Exploring the relationship between underlying dimensions of posttraumatic stress disorder and depression in a national, trauma-exposed military sample

Post-traumatic stress disorder in peacekeepers: a systematic literature review and meta-analysis

Background: In peacekeeping operations, soldiers are often exposed to the same traumatic factors as in conventional war and may also be subject to physical risks and psychological stressors associated with post-traumatic stress disorder (PTSD). According to the Conservation of Resources Theory (COR), PTSD stems from resource depletion and inadequate restoration.Objectives: To discuss and meta-analyse PTSD-related factors among peacekeepers, based on the COR theory, framing them as resources or loss/threat of loss of resources.Methods: A systematic literature search was performed with relevant keywords, 51 articles were reviewed and 21 of them meta-analysed.Results: Factors mentioned in prior reviews, reinforced by ours, include: family/community and military support as resources; single marital status, female gender, serving in infantry, and longer time since deployment as lack of resources. Factors mentioned in prior reviews, confirmed by our meta-analysis, include: education, rank, and problem-focused coping as resources; negative perceptions about deployment, combat/trauma exposure, deployment stressors, and deployment duration as lack of resources. Factors overlooked in prior reviews include: age as a resource; negative life events, and negative social interactions as lack of resources. Comorbidities include: physical health problems, post-deployment impact on functioning, and post-deployment psychopathology (e.g., depression, substance use).Conclusions: Significantly more individual than contextual factors were identified. While some factors inherent to missions (e.g., combat exposure, deployment stressors) cannot be mitigated, others are crucial to prevent peacekeepers' PTSD (e.g., coping strategies, deployment duration, perceptions about deployment, social interactions, support during deployment) and to inform selection and monitoring by the Armed Forces (e.g., pre-, during and post-deployment psychopathology). However, the findings should be interpreted with caution due to limitations (e.g., publication bias, study heterogeneity) that may have affected the generalizability and strength of the recommendations.

Mindful nonreactivity moderates the relationship between posttraumatic stress disorder and depression

PTSD and depression represent major individual and societal burdens. Depression is commonly comorbid with PTSD among veterans, although buffers of this relationship are unclear. We evaluated whether facets of mindfulness moderated the relationship between PTSD and depression in veterans with PTSD (N = 70). Three facets - nonjudging, acting with awareness, and nonreactivity - were assessed as moderators. Results indicated nonreactivity significantly attenuated the relationship between PTSD and depression (p=.013), such that veterans with high nonreactivity (+1 SD) showed a nonsignificant relationship between PTSD and depression, whereas veterans with average (Mean; p<.001) and low (-1 SD; p<.001) nonreactivity exhibited a significant relationship.

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.

The factor structure of major depressive symptoms in a sample of Chinese earthquake survivors

BACKGROUND

Experiencing natural disasters is associated with common mental disorders including major depressive disorder (MDD). However, the latent structure of MDD is widely debated, and few studies tested the MDD factor structure in Chinese natural disaster survivors. Therefore, the aim of the current study was to evaluate the factorial validity of the Patient Health Questionnaire-9 (PHQ-9) for DSM-5 major depressive disorder (MDD) symptoms in Chinese earthquake survivors.

METHOD

Participants were 1058 Chinese earthquake survivors. Self-reported measures included the PHQ-9 and the Short-Form Health Survey (SF-36). Confirmatory factor analysis (CFA) and structural equation modelling (SEM) was used to examine the latent structure of MDD and the associations between latent factors of MDD and different domains of health-related quality of life (HRQoL), respectively.

RESULTS

In the current sample, the model consisted of somatic and cognitive/affective (non-somatic) factors demonstrated significantly better fit than the other competing MDD models (χ² = 173.89, df = 26, CFI = 0.986, TLI = 0.981, RMSEA = 0.073, BIC = 18,091.13). Further SEM analyses indicated that the non-somatic factor was significantly related to both physical (β = - 0.362, p < .01) and psychosocial HRQoL (β = - 0.773, p < .01), while the somatic factor was a uniquely predictor of physical HRQoL (β = - 0.336, p < .01). Furthermore, we found the somatic factor partially mediated the relationship between the cognitive/affective factor and physical HRQoL (all ps < .05).

CONCLUSIONS

The MDD symptoms was best captured by a two-factor model comprised of somatic and cognitive/affective factors in Chinese natural disaster survivors. The two MDD factors were differentially associated with physical and psychosocial HRQoL, and the cognitive/affective factor associated physical HRQoL partially through the somatic factor. The current findings increase our understanding of latent structure of MDD symptoms, and carry implications for assessment and intervention of post-disaster mental health problems.

