US Department of Veterans Affairs disability policies for posttraumatic stress disorder: administrative trends and implications for treatment, rehabilitation, and research

A Stage 1 Pilot Cohort Exploring the Use of EMDR Therapy as a Videoconference Psychotherapy During COVID-19 With Frontline Mental Health Workers: A Proof of Concept Study Utilising a Virtual Blind 2 Therapist Protocol

Objective

The COVID-19 pandemic has had a major impact on the delivery of psychological treatment. Due to social distancing requirements, the provision moved to videoconferencing psychotherapy (VCP). There is a paucity of empirical data supporting the efficacy of EMDR therapy as a VCP. This stage 1 pilot study tested an EMDR therapy scripted protocol, such as Virtual Blind 2 Therapist (VB2Tr), on frontline mental health workers as a VCP regarding fitness for purpose, distinctiveness, relevance, and efficiency.

Methods

A total of 24 participants were recruited for the study. The design included a one-session treatment intervention with pre, post, 1-month, and 6-month follow-up (FU) measurements. This treatment session used a “Blind 2 Therapist” EMDR therapy scripted protocol as videoconference psychotherapy that involves non-disclosure of traumatic memory. The research explored the treatment effect on the core characteristics of trauma memory, including subjective disturbance, belief systems, memory intensity (MI), vividness, and levels of emotionality. Additionally, the research explored participants’ experiences of adverse and benevolent childhood experiences (ACEs/BCEs) during their childhood.

Results

Regarding the four tests, namely, fitness for purpose, distinctiveness, relevance, and efficiency, results are favourably suggesting potential clinical benefits of using EMDR as videoconference psychotherapy. Although this is a proof-of-concept study showing positive results, no clinical population or control group was used. The purpose of the study is to explore the potential for scalability toward a larger clinical trial. The treatment intervention was achieved irrespective of either ACEs/BCEs during childhood.

Conclusion

The research tentatively supports the case for EMDR therapy as a credible treatment when used as video conference psychotherapy and in using the Blind 2 Therapist protocol. However, more research is needed to scale toward a clinical trial.

Clinical Trial Registration

Clinical Trial Registration:https://www.isrctn.com/ISRCTN12099530, identifier ISRCTN12099530.

The Association Between Service Connection and Treatment Outcome in Veterans Undergoing Residential PTSD Treatment

The Department of Veterans Affairs has invested significant time and resources into the treatment of posttraumatic stress disorder (PTSD). Despite concerted efforts, a significant portion of patients do not respond optimally to trauma-focused treatment. One of the factors that has been hypothesized to be associated with treatment response is participation in the Veterans Benefits Administration service-connected disability process. This factor may be particularly relevant in the residential treatment setting, where most participants are engaged in the compensation seeking process. We conducted a retrospective chart review of 105 veterans who completed Cognitive Processing Therapy (CPT) in a residential rehabilitation program. ANCOVAs that adjusted for baseline PTSD severity compared symptom change between those who were and were non-compensation seeking at the time of treatment. Compensation seeking status was associated with significantly less symptom improvement over the course of CPT after adjusting for baseline PTSD severity (F(1, 102) = 4.29, p < .001, η² = .03). Sensitivity analyses did not detect a similar effect during a prior coping skills phase of treatment. During CPT, clinically significant change was met by 66.7% of non-compensation seeking veterans (M = -15, SD = 14.56) and by 40.1% of the compensation seeking group (M = -7.1, SD = 12.24). Compensation-seeking may be associated with reduced response to trauma-focused treatment in certain settings. Future research is needed to better understand the mechanisms underlying this effect.

The Research-Practice Psychotherapy Wars: The Case of Group Psychotherapy in the Treatment of PTSD

In light of two recent meta-analyses of the efficacy of group psychotherapy in treating posttraumatic stress disorder (PTSD), this article critically reviews the randomized control trial (RCT) generated findings as well as two of its outgrowths-the production of a variety of clinical practice guidelines for treating PTSD and the dissemination efforts to transfer laboratory findings to clinical practice. All three of these activities have received considerable pushback from experienced clinicians and Boulder-identified scientist practitioners, creating an ongoing and entrenched gap or split between researcher and clinician. The article also reviews the various suggestions that have been offered to heal this gap and ending the hegemony of RCT outcome research as the only game in town for declaring what constitutes evidence. Specifically, the literature suggests two primary strategies for helping to realize the scientist-practitioner model and thus advancing the cause of psychotherapy, in general, and group psychotherapy, in particular: (a) leveling the playing field so that both researcher and practitioner have real authority and voices for shaping the field; and (b) shifting the research priority away from a purely outcome focus, asking only does it work, and moving to a more sophisticated, theoretically guided empirical study of process-outcome, examining the how, why, when, and for whom it works.

Disability Status Attenuates Treatment Effects in an Intensive Outpatient Program for PTSD

INTRODUCTION

The utilization of intensive outpatient programs for the treatment of military-related post-traumatic stress disorder (PTSD) has increased through initiatives both inside and outside the military health care system. However, research in veteran populations suggest that patients concurrently undergoing disability evaluation may not respond well to such interventions. This study evaluates the relationship between disability separation and endorsement of PTSD symptoms during treatment at an intensive outpatient program.

METHODS

Patients in this retrospective study were 81 service members enrolled in a half-day, 6-week intensive outpatient program for PTSD. Sixty-seven percent (n = 54) were concurrently enrolled in the integrated disability evaluation system and were pending medical separation. Fifty-two percent (n = 42) also received a 4-week skills training intervention before beginning PTSD treatment. Patients completed the PTSD Checklist before, during, and after the treatment program as an index of PTSD symptoms.

RESULTS

A significant interaction effect was observed in which PTSD symptoms throughout program enrollment differed as a function of enrollment in the integrated disability evaluation system. Patients undergoing disability evaluations did not show significant changes in endorsed PTSD symptoms during program enrollment, whereas significant decreases in PTSD symptoms were observed in patients not undergoing disability evaluations. These effects controlled for lost treatment days as a result of training or other appointments.

