Post-traumatic stress disorder, drug dependence, and suicidality among male Vietnam veterans with a history of heavy drug use

Post-traumatic stress and future substance use outcomes: leveraging antecedent factors to stratify risk

Background

Post-traumatic stress disorder (PTSD) and substance use (tobacco, alcohol, and cannabis) are highly comorbid. Many factors affect this relationship, including sociodemographic and psychosocial characteristics, other prior traumas, and physical health. However, few prior studies have investigated this prospectively, examining new substance use and the extent to which a wide range of factors may modify the relationship to PTSD.

Methods

The Advancing Understanding of RecOvery afteR traumA (AURORA) study is a prospective cohort of adults presenting at emergency departments (N = 2,943). Participants self-reported PTSD symptoms and the frequency and quantity of tobacco, alcohol, and cannabis use at six total timepoints. We assessed the associations of PTSD and future substance use, lagged by one timepoint, using the Poisson generalized estimating equations. We also stratified by incident and prevalent substance use and generated causal forests to identify the most important effect modifiers of this relationship out of 128 potential variables.

Results

At baseline, 37.3% (N = 1,099) of participants reported likely PTSD. PTSD was associated with tobacco frequency (incidence rate ratio (IRR): 1.003, 95% CI: 1.00, 1.01, p = 0.02) and quantity (IRR: 1.01, 95% CI: 1.001, 1.01, p = 0.01), and alcohol frequency (IRR: 1.002, 95% CI: 1.00, 1.004, p = 0.03) and quantity (IRR: 1.003, 95% CI: 1.001, 1.01, p = 0.001), but not with cannabis use. There were slight differences in incident compared to prevalent tobacco frequency and quantity of use; prevalent tobacco frequency and quantity were associated with PTSD symptoms, while incident tobacco frequency and quantity were not. Using causal forests, lifetime worst use of cigarettes, overall self-rated physical health, and prior childhood trauma were major moderators of the relationship between PTSD symptoms and the three substances investigated.

Conclusion

PTSD symptoms were highly associated with tobacco and alcohol use, while the association with prospective cannabis use is not clear. Findings suggest that understanding the different risk stratification that occurs can aid in tailoring interventions to populations at greatest risk to best mitigate the comorbidity between PTSD symptoms and future substance use outcomes. We demonstrate that this is particularly salient for tobacco use and, to some extent, alcohol use, while cannabis is less likely to be impacted by PTSD symptoms across the strata.

A Practical Review of Suicide Among Veterans: Preventive and Proactive Measures for Health Care Institutions and Providers

Suicide rates among veterans are higher than those of the general US population. Although veterans compose only 7.6% of the US population, nearly 14% of American adult suicides are among veterans. The rate of suicide is 1.5 times higher among all veterans and 2.1 times higher among female veterans compared with the general population. Only 47% of all veterans are enrolled in the US Department of Veterans Affairs (VA) Healthcare System, leaving a large number either not receiving health care or receiving it outside the VA. Recent legislation has improved access to care for veterans outside the VA, highlighting the need for a broad public health approach to address veteran suicide and the need for all health care institutions and clinicians to be familiar with the unique health concerns in this population. The purpose of this narrative review was to summarize the risk factors contributing to veteran suicide and to provide guidance on how to assess and mitigate these risks. Suicide is preventable through recognition of risk and prompt intervention. Health care providers both inside and outside the VA system are uniquely situated at the intersection of the many contributing factors to veteran suicide and should have a structured, proactive approach to address the problem.

Posttraumatic stress disorder and risk of suicidal behavior: A systematic review and meta-analysis

INTRODUCTION

This study conducted a systematic review and meta-analysis of the association between posttraumatic stress disorder (PTSD) and (i) death by suicide, (ii) attempted suicide (AS), and (iii) suicidal ideation (SI).

METHODS

The systematic review identified seven studies on PTSD and suicide, 33 studies for AS, and 20 studies for SI. A series of stratified meta-analyses were conducted to estimate pooled effects, in addition to meta-regression to investigate sources of heterogeneity.

RESULTS

A higher relative risk of suicide was evident among those diagnosed with PTSD (RR = 2.09 [95% confidence interval (CI): 1.11-3.94]), with strongest associations among combat veterans (RR = 3.97, 95% CI 2.22-7.10). A lower relative risk of suicide among those with PTSD and co-morbid psychiatric conditions was evident (RR = 0.74, 95% CI 0.63-0.86). A strong association between PTSD and attempted suicide (RR = 4.05, 95% CI 3.14-5.23) and suicidal ideation (RR = 2.91, 95% CI 2.22-3.82) was also found, with a consistently strong association among those with co-morbid psychiatric conditions and non-clinical cohorts.

CONCLUSION

This review found a strong association between PTSD and death by suicide, attempted suicide, and suicidal ideation, and also suicide among veteran populations. Early identification and treatment of PTSD across both clinical and non-clinical cohorts should be a priority for suicide prevention.

