products in Complex PTSD: A Comprehensive Examination of Lifestyle and Cardiovascular Risk in War Veterans

As accumulated evidence suggests that individuals with post-traumatic stress disorder (PTSD) encounter earlier and more frequent occurrences of cardiovascular diseases, the aim of this study was to ascertain the differences in lifestyle and cardiovascular risk between PTSD and complex PTSD patients. We enrolled 137 male war veterans with PTSD (89 had complex PTSD). The diagnosis was established based on 11th revision of International Classification of Diseases (ICD-11), and cardiovascular risk was estimated by the measurement of advanced glycation end products. Adherence to Mediterranean diet (MD) was lower in the complex PTSD group (2.2% vs. 12.5%, p = 0.015). Accordingly, patients with complex PTSD had lower healthy lifestyle scores in comparison to PTSD counterparts (50.6 ± 9.7 vs. 59.6 ± 10.1, p < 0.001), and a positive association was noted between MD adherence and a healthy lifestyle (r = 0.183, p = 0.022). On the other hand, differences were not noted in terms of physical activity (p = 0.424), fat % (p = 0.571) or cardiovascular risk (p = 0.573). Although complex PTSD patients exhibit worse adherence to MD and lower healthy lifestyle scores, these differences do not seem to impact physical activity, body composition, or estimated cardiovascular risk. More research is needed to clarify if this lack of association accurately reflects the state of the PTSD population or results from insufficient statistical power.

Efficacy of an internet-based written imagery rescripting intervention for survivors of institutional childhood abuse - A randomized controlled trial

BACKGROUND

Institutional childhood abuse can have a long-term impact on the survivors' mental health, however, treatment for this group is limited and not always accessible. An internet-based intervention was developed, with the aim to reduce psychological sequelae relating to institutional abuse.

OBJECTIVE

This study aimed to examine the efficacy of an online imagery rescripting intervention for survivors of institutional abuse, through assessing symptoms of depression, anxiety, PTSD, and CPTSD.

PARTICIPANTS AND SETTING

Seventy-two adult survivors of institutional childhood abuse in the former German Democratic Republic were randomized either to the intervention (n = 38) or to the waitlist condition (n = 34). The intervention consisted of 10 modules, based on written imagery rescripting, and involved asynchronous therapist contact.

METHODS

Primary outcomes included symptoms of depression (PHQ-9), anxiety (GAD-7), PTSD (ITQ), and CPTSD (ITQ DSO). The intervention condition was assessed at baseline, post-intervention, 3-, and 6-month follow-up.

RESULTS

Intention-to-treat analyses revealed a significant symptom reduction from baseline to post-assessment with medium to large effects for all main outcomes (d = 0.45 to d = 0.76), in favor of the intervention condition. Significant interactions between condition (intervention vs. wailist) and time (baseline vs. post-assesment) were revealed for all main outcomes (p < .001 to p = .024). The effects were maintained at follow-up.

CONCLUSIONS

The results suggest online writing-based imagery rescripting as a promising treatment option for adults formerly institutionalized in residential care. Future research is needed to explore its effectiveness for other groups of patients suffering from abuse and neglect.

The Impact of Service Dogs on Military Veterans and (Ex) First Aid Responders With Post-traumatic Stress Disorder

Due to its novelty and lack of empirical study it remains unclear if a service dog truly mitigates the burden of post-traumatic stress disorder (PTSD) symptoms. To cross sectionally investigate the effect of service dogs on veterans and first aid responders with PTSD, we studied subjective and physiological parameters in 65 individuals divided over four groups. These groups were: veterans and first aid responders with PTSD and a service dog (n = 20), with PTSD and a companion dog (n = 10), with PTSD without a dog (n = 12) and a group without PTSD (n = 23). We found that veterans and first aid responders with PTSD who had a service dog showed significantly less PTSD related symptoms, better sleep quality, and better wellbeing experience, than those with a companion dog. Those with a service dog additionally experienced fewer PTSD related symptoms than those without a service dog and tended to walk more than individuals without PTSD. No differences were found in cortisol levels between groups though and changes in both salivary cortisol and activity were not linked to improved welfare experience. Though the use of physiological measurement methods thus warrants more research, our study indicates that the subjective experience of wellbeing, sleep quality and PTSD related symptoms is improved by the presence of a service dog.

