Posttraumatic stress disorder associated with combat service in Iraq or Afghanistan: reconciling prevalence differences between studies

Post-traumatic stress disorder among military personnel admitted at the Northwest Command Level Three Military Hospital, Bahir Dar, Ethiopia, 2022: an institution-based cross-sectional study

Background

Post-traumatic stress disorder (PTSD) is one of the most common mental health problems that military personnel encounter. It could be lifelong and affect every aspect of military personnel, including their mental and physical health, family and social interactions, and their work. However, in Ethiopia, the magnitude and its associated factors have not been well investigated.

Objective

This study aimed to determine the prevalence of PTSD and its associated factors among military personnel, who were admitted at the Northwest Command Level Three Military Hospital, Bahir Dar, Northwest, Ethiopia, 2022.

Methods

An institution-based cross-sectional study was conducted from 21 June to 21 July 2022, at the Northwest Command Level Three Military Hospital. A computer-generated simple random sampling technique was used to select a total of 627 participants. The 17-item Military Version Checklist was utilized to measure PTSD. The Patient Health Questionnaire, Brief Resilience Coping, and Critical War Zone Experience scale were utilized to measure depression, resilience, and combat exposure, respectively. Descriptive, bivariate, and multivariate binary logistic regressions with odds ratios and a 95% confidence interval were used. The level of significance of the association was determined at a p-value < 0.05.

Results

A total of 612 respondents participated, with a response rate of 97.6%. The prevalence of PTSD in this study was 21.9% (95% CI: 18.6, 25.2). In multivariable regression, female sex [adjusted odds ratio (AOR) = 2.3, 95% CI; 1.3, 3.87], combat personnel (AOR = 2.75, 95% CI; 1.44, 6.36), handling dead bodies (AOR = 2.5, 95% CI,1.24, 5.02), having 4-5 deployments (AOR = 2.94, 95% CI, 1.63, 5.32), having ≥6 deployments (AOR = 3.4, 95% CI, 1.95, 6.17), low resilience coping (AOR = 2.02, 95% CI; 1.16, 3.53), poor social support (AOR = 2.46, 95% CI, 1.39, 4.35), very high combat exposures (AOR = 4.8, 95% CI, 2.03, 11.93), and depression (AOR = 2.8, 95% CI, 1.68, 4.67) were significantly associated with PTSD.

Conclusion

PTSD is markedly prevalent among the Ethiopian military population, with key risk factors identified as being female, poor social support, low resilience coping skills, handling dead bodies, multiple deployments (four or more), high combat experiences, and depression. Healthcare professionals must prioritize the early diagnosis and intervention of PTSD in vulnerable groups of military personnel.

Case report: "Scared to deaf": medical-legal evaluation of a suspected post -traumatic stress disorder"

The case concerns the alleged failure by the resisting administration to fulfill obligations arising from the contract and employment relationship, as well as the violation of safety regulations leading to the workplace accident reported by an Airforce Sergeant. Following the accident, the soldier complains of developing barotraumatic hearing loss with tinnitus and reactive post-traumatic stress disorder to the traumatic event. The case provides an opportunity to analyze the relevance of forensic medical assessment and its integration with psychodiagnostic examination for the correct nosographic classification aimed at evaluating and quantifying biological damage.

Post-traumatic stress disorder and associated factors among inpatients at Eastern Command Referral Hospital in Dire Dawa, Eastern Ethiopia

Background

Post-traumatic stress disorder (PTSD) is characterized by heightened stress and anxiety after experiencing a traumatic event. While numerous studies have been conducted to investigate the magnitude and factors associated with PTSD, there is limited evidence available on specific study populations of military personnel.

Objective

The study aimed to determine the magnitude of post-traumatic stress disorder and associated factors among military personnel admitted to the Eastern Command Referral Hospital in Eastern Ethiopia from May 1 to 30, 2023.

Methods and materials

A cross-sectional study was carried out at an institution. Face-to-face interviews were conducted to collect data using the post-traumatic stress disorder military version checklist for the Diagnostic and Statistical Manual, Fifth Edition. Data were entered and analyzed using EpiData version 3.1 and STATA version 14. Descriptive statistics were employed to summarize the information. To investigate factors linked with outcome variables, bivariate and multivariate logistic regression analyses were conducted. The results were presented using odds ratios with 95% confidence intervals, with statistical significance given at a p-value of 0.05.

Results

This study found that approximately 23.6% (95% CI = 19.9-27.8) of admitted military members fulfilled the diagnostic criteria for PTSD. Participants' history of mental illness [adjusted odds ratio (AOR) = 5.73, 95% CI = 2.66-12.31], family history of mental illness (AOR = 10.38, 95% CI = 5.36-20.10), current chewing of khat (AOR = 2.21, 95% CI = 1.13-4.32), physical trauma (AOR = 2.03, 95% CI = 1.00-4.13), moderate social support (AOR = 0.27, 95% CI = 0.1-4.53), strong social support (AOR = 0.09, 95% CI = 0.02-0.35), and severe depression (AOR = 2.06, 95% CI = 1.74-5.71) were factors significantly associated with post-traumatic stress disorder.

Conclusions

The magnitude of post-traumatic stress disorder is high among military personnel. Factors such as participants' history of mental illness, family history of mental illness, depression, lack of social support, current use of khat, and physical trauma are significantly associated with PTSD. It is crucial to identify and intervene early in individuals with these risk factors to address PTSD effectively.

Resilience enhancing programs in the U.S. military: An exploration of theory and applied practice

U.S. service members are at an enhanced risk for developing mental disorders. To address these challenges, while promoting operational readiness and improving mental health outcomes, the Department of Defense directed each service component to develop and implement universal resilience enhancing programs. This paper provides a review of theoretical approaches conceptualizing resilience to trauma, including the theoretical foundations of programs currently in place. The resilience programs of U.S. Army, U.S. Air Force, U.S. Navy and U.S. Marine Corps are described, and available program effectiveness data are reviewed. Gaps between theory and practice are identified and an alternative method of assessing psychological readiness in Army units that is informed by resilience theory is offered as one way to address these gaps and scientific concerns. By comprehensively assessing the stressors affecting Soldiers at regular intervals, military leaders may be able to better identify and mitigate stressors in a systematic way that bolsters individual and unit psychological fitness. An enhanced psychological readiness metric stands to strengthen the validity of current resilience programs, bring clarity to the mechanisms of resilience, and provide a novel way for leaders to promote readiness in their units. Application of this metric within the infrastructure of existing reporting systems stands to improve mental health outcomes for Service Members, enhance the psychological readiness of the force, and reduce healthcare costs over time.

The role of self-criticism and self-compassion in the development of PTSD among midwives

OBJECTIVE

Healthcare providers might develop emotional distress following direct and indirect exposure to traumatic events. Evidence shows that midwives, who care for women in complicated situations, are often exposed to circumstances that have a potential to lead to a variety of psychological reactions, including symptoms identified with post-traumatic stress disorder (PTSD). Nevertheless, the positive-healthy context in which childbirth is mainly perceived raises questions regarding the protective role of personality traits, which are related to processing methods of stress and pain, in the development of PTSD among this unique population. This study aimed to explore the associations between traits such as self-compassion, self-criticism, resilience, cognitive thinking, and pain catastrophizing and PTSD symptoms among Israeli midwives.

SETTING

Using a quantitative cross-sectional study,123 midwives from ten hospitals in Israel anonymously reported their characteristics and severity of stress and/or PTSD symptoms by filling out the Psychopathy Checklist questionnaire. Analysis of personality traits was performed via the following questionnaires: Self-Compassion Scale - Short Form, Depressive Experiences Questionnaire - Self Criticism, and the Connor-Davidson Resilience Scale. Additionally, we measured the level of catastrophizing pain by employing the Pain Catastrophizing Scale questionnaire.

FINDINGS

Most of the midwives reported existing post-trauma symptoms, among them 11.38% had been diagnosed with PTSD. Severity of the PTSD correlated with their self-criticism and the pain catastrophizing rates. Additional examination of the involvement of personality traits showed that midwives with high self-criticism, low mental resilience, besides a high rate of pain catastrophizing, were more vulnerable to developing PTSD.

CONCLUSIONS

The findings can help to refine the understanding regarding the involvement of midwives' personality characteristics in the process of PTSD onset. Vulnerable midwives have been identified as those at risk to develop PTSD symptoms.

IMPLICATIONS FOR PRACTICE

The clinical significance of these insights is to promote the ability to identify midwives who are at risk to develop PTSD. Furthermore, this information might help to produce training programs and a support network to empower self-compassion and mental resilience, and to minimize self-criticism in order establish a support network, which would help to deal with the difficult experiences they face at work.