Gender differences in the interaction effect of community resources and attitudes toward seeking professional help on posttraumatic stress, depression, and posttraumatic growth

The current study examined the gender differences in the interaction effect of community resources and attitudes toward seeking professional help in predicting posttraumatic stress, depression, and posttraumatic growth for female and male survivors of Hurricane Harvey. Participants were 413 adults who reported directly experiencing Hurricane Harvey, which made landfall on August 26, 2017. Purposive sampling was used to recruit participants approximately 16 months after the hurricane via an online survey. Among men, significant interaction effects of community resources and attitudes toward seeking help on posttraumatic stress, depression, and posttraumatic growth were found even after statistically controlling for age, educational attainment, income, marital status, and racial minority status. Among women, no interaction effects were found. Women with open attitudes toward seeking psychological treatment experienced higher posttraumatic stress and posttraumatic growth, and higher resources were positively associated with growth. The current study raises important implications on gender differences on community resources and attitudes toward seeking professional help after a hurricane.

Associations among trauma exposure, post-traumatic stress disorder, and depression symptoms in adolescent survivors of the 2013 Lushan earthquake

BACKGROUND

Post-traumatic stress disorder (PTSD) frequently occurs in survivors of natural disasters, while symptom of depression is related mostly to interpersonal trauma. These conditions are highly correlated and strongly impact adolescent quality of life. This study aimed to explore the relationship among trauma exposure, PTSD symptoms, and/or depression symptoms in adolescent survivors of the 2013 Lushan (China) earthquake.

METHODS

A cross-sectional survey of 2921 adolescents in the Longmenshan seismic fault zone was conducted three years after the Lushan earthquake. Participants were evaluated using the Earthquake Experience Scale, the Adolescent Self-rating Life Events Checklist (ASLEC), the Children's Revised Impact of Event Scale (CRIES-13), and the Depression Self-Rating Scale (KADS-6). Stepwise regression was used to explore relationships between trauma exposure and PTSD or depression symptoms.

RESULTS

There was a strong correlation between PTSD and depression symptoms, with a 10.7% comorbidity. Earthquake-related exposure, negative life events, prior exposure to the 2008 Wenchuan (China) earthquake, and being left behind by parents all contributed to PTSD and depressive symptoms. Earthquake exposures contributed mainly to PTSD symptoms, while interpersonal traumas contributed mainly to depression symptoms.

CONCLUSION

PTSD and depression symptoms strongly correlate in adolescent survivors of the 2013 Lushan earthquake. The high comorbidity between PTSD and depression symptoms may reflect shared risk factors. Natural disasters are more likely to cause PTSD symptoms, while interpersonal traumas are more likely to cause depression symptoms.

Examining the boundaries between ICD-11 PTSD/CPTSD and depression and anxiety symptoms: A network analysis perspective

BACKGROUND

Two newly identified sibling disorders - ICD-11 PTSD and CPTSD - have been well validated in the last few years. Although these trauma-related disorders are suggested to be neatly separated from depression and anxiety, no study has used a network analysis to examine those definitions' construct validity when they also interplay with symptoms of depression and anxiety. Additionally, no research has focused upon the specific boundaries between these four disorders' symptoms, the bridges between them, and the ways they influence each other among clinical populations.

METHODS

A sample of 234 men drawn randomly from a national sample of 1,600 Jewish men receiving treatment for domestic violence in Israel completed the ICD-11 International Trauma Questionnaire (ITQ) and Brief Symptom Inventory (BSI).

RESULTS

The ICD-11 CPTSD, depression and anxiety clustering network results revealed, within the EGA, a four-cluster solution in which PTSD and CPTSD symptoms are differentiated from two other distinct clusters of anxiety and depression symptoms. Feelings of worthlessness and avoiding internal reminders of the experience were the most central symptoms.

LIMITATIONS

Due to the use of a cross-sectional design, causal interpretation of the network correlation between symptoms should be made cautiously.

CONCLUSIONS

These findings strengthen the approach that ICD-11 PTSD and CPTSD have a distinct construct; however, they also reflect a strong positive connection to anxiety and depression symptoms and no clear boundaries between disorders. Specifically, dysphoria/avoidance-related symptoms act as a bridge between the disorders, which may be important targets for specific assessments and related interventions.

Examining reciprocal influence between posttraumatic stress and depressive symptoms among natural disaster survivors

BACKGROUND

The current study examined reciprocal effects of symptoms of posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) among individuals affected by Hurricane Ike, which made landfall on September 13, 2008 METHODS: Participants were 658 survivors, who participated in the Galveston Bay Recovery Study (GBRS; National Center for Disaster Mental Health Research, Galea, and Norris, 2016). Assessment was conducted at 3, 6, and 15 months after the disaster. Bivariate latent change score modeling was conducted to examine the nature of the time-sequential associations between symptoms of PTSD and MDD RESULTS: Results revealed a unidirectional coupling effect from depression to change in PTSD, but unidirectional coupling effect from PTSD to change in depression was not supported.

LIMITATIONS

Only linear relations of within-individual change and time-sequential associations between PTSD and depression were examined, and therefore, it precludes potential nonlinear relations between these constructs. Also, the results of the current study are limited to the studied timespan (i.e., 3 to 15 months). Lastly, other factors that could be confounding the change in PTSD symptoms were not examined, leaving a possibility of other constructs that may influence the change in future PTSD symptoms CONCLUSIONS: The current study suggests that disaster survivors with higher symptoms of depression may be at higher risk of experiencing increased PTSD symptoms even after one year, raising an importance of tailoring a treatment to alleviate depressive symptoms and to mitigate the risk of future symptoms of PTSD.

