Mental disorders and mental health treatment among U.S. Department of Veterans Affairs outpatients: the Veterans Health Study

Mental health treatment utilization among Gulf War era veterans with probable alcohol use disorder

INTRODUCTION

Alcohol use disorder (AUD) is prevalent among veterans, and excessive alcohol use is associated with significant mental and physical health consequences. Currently, the largest cohort of veterans seeking services at the VA are those from the 1990s Gulf War Era. This cohort of veterans is unique due to the nature of their deployment resulting in a myriad of unexplained symptoms collectively known as "Gulf War Illness" and higher rates of mental health problems. The present study sought to examine the association between probable AUD and mental health treatment utilization in a sample of 1126 (882 male) Gulf War-era veterans.

METHODS

Veterans completed a self-report survey including the AUDIT-C, questions about mental health treatment engagement, and demographic questions.

RESULTS

Results demonstrated that approximately 20 % of the sample screened positive for probable AUD, determined by standard AUDIT-C cutoff scores. Among those screening positive for AUD, 25 % reported engaging in mental health treatment in the past year. Veterans with probable AUD who use VA care had 3.8 times the odds of receiving mental health services than veterans not using VA care. Use of mental health services was associated with mental health comorbidity and identifying as Black/African American.

CONCLUSIONS

The results of the present study highlight a significant unmet need for mental health treatment among Gulf War-era veterans with AUD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An open trial of VA CONNECT: Caring for Our Nation's Needs Electronically during the COVID-19 Transition

The COVID-19 pandemic impacted emotional well-being due to safety concerns, grief, employment impacts, and social interaction limitations. Face-to-face mental health treatment restrictions were especially impactful to veterans who often gain social enrichment from Veterans Health Administration (VHA) care. We present results from a novel group-based telehealth intervention, VA Caring for Our Nation's Needs Electronically during the COVID-19 Transition (VA CONNECT), which integrates skills training and social support to develop a COVID-19 Safety & Resilience Plan. Veterans (n ​= ​29) experiencing COVID-related stress participated in an open trial of this 10-session, manualized group VHA telehealth intervention. We examined whether COVID-19-related stress, adjustment disorder symptoms, and loneliness decreased, and coping strategy use increased after participation in VA CONNECT. Between baseline and two-month follow-up, participants reported a significant reduction in perceived stress and adjustment disorder symptoms, and an increase in planning coping skills use. Significant changes were not observed in loneliness or other specific coping strategies. Findings may support the utility of VA CONNECT as an intervention for pandemic-related stress and improving certain coping skills. Future research should explore group-based telehealth interventions like VA CONNECT with other populations within and outside of the VA, which have value during major disruptions to face-to-face mental healthcare access.

Psychometric Properties of the CAGE Questionnaire Amongst Middle-Aged and Older Adults in Khuzistan Province of Iran

The CAGE questionnaire is an instrument, proved useful in helping to make a diagnosis of alcoholism. The questions focus on Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers. The questionnaire has been more pervasive simple tool than AUDIT and LAST scales to screen in busy medical settings where limited time is considered for adult patient interviews. The present study aimed to determine the reliability and validity of the CAGE questionnaire in Khuzistan province, Iran and evaluate its role in detecting alcohol-related problems. For this purpose, 382 men with mean age of 65 ± 5 were sampled by cluster-random sampling method in convenience model from the medical centers in eight counties of Khuzistan province during 2019 and they responded to the CAGE questionnaire. The coefficients of Cronbach's alpha (α = 0.82), convergent validity (0.73), divergent validity (-0.06), and criterion validity (0.87) were estimated (ρ < 0.01). The exploratory factor analysis demonstrated that the four -items related to the CAGE for the aged samples are organized into one factor, which clarifies 94% of the variance. Based on the results of the second-order confirmatory factor analysis, all factors were matched up well into a principal factor. Finally, the one -factor model was appropriate for the data by using the fit index techniques for adjusting the scale (AGFI = 0.81, TLI = 0.91, GFI = 0.93, RMSEA = 0.006, IFI = 0.94, NFI = 0.91, CFI = 0.97).The results could prove the well-adjusted reliability and validity of the CAGE and its usefulness for the relevant studies.

Post-traumatic stress disorder and depressive symptoms among firefighters: a network analysis

Background

Firefighters, as first responders with a high risk of occupational exposure to traumatic events and heavy working stress, have a high prevalence of PTSD symptoms and depressive symptoms. But no previous studies analyzed the relationships and hierarchies of PTSD and depressive symptoms among firefighters. Network analysis is a novel and effective method for investigating the complex interactions of mental disorders at the symptom level and providing a new understanding of psychopathology. The current study was designed to characterize the PTSD and depressive symptoms network structure in the Chinese firefighters.

Method

The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) and the Self-Rating Depression Scale (SDS) were applied to assess PTSD and depressive symptoms, respectively. The network structure of PTSD and depressive symptoms was characterized using "expected influence (EI)" and "bridge EI" as centrality indices. The Walktrap algorithm was conducted to identify communities in the PTSD and depressive symptoms network. Finally, Network accuracy and stability were examined using the Bootstrapped test and the case-dropping procedure.

Results

A total of 1,768 firefighters were enrolled in our research. Network analysis revealed that the relationship between PTSD symptoms, "Flashback" and "Avoidance," was the strongest. "Life emptiness" was the most central symptom with the highest EI in the PTSD and depression network model. Followed by "Fatigue" and "Interest loss." Bridge symptoms connecting PTSD and depressive symptoms in our study were "Numb," "High alertness," "Sad mood," and "Compunction and blame," successively. The data-driven community detection suggested the differences in PTSD symptoms in the clustering process. The reliability of the network was approved by both stability and accuracy tests.

Conclusion

To the best of our knowledge, the current study first demonstrated the network structure of PTSD and depressive symptoms among Chinese firefighters, identifying the central and bridge symptoms. Targeting interventions to the symptoms mentioned above may effectively treat firefighters suffering from PTSD and depressive symptoms.

Epigenetic citizenship and political claims-making: the ethics of molecularizing structural racism

Epigenetics has generated excitement over its potential to inform health disparities research by capturing the molecular signatures of social experiences. This paper highlights the concerns implied by these expectations of epigenetics research and discusses the possible ramifications of 'molecularizing' the forms of social suffering currently examined in epigenetics studies. Researchers working with oppressed populations-particularly racially marginalized groups-should further anticipate how their results might be interpreted to avoid fueling prejudiced claims of biological essentialism. Introducing the concept of 'epigenetic citizenship,' this paper considers the ways environmentally responsive methylation cues may be used in direct-to-consumer testing, healthcare, and biopolitical interactions. The conclusion addresses the future of social epigenetics research and the utility of an epigenetic citizenship framework.

PTSD symptomatology is selectively associated with impaired sustained attention ability and dorsal attention network synchronization

Posttraumatic Stress Disorder (PTSD) symptomatology is associated with dysregulated sustained attention, which produces functional impairments. Performance on sustained attention paradigms such as continuous performance tasks are influenced by both the ability to sustain attention and response strategy. However, previous studies have not dissociated PTSD-related associations with sustained attention ability and strategy, which limits characterization of neural circuitry underlying PTSD-related attentional impairments. Therefore, we characterized and replicated PTSD-related associations with sustained attention ability and response strategy in trauma-exposed Veterans, which guided characterization of PTSD-related differences in neural circuit function. In Study 1, PTSD symptoms were selectively associated with reduced sustained attention ability, but not more impulsive response strategies. In Study 2, we utilized task and resting-state fMRI to characterize neural circuitry underlying PTSD-related differences in sustained attention ability. Both PTSD symptomatology and sustained attention ability exhibited converging associations with reduced dorsal attention network (DAN) synchronization to endogeneous attentional fluctuations. Post-hoc time course analyses demonstrated that PTSD symptoms were most accurately characterized by delayed, rather than globally reduced, DAN synchronization to endogenous attentional fluctuations. Together, these findings suggest that PTSD symptomatology may selectively impair sustained attention ability by disrupting proactive engagement of attentional control circuitry.

Mental health and suicidal ideation in US military veterans with histories of COVID-19 infection

INTRODUCTION

There have been reports of increased prevalence in psychiatric conditions in non-veteran survivors of COVID-19. To date, however, no known study has examined the prevalence, risk and protective factors of psychiatric conditions among US military veterans who survived COVID-19.