The international trauma questionnaire (ITQ) measures reliable and clinically significant treatment-related change in PTSD and complex PTSD

Background: The International Trauma Questionnaire (ITQ) is a validated measure that assesses ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD). An important task is to determine whether the ITQ is an appropriate evaluative measure for clinical trials. Objective: To assess the psychometric properties of the ITQ in the context of treatment and determine if the ITQ measures reliable and clinically significant change over the course of a psychosocial intervention. Method: Analyses were based on data from an online skills training programme delivered to 254 U.S. Veterans. Reliability and validity of the ITQ scores were assessed at baseline. Changes in symptom scores and probable diagnostic rates were compared at pre-, mid- and post-treatment. A reliable change index (RCI) score was computed to classify participants as improved, unchanged, or worsened. The PCL-5 was used as a comparison measure. Results: Baseline concurrent and factorial validity was similar to previous studies. Internal consistency at each assessment was excellent and comparable to the PCL-5. Decline in symptoms from pre-to-post-treatment was significant for PTSD and CPTSD symptom profiles. Rate of probable disorder (PTSD or CPTSD) declined significantly from pre-treatment to post-treatment. Pre-to-post treatment declines exceeded the critical RCI values for the ITQ. Clinically significant changes were observed where most participants improved, some stayed the same, and few worsened. The performance of the ITQ was consistent with the PCL-5 regarding sensitivity to change. Conclusion: This study provides the first demonstration that the ITQ measures reliable and clinically significant treatment-related change of ICD-11 PTSD and CPTSD symptoms.

Using patient-reported outcomes to understand the effectiveness of guideline-concordant care for post-traumatic stress disorder in clinical practice

RATIONALE

Identifying predictors of improvement amongst patients receiving routine treatment for post-traumatic stress disorder (PTSD) could provide information about factors that influence the clinical effectiveness of guideline-concordant care. This study builds on prior work by accounting for delivery of specific evidence-based treatments (EBTs) for PTSD while identifying potential predictors of clinical improvement using patient-reported outcomes measurement.

METHOD

Our sample consisted of 2 643 US Department of Veterans Affairs (VA) outpatients who initiated treatment for PTSD between 2008 and 2013 and received at least four PTSD checklist (PCL) measurements over 12 weeks. We obtained PCL data as well as demographic, diagnostic, and health services use information from the VA corporate data warehouse. We used latent trajectory analysis to identify classes of patients based on PCL scores, then determined demographic, diagnostic, and treatment predictors of membership in each class.

RESULTS

Patients who met our PCL-based inclusion criteria were far more likely than those who did not receive EBTs. We identified two latent trajectories of PTSD symptoms. Patients in the substantial improvement group (25.9%) had a mean decrease in PCL score of 16.24, whereas patients in the modest improvement group improved by a mean of 8.09 points. However, there were few differences between the groups, and our model to predict group membership was only slightly better than chance (area under the curve [AUC] = 0.55). Of the 64 covariates we tested, the only robust individual predictor of improvement was gender, with men having lower odds of being in the substantial improvement group compared with women (odds ratio [OR] 0.76; 95% confidence interval [CI] 0.58-0.96).

CONCLUSION

VA patients with PTSD can realize significant improvement in routine clinical practice. Although available medical records-based variables were generally insufficient to predict improvement trajectory, this study did indicate that men have lower odds of substantial improvement than women.

Cognitive Behavior Therapy for Persistent Severe Fatigue in Childhood Cancer Survivors: A Pilot Study

OBJECTIVES

Fatigue is a common and disabling late effect in childhood cancer survivors (CCS). In this pilot study, the effectiveness of cognitive behavior therapy (CBT) in CCS with persistent and severe fatigue was retrospectively evaluated.

MATERIALS AND METHODS

In total, 33 consecutively referred CCS with persistent severe fatigue were offered CBT. The primary outcome was fatigue severity (Checklist Individual Strength, Fatigue Severity Subscale). Secondary outcomes were functional impairment, psychologic distress, and quality of life (QoL).

