Physical health burden of PTSD, depression, and their comorbidity in the U.S. veteran population: Morbidity, functioning, and disability

Impact of SARS-CoV-2 Infection on Long-Term Depression Symptoms among Veterans

BACKGROUND

Prior research demonstrates that SARS-COV-2 infection can be associated with a broad range of mental health outcomes including depression symptoms. Veterans, in particular, may be at elevated risk of increased depression following SARS-COV-2 infection given their high rates of pre-existing mental and physical health comorbidities. However, few studies have tried to isolate SARS-COV-2 infection associations with long term, patient-reported depression symptoms from other factors (e.g., physical health comorbidities, pandemic-related stress).

OBJECTIVE

To evaluate the association between SARS-COV-2 infection and subsequent depression symptoms among United States Military Veterans.

DESIGN

Survey-based non-randomized cohort study with matched comparators.

PARTICIPANTS

A matched-dyadic sample from a larger, stratified random sample of participants with and without known to SARS-COV-2 infection were invited to participate in a survey evaluating mental health and wellness 18-months after their index infection date. Sampled participants were stratified by infection severity of the participant infected with SARS-COV-2 (hospitalized or not) and by month of index date. A total of 186 participants in each group agreed to participate in the survey and had sufficient data for inclusion in analyses. Those in the uninfected group who were later infected were excluded from analyses.

MAIN MEASURES

Participants were administered the Patient Health Questionnaire-9 as part of a phone interview survey. Demographics, physical and mental health comorbidities were extracted from VHA administrative data.

KEY RESULTS

Veterans infected with SARS-COV-2 had significantly higher depression symptoms scores compared with those uninfected. In particular, psychological symptoms (e.g., low mood, suicidal ideation) scores were elevated relative to the comparator group (MInfected = 3.16, 95%CI: 2.5, 3.8; MUninfected = 1.96, 95%CI: 1.4, 2.5). Findings were similar regardless of history of depression.

CONCLUSION

SARS-COV-2 infection was associated with more depression symptoms among Veterans at 18-months post-infection. Routine evaluation of depression symptoms over time following SARS-COV-2 infection is important to facilitate adequate assessment and treatment.

A Systematic Review of the Department of Veterans Affairs Mental Health-Care Access Interventions for Veterans With PTSD

INTRODUCTION

Access to mental health care has been a priority area for the U.S. Department of Veterans Affairs (DVA) for decades. Access for veterans with PTSD is essential because untreated PTSD is associated with numerous adverse outcomes. Although interventions have been developed to improve access to DVA mental health care, the impact of these interventions on access for veterans with untreated PTSD has not been examined comprehensively, limiting guidance on appropriate implementation.

MATERIALS AND METHODS

We conducted a systematic review of PubMed and PTSDpubs between May 2019 and January 2022 to identify DVA access interventions for veterans with PTSD not engaged in DVA mental health care. We identified 17 interventions and 29 manuscripts reporting quantitative access outcomes. We categorized interventions into four major categories: Primary care mental health integration, other national initiatives, telemental health, and direct outreach. We evaluated five outcome domains: Binary attendance, number of sessions attended, wait time, number of patients seen, and care initiation. We assessed the risk of bias using the Cochrane Collaboration criteria.

RESULTS

Across articles, binary attendance generally improved, whereas the impact on the number of sessions attended was equivocal. Overall, the number of patients seen increased compared to control participants and retrospective data. The few articles that examined care initiation had mixed results. Only one article examined the impact on wait time.

CONCLUSIONS

Access interventions for veterans with PTSD demonstrated varied success across interventions and outcomes. The national initiatives-particularly primary care mental health integration -were successful across several outcomes; telemental health demonstrated promise in improving access; and the success of direct outreach varied across interventions. Confidence in these findings is tempered by potential bias among studies. Limited literature on how these interventions impact relevant preattendance barriers, along with incomplete data on how many perform nationally, suggests that additional work is needed to ensure that these interventions increase access for veterans with PTSD nationwide.

Blood-based DNA methylation and exposure risk scores predict PTSD with high accuracy in military and civilian cohorts

Background

Incorporating genomic data into risk prediction has become an increasingly useful approach for rapid identification of individuals most at risk for complex disorders such as PTSD. Our goal was to develop and validate Methylation Risk Scores (MRS) using machine learning to distinguish individuals who have PTSD from those who do not.

Methods

Elastic Net was used to develop three risk score models using a discovery dataset (n = 1226; 314 cases, 912 controls) comprised of 5 diverse cohorts with available blood-derived DNA methylation (DNAm) measured on the Illumina Epic BeadChip. The first risk score, exposure and methylation risk score (eMRS) used cumulative and childhood trauma exposure and DNAm variables; the second, methylation-only risk score (MoRS) was based solely on DNAm data; the third, methylation-only risk scores with adjusted exposure variables (MoRSAE) utilized DNAm data adjusted for the two exposure variables. The potential of these risk scores to predict future PTSD based on pre-deployment data was also assessed. External validation of risk scores was conducted in four independent cohorts.

Results

The eMRS model showed the highest accuracy (92%), precision (91%), recall (87%), and f1-score (89%) in classifying PTSD using 3730 features. While still highly accurate, the MoRS (accuracy = 89%) using 3728 features and MoRSAE (accuracy = 84%) using 4150 features showed a decline in classification power. eMRS significantly predicted PTSD in one of the four independent cohorts, the BEAR cohort (beta = 0.6839, p-0.003), but not in the remaining three cohorts. Pre-deployment risk scores from all models (eMRS, beta = 1.92; MoRS, beta = 1.99 and MoRSAE, beta = 1.77) displayed a significant (p < 0.001) predictive power for post-deployment PTSD.

Conclusion

Results, especially those from the eMRS, reinforce earlier findings that methylation and trauma are interconnected and can be leveraged to increase the correct classification of those with vs. without PTSD. Moreover, our models can potentially be a valuable tool in predicting the future risk of developing PTSD. As more data become available, including additional molecular, environmental, and psychosocial factors in these scores may enhance their accuracy in predicting the condition and, relatedly, improve their performance in independent cohorts.

Effects of Daily Posttraumatic Stress Disorder Symptoms on Heart Rate Variability

OBJECTIVE

Posttraumatic stress disorder (PTSD) is common, debilitating, and associated with an increased risk of health problems, including cardiovascular disease. PTSD is related to poor autonomic function indicated by reduced heart rate variability (HRV). However, very little work has tested the timescale or direction of these effects, given that most evidence comes from cross-sectional studies. Documentation of when effects occur and in what direction can shed light on mechanisms of cardiovascular disease risk and inform treatment. The present study of 169 World Trade Center responders, oversampled for PTSD, tested how daily PTSD symptoms were associated with autonomic function as reflected through HRV.

METHODS

Participants ( N = 169) completed surveys of PTSD symptoms three times a day at 5-hour intervals for 4 days while also wearing ambulatory monitors to record electrocardiograms to derive HRV (i.e., mean absolute value of successive differences between beat-to-beat intervals).

RESULTS

HRV did not predict PTSD symptoms. However, PTSD symptoms during a 5-hour interval predicted reduced HRV at the next 5-hour interval ( β = -0.09, 95% confidence interval = -0.16 to -0.02, p = .008). Results held adjusting for baseline age, current heart problems, and current PTSD diagnosis.

CONCLUSIONS

Findings underscore growing awareness that PTSD symptoms are not static. Even their short-term fluctuations may affect cardiovascular functioning, which could have more severe impacts if disruption accumulates over time. Research is needed to determine if momentary interventions can halt increases in PTSD symptoms or mitigate their impact on cardiovascular health.

Chronic disease multimorbidity and substance use among African American men: veteran-non-veteran differences

OBJECTIVES

The purpose of the study was to explore the extent to which prior military service may moderate the relationship between chronic disease multimorbidity and substance use among African American men in the United States.

DESIGN

Data for this cross-sectional study was downloaded from the 2016 -2019 United States (US) National Survey on Drug Use and Health. We estimated three survey-weighted multivariable logistic regression models, where use of each of the following substances served as the dependent variables: illicit drugs, opioids, and tobacco. Differences in these outcomes were examined along two primary independent variables: veteran status and multimorbidity (and an interaction term for these variables). We also controlled for the following covariates: age, education, income, rurality, criminal behavior, and religiosity.

RESULTS

From the 37,203,237 (weighted N) African American men in the sample, approximately 17% reported prior military service. Veterans with ≥ 2 chronic diseases had higher rates of illicit drug use (aOR = 1.37, 95% CI = 1.01, 1.87; 32% vs. 28%) than non-veterans with ≥ 2 chronic diseases. Non-veterans with one chronic disease had higher rates of tobacco use (aOR = 0.80, 95% CI = 0.69, 0.93; 29% vs. 26%) and opioid misuse (aOR = 0.49, 95% CI = 0.36, 0.67; 29% vs. 18%) than veterans with one chronic disease.

