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Chen HL, Li BH, Du YN, Jin ZF, Zhou LJ. Mindfulness-Based Therapy for Military Populations with Chronic Pain: A Systematic Review. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2024; 30:832-839. [PMID: 38629676 DOI: 10.1089/jicm.2023.0343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
Background: Due to the limited role of chronic pain medication in military personnel and the distress caused to the military population, mindfulness-based therapy has been considered for the follow-up treatment of military personnel with chronic pain. The purpose of this review is to explore the effect and the implementation of mindfulness-based therapy for the military population with chronic pain. Methods: The keywords for the search included "mindfulness" AND ("pain" OR "chronic pain") AND ("military" OR "veteran"). The PubMed, Embase, and Cochrane Library databases were searched. The Cochrane Collaboration tool was used to independently assess the risk of bias of the included randomized controlled trials, and the Newcastle-Ottawa Scale was used to independently assess the risk of bias of the included case-control studies. Results: A total of 175 papers were identified; 65 duplicates were excluded, and 59 papers that did not meet the inclusion criteria were excluded after reading the titles and abstracts. The remaining 51 papers were read in full, 42 of which did not meet the inclusion criteria. Nine papers met the inclusion criteria and were included in the study. The nine studies included 507 veterans and 56 active-duty female military personnel. All pain interventions were mindfulness-based therapy, and all of them were integrated into or adapted from standard mindfulness courses. The results all showed that after mindfulness-based therapy, the relevant indicators improved. Conclusions: Mindfulness-based therapy is an effective treatment method for the military population with chronic pain. The review indicates that future research should focus on the best setting for mindfulness-based therapy, including the course content and time.
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Affiliation(s)
- Hua-Liang Chen
- College of Basic Medical Science, Naval Medical University, Shanghai, China
| | - Bing-Hua Li
- College of Basic Medical Science, Naval Medical University, Shanghai, China
| | - Yi-Nuo Du
- College of Basic Medical Science, Naval Medical University, Shanghai, China
| | - Zhao-Feng Jin
- School of Psychology, Weifang Medical University, Weifang, China
| | - Ling-Jun Zhou
- School of Nursing, Naval Medical University, Shanghai, China
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Bond GR, Al-Abdulmunem M, Ressler DR, Drake RE. Mental Health Impact of COVID Pandemic on Veterans Transitioning from Military. J Behav Health Serv Res 2024; 51:275-288. [PMID: 38133794 PMCID: PMC10940484 DOI: 10.1007/s11414-023-09869-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Gary R Bond
- Social Policy and Economics Research, Westat, Inc., New Hampshire Office, Wheeler Professional Park, 1 Oak Ridge Road, Building 3, Second Floor, Suite 2 West, West Lebanon, NH, 03784, USA.
| | - Monirah Al-Abdulmunem
- Social Policy and Economics Research, Westat, Inc., New Hampshire Office, Wheeler Professional Park, 1 Oak Ridge Road, Building 3, Second Floor, Suite 2 West, West Lebanon, NH, 03784, USA
| | - Daniel R Ressler
- Social Policy and Economics Research, Westat, Inc., New Hampshire Office, Wheeler Professional Park, 1 Oak Ridge Road, Building 3, Second Floor, Suite 2 West, West Lebanon, NH, 03784, USA
| | - Robert E Drake
- Social Policy and Economics Research, Westat, Inc., New Hampshire Office, Wheeler Professional Park, 1 Oak Ridge Road, Building 3, Second Floor, Suite 2 West, West Lebanon, NH, 03784, USA
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Kim R, Lin T, Pang G, Liu Y, Tungate AS, Hendry PL, Kurz MC, Peak DA, Jones J, Rathlev NK, Swor RA, Domeier R, Velilla MA, Lewandowski C, Datner E, Pearson C, Lee D, Mitchell PM, McLean SA, Linnstaedt SD. Derivation and validation of risk prediction for posttraumatic stress symptoms following trauma exposure. Psychol Med 2023; 53:4952-4961. [PMID: 35775366 DOI: 10.1017/s003329172200191x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Posttraumatic stress symptoms (PTSS) are common following traumatic stress exposure (TSE). Identification of individuals with PTSS risk in the early aftermath of TSE is important to enable targeted administration of preventive interventions. In this study, we used baseline survey data from two prospective cohort studies to identify the most influential predictors of substantial PTSS. METHODS Self-identifying black and white American women and men (n = 1546) presenting to one of 16 emergency departments (EDs) within 24 h of motor vehicle collision (MVC) TSE were enrolled. Individuals with substantial PTSS (⩾33, Impact of Events Scale - Revised) 6 months after MVC were identified via follow-up questionnaire. Sociodemographic, pain, general health, event, and psychological/cognitive characteristics were collected in the ED and used in prediction modeling. Ensemble learning methods and Monte Carlo cross-validation were used for feature selection and to determine prediction accuracy. External validation was performed on a hold-out sample (30% of total sample). RESULTS Twenty-five percent (n = 394) of individuals reported PTSS 6 months following MVC. Regularized linear regression was the top performing learning method. The top 30 factors together showed good reliability in predicting PTSS in the external sample (Area under the curve = 0.79 ± 0.002). Top predictors included acute pain severity, recovery expectations, socioeconomic status, self-reported race, and psychological symptoms. CONCLUSIONS These analyses add to a growing literature indicating that influential predictors of PTSS can be identified and risk for future PTSS estimated from characteristics easily available/assessable at the time of ED presentation following TSE.
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Affiliation(s)
- Raphael Kim
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, USA
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, USA
- Department of Computer Science, University of North Carolina, Chapel Hill, NC, USA
- Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, NC, USA
| | - Tina Lin
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, USA
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, USA
| | - Gehao Pang
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, USA
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, USA
| | - Yufeng Liu
- Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, NC, USA
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
- Department of Genetics, Carolina Center for Genome Sciences, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Andrew S Tungate
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, USA
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, USA
| | - Phyllis L Hendry
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Michael C Kurz
- Department of Emergency Medicine, University of Alabama, Birmingham, AL, USA
| | - David A Peak
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey Jones
- Department of Emergency Medicine, Spectrum Health Butterworth Campus, Grand Rapids, MI, USA
| | - Niels K Rathlev
- Department of Emergency Medicine, Baystate State Health System, Springfield, MA, USA
| | - Robert A Swor
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Robert Domeier
- Department of Emergency Medicine, St Joseph Mercy Health System, Ann Arbor, MI, USA
| | | | | | - Elizabeth Datner
- Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Claire Pearson
- Department of Emergency Medicine, Detroit Receiving, Detroit, MI, USA
| | - David Lee
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, USA
| | - Patricia M Mitchell
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Samuel A McLean
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, USA
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, USA
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Sarah D Linnstaedt
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, USA
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, USA
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4
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Jones CW, An X, Ji Y, Liu M, Zeng D, House SL, Beaudoin FL, Stevens JS, Neylan TC, Clifford GD, Jovanovic T, Linnstaedt SD, Germine LT, Bollen KA, Rauch SL, Haran JP, Storrow AB, Lewandowski C, Musey PI, Hendry PL, Sheikh S, Punches BE, Lyons MS, Kurz MC, Swor RA, McGrath ME, Hudak LA, Pascual JL, Seamon MJ, Datner EM, Harris E, Chang AM, Pearson C, Peak DA, Merchant RC, Domeier RM, Rathlev NK, O'Neil BJ, Sergot P, Sanchez LD, Bruce SE, Miller MW, Pietrzak RH, Joormann J, Barch DM, Pizzagalli DA, Sheridan JF, Smoller JW, Harte SE, Elliott JM, Koenen KC, Ressler KJ, Kessler RC, McLean SA. Derivation and Validation of a Brief Emergency Department-Based Prediction Tool for Posttraumatic Stress After Motor Vehicle Collision. Ann Emerg Med 2023; 81:249-261. [PMID: 36328855 PMCID: PMC11181458 DOI: 10.1016/j.annemergmed.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/28/2022] [Accepted: 08/04/2022] [Indexed: 11/05/2022]
Abstract
STUDY OBJECTIVE To derive and initially validate a brief bedside clinical decision support tool that identifies emergency department (ED) patients at high risk of substantial, persistent posttraumatic stress symptoms after a motor vehicle collision. METHODS Derivation (n=1,282, 19 ED sites) and validation (n=282, 11 separate ED sites) data were obtained from adults prospectively enrolled in the Advancing Understanding of RecOvery afteR traumA study who were discharged from the ED after motor vehicle collision-related trauma. The primary outcome was substantial posttraumatic stress symptoms at 3 months (Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders-5 ≥38). Logistic regression derivation models were evaluated for discriminative ability using the area under the curve and the accuracy of predicted risk probabilities (Brier score). Candidate posttraumatic stress predictors assessed in these models (n=265) spanned a range of sociodemographic, baseline health, peritraumatic, and mechanistic domains. The final model selection was based on performance and ease of administration. RESULTS Significant 3-month posttraumatic stress symptoms were common in the derivation (27%) and validation (26%) cohort. The area under the curve and Brier score of the final 8-question tool were 0.82 and 0.14 in the derivation cohort and 0.76 and 0.17 in the validation cohort. CONCLUSION This simple 8-question tool demonstrates promise to risk-stratify individuals with substantial posttraumatic stress symptoms who are discharged to home after a motor vehicle collision. Both external validation of this instrument, and work to further develop more accurate tools, are needed. Such tools might benefit public health by enabling the conduct of preventive intervention trials and assisting the growing number of EDs that provide services to trauma survivors aimed at promoting psychological recovery.