CONCLUSIONS

These results provide preliminary data indicating that participation in disability separation may attenuate the effect of PTSD treatment and endorsement of PTSD symptoms in an intensive outpatient setting.

Psychometric Performance of the Miller Forensic Assessment of Symptoms Test (M-FAST) in Veteran PTSD Assessment

This study examined the psychometric properties of a widely used measure of symptom exaggeration, the Miller Forensic Assessment of Symptoms Test (M-FAST, Miller, 2001), in a sample of 209 (83.7% male) trauma-exposed veterans (57.9% probable current posttraumatic stress disorder; PTSD). M-FAST total scores evidenced acceptable internal consistency, but several subscales showed poor internal consistency. Factor analytic and item-response theory analyses identified seven poorly performing items. Comparisons with other measures of psychopathology and response validity (including subscales from the Minnesota Multiphasic Personality Inventory-2 Restructured Form) revealed that M-FAST scores were highly correlated with indices of psychopathology while less strongly associated with measures of symptom over-reporting. Empirically and clinically-derived (using a follow-up testing-the-limits procedure) revised M-FAST scores failed to improve the measure's psychometric performance. Results raise concerns about the validity of the M-FAST for identifying malingering in veterans with PTSD and carry implications for access to care and forensic evaluations in this population.

Spinal Cord Injury Veterans' Disability Benefits, Outcomes, and Health Care Utilization Patterns: Protocol for a Qualitative Study

BACKGROUND

An estimated 42,000 people currently living with chronic spinal cord injury (SCI) are veterans. SCI was a common combat-related injury in the World Wars and Vietnam era and now affects more than 11% of military personnel injured in Operation Iraqi Freedom and Operation Enduring Freedom. The Veterans Benefits Administration primarily offers financial compensation for disabilities sustained or re-aggravated during military service, called service-connected disability compensation. With the overwhelming cost of living with an SCI, this monthly financial compensation can provide service-connected veterans and their families with access to additional supportive resources (eg, assistive devices and personal aide) and maintain their quality of life (QOL). Little is known about personal, health, functional, and QOL outcomes associated with service-connected and nonservice-connected status for veterans living with an SCI.

OBJECTIVE

The aim of this study is to compare the ways in which Veterans Affairs' (VA) service-connected and nonservice-connected status may be associated with health and functional outcomes, choice of health care provider, and overall QOL for veterans living with an SCI and their caregivers.

METHODS

This cross-sectional qualitative study will gather data using retrospective chart reviews, semistructured interviews, and focus groups. After obtaining institutional review board (IRB) approval, purposeful sampling techniques will be used to recruit and enroll the following key stakeholders: veterans living with an SCI, family caregivers, and SCI health care providers. Concurrent data collection will take place at 2 sites: Veterans Administration New Jersey Healthcare System and Northern New Jersey Spinal Cord Injury System.

RESULTS

This study was funded in July 2015. IRB approval was obtained by November 2016 at both sites. Enrollment and data collection for phase 1 to phase 4 are complete. A total of 69 veterans, 18 caregivers, and 19 SCI clinicians enrolled in the study. Data analyses for these phases are underway. In phase 5, the follow-up focus group activities are scheduled. The final results are expected by the end of 2019.

CONCLUSIONS

The factors that contribute to veterans living with SCI seeking and not seeking VA disability compensation benefits are not well understood in rehabilitation research. Triangulation of these data sources will allow us to compare, contrast, and integrate the results, which can be used to develop clinical guidelines, caregiver training, and patient education programs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14039.

Positive impact of IPS supported employment on PTSD-related occupational-psychosocial functional outcomes: Results from a VA randomized-controlled trial

OBJECTIVE

Posttraumatic stress disorder (PTSD) has significant negative effects on occupational, interpersonal, and social functioning. Supported employment is highly effective in helping people with a diagnosis of PTSD obtain and maintain competitive employment. However, less is known about the impact of supported employment on functioning in work or school, social, and interpersonal areas as specifically related to the symptoms of PTSD.

METHOD

The Veterans Individual Placement and Support Toward Advancing Recovery study was a prospective, multisite, randomized, controlled trial that compared Individual Placement and Support (IPS) supported employment with a stepwise vocational rehabilitation involving transitional work (TW) assignments with unemployed veterans with PTSD diagnoses (n = 541) at 12 Veterans Administration (VA) medical centers. This analysis focuses on the PTSD-related functional outcomes over the 18-month follow-up period.

RESULTS

Compared with those randomized to TW, the PTSD Related Functioning Inventory (PRFI) total score significantly improved for participants randomized to IPS (LSMeans difference = -3.92, 95% CI [-7.49, -.36]; p = .03) over 18 months. When the Work/School subscale of the PRFI was removed from the analysis, the IPS group continued to show significant improvements compared with the TW group on the PRFI relationship and lifestyle domains (LSMeans difference = -2.37, 95% CI [-4.74, .00]; p = .05), suggesting a positive impact of IPS beyond work/school functioning.

CONCLUSION

Compared with the usual-care VA vocational services for veterans with PTSD, IPS supported employment is associated with greater improvement in overall PTSD-related functioning, including occupational, interpersonal, and lifestyle domains. In addition to superior employment outcomes, IPS has a positive impact on occupational-psychosocial functioning outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Brief Counseling for Veterans with Musculoskeletal Disorder, Risky Substance Use, and Service Connection Claims

OBJECTIVE

High proportions of post-9/11 veterans have musculoskeletal disorders (MSDs), but engaging them in care early in their course of illness has been challenging. The service connection application is an ideal point of contact for referring veterans to early interventions for their conditions.

