Posttraumatic stress and stigma in active-duty service members relate to lower likelihood of seeking support

No pain, no gain: The military overtraining hypothesis of musculoskeletal stress and injury

The purpose of this manuscript is to present a model of military overtraining and subsequent injury, discharge, and disability. Military training and combat operations are physically and physiologically demanding, placing great strain on the musculoskeletal system of warfighters. Non-battle musculoskeletal injuries (MSKI) are common and present a serious threat to operational readiness in today's military. MSKI risk stratification and prevention are an active area of research and is steeped in the background of sports science. Here, a model is proposed that incorporates the theory of General Adaptation Syndrome to describe how military training stressors may exceed that of training in traditional athletics and may induce sub-optimal training stressors. Positive feedback loops are discussed to explain how military overtraining (MOT) creates a system of ever-increasing stressors that can only be fully understood in the greater context of all environmental factors leading to overtraining. The Military Overtraining Hypothesis (MOTH) is proposed as a model that encapsulates the elevated MSKI risk in combat arms and other operational military personnel as an effort to broaden understanding of multifactorial military MSKI etiologies and as a tool for researchers and commanders to contextualize MSKI research and risk mitigation interventions.

Inner Peace needs of male psychiatric patients in post-war Croatia are associated with their needs to clarify open issues in their life and their needs for forgiveness

Background

More than 25 years after the end of the Balkan war, many people belonging to the post-war population are still traumatized by the war events and have been treated for post-traumatic stress disorder or other psychiatric diagnoses. We were interested in their Inner Peace needs, how these relate to indicators of mental health, and their needs to clarify open processes in their lives and to forgive and be forgiven.

Materials and methods

In a cross-sectional survey with standardized questionnaires (i.e., SpNQ, PCL-M, HADS, and BMLSS), 638 male patients who were treated in seven psychiatric centers in Croatia were enrolled. 68% were diagnosed with PTSD and 32% had other psychiatric diagnoses. Most had actively participated in the Balkan war (79%), and 60% for the whole war period.

Results

Strong needs to "immerse into beauty of nature" were stated by 47%, to "dwell at a place of quietness and peace" by 66%, and to "find inner peace" by 57%. These Inner Peace needs were highest in men treated with PTSD diagnoses as compared to men with other psychiatric diagnoses and were slightly lower in men who were active during the whole war period as compared to shorter phases of war participation. Regression analyses with Inner Peace needs as a dependent variable revealed that Clarification/Forgiveness needs were the best predictor, with further influences of PTSD symptoms and life satisfaction, explaining altogether 49% of the variance. The best predictors of their PTSD symptoms were life satisfaction, perceived burden, depressive symptoms, Inner Peace needs, religious trust, and duration of war participation, explaining 60% of the variance.

Conclusion

In Croatian male war participants in clinical treatment decades after the war, Inner Peace needs indicate their ongoing intention to let go of their disturbing experiences and to find states of inner peace, particularly at specific places of quietness and peace. These needs can be considered metaphors for longing for wholeness, integrity, and safety, in contrast to the ongoing impact of unresolved issues. Thus, apart from psychotherapeutic treatment, sheltered places of nature, inspiration, and reconciliation might be elements to improve the difficult situation of post-war victims still suffering from their experiences.

Psychological Resilience in U.S. Military Veterans: Results from the 2019-2020 National Health and Resilience in Veterans Study

Following exposure to traumatic life events, most individuals are psychologically resilient, and experience minimal-to-no symptoms of posttraumatic stress, major depressive, or generalized anxiety disorders. To date, however, most research has focused on factors associated with adverse post-trauma mental health outcomes rather than understanding those associated with psychological resilience. In particular, little is known about factors associated with psychological resilience in veterans, despite their high rates of trauma exposure, such as combat and military sexual trauma. To address this gap, we used a discrepancy-based psychiatric resilience (DBPR) analytic approach to operationalize psychological resilience, and to identify modifiable health and psychosocial factors associated with resilience in a nationally representative sample of U.S. veterans (N = 4,069). DBPR scores were computed by regressing a composite measure of distress (posttraumatic stress, major depressive, and generalized anxiety disorder symptoms) onto measures of adverse childhood experiences, combat exposure, military sexual trauma, and cumulative potentially traumatic events (e.g., natural disaster, life-threatening illness/injury). Psychological resilience was operationalized as lower actual, relative to predicted, composite distress scores. Results revealed that greater emotional stability (22.9% relative variance explained [RVE]) and mindfulness (13.4% RVE), lower likelihood of lifetime histories of MDD or PTSD (12.8% RVE), greater purpose in life (11.9% RVE), and lower severity of somatic symptoms (10.8% RVE) explained the majority of the variance in resilience scores (total R2 = 0.40). Taken together, results of this study illustrate the utility of a DBPR score approach to operationalizing psychological resilience to traumatic stress in U.S. veterans, and identify several modifiable health and psychosocial factors that can be targeted in prevention and treatment efforts designed to bolster resilience in this population.

