Comorbidity of PTSD and depression in Korean War veterans: prevalence, predictors, and impairment

PTSD, depression, and treatment outcomes: A latent profile analysis among active duty personnel in a residential PTSD program

Depression frequently co-occurs with posttraumatic stress disorder (PTSD), including among active duty service members. However, symptom heterogeneity of this comorbidity is complex and its association with treatment outcomes is poorly understood, particularly among active duty service members in residential treatment. This study used latent profile analysis (LPA) to identify symptom-based subgroups of PTSD and depression among 282 male service members in a 10-week, residential PTSD treatment program with evidence-based PTSD psychotherapies and adjunctive interventions. The PTSD Checklist-Military Version and Patient Health Questionnaire-8 were completed by service members at pre- and posttreatment and weekly during treatment. Multilevel models compared subgroups on PTSD and depression symptom change across treatment. LPA indicated four subgroups provided optimal fit: Depressive (high depression severity, low PTSD avoidance; n = 33, 11.7%), Avoidant (high PTSD avoidance, moderate depression severity; n = 89, 31.6%), Moderate (moderate PTSD and depression severity; n = 27, 9.6%), and Distressed (high PTSD and depression severity; n = 133, 47.2%). Treatment response differed across classes for both PTSD and depression outcomes (time × LPA class interaction ps < 0.001). In PTSD models, post-hoc comparisons indicated the Moderate class was associated with less PTSD symptom improvement relative to the other classes (ps < 0.006). In depression models, symptom reduction was greatest for the Distressed and Depressive subgroups relative to the other two classes (ps < 0.009). Study results provide an initial model for two prevalent, impairing disorders among service members and show how these symptom-based subgroups may differentially respond to residential PTSD treatment.

Understanding Veterans' intimate partner violence use and patterns of healthcare utilization

OBJECTIVE

To understand the association between Veterans' healthcare utilization and intimate partner violence (IPV) use (i.e., perpetration) in order to (1) identify conditions comorbid with IPV use and (2) inform clinical settings to target for IPV use screening, intervention, and provider training.

DATA SOURCES AND STUDY SETTING

We examined survey data from a national sample of 834 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) Veterans.

STUDY DESIGN

We assessed associations between past-year IPV use and medical treatment, health issues, and use of Veterans Health Administration (VA) and non-VA services using chi-square tests and logistic regression.

DATA COLLECTION/EXTRACTION METHODS

Data were derived from the Department of Defense OEF/OIF/OND Roster. Surveys were sent to all women Veterans and a random sample of men from participating study sites.

PRINCIPAL FINDINGS

Half (49%) of the Veterans who reported utilizing VA healthcare in the past year indicated using IPV. Q values using a 5% false discovery rate indicated that Veterans who used IPV were more likely than Veterans who did not use IPV to have received treatment for post-traumatic stress disorder (PTSD; 39% vs. 27%), chronic sleep problems (36% vs. 26%), anxiety or depression (44% vs. 36%), severe chronic pain (31% vs. 22%), and stomach or digestive disorders (24% vs. 16%). Veterans who used IPV were also more likely than Veterans who did not use IPV to have received medical treatment in the past year (86% vs. 80%), seen psychiatrists outside VA (39% vs. 20%), and have outpatient healthcare outside VA (49% vs. 41%). IPV use was not related to whether Veterans received care from VA or non-VA providers.

CONCLUSIONS

Veterans' IPV use was related to greater utilization of services for mental health, chronic pain, and digestive issues. Future research should examine whether these are risk factors or consequences of IPV use.

Therapeutic and Economic Benefits of Service Dogs Versus Emotional Support Dogs for Veterans With PTSD

OBJECTIVE

This work aimed to assess the therapeutic and economic benefits of service dogs versus emotional support dogs for veterans with posttraumatic stress disorder (PTSD).

METHODS

Veterans with PTSD (N=227) participating in a multicenter trial were randomly assigned to receive a service or emotional support dog; 181 veterans received a dog and were followed up for 18 months. Primary outcomes included overall functioning (assessed with World Health Organization Disability Assessment Scale II [WHODAS 2.0]) and quality of life (Veterans RAND 12-Item Health Survey [VR-12]). Secondary outcomes included PTSD symptoms (PTSD Checklist for DSM-5), suicidal ideation, depression, sleep quality, health care costs and utilization, medication adherence, employment, and productivity.

RESULTS

Participants paired with a dog had a mean±SD age of 50.6±13.6 years (range 22-79), and most were male (80%), White (66%), and non-Hispanic (91%). Adjusted linear mixed repeated-measures models indicated no difference between the two groups on WHODAS 2.0 or VR-12 scores. Participants with service dogs had a 3.7-point greater reduction in PTSD symptoms versus participants with emotional support dogs (p=0.036). No reduced health care utilization or cost was associated with receiving a service dog. Veterans with service dogs had an increase of 10 percentage points in antidepressant adherence compared with those with emotional support dogs (p<0.01).

CONCLUSIONS

Both groups appeared to benefit from having a service or emotional support dog. No significant differences in improved functioning or quality of life were observed between the groups. Those in the service dog group had a greater reduction in PTSD symptoms and better antidepressant adherence, improvements that should be explored further.

Comparison of behavioral activation-enhanced cognitive processing therapy and cognitive processing therapy among U.S. service members: A randomized clinical trial

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) frequently co-occur and can cause significant impairment. Data are lacking as to whether interventions targeting both PTSD and MDD may improve treatment outcomes among individuals with this comorbidity compared with existing evidence-based PTSD treatments alone. This randomized trial compared the effectiveness of cognitive processing therapy (CPT) enhanced with behavioral activation (BA+CPT) versus CPT among 94 service members (52 women and 42 men; age M = 28.5 years) with comorbid PTSD and MDD. The primary outcome was clinician-administered depression symptom severity on the Montgomery-Åsberg Depression Rating Scale (MADRS) from pretreatment through 3-month follow-up. Intent-to-treat analyses using multilevel models showed statistically and clinically significant decreases in MADRS scores for both conditions over time, with no significant differences between BA+CPT and CPT. Secondary depression and PTSD symptom outcomes followed a similar pattern of results. For diagnostic MDD and PTSD outcomes using available data, no statistically significant differences between treatments emerged at posttreatment or 3-month follow-up. Sessions attended, dropout rate, and treatment satisfaction did not significantly differ between treatments. Outcomes were comparable for both treatments, suggesting that BA+CPT and CPT were similarly effective psychotherapy options for comorbid PTSD and MDD.

An in-depth look at latent classes of DSM-5 psychiatric comorbidity among individuals with PTSD: Clinical indicators and treatment utilization

OBJECTIVE

Posttraumatic stress disorder (PTSD) is associated with high comorbidity rates across the full range of psychiatric disorders. However, little is known about how psychiatric comorbidity manifests among people with PTSD, particularly with regard to concurrent diagnoses.

METHOD

Latent class analysis (LCA) was used to characterize discrete classes of PTSD comorbidity using past year DSM-5 diagnostic standards among a large nationally representative epidemiologic sample of U.S. adults. Follow-up analyses compared participant characteristics across latent classes.

RESULTS

The LCA was best characterized by five classes: low comorbidity, distress-fear, distress-externalizing, mania-fear-externalizing, and mania-externalizing. Excluding the low comorbidity class, proportions of borderline and schizotypal personality disorder were high across classes.

CONCLUSION

Participant characteristics across classes of past year PTSD comorbidity are explored through the lens of case conceptualization and treatment planning utility.

Effects of intranasal (S)-ketamine on Veterans with co-morbid treatment-resistant depression and PTSD: A retrospective case series

BACKGROUND

(S)-ketamine is a glutamatergic drug with potent and rapid acting effects for the treatment of depression. Little is known about the effectiveness of intranasal (S)-ketamine for treating patients with comorbid depression and post-traumatic stress disorder (PTSD).

METHODS

We performed a retrospective case series analysis of clinical outcomes in 35 Veterans with co-morbid depression and PTSD who were treated with intranasal (S)-ketamine treatments at the VA San Diego Neuromodulation Clinic between Jan 2020 and March 2021. Veterans were not randomized or blinded to treatment. The primary outcome measured was a change in patient health questionnaire-9 (PHQ-9) and PTSD Checklist for DSM-5 (PCL-5) scores across the first 8 treatments (induction period) using a repeated measures analysis of variance (ANOVA). In a smaller sub-group (n = 19) of Veterans who received at least 8 additional treatments, we analyzed whether intranasal (S)-ketamine continued to show treatment effects. Finally, we performed a sub-group and correlation analyses to understand how changes in PHQ-9 and PCL-5 scores were related across treatments.