DISCUSSION

Chronic disease multi-morbidity appears to be a context in which African American veterans may be at greater risk for certain undesirable health behaviors than African American non-veterans and at lower risk for others. This may be due to exposure to trauma, difficulty accessing care, socio-environmental factors, and co-occurring mental health conditions. These complex interactions may contribute to higher rates of SUDs among African American veterans compared to African American non-veterans.

Identifying depression in the United States veterans using deep learning algorithms, NHANES 2005-2018

BACKGROUND

Depression is a common mental health problem among veterans, with high mortality. Despite the numerous conducted investigations, the prediction and identification of risk factors for depression are still severely limited. This study used a deep learning algorithm to identify depression in veterans and its factors associated with clinical manifestations.

METHODS

Our data originated from the National Health and Nutrition Examination Survey (2005-2018). A dataset of 2,546 veterans was identified using deep learning and five traditional machine learning algorithms with 10-fold cross-validation. Model performance was assessed by examining the area under the subject operating characteristic curve (AUC), accuracy, recall, specificity, precision, and F1 score.

RESULTS

Deep learning had the highest AUC (0.891, 95%CI 0.869-0.914) and specificity (0.906) in identifying depression in veterans. Further study on depression among veterans of different ages showed that the AUC values for deep learning were 0.929 (95%CI 0.904-0.955) in the middle-aged group and 0.924(95%CI 0.900-0.948) in the older age group. In addition to general health conditions, sleep difficulties, memory impairment, work incapacity, income, BMI, and chronic diseases, factors such as vitamins E and C, and palmitic acid were also identified as important influencing factors.

CONCLUSIONS

Compared with traditional machine learning methods, deep learning algorithms achieved optimal performance, making it conducive for identifying depression and its risk factors among veterans.

Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial

STUDY OBJECTIVES

Sleep disturbances are common in military personnel with posttraumatic stress disorder (PTSD) and may persist following treatment. This study examined service members seeking treatment for PTSD, reporting insomnia symptoms, nightmares, excessive daytime sleepiness, and potential obstructive sleep apnea at baseline and the impact of sleep disturbances on a course of PTSD treatment.

METHODS

In this secondary analysis, sleep was evaluated in 223 service members who participated in a randomized clinical trial comparing Cognitive Processing Therapy for PTSD delivered in individual or group formats. Sleep assessments included the Insomnia Severity Index, the Trauma-Related Nightmare Survey, and Epworth Sleepiness Scale administered at baseline and 2 weeks posttreatment.

RESULTS

Following PTSD treatment, there were significant improvements for insomnia symptoms (MΔ = -1.49; d = -0.27), nightmares (MΔ = -0.35; d = -0.27), and excessive daytime sleepiness (MΔ = -0.91; d = -0.16). However, mean scores remained in clinical ranges at posttreatment. Participants with baseline insomnia symptoms had worse PTSD severity throughout treatment. Participants with baseline excessive daytime sleepiness or probable obstructive sleep apnea had greater PTSD severity reductions when treated with Cognitive Processing Therapy individually vs. in a group. Those with insomnia symptoms, nightmare disorder, and sleep apnea had greater depressive symptoms throughout treatment.

CONCLUSIONS

Insomnia symptoms, nightmares, and excessive daytime sleepiness were high at baseline in service members seeking treatment for PTSD. While sleep symptoms improved with PTSD treatment, these sleep disorders were related to worse treatment outcomes with regards to symptoms of PTSD and depression. Individual Cognitive Processing Therapy is recommended over group Cognitive Processing Therapy for patients with either excessive daytime sleepiness or probable obstructive sleep apnea.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Group vs. Individual Cognitive Processing Therapy for Combat-related PTSD; URL: https://clinicaltrials.gov/ct2/show/NCT02173561; Identifier: NCT02173561.

CITATION

Puriksma KE, Taylor DJ, Wachen JS, et al. Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial. J Clin Sleep Med. 2023;19(8):1389-1398.

Dog ownership may promote cardiometabolic health in U.S. military veterans

Dog ownership has been associated with reduced cardiovascular and all-cause mortality in civilian epidemiological samples. Associations between dog ownership and cardiometabolic disease were examined in the 2019-2020 wave of the National Health and Resilience in Veterans Study. Dog and cat ownership data were obtained from 3078 Veterans and cross-tabulated with self-reported, professionally diagnosed, heart disease, heart attack, stroke, high blood pressure, diabetes, and high cholesterol. In unadjusted tests, dog ownership was associated with lower rates of heart disease, high blood pressure, diabetes, and high cholesterol, while cat ownership was not. Relative to non-owners, dog owners were younger, were more likely to screen positive for posttraumatic stress disorder and/or major depressive disorder, and more active. Binary logistic regression models of associations between dog ownership and cardiometabolic disease were adjusted for age, sex, trauma load, mood disorder, substance abuse, nicotine abuse, and exercise. After adjustment, dog ownership was still associated with lower odds of hypertension and high cholesterol. Dog ownership also interacted with exercise to lower odds of heart disease and attenuated the effect of trauma load on hypertension. Conversely, age interacted with dog ownership such that odds of diabetes and stroke were higher in older Veterans who owned dogs.

The Intersectionality of Sex and Race in the Relationship Between Posttraumatic Stress Disorder and Cardiovascular Disease: A Scoping Review

Objectives: Posttraumatic stress disorder (PTSD) has been linked with cardiovascular disease (CVD), suggesting a risk for negative health outcomes among individuals with PTSD. This review synthesizes the temporal relationship between PTSD and CVD and highlights the intersection of sex and race. Methods: Covidence was used to systematically review the literature published between 1980 and 2020. Results: 176 studies were extracted. 68 (38.64%) of the studies were a predominantly male sample. 31 studies (17.61%) were a predominantly female sample. Most reported participants of both sexes (n = 72; 40.91%) and only 5 (2.84%) did not report respondent sex. No studies reported transgender participants. 110 (62.5%) studies reported racial and ethnic diversity in their study population, 18 (10.22%) described a completely or predominantly white sample, and 48 (27.27%) did not report race or ethnicity of their study population. Conclusion: A compelling number of studies did not identify sex differences in the link between PTSD and CVD or failed to report race and ethnicity. Investigating sex, race, ethnicity, and the temporal relationship between PTSD and CVD are promising avenues for future research.

Temporal reciprocal relationships among anxiety, depression, and posttraumatic stress disorder for family surrogates from intensive care units over their first two bereavement years

BACKGROUND/OBJECTIVE

Bereaved family surrogates from intensive care units (ICU) are at risk of comorbid anxiety, depression, and post-traumatic stress disorder (PTSD), but the temporal reciprocal relationships among them have only been examined once among veterans. This study aimed to longitudinally investigate these never-before-examined temporal reciprocal relationships for ICU family members over their first two bereavement years.

METHODS

In this prospective, longitudinal, observational study, symptoms of anxiety, depression, and PTSD were assessed among 321 family surrogates of ICU decedents from 2 academically affiliated hospitals in Taiwan by the anxiety and depression subscales of the Hospital Anxiety and Depression Scale, and the Impact of Event Scale-Revised, respectively at 1, 3, 6, 13, 18, and 24 months postloss. Cross-lagged panel modeling was conducted to longitudinally examine the temporal reciprocal relationships among anxiety, depression, and PTSD.

RESULTS

Examined psychological-distress levels were markedly stable over the first 2 bereavement years: autoregressive coefficients for symptoms of anxiety, depression, and PTSD were 0.585-0.770, 0.546-0.780, and 0.440-0.780, respectively. Cross-lag coefficients showed depressive symptoms predicted PTSD symptoms in the first bereavement year, whereas PTSD symptoms predicted depressive symptoms in the second bereavement year. Anxiety symptoms predicted symptoms of depression and PTSD at 13 and 24 months postloss, whereas depressive symptoms predicted anxiety symptoms at 3 and 6 months postloss while PTSD symptoms predicted anxiety symptoms during the second bereavement year.

CONCLUSIONS

Different patterns of temporal relationships among symptoms of anxiety, depression, and PTSD over the first 2 bereavement years present important opportunities to target symptoms of specific psychological distress at different points during bereavement to prevent the onset, exacerbation, or maintenance of subsequent psychological distress.

Repetitive Transcranial Magnetic Stimulation for Depression and Posttraumatic Stress Disorder in Veterans With Mild Traumatic Brain Injury

OBJECTIVES

Mild traumatic brain injury (mTBI) is a signature injury of military conflicts and is prevalent in veterans with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). Although therapeutic transcranial magnetic stimulation (TMS) can reduce symptoms of depression and PTSD, whether traumatic brain injury (TBI) affects TMS responsiveness is not yet known. We hypothesized mTBI would be associated with higher pretreatment symptom burden and poorer TMS response.