DESIGN

Among MSD claimants who reported risky substance use, we pilot-tested a counseling intervention targeting pain and risky substance use called Screening Brief Intervention and Referral to Treatment-Pain Module (SBIRT-PM). Veterans were randomly assigned in a 2:1:1 ratio to SBIRT-PM, Pain Module counseling only, or treatment as usual (TAU).

METHODS

Participants assigned to either counseling arm were offered a single meeting with a study therapist with two follow-up telephone calls as needed. Participants completed outcome assessments at four and 12 weeks after randomization.

RESULTS

Of 257 veterans evaluated, 101 reported risky substance use and were randomized. Counseling was attended by 75% of veterans offered it and was well received. VA pain-related services were used by 51% of participants in either of the pain-focused conditions but only by 27% in TAU (P < 0.04). Starting with average pain severity ratings of 5.1/10 at baseline, only minimal changes in mean pain severity were noted regardless of condition. Self-reported risky substance use was significantly lower over time in the SBIRT-PM condition relative to the two other conditions (P < 0.02). At week 12, proportions of veterans reporting risky substance use were 0.39, 0.69, and 0.71 for the SBIRT-PM, Pain Module counseling, and TAU conditions, respectively.

CONCLUSIONS

SBIRT-PM shows promise as a way to engage veterans in pain treatment and reduce substance use.

Veterans' compensation claims beliefs predict timing of PTSD treatment use relative to compensation and pension exam

Introduction

In this study we developed the Disability Beliefs Scale to assess Veterans’ beliefs that engaging in treatment, as well as other behaviors, would affect the likelihood of a Veteran’s being awarded disability-related benefits. We posited that Veterans with stronger beliefs that attending mental health treatment would facilitate a service-connection award would be more likely to attend PTSD treatment before their compensation and pension examinations for PTSD.

Methods

Electronic health records for 307 post-9/11-era Veterans applying for compensation and pension for service-connected PTSD and engaging in a clinical trial of a treatment-referral intervention were analyzed for PTSD-specific and more general mental health treatment use around the time of their compensation examinations. All participants completed the Disability Beliefs Scale and other baseline assessments. Multilevel models assessed change in treatment use as a function of time relative to the C&P exam, compensation examination status (before or after), and the interaction between examination status and beliefs about treatment benefits.

Results

No main effects of time or examination status were observed. As hypothesized, beliefs about treatment benefits moderated the effect of examination status on PTSD treatment use. Veterans believing more strongly that mental health treatment would help a claim differentially attended PTSD treatment before the examination than after. The effect was not observed for general mental health treatment use.

Conclusion

The association between Veterans’ use of PTSD treatment and their service-connection examination status was moderated by beliefs that receiving treatment affects the service-connection decision. This suggests that factors reported to motivate seeking service-connection—finances, validation of Veterans’ experiences, and the involvement of significant others—might also help motivate Veterans’ use of effective PTSD treatments. However, the results reflect correlations that could be explained in other ways, and service-connection was one of many factors impacting PTSD treatment engagement.

Mental Health Service Utilization before and after Receipt of a Service-Connected Disability Award for PTSD: Findings from a National Sample

OBJECTIVE

To determine patterns of mental health service use before and after VA disability compensation awards for posttraumatic stress disorder (PTSD).

DATA SOURCES

A 10 percent random sample of VHA-enrolled Veterans with new or increased PTSD service connection between 2012 and 2014 (n = 22,249).

STUDY DESIGN

We used latent trajectory analysis to identify utilization patterns and multinomial logistic regression to assess associations between Veteran characteristics and trajectory membership.

DATA EXTRACTION METHODS

We assessed receipt of VHA mental health encounters in each of the 52 weeks prior to and following PTSD disability rating or rating increase.

PRINCIPAL FINDINGS

The best fitting model had five groups: No Use (36.6 percent), Low Use (37.7 percent), Increasing Use (9.4 percent), Decreasing Use (11.2 percent), and High Use (5.1 percent). Adjusting for demographic characteristics and compared with the No Use group, Veterans in the other groups were more likely to reside closer to a VHA facility, receive a higher PTSD disability rating, and screen positive for military sexual trauma.

CONCLUSIONS

Service use remained stable (80 percent) or increased (9 percent) for the vast majority of Veterans. Service utilization declined for only 11 percent. Data did not indicate substantial service discontinuation following rating. Low VHA service utilization suggests opportunities to enhance outreach for Veterans with PTSD-related disability benefits.

The Influence of Posttraumatic Stress Disorder on Health Functioning in Active-Duty Military Service Members

Researchers have suggested that posttraumatic stress disorder (PTSD) is associated with significant healthcare burden and utilization of medical services. The purpose of this study was to examine the impact of PTSD symptoms on health functioning among active-duty military personnel. Participants in the study were 366 treatment-seeking service members who had returned from deployment and were participating in a larger PTSD treatment study. Assessments included measures of PTSD symptom severity, combat experiences, life stress, health functioning, alcohol use, and depression. We hypothesized that at baseline, PTSD severity and its symptom clusters would be significantly associated with poorer physical and mental health functioning. We conducted separate hierarchical multiple regressions to examine the predictive contribution the hypothesized factors would have on the variance in physical and mental health scores. Consistent with previous literature, we found that PTSD severity was significantly associated with poorer mental health functioning, B = -0.25, SE = 0.08, β = -0.15, t(342) = -3.07, R² = .37, p = .002; however, contrary to our hypotheses, PTSD severity was not associated with poorer physical health functioning. Further, the hyperarousal symptom cluster was significantly associated with poorer physical health functioning, B = -0.83, SE = 0.26, β = -0.18, t(340) = -3.16, R² = .11, p = .002, but not mental health functioning. Limitations of our study included the use of self-report measures only and lack of objective measures. Future directions for study include examination of how health functioning perceptions change over a longer duration of PTSD symptoms and after treatment.