FINDINGS

During the induction phase of treatment there was an absolute reduction of 5.1 (SEM 0.7) on the patient health questionnaire-9 (PHQ-9) rating scale for depression, from 19.8 (SEM 0.7) at treatment 1 to 14.7 (SEM 0.8) at treatment 8 (week 4) (F(7238) = 8.3, p = 1e-6, partial η² = 0.2). Five Veterans (14%) showed a clinically meaningful response (50% reduction in PHQ-9 score) at treatment 8. There was an absolute reduction of 15.5 +/- 2.4 on the patient checklist 5 (PCL-5) rating scale for PTSD, from 54.8 (SEM 2) at treatment 1 down to 39.3 (SEM 2.5) at treatment 8 (F(7238) = 15.5, p = 2e-7, partial η² = 0.31). Sixteen Veterans (46%) showed a clinically meaningful response (reduction in PCL-5 of > 30%) in PTSD. Change in PHQ-9 correlated with change in PCL-5 at treatment 8 (r = 0.47, p = 0.005), but a decrease in PTSD symptoms were observable in some individuals with minimal anti-depressant response.

INTERPRETATIONS

While this is an open-label retrospective analysis, our results indicate that both depression and PTSD symptoms in Veterans with dual-diagnoses may improve with repeated intranasal (S)-ketamine treatment. The effects of (S)-ketamine on PTSD symptoms were temporally and individually distinct from those on depression, suggesting potentially different modes of action on the two disorders. This work may warrant formal randomized controlled studies on the effects of intranasal (S)-ketamine for individuals with co-morbid MDD and PTSD.

FUNDING

VA Center of Excellence in Stress and Mental Health, VA ORD (Career Development Award to DSR), Burroughs-Wellcome Fund Award (DSR), NIMH (EL).

Implicit Associations of Nonsuicidal Self-Injury with Relief in Posttraumatic Stress and Depressive Disorders

OBJECTIVE

Although once considered a defining feature of borderline personality disorder, research has found high rates of NSSI among individuals with other psychiatric disorders, particularly posttraumatic stress disorder (PTSD) and depressive disorders. A recent study from our research team found that lifetime PTSD and depressive disorders were associated with unique self-reported NSSI motives. Given well-established limitations of assessing motives via self-report measures, the present study sought to extend this line of research by using a novel laboratory measure of the implicit NSSI-relief association to examine NSSI emotional relief motives.

METHOD

A subset of participants from our previous study (N = 109) completed diagnostic interviews and the laboratory-based DSH-Relief Implicit Association Test (IAT).

RESULTS

Findings indicated that individuals with lifetime PTSD evidenced stronger NSSI-relief associations than those without PTSD. Further, this main effect was qualified by a PTSD by depressive disorder interaction, such that stronger NSSI-relief associations were found among individuals with lifetime PTSD but no lifetime depressive disorder than among individuals without a history of either PTSD or a depressive disorder.

CONCLUSIONS

Results highlight the importance of investigating NSSI motives associated with different symptom profiles using a multi-method approach.

PTSD and Depression in Healthcare Workers in the Italian Epicenter of the COVID-19 Outbreak

Background:

Increasing evidence highlights the susceptibility of Healthcare Workers to develop psychopathological sequelae, including Post-Traumatic Stress Disorder (PTSD) and depression, in the current COronaVIrus Disease-19 (COVID-19) pandemic, but little data have been reported in the acute phase of the pandemic.

Objective:

To explore Healthcare Workers’ mental health reactions in the acute phase of the COVID-19 pandemic in the first European epicenter (Lodi/Codogno, Italy), with particular attention to post-traumatic stress and depressive symptoms and their interplay with other psychological outcomes.

Methods:

74 Healthcare Workers employed at the Azienda Socio Sanitaria Territoriale of Lodi (Lombardy, Italy) were recruited and assessed by means of the Impact of Event Scale- Revised, the Professional Quality of Life Scale-5, the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7 item, the Resilience Scale and the Work and Social Adjustment Scale. Socio-demographic and clinical variables were compared across three subgroups of the sample (No PTSD, PTSD only, PTSD and depression).

Results:

A total of 31% of subjects endorsed a diagnosis of PTSD and 28.4% reported PTSD comorbid with major depression. Females were more prone to develop post-traumatic stress and depressive symptoms. Subjects with PTSD and depression groups showed high levels of PTSD, depression, burnout and impairment in functioning. Anxiety symptoms were higher in both PTSD and depression and PTSD groups rather than in the No PTSD group.

Conclusion:

Our results showed high rates of PTSD and depression among Healthcare Workers and their comorbidity overall being associated with worse outcomes. Current findings suggest that interventions to prevent and treat psychological implications among Healthcare Workers facing infectious outbreaks are needed.

Prior histories of posttraumatic stress disorder and major depression and their onset and course in the three months after a motor vehicle collision in the AURORA study

BACKGROUND

A better understanding of the extent to which prior occurrences of posttraumatic stress disorder (PTSD) and major depressive episode (MDE) predict psychopathological reactions to subsequent traumas might be useful in targeting posttraumatic preventive interventions.

METHODS

Data come from 1306 patients presenting to 29 U.S. emergency departments (EDs) after a motor vehicle collision (MVC) in the advancing understanding of recovery after trauma study. Patients completed self-reports in the ED and 2-weeks, 8-weeks, and 3-months post-MVC. Associations of pre-MVC probable PTSD and probable MDE histories with subsequent 3-months post-MVC probable PTSD and probable MDE were examined along with mediation through intervening peritraumatic, 2-, and 8-week disorders.

RESULTS

27.6% of patients had 3-month post-MVC probable PTSD and/or MDE. Pre-MVC lifetime histories of these disorders were not only significant (relative risk = 2.6-7.4) but were dominant (63.1% population attributable risk proportion [PARP]) predictors of this 3-month outcome, with 46.6% prevalence of the outcome among patients with pre-MVC disorder histories versus 9.9% among those without such histories. The associations of pre-MVC lifetime disorders with the 3-month outcome were mediated largely by 2- and 8-week probable PTSD and MDE (PARP decreasing to 22.8% with controls for these intervening disorders). Decomposition showed that pre-MVC lifetime histories predicted both onset and persistence of these intervening disorders as well as the higher conditional prevalence of the 3-month outcome in the presence of these intervening disorders.

CONCLUSIONS

Assessments of pre-MVC PTSD and MDE histories and follow-ups at 2 and 8 weeks could help target early interventions for psychopathological reactions to MVCs.

MicroRNAs as biomarker and novel therapeutic target for posttraumatic stress disorder in Veterans

Posttraumatic stress disorder (PTSD) is a common psychiatric disorder for military Veterans, characterized by hyperarousal, intrusive thoughts, flashbacks, hypervigilance, and distress after experiencing traumatic events. Some of the known physiological effects of PTSD include hypothalamic-pituitary-adrenal (HPA)-axis imbalance, a cortical function resulting in neuronal deficit and changes in behavior. Moreover, excessive discharge of inflammatory molecules and a dysregulated immune system are implicated in the pathophysiology of PTSD. Due to complex nature of this disorder, the biological underpinnings of PTSD remain inexplicable. Investigating novel biomarkers to understanding the pathogenesis of PTSD may reflect the underlying molecular network for therapeutic use and treatment. Circulatory microRNAs (miRNAs) and exosomes are evolving biomarkers that have shown a key role in psychiatric and neurological disorders including PTSD. Given the unique nature of combat trauma, as well as evidence that a large portion of Veterans do not benefit from frontline treatments, focus on veterans specifically is warranted. In the present review, we delineate the identification and role of several miRNAs in PTSD among veterans. An association of miRNA with HPA-axis regulation through FKBP5, a key modulator in PTSD is discussed as an emerging molecule in psychiatric diseases. We conclude that miRNAs may be used as circulatory biomarker detection in Veterans with PTSD.

