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Porter KE, Stein MB, Grau PP, Kim HM, Powell C, Hoge CW, Venners MR, Smith ER, Martis B, Simon NM, Liberzon I, Rauch SAM. Impact of PTSD treatment on postconcussive symptoms in veterans: A comparison of sertraline, prolonged exposure, and their combination. J Psychiatr Res 2024; 173:64-70. [PMID: 38503135 DOI: 10.1016/j.jpsychires.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/29/2024] [Accepted: 03/07/2024] [Indexed: 03/21/2024]
Abstract
Many Veterans who served in Iraq and Afghanistan struggle with posttraumatic stress disorder (PTSD) and the effects of traumatic brain injuries (TBI). Some people with a history of TBI report a constellation of somatic, cognitive, and emotional complaints that are often referred to as postconcussive symptoms (PCS). Research suggests these symptoms may not be specific to TBI. This study examined the impact of PTSD treatment on PCS in combat Veterans seeking treatment for PTSD. As part of a larger randomized control trial, 198 Operation Iraqi Freedom, Operation Enduring Freedom, Operation New Dawn (OIF/OEF/OND) Veterans with PTSD received Prolonged Exposure Therapy, sertraline, or the combination. Potential deployment related TBI, PCS, PTSD and depression symptoms were assessed throughout treatment. Linear mixed models were used to predict PCS change over time across the full sample and treatment arms, and the association of change in PTSD and depression symptoms on PCS was also examined. Patterns of change for the full sample and the subsample of those who reported a head injury were examined. Results showed that PCS decreased with treatment. There were no significant differences across treatments. No significant differences were found in the pattern of symptom change based on TBI screening status. Shifts in PCS were predicted by change PTSD and depression. Results suggest that PCS reduced with PTSD treatment in this population and are related to shift in depression and PTSD severity, further supporting that reported PCS symptoms may be better understood as non-specific symptoms.
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Affiliation(s)
- Katherine E Porter
- Mental Health Service Line, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA; Mental Health Service Care VA San Diego Healthcare System, San Diego, CA, USA
| | - Peter P Grau
- Mental Health Service Line, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA; VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Ann Arbor, MI, USA
| | - H Myra Kim
- University of Michigan, Consulting for Statistics, Computing and Analytics Research, Ann Arbor, MI, USA
| | - Corey Powell
- University of Michigan, Consulting for Statistics, Computing and Analytics Research, Ann Arbor, MI, USA
| | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Margaret R Venners
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo, Park, CA, USA; Research Service Line, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Erin R Smith
- Mental Health Service Line, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Brian Martis
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA; Mental Health Service Care VA San Diego Healthcare System, San Diego, CA, USA
| | - Naomi M Simon
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, USA
| | - Israel Liberzon
- Department of Psychiatry & Behavioral Science, Texas A&M Health, Bryan, TX, USA
| | - Sheila A M Rauch
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, USA; Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, USA; Emory University School of Medicine, Atlanta, GA, USA
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Puhalla A, Sullivan C, Chard K, Dickstein B, Hoge CW. An examination of the potential core symptoms of posttraumatic stress disorder: What is integral after removing general psychopathology & distress? J Psychiatr Res 2024; 174:46-53. [PMID: 38613942 DOI: 10.1016/j.jpsychires.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 03/28/2024] [Accepted: 04/03/2024] [Indexed: 04/15/2024]
Abstract
Many confirmatory factor analyses (CFA) have examined the structure of posttraumatic stress disorder (PTSD) with some suggesting increased complexity (i.e., 6+ factors), while others suggesting a more refined structure (i.e., 2-factors). These competing PTSD structures may be due to conflation of non-trauma specific symptoms that have been added overtime. However, none of these studies examined if all symptoms being examined are specific to PTSD or potentially more related to general distress and psychopathology. The current study re-evaluated the structure of PTSD using bifactor exploratory factor analysis (EFA) to identify the construct's core symptoms. Data for EFA models were taken from a sample of Veterans (N = 694) attending outpatient therapy for PTSD and were cross-validated using CFA in a sample of 297 Veterans attending residential treatment. Clinician Administered PTSD Scale for DSM-5 (CAPS-5) at pre-treatment was used across sample. Factor analyses resulted in a 2-factor, bifactor model comprised of eight total items. Model fit was robust, RMSEA = 0 [0.000, 0.036]; robust CFI = 1; robust TLI = 1.017. The bifactor analytic approach captured what might be the core structure of PTSD, which were pathognomonic symptoms of PTSD (Factor one). A distinct second factor related to depression was also found. In identifying this structure, the model eliminates redundancies and lesser performing items and differentiates depressive reactions as potentially distinct and separate. Overall, these findings may assist in future research of PTSD by determining the unique elements of the construct within a veteran sample versus associated features, general psychological distress, and comorbid psychopathology.