Interdisciplinary Treatment for Survivors of Critical Illness in the Era of COVID-19: Expanding the Post-Intensive Care Recovery Model and Impact on Psychiatric Outcomes

BACKGROUND

Post-intensive care unit recovery programs for survivors of critical illness related to COVID-19 remain limited, ever-evolving, and under active investigation. Mental health professionals have an emerging role within this multidisciplinary care model.

OBJECTIVE

This article explores the design and implementation of an intensive care unit follow-up clinic in New Orleans during the era of COVID-19. Survivors of a critical illness due to COVID-19 were offered multidisciplinary outpatient treatment and systematic psychological screening up to 6 months after the initial clinic visit.

METHODS

We implemented a prospective, observational study at a post-intensive care syndrome (PICS) clinic for survivors of a critical illness related to COVID-19 embedded within an academic Veterans Affairs hospital. Our team identified patients at high risk of PICS and offered them a clinic consultation. Patients were provided the following interventions: review of the critical care course, medication reconciliation, primary care, psychopharmacotherapy, psychotherapy, and subspecialty referrals. Patients were followed up at 1- to 3-month intervals. Psychological symptom screening was conducted with Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition, 9-question Patient Health Questionnaire, and 7-item Generalized Anxiety Disorder assessments.

RESULTS

Seventy-seven total patients were identified to be at high risk of PICS from March to November 2020, and of this cohort, 44 (57.14%) survived their COVID-19 hospitalizations. Of the surviving 44 patients contacted, 21 patients established care in the PICS clinic and returned for at least 1 follow-up visit. At initial evaluation, 66.7% of patients demonstrated clinically meaningful symptoms of post-traumatic stress disorder. At 3-month follow-up, 9.5% of patients showed significant post-traumatic stress disorder symptoms. Moderate-to-severe symptoms of anxiety were present in 38.1% of patients at initial evaluation and in 4.8% of patients at 3 months. Moderate-to-severe symptoms of depression were present in 33.4% and 4.8% of patients at initial visit and at 3 months, respectively.

CONCLUSIONS

A PICS clinic opened by dually trained internist-psychiatrists serves as a successful posthospitalization model of care for COVID-19 intensive care unit survivors. This type of health care infrastructure expands the continuum of care for patients enduring the consequences of a critical illness. We identified a high prevalence of post-traumatic stress, anxiety, and depression, along with other post- intensive care unit complications warranting an intervention. The prevalence of distressing psychological symptoms diminished across all domains by 3 months. Our results deserve replication, along with further investigation of the value that PICS clinics can provide for patients and families.

In the face of change: Which coping strategies predict better psychosocial outcomes in face transplant recipients?

OBJECTIVES

Face transplantation aims to improve patients' quality of life and psychosocial functioning in patients with a disfiguring injury. With 40 cases worldwide, little is known about coping strategies predicting resilient outcomes.

DESIGN

Six patients followed in Boston, completed the Brief COPE (Carver, 1997) along with validated measures of depression, self-esteem, and quality of life - every 3 months during the first year post-transplant and every 6 months thereafter, up to 36 months post-transplant.

ANALYSES

Due to sample size and distribution of the data, nonparametric tests were used to characterize the relation of coping strategies with psychosocial outcomes.

RESULTS

As expected, active coping strategies were associated with better mental health pre-transplant, while avoidant coping strategies were associated with poorer mental health. Patients using support-based strategies reported better mental health at baseline. Post-transplant, the pattern reversed such that avoidant strategies appeared protective, when looking at mental health trajectories over 18 months. Importantly, trends identified during the first 18 months matched the trajectories of all patients with existing data up to 36 months post-transplant, for all outcomes measured.

CONCLUSION

Different coping strategies support optimal outcomes in the pre-versus post-transplant phases. Pre-transplant data may better inform interventions supporting mental health of transplant candidates than predict post-transplant behavior. Early post-transplant data seems to provide promising insight in long term psychosocial outcomes.

CLINICAL IMPLICATIONS

Our data stresses the need for pre-transplant assessment of coping and post-transplant coping training. Research aiming to optimize post-transplant psychosocial outcomes should consider coping as a promising target for intervention.

Military self-stigma as a mediator of the link between military identity and suicide risk

US military Veterans are at greater risk for suicide than those who have never served in the US military. Recent federal calls include the need to investigate military-specific suicide risk and protective factors among military-affiliated populations. To date, no study has examined the link between military identity, self-stigma, and suicide risk. The current study used a nationally representative sample of post-Vietnam US military Veterans (N = 1,461) in order to determine relationships between military identity, self-stigma, and suicide risk. Idealism (OR = 0.86) with less odds of elevated suicide risk, whereas individualism (OR = 1.15) and military self-stigma (OR = 1.39) were associated with increased odds of elevated suicide risk. Military self-stigma was found to mediate the relationship between military identity components and suicide risk. Implications for conceptualization of military Veteran identity, suicide prevention, and future research are discussed.