A Community Survey of Quality of Life and Psychiatric Disorders among Residents Following the Kaohsiung Gas Explosion: a 5-Year Cross-Sectional Follow-Up Study

To investigate factors associated with quality of life (QoL) and disaster-related psychiatric disorders, including posttraumatic stress disorder (PTSD) and major depressive episode (MDE), in the survivors of a gas explosion in Taiwan 5 years after the event. A community-based cross-sectional study of residents from an area that experienced a gas explosion was conducted 5 years after the event. The Short Form 12v2 (SF-12v2) was used to screen 2511 participants. The Disaster-Related Psychological Screening Test (DRPST) was used to assess probable MDE and PTSD. A total of 2511 participants, including 604 males and 1907 females, completed the QoL survey. The average age was 56.02 ± 16.78 years, and most participants were in the ≧65 age group (39.7%). The males had better QoL in the physical dimensions. Lifestyle was significantly positively associated with QoL. A total of 894 participants completed the DRPST, which showed some individuals with probable MDE (n = 93, 10.4%), probable PTSD (n = 22, 2.5%), or probable MDE and PTSD (n = 49, 5.5%); most people had no MDE or PTSD (n = 730, 81.7%). Those in the probable PTSD or MDE groups were significantly more likely to be female or to be experiencing stressors (p < 0.001). The participants continued to be affected by the disaster based on their QoL, even 5 years later. Females had a higher risk of probable psychiatric disorders and poorer QoL in the physical dimensions. Long-term follow-up, interventions and investigations after a disaster are needed.

Differential Effects of Comorbid Psychiatric Disorders on Treatment Outcome in Posttraumatic Stress Disorder from Childhood Trauma

Patients with posttraumatic stress disorder (PTSD) frequently have comorbid diagnoses such as major depressive disorder (MDD) and anxiety disorders (AD). Studies into the impact of these comorbidities on the outcome of PTSD treatment have yielded mixed results. The different treatments investigated in these studies might explain the varied outcome. The purpose of this study was to examine the impact of these comorbidities on the outcome of two specific PTSD treatments. MDD and AD were analyzed as predictors and moderators in a trial comparing 12 sessions of either eye movement desensitization and reprocessing (EMDR) or imagery rescripting (IR) in 155 adult patients with PTSD from childhood trauma. The primary outcome was reduction of PTSD symptoms (clinician-administered PTSD Scale for DSM-5, CAPS-5) assessed at eight-week follow-up and a secondary outcome was self-report PTSD symptoms (Impact of Event Scale, IES-R). MDD was not a predictor of treatment outcome but did have a significant moderator effect. Patients with MDD showed a better outcome if they were treated with IR, whereas patients without MDD improved more in the EMDR condition. No impact of AD emerged. It seems essential to consider comorbid MDD when planning PTSD treatment to improve treatment outcomes. More research is needed to replicate our findings and focus on different kinds of PTSD treatments and other comorbidities.

Comorbid mental disorders, depression symptom severity, and role impairment among Veterans initiating depression treatment through the Veterans Health Administration

BACKGROUND

Psychiatric comorbidities may complicate depression treatment by being associated with increased role impairments. However, depression symptom severity might account for these associations. Understanding the independent associations of depression severity and comorbidity with impairments could help in treatment planning. This is especially true for depressed Veterans, who have high psychiatric comorbidity rates.

METHODS

2,610 Veterans beginning major depression treatment at the Veterans Health Administration (VHA) were administered a baseline self-report survey that screened for diverse psychiatric comorbidities and assessed depression severity and role impairments. Logistic and generalized linear regression models estimated univariable and multivariable associations of depression severity and comorbidities with impairments. Population attributable risk proportions (PARPs) estimated the relative importance of depression severity and comorbidities in accounting for role impairments.

RESULTS

Nearly all patients (97.8%) screened positive for at least one comorbidity and half (49.8%) for 4+ comorbidities. The most common positive screens were for generalized anxiety disorder (80.2%), posttraumatic stress disorder (77.9%), and panic/phobia (77.4%). Depression severity and comorbidities were significantly and additively associated with impairments in multivariable models. Associations were attenuated much less for depression severity than for comorbidities in multivariable versus univariable models. PARPs indicated that 15-60% of role impairments were attributable to depression severity and 5-32% to comorbidities.

LIMITATIONS

The screening scales could have over-estimated comorbidity prevalence. The cross-sectional observational design cannot determine either temporal or causal priorities.

CONCLUSIONS

Although positive screens for psychiatric comorbidity are pervasive among depressed VHA patients, depression severity accounts for most of the associations of these comorbidities with role impairments.

Latent Profiles of Comorbid Depression as Predictors of PTSD Treatment Outcome

Posttraumatic stress disorder (PTSD) frequently co-occurs with major depressive disorder, and empirically supported PTSD treatments consistently improve depression. However, both diagnoses are heterogeneous and specific patterns of symptom overlap may be related to worse treatment outcome. Two hundred individuals with chronic PTSD participated in a doubly randomized preference trial comparing prolonged exposure and sertraline. Latent Profile Analysis was used to identify classes based on PTSD and depression symptoms prior to starting treatment. A three-class model best fit the data, with a high depression and PTSD severity class (distressed), a moderate depression and low PTSD avoidance class (depressive), and a low depression and high PTSD avoidance class (avoidant). The avoidant class showed the lowest rates of major depressive disorder diagnosis and transdiagnostic vulnerabilities to depression. Patients in the distressed class experienced more robust PTSD treatment response, with no differences between prolonged exposure and sertraline. These findings highlight the role of avoidance in nondepressed PTSD presentations while also demonstrating that co-occurring depression is not contraindicated in evidence-based PTSD treatment.

Cross-Lagged Relationships Between Insomnia and Posttraumatic Stress Disorder in Treatment-Receiving Veterans

Insomnia is a risk factor for the development of posttraumatic stress disorder (PTSD) while it is also plausible that PTSD symptoms can maintain insomnia symptoms. The present study examined longitudinal bidirectional relationships between insomnia and PTSD symptoms in treatment-seeking veterans. Participants were 693 ex-serving members of the Australian Defence Force who participated in an accredited, hospital-based outpatient PTSD program. Participants completed self-reported assessments of PTSD and insomnia symptoms at four time points: intake, discharge, 3-month, and 9-months posttreatment follow-up. Cross-lagged pathway analyses indicated significant bi-directional pathways between insomnia symptoms and PTSD symptoms at most time points. A final cross-lagged model between insomnia symptoms and the PTSD symptom clusters indicated that the PTSD symptom paths on insomnia symptoms, between intake and discharge, were attributable to reexperiencing PTSD symptoms. In contrast, across posttreatment follow-up time points there were significant paths of insomnia symptoms on all PTSD symptom clusters except from insomnia at 3-months to avoidance symptom at 9-months. PTSD symptoms and insomnia symptoms have bidirectional associations over time that may lead to the mutual maintenance or exacerbation of each condition following PTSD treatment. Where residual insomnia symptoms are present post-treatment, a sleep-focussed intervention is indicated and a sequenced approach to treatment recommended.

Presence of PTSD is Associated with Clinical and Functional Impact in Veterans with Depression Treated in Community-Based Clinics

Providers in non-traditional mental health settings (e.g., primary care, community medical clinics) face challenges involving patients who often present with multiple mental health conditions, but require rapid assessment and treatment. To help address this challenge, this study characterized differences in health symptom severity and mental health treatment perceptions between depressed Veterans with and without posttraumatic stress disorder (PTSD) served in community medical clinics. Relative to depressed Veterans without PTSD (N = 62), depressed Veterans with PTSD (N = 122) endorsed greater depression, suicidal ideation, anxiety, pain, and insomnia symptoms, as well as lower functioning. Veterans with depression and PTSD also reported greater mental health needs, prior utilization of mental health services, and higher perceived importance of mental health treatment. Results highlight the complexity of comorbid mental health conditions frequently seen in community medical care clinics and suggest that patients with comorbid mental health difficulties may present with a complex array of mental health symptoms.

Co-occurrence Pattern of Posttraumatic Stress Disorder and Depression in People Living With HIV: A Latent Profile Analysis

Background: The comorbidity of posttraumatic stress disorder (PTSD) and depression is common among people living with the HIV (PLWH). Given the high prevalence and serious clinical consequences of the comorbidity of these two disorders, we conducted a latent profile analysis to examine the co-occurrence pattern of PTSD and depression in PLWH.

Methods: The data for this cross-sectional study of PLWH were collected from 602 patients with HIV in China. A secondary analysis using latent profile analysis was conducted to examine HIV-related PTSD and depression symptoms.

Results: A four-class solution fits the data best, with the four classes characterized as asymptomatic (42.9%), mild symptoms (33.9%), low to moderate symptoms (19.8%), and high to moderate symptoms (3.4%). The severity of PTSD and depression symptoms was comparable in this solution, and no group was dominated by PTSD or depression.