Prominent genetic variants and epigenetic changes in post-traumatic stress disorder among combat veterans

Post-traumatic stress disorder (PTSD) is one of the most widespread and disabling psychiatric disorders among combat veterans. Substantial interindividual variability in susceptibility to PTSD suggests the presence of different risk factors for this disorder. Twin and family studies confirm genetic factors as important risk factors for PTSD. In addition to genetic factors, epigenetic factors, especially DNA methylation, can be considered as a potential mechanism in changing the risk of PTSD. So far, many genetic and epigenetic association studies have been conducted in relation to PTSD. In genetic studies, many single nucleotide polymorphisms have been identified as PTSD risk factors. Meanwhile, the variations in catecholamines-related genes, serotonin transporter and receptors, brain-derived neurotrophic factor, inflammatory factors, and apolipoprotein E are the most prominent candidates. CpG methylation in the upstream regions of many genes is also considered a PTSD risk factor. Accurate identification of genetic and epigenetic changes associated with PTSD can lead to the presentation of suitable biomarkers for susceptible individuals to this disorder. This study aimed to delineate prominent genetic variations and epigenetic changes associated with post-traumatic stress disorder in military veterans who have experienced combat, focusing on genetic and epigenetic association studies.

Daily exposure to combat-related cues and posttraumatic stress symptoms among veterans: Moderating effects of peri- and postdeployment experiences

One of the central symptoms of posttraumatic stress disorder (PTSD) is a heightened reactivity to trauma cues. The current study used experience sampling to investigate the associations between exposure to combat-related cues and PTSD symptoms in 93 U.S. veterans who served in support of recent military operations in Afghanistan and Iraq. We also examined the effects of peri- and postdeployment factors, including exposure to combat, unit support during deployment, and postdeployment social support on PTSD. Participants completed eight brief random surveys daily for 2 weeks using palmtop computers. The results indicated that more daytime exposure to trauma cues was associated with experiencing more PTSD symptoms at the within-person level, B = 3.18. At the between-person level, combat exposure, B = 4.20, was associated with more PTSD symptoms, whereas unit support, B = -0.89, was associated with experiencing fewer symptoms. At the cross-level interaction, unit support, B = -0.80, moderated the association between trauma cue exposure and PTSD symptom count. Contrary to our hypothesis, postdeployment social support, B = -0.59, was not associated with PTSD symptoms. These findings suggest a functional association between exposure to trauma cues and PTSD symptoms among recent-era U.S. veterans and underscore the importance of unit support during deployment.

Implementation of a Primary Prevention Program for Posttraumatic Stress Disorder in a Cohort of Professional Soldiers (PREPAR): Protocol for a Randomized Controlled Trial

BACKGROUND

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that can manifest after a traumatic event where the individual perceives a threat to his or her life or that of others. Its estimated prevalence in the European population is 0.7% to 1.9%. According to the "dose-response" model, individuals who are most exposed to traumatic events are most at risk of developing PTSD. Hence, it is unsurprising that studies have observed a higher prevalence among the military population, ranging from 10% to 18%, or even up to 45%. This project's overall goal is to evaluate the primary prevention actions that can strengthen the resilience of at-risk professionals, notably military personnel, in the short term, with the medium- to long-term aim of preventing the occurrence of PTSD and improving the patient's prognosis.

OBJECTIVE

This study's objectives are (1) to design a primary prevention program for PTSD, tailored to the studied military population and compatible with operational constraints; and (2) to implement and validate the Primary Prevention of Posttraumatic Stress Disorder in Military Professionals (PREPARE) program in the short term with operational personnel belonging to the French Mountain Infantry Brigade.

METHODS

This is a single-center, prospective, randomized, parallel-group controlled cohort study. The cohort is divided into 2 groups: the nonintervention group receives no training, and the intervention group follows a dedicated prevention program (structured into 8 workshops and 2 debriefing and practice reinforcement workshops). Each participant is evaluated 4 times (at inclusion, +4 months, +6 months, and +12 months). During each visit, participants complete several psychosocial questionnaires (which take 15-80 minutes to complete). Samples (a 30-mL blood sample and three 5-mL saliva samples) are collected on 3 occasions: at inclusion, +4 months, and +12 months. Emotional reactivity (electrocardiogram and electrodermal activity) is measured before, during, and after the classic and the emotional Stroop task.

RESULTS

The project is currently ongoing, and results are expected to be published by the end of 2024.

CONCLUSIONS

The study adopts an integrative approach to the processes that play a role in the risk of developing PTSD. Our biopsychosocial perspective makes it possible to target levers related to factors specific to the individual and socio-professional factors. The following dimensions are addressed: (1) biophysiology (by studying markers of the neurobiological stress response, wear and tear, and vulnerability phenomena and reinforcing the flexibility of the autonomic nervous system), (2) psychology (by facilitating and measuring the development of flexible coping strategies to deal with stress and evaluating the moderating role of the individual's sense of duty in the development of PTSD), and (3) social (by facilitating community strategies aimed at reducing stigmatization and supporting the use of care by professionals in difficulty, in the institutional context).

TRIAL REGISTRATION

ClinicalTrials.gov NCT05094531; https://clinicaltrials.gov/study/NCT05094531.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47175.

Post-Traumatic Stress Disorder and Risk of Parkinson's Disease in a Veteran Cohort

 Post-traumatic stress disorder (PTSD) may be a risk factor for Parkinson's disease (PD). We examined the relation between PTSD and PD in a cohort of 158,122 Veterans who had any Veterans Health Administration (VHA) or Medicare health care utilization between 10/1/1999- 2/17/2021. Using a nested case-control design we matched 10 controls to each Veteran with PD by sex, race, and rank. In conditional logistic regression models adjusted for camp and smoking, a PTSD diagnosis was significantly associated with PD (OR = 1.35; p = 0.0002); odds were higher if PTSD was coded before PD (OR = 1.53, p < 0.0001). PTSD may be a risk factor for PD.

An exploratory domain analysis of deployment risks and protective features and their association to mental health, cognitive functioning and job performance in military personnel

BACKGROUND

Meta-analyses of military deployment involve the exploration of focused associations between predictors and peri and post-deployment outcomes.

OBJECTIVE

We aimed to provide a large-scale and high-level perspective of deployment-related predictors across eight peri and post-deployment outcomes.

DESIGN

Articles reporting effect sizes for associations between deployment-related features and indices of peri and post-deployment outcomes were selected. Three-hundred and fourteen studies (N = 2,045,067) and 1,893 relevant effects were retained. Deployment features were categorized into themes, mapped across outcomes, and integrated into a big-data visualization.

METHODS

Studies of military personnel with deployment experience were included. Extracted studies investigated eight possible outcomes reflecting functioning (e.g., post-traumatic stress, burnout). To allow comparability, effects were transformed into a Fisher's Z. Moderation analyses investigating methodological features were performed.

RESULTS

The strongest correlates across outcomes were emotional (e.g., guilt/shame: Z = 0.59 to 1.21) and cognitive processes (e.g., negative appraisals: Z = -0.54 to 0.26), adequate sleep on deployment (Z = -0.28 to - 0.61), motivation (Z = -0.33 to - 0.71), and use of various coping strategies/recovery strategies (Z = -0.25 to - 0.59).

CONCLUSIONS

Findings pointed to interventions that target coping and recovery strategies, and the monitoring of emotional states and cognitive processes post-deployment that may indicate early risk.

Rumination and threat-biased interpretation mediate posttraumatic stress and growth responses to military stressors

We examined the role of rumination and threat-biased interpretation in stress and growth responses to military stressors. Two online surveys were completed by 183 (survey 1) and 393 (survey 2) currently serving or retired military personnel. The surveys measured exposure to potential military stressors (exposure to combat, witnessing the consequences of war, and perceived moral injury), posttraumatic stress symptomatology (PTSS), posttraumatic growth (PTG), and personal wellbeing, with survey 1 including measures of rumination, and survey 2 including a measure of threat-biased interpretation. Path analyses revealed that indirect paths from both witnessing the consequences of war and experiencing betrayal to PTSS were mediated by intrusive rumination and threat-biased interpretation, and that indirect paths from both betrayal and transgressions by others to PTG were mediated by deliberate rumination and threat-biased interpretation. The results reveal the idiosyncratic nature of military stressors, their differential involvement with cognitions that underpin rumination about past events and interpretation of current events, and their relevance to posttraumatic stress and growth in military personnel.

Effect of Dexmedetomidine on Posttraumatic Stress Disorder in Patients Undergoing Emergency Trauma Surgery: A Randomized Clinical Trial

Importance

Posttraumatic stress disorder (PTSD) is common in people who have experienced trauma, especially those hospitalized for surgery. Dexmedetomidine may reduce or reverse the early consolidation and formation of conditioned fear memory and prevent the occurrence of postoperative PTSD.

Objective

To evaluate the effects of intraoperative and postoperative low-dose intravenous pumping dexmedetomidine on PTSD among patients with trauma undergoing emergency surgery.

Design, Setting, and Participants

This double-blind, randomized clinical trial was conducted from January 22 to October 20, 2022, with follow-up 1 month postoperatively, in patients with trauma undergoing emergency surgery at 4 hospital centers in Jiangsu Province, China. A total of 477 participants were screened. The observers were blinded to patient groupings, particularly for subjective measurements.