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Affiliation(s)
- Alexander Puhalla
- Department of Education & Research, Coatesville VA Medical Center, Coatesville, PA, USA.
| | - Connor Sullivan
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Kathleen Chard
- Trauma Recovery Center Cincinnati VA Medical Center, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Benjamin Dickstein
- Trauma Recovery Center Cincinnati VA Medical Center, Cincinnati, OH, USA
| | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
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Hoge CW, Chard KM, Yehuda R. US Veterans Affairs and Department of Defense 2023 Clinical Guideline for PTSD-Devolving Not Evolving. JAMA Psychiatry 2024; 81:223-224. [PMID: 38198160 DOI: 10.1001/jamapsychiatry.2023.4920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
This Viewpoint discusses the updated 2023 clinical practice guidelines issued by the US Department of Veterans Affairs and the US Department of Defense regarding treatment approaches for posttraumatic stress disorder.
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Affiliation(s)
- Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, Maryland
| | | | - Rachel Yehuda
- James J. Peters Veterans Affairs Medical Center, and Icahn School of Medicine at Mount Sinai, New York, New York
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Wolfgang AS, Hoge CW. Psychedelic-Assisted Therapy in Military and Veterans Healthcare Systems: Clinical, Legal, and Implementation Considerations. Curr Psychiatry Rep 2023; 25:513-532. [PMID: 37682446 DOI: 10.1007/s11920-023-01446-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW This review discusses the current and projected landscape of psychedelic-assisted therapy (PAT), with a focus on clinical, legal, and implementation considerations in Department of Defense (DoD) and Department of Veterans Affairs (VA) healthcare systems. RECENT FINDINGS 3,4-Methylenedioxymethamphetamine (MDMA)- and psilocybin-assisted therapy have shown promising outcomes in efficacy, safety, tolerability, and durability for PTSD and depression, respectively. MDMA-assisted therapy is already approved by the Food and Drug Administration (FDA) on an Expanded Access ("compassionate use") basis for PTSD, with full approval projected for 2024. Psilocybin-assisted therapy is projected to be FDA-approved for depression soon thereafter. Other psychedelics are in earlier stages of development. The VA is currently conducting PAT clinical trials. Although there are clear legal pathways for the VA and DoD to conduct PAT trials, a number of implementation barriers exist, such as the very high number of clinical hours necessary to treat each patient, resource requirements to support treatment infrastructure, military-specific considerations, and the high level of evidence necessary for PAT to be recommended in clinical practice guidelines. Ongoing considerations are whether and how PAT will be made available to VA and DoD beneficiaries, feasibility and cost-effectiveness, and ethical safeguards that must be implemented to prioritize access to PAT given the likelihood of extremely limited initial availability. However, with imminent FDA approval of PATs and considerable national interest in these treatments, DoD and VA policymakers must be prepared with clearly delineated policies and plans for how these healthcare systems will approach PAT.
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Affiliation(s)
- Aaron S Wolfgang
- Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD, 20814, USA.
- Uniformed Services University, Bethesda, MD, USA.
- Yale University School of Medicine, New Haven, CT, USA.
| | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
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Wolfgang AS, Hoge CW. Cannabis and Cannabinoids for Pain and Posttraumatic Stress Disorder in Military Personnel and Veterans. JAMA Psychiatry 2023; 80:869-870. [PMID: 37436761 DOI: 10.1001/jamapsychiatry.2023.1685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
This Viewpoint reviews the evidence for using cannabis and cannabinoids to treat pain and PTSD in military and veteran populations.
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Affiliation(s)
- Aaron S Wolfgang
- Department of Psychiatry, Uniformed Services University, Bethesda, Maryland
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, Maryland
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Wilk JE, Clarke-Walper K, Nugent K, Hoge CW, Sampson M, Warner CH. Associations of health care staff burnout with negative health and organizational outcomes in the U.S. military health system. Soc Sci Med 2023; 330:116049. [PMID: 37418990 DOI: 10.1016/j.socscimed.2023.116049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 06/09/2023] [Accepted: 06/26/2023] [Indexed: 07/09/2023]
Abstract
RATIONALE Burnout is a personal and occupational phenomenon that has been associated with negative physical and psychological outcomes in medical staff. Additionally, there are implications for healthcare organizations, as those staff who are burned out are more likely to have lower productivity or leave the organization. As with the Covid-19 pandemic, future national emergencies and potentially large-scale conflicts will require similar and likely even larger scale responses from the U.S. Military Health System, thus it is important to understand burnout in this population so that the readiness of the staff and the military can remain at a high level. OBJECTIVE This assessment was designed to examine levels of burnout among United States Military Health System (MHS) staff working at Army installations and the factors that influence the development of burnout. METHODS Anonymous data was collected from 13,558 active-duty U.S. Soldiers and civilian MHS employees. Burnout was measured using the Copenhagen Burnout Inventory and the Mini-Z. RESULTS Results showed nearly half of staff who responded (48%) reported being burned out, an increase since last measured in 2019 (31%). Factors related to increased burnout included concerns about work/life balance and workload, low job satisfaction and feeling disconnected from others. Burnout was associated with increases in adverse physical and behavioral health (BH) outcomes. CONCLUSIONS Results indicate that burnout is a common problem across MHS Army staff and is related to significant adverse health consequences for the individual and reduced retention of staff for the organization. These findings highlight the need to address burnout through policies that standardize health care delivery policies and practices, providing support to leadership to promote a healthy workplace, and individual support to those who experience burnout.