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Affiliation(s)
- Christopher W Jones
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Xinming An
- Department of Anesthesiology, Department of Psychiatry, Institute for Trauma Recovery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Yinyao Ji
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC
| | - Mochuan Liu
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC
| | - Donglin Zeng
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC
| | - Stacey L House
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, MO
| | - Francesca L Beaudoin
- Department of Emergency Medicine and Department of Health Services, Policy, and Practice, The Alpert Medical School of Brown University, Rhode Island Hospital and The Miriam Hospital, Providence, RI
| | - Jennifer S Stevens
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Thomas C Neylan
- Department of Psychiatry and Neurology, University of California San Francisco, San Francisco, CA
| | - Gari D Clifford
- Department of Biomedical Informatics, Emory University School of Medicine and Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA
| | - Tanja Jovanovic
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI
| | - Sarah D Linnstaedt
- Department of Anesthesiology, Department of Psychiatry, Institute for Trauma Recovery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Laura T Germine
- Institute for Technology in Psychiatry, McLean Hospital, Belmont, MA; The Many Brains Project, Belmont, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Kenneth A Bollen
- Department of Psychology and Neuroscience and Department of Sociology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Scott L Rauch
- Institute for Technology in Psychiatry, McLean Hospital, Belmont, MA; Department of Psychiatry, Harvard Medical School, Boston, MA; Department of Psychiatry, McLean Hospital, Belmont, MA
| | - John P Haran
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Paul I Musey
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Phyllis L Hendry
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Sophia Sheikh
- Department of Emergency Medicine, University of Florida College of Medicine -Jacksonville, Jacksonville, FL; Department of Emergency Medicine, University of Cincinnati College of Medicine, and College of Nursing, University of Cincinnati, Cincinnati, OH
| | - Brittany E Punches
- Department of Emergency Medicine, University of Florida College of Medicine -Jacksonville, Jacksonville, FL
| | - Michael S Lyons
- College of Nursing, University of Cincinnati, Cincinnati, OH
| | - Michael C Kurz
- Department of Emergency Medicine, Division of Acute Care Surgery, Department of Surgery, University of Alabama School of Medicine, and Center for Injury Science, University of Alabama at Birmingham, Birmingham, AL
| | - Robert A Swor
- Department of Emergency Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI
| | - Meghan E McGrath
- Department of Emergency Medicine, Boston Medical Center, Boston, MA
| | - Lauren A Hudak
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA; Department of Surgery, Department of Neurosurgery, University of Pennsylvania, Pennsylvania, PA
| | - Jose L Pascual
- Department of Surgery, Department of Neurosurgery, University of Pennsylvania, Pennsylvania, PA; Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
| | - Mark J Seamon
- Division of Traumatology, Department of Surgery, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Pennsylvania, PA
| | - Elizabeth M Datner
- Department of Emergency Medicine, Einstein Healthcare Network, and the Sidney Kimmel Medical College, Thomas Jefferson University, Pennsylvania, PA
| | | | - Anna M Chang
- Department of Emergency Medicine, Jefferson University Hospitals, Pennsylvania, PA
| | - Claire Pearson
- Department of Emergency Medicine, Wayne State University, Ascension St John Hospital, Detroit, MI
| | - David A Peak
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Roland C Merchant
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Robert M Domeier
- Department of Emergency Medicine, Saint Joseph Mercy Hospital, Ypsilanti, MI
| | - Niels K Rathlev
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Brian J O'Neil
- Department of Emergency Medicine, Wayne State University, Detroit Receiving Hospital, Detroit, MI
| | - Paulina Sergot
- Department of Emergency Medicine, McGovern Medical School, University of Texas Health, Houston, TX
| | - Leon D Sanchez
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Steven E Bruce
- Department of Psychological Sciences, University of Missouri - St Louis, St Louis, MO
| | - Mark W Miller
- National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System, and Department of Psychiatry, Boston University School of Medicine, Boston, MA; Clinical Neurosciences Division, National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT
| | | | - Jutta Joormann
- Department of Psychology, Yale School of Medicine, New Haven, CT
| | - Deanna M Barch
- Department of Psychological and Brain Sciences, Washington University in St Louis, St Louis, MO
| | - Diego A Pizzagalli
- Department of Psychiatry, Harvard Medical School, Boston, MA; Division of Depression and Anxiety, McLean Hospital, Belmont, MA
| | - John F Sheridan
- Department of Biosciences, and the Institute for Behavioral Medicine Research, OSU Wexner Medical Center, Columbus, OH
| | - Jordan W Smoller
- Department of Psychiatry, Psychiatric and Neurodevelopmental Genetics Unit, Massachusetts General Hospital, Boston, and Stanley Center for Psychiatric Research, Broad Institute, Cambridge, MA
| | - Steven E Harte
- Department of Anesthesiology, and Department of Internal Medicine-Rheumatology, University of Michigan Medical School, Ann Arbor, MI
| | - James M Elliott
- Kolling Institute of Medical Research, University of Sydney, St Leonards, and Faculty of Medicine and Health, University of Sydney, Northern Sydney Local Health District, New South Wales, Australia, and Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Karestan C Koenen
- Department of Epidemiology, Harvard T H Chan School of Public Health, Harvard University, Boston, MA
| | - Kerry J Ressler
- Department of Psychiatry, Harvard Medical School, Boston, MA; Department of Psychological and Brain Sciences, Washington University in St Louis, St Louis, MO
| | - Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Samuel A McLean
- Departments of Emergency Medicine and Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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5
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Gianoli MO, Meisler AW, Rosen MI. Proposed Changes to the Department of Veterans Affairs Disability Rating Rubric for Mental Disorders. Psychiatr Serv 2022:appips20220377. [PMID: 36510762 DOI: 10.1176/appi.ps.20220377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The U.S. Department of Veterans Affairs (VA) provides disability benefits for general medical and mental health conditions related to military service. Despite advances in conceptualization, assessment, and diagnosis of mental disorders, the current rating rubric used to determine the award amounts received by veterans with posttraumatic stress disorder and other mental disorders has not been substantively revised since 1996. The VA recently proposed sweeping changes to the rating rubric for mental disorders, shifting the focus from a symptom-based algorithm to one based on functional impairment and bringing the rubric more in line with existing disability systems and guidelines. METHODS The authors examined the VA's current symptom-based rating rubric and reviewed and analyzed the proposed changes, including a comparison with other rating systems used for mental disorders. Research on the relationship between psychiatric symptoms and functional impairment is also discussed. RESULTS Bringing examination procedures in line with the new function-based rating schedule will require significant changes to current standard practice for both examiners and Veterans Benefits Administration raters. The new rubric requires more specific definitions, anchors, and operationalization of the domains of function in the rating schedule to improve reliability and validity. CONCLUSIONS The new system reflects an overdue shift away from a symptom-based formula toward real-world functioning. Concept study data suggest that the system may increase ratings for veterans awarded compensation, but the actual impact remains unknown. The authors discuss the implications of the new method for disability determination and offer suggestions for maximizing effective and fair implementation of the new rubric.
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Affiliation(s)
- Mayumi O Gianoli
- VA Connecticut Healthcare System, West Haven; Department of Psychiatry, Yale School of Medicine, New Haven
| | - Andrew W Meisler
- VA Connecticut Healthcare System, West Haven; Department of Psychiatry, Yale School of Medicine, New Haven
| | - Marc I Rosen
- VA Connecticut Healthcare System, West Haven; Department of Psychiatry, Yale School of Medicine, New Haven
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Bond GR, Al-Abdulmunem M, Ressler DR, Gade DM, Drake RE. A Randomized Controlled Trial of an Employment Program for Veterans Transitioning from the Military: Two-Year Outcomes. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2022; 49:1072-1083. [PMID: 35819542 PMCID: PMC9616746 DOI: 10.1007/s10488-022-01208-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Military personnel face numerous challenges transitioning from military jobs to meaningful civilian employment. Many veterans seek help finding employment, but few veteran employment programs have been rigorously studied. Transitioning veterans generally have access to Local Community Resources (LCR), which include the Veterans Health Administration vocational rehabilitation services, the state-federal Vocational Rehabilitation program, and the Department of Labor's American Job Centers. By contrast, the innovative National Career Coach Program (NCCP) offers intensive career coaching and financial incentives for working. METHODS This study used a randomized controlled design to compare the NCCP and LCR approaches for 208 transitioning service members (recent or pending transition). Researchers conducted interviews by telephone every four months for two years. Outcomes included earnings, months worked, and standardized self-report measures of health and well-being. Findings At two-year follow-up, significantly more NCCP participants had worked in paid employment than LCR participants (95% vs. 83%). NCCP participants averaged $2568 in monthly earnings compared to $1865 for LCR participants, thus averaging $16,872 more total income per participant over the two-year period. Employment outcomes significantly improved between Year 1 and Year 2. NCCP participants also reported significantly greater improvements in both physical and mental health compared to LCR participants. Average monthly earnings correlated with changes in health outcomes. CONCLUSIONS Veterans receiving multi-faceted employment services early in the transition from the military showed sustained benefit over a two-year period with increased earnings over time and improved mental and physical outcomes. Positive employment outcomes may have contributed to improved health outcomes.
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Affiliation(s)
- Gary R. Bond
- Social Policy and Economics Research, Westat, Rivermill Commercial Center, 85 Mechanic St., Lebanon, NH 03766 USA
| | - Monirah Al-Abdulmunem
- Social Policy and Economics Research, Westat, Rivermill Commercial Center, 85 Mechanic St., Lebanon, NH 03766 USA
| | - Daniel R. Ressler
- Social Policy and Economics Research, Westat, Rivermill Commercial Center, 85 Mechanic St., Lebanon, NH 03766 USA
| | - Daniel M. Gade
- Virginia Department of Veterans Services, Richmond, VA USA
| | - Robert E. Drake
- Social Policy and Economics Research, Westat, Rivermill Commercial Center, 85 Mechanic St., Lebanon, NH 03766 USA
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Bond GR, Al-Abdulmunem M, Drake RE, Davis LL, Meyer T, Gade DM, Frueh BC, Dickman RB, Ressler DR. Transition from Military Service: Mental Health and Well-being Among Service Members and Veterans with Service-connected Disabilities. J Behav Health Serv Res 2022; 49:282-298. [PMID: 35083657 PMCID: PMC9160081 DOI: 10.1007/s11414-021-09778-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 01/07/2023]
Abstract
Transitioning from military service is stressful for veterans with service-connected disabilities seeking civilian employment. This descriptive study examined self-assessed mental health, well-being, and substance use of men and women shortly before or after transition from US military service, compared to norms from community and military samples. As part of a prospective study evaluating an innovative employment program, researchers interviewed 229 current and former service members with service-connected disabilities transitioning from U.S. military service. Compared to published norms, respondents reported significantly poorer outcomes on 5 of 6 standardized measures, indicating less life satisfaction, poorer mental health, more symptoms of depression and posttraumatic stress disorder, and greater financial distress. In the previous year, 42% were prescribed opioid medications, over twice the annual opioid prescription rate of 19% in the general US population. Systematic strategies are needed to ensure access for transitioning veterans with serious behavioral health issues to appropriate evidence-based practices.
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Affiliation(s)
- Gary R Bond
- Westat, Rivermill Commercial Center, 85 Mechanic Street, Lebanon, NH, 03766, USA.
| | | | - Robert E Drake
- Westat, Rivermill Commercial Center, 85 Mechanic Street, Lebanon, NH, 03766, USA
| | - Lori L Davis
- Research Service, Tuscaloosa VA Medical Center, Tuscaloosa, AL, USA
- Department of Psychiatry, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Thomas Meyer
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, USA
| | - Daniel M Gade
- Department of Public Administration and Policy, American University, Washington, DC, USA
| | - B Christopher Frueh
- Department of Psychology, University of Hawaii, Hilo, HI, USA
- Department of Neurosurgery, Houston Methodist Academic Institute, Houston, TX, USA
| | | | - Daniel R Ressler
- Westat, Rivermill Commercial Center, 85 Mechanic Street, Lebanon, NH, 03766, USA
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8
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Bond GR, Al-Abdulmunem M, Ressler DR, Drake RE, Davis LL, Meyer T, Gade DM, Frueh BC, Dickman RB. Evaluation of an Employment Intervention for Veterans Transitioning From the Military: A Randomized Controlled Trial. J Nerv Ment Dis 2022; 210:321-329. [PMID: 34937846 PMCID: PMC9005093 DOI: 10.1097/nmd.0000000000001472] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Military personnel face numerous challenges transitioning from military jobs to meaningful civilian employment. The Independence Project compared an innovative employment program (National Career Coach Program) with standard employment services (Local Community Resources) in a randomized controlled trial. Study participants were transitioning veterans with self-reported service-connected disabilities seeking permanent employment. The primary outcomes were paid employment and disability ratings over 1 year. Secondary outcomes included health and well-being. At 1-year follow-up, National Career Coach Program participants were significantly more likely to work, had significantly greater earnings, and reported significantly greater improvements in physical and mental health compared with participants assigned to Local Community Resources. Both groups increased in disability ratings over 12 months, with no difference between groups. Multifaceted supports delivered by the National Career Coach Program increased employment, earnings, mental health, and physical health over 1 year. These significant differences appeared even though control group participants achieved considerable employment success.
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Affiliation(s)
- Gary R. Bond
- Social Policy and Economics Research, Westat, Rivermill Commercial Center, Lebanon, New Hampshire
| | - Monirah Al-Abdulmunem
- Social Policy and Economics Research, Westat, Rivermill Commercial Center, Lebanon, New Hampshire
| | - Daniel R. Ressler
- Social Policy and Economics Research, Westat, Rivermill Commercial Center, Lebanon, New Hampshire
| | - Robert E. Drake
- Social Policy and Economics Research, Westat, Rivermill Commercial Center, Lebanon, New Hampshire
| | - Lori L. Davis
- Research Service, Tuscaloosa VA Medical Center, Tuscaloosa
- Department of Psychiatry, University of Alabama School of Medicine, Birmingham, Alabama
| | - Thomas Meyer
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Daniel M. Gade
- Department of Public Administration and Policy, American University, Washington, DC
| | - B. Christopher Frueh
- Department of Psychology, University of Hawaii, Hilo, Hawaii
- Department of Neurosurgery, Houston Methodist Academic Institute, Houston, Texas
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9
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Norcliffe-Kaufmann L. Stress and the baroreflex. Auton Neurosci 2022; 238:102946. [PMID: 35086020 DOI: 10.1016/j.autneu.2022.102946] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/16/2021] [Accepted: 01/16/2022] [Indexed: 11/27/2022]
Abstract
The stress response to emotions elicits the release of glucocorticoids from the adrenal cortex, epinephrine from the adrenal medulla, and norepinephrine from the sympathetic nerves. The baroreflex adapts to buffer these responses to ensure that perfusion to the organs meets the demands while maintaining blood pressure within a within a narrow range. While stressor-evoked autonomic cardiovascular responses may be adaptive for the short-term, the recurrent exaggerated cardiovascular stress reactions can be maladaptive in the long-term. Prolonged stress or loss of the baroreflex's buffering capacity can predispose episodes of heightened sympathetic activity during stress leading to hypertension, tachycardia, and ventricular wall motion abnormalities. This review discusses 1) how the baroreflex responds to acute and chronic stressors, 2) how lesions in the neuronal pathways of the baroreflex alter the ability to respond or counteract the stress response, and 3) the techniques to assess baroreflex sensitivity and stress responses. Evidence suggests that loss of baroreflex sensitivity may predispose heightened autonomic responses to stress and at least in part explain the association between stress, mortality and cardiovascular diseases.