MATERIALS AND METHODS

We investigated a registry of veterans (N = 770) who received TMS for depression across the US Veterans Affairs system. Of these, 665 (86.4%) had data on TBI and lifetime number of head injuries while 658 had complete data related to depression outcomes. Depression symptoms were assessed using the nine-item Patient Health Questionnaire and PTSD symptoms using the PTSD Checklist for DSM-5. Linear mixed effects models and t-tests evaluated whether head injuries predicted symptom severity before treatment, and how TBI status affected clinical TMS outcomes.

RESULTS

Of the 658 veterans included, 337 (50.7%) reported previous mTBI, with a mean of three head injuries (range 1-20). TBI status did not predict depressive symptom severity or TMS-associated changes in depression (all p's > 0.1). TBI status was associated with a modest attenuation of TMS-associated improvement in PTSD (in patients with PTSD Checklist for DSM-5 scores > 33). There was no correlation between the number of head injuries and TMS response (p > 0.1).

CONCLUSIONS

Contrary to our hypothesis, presence of mTBI did not meaningfully change TMS outcomes. Veterans with mTBI had greater PTSD symptoms, yet neither TBI status nor cumulative head injuries reduced TMS effectiveness. Limitations include those inherent to retrospective registry studies and self-reporting. Although these findings are contrary to our hypotheses, they support the safety and effectiveness of TMS for MDD and PTSD in patients who have comorbid mTBI.

Heart Rate During Sleep in PTSD Patients: Moderation by Contact with a Service Dog

There is growing interest in the potential health benefits of dog ownership in both the lay and scientific communities. Large reductions in risk for cardiovascular disease and all-cause mortality in dog owners relative to non-owners have been observed in epidemiological samples. Persons diagnosed with posttraumatic stress disorder exhibit elevated risk for cardiovascular disease. The current study tested a sample of 45 U.S. military veterans with deployment-related posttraumatic stress disorder employing an intensive, longitudinal, within-subjects design contrasting sleep heart rate on nights with and without a service dog. As participants were engaged in residential psychiatric treatment, sleep opportunities, waking activities, meals, and medications, were consistently scheduled. The primary recording methodology, mattress actigraphy, enabled passive quantification of heart rate over a total sample of 1097 nights. Service dog contact was associated with reduced sleep heart rate especially in participants with more severe PTSD. Longer-term longitudinal studies will be needed to assess the durability and asymptotic magnitude of this effect. An unexpected effect of nights in study was associated with increased heart rate consistent with hospitalization-associated deconditioning.

Factors associated with a lack of health care utilization among Veterans after a positive suicide screen in the emergency department

OBJECTIVES

Many Veterans at high risk for suicide are identified in Veterans Health Administration (VHA) emergency departments (ED). Little is known about what may predict care utilization in this population. To address this knowledge gap, we explored factors associated with Veterans' lack of VHA care utilization following a positive suicide risk screen in the ED.

METHODS

In a retrospective observational study, we identified all patients who were seen in a VHA ED from October 1, 2019, to September 30, 2020. We examined factors associated with not utilizing VHA mental health (MH) and all VHA care in the 6 months following a positive suicide ED screen. Predictors included comorbidity, homelessness, and MH visit and diagnosis history.

RESULTS

We identified 23,446 Veterans with a positive suicide risk screen in the ED in fiscal year 2020. Overall, 4.1% had no VHA MH visits 6 months postscreen. The probability of not utilizing MH care was significantly higher for Veterans with no comorbidity (4.7% vs. 3.4% for mild comorbidity), no MH diagnosis (10.5% vs 2.8%), no past-year MH visits (13.6% vs 2.3%), and no past-year homelessness (5.4% vs. 1.1%). A smaller proportion of the population did not receive any VHA care 6 months postscreen (0.5%). Veterans who did not experience homelessness (0.6% vs 0.2%), had no MH diagnosis (1.6% vs. 0.3%), and had no previous MH visits (1.9% vs 0.2%) were significantly more likely to not utilize VHA care.

CONCLUSIONS

Veterans who do not utilize VHA care after a positive suicide risk screen appear to have fewer documented health and housing concerns than those who do receive care. Yet, Veterans with a positive suicide risk screen who are otherwise healthy may remain at elevated risk for suicide following their ED visit. ED providers may consider enhanced follow-up care to mitigate suicide risk for these Veterans.

A Pilot Study of a Three-Session Heart Rate Variability Biofeedback Intervention for Veterans with Posttraumatic Stress Disorder

Many veterans do not complete traditional trauma treatments; others may continue to struggle with posttraumatic stress disorder (PTSD) even after completing a full course of therapy (Blasé et al., in Int J Environ Res Public Health 18(7):Article 3329, https://doi.org/10.3390/ijerph18073329 , 2016). Heart rate variability (HRV) biofeedback (HRVB) is a non-invasive, non-pharmacological, breathing-based cardiorespiratory training technique that can reduce trauma symptoms and improve HRV parameters. Prior studies have demonstrated HRVB is well-tolerated by veterans with PTSD symptoms (Tan et al., in Appl Psychophysiol Biofeedback 36(1):27-35, 10.1007/s10484-010-9141-y, 2011; Schuman and Killian, in Appl Psychophysiol Biofeedback 44(1):9-20, https://doi.org/10.1007/s10484-018-9415-3 , 2019). This randomized wait-list controlled pilot study tested a short mobile app-adapted HRVB intervention in combination with treatment as usual for veterans with military-related PTSD to determine if further investigation was warranted. We assessed veterans' military-related PTSD symptoms, depression symptoms, and HRV time and frequency domain measures at baseline, after three clinical sessions, and one month later. This study combined clinical training and home biofeedback with a smartphone app and sensor to reinforce training and validate adherence. In the intervention group, depression and SDNN significantly improved, and we observed marginally significant improvements for PTSD Cluster B (intrusion) symptoms, whereas no significant improvements were observed in the control group. In addition, the brief protocol was acceptable to veterans with PTSD with over 83% of participants completing the study. However, adherence to home practice was low. Findings suggest brief HRVB interventions can decrease comorbid depression and improve overall autonomic function in veterans with PTSD; however, additional research on home biofeedback is necessary to determine the best strategies to increase adherence and which veterans would benefit from brief HRVB interventions.

Outreach to the Veterans Crisis Line During the COVID-19 Pandemic: A Mixed-Methods Analysis

OBJECTIVE

The mental health impacts of the COVID-19 pandemic have been widely felt among already vulnerable populations, such as U.S. military veterans, including a heightened risk for depression and suicidal ideation. Support hotlines such as the Veterans Crisis Line (VCL) took a central role in addressing various concerns from callers in distress; research has yet to examine the concerns of veterans who used the VCL during the early months of the pandemic.

METHODS

A mixed-methods analysis of characteristics of veteran outreach to the VCL during the first year of the COVID-19 pandemic in the United States was conducted on 342,248 calls during April-December 2020; 3.8% (N=12,869) of calls were coded as related to COVID-19. Quantitative examination was conducted regarding COVID-19-related reasons for contact, suicide risk screens, and caller concerns; 360 unique calls with synopsis notes that included a COVID-19 flag were qualitatively analyzed.

RESULTS

Quantitative analysis of the calls with a COVID-19 flag revealed mental health concerns, loneliness, and suicidal thoughts as top reasons veterans contacted the VCL during the pandemic. Qualitative analysis identified specific economic and mental health concerns, including negative impacts on income and housing, increased feelings of depression or anxiety, and pandemic-specific concerns such as testing and vaccine availability. Disrupted access to resources for coping, including support groups or gyms, had negative perceived impacts and sometimes exacerbated preexisting problems such as substance abuse or depression.

CONCLUSIONS

These findings emphasize the role of VCL as providing general support to veterans experiencing loneliness and supplying assistance in coping with pandemic-related distress.

Childhood adversities and risk of posttraumatic stress disorder and major depression following a motor vehicle collision in adulthood

AIMS

Childhood adversities (CAs) predict heightened risks of posttraumatic stress disorder (PTSD) and major depressive episode (MDE) among people exposed to adult traumatic events. Identifying which CAs put individuals at greatest risk for these adverse posttraumatic neuropsychiatric sequelae (APNS) is important for targeting prevention interventions.

METHODS

Data came from n = 999 patients ages 18-75 presenting to 29 U.S. emergency departments after a motor vehicle collision (MVC) and followed for 3 months, the amount of time traditionally used to define chronic PTSD, in the Advancing Understanding of Recovery After Trauma (AURORA) study. Six CA types were self-reported at baseline: physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect and bullying. Both dichotomous measures of ever experiencing each CA type and numeric measures of exposure frequency were included in the analysis. Risk ratios (RRs) of these CA measures as well as complex interactions among these measures were examined as predictors of APNS 3 months post-MVC. APNS was defined as meeting self-reported criteria for either PTSD based on the PTSD Checklist for DSM-5 and/or MDE based on the PROMIS Depression Short-Form 8b. We controlled for pre-MVC lifetime histories of PTSD and MDE. We also examined mediating effects through peritraumatic symptoms assessed in the emergency department and PTSD and MDE assessed in 2-week and 8-week follow-up surveys. Analyses were carried out with robust Poisson regression models.