Posttraumatic stress disorder, suicide, and unintended overdose death in later life: A national cohort study of veterans aged 50 and older

BACKGROUND/OBJECTIVES

Although studies have shown posttraumatic stress disorder (PTSD) associated with risk of suicide, the relationship in later life, especially for overdose death, remains unclear. Thus, the aim of the current study was to determine associations between PTSD, suicide, and unintended overdose death in mid- to late-life.

METHODS

A nationwide cohort study integrating Department of Veterans Affairs' (VA) data, Centers for Medicare & Medicaid Services data, and national cause-specific mortality data. Participants were US veterans aged ≥50 years with PTSD diagnoses at baseline (2012-2013) and were propensity-matched 1:1 with patients without PTSD based on sociodemographics, Charlson Comorbidity Index, and neuropsychiatric disorders (N = 951,018). Information on suicide attempts and unintended death by overdose through December 31, 2017 was provided by the VA's National Suicide Prevention Applications Network (non-fatal attempts) and Mortality Data Repository (death).

RESULTS

Veterans with PTSD (N = 475,509) had increased risk of suicide attempt (Hazard Ratio [HR], 1.59; 95% CI, 1.54-1.65; p < 0.001), non-fatal attempt (HR, 1.74; 95% CI, 1.67-1.81; p < 0.001), drug overdose death overall (HR, 1.32; 95% CI, 1.22-1.42; p < 0.001), and suicide overdose death (HR, 1.44; 95% CI, 1.15-1.80; p = 0.002), even after adjusting for sociodemographics, Charlson comorbidity index, and neuropsychiatric disorders. We found increased risk for overdose death by narcotics (HR, 1.30; 95% CI, 1.15-1.46; p < 0.001), antiepileptic/sedative-hypnotics (HR, 1.29; 95% CI, 1.02-1.62; p = 0.032), and for other/unspecified drugs (HR, 1.35; 95% CI, 1.20-1.51; p < 0.001), the last category indicative of polydrug. Results remained robust when examined for unintentional, suicide, and undetermined intent for cause-specific death by other/unspecified drugs.

CONCLUSIONS

PTSD persists throughout mid- to late-life with considerable increased risk for non-fatal suicide attempts and suicide overdose death. These findings suggest the importance of drug-monitoring in preventing late-life suicide.

A network approach to substance use, internalizing, and externalizing comorbidity in U.S. adults

INTRODUCTION

Use of conventional cigarettes (CIG), alcohol, marijuana, and sedatives [i.e., benzodiazepines and barbiturates]) commonly co-occur with internalizing and externalizing disorders. It is unclear how these relationships extend to electronic cigarettes (ECIGs) and prescription drugs not prescribed (i.e., sedatives, tranquilizers, and painkillers [PDNP]), and whether they differ by gender.

METHODS

Adult data (N = 30,211) from Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health Study were used to estimate a network of current or past-month use for six substances, experiencing four internalizing symptoms in the past month, and experiencing seven externalizing symptoms in the past month. Visual comparisons, global strength invariance, network structure invariance, and edge strength invariance were tested to detail substance use and internalizing/externalizing symptom networks.

RESULTS

Overall, networks were consistent between men and women. The strongest substance use/mental health symptom connections estimated as edge-weights (EW) were between marijuana with lying (EW = 0.60, 95% CI = 0.49; 0.70), marijuana with engaging in fights (EW = 0.54, 95% CI = 0.27; 0.81), PDNP with having trouble sleeping (EW = 0.53, 95% CI = 0.40; 0.66), and alcohol and impulsivity (EW = 0.48, 95% CI = 0.42; 0.53).

DISCUSSION

There were many weak connections throughout the substance use and internalizing/externalizing network. A few important connections were identified and encourage future study. In particular, PDNP was most strongly associated with internalizing symptoms. Marijuana, alcohol and PDNP use were most strongly associated with externalizing symptoms.

War across the life course: examining the impact of exposure to conflict on a comprehensive inventory of health measures in an aging Vietnamese population

BACKGROUND

The majority of evidence indicates that exposure to war and other traumatic events continue to have negative impacts on health across the life course. However, existing research on health effects of war exposure primarily concentrates on short-term impacts among veterans in high-income countries sent elsewhere to battle. Yet, most wars situate in lower- and middle-income countries, where many are now or will soon be entering old age. Consequently, the current burden of exposure to war has ignored an important global population.

METHODS

The Vietnam Health and Aging Study (VHAS) is a longitudinal study designed to examine historical exposure to highly stressful events during the American War. Two modes of data collection, involving a sample of 2447 individuals aged 60+ years in northern Vietnam, took place between May and August 2018. Using this first wave of data, we generate indexed measures of war exposure and analyze their associations with a set of 12 health outcomes, accounting for confounding variables.