UK extended Medical Assessment Programme for ex-service personnel: the first 150 individuals seen

Aims and method

To describe an interim service set up to examine the breadth of UK ex-service personnel's concerns in relation to their mental health and military service and provide a record of the first 150 individuals assessed following conformation of military service and examination of all available military and civilian medical records.

Results

The majority of attendees were White male ex-soldiers. Average age, service and time to assessment were 44.5, 15.8 and 11.7 years respectively. Two-thirds were receiving help from the National Health Service and ex-service nongovernmental organisations. Rates of post-traumatic stress disorder were similar to previous UK studies. Obsessional symptoms were of relevance to the clinical presentation in a third. Fabrication and/or exaggeration occurred in about 10%.

Clinical implications

The spread of diagnoses and delay in help-seeking are similar to civilians. The link between mental disorders and military service is seldom straightforward and fabrication or exaggeration is difficult for civilians to recognise. Verification and contextualisation of service using contemporaneous service medical records is important given the possible occupational origin of mental health conditions.

Key patterns and predictors of response to treatment for military veterans with post-traumatic stress disorder: a growth mixture modelling approach

BACKGROUND

To determine the patterns and predictors of treatment response trajectories for veterans with post-traumatic stress disorder (PTSD).

METHODS

Conditional latent growth mixture modelling was used to identify classes and predictors of class membership. In total, 2686 veterans treated for PTSD between 2002 and 2015 across 14 hospitals in Australia completed the PTSD Checklist at intake, discharge, and 3 and 9 months follow-up. Predictor variables included co-morbid mental health problems, relationship functioning, employment and compensation status.

RESULTS

Five distinct classes were found: those with the most severe PTSD at intake separated into a relatively large class (32.5%) with small change, and a small class (3%) with a large change. Those with slightly less severe PTSD separated into one class comprising 49.9% of the total sample with large change effects, and a second class comprising 7.9% with extremely large treatment effects. The final class (6.7%) with least severe PTSD at intake also showed a large treatment effect. Of the multiple predictor variables, depression and guilt were the only two found to predict differences in response trajectories.

CONCLUSIONS

These findings highlight the importance of assessing guilt and depression prior to treatment for PTSD, and for severe cases with co-morbid guilt and depression, considering an approach to trauma-focused therapy that specifically targets guilt and depression-related cognitions.

Predictors of Treatment Discontinuation During Prolonged Exposure for PTSD

Background: Post-traumatic stress disorder (PTSD) is a highly prevalent and impairing condition for which there are several evidence-based psychotherapies. However, a significant proportion of patients fail to complete a ‘sufficient dose’ of psychotherapy, potentially limiting treatment gains. Aims: The present study investigated predictors of premature treatment discontinuation during a trial of prolonged exposure (PE) therapy for PTSD. Method: Combat veterans with PTSD were recruited to participate in a randomized clinical trial of PE delivered in person or via telehealth technologies. Of the 150 initial participants, 61 participants discontinued the trial before the completion of eight sessions (of an 8‒12 session protocol). Treatment condition (telehealth or in person) and factors identified by prior research (age, combat theatre, social support, PTSD symptoms) were tested as predictors of treatment discontinuation. Results: A Cox proportional hazards model (a subtype of survival analysis) was used to evaluate predictors of treatment discontinuation. Disability status and treatment condition were identified as significant predictors of discontinuation, with a noted disability and use of telehealth demonstrating higher risk. Conclusions: The present findings highlight the influence of telehealth and disability status on treatment discontinuation, while minimizing the role of the previously identified variables from studies with less sensitive analyses.

PTSD in Court I: Introducing PTSD for Court

The first part of the series of three articles on posttraumatic stress disorder (PTSD) in Court to appear in the journal reviews the history of the construct of PTSD and its presentation in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; American Psychiatric Association, 2013) and the ICD-11 (International Classification of Diseases, 11th Edition; World Health Organization, 2018). There are 20 symptoms of PTSD in the DSM-5. PTSD symptoms are arranged into a four-cluster model, which has received partial support in the literature. Other four-factor models have been found that fit the data even better than that of the DSM-5. There is a five-factor dysphoria model and two six-factor models that have been found to fit better the DSM-5 PTSD symptoms. Finally, research is providing support for a hybrid seven-factor model. An eighth factor on dissociation seems applicable to the minority of people who express the dissociative subtype. At the epidemiological level, individuals can expect trauma exposure to take place about 70% over one's lifetime. Also, traumatic exposure leads to traumatic reactions in about 10% of cases, with PTSD being a primary diagnosis for trauma. Once initiated, PTSD becomes prolonged in about 10% of cases. Polytrauma and comorbidities complicate these prevalence statistics. Moreover, the possibility of malingered PTSD presents confounds. However, the estimate for malingered PTSD varies extensively, from 1 to 50%, so that the estimate is too imprecise for use in court without further research. This first article in the series of three articles appearing in the journal on PTSD in Court concludes with discussion of complications related to comorbidities and heterogeneities, in particular. For example, PTSD and its comorbidities can be expressed in over one quintillion ways. This complexity in its current structure in the DSM-5 speaks to the individual differences involved in its expression.

Identifying and Managing Malingering and Factitious Disorder in the Military

Malingering is the intentional fabrication of medical symptoms for the purpose of external gain. Along similar lines as malingering, factitious disorder is the intentional creation or exaggeration of symptoms, but without intent for a concrete benefit. The incidence of malingering and factitious disorder in the military is unclear, but likely under reported for a variety of reasons. One should be aware of potential red flags suggesting malingering or factitious disorder and consider further evaluation to look for these conditions. A deliberate and intentional management plan is ideal in these cases. Furthermore, a multi-disciplinary team approach, a non-judgmental environment, and the use of direct but dignity sparing techniques will likely be most "successful" when confronting the patient with malingering or factitious disorder.