Access and attitudinal barriers to engagement in integrated primary care mental health treatment for rural populations

PURPOSE

Compared to urban areas, rural populations are less likely to engage in mental health care. Using data from the Study to Promote Innovation in Rural Integrated Telepsychiatry, we examined the effect of rurality on engagement in mental health treatment as well as the role of potential mediators.

METHODS

Data were obtained from medical records and surveys. We defined rurality using the rural-urban commuting area codes. Baseline mediators included the Endorsed and Anticipated Stigma Inventory and the Assessment of Perceived Access to Care. Engagement outcomes included number of psychotherapy visits and self-reported medication use. We used path analysis to examine the relationship between rurality and engagement and the influence of mediating variables.

FINDINGS

Rural participants were less likely to initiate psychotherapy (OR = 0.49; adjusted P = .036), although rurality was not associated with number of psychotherapy sessions or medication use. Rurality was associated with a small elevation in negative beliefs about mental health, but this potential mediator was not associated with engagement. Rurality was negatively associated with lower perceived need for treatment (OR = 0.67, adjusted P = .040), which was in turn positively associated with initiating psychotherapy (OR = 1.99, adjusted P = .001).

CONCLUSIONS

Neither rurality itself nor the potential mediators had a large effect on engagement. Federally Qualified Health Centers offering colocated and/or integrated mental health care appear to be mostly mitigating rural-urban disparities in mental health engagement. Improving rates of psychotherapy initiation for rural patients should remain a policy goal.

Resilience to traumatic stress in U.S. military veterans: Application of a novel classification approach in a nationally representative sample

Resilience has been of particular interest to researchers and clinicians focused on response to trauma. In the current study, we employed a novel, discrepancy-based psychiatric resilience (DBPR) analytic approach to operationalizing resilience and examined its relation to potentially protective psychosocial factors in a nationally representative sample of U.S. veterans (N = 2704). Cumulative lifetime trauma burden, severity of PTSD symptoms, and protective factors such as personality characteristics (e.g., conscientiousness), protective psychosocial characteristics (e.g., purpose in life), and social connectedness (e.g., secure attachment style) were assessed. PTSD Checklist (PCL) scores were regressed onto cumulative trauma burden for the entire sample and a predicted PCL score was generated for each veteran. Resilience was operationalized as a lower actual relative to predicted PCL score. Results of a relative importance analysis revealed that somatic symptoms (22.5% relative variance explained [RVE]), emotional stability (22.4% RVE), and a secure attachment style (14.1%) explained the majority of the variance in resilience scores. These results demonstrate the utility of a DBPR approach to operationalizing resilience in U.S. military veterans. They also identify potentially modifiable psychosocial factors that may be bolstered in prevention and treatment efforts designed to mitigate the negative effects of trauma and promote resilience in this population.

Self-reported PTSD symptoms and social support in U.S. military service members and veterans: a meta-analysis

Background: The mental health burden of posttraumatic stress disorder (PTSD) is high in U.S. military samples. Social support is one of the most robust protective factors against PTSD and a recent meta-analysis indicates that this relationship is even stronger in military samples compared to civilian samples. Yet no meta-analyses have explored factors impacting this association in veterans and military service members (VSMs). Objective: The current meta-analysis examined demographic, social support, and military characteristics that may moderate the relationship of PTSD severity and social support among U.S. VSMs. Method: A search identified 37 cross-sectional studies, representing 38 unique samples with a total of 18,766 individuals. Results: The overall random effects estimate was -.33 (95% CI: -.38, -.27, Z = -10.19, p <.001), indicating that lower levels of social support were associated with more severe PTSD symptoms. PTSD measures based on the Diagnostic and Statistical Manual (DSM)-III had a larger effect size than measures based on DSM-IV or DSM-5. The social support source was a significant moderator such that support perceived from non-military sources was associated with a larger effect size than support perceived from military sources. This finding held after accounting for covariates. Deployment-era, timing of social support, and age were also significant moderators, but were no longer significantly associated with effect size after adjusting for covariates. Although previous meta-analyses have shown social negativity to be more impactful than positive forms of social support, there were too few studies conducted to evaluate social negativity in moderator analyses. Conclusion: Results suggest that social support received from civilians and in the home environment may play a greater protective role than social support received from military sources on long-term PTSD symptom severity. The literature on social support and PTSD in U.S. VSMs would be strengthened by studies examining the association of social negativity and PTSD symptoms.