METHODS

Data were analysed from the 2019 to 2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative, prospective cohort of 3078 US veterans. Prepandemic and 1-year peripandemic risk and protective factors associated with positive screens for peripandemic internalising (major depressive, generalised anxiety and/or posttraumatic stress disorders) and externalising psychiatric disorders (alcohol and/or drug use disorders) and suicidal ideation were examined using bivariate and multivariate logistic regression analyses.

RESULTS

A total of 233 veterans (8.6%) reported having been infected with COVID-19. Relative to veterans who were not infected, veterans who were infected were more likely to screen positive for internalising disorders (20.5% vs 13.9%, p=0.005), externalising disorders (23.2% vs 14.8%, p=0.001) and current suicidal ideation (12.0% vs 7.6%, p=0.015) at peripandemic. Multivariable analyses revealed that greater prepandemic psychiatric symptom severity and COVID-related stressors were the strongest independent predictors of peripandemic internalising disorders, while prepandemic trauma burden was protective. Prepandemic suicidal ideation, greater loneliness and lower household income were the strongest independent predictors of peripandemic suicidal ideation, whereas prepandemic community integration was protective.

CONCLUSION

Psychiatric symptoms and suicidal ideation are prevalent in veterans who have survived COVID-19. Veterans with greater prepandemic psychiatric and substance use problems, COVID-related stressors and fewer psychosocial resources may be at increased risk of these outcomes.

Problem recognition and treatment beliefs relate to mental health utilization among veteran primary care patients

Mental health concerns are prevalent among primary care patients, but many do not utilize services for these conditions. This study aims to conduct a comprehensive assessment of barriers and facilitators to mental health care utilization among veteran primary care patients with common mental health concerns. We hypothesized that beliefs and knowledge about mental illness and mental health care would be more strongly associated with recent mental health care utilization than stigma, help-seeking behaviors, or logistical barriers. Veterans (n = 116) enrolled in primary care with current symptoms of depression (58%), posttraumatic stress disorder (37%), and/or hazardous alcohol use (50%) who either recently used mental health services (47%) or had no recent mental health treatment utilization (53%) completed a telephone-based screening, medical records review, and mail survey of 10 measures of barriers and facilitators to mental health treatment utilization. Recognition of problems as a cause for concern, odds ratio = 5.95, 95% confidence interval [2.36, 15.01], and beliefs about psychotherapy, odds ratio = 2.53, 95% confidence interval [1.39, 4.60], emerged as stronger correlates of recent mental health care utilization than stigma, self-efficacy, and external barriers to treatment. Results suggest the use of specific theories, measures, and interventions that focus on patient recognition of problems and beliefs about treatment over those that focus on other treatment barriers and facilitators. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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

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

Motivational Interviewing to Address Suicidal Ideation: A Randomized Controlled Trial in Veterans

OBJECTIVE

Although the months following discharge from psychiatric hospitalization are a period of acute risk for veterans, there is a dearth of empirically supported treatments tailored to veterans in acute psychiatric hospitalization.

METHOD

We conducted a randomized controlled trial to test the efficacy of Motivational Interviewing to Address Suicidal Ideation (MI-SI) that explored and resolved ambivalence, and a revised MI-SI (MI-SI-R) that resolved ambivalence, on suicidal ideation (SI) in hospitalized veterans who scored > 2 on the Scale for Suicidal Ideation. Participants were randomized to receive MI-SI plus treatment as usual (TAU), MI-SI-R+TAU, or TAU alone. MI-SI+TAU and MI-SI-R+TAU included two in-hospital therapy sessions and one telephone booster session. Participants completed follow-up assessments over 6 months.

RESULTS

Participants in all groups experienced reductions in the presence and severity of SI, but there were no significant differences among the groups. For the presence of SI, results were in the hypothesized direction for both MI-SI+TAU conditions.

CONCLUSIONS

Results are nondefinitive, but the effect size of both versions of MI-SI+TAU on the presence of SI was consistent with prior MI findings. Exploratory analyses suggest MI-SI-R may be preferable to MI-SI. More intensive MI-SI-R with a greater number of follow-ups may increase its effectiveness.

Psychological burden of PTSD, depression, and their comorbidity in the U.S. veteran population: Suicidality, functioning, and service utilization

BACKGROUND

Emerging evidence suggests that comorbid posttraumatic stress disorder (PTSD) and major depressive disorder (PTSD/MDD) may impose an even greater burden than either disorder alone. However, nearly all previous studies examining these associations have relied on treatment-seeking samples. This study examined the mental health burden associated with co-occurring PTSD/MDD compared to PTSD and MDD alone using a nationally representative sample of U.S. veterans.

METHODS

Data were analyzed from National Health and Resilience in Veterans Study, a nationally representative survey of U.S. veterans (n = 2,732). Analyses (a) estimated the current prevalence of PTSD only, MDD only, and comorbid PTSD/MDD; (b) compared demographic/military variables by PTSD/MDD status; and (c) examined associations between PTSD/MDD status and suicidality, functioning, psychiatric comorbidities, and service utilization.

RESULTS

The current prevalences of probable PTSD only, probable MDD only, and probable comorbid PTSD/MDD were 1.7%, 4.8%, and 3.4%. Compared to all other groups, the PTSD/MDD group was more likely to screen positive for current suicidal ideation, lifetime suicide attempts, probable generalized anxiety and social anxiety disorders, and ever utilize mental health services. They also scored lower on measures of mental health functioning (d = 1.49), cognitive functioning (d = 1.03), and quality of life (d = 0.84). Veterans with comorbid PTSD/MDD were more than twice as likely as those with PTSD only to have attempted suicide.

LIMITATIONS

The cross-sectional design of this study precludes causal inference.

CONCLUSIONS

Results provide a population-based characterization of the psychological burden of PTSD/MDD comorbidity in U.S. veterans. Findings further underscore the importance of screening, monitoring, and treatment of the comorbid manifestation of these disorders.

Social rhythm regularity moderates the relationship between sleep disruption and depressive symptoms in veterans with post-traumatic stress disorder and major depressive disorder

Approximately 50% to 80% of individuals with posttraumatic stress disorder (PTSD) also meet criteria for major depressive disorder (MDD). Sleep disturbance is a major concern in both PTSD and MDD, and is associated with poor treatment response, poor functional outcome and increased suicide risk. Social rhythm regularity, or the consistency of daily habitual behaviors, is theoretically linked to circadian rhythms and may be disturbed in both PTSD and MDD. The present study examined the relationship between social rhythm regularity, sleep disruption and MDD and PTSD symptoms in a sample of veterans with comorbid PTSD and MDD. Baseline data were obtained from 56 male veterans who met DSM-IV criteria for PTSD and MDD. Veterans completed the Social Rhythm Metric (SRM), a self-report questionnaire that assesses the regularity of routines by determining how regularly individuals completed 17 different types of activities. In a linear regression model, increased minutes awake after sleep onset (WASO) was a significant predictor of increased depression scores on the Hamilton Rating Scale for Depression (p < .05). SRM scores did not significantly predict depressive symptoms, however the interaction of WASO and SRM significantly predicted depressive symptoms (p = <.05), with significant relationships found at SRM scores less than 3.62. Neither minutes awake after sleep onset, SRM scores, nor their interaction was associated with PTSD symptom severity. Social and possibly circadian rhythm regularity may represent a risk or resilience factor for individuals with comorbid PTSD and MDD. Findings highlight the importance of exploring the interactions of sleep and social/circadian rhythms in depression in order to inform continued treatment development.

Posttraumatic Stress Disorder in Older Adults: A Conceptual Review

Objectives: We provide a review of the literature on posttraumatic stress disorder (PTSD) in older adults, focusing largely on older U.S. military veterans in two primary areas: 1) assessment and diagnosis and 2) non-pharmacological treatment of PTSD in late life. Methods: We performed a search using PubMed and Academic Search Premier (EBSCO) databases and reviewed reference sections of selected papers. We also drew on our own clinical perspectives and reflections of seven expert mental health practitioners. Results: Rates of PTSD are lower in older compared with younger adults. The presence of sub-syndromal/partial PTSD is important and may impact patient functioning. Assessment requires awareness and adaptation for potential differences in PTSD experience and expression in older adults. Psychotherapies for late-life PTSD appear safe, acceptable and efficacious with cognitively intact older adults, although there are relatively few controlled studies. Treatment adaptations are likely warranted for older adults with PTSD and co-morbidities (e.g., chronic illness, pain, sensory, or cognitive changes). Conclusions: PTSD is an important clinical consideration in older adults, although the empirical database, particularly regarding psychotherapy, is limited. Clinical Implications: Assessment for trauma history and PTSD symptoms in older adults is essential, and may lead to increased recognition and treatment.