RESULTS

Results indicate that greater exposure to three types of war exposure (death and injury, stressful living conditions, and fearing death and/or injury) in earlier life is associated with worse health in later-life across a large number of health outcomes, such as number of diagnosed health conditions, mental distress, somatic symptoms, physical functioning, post-traumatic stress symptoms and chronic pain.

CONCLUSIONS

Findings support a life course theory of health and point to long-term effects of war on health that require detailed attention.

Suicidality: An Evolutionary Concept Analysis

Suicide is a preventable health problem. Multiple definitions and inconsistent use of the term suicidality can result in failure to properly recognize suicide risk and behavior and confuses suicide research. Clarification of the suicidality concept is needed to facilitate the care for individuals at risk for suicide. Using Rodgers' evolutionary concept analysis method, this analysis describes the breadth and scope of the suicidality concept. Findings indicate suicidality covers a spectrum of suicidal risk and levels of emotional suffering and intent. The analysis does not draw definite conclusions, but outlines a direction for further research.

The Mediation Effect of Hyperarousal Symptoms on the Relationship Between Childhood Physical Abuse and Suicidal Ideation of Patients With PTSD

Objective: This study examined the relationship of childhood physical abuse, posttraumatic stress disorder (PTSD), depression, and suicide in patients with PTSD through path analysis. Materials and Methods: A total of 114 patients with PTSD (36 men and 78 women) were recruited and completed psychological assessments including the Childhood Trauma Questionnaire, the scale for suicidal ideation, the clinician-administered PTSD scale for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the PTSD checklist, and the Hospital Anxiety and Depression Scale. Structural equation modeling was used to evaluate the results. We developed a model including childhood physical abuse experience as the causal variable, suicidal ideation as a result variable, and PTSD and depression as mediation variables. PTSD symptoms were divided into four clusters [intrusion, avoidance, negative cognition and mood, and altered arousal and reactivity (hyperarousal)] to determine predictive power for suicide. Results: PTSD symptoms fully mediated the relationship between childhood physical abuse and suicidal ideation. Furthermore, PTSD symptoms fully mediated the relationship between childhood physical abuse and depression. Among the PTSD symptoms, hyperarousal was the only symptom cluster that mediated the relationship between childhood physical abuse and suicidal ideation. The symptom clusters of negative cognition and mood as well as hyperarousal mediated the relationship between childhood physical abuse and depression. Conclusions: This study presents a link between childhood physical abuse and current symptoms in patients with PTSD, and highlights specific PTSD symptom clusters (i.e., hyperarousal, negative cognition and mood) that may increase the risk for psychopathology later in life.

Neuropsychological Performance and Subjective Symptom Reporting in Military Service Members With a History of Multiple Concussions: Comparison With a Single Concussion, Posttraumatic Stress Disorder, and Orthopedic Trauma

OBJECTIVE

To examine differences in objective neurocognitive performance and subjective cognitive symptoms in individuals with a history of a single concussion, multiple concussions, orthopedic injuries, and posttraumatic stress disorder (PTSD).

METHOD

Participants included 116 military service members who sustained a mild traumatic brain injury (mTBI) during combat deployment. Subjects were subdivided into groups based on concussion frequency: a single concussion (n = 42), 2 concussions (n = 21), and 3 or more concussions (n = 53). Eighty-one subjects sustained an orthopedic injury (n = 60) during deployment or were diagnosed with PTSD (n = 21), but had no history of mTBI. Subjects completed a battery of neuropsychological tests and self-report measures of postconcussive symptoms, PTSD symptoms, and psychopathology.

RESULTS

No differences were found among the concussion groups on a composite neuropsychological measure. The PTSD group had the highest number of symptom complaints, with the 2-concussion and 3-plus-concussion groups being most similar to the PTSD group. The concussion groups showed a nonsignificant pattern of increasing distress with increasing number of concussions.

CONCLUSIONS

The current findings are consistent with meta-analytic results showing no differential effect on neuropsychological functioning due to multiple concussions. Results also support the burden of adversity hypothesis suggesting increasing symptom levels with increasing psychological or physically traumatic exposures.

The Role of Maternal Relationship in the Persisting Effect of Combat Exposure

Background and Objectives

The veteran population is aging. Combat exposure is associated with negative health and psychological outcomes in some, but not all veterans; others even appear to experience gains. One mechanism driving these varied responses might be early life relationships. This study investigated the extent to which the quality of early maternal relationships influences the association between combat exposures and life satisfaction (LS) among older male veterans.

Research Design and Methods

Data were drawn from a pooled sample of male veterans in the Health and Retirement Study who completed the 2013 Veteran Mail Survey (N = 1,160). We used ordinary least squares regression to examine the association between combat exposures (with and without exposure to death) and LS, and the moderating effect of maternal relationship quality on this association.