Social Robots for Supporting Post-traumatic Stress Disorder Diagnosis and Treatment

Post-Traumatic Stress Disorder (PTSD) is a severe psychiatric disorder with profound public health impact due to its high prevalence, chronic nature, accompanying functional impairment, and frequently occurring comorbidities. Early PTSD symptoms, often observed shortly after trauma exposure, abate with time in the majority of those who initially express them, yet leave a significant minority with chronic PTSD. While the past several decades of PTSD research have produced substantial knowledge regarding the mechanisms and consequences of this debilitating disorder, the diagnosis of and available treatments for PTSD still face significant challenges. Here, we discuss how novel therapeutic interventions involving social robots can potentially offer meaningful opportunities for overcoming some of the present challenges. As the application of social robotics-based interventions in the treatment of mental disorders is only in its infancy, it is vital that careful, well-controlled research is conducted to evaluate their efficacy, safety, and ethics. Nevertheless, we are hopeful that robotics-based solutions could advance the quality, availability, specificity and scalability of care for PTSD.

PTSD networks of veterans with combat versus non-combat types of index trauma

BACKGROUND

Network analysis has become popular among PTSD researchers for studying causal structure or interrelationships among symptoms. However, some have noted that results do not seem to be consistent across studies. Preliminary evidence suggests that trauma type may be one source of variability.

METHODS

The current study sought to examine the PTSD networks of veterans with combat versus non-combat index trauma. Participants included 944 veterans who completed the PTSD Checklist for DSM-5 at intake at two VA PTSD clinics.

RESULTS

There were many similarities between the combat and non-combat trauma networks, including strong edges between symptoms that were theoretically related or similar (e.g., avoidance) and negative emotion being a highly central symptom. However, correlations of edge weights (0.509) and node centrality (0.418) across networks suggested moderate correspondence, and there appeared to be some differences associated with certain symptoms. Detachment was relatively more central and the connections of negative emotion with blame and lack of positive emotion with reckless behavior were stronger for veterans with combat-related index trauma.

LIMITATIONS

The data were cross-sectional, which limits the ability to infer directional relationships between symptoms. In addition, the sample was likely not large enough to directly test for differences between networks via network comparison tests.

CONCLUSIONS

Although there were many similarities, results also suggested some variability in PTSD networks associated with combat versus non-combat index trauma that could have implications for conceptualizing and treating PTSD among veterans.

Outdoor recreational activity experiences improve psychological wellbeing of military veterans with post-traumatic stress disorder: Positive findings from a pilot study and a randomised controlled trial

Exposure to the natural environment is increasingly considered to benefit psychological health. Recent reports in the literature also suggest that outdoor exposure that includes recreational pursuits such as surfing or fishing coupled with opportunities for social interaction with peers may be beneficial to Armed Forces Veterans experiencing Post-Traumatic Stress Disorder (PTSD). Two studies were conducted to evaluate this possibility. In particular, these studies aimed to test the hypothesis that a brief group outdoor activity would decrease participants’ symptoms as assessed by established measures of PTSD, depression, anxiety and perceived stress, and increase participants’ sense of general social functioning and psychological growth. Experiment one employed a repeated measures design in which UK men and women military veterans with PTSD (N = 30) participated in a group outdoor activity (angling, equine care, or archery and falconry combined). Psychological measures were taken at 2 weeks prior, 2 weeks post, and at 4 month follow up. We obtained a significant within participant main effect indicating significant reduction in PTSD symptoms. Experiment two was a waitlist controlled randomised experiment employing an angling experience (N = 18) and 2 week follow up. In experiment 2 the predicted interaction of Group (Experimental vs. Waitlist Control) X Time (2 weeks pre vs. 2 weeks post) was obtained indicating that the experience resulted in significant reduction in PTSD symptoms relative to waitlist controls. The effect size was large. Additional analyses confirmed that the observed effects might also be considered clinically significant and reliable. In sum, peer outdoor experiences are beneficial and offer potential to complement existing provision for military veterans with Post Traumatic Stress Disorder.

Barriers and Facilitators to Help-Seeking for Individuals With Posttraumatic Stress Disorder: A Systematic Review

Posttraumatic stress disorder (PTSD) brings with it diagnostic symptoms that can be debilitating and persist for years. Left untreated, PTSD can have far-reaching and damaging consequences for the individual, families, communities, and society at large. Although early detection and intervention are recognized as key to the effective treatment of PTSD, many individuals who suffer from PTSD do not seek essential health services. The aim of the present study was to identify the barriers and facilitators to help-seeking for individuals with PTSD, based on existing literature. A systematic review, modeled on the Joanna Briggs Institute methodology for systematic reviews, examined studies cited in PsycINFO, Medline, Embase, CINAHL, and PILOTS published from January 1980 to January 2019. Eligible studies measured barriers and facilitators to help-seeking for adults with PTSD. Two reviewers independently screened citations, and double data extraction was exercised. Of 2,391 potentially relevant citations, 21 studies, published between 1989 and 2018 and based in six countries, were included. Seventeen studies focused on military as a target population. We identified 10 principal barrier and facilitator themes: trauma-related; treatment; therapist or provider; knowledge; access; health care system; sociocultural environment; values, beliefs, and priorities; past experiences; and medical care needs and illness burden. In identifying prominent barriers and facilitators to help-seeking for individuals with PTSD, this review highlights opportunities to inform policies and programs that promote PTSD knowledge and recognition, reduce public and personal stigma, improve access and quality of care, and encourage support for patients and families living with PTSD.