RESULTS

Most participants (90.9%) reported at least rarely having experienced some CA. Ever experiencing each CA other than emotional neglect was univariably associated with 3-month APNS (RRs = 1.31-1.60). Each CA frequency was also univariably associated with 3-month APNS (RRs = 1.65-2.45). In multivariable models, joint associations of CAs with 3-month APNS were additive, with frequency of emotional abuse (RR = 2.03; 95% CI = 1.43-2.87) and bullying (RR = 1.44; 95% CI = 0.99-2.10) being the strongest predictors. Control variable analyses found that these associations were largely explained by pre-MVC histories of PTSD and MDE.

CONCLUSIONS

Although individuals who experience frequent emotional abuse and bullying in childhood have a heightened risk of experiencing APNS after an adult MVC, these associations are largely mediated by prior histories of PTSD and MDE.

Post-Traumatic Orientation to Bodily Signals: A Systematic Literature Review

Theoretical literature suggests that trauma and (PTSD) may instigate changes in the interpretation of bodily signals. Some findings support these inquiries, revealing that exposure to traumatic events and PTSD are associated with pain catastrophizing, body vigilance, fear of pain, and other manifestations of bodily perceptions and interpretations. However, these findings are not integrated into an inclusive empirically based conceptualization, thus leading to a limited comprehension of this phenomenon. This systematic literature review was conducted to synthesize the existing literature referring to orientation to bodily signals. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the review included a final of 48 manuscripts that addressed orientation to bodily signals among participants (aged 18 and above) and its potential associations with PTSD. The review revealed that most studies assessed one orientation manifestation, which was tested for its link to PTSD. The majority of the manuscripts were cross-sectional and included participants who faced combat, vehicle accidents, or various types of traumas. Only five manuscripts focused on interpersonal trauma and abuse. Most manuscripts reported significant correlations, revealing that trauma and PTSD are associated with a negative, catastrophic and frightful interpretation of bodily signals. These findings emphasize the need to encapsulate the various manifestations of orientation to bodily signals under a unified construct, as proposed by the term post-traumatic orientation to bodily signals. Further research is needed to illuminate the circumstances and processes by which trauma is implicated in post-traumatic orientation to bodily signals.

Symptoms of major depressive disorder and post-traumatic stress disorder in veterans with mild traumatic brain injury: A network analysis

Mild Traumatic Brain Injury (mTBI, or concussion) is a debilitating condition that often leads to persistent cognitive and mental health problems post-injury. Post-traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) are two most commonly occurring mental health problems following mTBI and are suggested to be strong contributors to the persistent post-concussion symptoms. Thus, it is important to understand the symptomatology of PTSD and MDD post-mTBI, to better inform targets for behavioral health interventions. Therefore, the current study examined the symptom structure of post-mTBI co-morbid PTSD and MDD through network approaches; we compared the network structure of participants with a positive mTBI screen (N = 753) to the network structure of participants with a negative mTBI screen (N = 2044); lastly, we examined a network of PTSD and MDD symptoms with clinical covariates in a positive mTBI sample. We found that feeling distant/cutoff (P10) and difficulty concentrating (P15) were the most central symptoms in the positive mTBI network and sleep problems were the most prominent bridge nodes across the disorders. No significant difference between the positive and negative mTBI network were found through network comparison tests. Moreover, anxiety and insomnia were strongly associated with sleep symptoms and irritability symptoms, and emotional support and resilience were potential buffers against most of the PTSD and MDD symptoms. The results of this study might be particularly useful for identifying targets (i.e., feeling distant, concentration and sleep problems) for screening, monitoring and treatment after concussion to better inform post-mTBI mental health care and to improve treatment outcomes.

Analysis of the bidirectional relationships between posttraumatic stress and depression symptoms with physical health functioning in post-9/11 veteran men and women deployed to a war zone

OBJECTIVE

Many war-zone deployed post-9/11 veterans report negative mental health symptoms related to their military service, which can have consequences for physical health symptoms and the impact of physical health on functioning. The current study examined the longitudinal, bidirectional relationships between mental health symptoms and physical health functioning in veteran men and women, allowing for exploration of gender differences.

METHODS

A sample of 1032 post-9/11 veterans (women: n = 554; men: n = 478) who recently returned from a war-zone deployment completed self-report measures of posttraumatic stress disorder (PTSD) symptoms, depression symptoms, and physical health functioning at 3 time points spanning approximately 7 years. Gender-stratified longitudinal cross-lagged panel analyses were used to examine bidirectional relationships.

RESULTS

PTSD symptom severity was negatively associated with physical health functioning across time. For women, associations were reciprocal, such that those reporting poorer physical health functioning reported more severe PTSD symptoms at later time points. Men with greater PTSD symptom severity reported poorer physical health functioning at later time points, but there was no evidence of bidirectionality. Men and women with more severe depression symptoms reported worse later physical health functioning, which further exacerbated depression symptoms across time.

CONCLUSIONS

Findings showed that individual differences in mental health symptoms both set the stage for and were impacted by physical health functioning in post-9/11 veterans. Although additional research is needed, the current study suggests that healthcare approaches that consider the whole person, such as through integration of mental and physical health treatments, may be particularly relevant for post-9/11 veterans.

Use of Cannabidiol (CBD) oil in the treatment of PTSD: Study design and rationale for a placebo-controlled randomized clinical trial

BACKGROUND

The burden of illness for PTSD is staggering and confers significant interference in work, social functioning, as well as increased risk for other physical and mental health problems. Recently, there's been considerable attention paid to the potential therapeutic use of cannabidiol (CBD) products in the treatment of a variety of physical and mental health problems. The endocannabinoid system (ECS) is a logical therapeutic target for combating PTSD and other fear-based disorders given that cannabinoid receptors and other molecular mediators crucial for ECS signaling are richly expressed in a variety of brain regions that govern the regulation of learned fear and defensive behavior.

METHODS

This is an 8-week single-site Phase II randomized double-blind placebo-controlled fixed dose clinical trial. Participants recruited throughout the United States (N = 150) meeting DSM-5 criteria for posttraumatic stress disorder are randomly assigned to one of three treatment arms: (a) 300 mg CBD Isolate; (b) 300 mg CBD Broad Spectrum; and (c) Placebo oil. The primary outcome is PTSD symptom severity as indexed by the PTSD Checklist for DSM-5 (PCL-5) assessed at post treatment (Week 9) and follow-up (Week 13). Secondary outcomes including patient-rated depression, overall disability, anxiety, quality of life, and alcohol use are assessed weekly throughout the trial. Safety and CBD adherence are assessed daily throughout the trial.

CONCLUSION

This is the first placebo-controlled clinical trial investigating (a) CBD for the treatment of PTSD; and (b) the first study to test the relative efficacy of CBD Isolate vs CBD Broad Spectrum. Trial registration ClinicalTrials.gov registered (12/12/2019), trial identifier NCT04197102.

PROTOCOL VERSION

issued 08/04/2022, protocol amendment number #2019-05-0123.

The impact of depression and post-traumatic stress symptoms on physical health perceptions and functional impairment among sexual minority men living with HIV with histories of trauma

Mental health symptoms may compromise health-related quality of life (HRQOL), including among men who have sex with men (MSM) living with HIV, who experience high rates of trauma and other stressors. This study sought to examine the relative contributions of post-traumatic stress disorder (PTSD) symptoms, depression symptoms, and biological indices of HIV disease status on HRQOL in this population. Participants were 79 MSM with HIV (49% White; 35% Black; 8% Hispanic/Latinx) with trauma histories (52% met current PTSD diagnostic criteria). HRQOL outcomes were general perceptions of health (0-100 visual analog scale) and functional disability (WHODAS 2.0). Dominance analysis was applied to examine the relative share of variance in these outcomes accounted for by PTSD symptom severity, depression symptom severity, viral suppression status, and CD4 count. Depression symptom severity accounted for 70% and 92% of variance in perceived health, respectively, across models (p's < 0.05). Both PTSD symptom severity (45%) and depression symptom severity (43%) scores also accounted for significant variance in functional disability (p's < 0.05). Medical indices of HIV disease progression did not explain significant variance in HRQOL in any model. A trauma-informed approach may aid clinicians in interpreting reports of health and physical functioning in MSM with HIV.

Early-Life War Exposure and Later-Life Frailty Among Older Adults in Vietnam: Does War Hasten Aging?

OBJECTIVES

This study aimed to assess the nature and degree of association between exposure to potentially traumatic wartime experiences in early life, such as living in a heavily bombed region or witnessing death firsthand, and later-life frailty.