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Affiliation(s)
- Joshua E Wilk
- Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA.
| | - Kristina Clarke-Walper
- Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA.
| | - Katie Nugent
- Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA.
| | - Charles W Hoge
- U.S. Army Office of the Surgeon General, 7700 Arlington Blvd, Falls Church, VA 22042, USA.
| | - Mary Sampson
- Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA.
| | - Christopher H Warner
- U.S. Army Office of the Surgeon General, 7700 Arlington Blvd, Falls Church, VA 22042, USA; Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA.
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Duffy FF, Sudom K, Jones M, Fear NT, Greenberg N, Adler AB, Hoge CW, Wilk JE, Riviere LA. Calibrating the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) for detecting alcohol-related problems among Canadian, UK and US soldiers: cross-sectional pre-deployment and post-deployment survey results. BMJ Open 2023; 13:e068619. [PMID: 37130676 PMCID: PMC10163557 DOI: 10.1136/bmjopen-2022-068619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
OBJECTIVES Excessive alcohol use can bring about adverse health and work-related consequences in civilian and military populations. Screening for excessive drinking can help identify individuals at risk for alcohol-related problems who may require clinical interventions. The brief validated measures of alcohol use such as the Alcohol Use Disorders Identification Test (AUDIT), or abbreviated AUDIT-Consumption (AUDIT-C), are often included in military deployment screening and epidemiologic surveys, but appropriate cut-points must be used to effectively identify individuals at risk. Although the conventional AUDIT-C cut-points ≥4 for men and ≥3 for women are commonly used, recent validation studies of veterans and civilians recommend higher cut-points to minimise misclassification and overestimation of alcohol-related problems. This study aims to ascertain optimal AUDIT-C cut-points for detecting alcohol-related problems among serving Canadian, UK and US soldiers. DESIGN Cross-sectional pre/post-deployment survey data were used. SETTINGS Comprised Army locations in Canada and UK, and selected US Army units. PARTICIPANTS Included soldiers in each of the above-mentioned settings. OUTCOME MEASURES Soldiers' AUDIT scores for hazardous and harmful alcohol use or high levels of alcohol problems served as a benchmark against which optimal sex-specific AUDIT-C cut-points were assessed. RESULTS Across the three-nation samples, AUDIT-C cut-points of ≥6/7 for men and ≥5/6 for women performed well in detecting hazardous and harmful alcohol use and provided comparable prevalence estimates to AUDIT scores ≥8 for men and ≥7 for women. The AUDIT-C cut-point ≥8/9 for both men and women performed fair-to-good when benchmarked against AUDIT ≥16, although inflated AUDIT-C-derived prevalence estimates and low positive predictive values were observed. CONCLUSION This multi-national study provides valuable information regarding appropriate AUDIT-C cut-points for detecting hazardous and harmful alcohol use, and high levels of alcohol problems among soldiers. Such information can be useful for population surveillance, pre-deployment/post-deployment screening of military personnel, and clinical practice.