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Roberts JM, Arbisi PA, John MA, Seamans RN. The Utility of the Trauma Symptom Inventory as a Primary and Secondary Assessment Instrument for Forensic Practice in Legal Settings. J Pers Assess 2022; 104:221-233. [PMID: 35112940 DOI: 10.1080/00223891.2022.2029461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This paper examines the utility of the Trauma Symptom Inventory-2 (TSI-2) and its predecessor, the Trauma Symptom Inventory (TSI) in forensic psychology practice. The instrument's psychometric properties, use with special populations, legal case review and admissibility considerations are discussed. Recommendations regarding the strengths and limitations of the TSI/TSI-2 are suggested for forensic practitioners and lawyers. Considerations related to potential expert witness cross-examination are also presented. Psychological research and legal review suggest that the TSI/TSI-2 is admissible as an instrument under the Daubert Standard, especially as related to civil court disability claims. Still, lingering issues with the ATR validity scale remain and there is limited independent research establishing the predictive and discriminant validity of the TSI-2 across diverse forensic samples. In summary, this suggests the instrument is most effective as part of a comprehensive assessment battery for identifying PTSD symptomology within legal proceedings where a trauma diagnosis is relevant.
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Affiliation(s)
- Joseph M Roberts
- Department of Psychology, Counseling and Criminology, Carlow University
| | - Paul A Arbisi
- Minneapolis VA Health Center, Departments of Psychiatry and Psychology, University of Minnesota
| | - Melissa A John
- Department of Psychology, Counseling and Criminology, Carlow University
| | - Rachel N Seamans
- Department of Psychology, Counseling and Criminology, Carlow University
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11
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Kumar SA, Hein CL, DiLillo D, Pietrzak RH. Resilience to Suicidal Ideation Among U.S. Military Veterans with Posttraumatic Stress: Results from the National Health and Resilience in Veterans Study. MILITARY BEHAVIORAL HEALTH 2022; 10:328-337. [PMID: 36393818 PMCID: PMC9642972 DOI: 10.1080/21635781.2021.2015019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Veterans with combat exposure experience high rates of posttraumatic stress symptoms (PTSS) and associated suicidal ideation. The current study examined whether social support (i.e., social connectedness and social engagement) and protective psychological factors (i.e., resilience and altruism) moderated the relation between PTSS and suicidal ideation severity in a sample of 149 U.S. military combat veterans who served in the Vietnam War or Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND). Consistent with expectations, initial PTSS were positively associated with concurrent and three-year follow-up severity of suicidal ideation. Moderation analyses revealed the relation between initial PTSS and concurrent suicidal ideation severity was no longer significant at above average levels of social connectedness, social engagement, and psychological resilience. Further, the relation between initial PTSS and suicidal ideation severity three years later continued to be buffered by above average levels of social engagement. Results suggest social connectedness, psychological resilience, and social engagement help moderate initial severe thoughts of suicide linked to PTSS, while social engagement might be the strongest protective factor against severe suicidal ideation over time. Empirically-supported prevention and treatment efforts enhancing social engagement may help promote resilience to severe PTSS-related suicidal ideation among veterans from Vietnam and OEF/OIF/OND combat eras.
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Affiliation(s)
| | - Christina L. Hein
- U.S. Department of the Army, 25th Combat Aviation Brigade, Wheeler Army Airfield, Hawaii
| | - David DiLillo
- University of Nebraska-Lincoln, Department of Psychology
| | - Robert H. Pietrzak
- U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System,Department of Psychiatry, Yale School of Medicine,Department of Social and Behavioral Sciences, Yale School of Public Health
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12
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Fisher MP. Politicized disease surveillance: A theoretical lens for understanding sociopolitical influence on the monitoring of disease epidemics. Soc Sci Med 2021; 291:114500. [PMID: 34757240 DOI: 10.1016/j.socscimed.2021.114500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/16/2021] [Accepted: 10/19/2021] [Indexed: 10/20/2022]
Abstract
Sociopolitical forces commonly influence the collection, analysis, dissemination, and general perceptions of epidemiological information. Yet few theoretical lenses provide insight into the mechanisms through which such influence occurs. In this article, I draw and expand upon empirical findings to propose a novel theoretical lens, politicized disease surveillance, which I define as extreme or undue sociopolitical influence on public health surveillance systems or processes in ways that impact disease incidences and prevalences, or estimates or perceptions thereof. This lens foregrounds disease incidence and prevalence as objects of contestation and policy influence and articulates how certain facets of sociopolitical forces shape disease incidences and prevalences-especially amid an epidemic-through one or more channels: (1) the diagnostic construct; (2) screening tools, procedures, or systems; or (3) the behaviors of individuals who are living with or at risk for a certain disease. I provide several contemporary illustrations of politicized disease surveillance and discuss its theoretical and practical implications.
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Affiliation(s)
- Michael P Fisher
- Towson University, Department of Health Sciences, 8000 York Road, Linthicum Hall, #121L, Towson, MD, 21252, USA.
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13
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Ellenberg E, Yakir A, Bar-On Z, Sasson Y, Taragin M, Luft-Afik D, Cohen O, Lavenda O, Mahat-Shamir M, Hamama-Raz Y, Ben Ezra M, Frueh BC, Ostfeld I. Naturalistic Study of Posttraumatic Stress Disorder Among Israeli Civilians Exposed to Wartime Attacks. Psychiatr Serv 2021; 72:1026-1030. [PMID: 33882689 DOI: 10.1176/appi.ps.201900313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Civilians who survive wartime attacks commonly experience substantial psychological distress, including acute stress reactions (ASRs) and posttraumatic stress disorder (PTSD). The authors sought to determine the level of Israeli civilian exposure to wartime attacks, prevalence of posttraumatic stress disorder (PTSD) and physical injuries, and associated medical costs over a 7-year period. METHODS Data from the National Insurance Institute of Israel on civilian survivors of wartime attacks in the 2009-2015 period were retrospectively examined. RESULTS Overall, 11,476 civilians were affected by 243 wartime attacks during the study period. Of these individuals, 7,561 (65.9%) received early intervention (EI) psychological treatment for ASRs, 1,332 (11.6%) were subsequently adjudicated as having a disability (all causes), and 519 (4.5%) were adjudicated as disabled by PTSD through the end of 2016. Individuals who received immediate ASR treatment were less likely to be disabled by PTSD (p=0.001). Among those without physical injuries, the EI was associated with decreased PTSD disability (2.6% of those receiving the EI developed PTSD, whereas 7.2% of those who did not receive the EI developed PTSD); however, for those with physical injuries, the PTSD rate was higher among those who received the EI (30.4%) than among those who did not receive the EI (5.2%). Individuals having a disability other than PTSD incurred higher medical costs ($7,153 in 2016 U.S. dollars) than individuals with PTSD ($1,960). CONCLUSIONS An approach of providing case management, medical care, behavioral health screening, and EI for ASRs in the wake of wartime attacks on civilians minimized long-term PTSD-related disability.
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Affiliation(s)
- Eytan Ellenberg
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem (Ellenberg, Yakir, Bar-On, Sasson, Taragin, Cohen, Ostfeld); Medintec, Petach-Tikva, Israel (Luft-Afik); Department of Social Work, Ariel University, Ariel, Israel (Lavenda, Mahat-Shamir, Hamama-Raz, Ben Ezra, Ostfeld); Department of Psychology, University of Hawaii, Hilo, and Trauma and Resilience Center, Department of Psychiatry, University of Texas Health Sciences Center, Houston (Frueh)
| | - Avi Yakir
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem (Ellenberg, Yakir, Bar-On, Sasson, Taragin, Cohen, Ostfeld); Medintec, Petach-Tikva, Israel (Luft-Afik); Department of Social Work, Ariel University, Ariel, Israel (Lavenda, Mahat-Shamir, Hamama-Raz, Ben Ezra, Ostfeld); Department of Psychology, University of Hawaii, Hilo, and Trauma and Resilience Center, Department of Psychiatry, University of Texas Health Sciences Center, Houston (Frueh)
| | - Zvia Bar-On
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem (Ellenberg, Yakir, Bar-On, Sasson, Taragin, Cohen, Ostfeld); Medintec, Petach-Tikva, Israel (Luft-Afik); Department of Social Work, Ariel University, Ariel, Israel (Lavenda, Mahat-Shamir, Hamama-Raz, Ben Ezra, Ostfeld); Department of Psychology, University of Hawaii, Hilo, and Trauma and Resilience Center, Department of Psychiatry, University of Texas Health Sciences Center, Houston (Frueh)
| | - Yehuda Sasson
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem (Ellenberg, Yakir, Bar-On, Sasson, Taragin, Cohen, Ostfeld); Medintec, Petach-Tikva, Israel (Luft-Afik); Department of Social Work, Ariel University, Ariel, Israel (Lavenda, Mahat-Shamir, Hamama-Raz, Ben Ezra, Ostfeld); Department of Psychology, University of Hawaii, Hilo, and Trauma and Resilience Center, Department of Psychiatry, University of Texas Health Sciences Center, Houston (Frueh)
| | - Mark Taragin
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem (Ellenberg, Yakir, Bar-On, Sasson, Taragin, Cohen, Ostfeld); Medintec, Petach-Tikva, Israel (Luft-Afik); Department of Social Work, Ariel University, Ariel, Israel (Lavenda, Mahat-Shamir, Hamama-Raz, Ben Ezra, Ostfeld); Department of Psychology, University of Hawaii, Hilo, and Trauma and Resilience Center, Department of Psychiatry, University of Texas Health Sciences Center, Houston (Frueh)
| | - Danielle Luft-Afik
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem (Ellenberg, Yakir, Bar-On, Sasson, Taragin, Cohen, Ostfeld); Medintec, Petach-Tikva, Israel (Luft-Afik); Department of Social Work, Ariel University, Ariel, Israel (Lavenda, Mahat-Shamir, Hamama-Raz, Ben Ezra, Ostfeld); Department of Psychology, University of Hawaii, Hilo, and Trauma and Resilience Center, Department of Psychiatry, University of Texas Health Sciences Center, Houston (Frueh)
| | - Osnat Cohen
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem (Ellenberg, Yakir, Bar-On, Sasson, Taragin, Cohen, Ostfeld); Medintec, Petach-Tikva, Israel (Luft-Afik); Department of Social Work, Ariel University, Ariel, Israel (Lavenda, Mahat-Shamir, Hamama-Raz, Ben Ezra, Ostfeld); Department of Psychology, University of Hawaii, Hilo, and Trauma and Resilience Center, Department of Psychiatry, University of Texas Health Sciences Center, Houston (Frueh)
| | - Osnat Lavenda
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem (Ellenberg, Yakir, Bar-On, Sasson, Taragin, Cohen, Ostfeld); Medintec, Petach-Tikva, Israel (Luft-Afik); Department of Social Work, Ariel University, Ariel, Israel (Lavenda, Mahat-Shamir, Hamama-Raz, Ben Ezra, Ostfeld); Department of Psychology, University of Hawaii, Hilo, and Trauma and Resilience Center, Department of Psychiatry, University of Texas Health Sciences Center, Houston (Frueh)
| | - Michal Mahat-Shamir
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem (Ellenberg, Yakir, Bar-On, Sasson, Taragin, Cohen, Ostfeld); Medintec, Petach-Tikva, Israel (Luft-Afik); Department of Social Work, Ariel University, Ariel, Israel (Lavenda, Mahat-Shamir, Hamama-Raz, Ben Ezra, Ostfeld); Department of Psychology, University of Hawaii, Hilo, and Trauma and Resilience Center, Department of Psychiatry, University of Texas Health Sciences Center, Houston (Frueh)
| | - Yaira Hamama-Raz
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem (Ellenberg, Yakir, Bar-On, Sasson, Taragin, Cohen, Ostfeld); Medintec, Petach-Tikva, Israel (Luft-Afik); Department of Social Work, Ariel University, Ariel, Israel (Lavenda, Mahat-Shamir, Hamama-Raz, Ben Ezra, Ostfeld); Department of Psychology, University of Hawaii, Hilo, and Trauma and Resilience Center, Department of Psychiatry, University of Texas Health Sciences Center, Houston (Frueh)
| | - Menahem Ben Ezra
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem (Ellenberg, Yakir, Bar-On, Sasson, Taragin, Cohen, Ostfeld); Medintec, Petach-Tikva, Israel (Luft-Afik); Department of Social Work, Ariel University, Ariel, Israel (Lavenda, Mahat-Shamir, Hamama-Raz, Ben Ezra, Ostfeld); Department of Psychology, University of Hawaii, Hilo, and Trauma and Resilience Center, Department of Psychiatry, University of Texas Health Sciences Center, Houston (Frueh)
| | - B Christopher Frueh
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem (Ellenberg, Yakir, Bar-On, Sasson, Taragin, Cohen, Ostfeld); Medintec, Petach-Tikva, Israel (Luft-Afik); Department of Social Work, Ariel University, Ariel, Israel (Lavenda, Mahat-Shamir, Hamama-Raz, Ben Ezra, Ostfeld); Department of Psychology, University of Hawaii, Hilo, and Trauma and Resilience Center, Department of Psychiatry, University of Texas Health Sciences Center, Houston (Frueh)
| | - Ishay Ostfeld
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem (Ellenberg, Yakir, Bar-On, Sasson, Taragin, Cohen, Ostfeld); Medintec, Petach-Tikva, Israel (Luft-Afik); Department of Social Work, Ariel University, Ariel, Israel (Lavenda, Mahat-Shamir, Hamama-Raz, Ben Ezra, Ostfeld); Department of Psychology, University of Hawaii, Hilo, and Trauma and Resilience Center, Department of Psychiatry, University of Texas Health Sciences Center, Houston (Frueh)
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Baig MR, Ouyang S, Mata-Galán E, Dawes MA, Roache JD. A Comparison of Cognitive Processing Therapy and Seeking Safety for the Treatment of Posttraumatic Stress Disorder in Veterans. Psychiatr Q 2021; 92:735-750. [PMID: 32964375 DOI: 10.1007/s11126-020-09850-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 11/30/2022]
Abstract
To compare the outcomes of Seeking Safety (SS) and cognitive processing therapy (CPT) in veterans with PTSD in a specialty clinic of an urban VA medical center. Retrospective chart review of electronic medical records was conducted for 420 veterans with PTSD who received treatment with either CPT (n = 227) or SS (n = 193) in group setting. 1) treatment completion rate, 2) self-reported PTSD symptom severity measured by PTSD checklist (PCL), and 3) additional mental health services received within 12 months after treatment. Data were analyzed for the 160 who had both a pre and post PCL documented in their charts. The final analysis sample included n = 94 for CPT and n = 66 for SS veterans with a mean age of 49.71[SD = 14] years, 24 women [15%]; mean baseline PCL score was 68.41 [9]. Significantly more veterans completed SS treatment (SS, 59 [89%] than CPT, 47 [50%] (p = <.001). However, PCL score decreases were significantly greater for patients who completed CPT treatment than those in SS (treatment x time interaction, 9.60 vs.4.98, respectively; difference, 4.62; t84 = 2.16; p = .02). The patients who received SS used significantly more mental health services of the PTSD clinical team than patients who completed CPT treatment (p = .01). The results of this study demonstrate the need for alternative approaches where dually diagnosed patients would not be delayed in their receipt of trauma-focused care - i.e., where treatment is initiated concurrently rather than sequentially to substance abuse treatment.