Conclusion: The absence of a distinct subcluster of PLWH with only PTSD or depression symptoms supports that PTSD and depression in PLWH are psychopathological manifestations after traumatic exposures. Health care staff should pay more attention to the existence of comorbid symptoms of individuals, develop integrated interventions for the symptoms cluster, and evaluate their effectiveness in clinical practice.

Network analysis of PTSD and depressive symptoms in 158,139 treatment-seeking veterans with PTSD

BACKGROUND

In recent years, a new framework for analyzing and understanding posttraumatic stress disorder (PTSD) was introduced; the network approach. Up until now, network analysis studies of PTSD were largely conducted on small to medium sample sizes (N < 1,000), which might be a possible cause of variability in main findings. Moreover, only a limited number of network studies investigated comorbidity.

METHODS

In this study, we utilized a large sample to conduct a network analysis of 17 symptoms of PTSD (DSM-IV), and compared it to the result of a second network consisting of symptoms of PTSD and depression (based on Patient Health Questionnaire-9 [PHQ-9]). Our sample consisted of 502,036 treatment-seeking veterans, out of which 158,139 had fully completed the assessment of symptoms of PTSD and a subsample of 32,841 with valid PCL and PHQ-9 that was administered within 14 days or less.

RESULTS

Analyses found that in the PTSD network, the most central symptoms were feeling distant or cut off from others, followed by feeling very upset when reminded of the event, and repeated disturbing memories or thoughts of the event. In the combined network, we found that concentration difficulties and anhedonia are two of the five most central symptoms.

CONCLUSION

Our findings replicate the centrality of intrusion symptoms in PTSD symptoms' network. Taking into account the large sample and high stability of the network structure, we believe our study can answer some of the criticism regarding stability of cross-sectional network structures.

Dopamine, endocannabinoids and their interaction in fear extinction and negative affect in PTSD

There currently exist few frameworks for common neurobiology between reexperiencing and negative cognitions and mood symptoms of PTSD. Adopting a dopaminergic framework for PTSD unites many aspects of unique symptom clusters, and this approach also links PTSD symptomology to common comorbidities with a common neurobiological deficiency. Here we review the dopamine literature and incorporate it with a growing field of research that describes both the contribution of endocannabinoids to fear extinction and PTSD, as well as the interactions between dopaminergic and endocannabinoid systems underlying this disorder. Based on current evidence, we outline an early, preliminary model that links re-experiencing and negative cognitions and mood in PTSD by invoking the interaction between endocannabinoid and dopaminergic signalling in the brain. These interactions between PTSD, dopamine and endocannabinoids may have implications for future therapies for treatment-resistant and comorbid PTSD patients.

Association of remote traumatic brain injury and military employment with late-life trajectories of depressive symptom severity

BACKGROUND

Traumatic brain injury (TBI) and military service are common lifetime exposures among current older adults that may affect late-life mental health. The objective of the present study was to evaluate the association between TBI with loss of consciousness (LOC) and military employment and late-life depressive symptom severity trajectory.

METHODS

1445 males and 2096 females adults at least 65 years old without dementia or recent TBI were enrolled and followed biennially for up to 10 years in the Adult Changes in Thought study from Kaiser Permanente Washington in Seattle, Washington.

RESULTS

Using group-based trajectory modeling, we documented four distinct depressive symptom severity trajectories that followed a similar course in males and females (Minimal, Decreasing, Increasing, and Persistent). In multinomial regression analyses, TBI with LOC in males was associated with greater likelihood of Persistent versus Minimal depressive symptom severity compared to individuals without TBI (OR = 1.51, 95% CI: 1.01, 2.27; p=0.046). Males reporting past military employment had greater likelihood of Decreasing versus Minimal depressive symptom severity compared to individuals without past military employment (OR = 1.54, 95% CI: 1.03, 2.31; p=0.035). There was no association between TBI or military employment and depression trajectories in females, and no evidence of effect modification by age or between exposures.

LIMITATIONS

Lifetime history of TBI was ascertained retrospectively and may be subject to recall bias. Also, past military employment does not presuppose combat exposure.

CONCLUSIONS

Remote TBI and past military employment are relevant to late-life trajectories of depressive symptom severity in dementia-free older males.

The Mediating Role of Meaning in Life in the Effects of Calling on Posttraumatic Stress Symptoms and Growth: A Longitudinal Study of Navy Soldiers Deployed to the Gulf of Aden

This study examined the mediating role of meaning in life in the effect of calling on posttraumatic stress disorder (PTSD) and posttraumatic growth (PTG) among navy soldiers of the Republic of Korea deployed to the Gulf of Aden, Somalia. Participants responded to the questionnaire survey three times (pre-deployment, deployment, and post-deployment) at 4-month intervals. From the first, second, and third surveys, data were collected for 223, 195, and 103 respondents, respectively. Results showed that calling had a negative effect on PTSD, fully mediated by meaning in life, whereas calling had a positive effect on PTG, partially mediated by meaning in life. Our findings suggest that calling acts as a positive psychological resource for maintaining the meaning in life throughout stressful events experienced during deployment, thereby reducing posttraumatic stress symptoms and promoting post-deployment psychological growth. Finally, theoretical and practical implications and the need for follow-up studies are discussed.

Association of Posttraumatic Stress and Depressive Symptoms With Mortality in Women

Importance

Consistent evidence has found associations between posttraumatic stress disorder (PTSD) and increased risk of chronic disease and greater prevalence of health risk factors. However, the association between PTSD and all-cause mortality has not been thoroughly investigated in civilians.

Objective

To investigate the association between PTSD symptoms, with or without comorbid depressive symptoms, and risk of death.

Design, Setting, and Participants

This prospective cohort study was conducted using data on female US nurses in the Nurses' Health Study II followed up from 2008 to 2017. Women who responded to a 2008 questionnaire querying PTSD and depressive symptoms were included. Data were analyzed from September 2018 to November 2020.

Exposures

Symptoms of PTSD, measured using the short screening scale for Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) PTSD, and depression symptoms, measured using the Center for Epidemiologic Studies Depression Scale-10 in 2008.

Main Outcomes and Measures

All-cause mortality was determined via National Death Index, US Postal Service, or report of participant's family. The hypothesis being tested was formulated after data collection. Trauma exposure and PTSD symptoms were jointly coded as no trauma exposure (reference), trauma and no PTSD symptoms, 1 to 3 PTSD symptoms (subclinical), 4 to 5 PTSD symptoms (moderate), and 6 to 7 PTSD symptoms (high).

Results

Among 51 602 women (50 137 [97.2%] White individuals), the mean (range) age was 53.3 (43-64) years at study baseline in 2008. PTSD and probable depression were comorbid; of 4019 women with high PTSD symptoms, 2093 women (52.1%) had probable depression, while of 10 105 women with no trauma exposure, 1215 women (12.0%) had probable depression. Women with high PTSD symptoms and probable depression were at nearly 4-fold greater risk of death compared with women with no trauma exposure and no depression (hazard ratio [HR], 3.80; 95% CI, 2.65-5.45; P < .001). After adjustment for health factors, women with these conditions had a more than 3-fold increased risk (HR, 3.11; 95% CI, 2.16-4.47, P < .001). Women with subclinical PTSD symptoms without probable depression had increased risk of death compared with women with no trauma exposure and no depression (HR, 1.43; 95% CI, 1.06-1.93; P = .02). Among 7565 women with PTSD symptoms and probable depression, 109 deaths (1.4%) occurred for which we obtained cause of death information, compared with 124 such deaths (0.6% ) among 22 215 women with no depression or PTSD symptoms. Women with PTSD symptoms and probable depression, compared with women with no PTSD or depression, had higher rates of death from cardiovascular disease (17 women [0.22%] vs 11 women [0.05%]; P < .001), diabetes (4 women [0.05%] vs 0 women; P < .001), unintentional injury (7 women [0.09%] vs 7 women [0.03%]; P = .03), suicide (9 women [0.12%] vs 1 woman [<0.01%]; P < .001), and other causes of death (14 women [0.19%] vs 17 women [0.08%]; P = .01).

Conclusions and Relevance

These findings suggest that at midlife, women with high PTSD symptoms and co-occurring probable depression are at increased risk of death compared with women without these disorders. Treatment of PTSD and depression in women with symptoms of both disorders and efforts to improve their health behaviors may reduce their increased risk of mortality.