Multimorbidity among Veterans Diagnosed with PTSD in the Veterans Health Administration Nationally

Over 30% of veterans treated for psychiatric disorders in the Veterans Health Administration (VHA) are diagnosed with Post-Traumatic Stress Disorder (PTSD), with most receiving treatment for war-zone stress they experienced decades previously. We examined psychiatric multimorbidity among these patients and consider its implications for treatment and research. Using national VHA data from Fiscal Year 2012 on all veterans diagnosed with PTSD, we compared those with PTSD only to those with one, two, and three or more concurrent (non-substance use) psychiatric disorders. Comparisons of these four groups on sociodemographic characteristics, medical and substance use co-morbidities, health service use, and psychotropic prescription fills were conducted using bi-variate and ordinal logistic regression methods. Of 638,451 veterans diagnosed with PTSD in FY2012, only 29.8% had PTSD alone; 36.7% had one concurrent psychiatric diagnosis, 21.3% had two, and 12.2% had three or more. Anxiety disorder and major depressive disorder were the most common concurrent diagnoses. Veterans with higher levels of multimorbidity were younger, had greater likelihood of recent homelessness, substance use disorder, and diverse medical diagnoses, along with increased mental health and medical service use and greater psychotropic medication use. Psychiatric multimorbidity is highly prevalent among VHA patients diagnosed with PTSD, and may represent an underappreciated and poorly understood clinical complication that poses unique challenges to effective treatment. Clinical attention and both epidemiological and interventional research on multimorbidity in PTSD patients are needed in order to better understand and treat this common but understudied phenomenon.

The Health Status of Veteran Employees Compared to Civilian Employees in Veterans Health Administration

Introduction

Veterans Health Administration (VHA) is undergoing changes in the practice of health care focusing on approaches that prioritize veteran well-being. Given transformation efforts, opportunities exist to enhance the health and well-being of patients and employees alike – a significant proportion of whom are veterans. To date, differences in health status between veteran and civilian employees within VHA have not been examined.

Materials and Methods

Data from an annual organizational census survey with health promotion module conducted in 2015 were analyzed to estimate the prevalence of health risk behaviors, mental health, and chronic health conditions by veteran status within genders (n = 86,257). To further examine associations by gender between veteran status and health measures controlling for covariates, multivariate logistic regression analyses were utilized.

Results

Prevalence estimates generally indicated veterans have worse health status and health risk behaviors than their civilian counterparts. Results from multivariate logistic regression analyses indicated many significant associations between veteran status and health by gender controlling for other important demographic variables and a total comorbidity score. Compared to civilian employees within respective genders, both male and female veteran employees have increased odds of being a current smoker. Both male and female veteran employees have decreased odds of physical inactivity compared to civilian employees. For mental health and chronic health conditions, there are several conditions that veteran employees have increased odds for when compared to civilian employees of like gender; these include low back problems, arthritis, anxiety, depression, and sleep disorders.

Conclusions

Veteran employees in VHA have worse health status than their civilian counterparts on a number of measures of health risk behaviors, mental health, and chronic health conditions. Given current organizational priorities aimed at cultural transformation, the present time is an optimal one to work collaboratively to enhance the health and well-being services that are available for patients and employees alike. All employees, particularly our unique population of veteran employees, will benefit from such an approach.

The Role of Integrated Primary Care in Increasing Access to Effective Psychotherapies in the Veterans Health Administration

American military veterans have higher rates of psychiatric disorders, and timely access to high-quality mental health treatment in the Veterans Health Administration (VHA) is a persistent challenge. Integrated primary care (IPC) is one of many strategies implemented by VHA to increase access to care. IPC, including collaborative care and primary care behavioral health services, successfully increases access to initial behavioral health services in primary care (e.g., brief psychotherapies, pharmacotherapy) and continued engagement in specialty mental health services. IPC components that drive increased access include population-based care, response to patient preferences, and team-based care. The state of the evidence for IPC interventions for common behavioral health concerns in primary care (depression, anxiety, posttraumatic stress disorder, alcohol use, tobacco use, and insomnia) is reviewed, with areas for future research and implementation discussed, including how technology can assist IPC services and the importance of incorporating evidence-based psychotherapies into IPC.

Associations between healthcare use and disordered eating among female veterans

OBJECTIVE

Individuals with eating disorders (EDs) have considerable medical and psychiatric comorbidity as well as increased healthcare use and associated costs. However, EDs remain largely undetected and understudied among veteran populations, and EDs are not routinely screened for or treated in Veterans Affairs (VA) medical settings. Research elucidating the links between disordered eating and VA and non-VA healthcare use is needed to inform policy and practice for ED screening and treatment.

METHOD

Data regarding probable EDs and VA and non-VA healthcare use was obtained through a mail survey of 198 female veterans receiving care from VA.

RESULTS

A total of 21 participants (10.6%) met probable criteria for subthreshold anorexia nervosa, bulimia nervosa, or binge-eating disorder. Negative binomial regression models revealed that female veterans with EDs reported higher frequency of VA mental healthcare use and substance use disorder treatment, above and beyond the association of comorbid PTSD and depression symptoms.

DISCUSSION

These findings confirm the high probability that female veterans with EDs are utilizing significant VA mental health resources. Screening for EDs may be particularly important in VA medical and mental health settings.

Alcohol-related and mental health care for patients with unhealthy alcohol use and posttraumatic stress disorder in a National Veterans Affairs cohort

OBJECTIVE

Unhealthy alcohol use and posttraumatic stress disorder (PTSD) frequently co-occur. Patients with both conditions have poorer functioning and worse treatment adherence compared to those with either condition alone. Therefore, it is possible that PTSD, when co-occurring with unhealthy alcohol use, may influence receipt of evidence-based alcohol-related care and mental health care. We evaluated receipt of interventions for unhealthy alcohol use and receipt of mental health follow-up care among patients screening positive for unhealthy alcohol use with and without PTSD in a national sample from the Veterans Health Administration (VA).

METHODS

National clinical and administrative data from VA's electronic medical record were used to identify all patients who screened positive for unhealthy alcohol use (AUDIT-C score≥5) between 10/1/09-5/30/13. Unadjusted and adjusted Poisson regression models were fit to estimate the relative rate and prevalence of receipt of: brief interventions (advice to reduce or abstain from drinking≤14days after positive screening), specialty addictions treatment for alcohol use disorder (AUD; documented visit≤365days after positive screening), pharmacotherapy for AUD (filled prescription≤365days after positive screening), and mental health care ≤14days after positive screening for patients with and without PTSD (documented with ICD-9 CM codes). In secondary analyses, we tested effect modification by both severity of unhealthy alcohol use and age.

RESULTS

Among 830,825 patients who screened positive for unhealthy alcohol use, 140,388 (16.9%) had documented PTSD. Of the full sample, 71.6% received brief interventions, 10.3% received specialty AUD treatment, 3.1% received pharmacotherapy for AUD, and 24.0% received mental health care. PTSD was associated with increased likelihood of receiving all types of care. Adjusted relative rates were 1.04 (95% CI 1.03-1.05) for brief interventions, 1.06 (1.05-1.08) for specialty AUD treatment, 1.35 (1.31-1.39) for AUD pharmacotherapy, and 1.82 (1.80-1.84) for mental health care. Alcohol use severity modified effects of PTSD for specialty AUD treatment, AUD pharmacotherapy, and mental health care such that effects were maintained at lower severity but attenuated among patients with severe unhealthy alcohol use. Age modified all effects with the strength of the association between PTSD and care outcomes being strongest for younger (18-29years) and older veterans (65+ years) and weaker or non-significant for middle-aged veterans (30-44 and 45-64years).