DSM-5 Criteria and Its Implications for Diagnosing PTSD in Military Service Members and Veterans

This review addresses how changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 posttraumatic stress disorder (PTSD) criteria has the potential to affect the care and careers of those who have served in the military, where the diagnosis often determines fitness for duty and veterans' benefits. PTSD criteria changes were intended to integrate new knowledge acquired since previous DSM editions. Many believe the changes will improve diagnosis and treatment, but some worry these could have negative clinical, occupational, and legal consequences. We analyze the changes in classification, trauma definition, symptoms, symptom clusters, and subtypes and possible impacts on the military (e.g., over- and under-diagnosis, "drone" video exposure, subthreshold PTSD, and secondary PTSD). We also discuss critiques and proposals for future changes. Our objectives are to improve the screening, diagnosis, and treatment of those service members who have survived trauma and to improve policies related to the military mental healthcare and disability systems.

The influence of trauma and patient characteristics on provider burnout in VA post-traumatic stress disorder specialty programmes

OBJECTIVE

Prolonged exposure (PE) and cognitive processing therapy (CPT) - post-traumatic stress disorder (PTSD) treatments now available at the Veterans Health Administration (VHA) - expose the provider to graphic traumatic material. Little is known about the impact of traumatic material on VHA providers. The purpose of this study was to examine the relationship between trauma content, patient characteristics, and burnout among VHA PTSD Clinical Team (PCT) providers. It was hypothesized that trauma content and patient characteristics would significantly predict burnout in this population.

DESIGN

This cross-sectional study consisted of 137 participants. The sample was mostly female (67%), Caucasian (non-Hispanic; 81%), and married (70%) with a mean age of 44.3 years (SD = 11.3).

METHODS

Participants completed an electronic survey that assessed demographics, patient characteristics (i.e., anger, personality disorder, malingering), trauma content characteristics (e.g., killing of women and children) as well as burnout as measured by the Maslach Burnout Inventory-General Survey (MBI-GS; Maslach et al., 1996, Burnout inventory manual. Palo Alto: Consulting Psychologist Press).

RESULTS

Over half of the study population reported being bothered by trauma content; however, trauma content did not predict burnout. Treating patients with personality disorders and suspected malingering predicted burnout in PCT providers. High numbers (77%) reported perceiving that emotional exhaustion impacted the quality of care they provided.

CONCLUSION

These findings suggest an important role of burnout assessment, prevention, and treatment strategies at the VHA.

PRACTITIONER POINTS

This paper addresses the impact of provider burnout on perceived quality of care. This paper also addresses potential predictors of burnout in PCT settings. This paper outlines potential remedies to provider burnout in the VHA.

Cognitive-behavioral therapy for late-life anxiety: Similarities and differences between Veteran and community participants

Cognitive-behavioral therapy (CBT) is an evidence-based treatment for anxiety; however, a growing body of research suggests that CBT effect sizes are smaller in Veteran samples. The aim of this study was to perform secondary data analyses of a randomized controlled trial of CBT for late-life generalized anxiety disorder compared with treatment as usual (TAU) in a Veteran (n = 101) and community-based (n = 122) sample. Veterans had lower income and less education than community participants, greater severity on baseline measures of anxiety and depression, poorer physical health, and higher rates of psychiatric comorbidity. Treatment effects were statistically significant in the community sample (all ps < 0.01), but not in Veterans (all ps > 0.05). Further analyses in Veterans revealed that poorer perceived social support significantly predicted poorer outcomes (all ps < 0.05). Our results underscore the complexity of treating Veterans with anxiety, and suggest that additional work is needed to improve the efficacy of CBT for Veterans, with particular attention to social support.

The mental health of the UK Armed Forces: where facts meet fiction

A substantial amount of research has been conducted into the mental health of the UK military in recent years. This article summarises the results of the various studies and offers possible explanations for differences in findings between the UK and other allied nations. Post-traumatic stress disorder (PTSD) rates are perhaps surprisingly low amongst British forces, with prevalence rates of around 4% in personnel who have deployed, rising to 6% in combat troops, despite the high tempo of operations in recent years. The rates in personnel currently on operations are consistently lower than these. Explanations for the lower PTSD prevalence in British troops include variations in combat exposures, demographic differences, higher leader to enlisted soldier ratios, shorter operational tour lengths and differences in access to long-term health care between countries. Delayed-onset PTSD was recently found to be more common than previously supposed, accounting for nearly half of all PTSD cases; however, many of these had sub-syndromal PTSD predating the onset of the full disorder. Rates of common mental health disorders in UK troops are similar or higher to those of the general population, and overall operational deployments are not associated with an increase in mental health problems in UK regular forces. However, there does appear to be a correlation between both deployment and increased alcohol misuse and post-deployment violence in combat troops. Unlike for regular forces, there is an overall association between deployment and mental health problems in Reservists. There have been growing concerns regarding mild traumatic brain injury, though this appears to be low in British troops with an overall prevalence of 4.4% in comparison with 15% in the US military. The current strategies for detection and treatment of mental health problems in British forces are also described. The stance of the UK military is that psychological welfare of troops is primarily a chain of command responsibility, aided by medical advice when necessary, and to this end uses third location decompression, stress briefings, and Trauma Risk Management approaches. Outpatient treatment is provided by Field Mental Health Teams and military Departments of Community Mental Health, whilst inpatient care is given in specific NHS hospitals.

Examination of Veterans Affairs disability compensation as a disincentive for employment in a population-based sample of Veterans under age 65

PURPOSE

Concerns that disability benefits may create disincentives for employment may be especially relevant for young American military veterans, particularly veterans of the recent wars in Iraq and Afghanistan who are facing a current economic recession and turning in large numbers to the Department of Veterans Affairs (VA) for disability compensation. This study describes the rate of employment and VA disability compensation among a nationally representative sample of veterans under the age of 65 and examines the association between levels of VA disability compensation and employment, adjusting for sociodemographics and health status.