Effects of early life social experience on fear extinction and related glucocorticoid profiles - behavioral and neurochemical approaches in a rat model of PTSD

People may agonize over an intrusive fear-inducing memory even when the traumatic event has passed, which is the principle manifestation of posttraumatic stress disorder (PTSD). However, many traumatized people do not present symptoms of PTSD, implying that certain hidden factors help those individuals to cope with the traumatic stress. Increasing evidence suggests that early life experience may serve as a predisposing factor in the development of PTSD. For example, early life social deprivation disrupts the glucocorticoid system, one of the biological abnormalities of PTSD. By employing isolation rearing (IR) with a subsequent single prolonged stress (SPS) paradigm, we examined the hypothesis that early-life social experience may change the outcome of traumatic stress in both behavioral and neurochemical profiles. Behaviorally, the performance of rats on a Pavlovian fear conditioning test was measured to evaluate their retrieval ability of fear memory extinction. Neurochemically, plasma corticosterone levels and glucocorticoid receptor (GR), FK506-binding proteins 4 and 5 (FKBP4 and FKBP5) and early growth response-1 (Egr-1) expression were measured in GR-abundant brain areas, including the hypothalamus, medial prefrontal cortex, and hippocampus. Our results demonstrated an area-dependent IR effect on the SPS outcomes. IR prevented the SPS-impaired fear extinction retrieval ability and averted the SPS-elevated expression of GR, FKBP4, and Egr-1 in the hippocampus, whereas it did not change the SPS-reduced plasma corticosterone levels and SPS-enhanced GR activity in the mPFC and hypothalamus. The present study provides some new insights to support the hypothesis that early-life experience may play a role in the occurrence of PTSD.

Heterogeneous patterns of posttraumatic stress symptoms and depression in cancer patients

BACKGROUND

Studies suggest that posttraumatic stress symptoms (PTSSs) and depression are common psychological outcomes in cancer patients and have high co-occurring prevalence. However, it is unclear whether PTSSs and depression always co-occur in cancer patients. This study aimed to clarify these co-occurring patterns.

METHODS

Participants were 270 cancer patients who completed self-report questionnaires. Latent profile analysis was used to examine co-occurring patterns of PTSSs and depression.

RESULTS

The results indicated four patient types: a low symptom group (n = 34, 13.0%), a depression symptom group (n = 99, 37.8%), a moderate co-occurring symptom group (n = 97, 37.0%), and a severe co-occurring symptom group (n = 32, 12.2%). Multinomial logistic regression was used to examine the role of social support, core belief challenge, and intrusive rumination in differentiating these groups. Intrusive rumination was more likely to be associated with depression symptoms, moderate co-occurring symptoms, and severe co-occurring symptoms. Core belief challenge was more likely to be associated with both moderate and severe co-occurring symptoms, and social support was less likely to be associated with moderate co-occurring symptoms.

LIMITATIONS

All variables were measured using self-report scales.

CONCLUSIONS

The coexisting patterns of PTSSs and depression in cancer patients are heterogeneous. Core belief challenge and intrusive rumination effectively differentiated PTSSs and depression patterns. Social support differentiated the low symptom group from the moderate co-occurring symptom group.

Prevalence and correlates of comorbid PTSD with depression among older people exposed to the Jeju April 3 incident

BACKGROUND

The psychological consequences of the Jeju April 3 incident, which occurred almost 70 years ago, may be long-lasting. Thus, the present study investigated the prevalence and impact of comorbid post-traumatic stress disorder (PTSD) and depression among older people exposed to this incident.

METHODS

A total of 110 survivors and 1,011 immediate family members of the victims of the Jeju April 3 incident completed a questionnaire that collected demographic information, the Center for Epidemiologic Studies Depression Scale (CES-D), and the PTSD Checklist-Civilian Version (PCL-C). Comorbidity was defined as a combination of CES-D positivity and PCL-C positivity. To identify trends among clinical characteristics according to the severity of the comorbid PTSD and depression condition, linear-by-linear association tests were conducted.

RESULTS

Of the 1,121 older people included in the present study, 10.8% met the criteria for comorbid PTSD and depression, 3.0% had PTSD only, and 24.3% had depression only. Additionally, as the severity of the comorbid condition increased, there were trends for lower levels of socioeconomic status and perceived family support and higher suicidality. Compared to either disorder alone, individuals with the comorbid condition were 2.04 times more likely to have a higher suicidal risk.

LIMITATIONS

Standardized diagnostic tools for assessing the case findings were not employed in the present study.

CONCLUSION

Comorbid PTSD and depression was prevalent among older people exposed to the Jeju April 3 incident. Additionally, this comorbid condition was related to a serious clinical phenomenology, including a higher suicidal risk.

The influence of depression-PTSD comorbidity on health-related quality of life in treatment-seeking veterans

OBJECTIVE

Posttraumatic stress disorder (PTSD) and depression substantially impair health-related quality of life (HRQOL) for many Canadian Armed Forces (CAF) veterans. Although PTSD and depression are highly comorbid, little is known about whether the disorders may interact in their association with HRQOL. We sought to investigate whether depressive symptoms modify the relation between PTSD and HRQOL in treatment-seeking veterans.

METHOD

We accessed the clinical data of 545 CAF veterans aged 18 to 65 years who were seeking treatment at a specialized clinic in London, Ontario. We used hierarchical linear regression to assess the additive and multiplicative relations between depression and PTSD symptoms on HRQOL, controlling for age and alcohol/substance abuse. Simple slopes were examined to probe significant interactions.

RESULTS

Probable PTSD and major depression were present in 77.4% and 85.3% of the sample, respectively, and 73.0% of the sample presented with probable PTSD-depression comorbidity. Depression symptoms significantly modified the relation between PTSD symptoms and overall mental HRQOL (β = 0.12, p <0.001, ∆R²  = 0.014), and role impairment due to emotional difficulties (β = 0.20, p <0.001, ∆R²  = 0.035). Simple slope analyses revealed the impact of PTSD was greater among those with lower depression symptoms and became weaker with greater depression symptom severity. In adjusted models, only depression was significantly associated with all mental and physical HRQOL domains; PTSD was not associated with physical HRQOL, role emotional impairment, or vitality.

CONCLUSIONS

For those with severe comorbid depression, PTSD symptoms were no longer associated with mental HRQOL, particularly in areas related to emotional functioning. Findings suggest the importance of targeting depression in patients presenting with PTSD-depression comorbidity.

Message Delivery for the Treatment of Posttraumatic Stress Disorder: Longitudinal Observational Study of Symptom Trajectories

Background

Individuals with posttraumatic stress disorder (PTSD) face symptoms that can hinder access to treatment, such as avoidance and guilt. Telemedicine offers a technological solution to increase access to mental health care and overcome barriers to treatment. Although an increasing body of literature focused on synchronous telehealth (eg, live video), no studies have examined the delivery of PTSD treatment via two-way multimedia messages (ie, texting or messaging).

Objective

The aim of this study was to conduct a longitudinal observation of treatment for PTSD delivered using two-way asynchronous messaging. We also sought to identify individual and treatment characteristics that could predict the observed outcome differences.

Methods

Outpatients diagnosed with PTSD (N=475) received interventions from licensed therapists, which were delivered via messaging once or more than once per day, 5 days a week for 12 weeks. PTSD symptoms were assessed every 3 weeks using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5. Trajectories of PTSD symptoms were identified using growth mixture modeling (GMM). Using logistic regression, the demographic, treatment, and messaging characteristics of patient groups that improved were compared with the characteristics of patient groups that did not improve.

Results

The GMM identified 4 trajectories of PTSD symptoms: moderate improvement (197/475, 41.4%), high symptoms (197/475, 41.4%), chronic symptoms (61/475, 12.9%), and acute improvement (20/475, 4.3%). Patients with a clinically significant reduction in PTSD symptoms (231/475, 48.6%) were more likely to communicate via video (odds ratio [OR] 1.01, 95% CI 1.01-1.05; P=.03), have a higher working alliance with their therapist (OR 1.03, 95% CI 1.01-1.05; P=.02), and be at their first treatment experience (OR 2.03, 95% CI 1.18-3.54; P=.01). Treatment adherence was associated with greater therapeutic alliance (OR 1.07, 95% CI 1.03-1.10; P<.001), education (OR 2.13, 95% CI 1.13-4.03; P=.02), and more patient-generated messages per week (OR 1.08, 95% CI 1.04-1.13; P<.001).

Conclusions

Multimedia message delivery for PTSD treatment showed symptom-reduction rates similar to traditional forms of treatment delivery, suggesting further study of messaging as a treatment medium. Most patients completed an 8-week course, reflecting the acceptability of messaging interventions. Delivering treatment via two-way messaging offers increased opportunities for widespread access to mental health care.

