Prevalence Estimates of Combat-Related PTSD: A Critical Review

Trends and disparities in coronary artery disease prevalence among U.S. adults from 2019 to 2022

BACKGROUND

Coronary artery disease (CAD) is the leading cause of death in the U.S. Understanding trends and potential disparities in CAD prevalence is crucial for public health strategies.

OBJECTIVE

Examine trends and disparities in CAD prevalence among U.S. adults (2019-2022).

METHODS

CDC's National Health Interview Survey's data was analyzed, employing regression analysis with Joinpoint and ARIMA models by ChatGPT-4 for trend forecasting.

RESULTS

CAD prevalence among U.S. adults was relatively stable, increasing slightly from 4.6 % (95 % CI: 4.3-4.9) in 2019 to 4.9 % (95 % CI: 4.7-5.2) in 2022. Males experienced significant rise in prevalence, with an APC of 3.1 % (95 % CI: 1.45-4.85, p-value < 0.000001), increasing from 5.9 % to 6.4 %. Female prevalence also increased significantly, with APC of 2.0 % (95 % CI: 0.46-3.59, p-value = 0.003599), moving from 3.4 % to 3.6 %. Notable age-related disparities appeared, especially in those aged 75 and over, with rates peaking at 20.0 % in 2020 before decreasing to 19.7 % in 2022. Racial disparities revealed higher prevalence among White adults at 5.4 % and noticeable increase among Asian adults from 2.8 % to 3.8 %. Geographic factors also influenced prevalence, particularly outside metropolitan areas, Northeast, and South regions of US. Employment status influenced CAD rates and a lower prevalence observed in the employed (1.7 % to 1.9 %) compared to unemployed (9.9 % to 10.3 %). Veterans (13.4 % to 12.6 %) reported higher prevalence rates than non-veterans. ARIMA projections suggest stable prevalence until 2026.

CONCLUSION

Despite stable overall prevalence, significant disparities exist. Targeted interventions are essential, particularly for high-risk demographics such as males, older adults, and veterans.

Comparing the effect of prolonged exposure therapy (PET) and metacognitive therapy (MCT) on the quality of life among veterans with PTSD

Veterans' quality of life (QoL) can be drastically affected by posttraumatic stress disorder (PTSD). We compared prolonged exposure therapy (PET) with metacognitive therapy (MCT) in their effects on quality of life (QoL) among veterans with post-traumatic stress disorder (PTSD). Overall, 57 veterans with PTSD were randomly assigned to three groups MCT (N = 17), PET (N = 17), and Control (N = 23). The 36-item short-form survey (SF-36) was used to evaluate QoL pretest, posttest, and after a 3-month follow-up. The MCT was based on the practice of detached mindfulness, controlling rumination/anxiety, and challenging negative beliefs about symptoms. The PET was based on in-vivo and imaginal exposure to trauma-related events, and discontinuation of avoidance-oriented coping strategies. Both MCT and PET groups significantly improved QoL at posttest and follow-up, compared with the control group (P < .001); however, the MCT and PET groups showed no significant difference at posttest (P = .644) or follow-up (P = .646). Our results support the efficacy of PET as the standard for PTSD treatment, while also signifying the effectiveness of MCT at increasing the QoL in war-related PTSD at a 3-month follow-up.

Associations of humor, morale, and unit cohesion on posttraumatic stress disorder symptoms

Military personnel experience many stressors during deployments that can lead to symptoms of posttraumatic stress disorder (PTSD). However, not all military personnel who are exposed to deployment stressors develop PTSD symptoms. Recent research has explored factors that contribute to military personnel resilience, a multifaceted and multidetermined construct, as a means to mitigate and prevent PTSD symptoms. Much of this research has focused on the effects of individual-level factors (e.g., use of coping strategies like humor, the morale of individual unit members), with some research focusing on unit-level factors (e.g., the cohesiveness of a unit). However, there is little research exploring how these factors relate to each other in mitigating or reducing PTSD symptoms. In this study, we examined the association between deployment stressors, perceived unit cohesion, morale, humor, and PTSD symptoms in a sample of 20,901 active-duty military personnel using structural equation modeling. Results indicated that perceived unit cohesion, humor, and morale were positively associated with each other and negatively associated with PTSD symptoms over and above the effect of deployment stressors. These findings highlight the influence of resilience factors on PTSD symptoms beyond their substantial overlap and have implications for future research as well as the potential development of interventions for military personnel.

A multistep mediation model examining how consultation in prolonged exposure therapy affects PTSD treatment outcomes

Prolonged exposure therapy (PE) is an evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) that is underutilized in the military health system. Previous research suggests that postworkshop consultation is important for successful implementation. However, little is known about how consultation may relate to EBP adoption or patient outcomes. The present study addressed these gaps by examining associations between consultation, provider self-efficacy, use of PE, and patient outcomes using a multistep mediation model. This study used data from Foa et al. (2020), a two-armed randomized implementation trial comparing two PE training models: standard training (workshop only) and extended training (workshop + 6-8 months of postworkshop expert consultation) at three U.S. Army sites. Participants were patients with PTSD (N = 242) receiving care from the participating providers (N = 103). Providers who received extended training reported greater PE self-efficacy compared to standard training providers, but self-efficacy was unrelated to their use of PE components or to patient outcomes. Extended training providers used more PE components and had superior patient outcomes than standard training providers, and patient outcomes were mediated by the use of PE components. To our knowledge, this is the first study to demonstrate that EBP consultation leads to improved clinical outcomes for patients through increased use of the EBP. PE adoption (i.e., use of PE components in therapy) was not explained by increases in self-efficacy among providers who received extended training. Therefore, future research should assess how other factors may influence provider behavior in implementing EBPs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Serotonin Transporter (SLC6A4) and FK506-Binding Protein 5 (FKBP5) Genotype and Methylation Relationships with Response to Meditation in Veterans with PTSD

Meditation-based interventions are novel and effective non-pharmacologic treatments for veterans with PTSD. We examined relationships between treatment response, early life trauma exposure, DNA polymorphisms, and methylation in the serotonin transporter (SLC6A4) and FK506-binding protein 5 (FKBP5) genes. DNA samples and clinical outcomes were examined in 72 veterans with PTSD who received meditation-based therapy in two separate studies of mindfulness-based stress reduction (MBSR) and Transcendental Meditation (TM). The PTSD Checklist was administered to assess symptoms at baseline and after 9 weeks of meditation intervention. We examined the SLC6A4 promoter (5HTTLPR_L/S insertion/deletion + rs25531_A/G) polymorphisms according to previously defined gene expression groups, and the FKBP5 variant rs1360780 previously associated with PTSD disease risk. Methylation for CpG sites of SLC6A4 (28 sites) and FKBP5 (45 sites) genes was quantified in DNA samples collected before and after treatment. The 5HTTLPR LALA high expression genotype was associated with greater symptom improvement in participants exposed to early life trauma (p = 0.015). Separately, pre to post-treatment change of DNA methylation in a group of nine FKBP5 CpG sites was associated with greater symptom improvement (OR = 2.8, 95% CI 1.1-7.1, p = 0.027). These findings build on a wealth of existing knowledge regarding epigenetic and genetic relationships with PTSD disease risk to highlight the potential importance of SLC6A4 and FKBP5 for treatment mechanisms and as biomarkers of symptom improvement.

"Caught in the crossfire" - women veterans' testimonies regarding excessively violent acts committed in combat zones

As women in the Israeli Defense Forces (IDF) are increasingly placed in supportive and combat roles in active war zones, they routinely encounter and participate in violent acts. This study focusses on the centrality of gendered inequality and oppression as a factor that shapes not only women's experience in the military but also their responses in cases of excessive violence. The goal of this study was to explore the ways women veterans of combat or combat-support units conceptualize their stance regarding violent acts which they either committed or witnessed in war zones. Using a qualitative approach, we analyzed the retrospective testimonies of 58 Israeli women veterans from the archives of an NGO that documents veteran combatants exposure to excessive violence. Most women explained their violent acts as inherent to the military system and culture, which in our analysis was categorized as examples of either internalized gender oppression or as identification with the aggressor. A smaller number of women described their attempts to protest, as they took a moral stance rooted in a feminine perspective. The three explanations revealed through the analysis of the testimonies reflect the inner tension experienced by many women in the military, as they navigate between two extreme positions, either as victims of male dominance, or as aggressors that are part of a powerful military system. In this study, gendered inequality provides a framework for analyzing the data. Thus, this study contributes to the theoretical knowledge and methodological approaches concerning violent situations in combat areas, focusing on the various ways in which women veterans subjectively and retroactively conceptualize their participation in and responses to violent acts.

A Literature Review of Mental Health Symptom Outcomes in U.S. Veterans and Servicemembers Following Combat Exposure and Military Sexual Trauma

Combat exposure (CE) and military sexual trauma (MST) are among the most common types of traumatic experiences faced by veterans and active duty servicemembers and, as such, have both garnered increased research focus over the past decades. However, there has not yet been a critical review of the literature to examine the distinct clinical presentations associated with different trauma types. This is particularly important, as understanding distinct clinical profiles could help researchers and clinicians refine treatment approaches based on trauma type. To address this question, we conducted a search of the available literature in PsycINFO and PubMed prior to October 2022. We identified 43 articles evaluating the distinct and overlapping clinical symptoms of CE and MST. Study findings were conceptually organized by psychiatric condition. In general, there was substantial variability in study methodology including sample size, composition, and operationalizations of CE and MST. Despite this variability, notable patterns emerged across studies. Specifically, MST and CE uniquely predicted posttraumatic stress disorder symptoms, MST was more related to depressive symptoms and suicidality than CE, and CE appeared to be more related to alcohol use and other externalizing behaviors. Gender also played a significant role in the relationship between CE, MST, and clinical variables across studies. This review suggests that individuals with a history of MST and CE likely have distinct clinical presentations and more research into these presentations could better inform assessment and treatment. Important methodological gaps in the literature are also discussed.