METHODS

Data on a total of 4,787 veterans from the 2010 National Survey of Veterans were analyzed using multinomial logistic regressions to compare employed veterans with two groups that were not employed.

RESULTS

Two-thirds of veterans under the age of 65 were employed, although only 36 % of veterans with a VA service-connected disability rating of 50 % or higher were employed. Veterans who received no VA disability compensation or who were service-connected 50 % or more were more likely to be unemployed and not looking for employment than veterans who were not service-connected or were service-connected less than 50 %, suggesting high but not all levels of VA disability compensation create disincentives for employment. Results were similar when analyses were limited to veterans who served in Iraq and Afghanistan.

CONCLUSIONS

Education and vocational rehabilitation interventions, as well as economic work incentives, may be needed to maximize employment among veterans with disabilities.

Nature adventure rehabilitation for combat-related posttraumatic chronic stress disorder: a randomized control trial

Chronic combat-related posttraumatic stress disorder (CR-PTSD) is a condition with many treatment barriers. Nature Adventure Rehabilitation (NAR) as a second line or as a supplemental intervention has the potential to overcome some of these barriers and incorporate aspects of successful treatment modalities for PTSD within an experiential learning paradigm. In a pre-post controlled trial, CR-PTSD veterans (n=22) underwent a 1-year NAR intervention compared to a waiting list (WL) control group (n=20). Posttraumatic symptoms (PTS), depression, functional problems, quality of life, perceived control over illness (PCI) and hope were measured by self report measures. PTS, emotional and social quality of life, PCI, hope and functioning improved significantly. Change in PTS was contingent upon change in PCI. The current study is the first to present NAR as a promising supplemental intervention for chronic CR-PTSD. NAR seems to work through a process of behavioral activation, desensitization, gradual exposure to anxiety evoking situations and gaining control over symptomatology.

Predictors of completion of exposure therapy in OEF/OIF veterans with posttraumatic stress disorder

BACKGROUND

Despite large-scale dissemination and implementation efforts of evidence-based psychotherapy to veterans from Operation Enduring/Iraqi Freedom (OEF/OIF), little is known regarding the factors that contribute to the successful completion of these treatments in this high-risk population. The present study investigated predictors of treatment completion during a standardized exposure-based psychotherapy for PTSD.

METHODS

Ninety-two OEF/OIF combat veterans enrolled in a randomized controlled trial for an eight session exposure-based psychotherapy for PTSD. All participants completed structured clinical interviews and several background and symptom questionnaires. Of the initial 92 participants, 28% of the sample (n = 26) discontinued treatment prior to completion of the trial.

RESULTS

Predictors of discontinuation of treatment were assessed with a hierarchical logistic regression. Disability status was positively associated with treatment discontinuation, and postdeployment social support was negatively associated with discontinuation. In contrast to previous findings, other factors, such as age and PTSD symptomatology, were not identified as significant predictors.

CONCLUSIONS

The present study suggested that disability status at the start of treatment increases the risk for treatment discontinuation whereas increased social support buffers against discontinuation. Together, these findings highlight the importance of increased assessment and early intervention when these factors are present to potentially reduce treatment discontinuation and improve treatment outcomes in OEF/OIF veterans with PTSD.

Why are Iraq and Afghanistan War veterans seeking PTSD disability compensation at unprecedented rates?

The wars in Iraq and Afghanistan have produced historically low rates of fatalities, injuries, and posttraumatic stress disorder (PTSD) among U.S. combatants. Yet they have also produced historically unprecedented rates of PTSD disability compensation seeking from the U.S. Department of Veterans Affairs. The purpose of this article is to consider hypotheses that might potentially resolve this paradox, including high rates of PTSD, delayed onset PTSD, malingered PTSD, and economic variables.

Compensation and treatment: disability benefits and outcomes of U.S. veterans receiving residential PTSD treatment

The U.S. Department of Veterans Affairs (VA) provides specialized intensive posttraumatic stress disorder (PTSD) programs to treat trauma-related symptoms in addition to providing service-connected disability to compensate veterans for injury sustained while serving in the military. Given the percentage of veterans who are receiving treatment for PTSD, in addition to seeking compensation for PTSD, a debate has emerged about the impact of compensation on symptom recovery. This study examined the associations among status of compensation, treatment expectations, military cohort, length of stay, and outcomes for 776 veterans who were enrolled in 5 VA residential PTSD programs between the years of 2005 and 2010. Mixed model longitudinal analyses, with age, gender, and baseline symptoms nested within treatment site in the model, found that treatment expectations were modestly predictive of treatment outcomes. Veterans seeking increased compensation reported marginally lower treatment expectations (d = .008), and did not experience poorer outcomes compared to veterans not seeking increased compensation with the effect of baseline symptoms partialled out. Veterans from the era of the Iraq and Afghanistan conflicts reported lower treatment expectations (d = .020) and slightly higher symptoms at intake (d = .021), but had outcomes at discharge equivalent to veterans from other eras with baseline symptoms partialled out. These findings help further inform the debate concerning disability benefits and symptom changes across time.

Why we should worry about malingering in the VA system: comment on Jackson et al. (2011)

In a recent survey, Jackson et al. (2011) found that clinicians who evaluate veterans for service-connected disability pensions rarely use recommended best practices to assess for posttraumatic stress disorder (PTSD) within the Department of Veterans Affairs (VA). We share their dismay, and we hope that their article will help foster evidence-based assessments for diagnosing PTSD in veterans. Jackson et al. briefly discussed scholarship on malingering among applicants for service-connected disability compensation for PTSD, concluding that concerns about malingering are largely unfounded. The data they adduce, however, in support of this conclusion actually provide reasons for concern as we document in this article. We cite recent work by labor economists in support of our argument.