Design of a randomized superiority trial of a brief couple treatment for PTSD

Interpersonal difficulties are common among veterans with posttraumatic stress disorder (PTSD) and are associated with poorer treatment response. Treatment outcomes for PTSD, including relationship functioning, improve when partners are included and engaged in the therapy process. Cognitive-behavioral conjoint therapy for PTSD (CBCT) is a manualized 15-session intervention designed for couples in which one partner has PTSD. CBCT was developed specifically to treat PTSD, engage a partner in treatment, and improve interpersonal functioning. However, recent research suggests that an abbreviated CBCT protocol may lead to sufficient gains in PTSD and relationship functioning, and yield lower dropout rates. Likewise, many veterans report a preference for receiving psychological treatments through clinical videoteleconferencing (CVT) rather than traditional face-to-face modalities that require travel to VA clinics. This manuscript describes the development and implementation of a novel randomized controlled trial (RCT) that examines the efficacy of an abbreviated 8-session version of CBCT ("brief CBCT," or B-CBCT), and compares the efficacy of this intervention delivered via CVT to traditional in-person platforms. Veterans and their partners were randomized to receive B-CBCT in a traditional Veterans Affairs office-based setting (B-CBCT-Office), CBCT through CVT with the veteran and partner at home (B-CBCT-Home), or an in office-delivered, couple-based psychoeducation control condition (PTSD Family Education). This study is the first RCT designed to investigate the delivery of B-CBCT specifically to veterans with PTSD and their partners, as well as to examine the delivery of B-CBCT over a CVT modality; findings could increase access to care to veterans with PTSD and their partners.

Relations between PTSD and depression symptom clusters in samples differentiated by PTSD diagnostic status

Co-occurring posttraumatic stress disorder (PTSD) and depression following traumatic experiences are cumulatively associated with functional impairment. To examine mechanisms for the PTSD-depression comorbidity, we investigated their cluster-level associations. Using data obtained from Amazon's Mechanical Turk platform, 368 trauma-exposed participants were split into two subsamples: those with (n = 163) and without (n = 185) probable PTSD. In both subsamples, confirmatory factor analyses indicated an optimal seven-factor PTSD Hybrid Model. Results of Wald tests of parameter constraints indicated that, in both subsamples, PTSD's dysphoric arousal cluster strongly related to somatic depression compared to all/most other PTSD Hybrid Model clusters. Additionally, in both subsamples, PTSD's negative affect, externalizing behaviors, and anhedonia clusters each strongly related to non-somatic depression compared to PTSD's anxious arousal cluster. Our results indicated that PTSD's dysphoric arousal symptoms mainly accounted for PTSD's shared variance with somatic depression, while the negative alterations in cognitions and mood (NACM)/dysphoria and arousal symptoms (primarily externalizing behaviours) mainly accounted for PTSD's shared variance with non-somatic depression. Our findings have implications for the discussion on PTSD's specific/non-specific clusters tied to diagnostic modifications, for understanding mechanisms underlying PTSD-depression comorbidity, and for the use of transdiagnostic and multi-component treatment protocols for PTSD-depression symptoms.

Sexual Satisfaction, Marital Intimacy, and Depression in Married Iranian Nurses With and Without Symptoms of Secondary Traumatic Stress

Nurses tend to experience a lot of stress and psychological pressure in their workplace. Secondary Traumatic Stress (STS) is a condition that can cause marital and psychological problems in married nurses. The present study was conducted to compare sexual satisfaction, marital intimacy, and depression in married nurses with and without severe symptoms of STS. The statistical population consisted of 303 married nurses selected through cluster sampling from three hospitals in Kermanshah, Iran, including Imam Reza (86 nurses), Imam Ali (110 nurses), and Taleghani (107 nurses) hospitals. Data were collected using the STS Scale, the Sexual Satisfaction Scale, the Marital Intimacy Questionnaire, and Beck's Depression Inventory (short-form) or BDI-13. The results obtained showed that 22.4% of all the nurses, 22.9% of the female nurses, and 21.8% of the male nurses had symptoms of STS and the mean score of the symptoms was higher in the female compared with the male nurses (P < .01). The results of the two-way multivariate analysis of covariance showed higher mean scores of sexual satisfaction and marital intimacy in the group without STS symptoms and a higher mean score of depression in the group with STS symptoms (P < .01). Psychologists and hospital authorities should pay more attention to the psychological problems faced by nurses, such as STS and its effects on sexual satisfaction, marital intimacy, and depression.