RESULTS

In total, 25 CCS completed CBT (76%). The mean age of CCS was 23.1 years (range, 11 to 42 y), mean age at primary cancer diagnosis was 9.7 years (range, 0 to 17 y), and mean time since primary cancer diagnosis was 13 years (range, 5 to 34 y). Fatigue severity ([INCREMENT] 17.4; confidence interval (CI)=12.7-22.1; P<0.001), functional impairment (SIP8 [INCREMENT] 470.3; CI=312.3-628.4; P<0.001/SF36 [INCREMENT] 11.7; CI=17.2-6.3; P<0.001), and psychologic distress ([INCREMENT] 26.4; CI=15.6-34.9; P<0.001) were significantly decreased at second assessment. QoL ([INCREMENT] 13.5; CI=22.0-4.3; P=0.005) was significantly improved. A total of 23 CCS of the 33 CCS (70%) met the criteria for clinically significant improvement of fatigue.

CONCLUSIONS

In this pilot study, the majority of severely fatigued CCS showed a clinically significant reduction in fatigue following CBT. Moreover, daily function and QoL improved, and psychologic distress decreased.

Longitudinal association of PTSD symptoms and self-reported physical functioning among Veterans

BACKGROUND

Few longitudinal studies have investigated the potentially dynamic relationship between Posttraumatic Stress Disorder (PTSD) and physical functioning, and the number of follow-up timepoints have been limited. We evaluated whether PTSD symptoms predicted future physical functioning and vice versa using five assessments over four years.

METHODS

Data was used from a longitudinal cohort of 695 participants recruited from Veteran Affairs medical outpatient clinics who experienced a traumatic event. PTSD symptom severity was assessed annually with the PTSD Checklist (PCL). Physical functioning was measured with the 10-item subscale of the SF-36. An autoregressive cross-lagged panel model was used to determine the temporal associations between PTSD and physical functioning, adjusting for age, sex, ethnicity, education and employment. Comorbidities and health behaviors were added to assess their roles in the relationship.

RESULTS

Greater PTSD symptom severity predicted worse physical functioning the following year (average β = -0.10, P <0.001), where a 10-point increase in PCL score predicted a 0.3-point decline in physical function score over one year. Similarly, better physical functioning also predicted reduced PTSD severity the following year, but to a smaller magnitude (average β = -0.04, P = .003). The pattern of effects was similar after controlling for comorbidities and health behaviors.

LIMITATIONS

Both primary variables relied on self-report, and generalizability may be limited by the mostly male Veteran sample.

CONCLUSIONS

Our results support a bidirectional, but unequal, relationship between PTSD and physical functioning over time. They also highlight the importance of long-term control of PTSD symptoms in preventing functional decline.

A Retrospective Comparative Effectiveness Study of Medications for Posttraumatic Stress Disorder in Routine Practice

OBJECTIVE

Fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine have consistently shown efficacy for posttraumatic stress disorder (PTSD) in meta-analyses of randomized controlled trials. However, no study has compared the effectiveness of these agents in routine clinical practice. We conducted a retrospective comparative effectiveness study of these 5 medications using electronic medical record data.

METHODS

We identified 2,931 Department of Veterans Affairs outpatients initiating treatment for PTSD between fiscal years 2004 and 2013 who received 1 of the 5 medications at an adequate dose and duration, combined with baseline and endpoint PTSD Checklist (PCL) measurements. Patients were identified based on clinical diagnoses of PTSD (DSM-IV criteria). We weighted participants in order to balance pretreatment characteristics. We compared continuous changes on total PCL score, symptom cluster scores, and sleep items, as well as categorical changes including reliable improvement and loss of PTSD diagnosis, using weighted regression analyses. We conducted exploratory analysis to determine whether any patient characteristics or service use variables predicted loss of PTSD diagnosis.

RESULTS

Patients improved by a mean of 5-6 points on the PCL over approximately 6 months of treatment. While half of patients had a reliable improvement of 5 points or more on the PCL, less than a fifth achieved loss of PTSD diagnosis. There were no differences between medications. The only significant (P < .001) predictor of loss of PTSD diagnosis was concurrent treatment with evidence-based psychotherapy.

CONCLUSIONS

Available evidence-based medications for PTSD are equally effective in clinical practice. Although effective, our data suggest that patients choosing medication treatment for PTSD should consider concurrent treatment with evidence-based psychotherapy in order to maximize their chances of meaningful improvement.