CONCLUSIONS

In this large national sample of patients with unhealthy alcohol use, PTSD was associated with increased likelihood of receiving alcohol-related and mental health care. PTSD does not appear to be a barrier to care among VA patients with unhealthy alcohol use.

Veterans Experiencing Elder Abuse: Improving Care of a High-Risk Population About Which Little Is Known

At least 10% of older adults experience abuse, neglect, or exploitation annually in the United States, and this problem is expected to grow as our population ages. Little is known about the prevalence and characteristics of elder abuse of veterans, but it is likely that this population is at high risk based on established elder abuse risk factors. Veterans who receive their care through the Veterans Health Administration (VHA) have a higher prevalence of poor psychological health, poor physical health, functional impairment, cognitive impairment, and social isolation than the general population. As the largest integrated healthcare system in the United States, the VHA has long been a leader in the development of innovative, integrated care programs for older adults. The VHA has another opportunity to lead by promoting research, clinical care, and education on elder abuse, furthering their mission of serving those who served. This article outlines the rationale for developing a research agenda for elder abuse in the VHA, as well as potential first steps toward understanding more about this complex problem affecting veterans.

Prevalence of depression and depressive symptoms among outpatients: a systematic review and meta-analysis

OBJECTIVES

Depression and depressive symptoms are common mental disorders that have a considerable effect on patients' health-related quality of life and satisfaction with medical care, but the prevalence of these conditions varies substantially between published studies. The aim of this study is to conduct a systematic review and meta-analysis to provide a precise estimate of the prevalence of depression or depressive symptoms among outpatients in different clinical specialties.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES AND ELIGIBILITY CRITERIA

The PubMed and PsycINFO, EMBASE and Cochrane Library databases were searched to identify observational studies that contained information on the prevalence of depression and depressive symptoms in outpatients. All studies included were published before January 2016. Data characteristics were extracted independently by two investigators. The point prevalence of depression or depressive symptoms was measured using validated self-report questionnaires or structured interviews. Assessments were pooled using a random-effects model. Differences in study-level characteristics were estimated by meta-regression analysis. Heterogeneity was assessed using standard χ² tests and the I² statistic. The study protocol has been registered with PROSPERO under number CRD42017054738.

RESULTS

Eighty-three cross-sectional studies involving 41 344 individuals were included in this study. The overall pooled prevalence of depression or depressive symptoms was 27.0% (10 943/41 344 individuals; 95% CI 24.0% to 29.0%), with significant heterogeneity between studies (p<0.0001, τ²=0.3742, I²=96.7%). Notably, a significantly higher prevalence of depression and depressive symptoms was observed in outpatients than in the healthy controls (OR 3.16, 95% CI 2.66 to 3.76, I²=72.0%, χ ² =25.33). The highest depression/depressive symptom prevalence estimates occurred in studies of outpatients from otolaryngology clinics (53.0%), followed by dermatology clinics (39.0%) and neurology clinics (35.0%). Subgroup analyses showed that the prevalence of depression and depressive symptoms in different specialties varied from 17.0% to 53.0%. The prevalence of depression and depressive symptoms was higher among outpatients in developing countries than in outpatients from developed countries. Moreover, the prevalence of depression and depressive symptoms in outpatients slightly decreased from 1996 to 2010. Regarding screening instruments, the Beck Depression Inventory led to a higher estimate of the prevalence of depression and depressive symptoms (1316/4702, 36.0%, 95% CI 29.0% to 44.0%, I²=94.8%) than the Hospital Anxiety and Depression Scale (1003/2025, 22.0%, 95% CI 12.0% to 35.0%, I²=96.6%).

CONCLUSION

Our study provides evidence that a significant proportion of outpatients experience depression or depressive symptoms, highlighting the importance of developing effective management strategies for the early identification and treatment of these conditions among outpatients in clinical practice. The substantial heterogeneity between studies was not fully explained by the variables examined.

Stroke survivors with severe mental illness: Are they at-risk for increased non-psychiatric hospitalizations?

BACKGROUND

This study examined outcomes for two groups of stroke survivors treated in Veteran Health Administration (VHA) hospitals, those with a severe mental illness (SMI) and those without prior psychiatric diagnoses, to examine risk of non-psychiatric medical hospitalizations over five years after initial stroke.

METHODS

This retrospective cohort study included 523 veterans who survived an initial stroke hospitalization in a VHA medical center during fiscal year 2003. The survivors were followed using administrative data documenting inpatient stroke treatment, patient demographics, disease comorbidities, and VHA hospital admissions. Multivariate Poisson regression was used to examine the relationship between patients with and without SMI diagnosis preceding the stroke and their experience with non-psychiatric medical hospitalizations after the stroke.

RESULTS

The study included 100 patients with SMI and 423 without SMI. Unadjusted means for pre-stroke non-psychiatric hospitalizations were higher (p = 0.0004) among SMI patients (1.47 ± 0.51) compared to those without SMI (1.00 ± 1.33), a difference which persisted through the first year post-stroke (SMI: 2.33 ± 2.46; No SMI: 1.74 ± 1.86; p = 0.0004). Number of non-psychiatric hospitalizations were not significantly different between the two groups after adjustment for patient sociodemographic, comorbidity, length of stay and inpatient stroke treatment characteristics. Antithrombotic medications significantly lowered risk (OR = 0.61; 95% CI: 0.49-0.73) for stroke-related readmission within 30 days of discharge.

CONCLUSIONS

No significant differences in medical hospitalizations were present after adjusting for comorbid and sociodemographic characteristics between SMI and non-SMI stroke patients in the five-year follow-up. However, unadjusted results continue to draw attention to disparities, with SMI patients experiencing more non-psychiatric hospitalizations both prior to and up to one year after their initial stroke. Additionally, stroke survivors discharged on antithrombotic medications were at lower risk of re-admission within 30 days suggesting the VHA should continue to focus on effective stroke management irrespective of SMI.

Protocol for the evaluation of a digital storytelling approach to address stigma and improve readiness to seek services among veterans

BACKGROUND

Research suggests that at least 10% of veterans returning from Iraq and Afghanistan meet criteria for posttraumatic stress disorder (PTSD) related to their military experiences. National dissemination initiatives have increased veterans' access to best-practice interventions. However, treatment-seeking remains low among veterans with PTSD, often due to perceived stigma and other associated barriers. The National Center for PTSD recently developed and launched AboutFace, a digital storytelling (DST) resource designed to help veterans recognize PTSD and motivate them to seek evidence-based treatment. The Ralph H. Johnson Veterans Affairs Medical Center (VAMC) and the National Center for PTSD have partnered to conduct pilot work to evaluate veterans' reactions to AboutFace to set the stage for a large-scale study to examine whether AboutFace effectively reduces stigma and improves attitudes toward treatment-seeking among veterans. If effective, this DST approach may serve as a valuable national model for a variety of treatment-seeking populations.

METHODS

During the first phase of the pilot, in-person usability assessments of AboutFace will be conducted via semi-structured interviews with 20 veterans. Audio recordings of interviews will undergo transcription and coding. A report of the results of qualitative analyses of these interviews will be provided to the National Center for PTSD and will inform revisions to the site. In the second phase of the pilot, 60 veterans referred to a specialized PTSD clinic will be recruited to demonstrate and refine the methodology that we propose to use in a larger randomized controlled trial evaluation of AboutFace. Veterans will be randomly assigned to receive AboutFace plus standard education vs. standard education alone. Baseline and 2-week telephone assessments will be conducted with participating veterans to measure stigma, attitudes toward seeking mental health services, and treatment access/engagement.

DISCUSSION

The feedback we receive in this pilot will be used to strengthen the quality of the DST website in preparation for a large-scale evaluation. Future work will involve evaluation of reach and impact of the site relative to stigma, attitudes toward seeking mental health service, and utilization of care. If AboutFace is found to increase access to care, this finding would have broad and significant implications for overcoming barriers to care for veterans and other populations with stigmatized conditions.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02486692.

Trust in health care providers: factors predicting trust among homeless veterans over time

We examined whether a combination of predisposing, enabling, need, and primary care experience variables would predict trust in medical health care providers for homeless veterans over 18 months. Linear mixed model analysis indicated that, among these variables, race, social support, service-connected disability status, and satisfaction and continuity with providers predicted trust in provider over time. Trust in providers improved during the initial stages of the relationship between patient and provider and then declined to slightly below baseline levels over time. Further research is needed to determine generalizability and effects of provider trust on patient health care status over longer periods of time.