Interventions

Dexmedetomidine or placebo (normal saline) was administered at a maintenance dose of 0.1 μg/kg hourly from the start of anesthesia until the end of surgery and at the same rate after surgery from 9 pm to 7 am on days 1 to 3.

Main Outcomes and Measures

The primary outcome was the difference in the incidence of PTSD 1 month after surgery in the 2 groups. This outcome was assessed with the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (CAPS-5). The secondary outcomes were the pain score within 48 hours and 1 month postoperatively; incidence of postoperative delirium, nausea, and pruritus; subjective sleep quality; anxiety; and occurrence of adverse events.

Results

A total of 310 patients (154 in the normal saline group and 156 in the dexmedetomidine group) were included in the modified intention-to-treat analysis (mean [SD] age, 40.2 [10.3] years; 179 men [57.7%]). The incidence of PTSD was significantly lower in the dexmedetomidine group than in the control group 1 month postoperatively (14.1% vs 24.0%; P = .03). The participants in the dexmedetomidine group had a significantly lower CAPS-5 score than those in the control group (17.3 [5.3] vs 18.9 [6.6]; mean difference, 1.65; 95% CI, 0.31-2.99; P = .02). After adjusting for potential confounders, the patients in the dexmedetomidine group were less likely to develop PTSD than those in the control group 1 month postoperatively (adjusted odds ratio, 0.51; 95% CI, 0.27-0.94; P = .03).

Conclusions and Relevance

In this randomized clinical trial, the administration of intraoperative and postoperative dexmedetomidine reduced the incidence of PTSD among patients with trauma. The findings of this trial support the use of dexmedetomidine in emergency trauma surgery.

Trial Registration

Chinese Clinical Trial Register Identifier: ChiCTR2200056162.

Comparison of Accelerated Resolution Therapy for PTSD Between Veterans With and Without Prior PTSD Treatment

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a psychiatric disorder commonly caused by a traumatic event(s) and prevalent among service members and veterans. Accelerated Resolution Therapy (ART) is an emerging "mind-body" psychotherapy for PTSD that is generally briefer and less expensive than current first-line treatments, such as cognitive processing therapy (CPT) and prolonged exposure (PE) therapy. This study examined the results of ART for treatment of military-related PTSD, with stratification by prior PTSD treatment types, including service members/veterans with reported residual PTSD symptoms following receipt of first-line recommended psychotherapy.

MATERIALS AND METHODS

Four groups were constructed and compared based on self-reported prior PTSD treatment history: treatment-naïve (n = 33), pharmacotherapy only (n = 40), first-line psychotherapy (CPT and/or PE) (n = 33), and other psychotherapy (n = 42). Participants were assessed for PTSD symptoms at baseline, post-treatment, and 6-month follow-up using the 17-item Military PTSD Checklist (PCL-M), as well as assessment of depressive, anxiety, and sleep symptoms. The study was approved by the Institutional Review Board at University of South Florida.

RESULTS

Among 148 veterans/service members who enrolled and started treatment with ART, 106 (71.6%) completed treatment in a mean of 3.5 treatment sessions, and 55 (51.9%) provided 6-month follow-up data. Mean age was 43.8 years, 95% were male, and 84% were of white race. Within-group standardized effect sizes for pre-to-post changes in PTSD scores (PCL-M) were large at 1.48, 1.11, 1.88, and 1.03 for the treatment-naïve, pharmacotherapy only, first-line psychotherapy, and other psychotherapy groups, respectively. Among treatment completers, the clinically significant treatment response rate (reduction of ≥10 points on the PCL-M) was highest in the treatment-naïve (83%) and first-line psychotherapy (88%) groups. Similar significant symptom reductions were observed for measures of depression and anxiety, and favorable treatment effects were generally sustained at 6-month follow-up.

CONCLUSION

In a brief treatment period, ART appears to result in substantial reductions in symptoms of PTSD among veterans, including those with residual PTSD symptoms after prior treatment with first-line psychotherapies endorsed by the U.S. Department of Defense and Veterans Affairs. These results suggest that ART be considered as a potential first-line treatment modality for veterans with PTSD.

Posttraumatic stress, visual working memory, and visual imagery in military personnel

Posttraumatic stress disorder (PTSD) is characterized by disruptions to cognitive functioning. Two studies were conducted to examine the relevance of military-related PTSD to two cognitive functions - visual working memory and visual imagery. Participants were military personnel who reported their PTSD diagnosis history and completed a self-administered screening tool for PTSD, the PTSD Checklist - Military Version. In Study 1, 138 personnel also completed a memory span task and a 2-back task using colored words in which Stroop interference was introduced via the semantic content of the words. In Study 2, a separate group of 211 personnel completed measures of perceived imagery vividness and spontaneous use of visual imagery. Interference effects on working memory in PTSD-diagnosed military personnel were not replicated. However, ANCOVA and structural equation modelling revealed that PTSD-intrusions were associated with poorer working memory whereas PTSD-arousal was associated with spontaneous use of visual imagery. We interpret these results as evidence that intrusive flashbacks disrupt working memory performance not by limiting memory capacity nor by interfering directly with memory functions such as inhibition, but by adding internal noise in the form of task-irrelevant memories and emotions. Visual imagery appears to be unrelated to these flashbacks but with arousal symptoms of PTSD, perhaps in the form of flashforwards about feared/anticipated threats.

PTSD as a Moderator of the Relationship Between the Distribution of Personal Resources and Spiritual Change Among Participants of Hostilities in Ukraine

The theory of conservation of resources (COR) can be used to search for mechanisms that explain spiritual changes caused by trauma. The present study aimed to verify whether PTSD could be a potential moderator between the distribution of personal resources and spiritual changes. The study included a total of 324 adults (75 women and 243 men) aged 18-74. The mean age was 34.3 (SD = 9.9). The Polish adaptation of Hobfoll's Conservation of Resources-Evaluation (COR-E), the posttraumatic stress disorder (PTSD) Checklist-Civilian Version and the Posttraumatic Growth Inventory were employed in the research. This study analyzed the spiritual change, which is one of the five domains of posttraumatic growth. The outcomes indicated the significant role of PTSD as a moderator of the relationships between 1) personal resources gain and spiritual change and 2) personal resources loss and spiritual change. PTSD is not a moderator in the relationship between assigning value to personal resources and spiritual change.

The role of posttraumatic stress symptoms on memory complaints and performance in active-duty service members

OBJECTIVE

Memory complaints are the most common form of cognitive limitation reported by military service members, but prior research suggests that posttraumatic stress symptoms (PTSS) may account for the link between subjective cognitive complaints and objective cognitive performance. The mechanisms underlying this relationship are largely unknown, including whether the finding applies to memory complaints and performance, which clinical dimensions are involved, and how the association varies when memory complaints are non-credible.

METHOD

Using a sample of 196 US military service members, the present study aims to address these gaps by modeling the relationship between objective memory performance and plausible/implausible subjective memory complaints, then evaluating how the association is influenced by PTSS and clinical traits commonly found within PTSS (e.g. depression, anxiety, and somatic concerns).

RESULTS

Overall memory complaints were associated with immediate and delayed recall, but both associations were fully mediated by PTSS (95% CI -0.14, -0.01; 95% CI -0.14, -0.02, respectively). Implausible memory complaints, however, were inconsistently linked to memory performance, and no PTSS mediation was observed. Of the clinical traits, only depression moderated the impact of PTSS, specifically by influencing the link between PTSS and overall memory complaints (β = -0.02, SE = 0.004, p < .001).

CONCLUSIONS

These results corroborate the importance of assessment for PTSS and depression in service members who report subjective memory complaints and highlight how targeted intervention for these conditions may play a key role in the management of memory complaints.

The influence of sleep on fear extinction in trauma-related disorders

In Posttraumatic Stress Disorder (PTSD), fear and anxiety become dysregulated following psychologically traumatic events. Regulation of fear and anxiety involves both high-level cognitive processes such as cognitive reattribution and low-level, partially automatic memory processes such as fear extinction, safety learning and habituation. These latter processes are believed to be deficient in PTSD. While insomnia and nightmares are characteristic symptoms of existing PTSD, abundant recent evidence suggests that sleep disruption prior to and acute sleep disturbance following traumatic events both can predispose an individual to develop PTSD. Sleep promotes consolidation in multiple memory systems and is believed to also do so for low-level emotion-regulatory memory processes. Consequently sleep disruption may contribute to the etiology of PTSD by interfering with consolidation in low-level emotion-regulatory memory systems. During the first weeks following a traumatic event, when in the course of everyday life resilient individuals begin to acquire and consolidate these low-level emotion-regulatory memories, those who will develop PTSD symptoms may fail to do so. This deficit may, in part, result from alterations of sleep that interfere with their consolidation, such as REM fragmentation, that have also been found to presage later PTSD symptoms. Here, sleep disruption in PTSD as well as fear extinction, safety learning and habituation and their known alterations in PTSD are first briefly reviewed. Then neural processes that occur during the early post-trauma period that might impede low-level emotion regulatory processes through alterations of sleep quality and physiology will be considered. Lastly, recent neuroimaging evidence from a fear conditioning and extinction paradigm in patient groups and their controls will be considered along with one possible neural process that may contribute to a vulnerability to PTSD following trauma.