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

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

Disentangling the effects of PTSD from Gulf War Illness in male veterans via a systems-wide analysis of immune cell, cytokine, and symptom measures

BACKGROUND

One-third of veterans returning from the 1990-1991 Gulf War reported a myriad of symptoms including cognitive dysfunction, skin rashes, musculoskeletal discomfort, and fatigue. This symptom cluster is now referred to as Gulf War Illness (GWI). As the underlying mechanisms of GWI have yet to be fully elucidated, diagnosis and treatment are based on symptomatic presentation. One confounding factor tied to the illness is the high presence of post-traumatic stress disorder (PTSD). Previous research efforts have demonstrated that both GWI and PTSD are associated with immunological dysfunction. As such, this research endeavor aimed to provide insight into the complex relationship between GWI symptoms, cytokine presence, and immune cell populations to pinpoint the impact of PTSD on these measures in GWI.

METHODS

Symptom measures were gathered through the Multidimensional fatigue inventory (MFI) and 36-item short form health survey (SF-36) scales and biological measures were obtained through cytokine & cytometry analysis. Subgrouping was conducted using Davidson Trauma Scale scores and the Structured Clinical Interview for Diagnostic and statistical manual of mental disorders (DSM)-5, into GWI with high probability of PTSD symptoms (GWIH) and GWI with low probability of PTSD symptoms (GWIL). Data was analyzed using Analysis of variance (ANOVA) statistical analysis along with correlation graph analysis. We mapped correlations between immune cells and cytokine signaling measures, hormones and GWI symptom measures to identify patterns in regulation between the GWIH, GWIL, and healthy control groups.

RESULTS

GWI with comorbid PTSD symptoms resulted in poorer health outcomes compared with both Healthy control (HC) and the GWIL subgroup. Significant differences were found in basophil levels of GWI compared with HC at peak exercise regardless of PTSD symptom comorbidity (ANOVA F = 4.7, P = 0.01,) indicating its potential usage as a biomarker for general GWI from control. While the unique identification of GWI with PTSD symptoms was less clear, the GWIL subgroup was found to be delineated from both GWIH and HC on measures of IL-15 across an exercise challenge (ANOVA F > 3.75, P < 0.03). Additional differences in natural killer (NK) cell numbers and function highlight IL-15 as a potential biomarker of GWI in the absence of PTSD symptoms.

CONCLUSION

We conclude that disentangling GWI and PTSD by defining trauma-based subgroups may aid in the identification of unique GWI biosignatures that can help to improve diagnosis and target treatment of GWI more effectively.

The transition to civilian life: Impact of comorbid PTSD, chronic pain, and sleep disturbance on veterans' social functioning and suicidal ideation

OBJECTIVE

Trauma-exposed veterans may be more likely to experience posttraumatic stress disorder (PTSD), chronic pain, and sleep disturbance together rather than in isolation. Although these conditions are independently associated with distress and impairment, how they relate to social functioning and suicidal ideation (SI) when experienced comorbidly is not clear.

METHOD

Using longitudinal data on 5,461 trauma-exposed U.S. veterans from The Veterans Metrics Initiative study and self-reported disorders, we assessed (a) the extent to which PTSD co-occurs with sleep disturbance and chronic pain (CP); (b) the relationship of PTSD in conjunction with sleep disturbance and chronic pain with later social functioning and SI; and (c) the extent to which social functioning mediates the impact of multimorbidity on SI.

RESULTS

At approximately 15 months postseparation, 90.5% of veterans with probable PTSD also reported sleep disturbance and/or CP. Relative to veterans without probable PTSD, veterans with all 3 conditions (n = 907) experienced the poorest social functioning (B = -.56, p < .001) and had greater risk for SI (OR = 3.78, p < .001); Social functioning partially mediated the relationship between multimorbidity and SI. However, relative to those with PTSD alone, sleep disturbance and CP did not confer greater risk for SI.

CONCLUSIONS

Although these findings underscore the impact of PTSD on functioning and SI, they also highlight the complexity of multimorbidity and the importance of bolstering social functioning for veterans. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A brief treatment for veterans with PTSD: an open-label case-series study

Introduction

Despite the positive outcomes observed in numerous individuals undergoing trauma-focused psychotherapy for PTSD, veterans with this condition experience notably diminished advantages from such therapeutic interventions in comparison to non-military populations.

Methods

In a preliminary study we investigated the efficacy of an innovative treatment approach in a small sample of veterans (n = 7). Recognizing that accessing and targeting trauma memory in veterans with PTSD may be more challenging compared to other patient populations, we employed unique and personalized retrieval cues that engaged multiple senses and were connected to the context of their trauma. This was followed by a session focused on memory reconsolidation, which incorporated both psychological techniques (i.e., imagery rescripting) and a pharmacological component (i.e., 40 mg of propranolol).

Results

The findings from this small-scale case series cautiously indicate that this brief intervention, typically consisting of only one or two treatment sessions, shows promise in producing significant effects on symptoms of PTSD, distress and quality of life.This is particularly noteworthy given the complex symptomatology experienced by the veterans in this study.

Conclusion

To summarize, there are grounds for optimism regarding this brief treatment of combat-related PTSD. It appears that the potential for positive outcomes is far greater than commonly believed, as demonstrated by the encouraging results of this pilot study.

Families' experiences of supporting Australian veterans to seek help for a mental health problem: a linked data analysis of national surveys with families and veterans

BACKGROUND

Families play a critical role in supporting currently serving and transitioned veterans' wellbeing and help-seeking for mental health concerns; however, little is known about families' experiences.

AIMS

This study used Australian national survey linked-data (n = 1217) from families (Family Wellbeing Study-FWS) and veterans (Mental Health Wellbeing Transition Study-MHWTS) to understand veteran-family help-seeking relationships.

METHODS

Veterans' and family members' responses to mental health and help-seeking questions in FWS and MHWTS datasets from perspective of family members were cross-tabulated. Help-seeking support provided by family members was compared by veterans' probable disorder.

RESULTS

Results highlighted high levels of involvement and continuous assistance provided by families. Two in three family members thought the veteran had probable mental health concerns although they have never been diagnosed or treated. Clear disparities between family and veteran perspectives regarding mental health concerns indicates the extent of non-treatment seeking in this population, missed opportunities for early intervention, and need for greater support to families to promote help-seeking.

CONCLUSIONS

Encouraging help-seeking is complex for veteran families particularly where veterans' reluctance to seek help may lead to family relationship strain and conflict. Families need early information, support, and recognition by service agencies of the role of the family in encouraging help-seeking.

Aerobic exercise improves sleep in U. S. active duty service members following brief treatment for posttraumatic stress disorder symptoms

Introduction

Physical exercise is a lifestyle intervention that can positively impact aspects of physical and psychological health. There is a growing body of evidence suggesting that physical exercise, sleep, and PTSD are interrelated. This study investigated possible relationships. Three research questions were posed: (1) Did randomization to an aerobic exercise intervention reduce insomnia more than being randomized to an intervention without exercise, (2) Did change in sleep predict change in PTSD symptoms, and (3) Did change in sleep impact the relationship between exercise and PTSD symptom reductions?

Methods

Data were collected from 69 treatment-seeking active duty service members with PTSD symptoms randomized into one of four conditions; two conditions included aerobic exercise, and two conditions did not include exercise. Participants in the exercise groups exercised five times per week keeping their heart rate > 60% of their heart rate reserve for 20-25 min.

Results

At baseline, 58% of participants reported moderate or severe insomnia. PTSD symptom severity decreased following treatment for all groups (p < 0.001). Participants randomized to exercise reported greater reductions in insomnia compared to those in the no exercise group (p = 0.47). However, change in insomnia did not predict change in PTSD symptoms nor did it significantly impact the relationship between exercise and PTSD symptom reductions.

Discussion

Adding exercise to evidence-based treatments for PTSD could reduce sleep disturbance, a characteristic of PTSD not directly addressed with behavioral therapies. A better understanding of exercise as a lifestyle intervention that can reduce PTSD symptoms and insomnia is warranted.

The adaptation of soldiers to post-service life - the mediating impact of political views on the relationship between violence and adaptation

Introduction

The current research explores the association between political views, combat experiences, and the adaptation of soldiers to post-service life. Violent experiences in military service were explored as contributors to both positive and negative dimensions of adaptation, while political views served as possible mediators.

Methods

Three hundred and twenty Israeli veterans participated in the study.

Results

Political views were correlated with adaptation, especially left-to-right voting and anti-militarism. The results support the mediating role of political beliefs (left-right voting and militarism) in the relationship between combat experience and adaptation to post-service life.

Discussion

We contend that political perceptions affect adaptation through sense-making of the combat experiences and the individual processing of these experiences, and the willingness to continue in reserve service, which allows social support and recognition. In addition, they are linked to a sense of bitterness following the reduction of public participation in military and reserve service.

Therapeutic and Economic Benefits of Service Dogs Versus Emotional Support Dogs for Veterans With PTSD

OBJECTIVE

This work aimed to assess the therapeutic and economic benefits of service dogs versus emotional support dogs for veterans with posttraumatic stress disorder (PTSD).