Results

We found a significant positive association between maternal relationship quality and LS, and a significant association of combat that was dependent on maternal relationship quality. Specifically, combat-exposed veterans with poor maternal relationship quality reported lower LS, whereas combat-exposed veterans with high relationship quality reported higher LS—relative to their noncombat-exposed counterparts. The effects of exposure to death of hazardous toxins did not mediate or moderate this relationship.

Discussion and Implications

Findings indicate that maternal relationships had a lasting influence on whether combat contributed to a positive, negative, or neutral long-term effect on wellbeing. Findings support previous studies that suggest early life factors may play an important role in the fostering of resilient health outcomes over the life course. Implications for preventative strategies in soldiers are discussed.

Suicidality in Subjects With Anxiety or Obsessive-Compulsive and Related Disorders: Recent Advances

PURPOSE OF REVIEW

Historically, anxiety disorders have not been considered as important determinants of suicide, but in the last years, many works have challenged this assumption. Here, we will review the available evidence on the relationship between suicide and anxiety disorders (e.g., obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, panic disorder, and body dysmorphic disorder), with special emphasis on findings published in the last years.

RECENT FINDINGS

Overall, anxiety disorders increase the risk of suicide. Specifically, 16% of patients with social anxiety disorder reported suicidal ideation in the previous month, and 18% of them had a history of suicide attempts. Similarly, in patients with panic disorder, suicidal ideation prevalence ranged between 17 and 32%, and 33% of them had a history of suicide attempts. Generalized anxiety disorder (GAD) was the most frequent anxiety disorder in completed suicides (present in 3% of people who committed suicide) and also subthreshold GAD was clearly linked to suicide ideation. Post-traumatic stress disorder was positively associated with suicidal ideation, and in patients with obsessive-compulsive disorder, suicide ideation rates ranged from 10 to 53% and suicide attempts from 1 to 46%. Body dysmorphic disorders presented a suicide ideation prevalence of about 80%. Suicide risk is increased in subjects with anxiety disorder. This risk is higher in the presence of comorbidities, but it is not clear whether it is independent from such comorbidities in some disorders.

Trauma characteristics, post-traumatic symptoms, psychiatric disorders and suicidal behaviours: Results from the 2007 Australian National Survey of Mental Health and Wellbeing

OBJECTIVE

The current study examined whether trauma characteristics such as the type and number of traumatic events were associated with three suicidal behaviours (i.e. ideation, plan and attempt) after adjusting for sociodemographic factors, post-traumatic symptoms and history of psychiatric disorders.

METHOD

Data came from the 2007 Australian National Survey of Mental Health and Wellbeing ( N = 8841). Respondents were asked about exposure to 28 traumatic events that occurred during their lifetime. Suicidal behaviours were measured using three statements about whether the person ever seriously thought about or planned or attempted suicide.

RESULTS

Sexual violence and exposure to multiple traumatic events were particularly associated with suicidal behaviours. The presence of the emotional numbing symptom cluster and co-occurrence of three psychiatric disorders (major depressive disorder, alcohol use disorder and substance use disorder) also increased the odds of suicidal behaviours. Analysis of age of onset revealed that the mean age of traumatic exposure was earlier than the age at which suicidal behaviours emerged.

CONCLUSIONS

The current study is the first to demonstrate that sexual violence and exposure to multiple traumatic events are associated with suicidal behaviours in a representative sample of Australian adults. The results underline the potential benefits of thorough assessment of trauma history, post-traumatic symptoms and history of psychiatric disorders and their additive contribution in suicide risk among trauma victims. These findings can be used by clinicians and researchers for early intervention programmes.

Role of Inflammation in Suicide: From Mechanisms to Treatment

Suicidal behavior is complex and manifests because of a confluence of diverse factors. One such factor involves dysregulation of the immune system, which has been linked to the pathophysiology of suicidal behavior. This review will provide a brief description of suicidality and discuss the contribution of upstream and downstream factors in the etiology of suicidal behavior, within the contextual framework of inflammation. The contribution of inflammatory conditions such as traumatic brain injury, autoimmune disorders, and infections to neuropsychiatric symptoms and suicidality is only beginning to be explored. We will summarize studies of inflammation in the etiology of suicide, and provide a neurobiological basis for different mechanisms by which inflammation might contribute to the pathophysiology. Finally, we will review treatments that affect upstream and downstream pathways related to inflammation in suicidality.

The effect of military deployment on mental health

Public concern about soldiers' mental health has increased over the last decade. Yet the large literature on the mental health problems of returning soldiers relies primarily on self-reported measures that may suffer from non-response bias, usually refers to older conflicts, and focuses mainly on specific diagnoses such as PTSD. Another challenge is that the differences between soldiers and non-soldiers are not necessarily causal, instead possibly reflecting an underlying propensity towards active military service. Using the objective measures of hospitalizations and the purchase of mental health medication, this paper is the first to investigate the effect of recent military deployments on a broader measure of mental health, for a full population of Danish soldiers and a comparison group of eligible men. We exploit a panel of Danish health administrative records and use propensity score matching process, using unique observables such as ability tests. Matching is helpful in both reducing the selection bias from observables and determining pre- and post-deployment period for the comparison group. Then, we estimate the effect of deployment in a difference-in-differences setting, controlling for time trends and other omitted variables affecting both groups. Overall, we find a significant and long-lasting adverse effect of military deployment on soldiers' mental health, regardless of the comparison groups and underlying assumptions.