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Affiliation(s)
- Muhammad R Baig
- Mental Health, South Texas Veterans Healthcare System, 116 A, 7400 Merton Minter Blvd, San Antonio, TX, USA. .,Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, San Antonio, TX, USA. .,Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Shuang Ouyang
- Pharmacy Service, South Texas Veterans Healthcare System, San Antonio, TX, USA
| | - Emma Mata-Galán
- Mental Health, South Texas Veterans Healthcare System, 116 A, 7400 Merton Minter Blvd, San Antonio, TX, USA
| | - Michael A Dawes
- Department of Psychiatry, Boston University Medical Campus, Boston, MA, USA.,VA Boston Healthcare System-Brockton Campus, Boston, MA, USA
| | - John D Roache
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Department of Pharmacology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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15
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Schneider JC, Hendrix-Bennett F, Beydoun HA, Johnstone B. A Retrospective Study of Demographic, Medical, and Psychological Predictors of Readiness in Service Members With Mild Traumatic Brain Injury. Mil Med 2021; 186:e401-e409. [PMID: 33175963 DOI: 10.1093/milmed/usaa274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/17/2020] [Accepted: 08/09/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Given the significant number of service members who have incurred mild traumatic brain injury (TBI) over the past two decades, this study was completed to determine the relative contribution of demographic, TBI-related, and psychological factors that predict the readiness of service members with primarily mild TBI. METHODS AND MATERIALS This retrospective study included 141 service members who were evaluated at an outpatient military TBI rehabilitation clinic. Information regarding demographics, TBI-related variables, and psychological factors was collected and entered into hierarchical multinomial logistic regressions to predict military work status. Demographic predictor variables included age, race, gender, rank, service branch; TBI-specific variables including time since injury and neuropsychological variables (i.e., Wechsler Adult Intelligence Scale-IV (WAIS-IV) Full Scale Intelligence Quotient (FSIQ) and Processing Speed Indices; California Verbal Learning Test-IV total recall t-score); and psychiatric variables including concomitant psychiatric diagnoses and Personality Assessment Inventory indices. The outcome variable was the service member's military work status (i.e., return to duty (RTD); Medical Evaluation Board-disabled (MEB); retired) at time of discharge from the TBI clinic. RESULTS Statistical analyses indicated that the total model predicted 31% of the variance in work status, with demographics predicting 16% of the variance, concomitant psychiatric diagnoses and WAIS-IV FSIQ predicting an additional 12%, and subjective somatic/psychological distress (Personality Assessment Inventory indices) predicting an additional 3%. Regarding the primary groups of interest (i.e., RTD vs. MEB), stepwise regressions indicated that those who RTD have higher intelligence and report less physical/psychological distress than the disabled group. CONCLUSIONS In general, those service members who were able to RTD versus those who were classified as disabled (MEB) were of higher IQ and reported less somatic/psychological distress. Of note, traditional indices of TBI severity did not predict the ability of the sample to RTD. The results suggest the importance of treating psychological conditions and identifying possible indicators of resilience (e.g., higher intelligence) to increase the readiness of service members with mild TBI.
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Affiliation(s)
| | - Felicia Hendrix-Bennett
- Fort Belvoir Intrepid Spirit Center, Fort Belvoir, VA 22060, USA.,Defense and Veterans Brain Injury Center, Fort Belvoir Intrepid Spirit Center, Fort Belvoir, VA 22060, USA.,General Dynamics Information Technology, Falls Church, VA 22042, USA
| | - Hind A Beydoun
- Department of Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, VA 22060, USA
| | - Brick Johnstone
- Fort Belvoir Intrepid Spirit Center, Fort Belvoir, VA 22060, USA.,Defense and Veterans Brain Injury Center, Fort Belvoir Intrepid Spirit Center, Fort Belvoir, VA 22060, USA.,Virginia Crawford Research Institute, Shepherd Center, Atlanta, GA 30309, USA
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Hoyt T, Shumaker BES. Disability Status Attenuates Treatment Effects in an Intensive Outpatient Program for PTSD. Mil Med 2021; 186:190-197. [PMID: 33499524 DOI: 10.1093/milmed/usaa394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/16/2020] [Accepted: 10/01/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The utilization of intensive outpatient programs for the treatment of military-related post-traumatic stress disorder (PTSD) has increased through initiatives both inside and outside the military health care system. However, research in veteran populations suggest that patients concurrently undergoing disability evaluation may not respond well to such interventions. This study evaluates the relationship between disability separation and endorsement of PTSD symptoms during treatment at an intensive outpatient program. METHODS Patients in this retrospective study were 81 service members enrolled in a half-day, 6-week intensive outpatient program for PTSD. Sixty-seven percent (n = 54) were concurrently enrolled in the integrated disability evaluation system and were pending medical separation. Fifty-two percent (n = 42) also received a 4-week skills training intervention before beginning PTSD treatment. Patients completed the PTSD Checklist before, during, and after the treatment program as an index of PTSD symptoms. RESULTS A significant interaction effect was observed in which PTSD symptoms throughout program enrollment differed as a function of enrollment in the integrated disability evaluation system. Patients undergoing disability evaluations did not show significant changes in endorsed PTSD symptoms during program enrollment, whereas significant decreases in PTSD symptoms were observed in patients not undergoing disability evaluations. These effects controlled for lost treatment days as a result of training or other appointments. CONCLUSIONS These results provide preliminary data indicating that participation in disability separation may attenuate the effect of PTSD treatment and endorsement of PTSD symptoms in an intensive outpatient setting.
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Affiliation(s)
- Tim Hoyt
- Psychological Health Center of Excellence, Defense Health Agency, Silver Spring, MD 20910, USA
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Williams MW, Graham D, Sciarrino NA, Estey M, McCurry KL, Chiu P, King-Casas B. Does Validity Measure Response Affect CPT Group Outcomes in Veterans with PTSD? Mil Med 2021; 185:e370-e376. [PMID: 31735961 DOI: 10.1093/milmed/usz385] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 09/08/2019] [Accepted: 09/10/2019] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION There is a dearth of research on the impact of pre-treatment assessment effort and symptom exaggeration on the treatment outcomes of Veterans engaging in trauma-focused therapy, handicapping therapists providing these treatments. Research suggests a multi-method approach for assessing symptom exaggeration in Veterans with posttraumatic stress disorder (PTSD), which includes effort and symptom validity tests, is preferable. Symptom exaggeration has also been considered a "cry for help," associated with increased PTSD and depressive symptoms. Recently, research has identified resilience as a moderator of PTSD and depressive symptom severity and an important predictor of treatment response among individuals with PTSD. Thus, it is important to examine the intersection of symptom exaggeration, resilience, and treatment outcome to determine whether assessment effort and symptom exaggeration compromise treatment response. MATERIALS AND METHODS We recruited Veterans, aged 18-50 who served during the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) era, from mental health clinics and fliers posted in a large Veterans Affairs Medical Center. Veterans met inclusion criteria if they were diagnosed with PTSD via a clinician-administered assessment. Sixty-one Veterans consented to participate and self-selected into a cognitive processing therapy (CPT) group or treatment-as-usual. We offered self-selection because low recruitment rates delayed treatment start dates and were consistent with a Veteran-centered care philosophy. Veterans were assessed before and after treatment to determine the impact of assessment effort and symptom exaggeration scores on measures of PTSD and depressive symptoms and resilience. This study examined whether assessment effort failure and symptom exaggeration were associated with compromised psychotherapy outcomes in Veterans with PTSD undergoing CPT group. We hypothesized that a pattern of responding consistent with both effort and symptom exaggeration would result in higher (ie, more severe) pre- and post-treatment scores on PTSD and depressive symptom outcome measures and lower resiliency when compared to Veterans providing good effort and genuine responding. Hypotheses were evaluated using bivariate correlation analyses, analysis of variance, and chi-square analyses. RESULTS Pre-treatment scores on measures of PTSD and depressive symptoms were higher among Veterans whose pattern of responding was consistent with poor assessment effort and symptom exaggeration; these Veterans also scored lower on a measure of resiliency. At post-treatment, there were no differences between Veterans displaying good and failed effort testing on measures of PTSD and depressive symptoms or in whether they completed treatment. Post-treatment resiliency scores remained significantly lower in those with failed effort testing. CONCLUSION These results suggest that Veterans with PTSD whose validity testing scores are indicative of poor effort and symptom exaggeration may be less resilient but may still complete a CPT group treatment and benefit from treatment at a rate comparable to Veterans who evidence good assessment effort and genuine symptom reporting pre-treatment. These findings also challenge the assumption that pre-treatment assessment effort failure and symptom exaggeration accurately predict poor effort in trauma-focused psychotherapy.