Psychometric Properties of a Modified Moral Injury Questionnaire in a Military Population

Moral injury (MI) results from perpetration of or exposure to distressing events, known as morally injurious events (MIEs), that challenge moral beliefs and values. Due to the type of involvement in recent military conflicts, many veterans report MIEs that may cause dissonance and, in turn, MI. Although two existing measures assess MIEs, neither currently assesses the defining characteristics of MI (i.e., guilt, shame, difficulty forgiving self and others, and withdrawal). The present study reports the initial psychometric test of a modified version (Robbins, Kelley, Hamrick, Bravo, & White, 2017) of the Moral Injury Questionnaire - Military version (MIQ-M; Currier, Holland, Drescher, & Foy, 2015) in a sample of 328 military personnel (e.g., veterans, National Guard/reservists, active duty members). The MIQ-M was modified to assess both MIEs and the defining characteristics of MI. Exploratory factor analyses suggested a three-factor model of MIEs consisting of Atrocities of war, Psychological consequences of war, and Leadership failure or betrayal. The modified MIQ-M factors were correlated with defining characteristics of MI. In addition, each MIE factor and associated defining characteristics of MI were positively correlated with symptoms of posttraumatic stress disorder, depression, and anxiety, as well as substance use. The modified MIQ-M is a reliable measure of MI that is comprised of three subscales that are associated with, but distinct from, mental health outcomes. Although findings are promising, further research evaluating the applicability of the modified MIQ-M in clinical settings is required to establish construct validity of the defining characteristics and secondary manifestations of MI.

Examining the latent structure mechanisms for comorbid posttraumatic stress disorder and major depressive disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is a complex psychiatric illness that can be difficult to diagnose, due in part to its comorbidity with major depressive disorder (MDD). Given that researchers have found no difference in prevalence rates of PTSD and MDD after accounting for overlapping symptoms, the latent structures of PTSD and MDD may account for the high comorbidity. In particular, the PTSD Negative Alterations in Cognition and Mood (NACM) and Hyperarousal factors have been characterized as non-specific to PTSD. Therefore, we compared the factor structures of the Diagnostic and Statistical Manual of Mental Disorders, 5^thedition (DSM-5) PTSD and MDD and examined the mediating role of the PTSD NACM and Hyperarousal factors on the relationship between MDD and PTSD symptom severity.

METHODS

Participants included 598 trauma-exposed veterans (M_age = 48.39, 89% male) who completed symptom self-report measures of DSM-5 PTSD and MDD.

RESULTS

Confirmatory factor analyses indicated an adequate-fitting four-factor DSM-5 PTSD model and two-factor MDD model. Compared to other PTSD factors, the PTSD NACM factor had the strongest relationship with the MDD Affective factor, and the PTSD NACM and Hyperarousal factors had the strongest association with the MDD Somatic factor. Further, the PTSD NACM factor explained the relationship between MDD factors and PTSD symptom severity. More Affective and Somatic depression was related to more NACM symptoms, which in turn were related to increased severity of PTSD.

LIMITATIONS

Limitations include the reliance on self-report measures and the use of a treatment-seeking, trauma-exposed veteran sample which may not generalize to other populations.

CONCLUSIONS

Implications concerning the shared somatic complaints and psychological distress in the comorbidity of PTSD and MDD are discussed.

The relationship between PTSD, depression and negative life events: Ya'an earthquake three years later

PTSD (Posttraumatic Stress Disorder) is a common post-disaster psychological condition which research has shown to have comorbidity with depression. To explore the relationship between PTSD and depression further, a cross-sectional study design was adopted. Three years after the Ya'an earthquake, 4137 adolescents (mean age 15.12) who had personally experienced the earthquake were assessed. The study results showed that PTSD significantly predicted future depression, with the effect being partially mediated by the negative life events after the earthquake. Gender was not found to be a significant moderator between PTSD and depression.

Genetic deletion of P-glycoprotein alters stress responsivity and increases depression-like behavior, social withdrawal and microglial activation in the hippocampus of female mice

P-glycoprotein (P-gp) is an ABC transporter expressed at the blood brain barrier and regulates the brain uptake of various xenobiotics and endogenous mediators including glucocorticoid hormones which are critically important to the stress response. Moreover, P-gp is expressed on microglia, the brain's immune cells, which are activated by stressors and have an emerging role in psychiatric disorders. We therefore hypothesised that germline P-gp deletion in mice might alter the behavioral and microglial response to stressors. Female P-gp knockout mice displayed an unusual, frantic anxiety response to intraperitoneal injection stress in the light-dark test. They also tended to display reduced conditioned fear responses compared to wild-type (WT) mice in a paradigm where a single electric foot-shock stressor was paired to a context. Foot-shock stress reduced social interaction and decreased microglia cell density in the amygdala which was not varied by P-gp genotype. Independently of stressor exposure, female P-gp deficient mice displayed increased depression-like behavior, idiosyncratic darting behavior, age-related social withdrawal and hyperactivity, facilitated sensorimotor gating and altered startle reactivity. In addition, P-gp deletion increased microglia cell density in the CA3 region of the hippocampus, and the microglial cells exhibited a reactive, hypo-ramified morphology. Further, female P-gp KO mice displayed increased glucocorticoid receptor (GR) expression in the hippocampus. In conclusion, this research shows that germline P-gp deletion affected various behaviors of relevance to psychiatric conditions, and that altered microglial cell activity and enhanced GR expression in the hippocampus may play a role in mediating these behaviors.