METHODS

Veterans with PTSD (N=227) participating in a multicenter trial were randomly assigned to receive a service or emotional support dog; 181 veterans received a dog and were followed up for 18 months. Primary outcomes included overall functioning (assessed with World Health Organization Disability Assessment Scale II [WHODAS 2.0]) and quality of life (Veterans RAND 12-Item Health Survey [VR-12]). Secondary outcomes included PTSD symptoms (PTSD Checklist for DSM-5), suicidal ideation, depression, sleep quality, health care costs and utilization, medication adherence, employment, and productivity.

RESULTS

Participants paired with a dog had a mean±SD age of 50.6±13.6 years (range 22-79), and most were male (80%), White (66%), and non-Hispanic (91%). Adjusted linear mixed repeated-measures models indicated no difference between the two groups on WHODAS 2.0 or VR-12 scores. Participants with service dogs had a 3.7-point greater reduction in PTSD symptoms versus participants with emotional support dogs (p=0.036). No reduced health care utilization or cost was associated with receiving a service dog. Veterans with service dogs had an increase of 10 percentage points in antidepressant adherence compared with those with emotional support dogs (p<0.01).

CONCLUSIONS

Both groups appeared to benefit from having a service or emotional support dog. No significant differences in improved functioning or quality of life were observed between the groups. Those in the service dog group had a greater reduction in PTSD symptoms and better antidepressant adherence, improvements that should be explored further.

Lifetime posttraumatic stress disorder as a predictor of mortality: a systematic review and meta-analysis

BACKGROUND

Posttraumatic Stress Disorder (PTSD) could potentially increase the risk of mortality, and there is a need for a meta-analysis to quantify this association. This study aims to determine the extent to which PTSD is a predictor of mortality.

METHODS

EMBASE, MEDLINE, and PsycINFO were searched systematically on 12th February 2020, with updated searches conducted in July 2021, and December 2022 (PROSPERO CRD42019142971). Studies involving community-dwelling participants with a diagnosis of PTSD or PTSD symptoms, and a comparator group of individuals without PTSD, and which assessed mortality risk, were included. A random-effects meta-analysis was conducted on studies reporting Odds Ratio (OR), Hazard Ratio (HR), and Risk Ratio (RR), and subgroup analysis was also performed by age, sex, type of trauma experienced, PTSD diagnosis, and cause of death.

RESULTS

A total of 30 eligible studies of mostly good methodological quality were identified, with a total of more than 2.1 million participants with PTSD. The majority of studies involved male-dominated, veteran populations. PTSD was associated with a 47% (95% CI: 1.06-2.04) greater risk of mortality across six studies that reported OR/RR, and a 32% increased risk across 18 studies which reported time to death (HR: 1.32, 95% CI: 1.10-1.59). There was very high study heterogeneity (I² > 94%) and this was not explained by the prespecified subgroup analysis.

CONCLUSION

PTSD is associated with increased mortality risk, however further research is required amongst civilians, involving women, and in individuals from underdeveloped countries.

Exploring the trajectory and correlates of social isolation for veterans across a 6-month period during COVID-19

Social isolation is a relevant problem for veterans who are at risk for disengaging from others as a function of transition stress from military life to civilian life, and given high rates of exposure to trauma and psychological distress. Few researchers have examined social isolation in veterans over time, particularly during COVID-19 that led to significant barriers and restrictions on social interactions. The purpose of this longitudinal study was to assess veterans' experience of social isolation and its mental health and social functioning correlates during a 6-month period of the COVID-19 pandemic. Participants were 188 United States veterans of the Iraq and Afghanistan wars. A total of four assessments were administered: one every two months for a total duration of six months. The average number of completed assessments across all participants was 3.70 (SD = 0.75) with 159 participants (84.13%) completing all four timepoints. Surveys included measures of global mental health and social functioning as indicated by perceived emotional support, quality of marriage, and couple satisfaction. Multilevel modeling was used to assess 1) growth models to determine whether social isolation changed over time and the trajectory of that change (i.e., linear or quadratic); and 2) whether social isolation was related to both concurrent and prospective indicators of mental health and social functioning. All analyses included person mean centered and grand mean centered isolation to assess for within-and between-person effects. Veterans reported a quadratic trajectory in social isolation that decreased slightly and stabilized over time. Findings indicate that higher social isolation, at both the within- and between-person level, was negatively associated with concurrent emotional support, mental health, quality of marriage, and couple satisfaction. However, all prospective effects were nonsignificant at the within-person level. Results suggest although isolation may decrease over time, veterans report worse mental health and social functioning during times when they report higher levels of social isolation compared to themselves and others. Future work is needed to determine if interventions can be applied during those times to prevent or target those negative associations.

Cognitive biases in military personnel with and without PTSD: a systematic review

BACKGROUND

Some cognitive biases, such as excessive attention to threat, are associated with PTSD. However, they may be adaptive for military personnel; attending to threat may improve safety for deployed personnel.

AIMS

The extent to which military personnel with vs. without PTSD differ with respect to specific cognitive biases is currently unclear. This systematic review aimed to address this question.

METHODS

PRISMA guidelines were followed. Articles were identified using a comprehensive literature search; 21 studies (with 1977 participants) were reviewed.

RESULTS

All studies were of "moderate" or "strong" quality. Military personnel with vs. without PTSD used overgeneralised language when describing autobiographical memories and demonstrated impaired performance on a modified Stroop task. Studies using dot-probe paradigms conceptualised attentional response as a dynamic process, fluctuating between bias towards and away from threat; military personnel with vs. without PTSD demonstrated greater fluctuation. Studies using visual search tasks concluded that attentional bias in PTSD involves interference (difficulty disengaging from threat) rather than facilitation (enhanced threat detection). Finally, personnel with vs. without PTSD demonstrated interpretation bias, completing ambiguous sentences with negative rather than neutral endings.

CONCLUSION

The implications for military populations and recommendations for further research and clinical practice are considered.

PROSPERO REGISTRATION

PROSPERO 2018 CRD42018092235.

Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial

IMPORTANCE

Improved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD).

OBJECTIVE

To determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted among military personnel and veterans at 4 sites in Texas from 2017 to 2019. Assessors were blinded to conditions. Data were analyzed from November 2020 to October 2022.

INTERVENTIONS

The interventions were massed-PE, which included 15 therapy sessions of 90 minutes each over 3 weeks, vs intensive outpatient program PE (IOP-PE), which included 15 full-day therapy sessions over 3 weeks with 8 treatment augmentations. The IOP-PE intervention was hypothesized to be superior to massed-PE.

MAIN OUTCOMES AND MEASURES

Coprimary outcomes included the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) administered at baseline and posttreatment follow-ups. Measures ranged from 0 to 80, with higher scores indicating greater severity. Diagnostic remission and reliable change were secondary outcomes.

RESULTS

Among 319 military personnel and veterans screened, 234 were randomized (mean [SD] age, 39.20 [7.72] years; 182 [78%] male participants), with 117 participants randomized to IOP-PE and 117 participants randomized to massed-PE. A total of 61 participants (26%) were African American, 58 participants (25%) were Hispanic, and 102 participants (44%) were White; 151 participants (65%) were married. Linear mixed-effects models found that CAPS-5 scores decreased in both treatment groups at the 1-month follow-up (IOP-PE: mean difference, -13.85 [95% CI, -16.47 to -11.23]; P < .001; massed-PE: mean difference, -14.13 [95% CI, -16.63 to -11.62]; P < .001). CAPS-5 change scores differed from 1- to 6-month follow-ups (mean difference, 4.44 [95% CI, 0.89 to 8.01]; P = .02). PTSD symptoms increased in massed-PE participants during follow-up (mean difference, 3.21 [95% CI, 0.65 to 5.77]; P = .01), whereas IOP-PE participants maintained treatment gains (mean difference, 1.23 [95% CI, -3.72 to 1.27]; P = .33). PCL-5 scores decreased in both groups from baseline to 1-month follow-up (IOP-PE: mean difference, -21.81 [95% CI, -25.57 to -18.04]; P < .001; massed-PE: mean difference, -19.96 [95% CI, -23.56 to -16.35]; P < .001) and were maintained at 6 months (IOP-PE: mean change, -0.21 [95% CI, -3.47 to 3.06]; P = .90; massed-PE: mean change, 3.02 [95% CI, -0.36 to 6.40]; P = .08). Both groups had notable PTSD diagnostic remission at posttreatment (IOP-PE: 48% [95% CI, 36% to 61%] of participants; massed-PE: 62% [95% CI, 51% to 73%] of participants), which was maintained at 6 months (IOP-PE: 53% [95% CI, 40% to 66%] of participants; massed-PE: 52% [95% CI, 38% to 66%] of participants). Most participants demonstrated reliable change on the CAPS-5 (61% [95% CI, 52% to 69%] of participants) and the PCL-5 (74% [95% CI, 66% to 81%] of participants) at the 1-month follow-up.

CONCLUSIONS AND RELEVANCE

These findings suggest that PE can be adapted into compressed treatment formats that effectively reduce PTSD symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03529435.