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Affiliation(s)
- M Wright Williams
- Michael E. DeBakey Veterans Affairs Medical Center, Mental Health Care Line, 2002 Holcombe Blvd. Houston, TX 77030.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030.,VISN 16 South Central MIRECC Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd., Houston, TX 77030
| | - David Graham
- Michael E. DeBakey Veterans Affairs Medical Center, Mental Health Care Line, 2002 Holcombe Blvd. Houston, TX 77030.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030.,VISN 16 South Central MIRECC Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd., Houston, TX 77030
| | - Nicole A Sciarrino
- Ralph H. Johnson Veterans Affairs Medical Center, PTSD Clinical Team, 109 Bee St., Charleston, SC 29401
| | - Matt Estey
- Program Director Menninger 360, Menninger Clinic, 12301 S Main St., Houston, TX 77035
| | - Katherine L McCurry
- Salem VA Medical Center, 1970 Roanoke Blvd, Salem, VA 24153 University of Virginia School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA 24016.,Fralin Biomedical Research Institute at VTC, Virginia Tech, 2 Riverside Circle, Roanoke, VA 24016
| | - Pearl Chiu
- Salem VA Medical Center, 1970 Roanoke Blvd, Salem, VA 24153 University of Virginia School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA 24016.,Fralin Biomedical Research Institute at VTC, Virginia Tech, 2 Riverside Circle, Roanoke, VA 24016.,Department of Psychology, Virginia Tech, 109 Williams Hall, Blacksburg VA, 24061.,Department of Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine, 2017 South Jefferson, Roanoke, VA 24014
| | - Brooks King-Casas
- Salem VA Medical Center, 1970 Roanoke Blvd, Salem, VA 24153 University of Virginia School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA 24016.,Fralin Biomedical Research Institute at VTC, Virginia Tech, 2 Riverside Circle, Roanoke, VA 24016.,Department of Psychology, Virginia Tech, 109 Williams Hall, Blacksburg VA, 24061.,Department of Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine, 2017 South Jefferson, Roanoke, VA 24014
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Development of a Practice Tool for Primary Care Providers: Medication Management of Posttraumatic Stress Disorder in Veterans with Mild Traumatic Brain Injury. Psychiatr Q 2020; 91:1465-1478. [PMID: 32430697 DOI: 10.1007/s11126-020-09767-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Posttraumatic stress disorder (PTSD) and comorbid mild traumatic brain injury (mTBI) are highly prevalent in veterans who served in Iraq [Operation Iraqi Freedom/Operation New Dawn] and Afghanistan [Operation Enduring Freedom]. Complicated psychotropic medications are used for treatment of PTSD and comorbid mTBI symptoms lead to polypharmacy related complications. Primary care providers (PCPs) working in Community Based Outpatient Clinics (CBOCs) are usually burdened with the responsibility of managing this complicated medication regimen or relevant side effects. The PCPs do not feel equipped to provide this complicated psychopharmacological management. Thus, there is a need for a comprehensive yet concise tool for the medication management of PTSD in veterans with comorbid mTBI. (1) To conduct focus groups of interdisciplinary team of experts and other stake holders to assess need, (2) To carefully review current VA/Department of Defense practice guideline to identify content, (3) To develop an evidence based, user friendly, and concise pocket guide for the PCP's. Content was identified by review of current guidelines and available literature and was finalized after input from stakeholders, multidisciplinary team of experts, and review of qualitative data from focus groups/interviews of clinicians working in remote CBOCs. The pocket tool was formatted and designed by multimedia service. A pocket guide in the form of a bi-fold, 4″ × 5.5″ laminated card was developed. One thousand hard copies were distributed in the local VA medical center. This product is available online for download at the South-Central Mental Illness Research, Education, and Clinical Center website ( https://www.mirecc.va.gov/VISN16/ptsd-and-mtbi-pocket-card.asp ). This pocket card provides PCPs an easy to carry and user-friendly clinical decision-making tool to effectively treat veterans with PTSD and comorbid mTBI.
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Linnstaedt SD, Zannas AS, McLean SA, Koenen KC, Ressler KJ. Literature review and methodological considerations for understanding circulating risk biomarkers following trauma exposure. Mol Psychiatry 2020; 25:1986-1999. [PMID: 31863020 PMCID: PMC7305050 DOI: 10.1038/s41380-019-0636-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 11/24/2019] [Accepted: 12/11/2019] [Indexed: 12/29/2022]
Abstract
Exposure to traumatic events is common. While many individuals recover following trauma exposure, a substantial subset develop adverse posttraumatic neuropsychiatric sequelae (APNS) such as posttraumatic stress, major depression, and regional or widespread chronic musculoskeletal pain. APNS cause substantial burden to the individual and to society, causing functional impairment and physical disability, risk for suicide, lost workdays, and increased health care costs. Contemporary treatment is limited by an inability to identify individuals at high risk of APNS in the immediate aftermath of trauma, and an inability to identify optimal treatments for individual patients. Our purpose is to provide a comprehensive review describing candidate blood-based biomarkers that may help to identify those at high risk of APNS and/or guide individual intervention decision-making. Such blood-based biomarkers include circulating biological factors such as hormones, proteins, immune molecules, neuropeptides, neurotransmitters, mRNA, and noncoding RNA expression signatures, while we do not review genetic and epigenetic biomarkers due to other recent reviews of this topic. The current state of the literature on circulating risk biomarkers of APNS is summarized, and key considerations and challenges for their discovery and translation are discussed. We also describe the AURORA study, a specific example of current scientific efforts to identify such circulating risk biomarkers and the largest study to date focused on identifying risk and prognostic factors in the aftermath of trauma exposure.
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Affiliation(s)
- Sarah D Linnstaedt
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, USA
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, USA
| | - Anthony S Zannas
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, USA
- Departments of Psychiatry and Genetics, University of North Carolina, Chapel Hill, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Samuel A McLean
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, USA
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, USA
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Karestan C Koenen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kerry J Ressler
- Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA, USA.
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Vance MC, Howell JD. Shell Shock and PTSD: A Tale of Two Diagnoses. Mayo Clin Proc 2020; 95:1827-1830. [PMID: 32861323 DOI: 10.1016/j.mayocp.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/23/2019] [Accepted: 06/02/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Mary C Vance
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD.
| | - Joel D Howell
- Department of History, University of Michigan, Ann Arbor; Department of Internal Medicine, University of Michigan, Ann Arbor
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Maguen S, Holder N, Li Y, Madden E, Neylan TC, Seal KH, Lujan C, Patterson OV, DuVall SL, Shiner B. Factors associated with PTSD symptom improvement among Iraq and Afghanistan veterans receiving evidenced-based psychotherapy. J Affect Disord 2020; 273:1-7. [PMID: 32421589 DOI: 10.1016/j.jad.2020.04.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/02/2020] [Accepted: 04/24/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite availability of evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), not all veterans who initiate EBPs experience benefit. Better understanding factors associated with clinically significant improvement can help ameliorate care. METHODS A cohort of Iraq and Afghanistan War veterans who initiated an EBP was identified (N = 32,780) with ≥1 post-deployment psychotherapy visit at the Veterans Health Administration from 10/2001-6/2017, a post-deployment PTSD diagnosis, and ≥2 PTSD symptom measures. We used random-effects logistic regression to assess whether patient-level, diagnostic, and treatment factors were associated with achieving symptom improvement. RESULTS Increased odds of PTSD symptom improvement were seen in women (OR = 1.19; 95% CI: 1.09--1.29), those who initiated EBP within a year of engaging in mental healthcare compared with the delayed EBP group (OR = 1.20; 95% CI: 1.14--1.28), those who completed at least 8 EBP sessions in 16 weeks (OR = 1.23; 95% CI:1.11--1.36), those who received PE only (vs. CPT or both; OR = 2.23; 95% CI: 1.86--2.68) or CPT individual therapy only (vs. CPT group or both; OR = 1.34; 95% CI: 1.22--1.48), and those with a drug dependence diagnosis (OR = 1.24; 95% CI: 1.11--1.39). Decreased odds of improvement were seen in Black veterans (OR=0.75; 95% CI: 0.69--0.81) and those with service-connected disability (OR = 0.61; 95% CI: 0.52--0.71). LIMITATIONS Diagnoses were from medical charts and not confirmed with gold standard assessment tools; we only included veterans with at least two PTSD measurements, which may cause bias. CONCLUSION Modifiable factors associated with PTSD improvement (timing, dose, and modality) can be used to improve EBP outcomes.
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Affiliation(s)
- Shira Maguen
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine.
| | - Nicholas Holder
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine
| | - Yongmei Li
- San Francisco Veterans Affairs Health Care System
| | - Erin Madden
- San Francisco Veterans Affairs Health Care System
| | - Thomas C Neylan
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine
| | - Karen H Seal
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center
| | - Callan Lujan
- San Francisco Veterans Affairs Health Care System
| | - Olga V Patterson
- Department of Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine
| | - Scott L DuVall
- Department of Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine
| | - Brian Shiner
- White River Junction Veterans Affairs Medical Center; Geisel School of Medicine at Dartmouth; National Center for Posttraumatic Stress Disorder, Executive Division
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22
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Ramanathan-Elion DM, Baydoun HA, Johnstone B. Psychological predictors of functional outcomes in service members with traumatic brain injury. Brain Inj 2020; 34:1183-1192. [PMID: 32683899 DOI: 10.1080/02699052.2020.1793387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PRIMARY OBJECTIVE Research is increasingly demonstrating the significant impact that non-medical factors can have on outcomes of service members (SMs) with mild traumatic brain injury (mTBI). Thus, the current study examined which demographic, TBI-related factors, and psychological variables are most predictive of functional outcomes. RESEARCH DESIGN Retrospective database analysis from medical chart review. METHODS AND PROCEDURES One hundred forty-one patients who received rehabilitation services at an outpatient TBI military treatment facility between 2013 and 2018. Data collected included demographic variables, time since injury, neuropsychological measures, psychological diagnoses, Personality Assessment Inventory (PAI) scores, and Walter Reed Functional Impairment Scale (FIS). Hierarchical linear regression models were used to predict functional outcomes (measured by FIS total, work, social functioning scales). MAIN OUTCOMES AND RESULTS Results indicated that comorbid PTSD diagnosis and PAI Negative Impression Management (NIM) score were predictive of total functional, work, and social outcomes, over and above demographic and TBI-related factors. CONCLUSIONS Current findings confirmed the importance of evaluating and treating psychological factors, as well as exploring one's responding style (NIM), when managing chronic mTBI in SMs. Given ongoing findings of psychological underpinnings to mTBI outcome, there is further need to focus on early interventions to optimize psychological and functional outcomes for SMs.
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Affiliation(s)
- Deepa M Ramanathan-Elion
- Department of Behavioral Health, Fort Belvoir Intrepid Spirit Center , Fort Belvoir, Virginia, USA
| | - Hind A Baydoun
- Department of Research Programs, Fort Belvoir Community Hospital , Fort Belvoir, Virginia, USA
| | - Brick Johnstone
- Defense and Veterans Brain Injury Center, Fort Belvoir Intrepid Spirit Center , Fort Belvoir, Virginia, USA.,Virginia Crawford Research Institute, Shepherd Center , Atlanta, Georgia, USA
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23
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MacGregor AJ, Joseph AR, Walker GJ, Dougherty AL. Co-occurrence of hearing loss and posttraumatic stress disorder among injured military personnel: a retrospective study. BMC Public Health 2020; 20:1076. [PMID: 32641028 PMCID: PMC7341578 DOI: 10.1186/s12889-020-08999-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/27/2020] [Indexed: 01/03/2023] Open
Abstract
Background Posttraumatic stress disorder (PTSD) and hearing loss are hallmark public health issues related to military service in Iraq and Afghanistan. Although both are significant individual contributors to disability among veterans, their co-occurrence has not been specifically explored. Methods A total of 1179 male U.S. military personnel who sustained an injury between 2004 and 2012 during operations in Iraq or Afghanistan were identified from clinical records. Pre- and postinjury audiometric data were used to define new-onset hearing loss, which was categorized as unilateral or bilateral. Diagnosed PTSD was abstracted from electronic medical records. Logistic regression analysis examined the relationship between hearing loss and PTSD, while adjusting for age, year of injury, occupation, injury severity, injury mechanism, and presence of concussion. Results The majority of the study sample were aged 18–25 years (79.9%) and sustained mild-moderate injuries (94.6%). New-onset hearing loss was present in 14.4% of casualties (10.3% unilateral, 4.1% bilateral). Rates of diagnosed PTSD were 9.1, 13.9, and 29.2% for those with no hearing loss, unilateral hearing loss, and bilateral hearing loss, respectively. After adjusting for covariates, those with bilateral hearing loss had nearly three-times higher odds of PTSD (odds ratio = 2.92; 95% CI, 1.47–5.81) compared to those with no hearing loss. Unilateral hearing loss was not associated with PTSD. Conclusions Both PTSD and hearing loss are frequent consequences of modern warfare that adversely affect the overall health of the military. Bilateral, but not unilateral, hearing loss was associated with a greater burden of PTSD. This has implications for warfighter rehabilitation and should encourage collaboration between audiology and mental health professionals.