A confirmatory factor analysis of the PTSD checklist 5 in veteran and college student samples

An important change in the conceptualization of posttraumatic stress disorder (PTSD) has been the shift from a three-factor model used in the DSM-IV-TR to the current four-factor model used in DSM-5. Early research initially supported the three-factor model, but most recent data suggest a four-factor model provides the best fit. Still other research has examined evidence for a five-factor model that would include depression sequelae. By way of a confirmatory factor analysis, we demonstrate the reliability of DSM-5 PTSD criteria clustering in a sample of 124 OEF/OIF/OND Veterans treated at a VAMC (49% white, 89% men) and a sample of 737 college students (48% white, 78% women). All participants were trauma-exposed, and completed the PTSD Checklist for DSM-5. The current study shows both samples best support a five-factor model over two four factor models considered for the DSM-5, though none provided better than moderate fit. Implications of the current findings regarding the reliability of the new DSM-5 criteria of PTSD will be discussed.

Trauma exposure relates to heightened stress, altered amygdala morphology and deficient extinction learning: Implications for psychopathology

Stress exposure causes a structural reorganization in neurons of the amygdala. In particular, animal models have repeatedly shown that both acute and chronic stress induce neuronal hypertrophy and volumetric increase in the lateral and basolateral nuclei of amygdala. These effects are visible on the behavioral level, where stress enhances anxiety behaviors and provokes greater fear learning. We assessed stress and anxiety levels in a group of 18 healthy human trauma-exposed individuals (TR group) compared to 18 non-exposed matched controls (HC group), and related these measurements to amygdala volume. Traumas included unexpected adverse experiences such as vehicle accidents or sudden loss of a loved one. As a measure of aversive learning, we implemented a cued fear conditioning paradigm. Additionally, to provide a biological marker of chronic stress, we measured the sensitivity of the hypothalamus-pituitary-adrenal (HPA) axis using a dexamethasone suppression test. Compared to the HC, the TR group showed significantly higher levels of chronic stress, current stress and trait anxiety, as well as increased volume of the left amygdala. Specifically, we observed a focal enlargement in its lateral portion, in line with previous animal data. Compared to HC, the TR group also showed enhanced late acquisition of conditioned fear and deficient extinction learning, as well as salivary cortisol hypo-suppression to dexamethasone. Left amygdala volumes positively correlated with suppressed morning salivary cortisol. Our results indicate differences in trauma-exposed individuals which resemble those previously reported in animals exposed to stress and in patients with post-traumatic stress disorder and depression. These data provide new insights into the mechanisms through which traumatic stress might prompt vulnerability for psychopathology.

Dispositional mindfulness in trauma recovery: Prospective relations and mediating mechanisms

This study examined the protective properties and candidate mediating processes (cognitive fusion and cognitive suppression) linking dispositional mindfulness to distal risk factors (negative affect, anxiety sensitivity, rumination) and psychopathology symptom outcomes (depression and posttraumatic stress symptoms) following trauma exposure. To do so, a community-based sample of adults was longitudinally studied in the six-months following exposure--within 30-days (T1), 3-months (T2), and 6-months (T3)--to a shared disaster-related potentially traumatic event (PTE). Specifically, we found that cognitive fusion predicted, and mediated, the effect of mindfulness on outcomes related to distress post-trauma including negative affect, depression and posttraumatic stress symptoms. Complementary to these effects, we found that cognitive suppression predicted, and mediated, the effect of mindfulness on distal risk factors linked to negative self-referential processes including rumination and anxiety sensitivity. Findings are discussed with respect to their theoretical and clinical implications for the potential role and mechanisms of mindfulness in recovery following trauma.

Posttraumatic stress disorder's dysphoria dimension and relations with generalized anxiety disorder symptoms

The present study investigated symptom relations between two highly comorbid disorders--posttraumatic stress disorder (PTSD) and generalized anxiety disorder (GAD)--by exploring their underlying dimensions. Based on theory and prior empirical research it was expected that the dysphoria factor of PTSD would be more highly related to GAD. As part of a longitudinal project of mental health among Ohio National Guard Soldiers, 1266 subjects were administered the Posttraumatic Stress Disorder Checklist (PCL) and Generalized Anxiety Disorder-7 scale (GAD-7). Confirmatory factor analyses (CFAs) were conducted to examine two models of PTSD and to determine which PTSD factors were more related to the GAD factor. The results indicate that the GAD factor was significantly more highly correlated with PTSD's dysphoria factor than with all other PTSD factors, including PTSD's reexperiencing factor, avoidance factor, and hyperarousal factor. Results indicate GAD was not significantly more highly correlated with numbing than most other factors of PTSD. The results are consistent with prior research. Implications of the results are discussed in regards to PTSD in DSM-5, comorbidity and diagnostic specificity.