Relations Between Thwarted Belongingness, Perceived Burdensomeness, and History of Suicide Attempts and Readiness for Mental Health Treatment in High-Risk Veterans, Reserves, and Active Duty Service Members

Suicide rates for service members and veterans are growing rapidly in the United States. Despite availability of evidence-based approaches, a large number of high-risk individuals are reluctant to seek out treatment. The present study used the interpersonal theory of suicide, involving 3 primary predictors of death by suicide to investigate treatment readiness in high-risk U. S. veterans, reserves, and active duty service members. Four hundred and two service members were recruited. Inclusion criteria involved (a) reporting active suicidal ideation and (b) denying active behavioral health treatment. All participants completed a self-report battery that assessed burdensomeness, thwarted belongingness, lifetime suicide attempts, and perceptions about treatment. Regression analyses revealed that thwarted belongingness was significantly predictive of treatment perceptions and readiness, in that higher or more severe scores on the thwarted belongingness scale were significantly related to lower or less likely treatment perceptions and readiness scores. The findings suggested that, in high-risk service members, thwarted belongingness is predictive of lower treatment readiness, and contributes to the growing literature on perceived stigmas, treatment barriers and readiness, and suicidal behaviors and risk factors.

Impact and cultural acceptance of the Narrative Exposure Therapy in the aftermath of a natural disaster in Burundi

BACKGROUND

In the aftermath of natural disasters, affected populations are at risk of suffering from trauma-related mental health disorders such as posttraumatic stress disorder (PTSD) or depression. Particularly in poor post-conflict regions, these mental disorders have the potential to impair the ability of individuals to move on with their lives. We aimed to evaluate the feasibility, cultural acceptance, and effect of a trauma-focused psychotherapy, Narrative Exposure Therapy (NET), in the aftermath of a flood disaster in Burundi.

METHODS

Fifty-one individuals who were living in emergency camps overseen by the Burundian Red Cross in the aftermath of a flood disaster, and who had lost homes and close relatives, were invited to participate in semi-structured diagnostic interviews. Trained Burundian psychology students conducted these interviews, and six sessions of NET were offered to the 15 individuals most affected by trauma-related symptoms. An additional group of psychology students, blind to the treatment conditions, conducted three and 9 months follow-ups with them including also 25 participants who had reported significant but less severe trauma-related symptoms, assessing mental health symptoms, acceptance of NET, stigmatization due to trauma symptoms, and participants' economic well-being.

RESULTS

Between baseline and 9-months post-intervention assessment, symptoms of PTSD (Hedges' g = 3.44) and depression (Hedges' g = 1.88) improved significantly within participants who received NET and within those who received no treatment (Hedges' g_PTSD = 2.55; Hedges' g_depression = 0.72). Furthermore, those who received NET felt less stigmatized by their participation in the intervention than by the trauma-related mental health symptoms they experienced. Overall, participants reported that they would be willing to forego as much as 1 month's worth of income in exchange for receiving trauma-focused interventions in the months following the disaster.

CONCLUSIONS

Individuals severely affected by trauma-related mental health symptoms might benefit significantly from NET in the aftermath of natural disasters, while less affected individuals seem to recover spontaneously. Despite significant challenges conducting NET in emergency camps in the aftermath of natural disaster in a post-conflict country, such interventions are feasible, appreciated and might have long-lasting impacts on the lives of survivors if conducted with due respect to participants' privacy.

TRIAL REGISTRATION

UKCR2014 , the 19.06.2014, retrospectively registered.

Self-stigma in PTSD: Prevalence and correlates

Self-stigma is the internalization of negative societal stereotypes about those with mental illnesses. While self-stigma has been carefully characterized in severe mental disorders, like schizophrenia, the field has yet to examine the prevalence and correlates of self-stigma in post-traumatic stress disorder (PTSD). Thus, we assessed self-stigma in veterans diagnosed with PTSD and compared with veterans with schizophrenia. We further examined associations between PTSD, depressive symptoms and self-stigma in the PTSD sample. Data came from two larger studies of people with PTSD (n = 46) and schizophrenia-spectrum disorders (n = 82). All participants completed the Internalized Stigma of Mental Illness Scale (ISMIS). Results revealed that people with schizophrenia report more experiences of discrimination as a result of stigma than do those with PTSD, but these diagnostic groups did not differ for other subscales. In the PTSD group, feelings of alienation positively correlated with PTSD and depressive symptoms; other subscales positively correlated with depressive symptoms only. Taken together, results suggest a significant level of self-stigma exists among veterans with PTSD, and that self-stigma has an effect on PTSD and commonly comorbid symptoms, like depression. Future work should investigate whether current self-stigma interventions for other groups could be applicable for those with PTSD.