PTSD factor structure differences between veterans with and without a PTSD diagnosis

This study examined differences in posttraumatic stress disorder's (PTSD) factor structure between veterans with and without a PTSD diagnosis. An archival dataset of 378 trauma-exposed Canadian veterans (mostly men) was used. The sample was divided into participants who met DSM-IV criteria for PTSD (n=230) and those who did not (n=148), based on a structured diagnostic interview. Confirmatory factor analysis was conducted to determine which empirically supported four-factor PTSD model best fit the data: (1) King, Leskin, King, and Weathers' (1998) Emotional Numbing model of Reexperiencing, Avoidance, Emotional Numbing and Hyperarousal factors, or (2) Simms, Watson, and Doebbeling's (2002) Dysphoria model of Reexperiencing, Avoidance, Dysphoria, and Hyperarousal factors. Results indicated that both models fit slightly better in the No-PTSD group. A series of measurement invariance tests demonstrated that the two groups varied on all parameters with the exception of factor loadings. The PTSD-group had larger intercepts, factor means, and residual error variance, suggesting that these participants had greater PTSD severity but more measurement error associated with their PTSD ratings. This study contributes to our understanding of how a PTSD diagnosis impacts the structure of PTSD symptoms at the latent level.

Treatment of posttraumatic stress disorder in U.S. combat veterans: a meta-analytic review

Among U.S. veterans who have been exposed to combat-related trauma, significantly elevated rates of posttraumatic stress disorder (PTSD) are reported. Veterans with PTSD are treated for the disorder at Veterans Affairs (VA) hospitals through a variety of psychotherapeutic interventions. Given the significant impairment associated with PTSD, it is imperative to assess the typical treatment response associated with these interventions. 24 studies with a total sample size of 1742 participants were quantitatively reviewed. Overall, analyses showed a medium between-groups effect size for active treatments compared to control conditions. Thus, the average VA-treated patient fared better than 66% of patients in control conditions. VA treatments incorporating exposure-based interventions showed the highest within-group effect size. Effect sizes were not moderated by treatment dose, sample size, or publication year. Findings are encouraging for treatment seekers for combat-related PTSD in VA settings.

Anthropological discourses on the globalization of posttraumatic stress disorder (PTSD) in post-conflict societies

Posttraumatic stress disorder (PTSD) is a construct that has moved far beyond its origins in Veterans Administration hospitals after the Vietnam War. It is now commonly used in post-conflict societies by humanitarian agencies and researchers. This article looks at the ever-growing expansion of PTSD and reviews medical anthropologists' critiques of this cross-cultural dissemination of Western psychiatric knowledge. The article also reviews post-conflict ethnographies and their results, which often highlight a mismatch between local priorities and the psycho-social services being provided by outside agencies. Finally, the author highlights interventions that are currently being undertaken by humanitarian agencies in an attempt to bridge psychiatric expertise and local forms of healing. Although PTSD is a useful construct for conceptualizing the experience of those who have suffered traumatic events, it does not lend itself to universal cross-cultural application and should be cautiously applied in post-conflict societies.

The structure of posttraumatic psychopathology in veterans attending primary care

This study attempted to extend research indicating that posttraumatic stress disorder (PTSD) factors of Re-experiencing, Avoidance and Hyperarousal are more related to Fear/phobic disorders, while PTSD Dysphoria is more related to Anxious-Misery disorders. Trauma exposure, PTSD and comorbidity data for 668 veteran patients were analysed using confirmatory factor analyses and relative strengths of the relationships between PTSD factors and the Fear and Anxious-Misery factors were assessed. Combining Simms, Watson, and Doebbeling's (2002) model of PTSD symptoms and Krueger's (1999) Fear/Anxious Misery model of mood and anxiety disorders fit the data well. Contrary to previous research, PTSD Re-experiencing, Avoidance and Hyperarousal did not correlate more with the Fear factor; nor did PTSD Dysphoria correlate more with Anxious-Misery. Hyperarousal was more closely related to Fear than was Re-experiencing; however, Avoidance was not. Dysphoria was more closely related to the Anxious-Misery factor than all other PTSD factors.

Multicomponent behavioral treatment for chronic combat-related posttraumatic stress disorder: a randomized controlled trial

This study examined the efficacy of a multicomponent cognitive-behavioral therapy, Trauma Management Therapy, which combines exposure therapy and social emotional rehabilitation, to exposure therapy only in a group of male combat veterans with chronic posttraumatic stress disorder (PTSD). Thirty-five male Vietnam veterans with PTSD were randomly assigned to receive either Trauma Management Therapy (TMT) or Exposure Therapy Only (EXP). Participants were assessed at pre-treatment, mid-treatment, and post-treatment. Primary clinical outcomes were reduction of PTSD symptoms and improved social emotional functioning. Results indicated that veterans in both conditions showed statistically significant and clinically meaningful reductions in PTSD symptoms from pre- to post-treatment, though consistent with a priori hypotheses there were no group differences on PTSD variables. However, compared to the EXP group, participants in the TMT group showed increased frequency in social activities and greater time spent in social activities. These changes occurred from mid-treatment (after completion of exposure therapy) to post-treatment (after completion of the social emotional rehabilitation component); supporting the hypothesis that TMT alone would result in improved social functioning. Although the TMT group also had a significant decrease in episodes of physical rage, that change occurred prior to introduction of the social emotional component of TMT. This study demonstrates efficacy of exposure therapy for treating the core symptoms of PTSD among combat veterans with a severe and chronic form of this disorder. Moreover, multi-component CBT shows promise for improving social functioning beyond that provided by exposure therapy alone, particularly by increasing social engagement/interpersonal functioning in a cohort of veterans with severe and chronic PTSD.