Identifying latent profiles of posttraumatic stress and major depression symptoms in Canadian veterans: Exploring differences across profiles in health related functioning

Posttraumatic stress disorder (PTSD) has been consistently reported as being highly comorbid with major depressive disorder (MDD) and as being associated with health related functional impairment (HRF). We used archival data from 283 previously war-zone deployed Canadian veterans. Latent profile analysis (LPA) was used to uncover patterns of PTSD and MDD comorbidity as measured via the PTSD Checklist-Military version (PCL-M) and the Patient Health Questionnaire-9 (PHQ-9). Individual membership of latent classes was used in a series of one-way ANOVAs to ascertain group differences related to HRF as measured via the Short-Form-36 Health Survey (SF-36). LPA resulted in three discrete patterns of PTSD and MDD comorbidity which were characterized by high symptoms of PTSD and MDD, moderate symptoms, and low symptoms. All ANOVAs comparing class membership on the SF-36 subscales were statistically significant demonstrating group differences across levels of HRF. The group with the highest symptoms reported the worst HRF followed by the medium and low symptom groups. These findings are clinically relevant as they demonstrate the need for continual assessment and targeted treatment of co-occurring PTSD and MDD.

Structural relations between DSM-5 PTSD and major depression symptoms in military soldiers

BACKGROUND

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) are frequently comorbid. One explanation for this comorbidity is that PTSD has a constellation of "dysphoria" symptoms resembling depression.

METHOD

Using confirmatory factor analysis we tested the role of DSM-5 PTSD׳s dysphoria factor in relation to MDD symptom dimensions of somatic and non-somatic psychopathology. 672 Ohio National Guard soldiers completed DSM-5 measures of PTSD and MDD symptoms in an epidemiological study.

RESULTS

Results indicated that in contrast to other PTSD factors, PTSD׳s dysphoria factor was more related to MDD׳s somatic and non-somatic factors.

LIMITATIONS

Limitations include generalizability to the epidemiological population of trauma-exposed military veterans rather than civilians, and reliance on self-report measures.

CONCLUSIONS

Implications concerning clinical psychopathology and comorbidity of PTSD are discussed, including whether PTSD should be refined by removing its non-specific symptoms.

Telepsychology for Posttraumatic Stress Disorder: A systematic review

Summary

The effectiveness of psychological services provided remotely, telepsychology, for the management of Posttraumatic Stress Disorder (PTSD) was evaluated. Eleven studies ( n = 472 participants) were identified from electronic database searches. Study quality was assessed, with studies characterised by small and underpowered samples. Effect sizes and associated confidence intervals (CIs) were calculated to determine the direction and magnitude of treatment change. Short-term treatment gains were reported for internet and video-based interventions. This included significant medium to large improvements ( d range = 0.66–3.22) in cognitive and behavioural symptoms of depression, generalised anxiety and posttraumatic stress. However, the equivalence of telepsychology and face-to-face psychotherapy could not be determined, with few comparative studies available. Both treatment gains and deterioration were noted 1 to 6 months following treatment cessation, although this was based on limited follow-up data. Further larger scale and longitudinal research will help to ascertain the minimum requirements for the management and treatment of PTSD in a technology-supported environment.

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.

Sexual functioning in military personnel: preliminary estimates and predictors

INTRODUCTION

Although the military is a young and vigorous force, service members and veterans may experience sexual functioning problems (SFPs) as a result of military service. Sexual functioning can be impaired by physical, psychological, and social factors and can impact quality of life (QOL) and happiness.

AIMS

This study aims to estimate rates and correlates of SFPs in male military personnel across demographic and psychosocial characteristics, to examine the QOL concomitants, and to evaluate barriers for treatment seeking.

METHODS

This exploratory cross-sectional study was conducted using data from a larger nationwide study conducted between October 2013 and November 2013. This sample consists of 367 male active duty service members and recent veterans (military personnel) age 40 or younger.

MAIN OUTCOME MEASURES

Erectile dysfunction (ED) was determined using the five-item International Index of Erectile Function, sexual dysfunction (SD) was determined using the Arizona Sexual Experiences Scale, Male, and QOL was determined using the World Health Organization Quality of Life, Brief.

RESULTS

SFPs were associated with various demographic, physical, and psychosocial risk factors. The rates of SD and ED were 8.45% and 33.24%, respectively, for male military personnel aged 21-40. Those who were 36-40, nonmarried, nonwhite, and of lower educational attainment reported the highest rates of SFPs. Male military personnel with poor physical and psychosocial health presented the greatest risk for ED and SD. SFPs were associated with reduced QOL and lower happiness, and barriers for treatment were generally related to social barriers.

CONCLUSIONS

SFPs in young male military personnel are an important public health concern that can severely impact QOL and happiness.

Distinctiveness of prolonged grief disorder symptoms among survivors of the Great East Japan Earthquake and Tsunami

Prolonged Grief Disorder (PGD) has been proposed for diagnostic classification as an independent psychiatric disorder. Previous research has investigated it in relation to other axis I disorders in order to determine whether it could be considered an independent nosological entity. The distinctiveness of this condition was apparent in cases of ordinary bereavement and in those following human-made disasters. However, this disorder may be expanded to include bereavement resulting from natural disasters. The present study aims to explore the differences between this disorder and posttraumatic stress disorder or major depressive disorder as experienced after the Great East Japan Earthquake and Tsunami. The subjects were 82 hospital workers. Each type of disorder was assessed by means of the Inventory of Complicated Grief, the Impact of Event Scale-Revised, and the Center for Epidemiological Studies Depression Scale. Exploratory factor analysis showed 3 dimensions, with PGD items independently clustering in the same dimension. Our findings support the uniqueness of PGD even in a post-natural disaster situation in a non-Western culture and warrant grief intervention for high-risk bereaved survivors.