Randomized Placebo-Controlled Trial of Methylphenidate or Galantamine for Persistent Emotional and Cognitive Symptoms Associated with PTSD and/or Traumatic Brain Injury

We report findings from a 12-week randomized double-blinded placebo-controlled trial of methylphenidate or galantamine to treat emotional and cognitive complaints in individuals (n=32) with a history of PTSD, TBI, or both conditions. In this small pilot study, methylphenidate treatment was associated with clinically meaningful and statistically significant improvement compared with placebo on the primary outcome, a measure of cognitive complaints (Ruff Neurobehavioral Inventory-Postmorbid Cognitive Scale), as well as on the secondary outcomes reflecting post-concussive (Rivermead Post Concussive Symptom Questionnaire) and post-traumatic stress symptoms (Posttraumatic Stress Disorder Checklist). Treatment was well tolerated. These results suggest the need for a larger RCT to replicate and confirm these findings. Design considerations for such a trial should include the need for multiple sites to facilitate adequate recruitment and extension of the treatment and follow-up periods.

Current Status of Transcranial Direct Current Stimulation in Posttraumatic Stress and Other Anxiety Disorders

Several empirically supported treatments have been identified for post-traumatic stress disorder (PTSD), yet a sizable number of patients are either unable to tolerate these approaches or remain symptomatic following treatment. Transcranial direct current stimulation (tDCS) is a well-tolerated method of modulating neuronal excitability that may hold promise as a novel intervention in PTSD and related disorders. The current review summarizes literature on the disrupted neural circuitry in PTSD and discusses the rationale for the commonly targeted prefrontal cortex (PFC) as it relates to PTSD. We then review the few prior (case) studies that have evaluated tDCS in patients with PTSD (1 study) and other anxiety disorders (4 studies). There was considerable variability in both the methods/justification for selecting the targeted brain region(s) and the tDCS montage used, which obscured any clear trends in the data. Finally, we describe the rationale for our ongoing study that specifically targets the lateral temporal cortex as a method of treating the symptoms of hyperarousal and re-experiencing in PTSD. Overall, it is clear that additional work is needed to establish dosing (e.g., intensity and duration of sessions, number of sessions) and optimal treatment targets as well as to identify synergistic effects with existing treatments.

Military service and other socioecological factors influencing weight and health behavior change in overweight and obese Veterans: a qualitative study to inform intervention development within primary care at the United States Veterans Health Administration

BACKGROUND

Obesity affects 37 % of patients at Veterans Health Administration (VHA) medical centers. The VHA offers an intensive weight management program (MOVE!) but less than 10 % of eligible patients ever attend. However, VHA patients see their primary care provider about 3.6 times per year, supporting the development of primary care-based weight management interventions. To address gaps in the literature regarding Veterans' experiences with weight management and determine whether and how to develop a primary care-based weight management intervention to both improve obesity counseling and increase attendance to MOVE!, we conducted a qualitative study to assess: 1) Veterans' personal experiences with healthy weight-related behavior change (including barriers and facilitators to behavior change and experiences with primary care providers, staff, and the MOVE! program), and 2) potential new approaches to improve weight management within primary care at the VHA including goal setting and technology.

METHODS

Overweight/obese VHA patients (aged 18-75, BMI greater than 30 or greater than 25 with at least 1 co-morbidity) were recruited for focus group sessions stratified by gender, MOVE! referral, and attendance. Each session was facilitated by a trained moderator, audio-recorded, and professionally transcribed. Using an iterative coding approach, two coders separately reviewed and coded transcripts, and met frequently to negotiate codes and synthesize emerging themes.

RESULTS

Of 161 eligible patients, 54 attended one of 6 focus groups (2 female, 4 male, 9-11 participants per session): 63 % were male, 46 % identified as African-American, 32 % White/Caucasian, 74 % were college-educated or higher, and 61 % reported having attended MOVE!. We identified two major themes: Impact of Military Service and Promotion and Sustainability of Healthy Behaviors. After service in a highly structured military environment, Veterans had difficulty maintaining weight on their own. They perceived physical activity as having more impact than diet, but chronic pain was a barrier. We identified individual/interpersonal-, community/environment-, and healthcare system-related factors affecting healthy behaviors. We also received input about Veteran's preferences and experiences with technology and setting health goals.

CONCLUSIONS

Unique factors influence weight management in Veterans. Findings will inform development of a technology-assisted weight management intervention with tailored counseling and goal-setting within primary care at the VHA.

Prevalence and trends in psychotropic medication use among US male veterans, 1999-2010

PURPOSE

Prior studies of psychotropic medication use among US veterans are limited in their ability to generalize estimates to the full veteran population and make comparisons with non-veterans. This study estimated the prevalence of psychotropic medication use and trends over time among male US veterans, compared their use of psychotropic medications with non-veteran males, and examined differences among veteran subpopulations.

METHODS

The data for our analysis came from the National Health and Nutrition Examination Survey (1999-2010), a cross-sectional, nationally representative study of the civilian, non-institutionalized US population.

RESULTS

The percentage of male veterans who used any psychotropic medication increased from 10.4% in 1999-2002 to 14.3% in 2003-2006, then remained stable in 2007-2010 (14.0%). During the same time period, the percentage of non-veteran males who used psychotropic medications remained relatively stable (7.0%, 8.3%, and 9.2%, respectively). Veterans were more likely to use psychotropic medication, specifically antidepressants, than non-veterans. The percentage of non-Hispanic white veterans and veterans aged 60 years and over who used psychotropic medications increased between 1999-2002 and 2003-2006, but the percentages remained stable between 2003-2006 and 2007-2010. In 2003-2006 and 2007-2010, a higher percentage of non-Hispanic white veterans used psychotropic medications than non-Hispanic black veterans.

CONCLUSIONS

This study found that the use of psychotropic medications and antidepressants was higher among male veterans than male non-veterans, and that prevalence of use increased between 1999-2002 and 2007-2010 for male veterans but remained relatively stable for non-veterans. There were significant variations in the use of psychotropic medications among veteran subpopulations.

The effect of pre-existing mental health comorbidities on the stage at diagnosis and timeliness of care of solid tumor malignances in a Veterans Affairs (VA) medical center

There are limited data on the impact of mental health comorbidities (MHC) on stage at diagnosis and timeliness of cancer care. Axis I MHC affect approximately 30% of Veterans receiving care within the Veterans Affairs (VA) system. The purpose of this study was to compare stage at diagnosis and timeliness of care of solid tumor malignancies among Veterans with and without MHC. We performed a retrospective analysis of 408 charts of Veterans with colorectal, urothelial, and head/neck cancer diagnosed and treated at VA Connecticut Health Care System (VACHS) between 2008 and 2011. We collected demographic data, stage at diagnosis, medical and mental health co-morbidities, treatments received, key time intervals, and number of appointments missed. The study was powered to assess for stage migration of 15–20% from Stage I/II to Stage III/IV. There was no significant change in stage distribution for patients with and without MHC in the entire study group (p = 0.9442) and in each individual tumor type. There were no significant differences in the time intervals from onset of symptoms to initiation of treatment between patients with and without MHC (p = 0.1135, 0.2042 and 0.2352, respectively). We conclude that at VACHS, stage at diagnosis for patients with colorectal, urothelial and head and neck cancers did not differ significantly between patients with and without MHC. Patients with MHC did not experience significant delays in care. Our study indicates that in a medical system in which mental health is integrated into routine care, patients with Axis I MHC do not experience delays in cancer care.

An Investigation of Depression, Trauma History, and Symptom Severity in Individuals Enrolled in a Treatment Trial for Chronic PTSD

OBJECTIVE

To explore how factors such as major depressive disorder (MDD) and trauma history, including the presence of childhood abuse, influence diverse clinical outcomes such as severity and functioning in a sample with posttraumatic stress disorder (PTSD).

METHOD

In this study, 200 men and women seeking treatment for chronic PTSD in a clinical trial were assessed for trauma history and MDD and compared on symptom severity, psychosocial functioning, dissociation, treatment history, and extent of diagnostic co-occurrence.