Interpersonal Violence and Mental Health Outcomes among Asian American and Native Hawaiian/Other Pacific Islander College Students

In a cross-sectional survey of college students (N = 614) we studied interpersonal violence victimization, perpetration, and mental health outcomes in an ethnoracially diverse rural-based sample of Asian Americans (27%), and Native Hawaiian/Other Pacific Islanders (25%), two groups vastly underrepresented in trauma research. High rates of interpersonal violence (34%), violence perpetration (13%), and probable psychiatric diagnoses (77%), including posttraumatic stress disorder, were found. Exposure to physical violence, sexual violence, and life stress all were predictive of psychopathology. Female participants were associated with higher likelihood of sexual violence victimization compared to male participants, and Asian American status (especially among males) was associated with lower likelihood of physical and sexual violence compared with European Americans. These data enhance our understanding of interpersonal violence and mental health outcomes among previously understudied minority groups.

Equity in Veterans Affairs disability claims adjudication in a national sample of veterans

OBJECTIVES

To address potential equity concerns about the U.S. Department of Veterans Affairs' (VA) process for adjudicating military service-related disability claims.

METHODS

Participants were a nationally representative sample of 20,048 veterans completing the 2001 National Survey of Veterans. Sociodemographic, access, and illness correlates of both the award and rate of general disability benefits awarded by the VA were examined using an established theoretical framework.

RESULTS

Sociodemographic, access, and illness variables were associated with both the award ("yes/no") and rate of benefits (0-100%) awarded, with combat exposure, unemployment, and physical impairment accounting for the strongest model effects.

CONCLUSIONS

Veterans' needs were not overshadowed by factors related to demographic background or access (e.g., race, gender, insurance), reducing concerns about disparities in general VA disability disbursements. These data are timely as disability claims/payments will likely increase dramatically in the near future because of current conflicts in the Middle East.

Prevalence Estimates of Combat-Related PTSD: A Critical Review

The aim of the present study was to provide a critical review of prevalence estimates of combat-related post-traumatic stress disorder (PTSD) among military personnel and veterans, and of the relevant factors that may account for the variability of estimates within and across cohorts, including methodological and conceptual factors accounting for differences in prevalence rates across nations, conflicts/wars, and studies. MEDLINE and PsycINFO databases were examined for literature on combat-related PTSD. The following terms were used independently and in combinations in this search: PTSD, combat, veterans, military, epidemiology, prevalence. The point prevalence of combat-related PTSD in US military veterans since the Vietnam War ranged from approximately 2% to 17%. Studies of recent conflicts suggest that combat-related PTSD afflicts between 4% and 17% of US Iraq War veterans, but only 3-6% of returning UK Iraq War veterans. Thus, the prevalence range is narrower and tends to have a lower ceiling among combat veterans of non-US Western nations. Variability in prevalence is likely due to differences in sampling strategies; measurement strategies; inclusion and measurement of the DSM-IV clinically significant impairment criterion; timing and latency of assessment and potential for recall bias; and combat experiences. Prevalence rates are also likely affected by issues related to PTSD course, chronicity, and comorbidity; symptom overlap with other psychiatric disorders; and sociopolitical and cultural factors that may vary over time and by nation. The disorder represents a significant and costly illness to veterans, their families, and society as a whole. Further carefully conceptualized research, however, is needed to advance our understanding of disorder prevalence, as well as associated information on course, phenomenology, protective factors, treatment, and economic costs.

The importance of the DSM-IV E and F criteria in self-report assessments of PTSD

The purpose of the current study was to examine the DSM-IV E and F criteria when using self-report measures of Posttraumatic Stress Disorder (PTSD). According to DSM-IV there are six core criteria required for a PTSD diagnosis including specific trauma characteristics, re-experiencing, avoidance, hyperarousal, duration, and impairment level. The Impact of Events Scale (IES) is a widely used self-report measure designed to measure PTSD symptoms. It has recently been suggested that the IES may produce misleading results, making emotional reactions to obviously non-traumatic events look like PTSD. In two separate studies, when duration (E criterion) and subjective impairment (F criterion) were included, the rates of those meeting PTSD criteria dropped from 20% to 3%. In addition, only 30% of events identified by a trauma history questionnaire met the DSM-IV definition of a traumatic event. The results have implications for the use of self-report measures in the assessment of PTSD.

Forever changed: posttraumatic stress disorder in female military veterans, a case report

PURPOSE. This paper examines the experience of posttraumatic stress disorder (PTSD) in a female veteran of Operation Iraqi Freedom, including the barriers to treatment she encountered in an outpatient psychiatry clinic. DESIGN AND METHODS. Case report data were obtained through review of records and interviews with a veteran combat nurse diagnosed with chronic PTSD. CONCLUSIONS. Sex differences in PTSD are controversial, but PTSD in female military veterans is a significant problem. Gender may complicate diagnosis and treatment. This case report discusses these issues and invites further research. PRACTICE IMPLICATIONS. Advanced practice psychiatric nurses increasingly will see female veterans with PTSD in their practices.

Delayed-onset post-traumatic stress disorder among war veterans in primary care clinics

BACKGROUND

Only limited empirical data support the existence of delayed-onset post-traumatic stress disorder (PTSD).

AIMS

To expand our understanding of delayed-onset PTSD prevalence and phenomenology.

METHOD

A cross-sectional, epidemiological design (n = 747) incorporating structured interviews to obtain relevant information for analyses in a multisite study of military veterans.

RESULTS

A small percentage of veterans with identified current PTSD (8.3%, 7/84), current subthreshold PTSD (6.9%, 2/29), and lifetime PTSD only (5.4%, 2/37) met criteria for delayed onset with PTSD symptoms initiating more than 6 months after the index trauma. Altogether only 0.4% (3/747) of the entire sample had current PTSD with delayed-onset symptoms developing more than 1 year after trauma exposure, and no PTSD symptom onset was reported more than 6 years post-trauma.

CONCLUSIONS

Retrospective reports of veterans reveal that delayed-onset PTSD (current, subthreshold or lifetime) is extremely rare 1 year post-trauma, and there was no evidence of PTSD symptom onset 6 or more years after trauma exposure.