Neurotrauma: 2023 Update

2022 was a productive year for research in traumatic brain injury (TBI) and resultant neuropathology. After an extensive review, we present related studies and publications which we felt were of particular importance to the neuropathology community. First, 2022 was highlighted by important advancements in the diagnosis and, moreover, our understanding of chronic traumatic encephalopathy (CTE). Important publications include a pair concluding that CTE primarily concerns neuronal accumulation of phosphorylated tau (ptau), but that glial ptau accumulation often helps to facilitate diagnosis. In addition, a new large community study from Australia continues the indication that CTE is relatively uncommon in the community, and the first large-cohort study on brains of military personnel similarly demonstrates that CTE appears to be uncommon among service members and does not appear to explain high rates of neuropsychiatric sequelae suffered by the warfighter. The causation of CTE by impact-type TBI was supported by the application of the Bradford Hill criteria, within the brains of headbutting bovids, and interestingly within an artificial head model exposed to linear impact. Finally, a large-scale analysis of APOE genotypes contends that gene status may influence CTE pathology and outcomes. In experimental animal work, a study using mouse models provided important evidence that TDP-43 facilitates neurodegenerative pathology and is implicated in cognitive dysfunction following TBI, and another study using a swine model for concussion demonstrated that evidence that axonal sodium channel disruption may be a driver of neurologic dysfunction after concussion. Finally, we end with memoriam to Dr. John Q. Trojanowski, a giant of neurodegenerative research and an important contributor to the neurotrauma literature, who we lost in 2022.

The urocortin peptides: biological relevance and laboratory aspects of UCN3 and its receptor

The urocortins are polypeptides belonging to the corticotropin-releasing hormone family, known to modulate stress responses in mammals. Stress, whether induced physically or psychologically, is an underlying cause or consequence of numerous clinical syndromes. Identifying biological markers associated with the homeostatic regulation of stress could provide a clinical laboratory approach for the management of stress-related disorders. The neuropeptide, urocortin 3 (UCN3), and the corticotropin-releasing hormone receptor 2 (CRHR2) constitute a regulatory axis known to mediate stress homeostasis. Dysregulation of this peptide/receptor axis is believed to play a role in several clinical conditions including post-traumatic stress, sleep apnea, cardiovascular disease, and other health problems related to stress. Understanding the physiology and measurement of the UCN3/CRHR2 axis is important for establishing a viable clinical laboratory diagnostic. In this article, we focus on evidence supporting the role of UCN3 and its receptor in stress-related clinical syndromes. We also provide insight into the measurements of UCN3 in blood and urine. These potential biomarkers provide new opportunities for clinical research and applications of laboratory medicine diagnostics in stress management.

Post-traumatic stress symptoms experienced by healthcare workers in Lebanon four months following Beirut’s ammonium nitrate explosion: a survey-based study

Background

On August 4, 2020, Lebanon faced one of the deadliest mass casualty explosions the world has witnessed during the twenty-first century. The human and emotional tolls were heavy on attending physicians, clinical fellows, residents, interns, medical students, and registered nurses, who were working in dramatic conditions, triaging, and treating thousands of blast-related casualties. We evaluated the risk of developing post-traumatic stress disorder symptoms (PTSS), among these healthcare workers (HCWs) from different Lebanese hospitals.

Methods

This is a multicentered, cross-sectional study that was conducted in December 2020, using an online questionnaire that evaluated the risk of developing PTSS based on the validated self-reported PTSD-Checklist for DSM-V (PCL-5). We also explored possible correlates with the participants’ socio-demographic characteristics, job profile, mental health, and blast-related events.

Results

Out of 519 participants, 44% were at high risk of developing PTSS following Beirut-blast. Nurses, attending physicians, fellows, and participants who are older in age, married, or working at specific hospitals, were at a higher risk. Those identified at higher risk of PTSS were surgeons, anesthesiologists, emergency medicine doctors, or radiologists; and they were more likely to be willing to migrate; having a prior history of psychiatric medication intake for PTSD treatment, a prior history of PTSD, or a personal history of seeking mental health service. At last, the latter two parameters as well as the number of examined injuries, severe home damage, and testing positive for the COVID-19 virus during the two weeks’ period that followed the blast were found to be predictors for the development of PTSS.

Conclusion

Lebanese in-hospital HCWs were found to be at a high risk of developing PTSS following the Beirut-Blast, thus we recommend public health authorities to provide adequate resources to avoid the emergence of mental illnesses among these rescuers.

Associations of decayed teeth and localized periodontitis with mental stress in young adults: CHIEF oral health study

The associations of mental stress with decayed teeth in children and periodontitis in old-aged adults have been described. However, the associations for young adults were not clear. This study aimed to examine the associations of decayed teeth and localized periodontitis with mental stress in young adults. This study included 334 military recruiters, aged 19-45 years in Taiwan. Mental stress was assessed by the brief symptom rating scale-5 (BSRS-5), including five domains: anxiety, depression, hostility, interpersonal sensitivity and insomnia (maximum score of 20). Those with symptomatic mental stress were defined as having BSRS-5 > 5 (n = 34). Multiple linear and logistic regression models were used to determine the associations of decayed tooth numbers and periodontitis with BSRS-5, with adjustments for age, sex, education level, physical activity, body weight category and smoking status. The BSRS-5 was positively correlated with decayed tooth numbers [β: 0.26 (95% confidence interval: 0.01-0.52)]. Those who had more than two decayed teeth [odds ratio: 3.59 (1.52-8.46)] had a higher risk of symptomatic mental stress. In contrast, the correlation between BSRS-5 and localized severer periodontitis was null. Our study recommended that decayed teeth instead of localized periodontitis, was a risk factor for mental stress in young adults.

Medicaid Expansion and Veterans' Reliance on the VA for Depression Care

Background

In 2001, before the Affordable Care Act (ACA), some states expanded Medicaid coverage to include an array of mental health services, changing veterans' reliance on US Department of Veterans Affairs (VA) services.

Methods

Using Medicaid and VA administrative data from 1999 to 2006, we used a difference-in-difference design to calculate shifts in veterans' reliance on the VA for depression care in New York and Arizona after the 2 states expanded Medicaid coverage to adults in 2001. Demographically matched, neighbor states Pennsylvania and New Mexico/Nevada were used as paired comparisons, respectively. Fractional logit was used to capture the distribution of inpatient and outpatient depression care utilization between the VA and Medicaid, while ordered logit and negative binomial regressions were applied to model Medicaid-VA dual users and per capita utilization of total depression care services, respectively.

Results

Medicaid expansion was associated with a 9.50 percentage point (pp) decrease (95% CI, -14.61 to -4.38) in reliance on the VA for inpatient depression care among service-connected veterans and a 13.37 pp decrease (95% CI, -21.12 to -5.61) among income-eligible veterans. For outpatient depression care, VA reliance decreased by 2.19 pp (95% CI, -3.46 to -0.93) among income-eligible veterans. Changes among service-connected veterans were nonsignificant (-0.60 pp; 95% CI, -1.40 to 0.21).

Conclusions

After Medicaid expansion, veterans shifted depression care away from the VA, with effects varying by health care setting, income- vs service-related eligibility, and state of residence. Issues of overall cost, care coordination, and clinical outcomes deserve further study in the ACA era of Medicaid expansions.

Families' experiences of supporting Australian veterans and emergency service first responders (ESFRs) to seek help for mental health problems

The objective of this phenomenological study was to describe families' experiences of supporting veterans and emergency service first responders (ESFRs) (known also as public safety personnel) to seek help for a mental health problem. In-depth semi-structured open-ended interviews were undertaken with 25 family members of Australian veterans and ESFRs. Fourteen participants were family members of police officers. Data were analysed thematically. Participants described a long and difficult journey of supporting the person's help-seeking across six themes. Traumatic exposures, bullying in the workplace and lack of organisational support experienced by veterans/ESFRs caused significant family distress. Families played a vital role in help-seeking but were largely ignored by veteran/ESFR organisations. The research provides a rich understanding of distress and moral injury that is experienced not only by the service members but is transferred vicariously to their family within the mental health help-seeking journey. Veteran and ESFR organisations and mental health services need to shift from a predominant view of distress as located within an individual (intrapsychic) towards a life-course view of distress as impacting families and which is more relational, systemic, cultural and contextual.

Order effects in PTSD network analysis: important implications for diagnostic conceptualization, treatment refinement, and research

BACKGROUND

For decades confirmatory factor analysis (CFA) has been the preeminent method to study the underlying structure of posttraumatic stress disorder (PTSD); however, methodological limitations of CFA have led to the emergence of other analytic approaches. In particular, network analysis has become a gold standard to investigate the structure and relationships between PTSD symptoms. A key methodological limitation, however, which has significant clinical implications, is the lack of data on the potential impact of item order effects on the conclusions reached through network analyses.

METHODS

The current study, involving a large sample (N = 5055) of active duty army soldiers following deployment to Iraq, assessed the vulnerability of network analyses and prevalence rate to item order effects. This was done by comparing symptom networks of the DSM-IV PTSD checklist items to these same items distributed in random order. Half of the participants rated their symptoms on traditionally ordered items and half the participants rated the same items, but in random order and interspersed between items from other validated scales. Differences in prevalence rate and network composition were examined.

RESULTS

The prevalence rate differed between the ordered and random item samples. Network analyses using the ordered survey closely replicated the conclusions reached in the existing network analyses literature. However, in the random item survey, network composition differed considerably.

CONCLUSION

Order effects appear to have a significant impact on conclusions reached from PTSD network analysis. Prevalence rates were also impacted by order effects. These findings have important diagnostic and clinical treatment implications.