Postdeployment Treatment Gap: Symptoms and Treatment Utilization Among Returning National Guard Soldiers

This study evaluated rates of psychiatric symptoms and mental health treatment utilization among National Guard service members during the post-deployment period. National Guard service members (n=311) completed surveys assessing demographics, beliefs about mental health treatment, emotion regulation strategies, and psychiatric symptoms. Mental health treatment utilization was assessed at 6-month follow-up. Post-deployment, 41.2% of the sample had psychiatric symptoms above the clinical cut-off for at least one symptom measure. This proportion increased at follow-up (53.5%). Alcohol use disorder (AUD) symptoms showed the largest increase (d=0.66), although symptoms of depression and posttraumatic stress disorder (PTSD) also showed small magnitude increases. Among those with elevated symptoms post-deployment (n=128), only 27.8% received mental health treatment at follow-up. Severity of depression, anxiety, and PTSD were higher among those who utilized treatment. The post-deployment period is a vulnerable one. Continued efforts to understand and address barriers to treatment for this population are warranted.

Evaluation of post-traumatic stress disorder (PTSD) and related comorbidities in clinical studies

Patients with traumatic brain injury (TBI) of varying severities are experiencing adverse outcomes during and after rehabilitation. Besides depression and anxiety, post-traumatic stress disorder (PTSD) is highly encountered in civilian and military populations. As more prospective and retrospective studies - focused on evaluating new or old psychological therapies in inpatient, outpatient, or controlled environments, targeting patients with PTSD with or without a history of TBI - are carried out, researchers are employing various scales to measure PTSD as well as other psychiatric diagnoses or cognitive impairments that might appear following TBI. We aimed to explore the literature published between January 2010 and October 2021 by querying three databases. Our preliminary results showed that several scales - such as the Clinician-Administered PTSD Scale (CAPS), the Posttraumatic Stress Disorder Checklist Military Version (PCL-M) as well as Specific Version (PCL-S), and Civilian Version (PCL-C) - have been frequently used for PTSD diagnosis and symptom severity. However, heterogeneity in the scales used when assessing and evaluating additional psychiatric comorbidities and cognitive impairments are due to the study aim and therapeutic approaches. Therefore, conducting an intervention focusing on post-TBI PTSD patients requires increased attention to patients' medical history in capturing multiple cognitive impairments and affected neuropsychological processes when designing the study and including validated instruments for measuring primary and secondary neuropsychological outcomes.

Psychophysiological Responses to a Brief Self-Compassion Exercise in Armed Forces Veterans

Armed Forces personnel are exposed to traumatic experiences during their work; therefore, they are at risk of developing emotional difficulties such as post-traumatic stress disorder (PTSD), following traumatic experiences. Despite evidence to suggest that self-compassion is effective in reducing the symptoms of PTSD, and greater levels of self-compassion are associated with enhanced resilience, self-compassion in armed forces personnel and armed forces veterans remains under-researched. As a result, it is not known if therapeutic approaches that use self-compassion interventions are an acceptable and effective treatment for this population. Having previously shown that a one-off self-compassion exercise has temporary beneficial psychophysiological effects in non-clinical participants, we conducted this proof-of concept study to investigate whether this exercise is equally beneficial in veterans who had experienced deployment to a combat zone. Additionally, we examined if brief a self-compassion exercise can temporarily reduce hyperarousal symptoms and increase feelings of social connectedness. The current study also investigated the association between PTSD symptom severity, emotion regulation, and self-compassion in 56 veterans. All participants listened to a loving-kindness meditation for self-compassion (LKM-S) and psychophysiological recordings were taken throughout. Psychophysiological effects were observed including heart-rate (HR), skin conductance (SCL), and heart-rate variability (HRV) to determine associations with PTSD and changes in response associated with the self-compassion induction. PTSD symptom severity, dispositional emotion regulation, and self-compassion were measured, and participants also completed state measures of hyperarousal and social connectedness before and after the LKM-S. The findings partially demonstrated that self-compassion can be elicited in a veteran population but there were considerable individual differences in psychophysiological responses. The findings are discussed in light of existing theories of PTSD and self-compassion and the implications of using self-compassion based psychological approaches with veterans.

Genetic and Psychosocial Risk Factors Associated with Suicide Among Community Veterans: Implications for Screening, Treatment and Precision Medicine

Introduction

Since veteran suicide is a concern and our knowledge of predictive factors is still limited, our objective was to assess risk factors for suicide, including genetic factors, among deployed veterans.

Methods

For this study, we surveyed 1730 veterans who were outpatients in a multi-hospital system in Pennsylvania. Altogether, 1041 veterans (60%) provided a DNA sample. The genetic risk variants investigated were within loci previously associated with PTSD and substance misuse, including CRHR1, CHRNA5, RORA, and FKBP5 genetic variations, which were used to calculate a polygenic risk score (range=0–8, mean=3.6, SD=1.4).

Results

Most veterans (56.2%) were deployed to Vietnam while significant numbers were deployed to Iraq, Afghanistan, and other post-Vietnam conflicts. Overall, 95.1% of the veterans were male, their mean age was 56.2 (SD=12), and 95.6% were Caucasian. Among the veterans, 24% had high combat exposure. The prevalence of lifetime suicidal thoughts was 11.3%. Additionally, 5.7% ever developed a suicide plan or attempted suicide in their lifetimes. Among those with a history of a lifetime suicide attempt or suicide plan, the PTSD genetic risk score was significantly higher (OR=3.96 vs 3.55, p=0.033), but for suicidal thoughts, this association was not significant (p=0.717). In multivariable analysis (MVA) logistic regression, significant predictors of attempting suicide or having a suicide plan were history of depression (OR=5.04, p<0.001), PTSD genetic risk score (OR=1.25, p=0.036), history of childhood abuse/neglect (OR=2.24, p=0.009), and lifetime marijuana use (OR= 1.56, p=0.020). Conversely, rural residence was protective for suicide risk (OR=0.49; p=0.031). For suicidal thoughts, in the MVA genetic risk score was not significant (p=0.697), but history of child abuse/neglect (p<0.001), history of depression (p>0.001), low psychological resilience (p=0.004), and lifetime marijuana use (p=0.022) were significant.

Discussion

In this study, we identified genetic risk variants and other predictors for suicide among veterans that may have implications for future screening and clinical care. Further research is advised.

Effects of Sevoflurane and Propofol on Posttraumatic Stress Disorder After Emergency Trauma: A Double-Blind Randomized Controlled Trial

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a frequent and disabling consequence of traumatic events. A previous study found that early use of propofol was a potential risk factor for PTSD. This prospective study aimed to investigate the effect of propofol and sevoflurane on PTSD after emergency surgery in trauma patients.

METHODS

A total of 300 trauma patients undergoing emergency surgery were randomly divided into two groups and anesthetized with propofol and/or sevoflurane. Perioperative clinical data were collected. The incidence of PTSD was evaluated with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) in the two groups 1 month after the operation. The relevance of the injury time and CAPS-5 scores was assessed by Spearman correlation analysis. Logistic regression analysis was used to analyze the risk factors for PTSD.

RESULTS

The incidence of PTSD in the propofol group was higher than that in the sevoflurane group 1 month postoperatively (23.2 vs. 12.2%, P = 0.014). The injury time was negatively correlated with the CAPS-5 score in the propofol group (r = -0.226, P < 0.001). In the logistic regression analysis, the utilization of propofol was an independent risk factor for PTSD (P = 0.017).

CONCLUSION

Early use of propofol general anesthesia in emergency surgery for trauma patients may increase the risk of PTSD.

CLINICAL TRIAL REGISTRATION

www.chictr.org.cn, identifier: ChiCTR2100050202.