METHOD

The Vietnam Health and Aging Study included war survivors in Vietnam, 60+, who completed a survey and health exam between May and August 2018. Latent class analysis (LCA) is used to construct classes exposed to similar numbers and types of wartime experiences. Frailty is measured using a deficit accumulation approach that proxies biological aging. Fractional logit regression associates latent classes with frailty scores. Coefficients are used to calculate predicted frailty scores and expected age at which specific levels of frailty are reached across wartime exposure classes.

RESULTS

LCA yields 9 unique wartime exposure classes, ranging from extreme exposure to nonexposed. Higher frailty is found among those with more heavy/severe exposures with a combination of certain types of experiences, including intense bombing, witnessing death firsthand, having experienced sleep disruptions during wartime, and having feared for one's life during war. The difference in frailty-associated aging between the most and least affected individuals is more than 18 years.

DISCUSSION

War trauma hastens aging and warrants greater attention toward long-term implications of war on health among vast postconflict populations across the globe.

Risk for PTSD symptom worsening during new PTSD treatment episode in a nationally representative sample of treatment-seeking U.S. veterans with subthreshold PTSD

Previous research has examined risk factors associated with poorer treatment outcomes for military Veterans with PTSD. However, work has not examined risk for symptom worsening among Veterans with subthreshold PTSD. The aim of this study was to examine demographic, psychiatric, physical health, and pre-treatment PTSD symptom clusters associated with clinically significant worsening of PTSD among a nationally representative sample of United States (U.S.) Veterans with subthreshold PTSD. Participants were Veterans (weighted N = 3162; unweighted N = 236) with subthreshold PTSD entering a new episode of treatment at U.S. Veterans Affairs PTSD specialty clinics during fiscal years 2018 and 2019. Data was collected as part of the Veterans Outcome Assessment, a yearly baseline and 3-month follow-up telephone survey. Analyses used weighted calculations to support the use of VOA data to draw inferences about all eligible Veterans, and binary logistic regression was used to examine risk factors for symptom worsening. Over 1/3 (37.7%) of Veterans with subthreshold PTSD experienced clinically significant symptom worsening from baseline to follow-up. Adjusted analyses revealed several risk factors for symptom worsening, including demographic (e.g., male sex, White race), psychiatric (personality and anxiety disorders), health care utilization (e.g., more primary care encounters in the previous year), physical health disability, and specific baseline PTSD symptom clusters (negative affect and anxious arousal). Findings suggest that Veterans with subthreshold symptoms seeking treatment for PTSD are at risk for symptom worsening, and highlight the importance of assessment, prevention, and treatment in targeting veterans with PTSD symptoms below the diagnostic threshold.

Leisure Types, Coping, Happiness, and Life Satisfaction among Veterans

Objectives: Our purpose was to investigate the relationships between leisure types and coping, happiness, and life satisfaction among veterans. Methods: Our sample was 106 veterans. We used hierarchical multiple regression analysis to examine the relationships of the previously identified variables. Demographic variables were entered into the first block of the regression model, and all the demographic variables and types of leisure activities were then entered into the second block. Results: Age, disability status, sports, and volunteer activities were positively associated with the problem-solving coping strategy. Only outdoor activities were positively related to the social support coping strategy. Home-based activities were positively associated with the avoidance coping strategy. Disability status, outdoor activities, and social activities were positively associated with life satisfaction. Age and social activities were positively associated with happiness. Conclusions: Overall, participation in social and outdoor activities was positively associated with active coping, social-seeking coping, life satisfaction, and happiness. This finding supports the literature on leisure and health, suggesting the value of leisure activities as an effective coping strategy and a positive influence on the mental health of veterans.

Development of New Mental and Physical Health Sequelae among US Veterans after COVID-19

Background:COVID-19 sequelae among veterans need evaluation. Design: Propensity-score-matched retrospective cohort study. Participants: A total 778,738 veterans, who were tested for COVID-19 at VA facilities between 20 February 2020−27 March 2021. Main Outcomes: Development of new physical and mental health conditions (incidence) during the follow-up period of 7 days to 3 months after the diagnosis of COVID-19. Results: Out of 778,738 veterans, 149,205 (19.2%) were inpatients and 629,533 (80.8%) were outpatients. 123,757 (15.9%) diagnosed with COVID-19. Mean age was 61 ± 15.4, mostly men (89%) who were White (68%) and non-Hispanic (88%). In hospitalized patients, COVID-19 is associated with significantly higher incidences of physical conditions (venous thromboembolism (5.8% vs. 2.9%, p < 0.001), pulmonary circulation disorder (5.1% vs. 2.9%, p < 0.001), chronic lung disease (8.4% vs. 4.3%, p < 0.001), acute kidney injury (16.4% vs. 9.3%, p < 0.001), chronic kidney disease (6.5% vs. 4.8%, p < 0.001), cardiac arrhythmia (15.2% vs. 10.9%, p < 0.001), complicated hypertension (12% vs. 8.5%, p < 0.001), coagulopathy (6.1% vs. 2.6%, p < 0.001), fluid/electrolyte disorders (24.4% vs. 12.6%, p < 0.001) and neurological disorders (7.1% vs. 3.8%, p < 0.001)) and mental health conditions (depressive episode (6.6% vs. 4.3%, p < 0.001), adjustment disorder (2.5% vs. 1.7%, p < 0.001), insomnia (4.9% vs. 3.2%, p < 0.001) and dementia (3.0% vs. 1.9%, p < 0.001)) compared to propensity-matched hospitalized COVID-19 negative patients. In outpatient settings, COVID-19 diagnosis is associated with smaller increase in the incidences of the physical sequelae. Conclusions: In this propensity-score-matched analysis of US veterans, COVID-19 survivors, especially those who were hospitalized, developed new physical and mental health sequelae at a significantly higher rate than those without COVID-19.

Gender differences in disorders comorbid with posttraumatic stress disorder among U.S. Sailors and Marines

Psychological comorbidity, the co-occurrence of mental health disorders, is more often the rule than the exception among individuals with posttraumatic stress disorder (PTSD). Research shows that prevalence estimates for specific psychological disorders differ by gender; however, little is known about whether these patterns persist in the presence of a comorbid PTSD diagnosis. This study examined gender differences in prevalence estimates for conditions comorbid with PTSD using medical records for 523,626 active duty U.S. Sailors and Marines who entered the military over an 8-year period. Using chi-square tests of independence, we detected statistically significant gender differences for specific comorbid conditions in the subsample of 9,447 service members with a PTSD diagnosis. Women were more likely than men to have PTSD with comorbid adjustment, OR = 1.35; depressive, OR = 1.71; and generalized anxiety or other anxiety disorders, OR = 1.16, with the largest effects for eating, OR = 12.60, and personality disorders, OR = 2.97. In contrast, women were less likely than men to have a diagnosis of PTSD with comorbid alcohol use, OR = 0.69, and drug use disorders, OR = 0.72, with the largest effects for insomnia, OR = 0.42, and traumatic brain injury, OR = 0.17. No significant gender differences emerged for comorbid bipolar, obsessive-compulsive, panic/phobic, psychotic, or somatoform/dissociative disorders, ps = .029-.314. The results show gender differences in conditions comorbid with PTSD generally align with internalizing and externalizing dimensions. Differences in comorbidities with PTSD between women and men could have implications for treatment development and delivery.

Prevalence, Severity and Burden of Post-Traumatic Stress Disorder in Black Men and Women Across the Adult Life span

Objectives: To examine post-traumatic stress disorder (PTSD) among Black adults in younger, middle, and older ages. Methods: Using nationally representative data from the National Survey of American Life, we estimated lifetime and 12-month prevalence of PTSD in Black men and women ages 18-34, 35-49, and 50+. We determined PTSD persistence and severity by age group, then associations of PTSD with socio-economic status, chronic stress, and racial discrimination in middle age. Results: The lifetime prevalence of PTSD was higher in Black women/men ages 18-34 (prevalence=14.0%/6.3%) and 35-49 (12.8%/4.6%) versus 50 and older (8.7%/5.1%). Those ages 35-49 were more likely than younger/older Black adults to have severe interference in work, relationships, and activities domains. In middle age, PTSD was associated with unemployment, lower education, poverty, and stress in Black men, and unemployment, divorce, poverty, stress, and discrimination in Black women. Discussion: Black women experience a disproportionate burden of PTSD in middle age.

ICU bereaved surrogates' comorbid psychological-distress states and their associations with prolonged grief disorder

Background/objective

Bereaved ICU family surrogates’ psychological distress, e.g., anxiety, depression, and post-traumatic stress disorder (PTSD), is usually examined independently, despite the well-recognized comorbidity of these symptoms. Furthermore, the few studies exploring impact of psychological distress on development of prolonged grief disorder (PGD) did not consider the dynamic impact of symptom evolution. We identified surrogates’ distinct patterns/states of comorbid psychological distress and their evolution over the first 3 months of bereavement and evaluated their associations with PGD at 6-month postloss.