Postmortem Presence of Drugs and Method of Violent Suicide

The link between substance use and suicide is well established. However, little research analyzes how substance use is related to the method of suicide. This paper analyzes how specific drugs are associated with method of suicide, a critical topic because drug use bears on the etiology of suicide and may lead to policies aimed at deterring suicide. We use the COVDRS and logistic regression to examine postmortem presence of drugs among 3,389 hanging and firearm suicides in Colorado from 2004-2009. Net of demographic controls, we find that opiates are positively associated with firearms (OR: 1.92, 95% L: 1.27, 95% U: 2.86]) while antidepressants are positively associated with hanging (OR: 1.45, 95% L: 1.04, 95% U: 2.03). For cocaine and opiates, the association between drug use and violent method vary by educational attainment. Importantly, knowledge of the presence and type of specific drug is strongly associated with the method of suicide.

Cumulative trauma, hyperarousal, and suicidality in the general population: a path analysis

Although trauma exposure and posttraumatic stress disorder (PTSD) both have been linked to suicidal thoughts and behavior, the underlying basis for this relationship is not clear. In a sample of 357 trauma-exposed individuals from the general population, younger participant age, cumulative trauma exposure, and all three Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, PTSD clusters (reexperiencing, avoidance, and hyperarousal) were correlated with clinical levels of suicidality. However, logistic regression analysis indicated that when all PTSD clusters were considered simultaneously, only hyperarousal continued to be predictive. A path analysis confirmed that posttraumatic hyperarousal (but not other components of PTSD) fully mediated the relationship between extent of trauma exposure and degree of suicidal thoughts and behaviors.

Drug use disorders and post-traumatic stress disorder over 25 adult years: role of psychopathology in relational networks

BACKGROUND

In traumatized populations, drug use disorders and post-traumatic stress disorder (PTSD) persist for many years. Relational factors that mediate this persistence have rarely been systematically examined. Our aim is to examine the relative effects of psychopathology in familial and non-familial networks on the persistence of both disorders over adulthood.

METHODS

We utilized longitudinal data from an epidemiologically ascertained sample of male Vietnam veterans (n=642). Measures included DSM-IV drug use disorders, other psychiatric disorders, network problem history and time-varying marital and employment characteristics. Longitudinal measures of veterans' psychopathology and social functioning were retrospectively obtained for each year over a 25 year period. We used generalized estimating equations (GEE) to estimate the relative effects of network problems on veteran's drug use disorders and PTSD after adjusting for covariates.

RESULTS

Veterans' mean age was 47 years in 1996. Prevalence of illicit drug disorders declined from 29.8% in 1972 to 8.3% in 1996, but PTSD remained at 11.7% from 13.2% in 1972. While 17.0% of veterans reported a familial drug use problem, 24.9% reported a non-familial drug use problem. In full GEE models, a non-familial drug problem was a significant predictor of illicit drug use disorders over 25 years (OR=2.21, CI=1.59-3.09), while both familial depression (OR=1.69, CI=1.07-2.68) and non-familial drinking problem (OR=1.66, CI=1.08-2.54) were significant predictors of PTSD over 25 years.

CONCLUSIONS

Familial and non-familial problems in networks differentially affect the persistence of drug use disorders and PTSD in traumatized male adults.

The association between anxiety disorders and suicidal behaviors: a systematic review and meta-analysis

BACKGROUND

Although anxiety has been proposed to be a potentially modifiable risk factor for suicide, research examining the relationship between anxiety and suicidal behaviors has demonstrated mixed results. Therefore, we aimed at testing the hypothesis that anxiety disorders are associated with suicidal behaviors and evaluate the magnitude and quality of supporting evidence.

METHODS

A systematic literature search of multiple databases was conducted from database inception through August 2011. Two investigators independently reviewed and determined the eligibility and quality of the studies based upon a priori established inclusion criteria. The outcomes of interest were suicidal ideations, suicide attempts, completed suicides, and a composite outcome of any suicidal behaviors. We pooled odds ratios from the included studies using random effects models.

RESULTS

Forty-two observational studies were included. The studies had variable methodological quality due to inconsistent adjustment of confounders. Compared to those without anxiety, patients with anxiety were more likely to have suicidal ideations (OR = 2.89, 95% CI: 2.09, 4.00), attempted suicides (OR = 2.47, 95% CI: 1.96, 3.10), completed suicides (OR = 3.34, 95% CI: 2.13, 5.25), or have any suicidal behaviors (OR = 2.85, 95% CI: 2.35, 3.46). The increase in the risk of suicide was demonstrated for each subtype of anxiety except obsessive-compulsive disorder (OCD). The quality of this evidence is considered low to moderate due to heterogeneity and methodological limitations.