PTSD: Past, present and future implications for China

There has been a long history since human beings began to realize the existence of post-traumatic symptoms. Posttraumatic stress disorder (PTSD), a diagnostic category adopted in 1980 in the Diagnostic and Statistical Manual of Mental Disorders-Ⅲ, described typical clusters of psychiatric symptoms occurring after traumatic events. Abundant researches have helped deepen the understanding of PTSD in terms of epidemiological features, biological mechanisms, and treatment options. The prevalence of PTSD in general population ranged from 6.4% to 7.8% and was significantly higher among groups who underwent major public traumatic events. There has been a long way in the studies of animal models and genetic characteristics of PTSD. However, the high comorbidity with other stress-related psychiatric disorders and complexity in the pathogenesis of PTSD hindered the effort to find specific biological targets for PTSD. Neuroimage was widely used to elucidate the underlying neurophysiological mechanisms of PTSD. Functional MRI studies have showed that PTSD was linked to medial prefrontal cortex, anterior cingulate cortex and sub-cortical structures like amygdala and hippocampus, and to explore the functional connectivity among these brain areas which might reveal the possible neurobiological mechanism related to PTSD symptoms. For now, cognitive behavior therapy-based psychotherapy, including combination with adjunctive medication, showed evident treatment effects on PTSD. The emergence of more effective PTSD pharmacotherapies awaits novel biomarkers from further fundamental research. Several natural disasters and emergencies have inevitably increased the possibility of suffering from PTSD in the last two decades, making it critical to strengthen PTSD research in China. To boost PTSD study in China, the following suggestions might be helpful: (1) establishing a national psychological trauma recover project, and (2) exploring the mechanisms of PTSD with joint effort and strengthening the indigenized treatment of PTSD.

Military-related posttraumatic stress disorder and mindfulness meditation: A systematic review and meta-analysis

PURPOSE

Posttraumatic stress disorder (PTSD) is a significant global mental health concern, especially in the military. This study aims to estimate the efficacy of mindfulness meditation in the treatment of military-related PTSD, by synthesizing evidences from randomized controlled trials.

METHODS

Five electronic databases (Pubmed, EBSCO Medline, Embase, PsychINFO and Cochrane Library) were searched for randomized controlled trials focusing on the treatment effect of mindfulness meditation on military-related PTSD. The selection of eligible studies was based on identical inclusion and exclusion criteria. Information about study characteristics, participant characteristics, intervention details, PTSD outcomes, as well as potential adverse effects was extracted from the included studies. Risk of bias of all the included studies was critically assessed using the Cochrane Collaboration's tool. R Statistical software was performed for data analysis.

RESULTS

A total of 1902 records were initially identified and screened. After duplicates removal and title & abstract review, finally, 19 articles in English language with 1326 participants were included through strict inclusion and exclusion criteria. The results revealed that mindfulness meditation had a significantly larger effect on alleviating military-related PTSD symptoms compared with control conditions, such as treatment as usual, present-centered group therapy and PTSD health education (standardized mean difference (SMD) = -0.33; 95% CI [-0.45, -0.21]; p < 0.0001). Mindfulness interventions with different control conditions (active or non-active control, SMD = -0.33, 95% CI [-0.46, -0.19]; SMD = -0.49, 95% CI [-0.88, -0.10], respectively), formats of delivery (group-based or individual-based, SMD = -0.30, 95% CI [-0.42, -0.17], SMD = -0.49, 95% CI [-0.90, -0.08], respectively) and intervention durations (short-term or standard duration, SMD = -0.27, 95% CI [-0.46, -0.08], SMD = -0.40, 95% CI [-0.58, -0.21], respectively) were equally effective in improving military-related PTSD symptoms.

CONCLUSION

Findings from this meta-analysis consolidate the efficacy and feasibility of mindfulness meditation in the treatment of military-related PTSD. Further evidence with higher quality and more rigorous design is needed in the future.

Telomere Shortening and Psychiatric Disorders: A Systematic Review

Telomeres are aging biomarkers, as they shorten while cells undergo mitosis. The aim of this study was to evaluate whether psychiatric disorders marked by psychological distress lead to alterations to telomere length (TL), corroborating the hypothesis that mental disorders might have a deeper impact on our physiology and aging than it was previously thought. A systematic search of the literature using MeSH descriptors of psychological distress ("Traumatic Stress Disorder" or "Anxiety Disorder" or "depression") and telomere length ("cellular senescence", "oxidative stress" and "telomere") was conducted on PubMed, Cochrane Library and ScienceDirect databases. A total of 56 studies (113,699 patients) measured the TL from individuals diagnosed with anxiety, depression and posttraumatic disorders and compared them with those from healthy subjects. Overall, TL negatively associates with distress-related mental disorders. The possible underlying molecular mechanisms that underly psychiatric diseases to telomere shortening include oxidative stress, inflammation and mitochondrial dysfunction linking. It is still unclear whether psychological distress is either a cause or a consequence of telomere shortening.

Development and initial testing of a brief adjunctive intervention for family members of veterans in individual PTSD treatment

Family involvement in the treatment of posttraumatic stress disorder (PTSD) among veterans has the potential to improve treatment retention and outcomes. Current protocols that incorporate family members into treatment tend to involve at least 15 sessions, and none are designed to complement Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE), the two most widely used and heavily promoted evidence-based PTSD therapies in the Veterans Affairs (VA) healthcare system. The current paper describes the development and initial feasibility and acceptability of a Brief Family Intervention (the BFI) designed to be delivered as an adjunct to veterans' individual CPT/PE. The BFI focuses on providing psychoeducation about PTSD and treatment, building family member support for treatment, and reducing family symptom accommodation. A detailed review of the treatment structure and activities is provided, and qualitative data from four dyads (veterans and their spouses/significant others) at baseline and post-intervention are presented. Veterans and partners reported positive responses to the program and were enthusiastic about its utility. Larger randomized controlled studies will be needed to determine the protocol's efficacy and effectiveness.

Health-Promoting Leadership During an Infectious Disease Outbreak: A Cross-Sectional Study of US Soldiers Deployed to Liberia

ABSTRACT

Infectious disease outbreaks are uniquely stressful for essential employees. One way to support workers is for supervisors to engage in behaviors promoting employees' well-being and attitudes toward preventive medicine practices. We examined whether health-promoting leadership contributes to these outcomes in a population of active-duty soldiers (N = 173) deployed to provide nonmedical support in Liberia during the 2014 Ebola epidemic using data reported in Sipos, Kim, Thomas, and Adler (Mil Med 183[3-4]:e171-e178, 2018). Soldiers completed surveys assessing posttraumatic stress disorder (PTSD), depression, anxiety, sleep problems, burnout, morale, and attitudes and rated their leaders on health-promoting behaviors. Using mixed-effects logistic regression, health-promoting leadership focused on psychological health was associated with decreased odds of PTSD, depression, anxiety, and burnout, and increased odds of high morale and avoiding unnecessary risk. Health-promoting leadership focused on preventive medicine was associated with decreased odds of depression and anxiety, and increased odds of high morale, positive attitudes, and avoiding unnecessary risk. Findings suggest health-promoting leadership could be valuable for workers responding to epidemics.

Posttraumatic Stress Disorder Symptom Clusters in Service Members Predict New-Onset Depression Among Military Spouses

Military operations in Iraq and Afghanistan have brought increased attention to posttraumatic stress disorder (PTSD) among service members and, more recently, its impact on spouses. Existing research has demonstrated that PTSD among service members is associated with depression among military spouses. In the current study, we extended these findings by using data from service member-spouse dyads enrolled in the Millennium Cohort Family Study for which the service member had evidence of PTSD (n = 563). Prospective analyses identified the association between PTSD symptom clusters reported by the service member and new-onset depression among military spouses. Over the 3-year study period, 14.4% of these military spouses met the criteria for new-onset depression. In adjusted models, service member ratings of symptoms in the effortful avoidance cluster, odds ratio (OR) = 1.61, 95% CI [1.03, 2.50], predicted an increased risk of new-onset depression among military spouses, whereas reexperiencing symptoms, adjusted OR = 0.57; 95% CI [0.32, 1.01], were marginally protective. These findings suggest that PTSD symptom clusters in service members differentially predict new-onset depression in military spouses, which has implications for treatment provision.

Sex-Specific Differences in Rodents Following a Single Primary Blast Exposure: Focus on the Monoamine and Galanin Systems

Most blast-induced traumatic brain injuries (bTBI) are mild in severity and culpable for the lingering and persistent neuropsychological complaints in affected individuals. There is evidence that the prevalence of symptoms post-exposure may be sex-specific. Our laboratory has focused on changes in the monoamine and the neuropeptide, galanin, systems in male rodents following primary bTBI. In this study, we aimed to replicate these findings in female rodents. Brainstem sections from the locus coeruleus (LC) and dorsal raphe nuclei (DRN) were processed for in situ hybridisation at 1 and 7 days post-bTBI. We investigated changes in the transcripts for tyrosine hydroxylase (TH), tryptophan hydroxylase two (TPH2) and galanin. Like in males, we found a transient increase in TH transcript levels bilaterally in the female LC. Changes in TPH2 mRNA were more pronounced and extensive in the DRN of females compared to males. Galanin mRNA was increased bilaterally in the LC and DRN, although this increase was not apparent until day 7 in the LC. Serum analysis revealed an increase in corticosterone, but only in exposed females. These changes occurred without any visible signs of white matter injury, cell death, or blood–brain barrier breakdown. Taken together, in the apparent absence of visible structural damage to the brain, the monoamine and galanin systems, two key players in emotional regulation, are activated deferentially in males and females following primary blast exposure. These similarities and differences should be considered when developing and evaluating diagnostic and therapeutic interventions for bTBI.