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Affiliation(s)
- Farifteh Firoozmand Duffy
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- TechWerks LLC, Arlington Heights, Illinois, USA
| | - Kerry Sudom
- Director General Military Personnel Research and Analysis, Department of National Defence, Ottawa, Ontario, Canada
| | - Margaret Jones
- King's Centre for Military Health Research, King's College London, London, UK
| | - Nicola T Fear
- King's Centre for Military Health Research, King's College London, London, UK
- ADMMH, King's College London, London, UK
| | - Neil Greenberg
- King's Centre for Military Health Research, King's College London, London, UK
| | - Amy B Adler
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Charles W Hoge
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Joshua E Wilk
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Lyndon A Riviere
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, USA
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Bryan CJ, Allen MH, Hoge CW. Weighing the Costs and Benefits of Universal Suicide Risk Screening in Primary Care: An Evidence-Based Approach. Psychiatr Serv 2023; 74:79-81. [PMID: 35811562 DOI: 10.1176/appi.ps.202100611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Craig J Bryan
- Department of Psychiatry and Behavioral Health, Ohio State University College of Medicine, Columbus (Bryan); Department of Psychiatry and Emergency Medicine, University of Colorado School of Medicine, Denver (Allen); Walter Reed Army Institute of Research, Bethesda, Maryland (Hoge)
| | - Michael H Allen
- Department of Psychiatry and Behavioral Health, Ohio State University College of Medicine, Columbus (Bryan); Department of Psychiatry and Emergency Medicine, University of Colorado School of Medicine, Denver (Allen); Walter Reed Army Institute of Research, Bethesda, Maryland (Hoge)
| | - Charles W Hoge
- Department of Psychiatry and Behavioral Health, Ohio State University College of Medicine, Columbus (Bryan); Department of Psychiatry and Emergency Medicine, University of Colorado School of Medicine, Denver (Allen); Walter Reed Army Institute of Research, Bethesda, Maryland (Hoge)
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Krauss SW, Trachik BJ, Elliman TD, Toner KA, Zust J, Riviere LA, Hoge CW. The Impact of Just and Unjust War Events on Mental Health Need and Utilization within U.S. Service Members. Psychiatry 2023; 86:29-41. [PMID: 36265001 DOI: 10.1080/00332747.2022.2120310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Soldiers are resilient to just war events, such as killing enemy combatants and life-threatening experiences, but these same soldiers appear to struggle with unjust war events, such as killing a noncombatant or being unable to help civilian women and children in need. This study is the first to examine how just and unjust war experiences are associated with clinical health service outcomes. Methods: Two samples of soldiers in different stages of readjustment from deployment were drawn from a longitudinal, survey-based study of a US Army brigade. Measures included items related to combat events, mental health utilization, perceived mental health need, PTSD, depression, and functional impairment. Results: After controlling for other kinds of combat events, just war events (i.e., life-threatening events and killing enemy combatants) predicted outcomes in soldiers who are less than three months post-deployment, but only predicted 2 of 26 outcomes in soldiers one year post deployment. In contrast, unjust war events were found to be robust predictors of short-term and long-term outcomes related to mental health need and utilization, even after controlling for exposure to other combat events. Conclusions: The results extend previous longitudinal research that suggests that exposure to unjust war events carry a heavier long-term mental health burden than other types of events. Additionally, Soldiers exposed to unjust war events had an unmet need for care one year post deployment that was not directly tied to PTSD or depression. The results question the emphasis on life-threat within mental health pathogenesis models.
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Trachik B, Elliman TD, Ganulin ML, Dretsch MN, Riviere LA, Cabrera OA, Thomas JL, Hoge CW. Order effects in PTSD network analysis: important implications for diagnostic conceptualization, treatment refinement, and research. Psychol Med 2022; 52:2492-2499. [PMID: 33261701 DOI: 10.1017/s0033291720004377] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Benjamin Trachik
- US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, WA 98433, USA
| | - Toby D Elliman
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Michelle L Ganulin
- US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, WA 98433, USA
| | - Michael N Dretsch
- US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, WA 98433, USA
| | | | - Oscar A Cabrera
- US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, WA 98433, USA
| | | | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
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Fikretoglu D, Sharp ML, Adler AB, Bélanger S, Benassi H, Bennett C, Bryant R, Busuttil W, Cramm H, Fear N, Greenberg N, Heber A, Hosseiny F, Hoge CW, Jetly R, McFarlane A, Morganstein J, Murphy D, O'Donnell M, Phelps A, Richardson DJ, Sadler N, Schnurr PP, Smith P, Ursano R, Hooff MV, Wessely S, Forbes D, Pedlar D. Pathways to mental health care in active military populations across the Five-Eyes nations: An integrated perspective. Clin Psychol Rev 2021; 91:102100. [PMID: 34871868 DOI: 10.1016/j.cpr.2021.102100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 09/29/2021] [Accepted: 11/05/2021] [Indexed: 12/19/2022]
Abstract
Military service is associated with increased risk of mental health problems. Previous reviews have pointed to under-utilization of mental health services in military populations. Building on the most recent systematic review, our narrative, critical review takes a complementary approach and considers research across the Five-Eyes nations from the past six years to update and broaden the discussion on pathways to mental healthcare in military populations. We find that at a broad population level, there is improvement in several indicators of mental health care access, with greater gains in initial engagement, time to first treatment contact, and subjective satisfaction with care, and smaller gains in objective indicators of adequacy of care. Among individual-level barriers to care-seeking, there is progress in improving recognition of need for care and reducing stigma concerns. Among organizational-level barriers, there are advances in availability of services and cultural acceptance of care-seeking. Other barriers, such as concerns around confidentiality, career impact, and deployability persist, however, and may account for some remaining unmet need. To address these barriers, new initiatives that are more evidence-based, theoretically-driven, and culturally-sensitive, are therefore needed, and must be rigorously evaluated to ensure they bring about additional improvements in pathways to care.