DSM-5 PTSD's symptom dimensions and relations with major depression's symptom dimensions in a primary care sample

Existing literature indicates significant comorbidity between posttraumatic stress disorder (PTSD) and major depression. We examined whether PTSD's dysphoria and mood/cognitions factors, conceptualized by the empirically supported four-factor DSM-5 PTSD models, account for PTSD's inherent relationship with depression. We hypothesized that depression's somatic and non-somatic factors would be more related to PTSD's dysphoria and mood/cognitions factors than other PTSD model factors. Further, we hypothesized that PTSD's arousal would significantly mediate relations between PTSD's dysphoria and somatic/non-somatic depression. Using 181 trauma-exposed primary care patients, confirmatory factor analyses (CFA) indicated a well-fitting DSM-5 PTSD dysphoria model, DSM-5 numbing model and two-factor depression model. Both somatic and non-somatic depression factors were more related to PTSD's dysphoria and mood/cognitions factors than to re-experiencing and avoidance factors; non-somatic depression was more related to PTSD's dysphoria than PTSD's arousal factor. PTSD's arousal did not mediate the relationship between PTSD's dysphoria and somatic/non-somatic depression. Implications are discussed.

Symptoms of posttraumatic stress, depression, and body image distress in female victims of physical and sexual assault: exploring integrated responses

While body image concerns and interpersonal violence exposure are significant issues for women, their interrelationship has rarely been explored. We examined the associations between severity of acute injuries, symptoms of posttraumatic stress disorder (PTSD), depression, and body image distress within a sample of predominantly African American victims of interpersonal violence (N = 73). Severity of body image distress was significantly associated with each outcome. Moreover, body image distress was a significant, unique predictor of depression but not PTSD severity. We recommend continued exploration of body image concerns to further integrated research on violence against women.

Etiology of depression comorbidity in combat-related PTSD: a review of the literature

Posttraumatic stress disorder is often diagnosed with other mental health problems, particularly depression. Although PTSD comorbidity has been associated with more severe and chronic symptomology, relationships among commonly co-occurring disorders are not well understood. The purpose of this study was to review the literature regarding the development of depression comorbid with combat-related PTSD among military personnel. We summarize results of commonly tested hypotheses about the etiology of PTSD and depression comorbidity, including (1) causal hypotheses, (2) common factor hypotheses, and (3) potential confounds. Evidence suggests that PTSD may be a causal risk factor for subsequent depression; however, associations are likely complex, involving bidirectional causality, common risk factors, and common vulnerabilities. The unique nature of PTSD-depression comorbidity in the context of military deployment and combat exposure is emphasized. Implications of our results for clinical practice and future research are discussed.

Telemedicine: a cost-reducing means of delivering psychotherapy to rural combat veterans with PTSD

BACKGROUND

Although effective psychotherapies for posttraumatic stress disorder (PTSD) exist, high percentages of Veterans in need of services are unable to access them. One particular challenge to providing cost-effective psychological treatments to Veterans with PTSD involves the difficulty and high cost of delivering in-person, specialized psychotherapy to Veterans residing in geographically remote locations. The delivery of these services via clinical videoteleconferencing (CVT) has been presented as a potential solution to this access to care problem.

MATERIALS AND METHODS

This study is a retrospective cost analysis of a randomized controlled trial investigating telemedicine service delivery of an anger management therapy for Veterans with PTSD. The parent trial found that the CVT condition provided clinical results that were comparable to the in-person condition. Several cost outcomes were calculated in order to investigate the clinical and cost outcomes associated with the CVT delivery modality relative to in-person delivery.

RESULTS

The CVT condition was significantly associated with lower total costs compared with the in-person delivery condition. The delivery of mental health services via CVT enables Veterans who would not normally receive these services access to empirically based treatments. Additional studies addressing long-term healthcare system costs, indirect cost factors at the patient and societal levels, and the use of CVT in other geographic regions of the United States are needed.

CONCLUSIONS

The results of this study provide evidence that CVT is a cost-reducing mode of service delivery to Veterans with PTSD relative to in-person delivery.

Changes in the Beck Depression Inventory-II's underlying symptom structure over 1 month of inpatient treatment

Research has not investigated changes in the symptom structure of depression over the course of mental health treatment. In the present study, 1025 psychiatric inpatients were recruited and assessed for depression symptom severity using the Beck Depression Inventory-II (BDI-II) at admission and after 1 month of treatment. A three-factor BDI-II model was tested using confirmatory factor analysis and fit reasonably well at both time points. Measurement invariance testing results demonstrated that factor loadings increased, indicating that the meaning of the three underlying depression dimensions changed through treatment. However, observed variable intercepts and residual error variances decreased significantly after 1 month of treatment, reflecting decreases in symptom severity as well as measurement error. Thus, depressive symptom severity decreased over the course of treatment, and the underlying factor structure of depression improved in fit after treatment. Implications for changes to the structure of depression symptoms and in the clinical practice of tracking depression over time are discussed.