Gender Differences in Mental Health Screening Outcomes Among U.S. Marines in Combat Support Occupations

BACKGROUND

The role of women in the U.S. Military has expanded over the years. Recent policy changes allow for women to serve in all military occupations, including direct combat. Multiple studies have identified a higher risk of mental health problems with increasing levels of combat, but little is known regarding gender differences among specific combat support occupations.

METHODS

A total of 15,900 U.S. Marines (1,065 women and 14,835 men) with a deployment between 2007 and 2009 were identified from electronic military records. A standard health questionnaire was completed at the end of deployment, which queried the service member on combat exposure and mental health. Mental health problems were defined as screening positive for post-traumatic stress disorder or depression, or receiving a mental health referral. Military occupation was categorized as electrical/mechanical repair, communications/intelligence, functional support/administration, and service/supply.

RESULTS

Overall, men reported more combat exposure than women. The communications/intelligence and service/supply occupations had the highest rates of combat exposure. After adjusting for combat exposure, previous diagnosis of anxiety or depression, deployment time, age, and military rank, women had higher odds than men for mental health problems in service/supply (odds ratio, 1.76; 95% confidence interval, 1.21-2.56) and communications/intelligence occupations (odds ratio, 1.60; 95% confidence interval, 1.01-2.52).

CONCLUSIONS

As women become fully integrated into the military, the study of health disparities becomes essential for medical planning purposes. Occupation-specific exposures should be considered, along with combat exposures, when determining a risk profile for adverse mental health outcomes among women and men after wartime deployment.

Efficacy of a Web‐Based Tool in Reducing Burnout Among Behavioral Health Clinicians: Results From the PTSD Clinicians Exchange

Objective

Burnout is widespread among behavioral health clinicians treating posttraumatic stress disorder (PTSD) among military populations. Intervention‐based strategies have shown some benefit in addressing clinician burnout. One Web‐based tool, the PTSD Clinicians Exchange, was designed to disseminate clinical best practices for the treatment of PTSD and facilitate self‐care to mitigate burnout. This study sought to determine whether this tool could reduce burnout among clinicians treating military populations.

Methods

A total of 605 behavioral health clinicians from the U.S. Department of Veterans Affairs, the Department of Defense, and the community were enrolled in a randomized controlled trial to test the effectiveness of the PTSD Clinicians Exchange. Clinicians were assessed on demographic characteristics, practice patterns, and organizational support with an online survey at baseline and at 6 and 12 months. Burnout, secondary traumatic stress (STS), and compassion satisfaction were measured with the Professional Quality of Life Scale.

Results

At baseline, no differences were observed in mean±SD burnout scores for the intervention (19.9±5.1) and control groups (20.2±5.4). Participation in the Exchange had no effect on burnout score at 12 months; burnout scores remained stable across the study period. In a multivariable stepwise regression model, older age, lower burnout at baseline, and lower STS scores and higher compassion satisfaction scores at 12 months were significantly associated with lower burnout scores.

Conclusions

The PTSD Clinicians Exchange did not mitigate burnout among clinicians, possibly because of the content provided, the dissemination mechanism, or participants’ limited use of the Web site. These results can be used to inform and enhance future interventions.

Burnout is a prevalent issue among behavioral health clinicians treating posttraumatic stress disorder (PTSD) in military populations.

This study sought to determine whether a Web‐based tool could significantly reduce burnout among clinicians treating military populations that had experienced trauma.

The PTSD Clinicians Exchange did not mitigate burnout among behavioral health clinicians.

UK military women: mental health, military service and occupational adjustment

Background

Recently, the UK Armed Forces have revised the ground close combat role to include women.

Aims

To assess the potential mental health impact of this initiative we examined gender differences in deployment patterns, work strain, occupational factors, mental health, alcohol use and help-seeking following operational deployment.

Methods

The study was a secondary analysis of self-report survey data; 8799 men (88%) and 1185 women (12%) provided data. A sub-sample (47%, n = 4659) provided data concerning post-deployment help-seeking. The latter consisted of 408 women (8.8%) and 4251 men (91%).

Results

With the exception of alcohol misuse, which was significantly lower for women, women reported significantly more common mental disorder symptoms, subjective depression and self-harm. Women were significantly more likely to seek help from healthcare providers. Men were significantly more likely to have deployed operationally and for longer cumulative periods. Subjective work strain, but not job control, was significantly lower for women whose military careers were significantly shorter. Post-traumatic stress disorder (PTSD) symptom intensity was similar to men.

Conclusions

With the exception of PTSD and alcohol misuse, UK military women experience more mental health-related problems than military men. This finding was not related to the more arduous aspects of military service as women served for shorter times, deployed less and for shorter cumulative periods and were less likely to report work-related stress.

Efficacy of Self-Management Smartphone-Based Apps for Post-traumatic Stress Disorder Symptoms: A Systematic Review and Meta-Analysis

Post-traumatic stress disorder (PTSD) symptoms are prevalent in both civilian and military service members. As the number of smartphone-based applications (apps) grows rapidly in health care, apps are also increasingly used to help individuals with subthreshold PTSD or full PTSD. Yet, if the apps are self-managed, the feasibility and efficacy of such interventions are still rather unclear in these two populations with PTSD symptoms. Hence, the present meta-analysis set out to evaluate the effect of self-management smartphone-based apps on PTSD and depressive symptoms in populations with subthreshold PTSD or full PTSD. Studies were included if they conducted randomized controlled trials or pre-post comparisons. Six studies (n = 2 randomized controlled trials) were identified for meta-analysis. In pre-post comparisons, N = 209 participants were included in the analyses. In randomized controlled trials, N = 87 participants received smartphone-based self-management interventions and N = 82 participants were in waitlist control conditions. Meta-analysis for pre-post comparisons concluded an effect of g = 0.55 (p < 0.001) regarding the overall reduction in PTSD symptoms (n = 6) and g = 0.45 (p < 0.001) for reduction in depressive symptoms (n = 5). Yet, in randomized controlled trials, no significant difference was found between app-based treatment and waitlist control groups (g = 0.09, p = 0.574). The duration of the interventions did not significantly influence the results. Overall, despite positive pre-post effects, current results indicate that smartphone-apps for PTSD patients are not significantly more effective than waitlist control conditions. Nevertheless, a combined smartphone and standard therapy approach may be a fruitful field for future research.

Rates of Behavioral Health Conditions and Health Risk Behaviors in Operators and Support Personnel in U.S. Special Operations Forces

Objective: Rates of behavioral health disorders and potential protective factors in U.S. Special Operations Forces (SOF) have not been well studied, including differences between Operators and Support personnel, despite very high levels of combat exposure in these military personnel. The present study examined the prevalence of endorsed behavioral health problems and protective factors within a large sample of SOF personnel. Method: Anonymized data from 16,284 active duty SOF Service members from the 2016 Preservation of the Force and Family (POTFF) needs survey were analyzed. Results: Overall, the prevalence of PTSD (7.6%), depression (8.4%), alcohol misuse (12.8%), and nicotine use (28%) were comparable or lower than reported in conventional military populations. There were significant differences between Operators and Support personnel in a number of demographic and service-related variables. Operators also endorsed more direct combat exposure and scored higher on resilience and social support, and reported better quality and quantity of sleep. There were no significant group differences in rates of PTSD and depression, except lower odds (adjusted OR = 0.81) for alcohol problems in Support personnel (11.6%) compared to Operators (14.0%), p <.001, 95% CI [0.72, 0.91]. Conclusions: SOF personnel experience considerably higher exposure to combat deployments than conventional forces, yet the data from this study showed comparable or lower levels of behavioral health conditions. Although Operators were somewhat more likely than Support personnel to experience alcohol problems, they showed enhanced resilience, social support, and sleep health. Alcohol misuse is one potential target for preventive health efforts.

Neurological Soft Signs and Post-Traumatic Stress Disorder: A Biomarker of Severity?

BACKGROUND

The psychophysiological changes for individual suffering from chronic post-traumatic stress disorder (PTSD) raise to the questions of how facilitate recovery and return to work. Negative alterations in neuro-cognition remain a complaint for patients and participate to long-term functional impairments. Neurological soft signs (NSSs) appear as a candidate for better understanding these complaints. They have been reported in several mental disorders. They are found in several behavioral and/or neurocognitive disorders and are taken into account by psychiatric rehabilitation programs to support recovery. As few studies evaluate NSSs in PTSD, our exploratory study aims to assess NSSs in chronic PTSD and their relationships with PTSD severity.

METHOD

Twenty-two patients with a clinical diagnosis of chronic PTSD were evaluated in terms of PTSD severity (post-traumatic checklist scale, PCL5), NSSs (NSSs psychomotor skills scale, PASS), and well-being upon arrival to the hospital and compared with 15 healthy subjects. Statistical non-parametric analyses assessed the relationships between these variables.