Occupational posttraumatic stress disorder and workplace violence in workers' compensation claims

Acts of violence are the fifth leading cause of nonfatal occupational injuries in the United States. Experiencing a traumatic event at work can have serious mental health consequences, including the development of posttraumatic stress disorder (PTSD). This study aimed to quantify the prevalence of PTSD caused by workplace violence (WPV) in a statewide workers' compensation system and compare the outcomes and treatment of WPV cases versus those caused by other traumatic events. Using a retrospective cohort study design, workers who reported PTSD as the primary reason for a workers' compensation claim and had no coexisting physical injuries were found in California during 2009-2018. A total of 3,772 PTSD cases were identified, 48.9% of which were attributed to WPV. Demographic risk factors associated with WPV PTSD included lower income, younger age, female gender, and employment in retail or finance, p < .001-p = .007. For individuals who returned to work, claims due to WPV resulted in longer medically approved time away from work than non-WPV causes (Mdn = 132.5 days vs. Mdn = 91 days, respectively), p < .001. Three of the top 10 most frequently prescribed medications were administered against evidence-based guidelines. This study found that many treatments prescribed to PTSD patients are based on insufficient evidence, and the provision of existing empirically supported treatments is needed, particularly in generalized populations. The findings support the need for additional recognition of the cause of workplace PTSD to facilitate appropriate referrals to WPV or PTSD specialists to support return-to-work efforts.

Twice Daily Prazosin and Valproic Acid in the Treatment of Flashbacks in PTSD

Posttraumatic stress disorder (PTSD) is a debilitating stress disorder occurring in the context of a traumatic event and is characterized by intrusive and avoidance symptoms, negative alterations in cognition and mood, and arousal and reactivity changes. Despite its representation throughout literature, the pathophysiology of PTSD remains incompletely understood, thus contributing to broad, variable, and at times, experimental treatment options. The authors present the first documented case of the rapid and successful management of PTSD using valproic acid and twice daily dosing of prazosin aimed at targeting symptoms of hyperarousal and both daily and nightly intrusive symptoms of flashbacks and nightmares, respectively. The authors also discuss postulations of the underlying mechanisms of action responsible for such symptom alleviation. Further investigation is needed to expand upon our knowledge of the use of such agents in the treatment of PTSD to improve upon existing clinical guidelines, especially in the acute setting, thus providing better overall prognosis.

“It Depends on Where You Are and What Job You Do”: Differences in Tobacco Use across Career Fields in the United States Air Force

While tobacco use within the military is often discussed as being homogenously part of U.S. military culture, literature from civilian populations highlights that tobacco use varies by career field (e.g., “white collar” vs. “blue collar”). The objective of this qualitative study was to compare tobacco use by career fields in the U.S. Air Force. Airmen, Military Training Instructors, and Technical Training Instructors participated in 22 focus groups across five major Air Force Technical Training bases. Focus groups were conducted in-person using semi-structured interview guides and were audio-recorded. A conventional content-coding approach was used to code transcripts. Participants described substantial variation across the careers, which was attributed to social norms and the nature of jobs. Individuals in careers that spend most of their time outside were more likely to permit tobacco use. Conversely, tobacco use was seen as stigmatized in medical fields. Additionally, smokeless tobacco was identified as popular in certain careers because it could be used covertly on the job. Findings suggest that a one-size-fits-all approach to reducing tobacco use through policies and programs may not reflect the realities of military tobacco use. These findings may provide insights into other branches of the U.S. military with similar career fields.

Prevalence of the dissociative subtype of post-traumatic stress disorder: a systematic review and meta-analysis

The dissociative subtype of post-traumatic stress disorder (PTSD-DS) was introduced in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and is characterised by symptoms of either depersonalisation or derealisation, in addition to a diagnosis of post-traumatic stress disorder (PTSD). This systematic review and meta-analysis sought to estimate the point prevalence of current PTSD-DS, and the extent to which method of assessment, demographic and trauma variables moderate this estimate, across different methods of prevalence estimation. Studies included were identified by searching MEDLINE (EBSCO), PsycInfo, CINAHL, Academic Search Complete and PTSDpubs, yielding 49 studies that met the inclusion criteria (N = 8214 participants). A random-effects meta-analysis estimated the prevalence of PTSD-DS as 38.1% (95% CI 31.5-45.0%) across all samples, 45.5% (95% CI 37.7-53.4%) across all diagnosis-based and clinical cut-off samples, 22.8% (95% CI 14.8-32.0%) across all latent class analysis (LCA) and latent profile analysis (LPA) samples and 48.1% (95% CI 35.0-61.3%) across samples which strictly used the DSM-5 PTSD criteria; all as a proportion of those already with a diagnosis of PTSD. All results were characterised by high levels of heterogeneity, limiting generalisability. Moderator analyses mostly failed to identify sources of heterogeneity. PTSD-DS was more prevalent in children compared to adults, and in diagnosis-based and clinical cut-off samples compared to LCA and LPA samples. Risk of bias was not significantly related to prevalence estimates. The implications of these results are discussed further.

Problems With Sleep Are Common and Predict Increased Risk for Alcohol and Drug Use Among Reserve and National Guard Soldiers

OBJECTIVE

Sleep problems are common among military members and may increase substance use risk. This study examines longitudinal associations between sleep problems and substance use among U.S. Army Reserve and National Guard (USAR/NG) soldiers as well as differences between current and former soldiers.

METHOD

Data are drawn from Operation: SAFETY (Soldiers and Families Excelling Through the Years), an ongoing prospective study of the health and well-being of USAR/NG soldiers and their spouses. We used generalized estimating equation models (N = 485 soldiers; 79.8% male) to examine residual change in substance use (alcohol problems, heavy drinking, current use of any drug, nonmedical use of prescription drugs [NMUPD], and illicit drugs) associated with sleep problems (globally and particular dimensions) over 3 years, controlling for probable post-traumatic stress disorder, age, sex, and substance use at the prior time point. Interaction models examined differences by military status (current vs. former soldier).

RESULTS

Sleep problems were associated with increased risk of heavy drinking (p < .05), any current drug use (p < .05), current NMUPD (p < .01), and current illicit use (p < .05). There were significant interactions between sleep quality and military status on any current drug use (p < .01) and current illicit use (p < .05) and between sleep duration and military status on current NMUPD (p < .05), such that the risk of substance use was greater for former compared with current soldiers.

CONCLUSIONS

Sleep problems are prevalent among USAR/NG soldiers and are longitudinally associated with alcohol and drug use. This risk may increase for soldiers who have separated from the military. These findings support routine screening for sleep problems among soldiers and predischarge education around substance use risks related to unaddressed sleep problems.

Integrating human brain proteomes with genome-wide association data implicates novel proteins in post-traumatic stress disorder

Genome-wide association studies (GWAS) have identified several risk loci for post-traumatic stress disorder (PTSD); however, how they confer PTSD risk remains unclear. We aimed to identify genes that confer PTSD risk through their effects on brain protein abundance to provide new insights into PTSD pathogenesis. To that end, we integrated human brain proteomes with PTSD GWAS results to perform a proteome-wide association study (PWAS) of PTSD, followed by Mendelian randomization, using a discovery and confirmatory study design. Brain proteomes (N = 525) were profiled from the dorsolateral prefrontal cortex using mass spectrometry. The Million Veteran Program (MVP) PTSD GWAS (n = 186,689) was used for the discovery PWAS, and the Psychiatric Genomics Consortium PTSD GWAS (n = 174,659) was used for the confirmatory PWAS. To understand whether genes identified at the protein-level were also evident at the transcript-level, we performed a transcriptome-wide association study (TWAS) using human brain transcriptomes (N = 888) and the MVP PTSD GWAS results. We identified 11 genes that contribute to PTSD pathogenesis via their respective cis-regulated brain protein abundance. Seven of 11 genes (64%) replicated in the confirmatory PWAS and 4 of 11 also had their cis-regulated brain mRNA levels associated with PTSD. High confidence level was assigned to 9 of 11 genes after considering evidence from the confirmatory PWAS and TWAS. Most of the identified genes are expressed in other PTSD-relevant brain regions and several are preferentially expressed in excitatory neurons, astrocytes, and oligodendrocyte precursor cells. These genes are novel, promising targets for mechanistic and therapeutic studies to find new treatments for PTSD.

Chronic Traumatic Encephalopathy in the Brains of Military Personnel

BACKGROUND

Persistent neuropsychiatric sequelae may develop in military personnel who are exposed to combat; such sequelae have been attributed in some cases to chronic traumatic encephalopathy (CTE). Only limited data regarding CTE in the brains of military service members are available.

METHODS

We performed neuropathological examinations for the presence of CTE in 225 consecutive brains from a brain bank dedicated to the study of deceased service members. In addition, we reviewed information obtained retrospectively regarding the decedents' histories of blast exposure, contact sports, other types of traumatic brain injury (TBI), and neuropsychiatric disorders.

RESULTS

Neuropathological findings of CTE were present in 10 of the 225 brains (4.4%) we examined; half the CTE cases had only a single pathognomonic lesion. Of the 45 brains from decedents who had a history of blast exposure, 3 had CTE, as compared with 7 of 180 brains from those without a history of blast exposure (relative risk, 1.71; 95% confidence interval [CI], 0.46 to 6.37); 3 of 21 brains from decedents with TBI from an injury during military service caused by the head striking a physical object without associated blast exposure (military impact TBI) had CTE, as compared with 7 of 204 without this exposure (relative risk, 4.16; 95% CI, 1.16 to 14.91). All brains with CTE were from decedents who had participated in contact sports; 10 of 60 contact-sports participants had CTE, as compared with 0 of 165 who had not participated in contact sports (point estimate of relative risk not computable; 95% CI, 6.16 to infinity). CTE was present in 8 of 44 brains from decedents with non-sports-related TBI in civilian life, as compared with 2 of 181 brains from those without such exposure in civilian life (relative risk, 16.45; 95% CI, 3.62 to 74.79).