CONCLUSIONS

This systematic review and meta-analysis provides evidence that the rates of suicides are higher in patients with any type of anxiety disorders excluding OCD.

Protective factors for mental disorders and psychological distress in female, compared with male, service members in a representative sample

OBJECTIVE

Although military interest in promoting psychological resilience is growing, resources protective against psychopathology have been understudied in female service members. Using a representative sample of Canadian Forces personnel, we investigated whether religious attendance, spirituality, coping, and social support were related to mental disorders and psychological distress in female service members, and whether sex differences occurred in these associations.

METHOD

Religious attendance and spirituality were self-reported. Coping items were taken from 3 scales and produced 3 factors (active, avoidance, and self-medication). Social support was assessed with the Medical Outcomes Study Social Support Survey. Past-year mental disorders were diagnosed with the World Mental Health Composite International Diagnostic Interview. The Kessler Psychological Distress Scale assessed distress. Multivariate regression models investigated links between correlates and psychological outcomes within each sex. For associations that were statistically significant in only one sex, sex by correlate interactions were computed.

RESULTS

In female service members, inverse relations were found between social support and MDD, any MDD or anxiety disorder, suicidal ideation, and distress. No associations were found between religious attendance and outcomes, and spirituality was associated with an increased likelihood of some outcomes. Active coping was related to less psychological distress, while avoidance coping and self-medication were linked to a higher likelihood of most outcomes. Although several statistically significant associations were found in only one sex, only one sex by correlate interaction was statistically significant.

CONCLUSIONS

Social support was found to be inversely related to several negative mental health outcomes in female service members. Few differences between men and women reached statistical significance. Future research should identify additional helpful resources for female service members.

The psychological costs of war: military combat and mental health

We exploit plausibly exogenous variation in overseas deployment assignment to estimate the effect of combat exposure on psychological well-being. Controlling for pre-deployment mental health, we find that active-duty soldiers deployed to combat zones are more likely to suffer from post-traumatic stress disorder (PTSD) than their counterparts deployed outside the United States in non-combat zones. Among those deployed to combat zones, those deployed to locales where they engage in enemy firefight or witness allied or civilian deaths are at an increased risk for suicidal ideation and PTSD relative to their active-duty counterparts deployed to combat zones without enemy firefight.

Suicide among war veterans

Studies aiming to identify if war veterans are at higher risk of suicide have often produced inconsistent results; this could be due to the complexity of comparisons and different methodological approaches. It should be noted that this contingent has many risk factors, such as stressful exposures, wounds, brain trauma and pain syndrome. Most recent observations confirm that veterans are really more likely to die of suicide as compared to the general population; they are also more likely to experience suicidal ideation and suffer from mental health problems. Suicides are more frequent in those who develop PTSD, depression and comorbid states due to war exposure. Combat stress and its’ frequency may be an important factor leading to suicide within the frame of the stress-vulnerability model. According to this model, the effects of stress may interact with social factors, interpersonal relations and psychological variables producing suicidal tendencies. Modern understanding of stress-vulnerability mechanisms based on genetic predispositions, early life development, level of exposure to stress and stress-reactivity together with interpersonal aspects may help to build more effective suicide prevention programs based on universal/selective/indicated prevention principles.

Suicidal ideation among National Guard troops deployed to Iraq: the association with postdeployment readjustment problems

Despite well-documented postdeployment readjustment problems affecting veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), few studies have explored the possible relationship of readjustment stressors to the recent increase in military suicide. This study examined associations between suicidal ideation and postdeployment readjustment problems using cross-sectional population-based survey data from 1665 National Guard members who recently returned from Iraq. The findings suggested that readjustment problems are widespread, with 45% of veterans endorsing one or more financial or family problems 3 months postdeployment. After adjusting for mental health and combat exposure, veterans with the highest number of readjustment stressors were at 5½ times greater risk of suicidal ideation than those with no stressors. In a psychiatrically impaired subsample, the high stressor group experienced a fourfold risk of suicide ideation compared with those with no stressors. The findings argue for suicide prevention efforts that more directly target readjustment problems in returning OEF/OIF veterans.

A Model of Meaning-Making Coping and Growth in Combat Veterans

More than 1.6 million military men and women have deployed to fight the global war on terror. Although studies have suggested that approximately one third of these service men and women return with a mental health condition or a brain injury, a gap remains in our understanding about how these individuals cope with and grow from their experiences. In this article, we review the existing body of research related to growth and recovery from trauma and then propose an empirically informed and contextually sensitive model to guide future research with combat veterans. We draw from research focused on resilience, posttraumatic growth, and decline (negative or pathological) change trajectories, and we propose that meaning-making coping is a core mechanism of the posttraumatic growth process for combat veterans. Implications for practitioners and the next steps for future research are presented.