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Affiliation(s)
- Deniz Fikretoglu
- Defence Research and Development Canada, 1133 Sheppard Ave. West, Toronto, ON, Canada.
| | | | - Amy B Adler
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | | | | | | | | | | | - Heidi Cramm
- School of Rehabilitation Therapy, Queen's University, Kingston, ON, Canada
| | | | | | | | - Fardous Hosseiny
- Centre of Excellence on Post-Traumatic Stress Disorder (PTSD), Ottawa, ON, Canada
| | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Rakesh Jetly
- Department of National Defence, Ottawa, ON, Canada
| | | | | | - Dominic Murphy
- Combat Stress, Leatherhead, Surrey, UK; King's College London, London, UK
| | - Meaghan O'Donnell
- Phoenix, Australia: Centre for Posttraumatic Mental Health, Carlton, Australia
| | - Andrea Phelps
- Phoenix, Australia: Centre for Posttraumatic Mental Health, Carlton, Australia
| | - Don J Richardson
- Parkwood Institute- St. Joseph's Health Care London, London, ON, Canada
| | - Nicole Sadler
- Phoenix, Australia: Centre for Posttraumatic Mental Health, Carlton, Australia
| | | | - Patrick Smith
- Centre of Excellence on Post-Traumatic Stress Disorder (PTSD), Ottawa, ON, Canada
| | | | - Miranda Van Hooff
- Military and Emergency Services Health Australia (MESHA), Woodville, SA, Australia
| | | | - David Forbes
- Phoenix, Australia: Centre for Posttraumatic Mental Health, Carlton, Australia
| | - David Pedlar
- Canadian Institute for Military and Veteran Health Research, Queen's University, Kingston, ON, Canada
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LeardMann CA, McMaster HS, Warner S, Esquivel AP, Porter B, Powell TM, Tu XM, Lee WW, Rull RP, Hoge CW. Comparison of Posttraumatic Stress Disorder Checklist Instruments From Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition vs Fifth Edition in a Large Cohort of US Military Service Members and Veterans. JAMA Netw Open 2021; 4:e218072. [PMID: 33904913 PMCID: PMC8080232 DOI: 10.1001/jamanetworkopen.2021.8072] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE The definition of posttraumatic stress disorder (PTSD) changed markedly between the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and DSM-5, creating challenges for studies and in medical settings spanning this transition. OBJECTIVE To evaluate the ability to compare and assess PTSD, based on DSM-IV and DSM-5 criteria, using PTSD Checklists (PCLs). DESIGN, SETTING, AND PARTICIPANTS This diagnostic study was conducted with survey data collected in October 2019, from the Millennium Cohort Study, a population-based US military cohort study. The population for the present study was restricted to a subset of initial web responders of the 2019 survey cycle, randomly assigned to 1 of 4 survey groups. EXPOSURES Each group received the DSM-IV and DSM-5 PCL (PCL-Civilian [PCL-C] version and PCL for DSM-5 [PCL-5]). PCL instruments were counterbalanced to control for order effects. MAIN OUTCOMES AND MEASURES Survey data were used to assess PTSD (using the PCL-C and PCL-5), major depressive disorder (using the Patient Health Questionnaire), generalized anxiety (using the Generalized Anxiety Disorder scale), and problem drinking (using the Patient Health Questionnaire). Demographic and military characteristics included age, sex, race/ethnicity, marital status, education, service branch, pay grade, enrollment panel, and military service status. RESULTS Among the 1921 participants (mean [SD] age, 50.1 [12.5] years), 1358 (70.7%) were men, 1638 (85.3%) were non-Hispanic White individuals, 1440 (75.0%) were married, and 1190 (61.9%) had at least a bachelor's degree; 295 (15.4%) had probable PTSD according to DSM-IV criteria with PCL-C compared with 286 (14.9%) using DSM-5 criteria with PCL-5 (κ = 0.77). There was substantial agreement between PCLs for probable PTSD based on DSM-IV criteria (295 [15.4%] with PCL-C; 316 [16.4%] with PCL-5; κ = 0.80) and DSM-5 criteria (286 [14.9%] with PCL-5; 258 [13.4%] with PCL-C; κ = 0.77). Estimated PTSD sum scores showed excellent agreement with observed scores. Using an established crosswalk, PCL-5 sum scores estimated with the PCL-C were similar to observed PCL-5 scores. Of the 17 corresponding items between the 2 instruments, 16 had substantial agreement. Appending 2 additional PCL-C items to the PCL-5 did not significantly alter estimates. The PCL-C and PCL-5 had nearly identical associations with comorbid conditions. CONCLUSIONS AND RELEVANCE The findings of this diagnostic study suggest that PTSD can be successfully assessed and compared over time with either PCL instrument in veteran and military populations.