RESULTS

Overall, childhood abuse did not consistently predict clinical severity. However, co-occurring MDD, and to a lesser extent a high level of trauma exposure, did predict greater severity, worse functioning, greater dissociation, more extensive treatment history, and additional co-occurring disorders.

CONCLUSION

These findings suggest that presence of co-occurring depression may be a more critical marker of severity and impairment than history of childhood abuse or repeated trauma exposure. Furthermore, they emphasize the importance of assessing MDD and its effect on treatment seeking and treatment response for those with PTSD.

The epworth sleepiness scale in the assessment of sleep disturbance in veterans with tinnitus

Purpose. Tinnitus and sleep disturbance are prevalent in veterans, and a better understanding of their relationship can help with tinnitus treatment. Materials and Methods. Retrospective chart review of 94 veterans seen in audiology clinic between 2010 and 2013 is presented. Results. The mean age was 62 years, and 93 of 94 veterans were males. The majority (96%) had hearing loss. The positive predictive value of the ESS for sleep disorder was 97% and the negative predictive value was 100%. Veterans with a Tinnitus Handicap Inventory (THI) score ≥38 had significantly higher Epworth Sleepiness Scale (ESS) scores compared to those with THI score <38 (P = 0.006). The former had a significantly higher incidence of PTSD, anxiety, and sleep disorder. A subgroup of patients had normal sleep despite rising THI scores. Bilateral tinnitus, vertigo, and anxiety were found to be predictors of sleep disturbance. Conclusions. The ESS can be used as a tool in the initial assessment of sleep disorders in veterans with tinnitus. Higher tinnitus handicap severity is significantly associated with greater sleep disturbance. Optimal management of tinnitus may require concomitant treatment of sleep disorder, PTSD, anxiety, and depression.

Mental illness and intensification of diabetes medications: an observational cohort study

BACKGROUND

Mental health condition (MHC) comorbidity is associated with lower intensity care in multiple clinical scenarios. However, little is known about the effect of MHC upon clinicians' decisions about intensifying antiglycemic medications in diabetic patients with poor glycemic control. We examined whether delay in intensification of antiglycemic medications in response to an elevated Hemoglobin A1c (HbA1c) value is longer for patients with MHC than for those without MHC, and whether any such effect varies by specific MHC type.

METHODS

In this observational study of diabetic Veterans Health Administration (VA) patients on oral antiglycemics with poor glycemic control (HbA1c ≥8) (N =52,526) identified from national VA databases, we applied Cox regression analysis to examine time to intensification of antiglycemics after an elevated HbA1c value in 2003-2004, by MHC status.

RESULTS

Those with MHC were no less likely to receive intensification: adjusted Hazard Ratio [95% CI] 0.99 [0.96-1.03], 1.13 [1.04-1.23], and 1.12 [1.07-1.18] at 0-14, 15-30 and 31-180 days, respectively. However, patients with substance use disorders were less likely than those without substance use disorders to receive intensification in the first two weeks following a high HbA1c, adjusted Hazard Ratio 0.89 [0.81-0.97], controlling for sex, age, medical comorbidity, other specific MHCs, and index HbA1c value.

CONCLUSIONS

For most MHCs, diabetic patients with MHC in the VA health care system do not appear to receive less aggressive antiglycemic management. However, the subgroup with substance use disorders does appear to have excess likelihood of non-intensification; interventions targeting this high risk subgroup merit attention.

Costs associated with multimorbidity among VA patients

BACKGROUND

Multimorbidity (the presence of multiple chronic conditions) is associated with high levels of healthcare utilization and associated costs. We investigated the association between number of chronic conditions and costs of care for nonelderly and elderly Veterans Affairs (VA) patients, and estimated mean VA healthcare costs for the most prevalent and most costly combinations of 3 conditions (triads).

METHODS

We identified a cohort of 5,233,994 patients who received care within the VA system in fiscal year 2010. We estimated the costs of VA care for each patient using established methods and aggregated costs for inpatient care, outpatient care, prescription drugs, and contract care. Using ICD-9 diagnosis fields from all inpatient and outpatient records, we determined the prevalence of 28 chronic conditions and all condition triads. We then compared the condition-cost gradient, most prevalent triads, and most costly triads among nonelderly (below 65 y) and elderly (65 y and above) patients.

RESULTS

Almost one third of nonelderly and slightly more than a third of elderly VA patients had ≥3 conditions, but these patients accounted for 65% and 67% of total VA healthcare costs, respectively. The most common triad of chronic conditions for both nonelderly and elderly patients was diabetes, hyperlipidemia, and hypertension (24% and 29%, respectively). Conditions that were present in the most costly triads included spinal cord injury, heart failure, renal failure, ischemic heart disease, peripheral vascular disease, stroke, and depression. Although patients with the most costly triads had average costs that were 3 times higher than average costs among patients with ≥3 conditions, the prevalence of these costly triads was extremely low (0.1%-0.4%).

CONCLUSIONS

Patients with multiple chronic conditions account for a disproportionate share of VA healthcare expenditures. Interventions that aim to optimize care and contain costs for multimorbid patients need to incorporate strategies specific to the most prevalent and the most costly combinations of conditions.

The health and service needs of older veterans: a qualitative analysis

BACKGROUND

With substantial numbers of older people within the Australian veteran population continuing to age well within the community, appropriate planning of community support and health services is important for this ageing population.

OBJECTIVE

The purpose of this research study was to investigate the health and service usage of a group of older Australian war veterans who receive Australian Government support for their health-care needs and conditions.

DESIGN

This paper reports on qualitative data gathered from the longitudinal MELSHA study. Utilizing thematic analysis and the theoretical framework of locus of control, this article reports on 25 qualitative interviews of veterans and their widows about their DVA-related health and service usage.

RESULTS

Participants within this study were determined to maintain a sense of control and independence in relation to their living circumstances and service usage. In doing so, they attempted to maintain their current community living circumstances and independence while minimizing their utilization of services and perceived 'burden' on family members and friends. Participants accepted that a decline in health status was inevitable, but engaged in a number of different strategies to maintain their current way of life for as long as possible.

DISCUSSION & CONCLUSION

Participants, while valuing an internal locus of control, generally engaged in an integrative locus of control to maintain a sense of control and independence in their daily lives. In addition, participants were very grateful of the services provided by the DVA and acknowledged their role in maintaining their independence within the community.

Cognitive processing therapy for veterans with comorbid PTSD and alcohol use disorders

Posttraumatic stress disorder (PTSD) and alcohol-use disorders (AUD) frequently present comorbidity in veteran populations. Traditionally those with alcohol dependence have been excluded from PTSD treatment outcome studies, thus we do not know how those with alcohol dependence may tolerate or respond to PTSD-specific interventions; no studies to date have examined the extent to which cognitive PTSD interventions are tolerated or effective for those with comorbid PTSD/AUD. The present study examines the extent to which CPT is tolerated by and effective in treating PTSD symptoms for veterans with PTSD and AUD, as compared to veterans with PTSD only in an outpatient treatment setting. Data were obtained through chart review of 536 veterans diagnosed with PTSD who had received at least 1 session of CPT at a Midwestern US Veterans Affairs hospital. Nearly half (n=264, 49.3%) of the veterans in the study exhibited a current or past AUD diagnosis. Participants were grouped into the following diagnostic groups: current AUD (past 12 months), past AUD (prior to 12 months), and no AUD. Participants completed an average of 9 sessions of CPT with no significant difference between AUD diagnostic groups on the number of CPT sessions completed. Individuals with past AUD had higher initial symptoms of self-reported PTSD symptoms than those with no AUD. All groups reported significant reductions in PTSD symptoms and depression over time. Overall, the results suggest that CPT appears well tolerated among veterans with comorbid AUD and is associated with significant reductions in symptoms of PTSD and depression in an outpatient treatment setting.

Depression sudden gains and transient depression spikes during treatment for PTSD

OBJECTIVE

We know little about how change unfolds in depression symptoms during posttraumatic stress disorder (PTSD) treatment or how patient characteristics predict depression symptom change. This study examined critical transition points in depression symptoms during PTSD treatment, namely, depression sudden gains, which are rapid symptom improvements and transient depression spikes, which are transient depression worsenings. Social support, one of the strongest predictors of PTSD development, was examined as a predictor of depression symptom discontinuities.