Methods

A longitudinal observational study was conducted on 319 bereaved surrogates. Symptoms of anxiety, depression, PTSD, and PGD were measured by the anxiety and depression subscales of the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised scale, and the PGD-13, respectively. Distinct psychological-distress states and their evolution were examined by latent transition analysis. Association between psychological-distress states and PGD symptoms was examined by logistic regression.

Results

Three distinct comorbid psychological-distress states (prevalence) were initially identified: no distress (56.3%), severe-depressive/borderline-anxiety distress (30.5%), and severe-anxiety/depressive/PTSD distress (13.3%). Except for those in the stable no-distress state, surrogates tended to regress to states of less psychological distress at the subsequent assessment. The proportion of participants in each psychological-distress state changed to no distress (76.8%), severe-depressive/borderline-anxiety distress (18.6%), and severe-anxiety/depressive/PTSD distress (4.6%) at 3-month postloss. Surrogates in the severe-depressive/borderline-anxiety distress and severe-anxiety/depressive/PTSD-distress state at 3-month postloss were more likely to develop PGD at 6-month postloss (OR [95%] = 14.58 [1.48, 143.54] and 104.50 [10.45, 1044.66], respectively).

Conclusions

A minority of family surrogates of ICU decedents suffered comorbid severe-depressive/borderline-anxiety distress and severe-anxiety/depressive/PTSD symptoms during early bereavement, but they were more likely to progress into PGD at 6-month postloss.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03981-7.

Risk factors for suicide attempts among U.S. military veterans: A 7-year population-based, longitudinal cohort study

BACKGROUND

Population-based data on risk factors for suicide attempts among veterans remains limited.

METHODS

A national probability sample of 2307 veterans was followed over the course of four timepoints spanning seven years to examine how a range of baseline risk factors predict incident suicide attempt. Suicide attempt data were aggregated into a single follow-up timepoint.

RESULTS

Sixty-two veterans (3.1%) reported attempting suicide during the 7-year period. The strongest risk factors for suicide attempts were higher baseline levels of loneliness, lower baseline levels of adaptive psychosocial traits (e.g., dispositional gratitude), baseline thoughts of self-harm, and greater post-baseline trauma exposures (12.3%-41.3% of explained variance). Veterans with multiple co-occurring risk factors were at greatest risk for attempts; of veterans with 0, 1, 2, 3, and all 4 of these factors, the predicted probability of suicide attempt was 2.0%, 5.3%, 13.5%, 30.4%, and 55.0%, respectively.

CONCLUSIONS

Baseline loneliness, dispositional gratitude, thoughts of self-harm, and new-onset traumas emerged as the strongest risk factors for suicide attempts among veterans, underscoring the potential importance of targeting these factors in prevention efforts. Veterans with multiple co-occurring risk factors have substantially greater risk for suicide attempts, suggesting that examination of multiple coinciding vulnerability factors may help improve suicide risk prediction models.

Four Questions Nurses Can Ask to Predict PTSD 1 Year After a Motor Vehicle Crash

BACKGROUND

The role of nurses in screening for posttraumatic stress disorder is crucial in trauma units.

OBJECTIVES

To create and evaluate an easy and brief tool for nurses to predict chronic posttraumatic stress disorder 1 year after a motor vehicle crash.

METHODS

We performed a 1-year follow-up multicenter study from 2007 to 2015, including 274 patients injured in a motor vehicle crash who were hospitalized in an orthopedic trauma unit. Nurses administered the DEPITAC questionnaire. Posttraumatic stress disorder was measured by the Post-Traumatic Stress Disorder Checklist of symptoms during the first year following the crash. A multivariable logistic regression model was implemented to select items significantly associated with posttraumatic stress disorder to improve the DEPITAC questionnaire. Predictive performance to predict posttraumatic stress disorder 1 year after the motor vehicle crash was examined for these different models.

RESULTS

Of 274 patients studied, a total of 75.9% completed the questionnaire at 1 year of follow-up. We found that only two questions and two simple elements of the patient's medical record (other injury or a person dying during the crash, perception of vital threat, number of children, and length of stay in trauma) predicted posttraumatic stress disorder 1 year after a motor vehicle crash.

CONCLUSIONS

The brevity of this evaluation, simple scoring rules, and screening test performance suggest that this new screening tool can be easily administered in the acute care setting by nurses.

Disentangling the Symptom-Level Nuances in Comorbid Posttraumatic Stress Disorder and Problematic Alcohol Use in Northern Irish Military Veterans: A Network Analysis

Posttraumatic stress disorder (PTSD) and alcohol use are highly prevalent among military veteran populations. Several theories have been proposed to account for the comorbidity between PTSD and problematic alcohol use, but research examining the symptom-level associations between the two is limited. The current study used network analysis to examine the associations between PTSD and problematic alcohol use. Data were collected through a cross-sectional survey of veterans of the United Kingdom Armed Forces living in Northern Ireland. The sample comprised 511 (91.2% male) veterans with a history of trauma exposure and current alcohol use. A network consisting of PTSD symptoms from the PTSD Checklist for DSM-5 (PCL-5) and items from the Alcohol Use Disorders Identification Test (AUDIT) was constructed, and the bridge centrality of all items was estimated to identify items with the highest number of associations and the strongest associations between the two constructs. The PTSD symptom "reckless behavior" (2.43) had the highest bridge centrality values and thus the strongest connections and most connections to the alcohol use items. For the alcohol use items, "not being able to stop drinking" (2.31) and "number of drinks" (1.24) demonstrated the strongest bridge connections to the PTSD items. These results highlight the role of specific PTSD symptoms involved in the interaction between PTSD and problematic alcohol use.

A randomized controlled trial to evaluate a behavioral economic strategy for improving mobility in veterans with chronic pain

Rates of chronic pain and daily opioid use are higher among veterans relative to civilian populations. Increasing physical activity can reduce pain severity and decrease opioid use among patients with chronic pain. Behavioral economic strategies can improve physical activity levels but have been undertested in veterans with chronic pain. The objective of this study was to evaluate if a financial incentive combined with a loss aversion component-a "regret lottery" in which veterans could win money if they met a set goal or told how much they could have won had they met their goal-would increase physical activity levels among veterans with chronic pain. A 12-week single-blinded randomized controlled trial (ClinicalTrials.gov: NCT04013529) was designed. Veterans with chronic pain (N = 40) receiving care at a specialty pain clinic were eligible for participation, and were randomly assigned (1:1) to either (a) activity trackers and daily text message reminders to increase physical activity ("control arm"), or (b) the same plus a weekly regret lottery ("intervention arm"). For those in the intervention arm, participants who met their activity goal, had a chance to win a small ($30) or large ($100) gift card incentive; those who did not meet their goals were informed of what they would have won had they met their goal. The primary outcome, physical activity, was measured using self-reported physical activity and step counts using activity trackers. Secondary outcomes included changes in physical function, chronic pain severity, depression and opioid use. The sample was primarily white, male and disabled, with an average age of 57 years. No between-arm differences were noted for physical activity, physical function, chronic pain severity, depression or opioid use. Regret lottery-based approaches may be ineffective at increasing physical activity levels in veterans with chronic pain. Trial Registry: NCT04013529.

Prevalence and associated factors of post-traumatic stress disorder in Lebanon: A literature review

Lebanon has been under continuous conflict for more than four decades, putting millions of Lebanese at a high risk for post-traumatic stress disorder (PTSD) and creating a complex collective trauma. This paper aimed to review all studies from Lebanon reporting on PTSD in order to describe the prevalence of PTSD and its associated risk factors among Lebanese adults. A search of the MEDLINE/PubMed database was conducted in February/March 2021 to identify research articles on PTSD in Lebanese adults. A total of 1064 articles were identified, out of which 11 articles (5875 participants) published between 2003 and 2020 were included. PTSD prevalence estimates were highly variable across the individual studies, ranging from 2 % to 98 %. Female sex, economic hardship, lower educational level, being unemployed, number of witnessed/experienced traumatic events, and presence of comorbid psychological disorders were associated with higher PTSD rates. In light of the increasing PTSD risk in the Lebanese population as a result of the recent Beirut blast and ongoing social and economic crises, further culturally competent research is needed to provide rigorous evidence on the prevalence, course, and severity of PTSD in Lebanon.

Differentiating U.S. military veterans who think about suicide from those who attempt suicide: A population-based study

OBJECTIVE

Several vulnerability factors for suicidal behavior in U.S. veterans have been identified. However, little is known about factors that differentiate veterans who contemplate suicide from those who attempt suicide. This study examined sociodemographic and clinical characteristics that distinguish veterans who think about suicide from those who attempt suicide.