Comparison of latent typologies of posttraumatic stress disorder and depression symptoms across military personnel from India and the US

Research has identified heterogeneous subgroups of individuals based on posttraumatic stress disorder (PTSD) and depression symptoms. Using data collected from military personnel in India (N = 146) and U.S. (N = 194), we examined (1) the best-fitting latent class solution; (2) multi-group invariance of the class solution; and (3) construct validity of optimal class solution. Results indicated that the optimal 4-class solution differed in severity and severity/type in the India and U.S. samples respectively. With similarity in the optimal number of classes across cultural samples, the meaning/nature of classes differed. In the India sample, anxiety severity predicted the Low Severity Class vs. all other classes, and the Moderately High Severity/High Severity Classes vs. the Moderately Low Severity Class; number of traumas predicted the High Severity Class vs. other classes; and resilience predicted the Moderately Low Severity Class vs. the Moderately High Severity Class. In the U.S. sample, alcohol use predicted the High Severity Class vs. all other classes, and the High Depression-Low PTSD Class vs. the Low Severity Class; rumination significantly predicted the High Severity and High Depression-Low PTSD Classes vs. each of the High PTSD-Low Depression and Low Severity Classes. Thus, meaning and nature of PTSD-depression subgroups may vary culturally; hence, culturally-sensitive interventions need to account for this heterogeneity.

Combat exposure, posttraumatic stress disorder, and head injuries differentially relate to alterations in cortical thickness in military Veterans

Combat-exposed Veterans are at increased risk for developing psychological distress, mood disorders, and trauma and stressor-related disorders. Trauma and mood disorders have been linked to alterations in brain volume, function, and connectivity. However, far less is known about the effects of combat exposure on brain health. The present study examined the relationship between severity of combat exposure and cortical thickness. Post-9/11 Veterans (N = 337; 80% male) were assessed with structural neuroimaging and clinically for combat exposure, depressive symptoms, prior head injury, and posttraumatic stress disorder (PTSD). Vertex-wide cortical thickness was estimated using FreeSurfer autosegmentation. FreeSurfer's Qdec was used to examine relationship between combat exposure, PTSD, and prior head injuries on cortical thickness (Monte Carlo corrected for multiple comparisons, vertex-wise cluster threshold of 1.3, p < 0.01). Covariates included age, sex, education, depressive symptoms, nonmilitary trauma, alcohol use, and prior head injury. Higher combat exposure uniquely related to lower cortical thickness in the left prefrontal lobe and increased cortical thickness in the left middle and inferior temporal lobe; whereas PTSD negatively related to cortical thickness in the right fusiform. Head injuries related to increased cortical thickness in the bilateral medial prefrontal cortex. Combat exposure uniquely contributes to lower cortical thickness in regions implicated in executive functioning, attention, and memory after accounting for the effects of PTSD and prior head injury. Our results highlight the importance of examining effects of stress and trauma exposure on neural health in addition to the circumscribed effects of specific syndromal pathology.

Risk and protective factors associated with comorbid PTSD and depression in U.S. military veterans: Results from the National Health and Resilience in Veterans Study

Converging evidence suggests that veterans with co-occurring PTSD/MDD represent a high-risk group for poor mental health compared to those with PTSD alone. To date, however, little is known about the specific factors that may increase vulnerability for and buffer risk for comorbid PTSD/MDD. The purpose of this study was to provide a population-based characterization of sociodemographic, risk, and protective variables associated with comorbid PTSD/MDD among U.S. military veterans. Data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative survey of U.S. military veterans (n = 2,732). Analyses (1) compared veterans with PTSD alone and co-occurring PTSD/MDD on sociodemographic, military, and psychosocial characteristics; and (2) examined variables independently associated with PTSD/MDD status. Multivariable logistic regression analyses revealed that racial/ethnic minority status (odds ratio [OR] = 12.5), number of lifetime traumas (OR = 1.3), and time spent engaged in private religious/spiritual activities (OR = 1.8) were associated with PTSD/MDD status, while higher scores on measures of community integration (OR = 0.6) and dispositional optimism (OR = 0.7) were negatively associated with comorbid PTSD/MDD status. Relative importance analyses revealed that dispositional optimism (34%) and community integration (24%) explained the largest proportions of variance in PTSD/MDD comorbidity. Taken together, results of this study suggest that racial/ethnic minority status, greater lifetime trauma burden, and engagement in private religious/spiritual activities are key distinguishing characteristics of U.S. military veterans with comorbid PTSD/MDD vs. PTSD alone. They further underscore the need to study whether targeting community integration and optimism in prevention and treatment efforts may enhance clinical outcomes in this population.

Emotion dysregulation is associated with increased prospective risk for chronic PTSD development

While emotion dysregulation is associated with many psychological disorders, including posttraumatic stress disorder (PTSD), it remains uncertain whether pre-existing emotion dysregulation increases individual risk for prospectively developing PTSD in the aftermath of trauma exposure. Thus, the objective of the current study was to determine whether emotion dysregulation could prospectively predict the development of chronic PTSD symptoms following a traumatic event above and beyond other known associated factors, including depressive symptoms, baseline PTSD symptoms, total traumas experienced, and exposure to interpersonal trauma. Participants (N = 135) were recruited from the emergency department (ED) at Grady Memorial Hospital in Atlanta and follow-up assessments were conducted at 1-, 3-, 6-, and 12-months following trauma exposure. Latent Growth Mixture Modeling was used to identify PTSD symptom trajectories based on symptoms assessed at 1, 3, 6, and 12 months; three trajectories emerged: "chronic", "recovery", and "resilient". For the present study, probability of chronic PTSD symptoms was used as the outcome variable of interest. Linear regression modeling showed that emotion dysregulation was significantly associated with probability of developing chronic PTSD symptoms (p = 0.001) and accounted for an additional 7% of unique predictive variance when controlling for trauma exposure, baseline PTSD, and depressive symptoms. Our findings suggest that emotion dysregulation can be used as both a predictor of chronic PTSD and as a treatment target. Thus, identifying individuals with high levels of emotion dysregulation at the time of trauma and implementing treatments designed to improve emotion regulation could aid in decreasing the development of chronic PTSD among these at-risk individuals.

The epidemiology of antidepressant use in South Korea: Does short-term antidepressant use affect the relapse and recurrence of depressive episodes?

Background

The duration of antidepressant use affects the treatment of depression. Using the National Health Insurance database, which covers almost the entire national population, we verified the factors associated with the inadequate short-term use of initially prescribed antidepressants and their effects on the relapse and recurrence of depressive episodes.

Methods

There were 752,190 patients included who had been newly prescribed antidepressants in 2012 with the diagnosis of depressive disorder. They were followed-up until December 31, 2015. They were classified as short-term and long-term antidepressant users depending on whether they used a specific initial antidepressant for at least four weeks. Sociodemographic, clinical, and medical utilization factors affecting the duration of antidepressant use were investigated. We also identified whether the duration of antidepressant use affected the risk of relapse and recurrence, which was defined by the restarting of antidepressants.

Results

Initial antidepressants were taken for less than 28 days by 458,057 (60.84%) patients. Tricyclic antidepressants were used as the initial antidepressant more frequently than selective serotonin reuptake inhibitors (64.5% versus 19.3%). The type of initial antidepressant, polypharmacy, psychiatric and medical comorbidities, type of insurance coverage, and type of medical institution visited were associated with short-term use. Short-term use marginally increased the risk of relapse and recurrence of depressive episodes (Hazard ratio: 1.06, 95% confidence intervals 1.048–1.075).

Conclusions

Short-term antidepressant use is widespread in Korea, and assessment in various aspects are necessary to set proper treatment plans.