Course of alcohol dependence among Vietnam combat veterans and nonveteran controls

OBJECTIVE

Identifying developmental trajectories of alcohol use is fundamental in building theories of alcoholism etiology and course. The purpose of this study was to replicate and generalize our previous finding that had been based on a twin sample drawn from the Vietnam Era Twin Registry. In this study, we made use of a nontwin sample of Vietnam veterans drawn from the Vietnam Era Study--a 25-year follow-up of the Vietnam Drug User Returns project that assessed the long-term medical and psychiatric consequences of substance abuse or dependence in Vietnam.

METHOD

Alcohol-related behaviors and psychiatric status were assessed in a sample of 839 individuals that comprised 323 veterans who tested positive for drugs (i.e., opiates, barbiturates, or amphetamines) on discharge from Vietnam, 319 veterans who tested negative for drugs at that time, and a nonveteran control sample (n = 197). Individuals with a lifetime diagnosis of alcohol dependence (n = 293) were selected for further analysis. Using detailed life history charts, in-person structured interviews were conducted, which entailed retrospective reports covering the 25 years since the 1972 survey. Measures of alcohol and drug use as well as psychiatric symptoms were obtained by assessing each year of the follow-up interval, beginning with 1972.

RESULTS

Using latent growth mixture modeling, a four-class model was identified with trajectories that were parallel to those identified in our previous studies based on the Vietnam Era Twin Registry: severe chronic alcoholics, severe nonchronic alcoholics, late-onset alcoholics, and young-adult alcoholics.

CONCLUSIONS

Present findings provide additional support for the replicability and generalizability of meaningful differences in the course of alcoholism from early adulthood to midlife.

The locus coeruleus: A key nucleus where stress and opioids intersect to mediate vulnerability to opiate abuse

The interaction between the stress axis and endogenous opioid systems has gained substantial clinical attention as it is increasingly recognized that stress predisposes to opiate abuse. For example, stress has been implicated as a risk factor in vulnerability to the initiation and maintenance of opiate abuse and is thought to play an important role in relapse in subjects with a history of abuse. Numerous reports indicating that stress alters individual sensitivity to opiates suggest that prior stress can influence the pharmacodynamics of opiates that are used in clinical settings. Conversely, the effects of opiates on different components of the stress axis can impact on individual responsivity to stressors and potentially predispose individuals to stress-related psychiatric disorders. One site at which opiates and stress substrates may interact to have global effects on behavior is within the locus coeruleus (LC), the major brain norepinephrine (NE)-containing nucleus. This review summarizes our current knowledge regarding the anatomical and neurochemical afferent regulation of the LC. It then presents physiological studies demonstrating opposing interactions between opioids and stress-related neuropeptides in the LC and summarizes results showing that chronic morphine exposure sensitizes the LC-NE system to corticotropin releasing factor and stress. Finally, new evidence for novel presynaptic actions of kappa-opioids on LC afferents is provided that adds another dimension to our model of how this central NE system is co-regulated by opioids and stress-related peptides.

PTSD in the combat veteran: using Roy's Adaptation Model to examine the combat veteran as a human adaptive system

Posttraumatic stress disorder (PTSD) is the most prevalent mental disorder arising from combat and is poised to be a considerable health risk for our military veterans. To date, there is a paucity of nursing research that examines PTSD in this vulnerable population. The purpose of this article is to demonstrate how Roy's Adaptation Model can be an effective framework for nurses to understand the phenomenon of posttraumatic stress disorder in the combat veteran population. Current research conducted on PTSD across other disciplines is highlighted within the context of Roy's model to elucidate the idea of the combat veteran as a human adaptive system and to identify gaps for future nursing research.

Attachment representation and suicidal ideation in Vietnam combat veterans with posttraumatic stress disorder

Attachment representation has been linked to psychopathology and suicidality. Possible links between attachment representations and suicidal ideation in a PTSD sample were examined. Vietnam combat veterans in treatment for PTSD (N = 48) were assessed for PTSD severity, attachment representation and current and lifetime suicidality. Contrary to expectation individuals with secure attachment representations had higher levels of current suicidal ideation than those with insecure attachment representations, and unresolved/disorganized attachment was associated with lower levels of current suicidal ideation. Secure attachment may not provide protection against high levels of distress and suicidal ideation among combat veterans with PTSD.