METHOD

At pretreatment, 200 participants (76.6% female; 64.9% Caucasian; age M = 37.1, SD = 11.3 years) completed measures of PTSD severity (PTSD Symptom Scale-Self-Report), depression severity (Beck Depression Inventory), general social support (Inventory of Socially Supportive Behaviors; Social Support Questionnaire), and trauma-related social support (Social Reactions Questionnaire). During 10 weeks of prolonged exposure (PE) or sertraline, depression was assessed weekly.

RESULTS

Overall, 18.0% of participants experienced a depression sudden gain, and 22.5% experienced a transient depression spike. The presence of a depression sudden gain predicted better treatment outcome, β = -4.82, SE = 1.17, p = .001, 95% CI [-6.79, -2.90]. Higher perceptions of negative trauma-related reactions, albeit modestly, were associated with experiencing a transient depression spike (r = .18, p = .01). There were no differences in rates of depression sudden gains or transient depression spikes between treatments.

CONCLUSIONS

Encouragingly, rapid improvements in depression symptoms are beneficial for PTSD treatment outcome, but transient spikes in depressive symptoms do not strongly influence outcome. Understanding symptom discontinuities may help us to personalize current PTSD treatment options.

PTSD, depressive symptoms, and suicidal ideation in African American women: a mediated model

Although research has shown positive associations among post-traumatic stress disorder (PTSD), depressive symptoms, and suicidal ideation, the nature of these relations is unclear, especially in African American women. This study examined the associations among these comorbid psychological difficulties in a sample of 136 low-income, African American women. Specifically, the goal of this investigation was to ascertain if overall depressive symptoms, as well as both the cognitive-affective and somatic components of depression, mediated the PTSD-suicidal ideation link. Results from bootstrapping analyses revealed that overall depressive symptoms and the cognitive-affective components of depression, but not the somatic components, mediated the PTSD-suicidal ideation link.

Brief treatment of co-occurring post-traumatic stress and depressive symptoms by use of accelerated resolution therapy(®)

This uncontrolled prospective cohort study evaluated the use of accelerated resolution therapy (ART) for treatment of comorbid symptoms of post-traumatic stress disorder (PTSD) and major depressive disorder. Twenty-eight adult subjects, mean age of 41 years (79% female, 36% Hispanic), received a mean of 3.7 ± 1.1 ART treatment sessions (range 1-5). ART is a new exposure-based psychotherapy that makes use of eye movements. Subjects completed a range of self-report psychological measures before and after treatment with ART including the 17-item PCL-C checklist (symptoms of PTSD) and 20-item Center for Epidemiologic Studies Depression Scale (CES-D). For the PCL-C, the pre-ART mean (±standard deviation) was 62.5 (8.8) with mean reductions of -29.6 (12.5), -30.1 (13.1), and -31.4 (14.04) at post-ART, 2-month, and 4-month follow-up, respectively (p < 0.0001 for comparisons to pre-ART score). Compared to pre-ART status, this corresponded to standardized effect sizes of 2.37, 2.30, and 3.01, respectively. For the CES-D, the pre-ART mean was 35.1 (8.8) with mean reductions of -20.6 (11.0), -18.1 (11.5), and -15.6 (14.4) at post-ART, 2-month, and 4-month follow-up, respectively (p ≤ 0.0001 compared to Pre-ART score). This corresponded to standardized effect sizes of 1.88, 1.58, and 1.09, respectively. Strong correlations were observed at 2-month and 4-month follow-up for post-treatment changes in PTSD and depression symptom scores (r = 0.79, r = 0.76, respectively, p ≤ 0.0002). No serious treatment-related adverse effects were reported. In summary, ART appears to be a promising brief, safe, and effective treatment for adults with clinically significant comorbid symptoms of PTSD and depression. Future controlled and mechanistic studies with this emerging therapy are warranted, particularly given its short treatment duration, and in light of current heightened emphasis on health care cost constraints.

Neural dysregulation in posttraumatic stress disorder: evidence for disrupted equilibrium between salience and default mode brain networks

OBJECTIVE

Convergent research demonstrates disrupted attention and heightened threat sensitivity in posttraumatic stress disorder (PTSD). This might be linked to aberrations in large-scale networks subserving the detection of salient stimuli (i.e., the salience network [SN]) and stimulus-independent, internally focused thought (i.e., the default mode network [DMN]).

METHODS

Resting-state brain activity was measured in returning veterans with and without PTSD (n = 15 in each group) and in healthy community controls (n = 15). Correlation coefficients were calculated between the time course of seed regions in key SN and DMN regions and all other voxels of the brain.

RESULTS

Compared with control groups, participants with PTSD showed reduced functional connectivity within the DMN (between DMN seeds and other DMN regions) including the rostral anterior cingulate cortex/ventromedial prefrontal cortex (z = 3.31; p = .005, corrected) and increased connectivity within the SN (between insula seeds and other SN regions) including the amygdala (z = 3.03; p = .01, corrected). Participants with PTSD also demonstrated increased cross-network connectivity. DMN seeds exhibited elevated connectivity with SN regions including the insula (z = 3.06; p = .03, corrected), and SN seeds exhibited elevated connectivity with DMN regions including the hippocampus (z = 3.10; p = .048, corrected).

CONCLUSIONS

During resting-state scanning, participants with PTSD showed reduced coupling within the DMN, greater coupling within the SN, and increased coupling between the DMN and the SN. Our findings suggest a relative dominance of threat-sensitive circuitry in PTSD, even in task-free conditions. Disequilibrium between large-scale networks subserving salience detection versus internally focused thought may be associated with PTSD pathophysiology.

Altered resting-state amygdala functional connectivity in men with posttraumatic stress disorder

BACKGROUND

Converging neuroimaging research suggests altered emotion neurocircuitry in individuals with posttraumatic stress disorder (PTSD). Emotion activation studies in these individuals have shown hyperactivation in emotion-related regions, including the amygdala and insula, and hypoactivation in emotion-regulation regions, including the medial prefrontal cortex (mPFC) and anterior cingulate cortex (ACC). However, few studies have examined patterns of connectivity at rest in individuals with PTSD, a potentially powerful method for illuminating brain network structure.

METHODS

Using the amygdala as a seed region, we measured resting-state brain connectivity using 3 T functional magnetic resonance imaging in returning male veterans with PTSD and combat controls without PTSD.

RESULTS

Fifteen veterans with PTSD and 14 combat controls enrolled in our study. Compared with controls, veterans with PTSD showed greater positive connectivity between the amygdala and insula, reduced positive connectivity between the amygdala and hippocampus, and reduced anticorrelation between the amygdala and dorsal ACC and rostral ACC.

LIMITATIONS

Only male veterans with combat exposure were tested, thus our findings cannot be generalized to women or to individuals with non-combat related PTSD.

CONCLUSION

These results demonstrate that studies of functional connectivity during resting state can discern aberrant patterns of coupling within emotion circuits and suggest a possible brain basis for emotion-processing and emotion-regulation deficits in individuals with PTSD.

An open trial of motivational interviewing to address suicidal ideation with hospitalized veterans

OBJECTIVE

The purpose of this open trial was to test the acceptability of motivational interviewing to address suicidal ideation (MI-SI) for psychiatrically hospitalized veterans with suicidal ideation, estimate its pre-post effect size on the severity of suicidal ideation, and examine the rate of treatment engagement after discharge.

METHODS

Participants received a screening assessment, baseline assessment, one or two MI-SI sessions, posttreatment assessment, and 60-day follow-up assessment. Thirteen veterans were enrolled, 9 (70%) completed both MI-SI sessions and the posttreatment assessment, and 11 (85%) completed the follow-up assessment.

RESULTS

Participants found MI-SI to be acceptable. They experienced large reductions in the severity of suicidal ideation at posttreatment and follow-up. In the 2 months following discharge, 73% of participants completed two or more mental health or substance abuse treatment sessions each month.

CONCLUSIONS

These preliminary findings suggest that MI-SI has potential to reduce risk for suicide in psychiatrically hospitalized veterans and that a more rigorous trial is needed.