Symptoms of post-traumatic stress disorder in bereaved children and adolescents: factor structure and correlates

This study investigated the factor structure and correlates of posttraumatic stress-disorder (PTSD) symptoms among children and adolescents confronted with the death of a loved one. Three hundred thirty-two bereaved children and adolescents (aged 8-18; 56.9 % girls) who all received some form of psychosocial support after their loss, completed self-report measures of PTSD, together with measures tapping demographic and loss-related variables, depression, prolonged grief, and functional impairment. Parent-rated indices of impairment were also collected. We first evaluated the fit of six alternative models of the factor structure of PTSD symptoms, using confirmatory factor analyses. Outcomes showed that the 4-factor numbing model from King et al. (Psychological Assessment 10, 90-96, 1998), with distinct factors of reexperiencing, avoidance, emotional numbing, and hyperarousal fit the data best. Of all participants, 51.5 % met DSM-IV criteria for PTSD. PTSD-status and scores on the PTSD factors varied as a function of age and gender, but were unrelated to other demographic and loss-related variables. PTSD-status and scores on the PTSD factors were significantly associated symptom-levels of depression, prolonged grief, and functional impairment. Findings complement prior evidence that the DSM-IV model of the factor structure of PTSD symptoms may not represent the best conceptualization of these symptoms and highlight the importance of addressing PTSD symptoms in children and adolescents seeking help after bereavement.

Relations between the underlying dimensions of PTSD and major depression using an epidemiological survey of deployed Ohio National Guard soldiers

BACKGROUND

In the present study, the authors investigated the relationship between the underlying symptom dimensions of posttraumatic stress disorder (PTSD) and dimensions of major depressive disorder (MDD).

METHOD

A sample of 1266 Ohio National Guard soldiers with a history of overseas deployment participated and were administered the PTSD Checklist (assessing PTSD) and Patient Health Questionnaire-9 (assessing depression).

RESULTS

Using confirmatory factor analysis, results demonstrated that both PTSD's dysphoria and hyperarousal factors were more related to depression's somatic than non-somatic factor. Furthermore, depression's somatic factor was more related to PTSD's dysphoria than hyperarousal factor.

LIMITATIONS

Limitations of this study include the use of self-report measures and a predominately male military sample.

CONCLUSIONS

Results indicate that PTSD's dysphoria factor is related to depression specifically by way of depression's somatic construct. Given PTSD's substantial dysphoria/distress component, these results have implications for understanding the nature of PTSD's high comorbidity with depression.

The factor structure of major depression symptoms: a test of four competing models using the Patient Health Questionnaire-9

Little research has examined the underlying symptom structure of major depressive disorder (MDD) symptoms based on DSM-IV criteria. Our aim was to analyze the symptom structure of major depression, using the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 was administered to a sample of 2615 Army National Guard soldiers from Ohio. A one-factor model of depression and three separate two-factor models previously established in the literature were evaluated using confirmatory factor analysis. Results demonstrated greater support for the two-factor models of depression than for the one-factor model. The best fitting model was the two-factor model of somatic and non-somatic symptoms supported previously by Krause et al. (2010) and Richardson and Richards (2008). Implications for understanding the components and mechanisms of MDD are discussed.

Examining the dimensionality of combat-related posttraumatic stress and depressive symptoms in treatment-seeking OEF/OIF/OND veterans

BACKGROUND

This study examined the factor structure of two of the most commonly used screening measures of posttraumatic stress disorder and depression in 164 treatment-seeking veterans who served in Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND).

METHODS

Exploratory factor analysis was used to assess the dimensionality of items from the Posttraumatic Stress Disorder Checklist-Military Version (PCL-M) and the Patient Health Questionnaire-9 (PHQ-9). Regression analyses were then conducted to examine associations between factor scores of the resulting factor solution and measures of alcohol use, cognitive coping, psychological resilience, social support, and healthcare utilization.

RESULTS

A four-factor solution was found that consisted of clusters of symptoms reflecting reexperiencing/avoidance, detachment/numbing, hopelessness/depression, and bodily disturbance. Scores on the detachment/numbing factor were uniquely related to alcohol use, whereas scores on the hopelessness/depression factor was uniquely associated with emergency room visits. Compared to conventional PCL-M and PHQ-9 total scores, the four-factor solution explained 2 to 10% more variance in scores on measures of alcohol use, cognitive coping, psychological resilience, social support, and healthcare utilization.

LIMITATIONS

This study was limited by a small sample size and cross-sectional design.

CONCLUSIONS

Combat-related posttraumatic stress disorder and depressive symptoms in treatment-seeking OEF/OIF/OND veterans may be better conceptualized by four dimensions of reexperiencing/avoidance, detachment/numbing, hopelessness/depression, and bodily disturbance symptoms. This symptom structure may provide greater utility when examining other outcomes of interest in this population.