“Meet Me Where I Am”: Removing Barriers to End-of-Life Care for Homeless Veterans and Veterans Without Stable Housing

Objective:

To describe the barriers and facilitators of end-of-life (EOL) care for Veterans without stable housing (VWSH) as perceived by Veterans at 1 VA medical center and EOL care staff.

Design:

Qualitative descriptive study. Secondary applied content analysis of data from interviews and focus groups in our parent study.

Setting/Participants:

VA Puget Sound Health Care System and VWSH.

Results:

The core emergent theme in the words of Veterans and health-care workers was “meet me where I am,” a statement of what many Veterans want most from their health care. Barriers and facilitators often reflected the presence or absence of important factors such as relationship and trust building, care coordination and flexibility, key individuals and services, and assistance in navigating change.

Conclusions:

These findings suggest that to improve health care for VWSH, interventions must be multifaceted, including a suite of support services, flexibility and creative problem-solving, and adaptations in communication approaches. The authors offer specific recommendations for improving EOL care for VWSH based on these findings.

VA mobile apps for PTSD and related problems: public health resources for veterans and those who care for them

Many public health agencies, including the U.S. Department of Veterans Affairs (VA), have identified the use of mobile technologies as an essential part of a larger strategy to address major public health challenges. The VA's National Center for PTSD (NCPTSD), in collaboration with VA's Office of Mental Health and Suicide Prevention and the Defense Health Agency inside the U.S. Department of Defense (DoD), has been involved in the development, evaluation, and testing of 15 mobile apps designed specifically to address the needs and concerns of veterans and others experiencing symptoms of posttraumatic stress disorder (PTSD). These applications include seven treatment-companion apps (designed to be used with a provider, in conjunction with an evidence-based therapy) and eight self-management apps (designed to be used independently or as an adjunct or extender of traditional care). There is growing evidence for the efficacy of several of these apps for reducing PTSD and other symptoms, and studies of providers demonstrate that the apps are engaging, easy-to-use, and provide a relative advantage to traditional care without apps. While publicly available apps do not collect or share personal data, VA has created research-enabled versions of many of its mental health apps to enable ongoing product enhancement and continuous measurement of the value of these tools to veterans and frontline providers. VA and DoD are also collaborating on provider-based implementation networks to enable clinicians to optimize implementation of mobile technologies in care. Although there are many challenges to developing and integrating mHealth into care, including cost, privacy, and the need for additional research, mobile mental health technologies are likely here to stay and have the potential to reach large numbers of those with unmet mental health needs, including PTSD-related concerns.

A systematic review of help-seeking and mental health service utilization among military service members

Research has demonstrated that military service members are at elevated risk for a range of psychiatric problems, and mental health services use is a conduit to symptom reduction and remission. Nonetheless, there is a notable underutilization of mental health services in this population. This systematic review aimed to identify and critically examine: (1) rates of service use; (2) barriers and facilitators to care; and (3) programs and interventions designed to enhance willingness to seek care and increase help-seeking behaviors among current military personnel (e.g., active duty, National Guard, Reserve). Overall, 111 peer-reviewed articles were identified for inclusion. Across studies, the rate of past-year service use among service members with mental health problems during the same time frame was 29.3% based on weighted averages. Studies identified common barriers to care (e.g., concerns regarding stigma, career impact) and facilitators to care (e.g., positive attitudes toward treatment, family/friend support, military leadership support) among this population. Although programs (e.g., screening, gatekeeper training) have been developed to reduce these barriers, leverage facilitators, and encourage service use, further research is needed to empirically test the effectiveness of these interventions in increasing rates of service utilization. Critical areas for future research on treatment engagement among this high-risk population are discussed.

Treatment-refractory posttraumatic stress disorder (TRPTSD): a review and framework for the future

Post-traumatic stress disorder (PTSD) is a serious psychiatric consequence of trauma that occurs in a proportion of individuals exposed to life-threatening events. Trauma-focused psychotherapy is often recommended as first choice for those who do not recover spontaneously. But many individuals require medications. In the US, only paroxetine (PRX) and sertraline (SRT) are FDA approved for PTSD. But response and remission rates with these medications are low, so numerous other pharmacologic interventions have been tried. To date, there has not been a systematic review of the data on what are the best next-step pharmacologic strategies for individuals who fail standard treatments. To that end, we review 168 published trials of medications other than PRX or SRT and provide a detailed analysis of the 88/168 studies that describe alternative pharmacologic interventions in patients refractory to other treatment. We also review clinical factors relevant to treatment-refractory PTSD; the neurobiology of extinction, as well as evidence-based psychotherapy and neuromodulation strategies for this condition.