Prospective associations between changes in mental health symptoms and health-related quality of life in veterans seeking posttraumatic stress disorder residential treatment

BACKGROUND AND OBJECTIVES

This study examined prospective associations between changes in mental health symptoms (posttraumatic stress disorder [PTSD], depression) and health-related quality of life (physical health, psychological well-being) for veterans with PTSD.

DESIGN

This study focused on 139 patients who completed a residential treatment program for PTSD in the Veterans Health Administration.

METHODS

Patients completed the veteran-specific, 12-item Medical Outcomes Study Short Form, PTSD Checklist - Military version, and Beck Depression Inventory at pre-treatment, discharge, and a four-month follow-up. When accounting for demographic factors, combat exposure, and baseline scores on the respective outcome variables (e.g. mental health, physical health, PTSD, and depressive symptoms), a series of multivariate analyses were conducted for treatment-related changes in mental and physical health on the outcome measures.

RESULTS

Reductions in PTSD symptomatology during the treatment period were prospectively linked with better health-related outcomes at the four-month follow-up. In addition, improved physical health and psychological well-being during treatment were each similarly associated with better PTSD and depression outcomes in the months following treatment.

CONCLUSIONS

Addressing concerns in mental and physical health might have synergistic effects across both domains, supporting the need for holistic models and integrated health care strategies for treating veterans with PTSD.

Administration of an amino Acid-based regimen for the management of autonomic nervous system dysfunction related to combat-induced illness

The etiology and pathophysiology of posttraumatic stress disorder (PTSD) remains poorly understood. The nutritional deficiencies associated with the altered metabolic processes of PTSD have not previously been studied in detail. This pilot study measured the reduction in symptoms in 21 military veterans reporting moderate to severe symptoms associated with PTSD. Two amino acid–based medical foods specifically formulated with biogenic amines and other nutrients were administered to study subjects targeting specific neurotransmitter deficiencies resulting from altered metabolic activity associated with PTSD. This study included the Physician Checklist – Military (PCL-M), Short Form General Health Survey (SF-36), and Epworth Sleepiness Scale to measure the change in each subject’s score after 30 days of administration. An average decrease of 17 points was seen in the PCL-M, indicating a reduction in PTSD symptoms (P < 0.001). The mental health component of the SF-36 showed an average 57% increase in the subjects’ mental health rating (P < 0.001). The results of this initial study demonstrate that addressing the increased dietary requirements of PTSD can improve symptoms of the disease while eliminating significant side effects. A larger, double-blind, randomized, placebo-controlled trial is warranted.

The impact of PTSD symptoms on physical and mental health functioning in returning veterans

This study aimed to determine the unique impact of PTSD symptoms, beyond other frequently examined factors on physical and mental health functioning in a sample of returning veterans. Assessments of 168 returning OEF/OIF veterans conducted an average of six months following return from deployment included measures of emotional disorders and the Short Form (36) Health Survey. Hierarchical multiple regressions revealed significant, unique contribution of Clinician-Administered PTSD Scale (CAPS) score above all other predictors in the model (demographics, severity of trauma exposure, physical injury, substance abuse and depressive symptoms), for both the physical (8%) and mental (6%) health aggregate scores, along with significant prediction of physical health (4-10%) and mental health (3-7%) subscale scores. The only other significant predictors were age for physical health scores, and depressive symptoms for mental health scores. PTSD criterion B (re-experiencing) symptoms uniquely predicted reduced physical health functioning and higher experience of bodily pain, while criterion D (hyperarousal) symptoms uniquely predicted lower feelings of energy/vitality and poorer perceptions of emotional health.

PTSD is a chronic, fluctuating disorder affecting the mental quality of life in older adults

OBJECTIVES

Examine the longitudinal course of posttraumatic stress disorder (PTSD) in older adults and its influence on mental health quality of life (MHQoL).

DESIGN

Evaluation performed at baseline, and 3 and 6 months postrandomization as part of a longitudinal trial.

PARTICIPANTS AND SETTINGS

A total of 1,185 participants, with a mean (±SD) age of 73.53 (±5.98) years, at seven primary care sites (including five Veterans Affairs clinics), were divided into four groups, namely, no trauma (n = 661), trauma only (n = 319), partial PTSD (n = 114), and PTSD (n = 81), based on reports of trauma and associated PTSD symptoms.

MEASUREMENTS

The prevalence of comorbid depression, anxiety, and alcohol use disorders, assessed using the Diagnostic and Statistical Manual, Fourth Edition, criteria and changes in MHQoL, as assessed by the Short Form-36 mental component score.