Health-related quality of life among US veterans and civilians by race and ethnicity

INTRODUCTION

Among veterans, having been selected into the military and having easy access to medical care during and after military service may reduce premature mortality but not morbidity from mental distress and may not improve health-related quality of life. The objective of this study was to determine whether veterans in different racial/ethnic groups differ in their health-related quality of life from each other and from their civilian counterparts.

METHODS

Among 800,000 respondents to the 2007-2009 Behavioral Risk Factor Surveillance System surveys, approximately 110,000 identified themselves as veterans and answered questions about their sociodemographic characteristics, self-rated health, and recent health-related quality of life. Nonoverlapping 95% confidence intervals of means distinguished veterans and civilians of different racial/ethnic groups.

RESULTS

Veteran and civilian American Indians/Alaska Natives reported more physically unhealthy days, mentally unhealthy days, and recent activity limitation days than their veteran and civilian counterparts in other racial/ethnic groups. Non-Hispanic white veterans and Hispanic veterans reported more physically unhealthy days, mentally unhealthy days, and recent activity limitation days than their civilian counterparts.

CONCLUSION

Unlike findings in other studies, our findings show that veterans' health-related quality of life differs from that of civilians both within the same racial/ethnic group and among different racial/ethnic groups. Because once-healthy soldiers may not be as healthy when they return to civilian life, assessing their health-related quality of life over time may identify those who need help to regain their health.

The predictive power of depression screening procedures for veterans with coronary artery disease

Depression leads to a worse outcome for patients with coronary artery disease (CAD). Thus, accurately identifying depression in CAD patients is imperative. In many veterans affairs (VA) hospitals, patients are screened for depression once a year using the patient health questionnaire (PHQ-9). Although the PHQ-9 is generally considered a specific and sensitive measure of depression, there is reason to believe that these screening procedures may miss a large number of cases of depression within CAD patients and cardiology patients more generally. The goal of this study was to provide data as to the predictive power of this depression screening procedure by (a) comparing the prevalence rate of depression identified by the PHQ-9 to known prevalence rates and (b) examining whether patients identified as “depressed” also had conditions that consistently co-occur with depression (eg, post-traumatic stress disorder [PTSD], other medical issues). Participants were 813 consecutive patients who received an angiogram in the cardiac catheterization laboratory at a large VA Medical Center. Prevalence of depression was 6.9% in the overall sample and less than 6% when the sample was restricted to CAD patients with significant stenosis. Depression was significantly associated with PTSD, smoking, and alcohol problems. However, depression was not associated with other medical problems such as diabetes, renal failure, peripheral vascular disease, or anemia. In conclusion, the low prevalence rate of depression and lack of associations with comorbid medical problems may suggest that the VA’s depression screening procedures have low sensitivity for identifying depression in CAD patients. It is recommended that clinicians treating CAD regularly screen for depression and do not rely on archival depression screens.

Do veterans with posttraumatic stress disorder receive first-line pharmacotherapy? Results from the longitudinal veterans health survey

OBJECTIVE

Guidelines addressing the treatment of veterans with posttraumatic stress disorder (PTSD) strongly recommend a therapeutic trial of selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). This study examined veteran characteristics associated with receiving such first-line pharmacotherapy, as well as how being a veteran of the recent conflicts in Afghanistan and Iraq impact receipt of pharmacotherapy for PTSD.

METHOD

This was a national study of 482 Veterans Affairs (VA) outpatients between the ages of 18 and 69 years who had been newly diagnosed with PTSD (DSM-IV criteria: 309.81) during a VA outpatient visit between May 31, 2006, and December 7, 2007. Participants completed a mailed survey between August 11, 2006, and April 6, 2008. Veterans from the Afghanistan and Iraq conflicts and female veterans were intentionally oversampled. Logistic regression models were developed to predict 2 dependent variables: odds of initiating an SSRI/SNRI and, among veterans who initiated an SSRI/SNRI, odds of receiving an adequate therapeutic trial. Each dependent variable was regressed on a variety of sociodemographic and survey characteristics.

RESULTS

Of the 377 veterans prescribed a psychotropic medication, 73% (n = 276) received an SSRI/SNRI, of whom 61% (n = 168) received a therapeutic trial. Afghanistan and Iraq veterans were less likely to receive a therapeutic trial (odds ratio [OR] = 0.45; 95% CI, 0.27-0.75; P < .01), with presence of a comorbid depression diagnosis in the year after the index episode moderating this relationship, which further decreased the odds of completing a therapeutic trial (OR = 0.29; 95% CI, 0.09-0.95; P < .05).

CONCLUSIONS

Reduced levels of receipt of first-line pharmacotherapy among recent veteran returnees parallel previous findings of less mental health treatment utilization in this population and warrant investigation.

Suicidal behavior in a national sample of older homeless veterans

OBJECTIVES

We examined self-reported suicidal behavior of older homeless veterans to establish frequencies and predictors of recent suicidal behaviors, and their impact on transitional housing interventions.

METHODS

We analyzed the records of a national sample of 10,111 veterans who participated in a transition housing program over a 6-year period, ending in 2008.

RESULTS

Approximately 12% of homeless veterans reported suicidal ideation before program admission; 3% reported a suicide attempt in the 30 days before program admission. Older homeless veterans exhibiting suicidal behavior had histories of high rates of psychiatric disorders and substance abuse. Regression analyses showed that self-report of depression was the primary correlate of suicidal behavior. Suicidal behavior before program entry did not predict intervention outcomes, such as program completion, housing outcome, and employment.

CONCLUSIONS

Suicidal behavior was prevalent in older homeless veterans and was associated with a history of psychiatric disorder and substance abuse. Self-reported depression was associated with these behaviors at the time of housing intervention. Despite the association with poor mental health history, suicidal behavior in older homeless veterans did not impact outcomes of transitional housing interventions.

The current state of intervention research for posttraumatic stress disorder within the primary care setting

Posttraumatic Stress Disorder (PTSD) is common among primary care patients and is associated with significant functional impairment, physical health concerns, and mental health comorbidities. Significant barriers to receiving adequate treatment often exist for primary care patients with PTSD. Mental health professionals operating as part of the primary care team have the potential to provide effective brief intervention services. While good PTSD screening and assessment measures are available for the primary care setting, there are currently no empirically supported primary care-based brief interventions for PTSD. This article reviews early research on the development and testing of primary care-based PTSD treatments and also reviews other brief PTSD interventions (i.e., telehealth and early intervention) that could be adapted to the primary care setting. Cognitive and behavioral therapies currently have the strongest evidence base for establishing an empirically supported brief intervention for PTSD in primary care. Recommendations are made for future research and clinical practice.

Clinical effectiveness of using an integrated model to treat depressive symptoms in veterans affairs primary care clinics and its impact on health care utilization

OBJECTIVE

To determine if veterans treated in an integrated mental health program within a Veterans Affairs (VA) primary care clinic sustained long-term improvement in depressive symptoms and changed their use of health care.

METHOD

In this pilot program, 72 veterans were offered short-term treatment for depressive symptoms by a colocated psychiatrist who was integrated into a VA primary care team (October 1, 1997, through September 30, 1999). Patients were assessed initially and at their final session using the Hamilton Depression Rating Scale. Veterans who completed treatment were referred back to their primary care provider or to specialty mental health services. Patients were contacted and invited to be reevaluated 3 to 5 years later using the same measure (December 1, 2001, through November 30, 2002). Health care utilization data were collected for 1 year preintervention and 2 years postintervention. Outcomes for treatment completers were compared to outcomes for those who declined or dropped out of treatment.

RESULTS

Of 48 patients who agreed to participate in the study, 27 completed treatment and showed a significant decline in symptoms from pretreatment to follow-up (P = .008) compared to 16 noncompleters, as well as a moderate-to-large between-group effect size (d = 0.78) and trends for higher remission and response rates. Completers ranked significantly higher in the number of antidepressant prescriptions filled before (P = .002) and after treatment (P = .001) and in the number of medical visits postintervention (year 1: P = .021; year 2: P = .023), without an associated cost increase.

CONCLUSIONS

Colocated mental health care integrated into VA primary care is associated with sustained improvement of depressive symptoms in a heterogeneous patient population with a high incidence of psychiatric comorbidities. This finding compares favorably with the results of earlier controlled clinical trials and suggests a potential effect on health care utilization.