Delay to mental healthcare in a cohort of Canadian Armed Forces personnel with deployment-related mental disorders, 2002-2011: a retrospective cohort study

OBJECTIVE

To assess whether the delay to care among Canadian Armed Forces (CAF) personnel who sought care for a mental disorder changed over time and in association with CAF mental health system augmentations.

DESIGN

A stratified, random sample (n=2014) was selected for study from an Afghanistan-deployed cohort (N=30 513) and the 415 (weighted N=4108) individuals diagnosed with an Afghanistan service-related mental disorder were further assessed. Diagnosis-related data were abstracted from medical records (22 June 2010 to 30 May 2011). Other data were extracted from administrative databases. Delay to care was assessed across five mental health system eras: 2002/2004, 2005/2006, 2007, 2008 and 2009/2010. Weighted Cox proportional hazards regression assessed the association between era, handled as a time-dependent covariate, and the outcome while controlling for a broad range of potential confounders (ie, sociodemographic, military and clinical characteristics). Taylor series linearisation methods and sample design weights were applied in generating descriptive and regression analysis statistics.

PRIMARY OUTCOME

The outcome was the delay to mental healthcare, defined as the latency from most recent Afghanistan deployment return date to diagnosis date, among individuals with an Afghanistan service-related mental disorder diagnosis.

RESULTS

Mean delay to care was 551 days (95% CI 501 to 602); the median was 400 days. Delay to care decreased in subsequent eras relative to 2002/2004; however, only the most recent era (2009/2010) was statistically significant (adjusted HR (aHR): 3.01 (95% CI 1.91 to 4.73)). Men, operations support occupations, higher ranks, non-musculoskeletal comorbidities and fewer years of military service were also independently associated with longer delays to care.

CONCLUSIONS

CAF mental health system changes were associated with reduced delays to mental healthcare. Further evaluation research is needed to identify the key system changes that were most impactful.

Insomnia brings soldiers into mental health treatment, predicts treatment engagement, and outperforms other suicide-related symptoms as a predictor of major depressive episodes

Given the high rates of suicide among military personnel and the need to characterize suicide risk factors associated with mental health service use, this study aimed to identify suicide-relevant factors that predict: (1) treatment engagement and treatment adherence, and (2) suicide attempts, suicidal ideation, and major depressive episodes in a military sample. Army recruiters (N = 2596) completed a battery of self-report measures upon study enrollment. Eighteen months later, information regarding suicide attempts, suicidal ideation, major depressive episodes, and mental health visits were obtained from participants' military medical records. Suicide attempts and suicidal ideation were very rare in this sample; negative binomial regression analyses with robust estimation were used to assess correlates and predictors of mental health treatment visits and major depressive episodes. More severe insomnia and agitation were significantly associated with mental health visits at baseline and over the 18-month study period. In contrast, suicide-specific hopelessness was significantly associated with fewer mental health visits. Insomnia severity was the only significant predictor of major depressive episodes. Findings suggest that assessment of sleep problems might be useful in identifying at-risk military service members who may engage in mental health treatment. Additional research is warranted to examine the predictive validity of these suicide-related symptom measures in a more representative, higher suicide risk military sample.

Understanding help-seeking intentions in male military cadets: An application of perceptual mapping

Background

Research suggests that men are less likely to seek help for depression, substance abuse, and stressful life events due to negative perceptions of asking for and receiving help. This may be exacerbated in male military cadets who exhibit higher levels of gender role conflict because of military culture.

Methods

This exploratory study examined the perceptions of 78 male military cadets toward help-seeking behaviors. Cadets completed the 31-item Barriers to Help Seeking Scale (BHSS) and a component factor analysis was used to generate five composite variables and compare to validated factors. Perceptual mapping and vector modeling, which produce 3-dimensional models of a group’s perceptions, were then used to model how they conceptualize help-seeking.

Results

Factor analysis showed slightly different groupings than the BHSS, perhaps attributed to different characteristics of respondents, who are situated in a military school compared to general university males. Perceptual maps show that cadets perceive trust of doctors closest to them and help-seeking farthest, supporting the concept that these males have rigid beliefs about having control and its relationship to health seeking. Differences were seen when comparing maps of White and non-White cadets. White cadets positioned themselves far away from all variables, while non-White cadets were closest to “emotional control”.

Conclusion

To move these cadets toward help-seeking, vector modeling suggests that interventions should focus on their general trust of doctors, accepting lack of control, and decreasing feelings of weakness when asking for help. For non-White cadets a focus on self-reliance may also need to be emphasized. Use of these unique methods resulted in articulation of specific barriers that if addressed early, may have lasting effects on help-seeking behavior as these young men become adults. Future studies are needed to develop and test specific interventions to promote help-seeking among military cadets.