Living on the Edge: Emotional and Behavioral Problems in a Sample of Kosovar Veterans and Wives of Veterans 16 Years Postwar

Aim: This study aimed to explore the effects of war traumatic exposure on emotional and behavioral problems in a sample of Kosovar war veterans and the wives of veterans 16 years after the 1998-1999 war, as well as whether the level of education, income, well-being, and substance use are predictors for emotional and behavioral problems. Methods: Self-report data were obtained from 373 adults, 247 male war veterans (66.2% of the sample) and 126 wives of other male war veterans (33.8% of the sample). The sample was recruited from a list of war veterans provided by the Kosovar National Association of War Veterans. The mean age of participants was 45.42 [standard deviation (SD), 7.64] years. Measurements comprised a sociodemographic brief structured interview, the Well-Being Index (WHO-5), the Harvard Trauma Questionnaire, and the Adult Self Report (ASR). Logistic regression analysis was conducted to explore if the demographic variables were predictors for ASR general scales and subscales. Multivariate analysis of covariance was performed by adding as covariates the continuous variables pointed out in the logistic regression analysis as discriminating factors between the groups. Post hoc analyses were corrected, and we estimated partial η2 to measure the effect size. Results: The higher traumatic exposure during the war, the greater the tendency to have emotional problems and behavioral problems for both kinds of participants. The result showed that there were no differences on the prevalence of emotional and behavioral problems between the two groups, and both veterans and wives of veterans had no differences on seeking professional help for their emotional and behavioral problems. Wives of veterans living in rural areas showed higher scores on almost all ASR scales compared with those living in urban areas or even with those of veterans from urban and rural areas. Veterans with elementary education level had the highest scores compared with other groups. Veterans with poor well-being had the highest scores compared with other groups. Using Internalizing, Externalizing, and Total Problems as outcome variables and trauma exposure, smoking, drinking alcohol, and well-being as predictors, we found that the model was a significant predictor for both male and female participants on these three scales. Conclusion: The relationship found between the level of exposure to traumatic events and emotional and behavior problems, as well as the factors that moderated such relations, in war veterans and their wives, should help global mental health researchers address the contextual dimensions of this relationship and identify better ways to prevent and treat those problems.

Conceptualizing comorbid PTSD and depression among treatment-seeking, active duty military service members

BACKGROUND

Among active duty service members and veterans with PTSD, depression is the most commonly diagnosed comorbid psychiatric condition. More research is warranted to investigate the relationship between PTSD and depression to improve treatment approaches. Byllesby et al. (2017) used confirmatory factor analyses in a sample of trauma-exposed combat veterans with PTSD and found that only the general distress factor, and not any specific symptom cluster of PTSD, predicted depression. This study seeks to replicate Byllesby et al. (2017) in a sample of treatment-seeking active duty soldiers.

METHODS

Confirmatory factor analyses, bifactor modeling, and structural equation modeling (SEM) were used with data gathered at pretreatment and posttreatment as part of a large randomized clinical trial.

RESULTS

Confirmatory factor analyses and bifactor modeling demonstrated that PTSD symptom clusters, Negative Alterations in Cognition and Mood (NACM) and Alterations in Arousal and Reactivity (AAR), as well as the general distress factor significantly predicted depression at pretreatment and posttreatment.

LIMITATIONS

The current study was predominantly male, limiting the generalizability to female service members with PTSD. Also, self-report measures were used, which may introduce response-bias.

CONCLUSIONS

The current study did not replicate Byllesby et al. (2017). Results demonstrated that the relationship between PTSD and depression among active duty service members can be explained by both transdiagnostic factors and disorder-specific symptoms.

Psychological burden of PTSD, depression, and their comorbidity in the U.S. veteran population: Suicidality, functioning, and service utilization

BACKGROUND

Emerging evidence suggests that comorbid posttraumatic stress disorder (PTSD) and major depressive disorder (PTSD/MDD) may impose an even greater burden than either disorder alone. However, nearly all previous studies examining these associations have relied on treatment-seeking samples. This study examined the mental health burden associated with co-occurring PTSD/MDD compared to PTSD and MDD alone using a nationally representative sample of U.S. veterans.

METHODS

Data were analyzed from National Health and Resilience in Veterans Study, a nationally representative survey of U.S. veterans (n = 2,732). Analyses (a) estimated the current prevalence of PTSD only, MDD only, and comorbid PTSD/MDD; (b) compared demographic/military variables by PTSD/MDD status; and (c) examined associations between PTSD/MDD status and suicidality, functioning, psychiatric comorbidities, and service utilization.

RESULTS

The current prevalences of probable PTSD only, probable MDD only, and probable comorbid PTSD/MDD were 1.7%, 4.8%, and 3.4%. Compared to all other groups, the PTSD/MDD group was more likely to screen positive for current suicidal ideation, lifetime suicide attempts, probable generalized anxiety and social anxiety disorders, and ever utilize mental health services. They also scored lower on measures of mental health functioning (d = 1.49), cognitive functioning (d = 1.03), and quality of life (d = 0.84). Veterans with comorbid PTSD/MDD were more than twice as likely as those with PTSD only to have attempted suicide.

LIMITATIONS

The cross-sectional design of this study precludes causal inference.

CONCLUSIONS

Results provide a population-based characterization of the psychological burden of PTSD/MDD comorbidity in U.S. veterans. Findings further underscore the importance of screening, monitoring, and treatment of the comorbid manifestation of these disorders.

Residual Insomnia and Nightmares Postintervention Symptom Reduction Among Veterans Receiving Treatment for Comorbid PTSD and Depressive Symptoms

While evidence-based interventions can help the substantial number of veterans diagnosed with comorbid PTSD and depression, an emerging literature has identified sleep disturbances as predictors of treatment nonresponse. More specifically, predicting effects of residual insomnia and nightmares on postintervention PTSD and depressive symptoms among veterans with comorbid PTSD and depression has remained unclear. The present study used data from a clinical trial of Behavioral Activation and Therapeutic Exposure (BA-TE), a combined approach to address comorbid PTSD and depression, administered to veterans (N = 232) to evaluate whether residual insomnia and nightmare symptoms remained after treatment completion and, if so, whether these residual insomnia and nightmare symptoms were associated with higher levels of comorbid PTSD and depression at the end of treatment. Participants (ages 21 to 77 years old; 47.0% Black; 61.6% married) completed demographic questions, symptom assessments, and engagement-related surveys. Hierarchical multiple linear regression models demonstrated that residual insomnia was a significant predictor of PTSD and depression symptom reduction above and beyond the influence of demographic and engagement factors (e.g., therapy satisfaction). Consistent with previous research, greater residual insomnia symptoms were predictive of smaller treatment gains. Findings illustrate the potential significance of insomnia during the course of transdiagnostic treatment (e.g., PTSD and depression), leading to several important clinical assessment and treatment implications.

Neurocognitive and psychiatric comorbidities of posttraumatic stress disorder among older veterans: A systematic review

OBJECTIVES

Posttraumatic stress disorder (PTSD) is associated with neurocognitive and psychiatric comorbidities, and older adults experience comorbid illnesses disproportionately. Little is known about the comorbidities of PTSD among older veterans. This systematic review examines the prevalence, incidence, and patterns of neurocognitive and psychiatric comorbidities of PTSD among older veterans and explores the factors associated with these comorbidities.

METHODS

A systematic literature review was performed using PubMed, CINAHL, and PsycINFO databases. The search was limited to peer-reviewed articles published in English from January 1980 to October 2018. Eligible studies examined the comorbid neurocognitive and psychiatric disorders of PTSD among veterans aged 60 and older.

RESULTS

Twenty-four studies met the criteria for inclusion. The risk for dementia was higher in veterans with PTSD than those without PTSD; hazard ratios ranged from 1.21 to 1.77. Depressive disorder was the most prevalent psychiatric comorbidity with estimates ranging from 33% to 52.3%, followed by generalized anxiety disorder (14%-15%) and substance use disorders (1.9%-11.3%). Factors consistently associated with PTSD comorbidities included age, combat-related exposures, clinical conditions, and health-related and psychosocial outcomes.

CONCLUSIONS

Despite heterogeneity in research designs and methodological limitations, this review highlights the need to consider comorbid neurocognitive and psychiatric disorders among older veterans with PTSD in order to individualize care approaches. Future research should incorporate factors associated with neurocognitive and psychiatric comorbidities of PTSD into study designs that can help improve prediction of comorbidity and generate evidence for developing and implementing tailored treatments in older veterans.

Coping strategies of Dutch servicemembers after deployment

BACKGROUND

This study examines the relationship between coping strategies and symptoms of anxiety or depression among Dutch servicemembers deployed to Afghanistan.

METHODS

Coping strategies were assessed in 33 battlefield casualties (BCs) and the control group (CTRLs) of 33 uninjured servicemembers from the same combat units using the Cognitive Emotion Regulation Questionnaire. A factor analysis was performed, and two clusters of coping strategies were derived, namely, adaptive and maladaptive coping. Symptoms of anxiety and depression were evaluated using the depression and anxiety subscales of the Symptom Checklist-90-Revised. Correlations between coping and symptoms of anxiety and between coping and symptoms of depression were calculated, and a logistic regression was performed.