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Affiliation(s)
- Andrew J MacGregor
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, USA.
| | - Antony R Joseph
- Hearing Loss Prevention Laboratory, Communication Sciences and Disorders Department, Illinois State University, Normal, IL, USA.,Leidos, Inc., San Diego, CA, USA
| | - G Jay Walker
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, USA.,Leidos, Inc., San Diego, CA, USA
| | - Amber L Dougherty
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, USA.,Leidos, Inc., San Diego, CA, USA
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24
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Lee DJ, Lee LO, Bovin MJ, Moshier SJ, Dutra SJ, Kleiman SE, Rosen RC, Vasterling JJ, Keane TM, Marx BP. The 20-year course of posttraumatic stress disorder symptoms among veterans. JOURNAL OF ABNORMAL PSYCHOLOGY 2020; 129:658-669. [PMID: 32478530 DOI: 10.1037/abn0000571] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Although numerous longitudinal studies have examined heterogeneity in posttraumatic stress disorder (PTSD) symptom course, the long-term course of the disorder remains poorly understood. This study sought to understand and predict long-term PTSD symptom course among a nationwide sample of Operations Enduring Freedom and Iraqi Freedom veterans enrolled in Veterans Health Administration services. We assessed PTSD symptoms at 4 time points over approximately 4.5 years (M = 55.11 months, SD = 6.89). Participants (N = 1,353) with and without probable PTSD were sampled at a 3:1 ratio, and male and female veterans were sampled at a 1:1 ratio to fully explore the heterogeneity of PTSD symptom course and the effect of sex on symptom course. By coding time as years since index trauma, we estimated the course of PTSD symptoms over 20 years. Results indicate symptom course is most appropriately characterized by substantial heterogeneity. On average, veterans experienced initial PTSD symptom severity above the diagnostic threshold following trauma exposure, which was initially stable over time and later began to gradually improve. Although results indicate symptoms eventually began to decline, this effect was gradual; most participants continued to meet or exceed the PTSD provisional diagnostic threshold long after trauma exposure. We identified several predictors and correlates of symptom course, including Hispanic ethnicity, postdeployment social support, and co-occurring psychopathology. Results highlight the heterogeneous nature of PTSD symptom course following trauma exposure and the urgency of the need to ensure access to evidence-based care and to improve available treatments. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Daniel J Lee
- National Center for PTSD at VA Boston Healthcare System
| | - Lewina O Lee
- National Center for PTSD at VA Boston Healthcare System
| | | | | | - Sunny J Dutra
- National Center for PTSD at VA Boston Healthcare System
| | | | | | | | | | - Brian P Marx
- National Center for PTSD at VA Boston Healthcare System
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25
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Association Between Technology Use and Social Integration Among Veterans With Disabilities. J Nerv Ment Dis 2020; 208:306-311. [PMID: 32221185 DOI: 10.1097/nmd.0000000000001132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Social connectedness has positive effects on physical and mental health. Many aspects of life, including social networks, are increasingly technology-based, influenced by access to computers. Individuals with psychiatric disabilities may experience unique barriers to computer use. The current study evaluated computer use among 199 veterans in Connecticut and Houston, Texas, with psychiatric and/or physical disabilities, and its association with social integration. Two-thirds had used a computer within the past month, most commonly for information seeking, but also for social interaction. However, computer use and social integration were not significantly associated. The study suggests a greater rate of computer use than anticipated, encouraging given society's increasing reliance on technology. Future research into experience with other modalities is needed, as is research into veterans' willingness and desire to use technology for various purposes.
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26
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Moore BA, Brock MS, Brager A, Collen J, LoPresti M, Mysliwiec V. Posttraumatic Stress Disorder, Traumatic Brain Injury, Sleep, and Performance in Military Personnel. Sleep Med Clin 2020; 15:87-100. [DOI: 10.1016/j.jsmc.2019.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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27
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Redd AM, Gundlapalli AV, Suo Y, Pettey WBP, Brignone E, Chin DL, Walker LE, Poltavskiy EA, Janak JC, Howard JT, Sosnov JA, Stewart IJ. Exploring Disparities in Awarding VA Service-Connected Disability for Post-Traumatic Stress Disorder for Active Duty Military Service Members from Recent Conflicts in Iraq and Afghanistan. Mil Med 2020; 185:296-302. [PMID: 32074380 DOI: 10.1093/milmed/usz208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION We explore disparities in awarding post-traumatic stress disorder (PTSD) service-connected disability benefits (SCDB) to veterans based on gender, race/ethnicity, and misconduct separation. METHODS Department of Defense data on service members who separated from October 1, 2001 to May 2017 were linked to Veterans Administration (VA) administrative data. Using adjusted logistic regression models, we determined the odds of receiving a PTSD SCDB conditional on a VA diagnosis of PTSD. RESULTS A total of 1,558,449 (79% of separating service members) had at least one encounter in VA during the study period (12% female, 4.5% misconduct separations). Females (OR 0.72) and Blacks (OR 0.93) were less likely to receive a PTSD award and were nearly equally likely to receive a PTSD diagnosis (OR 0.97, 1.01). Other racial/ethnic minorities were more likely to receive an award and diagnosis, as were those with misconduct separations (award OR 1.3, diagnosis 2.17). CONCLUSIONS Despite being diagnosed with PTSD at similar rates to their referent categories, females and Black veterans are less likely to receive PTSD disability awards. Other racial/ethnic minorities and those with misconduct separations were more likely to receive PTSD diagnoses and awards. Further study is merited to explore variation in awarding SCDB.
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Affiliation(s)
- Andrew M Redd
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System, 500 Foothill Dr, Salt Lake City, UT 84148.,Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
| | - Adi V Gundlapalli
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System, 500 Foothill Dr, Salt Lake City, UT 84148.,Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
| | - Ying Suo
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System, 500 Foothill Dr, Salt Lake City, UT 84148.,Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
| | - Warren B P Pettey
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System, 500 Foothill Dr, Salt Lake City, UT 84148.,Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
| | - Emily Brignone
- VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA 15240
| | - David L Chin
- Department of Health Promotion and Policy, School of Public Health, University of Massachusetts Amherst, 715 N Pleasant St, Amherst, MA 01003
| | - Lauren E Walker
- David Grant USAF Medical Center, Clinical Investigation Facility, 101 Bodin Circle, Travis AFB, CA 94535
| | - Eduard A Poltavskiy
- David Grant USAF Medical Center, Clinical Investigation Facility, 101 Bodin Circle, Travis AFB, CA 94535
| | - Jud C Janak
- Department of Defense Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, 3698 Chambers Pass, San Antonio, TX 78234
| | - Jeffrey T Howard
- Department of Kinesiology, Health and Nutrition, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249
| | - Jonathan A Sosnov
- 375th Medical Group, Scott AFB, IL 62225.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814
| | - Ian J Stewart
- David Grant USAF Medical Center, Clinical Investigation Facility, 101 Bodin Circle, Travis AFB, CA 94535.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814
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Shura RD, Epstein EL, Armistead-Jehle P, Cooper DB, Eapen BC. Assessment and Treatment of Concussion in Service Members and Veterans. Concussion 2020. [DOI: 10.1016/b978-0-323-65384-8.00013-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Straud CL, Siev J, Messer S, Zalta AK. Examining military population and trauma type as moderators of treatment outcome for first-line psychotherapies for PTSD: A meta-analysis. J Anxiety Disord 2019; 67:102133. [PMID: 31472332 PMCID: PMC6739153 DOI: 10.1016/j.janxdis.2019.102133] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 07/31/2019] [Accepted: 08/17/2019] [Indexed: 11/20/2022]
Abstract
There is conflicting evidence as to whether military populations (i.e., veteran and active-duty military service members) demonstrate a poorer response to psychotherapy for posttraumatic stress disorder (PTSD) compared to civilians. Existing research may be complicated by the fact that treatment outcomes differences could be due to the type of trauma exposure (e.g., combat) or population differences (e.g., military culture). This meta-analysis evaluated PTSD treatment outcomes as a function of trauma type (combat v. assault v. mixed) and population (military v. civilian). Unlike previous meta-analyses, we focused exclusively on manualized, first-line psychotherapies for PTSD as defined by expert treatment guidelines. Treatment outcomes were large across trauma types and population; yet differences were observed between trauma and population subgroups. Military populations demonstrated poorer treatment outcomes compared to civilians. The combat and assault trauma subgroups had worse treatment outcomes compared to the mixed trauma subgroup, but differences were not observed between assault and combat subgroups. Higher attrition rates predicted poorer treatment outcomes, but did not vary between military populations and civilians. Overall, manualized, first-line psychotherapies for PTSD should continue to be used for civilians and military populations with various trauma types. However, greater emphasis should be placed on enhancing PTSD psychotherapies for military populations and on treatment retention across populations based on findings from this meta-analysis.
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Affiliation(s)
- Casey L Straud
- University of Texas Health Science Center at San Antonio, San Antonio, TX, United States.
| | | | - Stephen Messer
- Nova Southeastern University, Fort Lauderdale, FL, United States
| | - Alyson K Zalta
- University of California, Irvine, Irvine, CA, United States
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30
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Veterans' compensation claims beliefs predict timing of PTSD treatment use relative to compensation and pension exam. PLoS One 2018; 13:e0209488. [PMID: 30589882 PMCID: PMC6307722 DOI: 10.1371/journal.pone.0209488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 12/06/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction In this study we developed the Disability Beliefs Scale to assess Veterans’ beliefs that engaging in treatment, as well as other behaviors, would affect the likelihood of a Veteran’s being awarded disability-related benefits. We posited that Veterans with stronger beliefs that attending mental health treatment would facilitate a service-connection award would be more likely to attend PTSD treatment before their compensation and pension examinations for PTSD. Methods Electronic health records for 307 post-9/11-era Veterans applying for compensation and pension for service-connected PTSD and engaging in a clinical trial of a treatment-referral intervention were analyzed for PTSD-specific and more general mental health treatment use around the time of their compensation examinations. All participants completed the Disability Beliefs Scale and other baseline assessments. Multilevel models assessed change in treatment use as a function of time relative to the C&P exam, compensation examination status (before or after), and the interaction between examination status and beliefs about treatment benefits. Results No main effects of time or examination status were observed. As hypothesized, beliefs about treatment benefits moderated the effect of examination status on PTSD treatment use. Veterans believing more strongly that mental health treatment would help a claim differentially attended PTSD treatment before the examination than after. The effect was not observed for general mental health treatment use. Conclusion The association between Veterans’ use of PTSD treatment and their service-connection examination status was moderated by beliefs that receiving treatment affects the service-connection decision. This suggests that factors reported to motivate seeking service-connection—finances, validation of Veterans’ experiences, and the involvement of significant others—might also help motivate Veterans’ use of effective PTSD treatments. However, the results reflect correlations that could be explained in other ways, and service-connection was one of many factors impacting PTSD treatment engagement.
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31
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Elliott L, Bennett AS, Szott K, Golub A. Competing Constructivisms: The Negotiation of PTSD and Related Stigma Among Post-9/11 Veterans in New York City. Cult Med Psychiatry 2018; 42:778-799. [PMID: 29796782 PMCID: PMC6251768 DOI: 10.1007/s11013-018-9586-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Posttraumatic stress disorder (PTSD) stands as a form of psychopathology that straddles moral and psychiatric domains. Grounded in discrete instances of trauma, PTSD represents an etiological outlier in an era of increased attention to the genetics of mental illness and a prime location for social constructivist analyses of mental illness. This examination of PTSD narratives-as voiced in qualitative interviews and focus groups with 50 veterans of the recent Iraq and Afghanistan wars living in New York City-attends to the processes through which veterans conceive and navigate PTSD symptoms and diagnoses. In so doing we highlight the social constructivist positions undertaken by veterans themselves as they varyingly challenge and internalize symptomology in dialogue with psychiatric definitions and the stigma associated with PTSD. Findings demonstrate the rejection of classic psychopathological etiology-in brain disease, for example-by many veterans as well as the complex balancing of benefit and stigma that veterans undertake when making decisions about presenting to psychiatric clinicians. Drawing on veterans' accounts, we argue for greater cultural specificity in characterizing the diagnosis-seeking behavior of trauma survivors and a greater appreciation for the contradictions and compromise related to both acceptance and rejection of a mental health diagnosis.