Self-mutilative behaviors in male veterans with posttraumatic stress disorder

Self-mutilative behaviors (SMB) were examined in a sample of male veterans with posttraumatic stress disorder (PTSD). The primary objective was to determine the prevalence of SMB and any physical, cognitive, or affective antecedents and correlates for these behaviors. Participants included 509 male veterans with PTSD and levels of PTSD, depression, alcohol use, hostility, and impulsivity were evaluated to determine if these variables were related to SMB. Antecedents and sequelae of SMB were also examined to generate hypotheses regarding the functions of these behaviors. A second type of habit behavior, body-focused repetitive behaviors (BFRB), was also examined as part of the study. Findings indicated that veterans who engaged in either type of habit behavior were younger than those who did not engage in SMB or BFRB. Veterans reporting SMB also reported higher levels of PTSD, depression, hostility, and impulsivity compared to the BFRB and no-habit groups. Examination of habit antecedents and sequelae showed support for the automatic-positive reinforcement function of SMB. These findings are discussed in the context of research and treatment involving male veterans with PTSD who engage in SMB.

Vicarious exposure to terrorist attacks and substance use: results from an urban household survey

This study investigated the impact of the 9/11 attacks on substance use in Chicago, Illinois. The study design was a cross-sectional, audio-computer-assisted self-interview survey conducted in 2001 and 2002. Biological samples were also collected for toxicological analyses. Using a multistage area probability design, residents between the ages of 18 and 40 years were randomly selected. Compared to pre-9/11 interviewees, post-9/11 interviewees showed significantly less self-reported marijuana use, marijuana use per test results, and cocaine use per test results. Law enforcement and social-structural explanations for the findings are discussed.

Platelet serotonin concentration and suicidal behavior in combat related posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a serious and global problem, a psychiatric disorder that frequently occurs with different comorbidities, and is associated with a high suicide rate. Pathophysiologically, both PTSD and suicidal behavior are related to disturbances in the central serotonergic system. Serotonin (5-hydroxytryptamine, 5-HT) controls emotional behavior, anxiety, impulsivity and aggression, and nearly all known antidepressants and antianxiety drugs affect 5-HT transmission. Platelet 5-HT can be used as a limited peripheral marker of the central serotonergic synaptosomes, since it is related to particular basic psychopathological characteristics of several psychiatric disorders. Platelet 5-HT concentration has been reported to be similar in PTSD subjects and healthy controls, but suicidal patients across different psychiatric diagnoses have reduced platelet 5-HT concentration. This study examined platelet 5-HT concentration by the spectrofluorimetric method in male subjects: 73 suicidal and 47 non-suicidal veterans with current and chronic combat related PTSD, 45 suicidal and 30 non-suicidal comparative non-PTSD subjects and 147 healthy men. The presence of suicidal behavior (score=0, non-suicidal; scores > or =1, suicidal) was assessed with the Hamilton Depression Rating Scale-17 (HDRS). Platelet 5-HT concentration was significantly lower in suicidal PTSD and non-PTSD patients compared to non-suicidal patients or healthy controls. Since the majority of patients scored very low on item 3 of HDRS, no significant correlation between suicidal scores and platelet 5-HT concentration was found. These results show that reduced platelet 5-HT concentration is related to suicidal behavior in PTSD, and suggest that platelet 5-HT concentration might be used as a peripheral marker to predict suicidal behavior across psychiatric diagnoses.

Chronic morphine selectively impairs cued fear extinction in rats: implications for anxiety disorders associated with opiate use

Previous studies have shown that opioid transmission plays an important role in learning and memory. However, little is known about the course of opiate-associated learning and memory deficits after cessation of chronic opiate use in a behavioral animal model. In the present study, we examined the effects of chronic morphine on fear extinction, an important preclinical model for behavior therapy of human anxiety disorders. Rats were administrated subcutaneously morphine hydrochloride or saline twice per day for continuous 10 days. Rats received a cued or contextual fear conditioning session 7 days after the last morphine injection. During subsequent days, rats received four cued or contextual extinction sessions (one session per day). Percent freezing was assessed during all phases of training. Chronic morphine did not affect the acquisition of cued fear response or the initial encoding of extinction memory within each session, but produced an impairment in the between-session extinction. However, the same morphine treatment schedule did not affect the acquisition or extinction of contextual fear response. These results suggest that the effects of chronic morphine on memory for fear extinction are complex. Chronic morphine selectively impairs extinction of cued fear response. This deficit in fear extinction may be one of those critical components that contribute to the high prevalence of anxiety disorders in opiate addicts.

Modeling the role of environment in addiction

The aim of this review is to provide an overview of the main types of animal models used to investigate the modulatory role of environment on drug addiction. The environment can alter the responsiveness to addictive drugs in at least three major ways. First, adverse life experiences can make an individual more vulnerable to develop drug addiction or to relapse into drug seeking. Second, neutral environmental cues can acquire, through Pavlovian conditioning, the ability to trigger drug seeking even after long periods of abstinence. Third, the environment immediately surrounding drug taking can alter the behavioral, subjective, and rewarding effects of a given drug, thus influencing the propensity to use the same drug again. We have focused in particular on the results obtained using an animal model we have developed to study the latter type of drug-environment interaction.