CONCLUSIONS

Evidence of CTE was infrequently found in a series of brains from military personnel and was usually reflected by minimal neuropathologic changes. Risk ratios for CTE were numerically higher among decedents who had contact-sports exposure and other exposures to TBI in civilian life than among those who had blast exposure or other military TBI, but the small number of CTE cases and wide confidence intervals preclude causal conclusions. (Funded by the Department of Defense-Uniformed Services University Brain Tissue Repository and Neuropathology Program and the Henry M. Jackson Foundation for the Advancement of Military Medicine.).

Evidence for excess familial clustering of Post Traumatic Stress Disorder in the US Veterans Genealogy resource

A genealogy of the United States has been record-linked to National Veteran's Health Administration (VHA) patient data to allow non-identifiable analysis of familial clustering. This genealogy, including over 70 million individuals linked to over 1 million VHA patients, is the largest such combined resource reported. Analysis of familial clustering among VHA patients diagnosed with Post Traumatic Stress Disorder (PTSD) allowed a test of the hypothesis of an inherited contribution to PTSD. PTSD is associated strongly with military service and extended familial clustering data have not previously been presented. PTSD-affected VHA patients with genealogy data were identified by presence of an ICD diagnosis code in the VHA medical record in at least 2 different years. The Genealogical Index of Familiality (GIF) method was used to compare the average relatedness of VHA patients diagnosed with PTSD with their expected average relatedness, estimated from randomly selected sets of matched linked VHA patient controls. Relative risks for PTSD were estimated in first-, second-, and third-degree relatives of PTSD patients who were also VHA patients, using sex and age-matched rates for PTSD estimated from all linked VHA patients. Significant excess pairwise relatedness, and significantly elevated risk for PTSD in first-, second-, and third-degree relatives was observed; multiple high-risk extended PTSD pedigrees were identified. The analysis provides evidence for excess familial clustering of PTSD and identified high-risk PTSD pedigrees. These results support an inherited contribution to PTSD predisposition and identify a powerful resource of high-risk PTSD pedigrees for predisposition gene identification.

The prevalence of depression among iran-iraq war veterans, combatants and former prisoners of war: A systematic review and meta-analysis

By exposing individuals to trauma, wars can cause a host of psychiatric disorders. This study aimed to collect and compare the studies conducted to estimate the prevalence of depression among veterans, former prisoners of war (POWs) and military personnel in the Iran-Iraq war (1980-1988). In this systematic review, a search was conducted using relevant keywords in major national and international databases, personal archives and national academic libraries. We screened 135 records using their abstracts and selected a total of 56 studies for full-text review. Eventually, 19 studies were included in our systematic review and meta-analysis. The estimated pooled prevalence of depression among Iranian veterans and POWs was 22.4% (95% confidence interval = 15.0-32.0). Although the results indicated disparities in the prevalence of depression among veterans and POWs, the aggregate estimated prevalence was much higher than what has been reported for military personnel. Effective policies and strategies are required for prevention and treatment of depression and related psychiatric complications among veterans and former POWs.

Social Functioning in Individuals With Post-Traumatic Stress Disorder: A Systematic Review

Post-traumatic stress disorder (PTSD) can lead to multiple deleterious outcomes and has negative, sometimes debilitating, impacts on general functioning of those affected. This systematic review of 26 articles evaluates the existing literature on social functioning outcomes used in PTSD research, the association between PTSD and social functioning, and the impact of interventions for PTSD on social functioning. A review of 26 articles using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for systematic reviews showed that PTSD was associated with significant impairment in global social functioning. This review also reveals the need for both standardized definitions and better assessment methods to operationalize social functioning and improve our ability to compare findings across studies. The literature also suggests that some evidence-based treatments for PTSD improve social functioning despite not explicitly targeting social functioning in the treatment. The findings of this review suggest that there are ample opportunities for improving both research and interventions to improve global social functioning in PTSD.

Systematic Review and Meta-analysis: Prevalence of Posttraumatic Stress Disorder in Trauma-Exposed Preschool-Aged Children

OBJECTIVE

Trauma exposure is common in preschool-aged children. Understanding the psychological impact of such exposure and the prevalence of posttraumatic stress disorder (PTSD) in this population is important for provision of appropriate and timely intervention. This pre-registered (PROSPERO: CRD41019133984) systematic review and meta-analysis examined the prevalence of PTSD in trauma-exposed preschool-aged children.

METHOD

Literature searches were conducted of PubMed (Medline), PsycINFO and PILOTS, alongside reference lists of relevant reviews. Studies were selected if they comprised trauma-exposed samples with a mean age of less than 6.5 years, and PTSD was assessed using standardized interviews at least 1-month post trauma. Information on sample characteristics, trauma exposure, PTSD measurement, and diagnostic criteria were extracted. For studies that applied more than one PTSD diagnostic algorithm, the most age-appropriate criteria were used to estimate pooled prevalence estimate across studies. A random-effects model was used for meta-analysis.

RESULTS

Eighteen studies were included (N = 1941). The pooled PTSD prevalence was 21.5% (95% CI = 13.8%-30.4%) when using the most developmentally appropriate diagnostic algorithm that was available. When focusing on the subset of studies that reported both standard adult criteria and age-appropriate criteria (k = 12), a pooled estimate of 4.9% (95% CI = 2.5%-8.0%) was obtained for standard adult criteria (DSM-IV), and 19.9% (95% CI = 12.1%-29.0%) was obtained for age-appropriate criteria (PTSD-AA). Prevalence was 3-fold higher following interpersonal and repeated trauma exposure, compared to non-interpersonal or single-event trauma, respectively. Higher prevalence was found when age-appropriate diagnostic tools were used. There was significant heterogeneity across studies and a lack of studies conducted in low-income countries and applying age-appropriate diagnostic algorithms.

CONCLUSION

Preschool-aged children are vulnerable to developing PTSD following trauma exposure. Younger children show prevalence trends similar to those of older youths and adults following different types of trauma. Age-appropriate diagnostic criteria are essential to ensure that appropriate identification and early support are provided.

Intolerance of uncertainty prospectively predicts the transdiagnostic severity of emotional psychopathology: Evidence from a Veteran sample

Intolerance of uncertainty (IU) has been conceptualized as a transdiagnostic vulnerability for emotional psychopathology, but few studies have tested whether it prospectively predicts emotional psychopathology, and none have utilized transdiagnostic and clinician-rated outcomes. To fill this gap, the present study tested whether IU prospectively predicted the clinician-rated severity of transdiagnostic emotional psychopathology six months later in a treatment-seeking Veteran sample. Participants completed the Intolerance of Uncertainty 12-item scale (IUS-12) and the Structured Clinical Interview for the DSM-5 (SCID-5) at Time 1 and again six-months later (Time 2); assessed emotional disorders included both anxiety-related disorders (i.e., post-traumatic stress disorder, generalized anxiety disorder, panic disorder, social anxiety disorder, obsessive compulsive disorder, specific phobia) and depressive conditions (i.e., major depressive disorder and persistent depressive disorder). Linear regression analyses revealed a bidirectional prospective relation between IU and emotional psychopathology, wherein higher Time 1 IUS-12 predicted greater Time 2 emotional disorder severity and greater Time 1 emotional disorder severity predicted higher Time 2 IUS-12. Follow-up analyses revealed that IU prospectively predicted the maintenance (but not the development) of anxiety-related issues, whereas prediction of Time 2 depression was nullified when controlling for Time 1 anxiety pathology. These findings implicate IU as a transdiagnostic vulnerability for emotional psychopathology and suggest the construct can be particularly useful as a treatment target and prognostic indicator for anxiety-related conditions.

A Scoping Review on the Prevalence and Determinants of Post-Traumatic Stress Disorder among Military Personnel and Firefighters: Implications for Public Policy and Practice

Introduction: Firefighters and military personnel are public safety personnel who protect the safety of individuals and their properties. They are usually exposed to traumatic events leaving them at risk of developing mental health conditions such as post-traumatic stress disorder (PTSD). Increasing concern is being raised regarding the mental health impacts, specifically PTSD, among military personnel and firefighters. Objective: There is an increased exposure of firefighters and military personnel to traumatic events and the attendant risk of developing post-traumatic stress disorder. It is crucial to ascertain the level of PTSD amongst this cohort and determinants to formulate policies and practices that mitigate the risk and protect public safety personnel. This scoping review sought to determine the prevalence of PTSD among this cohort globally and to explore determinants of this mental health condition. Methods: A literature search in databases including MEDLINE, CINAHL, PubMed, PsycINFO, and EMBASE was conducted electronically from May 2021 to 31 July 2021. Two reviewers independently assessed full-text articles according to the predefined inclusion criteria and screening process undertaken to identify studies for the review. Articles were screened with a third reviewer, resolving conflicts where necessary and further assessing them for eligibility. During article selection, the PRISMA checklist was adopted, and with the Covidence software, a total of 32 articles were selected for the final examination. For the eligible studies, data extraction was conducted, information was collated and summarized, and the findings were reported. Original qualitative and quantitative data on the prevalence and predictors of PTSD among veterans, military, and firefighters were reported. Results: The prevalence of PTSD was 57% for firefighters and 37.8% for military personnel. Demographic factors, job factors, social support, injuries, physical and psychological factors, and individual traits were the main predictors of PTSD in this cohort. Conclusion: This information is vital for developing and implementing prevention and intervention strategies for PTSD in military personnel and firefighters. Recognizing and addressing factors that predict PTSD will help to improve mental wellbeing and increase productivity. More peer-reviewed studies are needed on the prevalence of PTSD amongst these cohorts.