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Affiliation(s)
| | | | - Kelly Szott
- National Development and Research Institutes
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32
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Butler O, Herr K, Willmund G, Gallinat J, Zimmermann P, Kühn S. Neural correlates of response bias: Larger hippocampal volume correlates with symptom aggravation in combat-related posttraumatic stress disorder. Psychiatry Res Neuroimaging 2018; 279:1-7. [PMID: 30014966 DOI: 10.1016/j.pscychresns.2018.06.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 01/04/2023]
Abstract
The diagnosis of posttraumatic stress disorder (PTSD) is vulnerable to the simulation or exaggeration of symptoms as it depends on the individual's self-report of symptoms. The use of symptom validity tests is recommended to detect malingering in PTSD. However, in neuroimaging research, PTSD diagnosis is often taken at face validity. To date, no neuroimaging study has compared credible PTSD patients with those identified as malingering, and the potential impacts of including malingerers along with credible patients on results is unclear. We classified male patients with combat-related PTSD as either credible (n = 37) or malingerers (n = 9) based on the Morel Emotional Numbing Test and compared structural neuroimaging and psychological questionnaire data. Patients identified as malingerers had larger gray matter volumes in the hippocampus, right inferior frontal gyrus and thalamus, and reported higher PTSD symptoms than credible PTSD patients. This is the first structural neuroimaging study to compare credible PTSD patients and malingerers. We find evidence of structural differences between these groups, in regions implicated in PTSD, inhibition and deception. These results emphasize the need for the inclusion of SVTs in neuroimaging studies of PTSD to ensure future findings are not confounded by an unknown mix of valid PTSD patients and malingerers.
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Affiliation(s)
- Oisin Butler
- Max Planck Institute for Human Development, Center for Lifespan Psychology, Lentzeallee 94, Berlin 14195, Germany.
| | - Kerstin Herr
- Center for Military Mental Health, Military Hospital Berlin, Scharnhorststr. 13, Berlin 10115, Germany
| | - Gerd Willmund
- Center for Military Mental Health, Military Hospital Berlin, Scharnhorststr. 13, Berlin 10115, Germany
| | - Jürgen Gallinat
- University Medical Centre Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistrasse 52, Hamburg 20246, Germany
| | - Peter Zimmermann
- Center for Military Mental Health, Military Hospital Berlin, Scharnhorststr. 13, Berlin 10115, Germany
| | - Simone Kühn
- Max Planck Institute for Human Development, Center for Lifespan Psychology, Lentzeallee 94, Berlin 14195, Germany; University Medical Centre Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistrasse 52, Hamburg 20246, Germany
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33
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Ragsdale KA, Gramlich MA, Beidel DC, Neer SM, Kitsmiller EG, Morrison KI. Does Traumatic Brain Injury Attenuate the Exposure Therapy Process? Behav Ther 2018; 49:617-630. [PMID: 29937262 DOI: 10.1016/j.beth.2017.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/26/2017] [Accepted: 09/26/2017] [Indexed: 11/25/2022]
Abstract
Research indicates that exposure therapy is efficacious for combat-related posttraumatic stress disorder (PTSD) comorbid with traumatic brain injury (TBI) as is shown by reduced PTSD treatment outcome scores. What is unknown, however, is whether the process of fear extinction is attenuated in veterans with TBI history. Increased PTSD symptomatology and possible cognitive deficits associated with TBI sequelae may indicate additional or longer exposure sessions to achieve habituation and extinction comparable to individuals without TBI history. As such, a more extensive course of treatment may be necessary to achieve comparable PTSD treatment outcome scores for individuals with TBI history. Using a sample of veterans with combat-related PTSD, some of whom were comorbid for TBI, this study compared process variables considered relevant to successful treatment outcome in exposure therapy. Individuals with and without TBI demonstrated similar rates of fear activation, length and number of exposure sessions, within-session habituation, between-session habituation, and extinction rate; results remained consistent when controlling for differential PTSD symptomatology. Furthermore, results indicated that self-perception of executive dysfunction did not impact the exposure process. Results suggest that individuals with PTSD and TBI history engage successfully and no differently in the exposure therapy process as compared to individuals with PTSD alone. Findings further support exposure therapy as a first-line treatment for combat-related PTSD regardless of TBI history.
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Sripada RK, Hannemann CM, Schnurr PP, Marx BP, Pollack SJ, McCarthy JF. Mental Health Service Utilization before and after Receipt of a Service-Connected Disability Award for PTSD: Findings from a National Sample. Health Serv Res 2018; 53:4565-4583. [PMID: 29667171 DOI: 10.1111/1475-6773.12859] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine patterns of mental health service use before and after VA disability compensation awards for posttraumatic stress disorder (PTSD). DATA SOURCES A 10 percent random sample of VHA-enrolled Veterans with new or increased PTSD service connection between 2012 and 2014 (n = 22,249). STUDY DESIGN We used latent trajectory analysis to identify utilization patterns and multinomial logistic regression to assess associations between Veteran characteristics and trajectory membership. DATA EXTRACTION METHODS We assessed receipt of VHA mental health encounters in each of the 52 weeks prior to and following PTSD disability rating or rating increase. PRINCIPAL FINDINGS The best fitting model had five groups: No Use (36.6 percent), Low Use (37.7 percent), Increasing Use (9.4 percent), Decreasing Use (11.2 percent), and High Use (5.1 percent). Adjusting for demographic characteristics and compared with the No Use group, Veterans in the other groups were more likely to reside closer to a VHA facility, receive a higher PTSD disability rating, and screen positive for military sexual trauma. CONCLUSIONS Service use remained stable (80 percent) or increased (9 percent) for the vast majority of Veterans. Service utilization declined for only 11 percent. Data did not indicate substantial service discontinuation following rating. Low VHA service utilization suggests opportunities to enhance outreach for Veterans with PTSD-related disability benefits.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI.,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI.,Department of Psychiatry, University of Michigan, Ann Arbor, MI.,Veterans Affairs Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI
| | - Claire M Hannemann
- Veterans Affairs Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI.,Office of Mental Health and Suicide Prevention, VA Central Office, Department of Veterans Affairs, Washington, DC
| | - Paula P Schnurr
- Executive Division, National Center for PTSD, White River Junction, VT.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Brian P Marx
- Behavioral Science Division, National Center for PTSD, Boston, MA.,Veterans Affairs Boston Healthcare System, Boston, MA.,Department of Psychiatry, School of Medicine, Boston University, Boston, MA
| | - Stacey J Pollack
- Office of Mental Health and Suicide Prevention, VA Central Office, Department of Veterans Affairs, Washington, DC
| | - John F McCarthy
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI.,Department of Psychiatry, University of Michigan, Ann Arbor, MI.,Veterans Affairs Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI.,Office of Mental Health and Suicide Prevention, VA Central Office, Department of Veterans Affairs, Washington, DC
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Russell MC, Schaubel SR, Figley CR. The Darker Side of American Military Mental Healthcare—Part Three: Five More Harmful Strategies to Manage Its Mental Health Dilemma. PSYCHOLOGICAL INJURY & LAW 2018. [DOI: 10.1007/s12207-018-9312-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kulas JF, Rosenheck RA. A Comparison of Veterans with Post-traumatic Stress Disorder, with Mild Traumatic Brain Injury and with Both Disorders: Understanding Multimorbidity. Mil Med 2017. [DOI: 10.1093/milmed/usx050] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joseph F Kulas
- Veterans Affairs Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510
| | - Robert A Rosenheck
- Veterans Affairs Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510
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Sleep Disturbances Among Combat Military Veterans: A Comparative Study Using Subjective and Objective Sleep Assessments. MILITARY PSYCHOLOGY 2017. [DOI: 10.1037/mil0000161] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Miles SR, Harik JM, Hundt NE, Mignogna J, Pastorek NJ, Thompson KE, Freshour JS, Yu HJ, Cully JA. Delivery of mental health treatment to combat veterans with psychiatric diagnoses and TBI histories. PLoS One 2017; 12:e0184265. [PMID: 28886114 PMCID: PMC5590892 DOI: 10.1371/journal.pone.0184265] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 08/21/2017] [Indexed: 11/18/2022] Open
Abstract
Traumatic brain injury (TBI) and mental health (MH) disorders are prevalent in combat veterans returning from Afghanistan and/or Iraq (hereafter referred to as returning veterans). Accurate estimates of service utilization for veterans with and without TBI exposure (referred to as TBI history) are imperative in order to provide high quality healthcare to returning veterans. We examined associations between TBI history and MH service utilization in a subsample of returning veterans who were newly diagnosed with posttraumatic stress disorder (PTSD), depression, and/or anxiety in the 2010 fiscal year (N = 55,458). Data were extracted from the Veterans Health Administration (VHA) National Patient Care Database. Veterans with MH diagnoses and TBI histories attended significantly more psychotherapy visits, (M = 8.32 visits, SD = 17.15) and were more likely to attend at least 8 psychotherapy visits, (15.7%) than veterans with MH diagnoses but no TBI history (M = 6.48 visits, SD = 12.12; 10.1% attended at least 8 sessions). PTSD and TBI history, but not depression or anxiety, were associated with a greater number of psychotherapy visits when controlling for demographic and clinical variables. PTSD, anxiety, depression, and TBI history were associated with number of psychotropic medication-management visits. TBI history was related to greater MH service utilization, independent of MH diagnoses. Future research should examine what MH services are being utilized and if these services are helping veterans recover from their disorders.
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Affiliation(s)
- Shannon R. Miles
- Health Service Research and Development Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans’ Hospital, Tampa, Florida, United States of America
- Department of Psychiatry & Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, Florida
- * E-mail:
| | - Juliette M. Harik
- National Center for PTSD-Executive Division, VA Medical Center (116D), White River Junction, Vermont, United States of America
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States of America
| | - Natalie E. Hundt
- VA South Central Mental Illness Research, Education, and Clinical Center, Michael E DeBakey VA Medical Center (MEDVAMC 152), Houston, Texas, United States of America
- Baylor College of Medicine, One Baylor Plaza, Houston, Texas, United States of America
- VA HSR&D Houston Center for Innovations in Quality, Effectiveness and Safety, MEDVAMC (152), Houston, Texas, United States of America
| | - Joseph Mignogna
- Center of Excellence for Research on Returning War Veterans, Waco, Texas, United States of America
- Central Texas Veterans Healthcare System, Waco, TX Texas A&M Health Science Center, Temple, Texas, United States of America
- Texas A&M Health Science Center, Temple, Texas, United States of America
| | - Nicholas J. Pastorek
- Rehabilitation and Extended Care Line, MEDVAMC, Houston, Texas, United States of America
| | - Karin E. Thompson
- VA South Central Mental Illness Research, Education, and Clinical Center, Michael E DeBakey VA Medical Center (MEDVAMC 152), Houston, Texas, United States of America
- Baylor College of Medicine, One Baylor Plaza, Houston, Texas, United States of America
| | - Jessica S. Freshour
- VA South Central Mental Illness Research, Education, and Clinical Center, Michael E DeBakey VA Medical Center (MEDVAMC 152), Houston, Texas, United States of America
- Baylor College of Medicine, One Baylor Plaza, Houston, Texas, United States of America
| | - Hong J. Yu
- VA South Central Mental Illness Research, Education, and Clinical Center, Michael E DeBakey VA Medical Center (MEDVAMC 152), Houston, Texas, United States of America
| | - Jeffrey A. Cully
- VA South Central Mental Illness Research, Education, and Clinical Center, Michael E DeBakey VA Medical Center (MEDVAMC 152), Houston, Texas, United States of America
- Baylor College of Medicine, One Baylor Plaza, Houston, Texas, United States of America
- VA HSR&D Houston Center for Innovations in Quality, Effectiveness and Safety, MEDVAMC (152), Houston, Texas, United States of America
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Denning JH, Shura RD. Cost of malingering mild traumatic brain injury-related cognitive deficits during compensation and pension evaluations in the veterans benefits administration. APPLIED NEUROPSYCHOLOGY-ADULT 2017; 26:1-16. [DOI: 10.1080/23279095.2017.1350684] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- John H. Denning
- Department of Veteran Affairs, Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert D. Shura
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Salisbury, North Carolina, USA
- Mental Health and Behavioral Science Service Line, W. G. (Bill) Hefner Veterans Affairs Medical Center (VAMC), Salisbury, North Carolina, USA
- Department of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Russo AC, Fingerhut EC. Consistency of Self-Reported Neurocognitive Symptoms, Post-Traumatic Stress Disorder Symptoms, and Concussive Events From End of First Deployment to Veteran Health Administration Comprehensive Traumatic Brain Injury Evaluation by Operations Enduring Freedom/Iraqi Freedom/New Dawn Veterans. Arch Clin Neuropsychol 2017; 32:184-197. [PMID: 28365745 DOI: 10.1093/arclin/acw093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2016] [Indexed: 11/12/2022] Open
Abstract
Objective This study examined the consistency of self-reported symptoms and concussive events in combat veterans who reported experiencing concussive events. Method One hundred and forty, single deployed, Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn combat veterans with Veteran Health Administration (VHA) Comprehensive Traumatic Brain Injury Evaluations (CTBIE) and no post-deployment head injury were examined to assess consistency of self-reported (a) traumatic brain injury (TBI)-related symptoms, (b) post-traumatic stress disorder (PTSD)-related symptoms, and (c) TBI-related concussive events from soon after deployment to time of VHA CTBIE. Results Compared to their self-report of symptoms and traumatic events at the time of their Post-Deployment Health Assessment, at the time of their comprehensive VHA evaluation, subjects reported significantly greater impairment in concentration, decision making, memory, headache, and sleep. In addition, although half the subjects denied any PTSD symptoms post-deployment, approximately three quarters reported experiencing all four PTSD screening symptoms near the time of the VHA CTBIEs. At the latter time, subjects also reported significantly more TBI-related concussive events, as well as more post-concussive sequelae such as loss of consciousness immediately following these concussive events. Finally, although 84% reported a level of impairment so severe as to render all but the simplest activity doable, the vast majority simultaneously reported working and/or attending college. Conclusions These findings raise questions regarding the accuracy of veteran self-report of both near and distant traumatic events, and argue for the inclusion of contemporaneous Department of Defense (DOD) records in veteran assessment and treatment planning.