METHOD

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a population-based sample of 4069 veterans. Analyses estimated the lifetime prevalence of suicide ideation (SI) and suicide attempts (SA); and examined differences between veterans with a history of attempt(s), and SI without a history of attempt(s).

RESULTS

A total 25.9% of U.S. veterans reported lifetime SI and 3.9% reported a SA. Several factors distinguished veterans with a history of SA from those with SI only: the strongest were younger age (odds ratio [OR] = 0.97, 95% CI = 0.95-0.98), nonsuicidal self-injury (OR = 1.81, 95% CI = 1.11-3.03), adverse childhood experiences (OR = 1.14; 95% CI = 1.06-1.23), alcohol use disorder (OR = 1.99; 95% CI = 1.28-3.12), lower household income (OR = 0.62; 95% CI = 0.40-0.95), and physical disability (OR = 1.69; 95% CI = 1.07-2.70).

CONCLUSIONS

Although a quarter of U.S. veterans contemplate suicide in their lifetimes, the majority do not attempt suicide. Specific sociodemographic and clinical features may differentiate veterans who contemplate versus attempt suicide.

Estimated Prevalence and Demographic Correlates of Compulsive Sexual Behavior Among Gay Men in the United States

BACKGROUND

Compulsive sexual behavior (CSB) is a clinical syndrome that causes significant distress and impairment for many individuals in the United States. Gay men are thought to have a higher prevalence of CSB, and it is associated with many relevant health outcomes including HIV risk behavior.

AIM

To estimate the prevalence and examine demographic correlates of CSB among gay men in the United States.

METHODS

A U.S. national probability sample of 227 gay-identified men were collected as part of the 2015 National Survey of Sexual Health and Behavior (NSSHB).

OUTCOMES

Participants completed the Compulsive Sexual Behavior Inventory (CSBI-13) and demographic measures.

RESULTS

Eighteen participants (7.93%) scored above the CSBI-13 clinical cut point, indicating they would likely meet criteria for clinically significant compulsive sexual behavior. To assess demographic correlates of CSB, demographic variables were entered into a logistic regression. Results of the logistic regression indicated that participant age, education, and religious affiliation were significant predictors of CSB status. Individuals scoring above the cut point were younger on average (M = 39.17; SD = 14.84) than those scoring below the cut point (M = 47.52; SD = 14.62; P = .02). Odds of scoring above the cut point were about six times greater for religiously affiliated participants compared to non-religiously affiliated participants (P = .005), and four times greater for those who had attended college compared to those who had not (P = .03).

CLINICAL IMPLICATIONS

These results indicate the prevalence of CSB in gay men is more modest than previously estimated, and is similar to the general population prevalence estimated in a previous study. The strongest predictor of CSB in this sample was religious affiliation, which underscores the importance of evaluating the role of religiosity in the etiology and/or identification of this clinical syndrome.

STRENGTHS AND LIMITATIONS

These findings are strengthened by the national probability sampling methodology and the use of the empirically validated CSBI-13 cut point. However, this sample was also older and had higher income and educational attainment than the larger population of gay men in the U.S.

CONCLUSION

These results indicate gay men may have a CSB prevalence rate similar to the general population, which contradicts previous research suggesting they are at greater risk for CSB. Gleason N, Finotelli I, Miner MH, et al. Estimated Prevalence and Demographic Correlates of Compulsive Sexual Behavior Among Gay Men in the United States. J Sex Med 2021;18:1545-1554.

Factors associated with multiple suicide attempts in a nationally representative study of U.S. military veterans

OBJECTIVE

Veterans with a history of multiple suicide attempts are at increased risk for suicide mortality relative to those with a single attempt. However, little is known about factors that differentiate veterans who attempt suicide once compared to more than once. This study examined factors that distinguish single suicide attempters (SSA) from multiple suicide attempters (MSA) in a nationally representative sample of U.S. military veterans.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a representative sample of 4069 U.S. veterans.

ANALYSES

(a) estimated the lifetime prevalence of SSA and MSA; and (b) examined factors that differentiated veterans with a SSA from MSA.

RESULTS

The lifetime prevalences of SSA and MSA were 1.9% and 2.0%. The strongest correlates of MSA were history of lifetime depression (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.43-8.35), non-suicidal self-injury (OR, 3.28; 95% CI, 1.27-8.45), drug use disorder (OR, 4.0; 95% CI, 1.67-9.54), and marital status (OR, 0.40, 95% CI, 0.18-0.87), which accounted for 15.5%-41.4% of the total explained variance in MSA.

DISCUSSION

Half of military veterans who have attempted suicide in the United States report more than one attempt, suggesting that suicide attempts are not a one-time occurrence for a substantial proportion of veterans. Veterans who attempt suicide more than once show more deliberate self-harm behavior and have greater psychiatric comorbidities relative to single attempters. Implications for future research examining risk factors for suicide attempts among veterans are discussed.

The negative association between trait mindfulness and post-traumatic stress disorder: A 4.5-year prospective cohort study

OBJECTIVE

Post-traumatic stress disorder (PTSD) is a chronic, disabling condition. Our main objective is to investigate the association between trait mindfulness and PTSD over a period of 54 months. The secondary objective is to provide an exhaustive description of PTSD trajectories after the Bataclan attack.

METHODS

We designed a prospective cohort study of 133 subjects present in the Bataclan concert hall during the November 2015 terrorist attack in Paris, France. Data were recorded 6, 18, 30, and 54 months after the attack. The primary endpoint was evaluated using the PTSD Check List Scale. Trait mindfulness was measured by the 14-item Freiburg Mindfulness Inventory.

RESULTS

FMI scores were consistently, significantly, and negatively associated with PCL-5 scores. Adjusted odds ratios were at 0.81 (6 months), 0.88 (18 months) 0.82 (30 months), and 0.81 (54 months). PTSD prevalence 6 months after the event was 77%; it remained at 41% after 54 months. PTSD status of subjects is fluctuating. Latent class analysis divided the cohort into 3 groups: 21% of subject who remained below PTSD threshold throughout, 30% who remained above throughout, and 49% who steadily reduced their PTSD scores over time.

CONCLUSION

In our cohort, mindfulness is negatively associated with PTSD. Mindfulness programs are designed to improve global resilience and treat anxiety and mood disorders. Further research is needed to investigate if improving trait mindfulness is possible and beneficial for patients suffering from PTSD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Characterizing chronological accumulation of comorbidities in healthy veterans: a computational approach

Understanding patient accumulation of comorbidities can facilitate healthcare strategy and personalized preventative care. We applied a directed network graph to electronic health record (EHR) data and characterized comorbidities in a cohort of healthy veterans undergoing screening colonoscopy. The Veterans Affairs Cooperative Studies Program #380 was a prospective longitudinal study of screening and surveillance colonoscopy. We identified initial instances of three-digit ICD-9 diagnoses for participants with at least 5 years of linked EHR history (October 1999 to December 2015). For diagnoses affecting at least 10% of patients, we calculated pairwise chronological relative risk (RR). iGraph was used to produce directed graphs of comorbidities with RR > 1, as well as summary statistics, key diseases, and communities. A directed graph based on 2210 patients visualized longitudinal development of comorbidities. Top hub (preceding) diseases included ischemic heart disease, inflammatory and toxic neuropathy, and diabetes. Top authority (subsequent) diagnoses were acute kidney failure and hypertensive chronic kidney failure. Four communities of correlated comorbidities were identified. Close analysis of top hub and authority diagnoses demonstrated known relationships, correlated sequelae, and novel hypotheses. Directed network graphs portray chronologic comorbidity relationships. We identified relationships between comorbid diagnoses in this aging veteran cohort. This may direct healthcare prioritization and personalized care.

The Role of Negative Affect in Differentiating Posttraumatic Stress Disorder, Depression, and Their Comorbidity Among United States Veterans

Following trauma exposure, two frequently co-occurring forms of psychopathology include posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Although these diagnoses have been identified as distinct constructs, the proper classification of these disorders remains a challenge due to overlapping symptoms. Instead, systematically establishing higher- and lower-order personality traits associated with each diagnosis may avoid this confound and improve differential diagnosis. In the present study, we examined how higher-order negative affect and its lower-order facets (i.e., anxiousness, emotional lability, and separation insecurity) may be associated with a diagnosis of PTSD only, MDD only, both diagnoses, or neither diagnosis. Participants were 1,175 veterans enrolled in the Veterans After Discharge Longitudinal Registry. Higher- and lower-order negative affect were assessed using the Personality Inventory for DSM-5 (PID-5), and PTSD and MDD diagnoses were based on the Structured Clinical Interview for DSM-5 (SCID-5). Multinomial logistic regressions were used to model the association between higher- and lower-order negative affect and diagnostic status, after controlling for potential covariates. Diagnostic utility analyses were conducted to examine the degree to which higher- and lower-order negative affect classified participants across groups. Higher-order negative affect and lower-order anxiousness differentiated diagnostic groups, ORs = 1.76-4.66, and had strong specificity and negative predictive value for individuals with PTSD and MDD and those with MDD only. These findings help explain the role of higher-order negative affect and lower-order anxiousness in differentiating PTSD from MDD and comorbid PTSD and MDD and may have implications for assessment, differential diagnosis, and treatment planning.