Systematic review of first responder post-deployment or post-incident psychosocial interventions

BACKGROUND

First responder populations, such as emergency services and the military, report elevated levels of mental health problems. Although post-deployment or post-incident psychosocial support interventions are widely implemented within these services, its effectiveness in preventing the development of mental disorders is unclear.

AIMS

To systematically assess which, if any, post-deployment or post-incident psychosocial interventions are effective at preventing the development of post-traumatic stress disorder (PTSD) and common mental disorders (CMD) amongst military and emergency service worker (ESW) settings.

METHODS

A systematic review was conducted by searching four databases for any randomized controlled trials (RCTs) or controlled trials of post-deployment or post-incident interventions. The primary outcomes assessed were differences in symptoms of PTSD and CMD. Study quality was examined using the Downs and Black checklist. Pooled effect sizes and 95% CI were calculated using random-effects modelling for main meta-analyses, planned subgroup and sensitivity analyses.

RESULTS

From 317 articles, seven RCTs were included in the final meta-analysis. Interventions identified included psychological debriefing, screening, stress education, team-based skills training and a peer-delivered risk assessment. A very small but significant effect was found for team-based skills training in reducing CMD symptoms. Some evidence was also found for team cohesion training in reducing both PTSD and CMD.

CONCLUSIONS

Limited evidence was found for post-deployment or post-incident psychosocial interventions within military and ESW populations. More high-quality studies, particularly among ESW settings, are urgently needed to determine how to better prevent the development of trauma related disorders after exposure.

Critical Care Nurse Burnout, Moral Distress, and Mental Health During the COVID-19 Pandemic: A United States Survey

BACKGROUND

The COVID-19 pandemic has and will continue to have a tremendous influence on intensive care unit (ICU) nurses' mental health.

OBJECTIVES

The purpose of this study was to describe the impact of COVID-19 on nurse moral distress, burnout, and mental health.

METHODS

Between October 2020 and January 2021 this descriptive study recruited a national sample of nurses who worked in the ICU during the COVID-19 pandemic through American Association of Critical Care Nurses newsletters and social media.

RESULTS

A total of 488 survey responses were received from critical care nurses working in the U.S. during the COVID pandemic. Over two thirds of respondents experienced a shortage of personal protective equipment (PPE). Nurse respondents reported moderate/high levels of moral distress and burnout. Symptoms of moderate to severe depression and anxiety were reported by 44.6% and 31.1% of respondents, respectively. Forty-seven percent of respondents were at risk for having posttraumatic stress disorder (PTSD). Lack of perceived support from administration and shortage of PPE were associated with higher levels of burnout, moral distress, and PTSD symptoms.

CONCLUSIONS

Respondents had higher anxiety and depression than the general population and higher risk for having PTSD than recent veterans or patients after traumatic injury. High levels of reported burnout and moral distress increase the risk of nurses leaving ICU practice or the profession. This study offers important insights about the mental health of nurses during a global pandemic that can guide the development of customized interventions for ICU nurses related to this health care crisis.

Change in prevalence of post-traumatic stress disorder in the two years following trauma: a meta-analytic study

BACKGROUND

Understanding the course of post-traumatic stress disorder (PTSD) and the factors that impact this is essential to inform decisions about when and for whom screening and intervention are likely to be beneficial.

OBJECTIVE

To provide meta-analytic evidence of the course of recovery from PTSD in the first year following trauma, and the factors that influence that recovery.

METHOD

We conducted a meta-analysis of observational studies of adult PTSD prevalence which included at least two assessments within the first 12 months following trauma exposure, examining prevalence statistics through to 2 years post-trauma. We examined trauma intentionality (intentional or non-intentional), PTSD assessment method (clinician or self-report), sample sex distribution, and age as moderators of PTSD prevalence over time.

RESULTS

We identified 78 eligible studies including 16,484 participants. Pooled prevalence statistics indicated that over a quarter of individuals presented with PTSD at 1 month post-trauma, with this proportion reducing by a third between 1 and 3 months. Beyond 3 months, any prevalence changes were detected over longer intervals and were small in magnitude. Intentional trauma, younger age, and female sex were associated with higher PTSD prevalence at 1 month. In addition, higher proportions of females, intentional trauma exposure, and higher baseline PTSD prevalence were each associated with larger reductions in prevalence over time.

CONCLUSIONS

Recovery from PTSD following acute trauma exposure primarily occurs in the first 3 months post-trauma. Screening measures and intervention approaches offered at 3 months may better target persistent symptoms than those conducted prior to this point.

HIGHLIGHTS

PTSD rates in the immediate aftermath of trauma exposure decline from 27% at 1 month to 18% at 3 months post-trauma, showing significant spontaneous recovery.Problems appear to stabilize after 3 months.Screening/intervention for PTSD at 3 months post-trauma is indicated.

Posttraumatic Stress Disorder, Suicidal Behavior, Substance Use, and Sexual Victimization Among Adolescent Girls Aged 10-19 Years Living Under Ethnic-Based Civil War in Ethiopia

BACKGROUND

Posttraumatic stress disorder (PTSD) is a chronic, impairing mental disorder that develops after exposure to a traumatic event. Despite many factors putting adolescent girls at risk of PTSD, little is known about the prevalence and how adolescent girls cope with the PTSD burden. So, this study aimed to investigate the prevalence of PTSD and associated factors among adolescent girls in three selected towns in Southwest Ethiopia.

METHODS

A community-based cross-sectional study was conducted among 397 adolescent girls from May 27 to July 27, 2021. The participants were selected by a systematic random sampling method. PTSD and substance use disorder were assessed by DSM V criteria for mental disorders. The data was entered into Epi Data Manager Version 4.0.2 before being exported to SPSS Version 25 for analysis. A logistic regression model was used, and variables with a p-value less than 0.05 in the final fitting model were stated as independent predictors of PTSD.

RESULTS

The prevalence of PTSD among the adolescent girls was 22%, and about three in four (72.7%) of the adolescent girls developed PTSD after exposure to sexual violence. Furthermore, PTSD was associated with Khat use disorder (AOR, 95% CI: 2.79 (1.47-5.30), alcohol use disorder (AOR, 95% CI: 5.27 (2.21-12.60), and suicidal behavior (AOR, 95% CI: 2.12 (1.20-3.74)).

CONCLUSION

The prevalence of PTSD was high among adolescent girls, and suicidal ideation or attempt, khat use disorder, and alcohol use disorder were risk factors for PTSD. Therefore, early screening for PTSD and comorbid risk factors among this particular age group and managing accordingly is warranted.

Repetitive Transcranial Magnetic Stimulation as a Treatment for Veterans with Cognitive Impairment and Multiple Comorbidities

BACKGROUND

Despite decades of research efforts, current treatments for Alzheimer's disease (AD) are of limited effectiveness and do not halt the progression of the disease and associated cognitive decline. Studies have shown that repetitive transcranial magnetic stimulation (rTMS) may improve cognition.

OBJECTIVE

We conducted a pilot study to investigate the effect of rTMS on cognitive function in Veterans with numerous medical comorbidities.

METHODS

Participants underwent 20 sessions, over the course of approximately 4 weeks, of 10 Hz rTMS at the left dorsolateral prefrontal cortex with intensity of 120% resting motor threshold. Outcome measures including memory, language, verbal fluency, and executive functions were acquired at baseline, end of treatment, and 4 months after the last rTMS session. Twenty-six Veterans completed the study (13 in the active rTMS group, 13 in the sham rTMS group).

RESULTS

The study protocol was well-tolerated. Active, compared to sham, rTMS showed improved auditory-verbal memory at the end of treatment and at 4-month follow-up. However, the active rTMS group demonstrated a trend in decreased semantic verbal fluency at the end of treatment and at 4-month follow up.

CONCLUSION

These preliminary results show rTMS is safe in general in this elderly Veteran population with multiple co-morbidities. Patients in the sham group showed an expected, slight decline in the California Verbal Learning Test scores over the course of the study, whereas the active treatment group showed a slight improvement at the 4-month post-treatment follow up. These effects need to be confirmed by studies of larger sample sizes.

Pre-deployment programmes for building resilience in military and frontline emergency service personnel

BACKGROUND

Military personnel and frontline emergency workers may be exposed to events that have the potential to precipitate negative mental health outcomes such as depression, symptoms of post-traumatic stress and even post-traumatic stress disorder (PTSD). Programmes have been designed to build psychological resilience before staff are deployed into the field. This review presents a synthesis of the literature on these "pre-deployment resilience-building programmes".

OBJECTIVES

The objective of this review was to assess the effectiveness of programmes that seek to build resilience to potentially traumatic events among military and frontline emergency service personnel prior to their deployment. These resilience programmes were compared to other interventions, treatment as usual or no intervention.

SEARCH METHODS

Studies were identified through searches of electronic databases including Ovid MEDLINE, Embase, PsycINFO, Web of Science and Google Scholar. The initial search took place in January 2019, with an updated search completed at the end of September 2020.

SELECTION CRITERIA

Only studies that used a randomised controlled trial (RCT)/cluster-RCT methodology were included. The programmes being evaluated must have sought to build resilience prior to exposure to trauma. Study participants must have been 18 years or older and be military personnel or frontline emergency workers.