RESULTS

At baseline, the PTSD group had higher frequencies of comorbid depression and anxiety disorders and worse MHQoL than the other groups. Both chronic (participants diagnosed with PTSD at all three assessments) and fluctuating (participants moving to or from one of the other groups) trajectories of course were observed during the follow-up period, which appeared to be separate from that of the comorbid disorders. Even after accounting for those comorbid disorders, PTSD had an independent association with poorer MHQoL at multiple time points, especially in men, whereas trauma without PTSD symptoms (trauma only) had better MHQoL.

CONCLUSIONS

PTSD had chronic and fluctuating courses, with negative effects on MHQoL, while partial PTSD might represent a transitional state, underscoring the need to better identify and treat PTSD at any phase in later life.

The association of PTSD with physical and mental health functioning and disability (VA Cooperative Study #569: the course and consequences of posttraumatic stress disorder in Vietnam-era veteran twins)

PURPOSE

To assess the relationship of posttraumatic stress disorder (PTSD) with health functioning and disability in Vietnam-era Veterans.

METHODS

A cross-sectional study of functioning and disability in male Vietnam-era Veteran twins. PTSD was measured by the Composite International Diagnostic Interview; health functioning and disability were assessed using the Veterans RAND 36-Item Health Survey (VR-36) and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). All data collection took place between 2010 and 2012.

RESULTS

Average age of the 5,574 participating Veterans (2,102 Vietnam theater and 3,472 non-theater) was 61.0 years. Veterans with PTSD had poorer health functioning across all domains of VR-36 and increased disability for all subscales of WHODAS 2.0 (all p < .001) compared with Veterans without PTSD. Veterans with PTSD were in poorer overall health on the VR-36 physical composite summary (PCS) (effect size = 0.31 in theater and 0.47 in non-theater Veterans; p < .001 for both) and mental composite summary (MCS) (effect size = 0.99 in theater and 0.78 in non-theater Veterans; p < .001 for both) and had increased disability on the WHODAS 2.0 summary score (effect size = 1.02 in theater and 0.96 in non-theater Veterans; p < .001 for both). Combat exposure, independent of PTSD status, was associated with lower PCS and MCS scores and increased disability (all p < .05, for trend). Within-pair analyses in twins discordant for PTSD produced consistent findings.

CONCLUSIONS

Vietnam-era Veterans with PTSD have diminished functioning and increased disability. The poor functional status of aging combat-exposed Veterans is of particular concern.

Treatment-related reductions in PTSD and changes in physical health symptoms in women

This study examined the relationship between change in posttraumatic stress disorder (PTSD) symptoms over the course of PTSD treatment and the association with changes in general physical health symptoms. Both positive health habits (e.g., exercise) and negative (e.g., smoking), were examined to determine if they accounted for the association between changes in PTSD severity over time and changes in physical health. Participants were 150 women seeking treatment for PTSD. Latent growth curve modeling indicated a substantial relationship (R (2) = 34%) between changes in PTSD and changes in physical health that occurred during and shortly following treatment for PTSD. However, there was no evidence to suggest that changes in health behaviors accounted for this relationship. Thus, PTSD treatment can have beneficial effects on self-reported physical health symptoms, even without direct treatment focus on health per se, and is not accounted for by shifts in health behavior.

Comparing the stability of diagnosis in full vs. partial posttraumatic stress disorder

We studied differences in diagnostic stability between patients with full and patients with partial posttraumatic stress disorder (PTSD). We collected self-reported symptoms of PTSD, anxiety, depression, and functioning at a Veterans Affairs mental health clinic (n = 1962). We classified patients as meeting full or partial PTSD based upon their initial assessment. We performed Kaplan-Meier survival analysis to compare stability of diagnosis over time and Cox proportional hazards models to understand how comorbid symptoms and level of functioning confounded the relationship. We performed a chart review to examine differences in treatment received by the two groups. Patients in the partial PTSD group lost their diagnosis significantly faster and at significantly higher rates than did patients with full PTSD. Comorbid symptoms contributed significantly to this difference. Mental health treatments delivered to the two groups were similar. These diagnoses appear to be different, suggesting that people with partial PTSD may benefit from a different clinical approach.