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Affiliation(s)
- Cynthia A. LeardMann
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Hope Seib McMaster
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Steven Warner
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Alejandro P. Esquivel
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Ben Porter
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
- Social Science Research Center, Mississippi State University, Starkville
| | - Teresa M. Powell
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Xin M. Tu
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California, San Diego, La Jolla
| | - William W. Lee
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Rudolph P. Rull
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
| | - Charles W. Hoge
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
- Office of the Army Surgeon General, Falls Church, Virginia
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LeardMann CA, Matsuno RK, Boyko EJ, Powell TM, Reger MA, Hoge CW. Association of Combat Experiences With Suicide Attempts Among Active-Duty US Service Members. JAMA Netw Open 2021; 4:e2036065. [PMID: 33528551 PMCID: PMC7856539 DOI: 10.1001/jamanetworkopen.2020.36065] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/14/2020] [Indexed: 12/02/2022] Open
Abstract
Importance There is uncertainty about the role that military deployment experiences play in suicide-related outcomes. Most previous research has defined combat experiences broadly, and a limited number of cross-sectional studies have examined the association between specific combat exposure (eg, killing) and suicide-related outcomes. Objective To prospectively examine combat exposures associated with suicide attempts among active-duty US service members while accounting for demographic, military-specific, and mental health factors. Design, Setting, and Participants This cohort study analyzed data from the Millennium Cohort Study, an ongoing prospective longitudinal study of US service members from all military branches. Participants were enrolled in 4 phases from July 1, 2001, to April 4, 2013, and completed a self-administered survey at enrollment and every 3 to 5 years thereafter. The population for the present study was restricted to active-duty service members from the first 4 enrollment phases who deployed in support of the wars in Iraq and Afghanistan. Questionnaire data were linked with medical encounter data through September 30, 2015. Data analyses were conducted from January 10, 2017, to December 14, 2020. Exposures Combat exposure was examined in 3 ways (any combat experience, overall combat severity, and 13 individual combat experiences) using a 13-item self-reported combat measure. Main Outcomes and Measures Suicide attempts were identified from military electronic hospitalization and ambulatory medical encounter data using the International Classification of Diseases, Ninth Revision codes. Results Among 57 841 participants, 44 062 were men (76.2%) and 42 095 were non-Hispanic White individuals (72.8%), and the mean (SD) age was 26.9 (5.3) years. During a mean (SD) follow-up period of 5.6 (4.0) years, 235 participants had a suicide attempt (0.4%). Combat exposure, defined broadly, was not associated with suicide attempts in Cox proportional hazards time-to-event regression models after adjustments for demographic and military-specific factors; high combat severity and certain individual combat experiences were associated with an increased risk for suicide attempts. However, these associations were mostly accounted for by mental disorders, especially posttraumatic stress disorder. After adjustment for mental disorders, combat experiences with significant association with suicide attempts included being attacked or ambushed (hazard ratio [HR], 1.55; 95% CI, 1.16-2.06), seeing dead bodies or human remains (HR, 1.34; 95% CI, 1.01-1.78), and being directly responsible for the death of a noncombatant (HR, 1.81; 95% CI, 1.04-3.16). Conclusions and Relevance This study suggests that deployed service members who experience high levels of combat or are exposed to certain types of combat experiences (involving unexpected events or those that challenge moral or ethical norms) may be at an increased risk of a suicide attempt, either directly or mediated through a mental disorder.
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Affiliation(s)
- Cynthia A. LeardMann
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Rayna K. Matsuno
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Edward J. Boyko
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Epidemiology, University of Washington School of Public Health, Seattle
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Teresa M. Powell
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Mark A. Reger
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Charles W. Hoge
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
- Psychiatry Division, Office of the Army Surgeon General, Falls Church, Virginia
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14
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Jacobson IG, Adler AB, Roenfeldt KA, Porter B, LeardMann CA, Rull RP, Hoge CW. Combat Experience, New-Onset Mental Health Conditions, and Posttraumatic Growth in U.S. Service Members. Psychiatry 2021; 84:276-290. [PMID: 34340639 DOI: 10.1080/00332747.2021.1929770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: Studies examining posttraumatic growth (PTG) rely on surveys evaluating PTG in relation to prior traumatic experiences, resulting in psychometric problems due to the linkage of the dependent and independent variables. Few studies have assessed PTG following combat deployment while also controlling for mental health problems.Method: Longitudinal data on PTG, combat experience, and mental health were examined among U.S. Millennium Cohort Study deployers (n = 8732). Scores from a short-form (SF) version of the PTG inventory assessing current-state beliefs (C-PTGI-SF) independent of any predictor variables were assessed at time 1 (T1), before deployment, and change in scores were assessed approximately 3 years later after deployment at time 2 (T2). All participants screened negative for posttraumatic stress disorder (PTSD) and depression at T1.Results: Combat deployment severity was associated with a worsening of C-PTGI-SF scores at T2 among participants with moderate C-PTGI-SF scores at T1. A positive screen for comorbid PTSD/depression was associated with a worsening of C-PTGI-SF scores at T2 among participants with moderate or high C-PTGI-SF scores at T1. At T2, a strong inverse correlation was found between C-PTGI-SF scores and PTSD (r = -0.38) and depression (-0.41). Only 5% of participants who screened positive for a mental health problem at T2 (23/517) also experienced positive growth.Conclusions: These results challenge the clinical utility of the PTG construct. While PTG may be a useful framework for supporting trauma recovery on an individual basis, PTG does not appear to be distinct and independent from the negative psychological impact of traumatic experiences.