DATA COLLECTION AND ANALYSIS

Studies that met the inclusion criteria were assembled. Data extracted included methods, participants' details, intervention details, comparator details, and information on outcomes. The primary outcomes of interest were resilience, symptoms of post-traumatic stress and PTSD. Secondary outcomes of interest included acute stress disorder, depression, social support, coping skills, emotional flexibility, self-efficacy, social functioning, subjective levels of aggression, quality of sleep, quality of life and stress. Assessment of risk of bias was also completed. A total of 28 studies were included in a narrative synthesis of results.

MAIN RESULTS

All 28 included studies compared an experimental resilience building intervention versus a control or no intervention. There was a wide range of therapeutic modalities used, including cognitive behavioural therapy (CBT) informed programmes, biofeedback based programmes, stress-management programmes, mindfulness and relaxation programmes, neuropsychological-based programmes, and psychoeducational-informed programmes. The main outcomes are specified here, secondary outcomes such as depression, social support, coping skills, self-efficacy, subjective levels of aggression and stress are reported in text. No studies reported on the following pre-specified outcomes; acute stress disorder, emotional flexibility, social functioning, quality of sleep and quality of life. Resilience Eight studies reported resilience as an outcome. We narratively synthesised the data from these studies and our findings show that five of these interventions had success in building resilience in their respective samples. Two of the studies that reported significant results utilised a CBT approach to build resilience, while the other three successful programmes were mindfulness-based interventions. Symptoms of post-traumatic stress Our narrative synthesis of results included eight studies. Two of the eight studies produced significant reductions in symptoms of post traumatic stress compared to controls. These interventions used neuropsychological and biofeedback intervention models respectively. PTSD caseness Four studies reported PTSD caseness as an outcome. Our narrative synthesis of results suggests that evidence is mixed as to the effectiveness of these interventions in reducing clinical diagnosis of PTSD. One study of a neuropsychology-orientated Attention Bias Modification Training (AMBT) programme had success in reducing both symptoms of post-traumatic stress and numbers of participants receiving a diagnosis of PTSD. A stress-management programme reported that, when baseline differences in rates of pre-deployment mental health issues were controlled for, participants in the control condition were at 6.9 times the risk of a diagnosis of PTSD when compared to the intervention group. Given the diversity of intervention designs and theoretical orientations used (which included stress-management, neuropsychological and psychoeducational programmes), a definitive statement on the efficacy of pre-deployment programmes at reducing symptoms of post-traumatic stress and PTSD cannot be confidently offered.

AUTHORS' CONCLUSIONS

While a number of evaluations of relevant programmes have been published, the quality of these evaluations limits our ability to determine if resilience-building programmes 'work' in terms of preventing negative outcomes such as depression, symptoms of post-traumatic stress and diagnoses of PTSD. Based on our findings we recommend that future research should: a) report pre-/post-means and standard deviation scores for scales used within respective studies, b) take the form of large, RCTs with protocols published in advance, and c) seek to measure defined psychological facets such as resilience, PTSD and stress, and measure these concepts using established psychometric tools. This will provide more certainty in future assessments of the evidence base. From a clinical implications point of view, overall there is mixed evidence that the interventions included in this review are effective at safe guarding military personnel or frontline emergency workers from experiencing negative mental health outcomes, including PTSD, following exposure to potentially traumatic events. Based on this, practitioners seeking to build resilience in their personnel need to be aware of the limitations of the evidence base. Practitioners should have modest expectations in relation to the efficacy of resilience-building programmes as a prophylactic approach to employment-related critical incident traumas.

Reductions in guilt cognitions following prolonged exposure and/or sertraline predict subsequent improvements in PTSD and depression

BACKGROUND AND OBJECTIVES

Reduction of trauma related negative cognitions, such as guilt, is thought to be a mechanism of change within PTSD treatments like prolonged exposure (PE). Research suggests PE can directly address guilt cognitions. However, whether pharmacotherapies for PTSD can remains unclear.

METHODS

Data from a randomized controlled trial of PE plus placebo (PE + PLB), sertraline plus enhanced medication management (SERT + EMM), and their combination (PE + SERT) in 195 Veterans from recent wars was analyzed.

RESULTS

The unadjusted means and mixed-effects model showed guilt decreased significantly over the follow-up time as expected; however, contrary to our hypothesis, PE conditions were not associated with greater reductions in guilt than the SERT + EMM condition. As hypothesized, week 12 reduction in guilt predicted post-treatment (weeks 24-52) reduction in PTSD and depression, but not impairments in function.

LIMITATIONS

Generalizability of findings is limited by the sample being comprised of combat Veterans who were predominantly male, not on SSRI at study entry, willing to be randomized to therapy or medication, and reporting low levels of guilt. To reduce differences in provider attention, SERT + EMM was administered over 30 min to include psychoeducation and active listening; it is unknown if this contributed to effects on guilt.

CONCLUSIONS

PE + PLB, SERT + EMM, and PE + SERT were equally associated with reduction in trauma related guilt. Reducing trauma related guilt may be a pathway to reducing PTSD and posttraumatic depression symptoms. Further study is needed to determine how best to treat trauma related guilt and to understand the mechanisms by which guilt improves across different treatments for PTSD.

General Perspective on the U.S. Military Conflicts in Iraq and Afghanistan After 20 Years

It has been 20 years since the September 11, 2001 terrorist attacks on America. The ongoing military conflicts in this region are the longest sustained conflicts in U.S. history. Almost 3 million military personnel have deployed, with over 7,000 fatalities and more than 53,000 wounded in action. The most common psychological health condition associated with combat deployments is PTSD. No data exist to compare the prevalence of PTSD across war eras. Therefore, a potential proxy for PTSD risk is the number of combat-related deaths, because this figure has been consistently tracked across U.S. military conflicts. This commentary includes a table of death statistics from major military conflicts, which shows that fewer military personnel have deployed, been killed, sustained wounds, and, one might conclude, suffered from PTSD than any other major U.S. military conflict in history. Advances in the military equipment, tactics, and healthcare programs perhaps mitigated casualties and suffering among Iraq/Afghanistan veterans compared to previous wars. The estimated causality differences across various military conflicts are not meant to minimize the significant contributions and sacrifices made by this new generation of military warriors but to help us gain perspective on military conflicts over the past century as we recognize the 20th anniversary of 9/11.

The experience of Basic Body Awareness Therapy and its transfer to daily life amongst Danish military veterans with PTSD

INTRODUCTION

The prevalence of Post-Traumatic Stress Disorder (PTSD) among Danish military veterans is estimated to be around 10%, and treatment primarily consists of recommended psychological trauma-focused therapy.

AIM

The aim of the study was to explore veterans' experiences of their body and its potential transfer of that experience in their daily life after BBAT.

METHODS

A hermeneutic-phenomenological qualitative study using semi-structured individual interviews was used. A slightly modified Interpretive Phenomenological Analysis was applied in the data analysis. The participants were four Danish military veterans with PTSD who had completed 12 individual sessions of BBAT in addition to psychological trauma-focused therapy.

RESULTS

All participants found the BBAT treatment sessions calming and reported the overall treatment was a positive experience. Three participants experienced increased body awareness and were able to apply the exercises and principles of BBAT in their daily lives to varying degrees. All participants estimated the benefits would have been greater with more sessions.

CONCLUSION

BBAT showed potential for enhancing the bodily awareness of military veterans with PTSD experience and their ability to apply that awareness in their daily life. The degree of transfer of this skill to everyday life appeared to be dependent on the participants' mentalizing capacity.

IMPLICATIONS OF THIS STUDY

The results indicate a benefit in using body-oriented therapies such as BBAT in the treatment of military veterans with PTSD, as a supplement to trauma-focused treatment although it is hard to distinguish which treatment had which effect or if the combination of psychotherapy and BBAT had a joint effect. Future studies are needed due to the limited research in this field.

Prevalence of complex post-traumatic stress disorder in refugees and asylum seekers: systematic review

BACKGROUND

Refugees and asylum seekers often report having experienced numerous complex traumas. It is important to understand the prevalence of complex post-traumatic stress disorder (CPTSD), which can follow complex traumas.

AIMS

This systematic review aims to summarise the available literature reporting the prevalence in refugees and asylum seekers of three operationalised definitions of CPTSD: the ICD-11 diagnostic criteria, the ICD-10 criteria (for enduring personality change after catastrophic experience) and the DSM-IV criteria (for disorders of extreme stress not otherwise specified).

METHOD

Six electronic databases were searched for studies reporting the prevalence of CPTSD in adult refugee and/or asylum-seeking samples. Owing to heterogeneity between the studies, a narrative synthesis approach was used to summarise studies. Methodological quality was assessed using the Joanna Briggs Critical Appraisal Checklist for Prevalence Studies. This systematic review has been registered with PROSPERO (registration number CRD42020188422, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=188422).

RESULTS

Systematic searches identified 15 eligible studies, with 10 examining treatment-seeking samples and five using population samples. CPTSD prevalence in treatment-seeking samples was between 16 and 38%. Prevalence in population samples ranged from 2.2 to 9.3% in four studies, with the fifth reporting a much higher estimate (50.9%).

CONCLUSIONS

This review highlights both the high prevalence of CPTSD in treatment samples and the lack of research aiming to establish prevalence of CPTSD in refugee and asylum-seeking populations. Understanding the prevalence of these disabling disorders has implications for policy and healthcare services for the appropriate promotion, planning and provision of suitable treatment and interventions for this highly traumatised population.