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Affiliation(s)
- Arthur C Russo
- Psychology Department, VA New York Harbor Healthcare System, Brooklyn Campus, Brooklyn, NY, USA
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Abstract
This article explores the experiences of social exclusion of individuals with visual impairment (IWVI) as they negotiate their daily lives in their homes and societal settings in the Oshana and Oshikoto regions of Namibia. Employing qualitative research approach, this research tried to better understand the lived experiences of IWVI. Nine IWVI with ages ranging from 30 to 90 years were initially engaged in focus group discussions, followed by semi-structured in-depth individual interviews. The findings of this research indicated that IWVI experience exclusion from education, employment and social and community participation as well as relationships. Based on these findings, we suggest more inclusive policies to address social exclusion of IWVI. At the same time, this group of individuals should be empowered to participate in community activities to promote interaction with people without visual impairments.
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Affiliation(s)
- Elina I. Tobias
- Department of Educational Psychology and Inclusive Education, Faculty of Education, University of Namibia
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Patient, Therapist, and System Factors Influencing the Effectiveness of Prolonged Exposure for Veterans With Comorbid Posttraumatic Stress Disorder and Traumatic Brain Injury. J Nerv Ment Dis 2017; 205:140-146. [PMID: 27668355 DOI: 10.1097/nmd.0000000000000594] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In contrast to concerns that cognitive limitations and neurobehavioral symptoms (NBS) associated with traumatic brain injury (TBI) may inhibit treatment effectiveness, a recent study found prolonged exposure (PE) led to large reductions in posttraumatic stress disorder (PTSD) symptoms among Iraq-Afghanistan veterans with a range of TBI severity (article by Wolf, Kretzmer, Crawford, Thors, Wagner, Strom, Eftekhari, Klenk, Hayward, and Vanderploeg [J Trauma Stress 28:339-347, 2015]). We further examined this sample of 69 veterans to determine whether system, veteran, and therapist factors predicted clinically significant responses. Results of hierarchical, logistic regressions revealed that therapist training in PE and lower service connection were associated with increased odds of large decreases in PTSD symptoms after adjusting for the robust effect of PE sessions completed. Other patient-level factors including age, time since injury, and baseline NBS were unrelated to significant improvements. Findings emphasized the impact of PE dosage, indicated greater mastery of the protocol was beneficial, and showed that service connection could impede self-reported, clinically significant change during PE in this important cohort.
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Vasterling JJ, Aslan M, Proctor SP, Ko J, Marx BP, Jakupcak M, Schnurr PP, Gleason T, Huang GD, Concato J. Longitudinal Examination of Posttraumatic Stress Disorder as a Long-Term Outcome of Iraq War Deployment. Am J Epidemiol 2016; 184:796-805. [PMID: 27852604 DOI: 10.1093/aje/kww151] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 10/18/2016] [Indexed: 11/12/2022] Open
Abstract
The mental health toll of the Iraq and Afghanistan Wars on military veterans has been considerable, yet little is known about the persistence of these adverse outcomes, especially relative to predeployment status. We prospectively examined posttraumatic stress disorder (PTSD) as a long-term consequence of warzone deployment, integrating data collected from 2003-2014. In the Neurocognition Deployment Health Study, we measured PTSD symptoms in US Army soldiers before and shortly after Iraq War deployment. We used the PTSD Checklist-Civilian Version and a structured clinical interview (i.e., Clinician-Administered PTSD Scale) to reassess PTSD in 598 service members and military veterans a median of 7.9 years (interquartile range, 7.2-8.5 years) after an index Iraq deployment. At long-term follow-up, 24.7% (95% confidence interval (CI): 21.5, 28.4) of participants met the case definition for PTSD, which was an absolute increase of 14.2% from the percentage assessed postdeployment (10.5%; 95% CI: 7.8, 13.7) and of 17.3% from the percentage assessed predeployment (7.4%; 95% CI: 5.5, 9.8). These findings highlight that PTSD is an enduring consequence of warzone participation among contemporary military personnel and veterans. The largest increase in PTSD cases occurred between the postdeployment and long-term follow-up assessments, which suggests that adverse stress reactions cannot necessarily be expected to dissipate over time and actually may increase.
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Abstract
Malingering is the intentional fabrication of medical symptoms for the purpose of external gain. Along similar lines as malingering, factitious disorder is the intentional creation or exaggeration of symptoms, but without intent for a concrete benefit. The incidence of malingering and factitious disorder in the military is unclear, but likely under reported for a variety of reasons. One should be aware of potential red flags suggesting malingering or factitious disorder and consider further evaluation to look for these conditions. A deliberate and intentional management plan is ideal in these cases. Furthermore, a multi-disciplinary team approach, a non-judgmental environment, and the use of direct but dignity sparing techniques will likely be most "successful" when confronting the patient with malingering or factitious disorder.
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Affiliation(s)
- Sebastian Schnellbacher
- Faculty Development Fellowship, Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431, USA.
| | - Heather O'Mara
- Faculty Development Fellowship, Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431, USA
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Vermetten E, Baker DG, Jetly R, McFarlane AC. Concerns Over Divergent Approaches in the Diagnostics of Posttraumatic Stress Disorder. Psychiatr Ann 2016. [DOI: 10.3928/00485713-20160728-02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Tsai J, Rosenheck RA. US Veterans’ Use Of VA Mental Health Services And Disability Compensation Increased From 2001 To 2010. Health Aff (Millwood) 2016; 35:966-73. [DOI: 10.1377/hlthaff.2015.1555] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jack Tsai
- Jack Tsai ( ) is a core investigator for the Veterans Affairs (VA) New England Mental Illness, Research, Education, and Clinical Center and an assistant professor of psychiatry at the Yale University School of Medicine, both in West Haven, Connecticut
| | - Robert A. Rosenheck
- Robert A. Rosenheck is a senior investigator for the VA New England Mental Illness, Research, Education, and Clinical Center and a professor of psychiatry at the Yale University School of Medicine
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Abstract
This review addresses how changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 posttraumatic stress disorder (PTSD) criteria has the potential to affect the care and careers of those who have served in the military, where the diagnosis often determines fitness for duty and veterans' benefits. PTSD criteria changes were intended to integrate new knowledge acquired since previous DSM editions. Many believe the changes will improve diagnosis and treatment, but some worry these could have negative clinical, occupational, and legal consequences. We analyze the changes in classification, trauma definition, symptoms, symptom clusters, and subtypes and possible impacts on the military (e.g., over- and under-diagnosis, "drone" video exposure, subthreshold PTSD, and secondary PTSD). We also discuss critiques and proposals for future changes. Our objectives are to improve the screening, diagnosis, and treatment of those service members who have survived trauma and to improve policies related to the military mental healthcare and disability systems.
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Garcia HA, McGeary CA, Finley EP, McGeary DD, Ketchum NS, Peterson AL. The influence of trauma and patient characteristics on provider burnout in VA post-traumatic stress disorder specialty programmes. Psychol Psychother 2016; 89:66-81. [PMID: 25643839 DOI: 10.1111/papt.12057] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 10/17/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Prolonged exposure (PE) and cognitive processing therapy (CPT) - post-traumatic stress disorder (PTSD) treatments now available at the Veterans Health Administration (VHA) - expose the provider to graphic traumatic material. Little is known about the impact of traumatic material on VHA providers. The purpose of this study was to examine the relationship between trauma content, patient characteristics, and burnout among VHA PTSD Clinical Team (PCT) providers. It was hypothesized that trauma content and patient characteristics would significantly predict burnout in this population. DESIGN This cross-sectional study consisted of 137 participants. The sample was mostly female (67%), Caucasian (non-Hispanic; 81%), and married (70%) with a mean age of 44.3 years (SD = 11.3). METHODS Participants completed an electronic survey that assessed demographics, patient characteristics (i.e., anger, personality disorder, malingering), trauma content characteristics (e.g., killing of women and children) as well as burnout as measured by the Maslach Burnout Inventory-General Survey (MBI-GS; Maslach et al., 1996, Burnout inventory manual. Palo Alto: Consulting Psychologist Press). RESULTS Over half of the study population reported being bothered by trauma content; however, trauma content did not predict burnout. Treating patients with personality disorders and suspected malingering predicted burnout in PCT providers. High numbers (77%) reported perceiving that emotional exhaustion impacted the quality of care they provided. CONCLUSION These findings suggest an important role of burnout assessment, prevention, and treatment strategies at the VHA. PRACTITIONER POINTS This paper addresses the impact of provider burnout on perceived quality of care. This paper also addresses potential predictors of burnout in PCT settings. This paper outlines potential remedies to provider burnout in the VHA.
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Affiliation(s)
- Hector A Garcia
- South Texas Veterans Health Care System, The University of Texas Health Science Center at San Antonio, Texas, USA.,Department of Psychiatry, The University of Texas Health Science Center at San Antonio, Texas, USA
| | - Cindy A McGeary
- Department of Psychiatry, The University of Texas Health Science Center at San Antonio, Texas, USA
| | - Erin P Finley
- South Texas Veterans Health Care System, The University of Texas Health Science Center at San Antonio, Texas, USA.,Department of Medicine, The University of Texas Health Science Center at San Antonio, Texas, USA
| | - Donald D McGeary
- Department of Psychiatry, The University of Texas Health Science Center at San Antonio, Texas, USA
| | - Norma S Ketchum
- Department of Epidemiology and Biostatistics, The University of Texas Health Science Center at San Antonio, Texas, USA
| | - Alan L Peterson
- Department of Psychiatry, The University of Texas Health Science Center at San Antonio, Texas, USA
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Trends in disability and program participation among U.S. veterans. Disabil Health J 2016; 9:449-56. [PMID: 26847668 DOI: 10.1016/j.dhjo.2015.12.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 12/08/2015] [Accepted: 12/29/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Disability is increasingly part of the lives of veterans and more research is needed to understand its impact on veterans' participation in disability benefit programs. OBJECTIVE/HYPOTHESIS We examine how recent trends in receipt of service-connected disability compensation from the Department of Veterans Affairs (VA) compare to trends in self-reported disability and participation in Social Security Disability Insurance (DI) and Supplemental Security Income (SSI) among veterans. METHODS We use 2002-2013 data from the Current Population Survey to describe trends in receipt of VA disability compensation and to compare between trends in self-reported disability and DI/SSI participation for veterans versus nonveterans. RESULTS The percentage of veterans reporting they receive VA disability compensation increased substantially from 2002 to 2013 and was especially notable among younger (ages 18-39) and older (ages 50-64) veterans. From 2009 to 2013, self-reported disability increased among the younger and older veterans but not among middle-age veterans and nonveterans, and self-reported cognitive disability increased substantially among young veterans. DI/SSI participation among older veterans increased more than for nonveterans over the period examined. CONCLUSIONS Effective policies are needed to incentivize work among young veterans and to help them obtain both the skills they need to succeed in the labor force and the supports (such as psychiatric health services) they need to do so. Older veterans are facing increasing challenges in the labor market, and further research is needed to determine whether these challenges are primarily related to health, a growing skills gap, or poorly-aligned incentives.
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