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15
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Dretsch MN, Neff D, Caserta R, Deagle E, Hoge CW, Adler AB. Rates of Behavioral Health Conditions and Health Risk Behaviors in Operators and Support Personnel in U.S. Special Operations Forces. Psychiatry 2020; 83:358-374. [PMID: 32924845 DOI: 10.1080/00332747.2020.1768787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objective: Rates of behavioral health disorders and potential protective factors in U.S. Special Operations Forces (SOF) have not been well studied, including differences between Operators and Support personnel, despite very high levels of combat exposure in these military personnel. The present study examined the prevalence of endorsed behavioral health problems and protective factors within a large sample of SOF personnel. Method: Anonymized data from 16,284 active duty SOF Service members from the 2016 Preservation of the Force and Family (POTFF) needs survey were analyzed. Results: Overall, the prevalence of PTSD (7.6%), depression (8.4%), alcohol misuse (12.8%), and nicotine use (28%) were comparable or lower than reported in conventional military populations. There were significant differences between Operators and Support personnel in a number of demographic and service-related variables. Operators also endorsed more direct combat exposure and scored higher on resilience and social support, and reported better quality and quantity of sleep. There were no significant group differences in rates of PTSD and depression, except lower odds (adjusted OR = 0.81) for alcohol problems in Support personnel (11.6%) compared to Operators (14.0%), p <.001, 95% CI [0.72, 0.91]. Conclusions: SOF personnel experience considerably higher exposure to combat deployments than conventional forces, yet the data from this study showed comparable or lower levels of behavioral health conditions. Although Operators were somewhat more likely than Support personnel to experience alcohol problems, they showed enhanced resilience, social support, and sleep health. Alcohol misuse is one potential target for preventive health efforts.
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16
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Allan NP, Ashrafioun L, Kolnogorova K, Raines AM, Hoge CW, Stecker T. Interactive effects of PTSD and substance use on suicidal ideation and behavior in military personnel: Increased risk from marijuana use. Depress Anxiety 2019; 36:1072-1079. [PMID: 31475423 DOI: 10.1002/da.22954] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 06/18/2019] [Accepted: 07/27/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The current study examines the unique and interactive effects of posttraumatic stress disorder (PTSD) symptoms and days using alcohol, opioids, and marijuana on PTSD symptoms, suicidal ideation, and suicidal behavior up to 1 year, later in a high-risk sample of military personnel not active in mental health treatment. METHODS Current and former military personnel at risk for suicide (N = 545; M age = 31.91 years, standard deviation = 7.27; 88.2% male) completed self-report measures of PTSD symptoms, past 30 days heavy alcohol use, opioid use, marijuana use, and current suicidal ideation via telephone at baseline and 1, 3, 6, and 12 months later. PTSD symptoms and the substance use variables (and relevant covariates) were entered as predictors of changes in PTSD symptoms, the likelihood of suicidal ideation, suicidal ideation severity, and the likelihood of suicidal behavior during the 11-month follow-up period. RESULTS PTSD symptoms predicted PTSD symptoms 1 month later. PTSD symptoms and marijuana use predicted the likelihood of suicidal ideation 1 month later and suicidal behavior during the 11-month follow-up period. The interaction between PTSD symptoms and marijuana use significantly predicted increased PTSD symptoms over time and suicidal behavior. At high, but not low levels of PTSD symptoms, more days using marijuana predicted increased PTSD symptoms over time and the likelihood of suicidal behavior. CONCLUSIONS Results suggest marijuana, especially for military personnel experiencing elevated PTSD symptoms may negatively impact suicidal thoughts and behavior. These results are relevant to suggestions that medical marijuana could be used in treating or augmenting treatment for PTSD.
