PTSD relapse in Veterans of Iraq and Afghanistan: A systematic review

Recurrence of post-traumatic stress disorder: systematic review of definitions, prevalence and predictors

BACKGROUND

Many people will experience a potentially traumatic event in their lifetime and a minority will go on to develop post-traumatic stress disorder (PTSD). A wealth of literature explores different trajectories of PTSD, focusing mostly on resilient, chronic, recovered and delayed-onset trajectories. Less is known about other potential trajectories such as recurring episodes of PTSD after initial recovery, and to date there has been no estimate of what percentage of those who initially recover from PTSD later go on to experience a recurrence. This systematic review aimed to synthesise existing literature to identify (i) how 'recurrence' of PTSD is defined in the literature; (ii) the prevalence of recurrent episodes of PTSD; and (iii) factors associated with recurrence.

METHODS

A literature search of five electronic databases identified primary, quantitative studies relevant to the research aims. Reference lists of studies meeting pre-defined inclusion criteria were also hand-searched. Relevant data were extracted systematically from the included studies and results are reported narratively.

RESULTS

Searches identified 5,398 studies, and 35 were deemed relevant to the aims of the review. Results showed there is little consensus in the terminology or definitions used to refer to recurrence of PTSD. Because recurrence was defined and measured in different ways across the literature, and prevalence rates were reported in numerous different ways, it was not possible to perform meta-analysis to estimate the prevalence of recurrence. We also found no consistent evidence regarding predictors of PTSD recurrence.

CONCLUSION

A clear and consistent evidence-based definition of recurrence is urgently needed before the prevalence and predictors of recurrence can be truly understood.

A mild stressor induces short-term anxiety and long-term phenotypic changes in trauma-related behavior in female rats

Introduction

Anxiety and anxiety-influenced disorders are sexually dimorphic with women being disproportionately affected compared to men. Given the increased prevalence in women and the documented differences in anxiety and trauma behavior between male and female rats this paper sought to examine the link between stress, anxiety, and fear learning and extinction in female rats. We tested the hypothesis that a mild stressor will induce short-and long-term increases in anxiety and produce long term effects on subsequent fear learning and extinction behavior.

Methods

We induced anxiety in female Sprague- Dawley rats with a short (3 min) exposure to a ball of cat hair infused with 150 μl of cat urine (mild stressor) that elicits innate fear but does not cause fear conditioning. The control group was exposed to fake cat hair. Anxiety was assessed in the Light-Dark Open Field (LDOF) or Elevated Plus Maze (EPM) before, immediately after and 4 days after stimulus exposure. Two weeks later, all animals were subject to Contextual Fear Conditioning (CFC) in the Shock Arm of a Y-maze, blocked off from the rest of the maze. Memory and fear extinction (learning of safety) was assessed in the following four days by placing each rat in one of the Safe Arms and measuring avoidance extinction (time spent and number of entries in the Shock Arm).

Results

Cat hair exposure induced changes in anxiety-like behavior in the short-term that appeared resolved 4 days later. However, the cat-hair exposed rats had long-term (2 weeks) phenotypic changes expressed as altered exploratory behavior in an emotionally neutral novel place. Fear learning and extinction were not impaired. Yet, using avoidance extinction, we demonstrated that the phenotypic difference induced by the mild stressor could be documented and dissociated from learning and memory.

Discussion

These findings demonstrate that the history of stress, even mild stress, has subtle long-term effects on behavior even when short-term anxiety appears resolved.

Computerized Psychological Interventions in Veterans and Service Members: Systematic Review of Randomized Controlled Trials

BACKGROUND

Computerized psychological interventions can overcome logistical and psychosocial barriers to the use of mental health care in the Veterans Affairs and Department of Defense settings.

OBJECTIVE

In this systematic review, we aim to outline the existing literature, with the goal of describing: the scope and quality of the available literature, intervention characteristics, study methods, study efficacy, and study limitations and potential directions for future research.

METHODS

Systematic searches of two databases (PsycINFO and PubMed) using PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) guidelines were conducted from inception until November 15, 2020. The following inclusion criteria were used: the study was published in an English language peer-reviewed journal, participants were randomly allocated to a computerized psychological intervention or a control group (non-computerized psychological intervention active treatment or nonactive control group), an intervention in at least one treatment arm was primarily delivered through the computer or internet with or without additional support, participants were veterans or service members, and the study used validated measures to examine the effect of treatment on psychological outcomes.

RESULTS

This review included 23 studies that met the predefined inclusion criteria. Most studies were at a high risk of bias. Targeted outcomes, participant characteristics, type of support delivered, adherence, and participant satisfaction were described. Most of the examined interventions (19/24, 79%) yielded positive results. Study limitations included participant characteristics limiting study inference, high rates of attrition, and an overreliance on self-reported outcomes.

CONCLUSIONS

Relatively few high-quality studies were identified, and more rigorous investigations are needed. Several recommendations for future research are discussed, including the adoption of methods that minimize attrition, optimize use, and allow for personalization of treatment.

Interrelationship of emotional stability, hassles, uplifts, coping and stress-related symptoms in Swedish female and male military veterans

Drawing on previous research, two hypotheses were tested: (1) the higher the frequency of daily uplifts and use of functional coping strategies, and the lower the frequency of daily hassles and use of dysfunctional coping strategies, the lower the prevalence of stress-related symptoms will be, and vice versa; and (2) the direct relationship between the personality dimension emotional stability and stress-related symptoms, will be moderated by daily hassles, daily uplifts and coping processes. A quantitative test of a qualitatively developed model was performed. A questionnaire was sent to all Swedish military veterans who had served in the period 2011-2015 and 1859 individuals (1,614 men and 199 women, 46 individuals did not mark gender) responded (40.5% total response rate). All analyses were made separately for men and women. Comparisons between theoretically favorable and unfavorable profiles across the model variables, daily uplifts, daily hassles, functional coping and dysfunctional coping (based on a cluster analysis), showed considerable differences regarding the prevalence of stress-related symptoms as predicted by the model and supporting the first hypothesis. Regression and moderation analyses yielded limited support for the second hypothesis. As predicted, female veterans reported a higher frequency of physical, emotional and cognitive stress-related symptoms than male veterans. The main conclusion is that the theoretical model stood up well when empirically tested and offers a promising approach to future studies on everyday stress and health. The results contribute with new knowledge of military veterans compared to the main stream PTSD, depression and drug abuse-oriented studies.