Assessing exposure to war-related traumatic events in older Vietnamese war survivors

Background

Though studies measuring war-related stressors and resultant trauma among U.S. military veterans are abundant, few studies address how wartime stressors affect military veterans native to warzones. Even fewer assess the stress exposure and resulting trauma experienced by Vietnamese civilians. This study aimed to construct a scale to quantify wartime stress exposure that is relevant for civilians and military veterans who survived the American War in Vietnam.

Methods

The study analyzed data from a novel source, the Vietnam Health and Aging Study, which surveyed older men and women residing in central and northern Vietnam. We used a combination of exploratory and confirmatory factor analysis with posthoc tests of reliability and validity to derive measures for assessing exposure to war-related traumatic events.

Results

We found that a mix of exposure to death, combat, inhospitable living conditions, and forced displacement comprises the traumatic events that potentially contribute to posttraumatic stress disorder and other mental health problems. However, the particular mix of stressful experiences constituting war trauma differs for civilians, veterans of the formal military, and former members of paramilitary organizations.

Conclusions

These findings suggest the need for distinct but parallel approaches to measuring war-related stressors for populations of veterans and civilians exposed to war in their home countries and the need for greater public attention to the potential lingering trauma of noncombatants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00343-y.

Outcomes of Orthopedic Hand Surgeries in Minor Procedure Rooms at a Veterans Affairs Medical Center

Purpose

There is a high demand for minor hand surgeries within the veteran population. The objective of this study was to compare clinical outcomes and resource use at a Veterans Affairs Medical Center (VAMC) of hand surgeries performed in minor procedure rooms (MPR) and operating rooms using local anesthesia with or without monitored anesthesia care.

Methods

We retrospectively evaluated all patients undergoing carpal tunnel release, de Quervain's release, foreign body removal, soft tissue mass excision, or A1 pulley release at a VAMC over a 5-year period. Data collected included demographic information, mental health comorbidities, presence of preoperative and postoperative pain, complications after surgery, time to surgery, number of personnel in surgery, turnover time between cases, and time spent in the postanesthesia care unit. Statistical analysis included Fisher exact or chi-square analysis to compare MPR versus operating room groups and Student t test or Mann-Whitney test to compare continuous variables.

Results

In this cohort of 331 cases, 123 and 208 patients underwent surgery in MPRs and operating rooms, respectively. Preoperative and postoperative pain were similar between the MPR and operating room groups. Complications were slightly lower in the MPR group versus the operating room group (0% MPR vs 2.9% operating room). Median time from surgical consult to surgery was 6 days less for MPR patients (15 vs 21). The MPR cases also used fewer personnel during surgery, averaging 4.76 versus 4.99 people. The MPR patients spent 9 minutes less in the postanesthesia care unit (median, 36 vs 45 minutes) and turnover time between cases was nearly 8 minutes faster in MPRs than in operating rooms (median, 20 vs 28 minutes).

Conclusions

Minor procedure rooms at a VAMC allow more veteran patients to be scheduled for minor hand surgeries within a shorter time frame, utilize less staff and postoperative monitoring, and maintain excellent outcomes with limited complications.

Clinical relevance

Minor hand surgeries in MPRs have outcomes equivalent to those of operating rooms with improved time savings and resource use.

The National Health and Resilience in Veterans Study: A Narrative Review and Future Directions

United States (U.S.) veterans are substantially older than their non-veteran counterparts. However, nationally representative, population-based data on the unique health needs of this population are lacking. Such data are critical to informing the design of large-scale outreach initiatives, and to ensure the effectiveness of service care delivery both within and outside of the Veterans Affairs healthcare system. The National Health and Resilience in Veterans Study (NHRVS) is a contemporary, nationally representative, prospective study of two independent cohorts (n = 3,157 and n = 1,484) of U.S. veterans, which is examining longitudinal changes, and key risk and protective factors for several health outcomes. In this narrative review, we summarize the main findings of all NHRVS studies (n = 82) published as of June 2020, and discuss the clinical implications, limitations, and future directions of this study. Review of these articles was organized into six major topic areas: post-traumatic stress disorder, suicidality, aging, resilience and post-traumatic growth, special topics relevant to veterans, and genetics and epigenetics. Collectively, results of these studies suggest that while a significant minority of veterans screen positive for mental disorders, the majority are psychologically resilient. They further suggest that prevention and treatment efforts designed to promote protective psychosocial characteristics (i.e., resilience, gratitude, purpose in life), and social connectedness (i.e., secure attachment, community integration, social engagement) help mitigate risk for mental disorders, and promote psychological resilience and post-traumatic growth in this population.

The Link Between Autonomic Nervous System and Rheumatoid Arthritis: From Bench to Bedside

Neuronal stimulation is an emerging field of research focused on the management and treatment of various diseases through the reestablishment of physiological homeostasis. Electrical vagus nerve stimulation has recently been proposed as a revolutionary therapeutic option for rheumatoid arthritis (RA) in combination with or even as a replacement for conventional and biological drugs. In the past few years, disruption of the autonomic system has been linked to RA onset and activity. Novel research on the link between the autonomic nervous system and the immune system (immune-autonomics) has paved the way for the development of innovative RA management strategies. Clinical evidence supports this approach. Cardiovascular involvement, in terms of reduced baroreflex sensitivity and heart rate variability-derived indices, and mood disorders, common comorbidities in patients with RA, have been linked to autonomic nervous system dysfunction, which in turn is influenced by increased levels of circulating pro-inflammatory cytokines. This narrative review provides an overview of the autonomic nervous system and RA connection, discussing most of the common cardiac and mental health-related RA comorbidities and their potential relationships to systemic and joint inflammation.

Comorbid posttraumatic stress disorder and major depressive disorder are associated with asthma morbidity among World Trade Center workers

BACKGROUND

World Trade Center (WTC) rescue and recovery workers have a high burden of asthma, comorbid posttraumatic stress disorder (PTSD), and major depressive disorder (MDD). PTSD is associated with worse asthma outcomes.

OBJECTIVE

In this study, we evaluated whether the relationship between PTSD and asthma morbidity is modified by the presence of MDD.

METHODS

We used data from a cohort of WTC workers with asthma. Asthma control (asthma control questionnaire), resource utilization, and quality of life (asthma quality of life questionnaire) were evaluated. We used regression analyses to evaluate the adjusted association of PTSD and MDD with asthma control, resource utilization, and quality of life.

RESULTS

Of the study cohort of 293 WTC workers with asthma, 19% had PTSD alone, 2% had MDD alone, and 12% had PTSD and MDD. Adjusted mean differences (95% confidence interval) in asthma control questionnaire scores were 1.32 (0.85-1.80) for WTC workers with PTSD and MDD, 0.44 (0.03-0.84) for those with PTSD alone, and 0.50 (-0.38 to 1.38) for workers with MDD alone compared with those without MDD or PTSD. WTC workers with PTSD and MDD, PTSD alone, and MDD alone had mean (95% confidence interval) adjusted differences in asthma quality of life questionnaire scores of -1.67 (-2.22 to -1.12), -0.56 (-2.23 to -1.12), and -1.21 (-2.23 to -0.18), respectively, compared with workers without MDD or PTSD. Similar patterns were observed for acute resource utilization.

CONCLUSION

PTSD and MDD seem to have a synergistic effect that worsens asthma control and quality of life. Efforts to improve asthma outcomes in this population should address the negative impacts of these common mental health conditions.

Impostorism, subjective age, and perceived health among aging veterans

RATIONALE

Aging veterans often suffer from increased vulnerability, manifested among other things in old subjective age and poor perceived health. Though research has documented the contribution of trauma related variables to these negative appraisals, their associations with impostorism (i.e., the subjective experience that one is less adequate than others perceive) remain unexamined.

OBJECTIVE

Filling this gap, this study explored the relations between impostorism and subjective age and perceived health among aging combat veterans.

METHOD

The study was conducted among 146 Israeli veterans of the 1973 Yom Kippur War. Participants were assessed for combat exposure, Posttraumatic Stress Disorder (PTSD) symptoms, and health-related behaviors during middle adulthood (1991; T1), and for subjective age, perceived health, impostorism, PTSD symptoms, and depressive symptoms during old age (2018; T2).

RESULTS

The veterans' impostorism was associated with relatively old subjective age and poor perceived health, above and beyond the effects of age, health-related behaviors, combat exposure, depressive symptoms, and PTSD symptoms.

CONCLUSIONS

The current results suggest that impostorism may contribute to veterans' stress and negatively affect their evaluations regarding age and health.