RESULTS

A moderate correlation was observed between maladaptive coping and symptoms of anxiety in the BC group (r = 0.42) and among the CTRLs (r = 0.56). A moderate correlation was observed between maladaptive coping and symptoms of depression in both groups (r = 0.55). The statistical analysis for the total sample (BCs and CTRLs) demonstrated no association between coping and symptoms of anxiety or depression.

CONCLUSIONS

A correlation but no association was observed between maladaptive coping and mental health disorders in deployed Dutch servicemembers. Further research should focus on constructing cluster profiles of coping strategies and associating them with mental health outcomes and reintegration into society.

Single and dual diagnoses of major depressive disorder and posttraumatic stress disorder predicted by triple comorbid trajectories of tobacco, alcohol, and marijuana use among urban adults

Background: The adverse consequences of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) affect a significant portion of the US population every year (i.e., 15 million for MDD; 8 million for PTSD) and are of public health concern. The current study examines tobacco, alcohol, and marijuana use as possible longitudinal predictors of MDD and/or PTSD. Methods: A community sample of 674 participants (53% African Americans and 47% Puerto Ricans; 405 females and 269 males) were recruited from the Harlem Longitudinal Development Study. We used Mplus software to obtain the triple trajectories of tobacco, alcohol, and marijuana use from mean age 14 to 36. Logistic regression analyses were then conducted to examine the associations between those triple trajectory groups and a single diagnosis of MDD or PTSD as well as a dual diagnosis of MDD with PTSD at age 36. Results: The observed percentages of MDD, PTSD, and the comorbidity of MDD and PTSD were 17%, 8%, and 5%, respectively. The heavy use of all 3 substances group was associated with an increased likelihood of having MDD (adjusted odds ratio [AOR] = 3.14, P < .01), PTSD (AOR = 3.91, P < .05), and MDD with PTSD (AOR = 6.64, P < .01), as compared with the tobacco and alcohol use group. Conclusions: Treatment programs to quit or reduce the use of tobacco, alcohol, and marijuana may help decrease the prevalence of MDD and PTSD. This could lead to improvements in individualized treatments for patients who use tobacco, alcohol, and marijuana and who have both MDD and PTSD.

Quality of life in elderly Portuguese war veterans with post-traumatic stress symptoms

Background

Studies show that post-traumatic stress symptoms among Portuguese veterans who participated in Colonial War (1961-75) are high, even though 43 years have gone by since the end of the war.

Aims

This study analyzed the role of family type, personality traits, and social support as predictors of post-traumatic stress symptoms and quality of life in war veterans, and whether satisfaction with social support was a mediator between neuroticism/post-traumatic stress symptoms and quality of life.

Method

A cross-sectional study was conducted including 230 war veterans with a mean age of 60 years (SD=3.82).

Results

Results indicated a high prevalence of post-traumatic stress symptoms as well as high neuroticism, 16.5 (SD=4.41); 81% of veterans presented high psychological distress, suggesting emotional disturbance and 71% belonged to extreme families (families with cohesion and adaptability problems). Results showed that age (β=-0.166, p<0.05), social support (β=-0.184, p<0.01), and neuroticism (β=0.325, p<0.001) predicted post-traumatic stress symptoms. Age, professional status, social support, post-traumatic stress symptoms, family type, neuroticism, and extroversion predicted different dimensions of quality of life. Finally, a path analysis showed that satisfaction with social support was a mediator in the relationship between neuroticism and quality of life (β=-0.066; p<0.01) and between post-traumatic stress symptoms and quality of life (β=-0.108; p<0.01).

Conclusion

Four decades after the Colonial War have passed, there is still a high prevalence of post-traumatic stress symptoms. Screening elderly veterans who present post-traumatic stress symptoms, for the presence of neuroticism traits, and assessing family type and social support, should be a standard practice in health care services, especially in the oldest and those who are retired. Social support should be promoted in order to enhance quality of life in this population.

PTSD, psychological morbidity and marital dissatisfaction in colonial war veterans

Background: Forty years after Colonial War, veterans still show psychological disturbances affecting their marital and sexual satisfaction.Aims: This study analyzed the relationships between Post-Traumatic Stress Disorder (PTSD), number of PTSD symptoms and symptom clusters, psychological morbidity, marital dissatisfaction and sexual dissatisfaction; the variables that contributed to marital dissatisfaction and the mediator role of marital dissatisfaction and sexual dissatisfaction, in a sample of colonial War Veterans.Method: The sample included 138 Portuguese war veterans who answered Index of Marital Satisfaction; Index of Sexual Satisfaction; Beck Depression Inventory; State Trait Anxiety Inventory; Post-Traumatic Stress Disorder Scale.Results: PTSD, number of PTSD symptoms and symptom clusters were associated with psychological morbidity, marital and sexual dissatisfaction. Age, depression symptoms and sexual dissatisfaction contributed to marital dissatisfaction and the model explained 55% of the variance. Marital dissatisfaction mediated the relationship between depression symptoms and sexual dissatisfaction, as well as between number of PTSD symptoms and sexual dissatisfaction.Conclusions: Health professionals need to take into consideration the veteran's marital and sexual relationship in clinical routine consultations. As such, treating the veteran in the couple' context seems warranted.

Interactive Effect of Traumatic Brain Injury and Psychiatric Symptoms on Cognition among Late Middle-Aged Men: Findings from the Vietnam Era Twin Study of Aging

Traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), and depressive symptoms each increase the risk for cognitive impairment in older adults. We investigated whether TBI has long-term associations with cognition in late middle-aged men, and examined the role of current PTSD/depressive symptoms. Participants were 953 men (ages 56-66) from the Vietnam Era Twin Study of Aging (VETSA), who were classified by presence or absence of (1) history of TBI and (2) current elevated psychiatric symptoms (defined as PTSD or depressive symptoms above cutoffs). TBIs had occurred an average of 35 years prior to assessment. Participants completed cognitive testing examining nine domains. In mixed-effects models, we tested the effect of TBI on cognition including for interactions between TBI and elevated psychiatric symptoms. Models adjusted for age, pre-morbid cognitive ability assessed at average age 20 years, apolipoprotein E genotype, and substance abuse; 33% (n = 310) of participants had TBI, mostly mild and remote; and 23% (n = 72) of those with TBI and 18% (n = 117) without TBI had current elevated psychiatric symptoms. TBI and psychiatric symptoms had interactive effects on cognition, particularly executive functioning. Group comparison analyses showed that men with both TBI and psychiatric symptoms demonstrated deficits primarily in executive functioning. Cognition was largely unaffected in men with either risk factor in isolation. Among late middle-aged men, the combination of even mild and very remote TBI with current elevated psychiatric symptoms is associated with deficits in executive function and related abilities. Future longitudinal studies should investigate how TBI and psychiatric factors interact to impact brain aging.

Acceptance and Commitment Therapy for Chronic Pain: Does Post-traumatic Stress Disorder Influence Treatment Outcomes?

Objective

The aim of this study was to determine whether post-traumatic stress disorder (PTSD) moderates treatment outcomes in Acceptance and Commitment Therapy for chronic pain.

Design

Longitudinal.

Setting

Veterans Affairs San Diego Healthcare System.

Subjects

A total of 126 veterans with chronic pain participating in an Acceptance and Commitment Therapy intervention for chronic pain. A structured clinical interview was used at baseline to designate PTSD-positive (N = 43) and -negative groups (N = 83).

Methods

Linear mixed-effects models to determine whether PTSD moderated change in pain interference, pain severity, pain acceptance, depressive symptoms, or pain-related anxiety at post-treatment and six-month follow-up.

Results

Participants with co-occurring PTSD reported greater pain interference, pain severity, depressive symptoms, and pain-related anxiety at baseline. PTSD status did not moderate treatment effects post-treatment. Rather, there were significant improvements on all study measures across groups (P &lt; 0.001). PTSD status moderated change in depressive symptoms at six-month follow-up (P &lt; 0.05). Specifically, participants with chronic pain alone demonstrated improvement in depressive symptoms compared with pretreatment levels, whereas participants with PTSD regressed to pretreatment levels.

Conclusions

PTSD status did not significantly affect treatment outcomes, with the exception of depressive symptoms at six-month follow-up. Overall, Acceptance and Commitment Therapy for chronic pain appears helpful for improving outcomes among veterans with co-occurring PTSD; however, veterans with co-occurring PTSD may experience fewer long-term gains compared with those with chronic pain alone.