RESULTS

PTSD subjects exhibited higher NSSs compared with healthy subjects. NSSs were positively associated with PTSD severity, with negative alterations in cognition and mood, and with impairment in well-being. They were higher in women compared with men. No impact of age was found. Three groups were identified based on the severity of the PTSD. Severe PTSD exhibited NSSs characterized by motor integration alterations.

CONCLUSIONS

This pilot study suggests that NSSs might be a biomarker of PTSD severity. This proof of concept highlights the need for further research for better evaluating the clinical neuro-functional impairment. This will be helping for defining neurological remediation for promoting PTSD recovery.

The Associations Between Physical and Psychological Symptoms and Traumatic Military Deployment Exposures

Current paradigms regarding the effects of traumatic exposures on military personnel do not consider physical symptoms unrelated to injury or illness as independent outcomes of trauma exposure, characteristically dealing with these symptoms as comorbidities of psychological disorders. Our objective was to ascertain the proportions of deployed military personnel who experienced predominantly physical symptoms, predominantly psychological symptoms, and comorbidity of the two and to examine the association between traumatic deployment exposures (TDEs) and these symptomatic profiles. Data were taken from a cross-sectional study of Australian Defence Force personnel who were deployed to the Middle East during 2001-2009 (N = 14,032). Four groups were created based on distributional splits of physical and psychological symptom scales: low-symptom, psychological, physical, and comorbid. Multinomial logistic regression models assessed the probability of symptom group membership, compared with low-symptom, as predicted by self-reported TDEs. Group proportions were: low-symptom, 78.3%; physical, 5.0%; psychological, 9.3%; and comorbid, 7.5%. TDEs were significant predictors of all symptom profiles. For subjective, objective, and human death and degradation exposures, respectively, the largest relative risk ratios (RRRs) were for the comorbid profile, RRRs = 1.47, 1.19, 1.48; followed by the physical profile, RRRs = 1.27, 1.15, 1.40; and the psychological profile, RRRs = 1.22, 1.07, 1.22. Almost half of participants with physical symptoms did not have comorbid psychological symptoms, suggesting that physical symptoms can occur as a discrete outcome trauma exposure. The similar dose-response association between TDEs and the physical and psychological profiles suggests trauma is similarly associated with both outcomes.

Typologies of Combat Exposure and Their Effects on Posttraumatic Stress Disorder and Depression Symptoms

The present study identified distinct classes of U.S. military service members based on their combat experiences and examined mental health outcomes and longitudinal growth curves of posttraumatic stress disorder (PTSD) and depression symptoms associated with each class. Participants were 551 active duty service members who screened positive for PTSD and/or depression based on DSM-IV-TR criteria. All participants completed the Combat Experiences Scale at baseline as well as PTSD and depression measures at baseline and at 3-, 6-, and 12-month follow-ups. A latent class analysis identified four classes of service members based on their combat experiences: limited exposure, medical exposure, unit exposure, and personal exposure. Service members in the personal exposure class were characterized by a distinct mental health profile: They reported a higher level of PTSD symptoms at baseline and a higher prevalence of traumatic brain injury and PTSD diagnoses during the course of the study. The limited exposure class was more likely to receive diagnoses of depression and adjustment disorders. All classes except the medical exposure class demonstrated a slight decrease in PTSD and depression symptoms over time. However, participants in the limited exposure class had a larger decrease in PTSD and depression symptoms earlier in care but did not demonstrate superior long-term symptom improvements at 12 months compared to the other groups. These results inform PTSD development models and have implications for the screening and clinical management of combat-exposed service members.

Brazilian Jiu Jitsu Training for US Service Members and Veterans with Symptoms of PTSD

Introduction

The United States has been actively involved in major armed conflicts over the last 15 years. As a result, a significant proportion of active duty service personnel and returning veterans have endured combat, putting them at risk for developing post-traumatic stress disorder (PTSD), a disabling disorder that may occur after exposure to a traumatic event. Current therapies often require long-term, time-intensive and costly commitment from the patient and have variable degrees of success. There remains an ongoing need for better therapies, including complementary medicine approaches that can effectively reduce PTSD symptoms. While anecdotal evidence suggests that routine practice of Brazilian Jiu Jitsu (BJJ) can reduce symptoms of PTSD, there have been no formal studies to address this.

Materials and Methods

This study was approved by the University of South Florida Institutional Review Board (#PRO00019430). Male US active duty service members and veterans from the Tampa area participated in a 5-month (40 sessions) BJJ training program. Before beginning and again midway through and upon completion of training the participants completed several validated self-report measures that addressed symptoms of PTSD and other co-morbid conditions. Effect size and 95% confidence intervals were determined using a within-person single-group pretest–posttest design.

Results

Study participants demonstrated clinically meaningful improvements in their PTSD symptoms as well as decreased symptoms of major depressive disorder, generalized anxiety and decreased alcohol use; effect sizes varied from 0.80 to 1.85.

Conclusions

The results from this first-of-kind pilot study suggest that including BJJ as a complementary treatment to standard therapy for PTSD may be of value. It will be necessary to validate these promising results with a larger subject cohort and a more rigorous experimental design before routinely recommending this complementary therapy.

Neurophysiology of threat processing bias in combat-related post-traumatic stress disorder

Post‐traumatic stress disorder (PTSD) is a debilitating condition that may develop after experiencing a traumatic event. Combat exposure increases an individual's chance of developing PTSD, making veterans especially susceptible to the disorder. PTSD is characterized by dysregulated emotional networks, memory deficits, and a hyperattentive response to perceived threatening stimuli. Recently, there have been a number of imaging studies that show structural and functional abnormalities associated with PTSD; however, there have been few studies utilizing electroencephalography (EEG). The goal of this study was to characterize **EEG brain dynamics in individuals with PTSD, in order to better understand the neurophysiological underpinnings of some of the salient features of PTSD, such as threat‐processing bias. Veterans of Operation Enduring Freedom/Iraqi Freedom completed an implicit visual threat semantic memory recognition task with stimuli that varied on both category (animals, items, nature, and people) and feature (threatening and nonthreatening) membership, including trauma‐related stimuli. Combat veterans with PTSD had slower reaction times for the threatening stimuli relative to the combat veterans without PTSD (VETC). There were trauma‐specific effects in frontal regions, with theta band EEG power reductions for the threatening combat scenes in the PTSD patients compared to the VETC group. Additionally, a moderate negative correlation was observed between trauma‐specific frontal theta power and hyperarousal symptoms as measured by clinically administered PTSD scale. These findings complement and extend current models of cortico‐limbic dysfunction in PTSD. The moderate negative correlation between frontal theta power and hyperarousal endorsements suggests the utility of these measures as therapeutic markers of symptomatology in PTSD patients.

Associations Among Childhood Trauma, Childhood Mental Disorders, and Past-Year Posttraumatic Stress Disorder in Military and Civilian Men

To identify early life factors associated with posttraumatic stress disorder (PTSD), we investigated the association between childhood trauma and mental disorders with International Classification of Diseases (ICD)-diagnosed past-year PTSD in employed military and civilian men. Data were derived from the 2010 Australian Defence Force (ADF) Mental Health Prevalence and Wellbeing Study (N = 1,356) and the 2007 Australian Bureau of Statistics (ABS) National Survey of Mental Health and Wellbeing Study (N = 2,120) and analyzed using logistic regression and generalized structural equation modeling. After controlling for demographics, PTSD was associated with childhood anxiety, adjusted odds ratio (AOR) = 3.94, 95% CI [2.36, 6.58]; and depression, AOR = 7.01, 95% CI [2.98, 16.49], but not alcohol use disorders, in the ADF. In civilians, PTSD was associated with childhood anxiety only, AOR = 7.06, 95% CI [3.50, 14.22]. These associations remained significant after controlling for childhood and adult trauma in both populations and service factors and deployment, combat, or adult trauma in the ADF. In both populations, PTSD was associated with more than three types of childhood trauma: AOR = 2.97, 95% CI [1.53, 5.75] for ADF and AOR = 5.92, 95% CI [3.00, 11.70] for ABS; and childhood interpersonal, but not noninterpersonal, trauma: AOR = 3.08, 95% CI [1.61, 5.90] for ADF and AOR = 6.63, 95% CI [2.74, 16.06] for ABS. The association between childhood trauma and PTSD was fully mediated by childhood disorder in the ADF only. Taking a lifetime perspective, we have identified that the risk of PTSD from childhood trauma and disorder is potentially predictable and, therefore, modifiable.