Posttraumatic stress disorder in reserve veterans: important reintegration considerations for the occupational health nurse

Posttraumatic stress disorder (PTSD) is a serious mental health concern for returning U.S. military personnel who have a higher prevalence rate of PTSD than the general population. Among the military population, reserve service members are at increased risk of developing PTSD compared with full-time active duty service members mainly due to difficulty reintegrating into civilian life. Understanding the social risk factors along with the protective effects social support has on PTSD in veterans will provide occupational health professionals the opportunity to support reserve veterans with adjustment into post-deployment life. This literature review examines PTSD in reserve veterans, with a focus on occupational factors, social factors, guideline recommendations, available resources, as well as provides suggestions for occupational health nurses caring for reserve veterans returning to the workplace.

Stigma as a barrier to seeking health care among military personnel with mental health problems

Approximately 60% of military personnel who experience mental health problems do not seek help, yet many of them could benefit from professional treatment. Across military studies, one of the most frequently reported barriers to help-seeking for mental health problems is concerns about stigma. It is, however, less clear how stigma influences mental health service utilization. This review will synthesize existing research on stigma, focusing on those in the military with mental health problems. We conducted a systematic review and meta-analysis of studies between 2001 and 2014 to examine the prevalence of stigma for seeking help for a mental health problem and its association with help-seeking intentions/mental health service utilization. Twenty papers met the search criteria. Weighted prevalence estimates for the 2 most endorsed stigma concerns were 44.2% (95% confidence interval: 37.1, 51.4) for "My unit leadership might treat me differently" and 42.9% (95% confidence interval: 36.8, 49.0) for "I would be seen as weak." Nine studies found no association between anticipated stigma and help-seeking intentions/mental health service use and 4 studies found a positive association. One study found a negative association between self-stigma and intentions to seek help. Counterintuitively, those that endorsed high anticipated stigma still utilized mental health services or were interested in seeking help. We propose that these findings may be related to intention-behavior gaps or methodological issues in the measurement of stigma. Positive associations may be influenced by modified labeling theory. Additionally, other factors such as self-stigma and negative attitudes toward mental health care may be worth further attention in future investigation.

PTSD in the U.S. military, and the politics of prevalence

Despite the long-standing codification of posttraumatic stress disorder (PTSD) as a mental disorder, the diagnosis is a controversial one whose legitimacy is at times disputed, particularly in U.S. military contexts (e.g., McNally and Frueh 2013; McNally, 2003, 2007). These disputes often manifest in a struggle over prevalence rates. Utilizing data from in-depth interviews and relying on situational analysis methodology (Clarke, 2005), I highlight this struggle in the wake of a decade of U.S.-led war in Afghanistan and Iraq. I focus on the objects of contestation employed by public officials, veterans' advocates, and researchers to make or refute claims about PTSD prevalence. These objects of contestation include the diagnostic category and criteria; screening tools, procedures, or systems; and the individuals who express symptoms of the disorder. Based on these claims, I make two key interrelated assertions. First, PTSD is viewed by some public officials as an overly generalized or invalid diagnostic category that is often induced in or falsified by veterans or servicemembers. As such, PTSD is perceived by these stakeholders to be over-diagnosed. Compounding these perceptions are beliefs that PTSD is costly and negatively impacts military duty performance, and thus overall manpower. Second, there exist perceptions, largely on the part of veterans' advocates but also some public officials, that many servicemembers and veterans are not seeking treatment (and thus, a diagnosis) when they experience symptoms of PTSD. Thus, PTSD is perceived by these stakeholders to be under-diagnosed. Paradoxically, some public officials make both claims: that PTSD is over-diagnosed and under-diagnosed. I conclude by exploring the implications of these findings.

Unique PTSD clusters predict intention to seek mental health care and subsequent utilization in US veterans with PTSD symptoms

Many veterans return from deployment with posttraumatic stress disorder (PTSD), but most attend only a limited number of mental health care visits. Although global PTSD relates to seeking mental health care, it is unclear whether specific features of PTSD inform the low rates of mental health care utilization. This study examined PTSD cluster severities of avoidance, reexperiencing, dysphoria, and hyperarousal as predictors of intention to seek mental health care and prospective treatment utilization. US veterans with at least subthreshold PTSD (N = 189) completed a PTSD symptom measure and indicated whether they intended to seek mental health care. Prospective Department of Veterans Affairs mental health care utilization was extracted from the medical record. At the bivariate level, each cluster was positively associated with a positive intention to seek mental health care and prospective treatment utilization. In multivariate models, however, dysphoria severity (OR = 1.16, 95% CI [1.06, 1.26]) was uniquely and positively correlated with intention to seek mental health care, whereas higher avoidance severity (IRR = 0.86, 95% CI [0.76, 0.98]) predicted lower treatment utilization, and higher reexperiencing severity (IRR = 1.07, 95% CI [1.01, 1.14]) predicted greater treatment utilization. It is critical to tailor interventions to target specific features of PTSD and to meet patients where they are.