Examining military population and trauma type as moderators of treatment outcome for first-line psychotherapies for PTSD: A meta-analysis

There is conflicting evidence as to whether military populations (i.e., veteran and active-duty military service members) demonstrate a poorer response to psychotherapy for posttraumatic stress disorder (PTSD) compared to civilians. Existing research may be complicated by the fact that treatment outcomes differences could be due to the type of trauma exposure (e.g., combat) or population differences (e.g., military culture). This meta-analysis evaluated PTSD treatment outcomes as a function of trauma type (combat v. assault v. mixed) and population (military v. civilian). Unlike previous meta-analyses, we focused exclusively on manualized, first-line psychotherapies for PTSD as defined by expert treatment guidelines. Treatment outcomes were large across trauma types and population; yet differences were observed between trauma and population subgroups. Military populations demonstrated poorer treatment outcomes compared to civilians. The combat and assault trauma subgroups had worse treatment outcomes compared to the mixed trauma subgroup, but differences were not observed between assault and combat subgroups. Higher attrition rates predicted poorer treatment outcomes, but did not vary between military populations and civilians. Overall, manualized, first-line psychotherapies for PTSD should continue to be used for civilians and military populations with various trauma types. However, greater emphasis should be placed on enhancing PTSD psychotherapies for military populations and on treatment retention across populations based on findings from this meta-analysis.

Impact of Repetitive Mild Traumatic Brain Injury on Behavioral and Hippocampal Deficits in a Mouse Model of Chronic Stress

Clinical studies examining the interaction between traumatic brain injury (TBI) and stress-related disorders (e.g., post-traumatic stress disorder) are often complicated by methodological constraints, such as heterogeneity in injury type and severity, time post-trauma, and predisposing risk factors. Developing relevant animal models whereby many variables can be efficiently controlled is thus essential to understanding this elusive relationship. Here, we use our repeated unpredictable stress (RUS) paradigm, in combination with our established mouse model of repetitive mild TBI (r-mTBI), to assess the impact of repeated exposures to these paradigms on behavioral and neurobiological measures. C57BL/6J male mice were exposed to RUS and r-mTBI at 3 and 6 months of age followed by batteries of behavioral testing. Mice were euthanized 10 days and 3 months post-exposure, with brain and plasma samples collected for molecular profiling. The RUS paradigm involved exposure to a predator odor (trimethylthiazoline; TMT) while under restraint, daily unstable social housing, five inescapable footshocks on separate days, and chronic social isolation. Animals receiving r-mTBI ( × 5) and stress were exposed to a single closed-head injury 1 h after each footshock. Stress-alone mice showed significant weight loss, recall of traumatic memories, and anxiety-like and passive stress-coping behavior when compared with control mice. However, in stress+r-mTBI animals, the changes in cued fear memory, anxiety, and stress-coping tests were diminished, possibly due to TBI-induced hyperactivity. We also report complex brain molecular and neuropathological findings. Stress and r-mTBI, either individually or comorbidly, were associated with a chronic reduction in dendritic spine GluN2A/GluN2B ratio in the hippocampus. While stress augmented the r-mTBI-dependent astrogliosis in the corpus callosum, it mitigated r-mTBI-induced increases in hippocampal pro-brain-derived neurotrophic factor. We anticipate that our model will be a good platform to untangle the complex comorbid pathophysiology in stress disorders and r-mTBI.

The Value of Physical Symptoms in Screening For Posttraumatic Stress Disorder in the Military

Physical symptoms are highly comorbid with posttraumatic stress disorder (PTSD). As PTSD is underdiagnosed, this study explored the value of self-reported physical symptoms in screening for 30-day PTSD in military personnel. Two physical symptom scales were constructed using items from a 67-item health symptom checklist, clinical interviews were used as the diagnostic reference standard, and diagnostic utility of physical symptoms was compared with the current gold standard screen, the PTSD checklist (PCL). Receiver operating characteristic analyses showed that both a 9-item and a 10-item physical symptom scale were of value in predicting PTSD (areas under the curve 0.81 and 0.85). Importantly, two thirds of PTSD positive personnel missed by the PCL were captured with physical symptoms scales, and when physical symptoms were added to the PCL, prediction was improved (areas under the curve 0.90 to 0.92). Our findings highlight the value of including assessing physical symptoms in PTSD screening.

Heart Rate Variability and Cognitive Bias Feedback Interventions to Prevent Post-deployment PTSD: Results from a Randomized Controlled Trial

Introduction

There is a long history of pre-deployment PTSD prevention efforts in the military and effective pre-deployment strategies to prevent post-deployment PTSD are still needed.

Materials and Methods

This randomized controlled trial included three arms: heart rate variability biofeedback (HRVB), cognitive bias modification for interpretation (CBM-I), and control. The hypothesis was that pre-deployment resilience training would result in lower post-deployment PTSD symptoms compared with control. Army National Guard soldiers (n = 342) were enrolled in the Warriors Achieving Resilience (WAR) study and analyzed. The outcome was PTSD symptom severity using the PTSD Checklist - Military version (PCL) measured at pre-deployment, 3- and 12-month post-deployment. Due to the repeated measures for each participant and cluster randomization at the company level, generalized linear mixed models were used for the analysis. This study was approved by the Army Human Research Protection Office, Central Arkansas Veterans Healthcare System Institutional Review Board (IRB), and Southeast Louisiana Veterans Health Care System IRB.

Results

Overall, there was no significant intervention effect. However, there were significant intervention effects for subgroups of soldiers. For example, at 3-months post-deployment, the HRVB arm had significantly lower PCL scores than the control arm for soldiers with no previous combat zone exposure who were age 30 and older and for soldiers with previous combat zone exposure who were 45 and older (unadjusted effect size -0.97 and -1.03, respectively). A significant difference between the CBM-I and control arms was found for soldiers without previous combat zone exposure between ages 23 and 42 (unadjusted effect size -0.41). Similarly, at 12-months post-deployment, the HRVB arm had significantly lower PCL scores in older soldiers.

Conclusion

Pre-deployment resilience training was acceptable and feasible and resulted in lower post-deployment PTSD symptom scores in subgroups of older soldiers compared with controls. Strengths of the study included cluster randomization at the company level, use of iPod device to deliver the resilience intervention throughout the deployment cycle, and minimal disruption of pre-deployment training by using self-paced resilience training. Weaknesses included self-report app use, study personnel not able to contact soldiers during deployment, and in general a low level of PTSD symptom severity throughout the study. In future studies, it would important for the study team and/or military personnel implementing the resilience training to be in frequent contact with participants to ensure proper use of the resilience training apps.

Mental Health Treatment Delay: A Comparison Among Civilians and Veterans of Different Service Eras

OBJECTIVE

The study compared delay of treatment for posttraumatic stress disorder (PTSD), major depressive disorder, and alcohol use disorder among post-9/11 veterans versus pre-9/11 veterans and civilians.

METHODS

The 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a nationally representative survey of U.S. noninstitutionalized adults, was used. Participants included 13,528 civilians, 1,130 pre-9/11 veterans, and 258 post-9/11 veterans with lifetime diagnoses of PTSD, major depression, or alcohol use disorder. Cox proportional hazard models, controlling for relevant demographic characteristics, were used to estimate differences in treatment delay (i.e., time between diagnosis and treatment).

RESULTS

Post-9/11 veterans were less likely to delay treatment for PTSD and depression than pre-9/11 veterans (adjusted hazard ratios [AHRs]=0.69 and 0.74, respectively) and civilians (AHRs=0.60 and 0.67, respectively). No differences in treatment delay were observed between post-9/11 veterans and pre-9/11 veterans or civilians for alcohol use disorder. In an exploratory analysis, post-9/11 veterans with past-year military health care coverage (e.g., Veterans Health Administration) had shorter delays for depression treatment compared with post-9/11 veterans without military coverage, pre-9/11 veterans regardless of health care coverage, and civilians, although past-year coverage did not predict treatment delay for PTSD or alcohol use disorder.

CONCLUSIONS

Post-9/11 veterans were less likely to delay treatment for some common psychiatric conditions compared with pre-9/11 veterans or civilians, which may reflect efforts to engage recent veterans in mental health care. All groups exhibited low initiation of treatment for alcohol use disorder, highlighting the need for further engagement efforts.

Service dog training programs for veterans with PTSD: results of a pilot controlled study

Service dog programs are increasingly being explored as complementary or alternative interventions for military veterans with posttraumatic stress disorder (PTSD). This paper details the results of a control group, pre-and-post pilot investigation evaluating the use of a 14-week service dog training program for veterans in central Florida. Thirty veterans diagnosed with PTSD, 15 in the intervention group and 15 in the waitlist controlled group, completed all pretests and posttests measures, consisting of the 136-item Trauma Symptom Inventory-2 and the 36-item World Health Organization-Disability Assessment Schedule 2.0. Compared to demographically similar veterans in the control group, participants who completed the service dog training program demonstrated significant decreases in posttraumatic symptomatology, intra/interpersonal difficulties associated with psychological trauma, and in disabilities secondary to their PTSD. Study findings, in combination with results from two other recently published controlled investigations, provide evidence supporting the endorsement and use of service dog programs as helpful complementary or alternative treatment options for some veterans. Social work practitioners may want to consider referring their veteran clients with PTSD to qualified service dog programs for adjunctive support when they are having difficulty engaging with or benefiting from office-based traditional therapy approaches.