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Affiliation(s)
| | - Lisham Ashrafioun
- VA VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, New York.,Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Amanda M Raines
- Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana.,South Central Mental Illness Research, Education, and Clinical Center (MIRECC), New Orleans, Louisiana
| | - Charles W Hoge
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland.,Behavioral Health Division, Office of the Army Surgeon General, Falls Church, Virginia
| | - Tracy Stecker
- VA VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, New York.,College of Nursing, Medical University of South Carolina, Charleston, South Carolina
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17
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Ivany CG, Bickel KW, Rangel T, Sarver J, Dinkel-Holzer J, Sarmiento DM, Hoge CW. Impact of a Service Line Management Model on Behavioral Health Care in the Military Health System. Psychiatr Serv 2019; 70:522-525. [PMID: 30947638 DOI: 10.1176/appi.ps.201800343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Large health care systems are seeking to reduce variation in care delivery and improve outcomes. This column describes the U.S. Army health care system's transformation to a service line management model and the impact on behavioral health care between 2013 and 2017. An evaluation found a promising association between the service line model and greater use of standard outpatient clinical programs, more frequent engagement of patients with serious conditions, and less use of inpatient services. The observational nature of these preliminary findings does not permit causal inferences; however, the service line model may help health care systems reduce variation between geographically distinct care delivery locations and improve performance.
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Affiliation(s)
- Christopher G Ivany
- Defense Health Agency, Falls Church, Virginia (Ivany). Office of the Surgeon General, United States Army, Falls Church (Bickel, Rangel, Sarver, Dinkel-Holzer, Sarmiento, Hoge). Marcela Horvitz-Lennon, M.D., and Kenneth Minkoff, M.D., are editors of this column
| | - Kelly W Bickel
- Defense Health Agency, Falls Church, Virginia (Ivany). Office of the Surgeon General, United States Army, Falls Church (Bickel, Rangel, Sarver, Dinkel-Holzer, Sarmiento, Hoge). Marcela Horvitz-Lennon, M.D., and Kenneth Minkoff, M.D., are editors of this column
| | - Tari Rangel
- Defense Health Agency, Falls Church, Virginia (Ivany). Office of the Surgeon General, United States Army, Falls Church (Bickel, Rangel, Sarver, Dinkel-Holzer, Sarmiento, Hoge). Marcela Horvitz-Lennon, M.D., and Kenneth Minkoff, M.D., are editors of this column
| | - James Sarver
- Defense Health Agency, Falls Church, Virginia (Ivany). Office of the Surgeon General, United States Army, Falls Church (Bickel, Rangel, Sarver, Dinkel-Holzer, Sarmiento, Hoge). Marcela Horvitz-Lennon, M.D., and Kenneth Minkoff, M.D., are editors of this column
| | - Joann Dinkel-Holzer
- Defense Health Agency, Falls Church, Virginia (Ivany). Office of the Surgeon General, United States Army, Falls Church (Bickel, Rangel, Sarver, Dinkel-Holzer, Sarmiento, Hoge). Marcela Horvitz-Lennon, M.D., and Kenneth Minkoff, M.D., are editors of this column
| | - Dennis M Sarmiento
- Defense Health Agency, Falls Church, Virginia (Ivany). Office of the Surgeon General, United States Army, Falls Church (Bickel, Rangel, Sarver, Dinkel-Holzer, Sarmiento, Hoge). Marcela Horvitz-Lennon, M.D., and Kenneth Minkoff, M.D., are editors of this column
| | - Charles W Hoge
- Defense Health Agency, Falls Church, Virginia (Ivany). Office of the Surgeon General, United States Army, Falls Church (Bickel, Rangel, Sarver, Dinkel-Holzer, Sarmiento, Hoge). Marcela Horvitz-Lennon, M.D., and Kenneth Minkoff, M.D., are editors of this column
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18
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Affiliation(s)
- Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA.
| | - Jonathan Wolf
- National Intrepid Center for Excellence, Bethesda, MD, USA
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19
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Affiliation(s)
- Charles W Hoge
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland.,Office of the Army Surgeon General, Falls Church, Virginia
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20
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Rauch SAM, Kim HM, Powell C, Tuerk PW, Simon NM, Acierno R, Allard CB, Norman SB, Venners MR, Rothbaum BO, Stein MB, Porter K, Martis B, King AP, Liberzon I, Phan KL, Hoge CW. Efficacy of Prolonged Exposure Therapy, Sertraline Hydrochloride, and Their Combination Among Combat Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2019; 76:117-126. [PMID: 30516797 PMCID: PMC6439753 DOI: 10.1001/jamapsychiatry.2018.3412] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/08/2018] [Indexed: 12/30/2022]
Abstract
Importance Meta-analyses of treatments for posttraumatic stress disorder (PTSD) suggest that trauma-focused psychotherapies produce greater benefits than antidepressant medications alone. Objective To determine the relative efficacy of prolonged exposure therapy plus placebo, prolonged exposure therapy plus sertraline hydrochloride, and sertraline plus enhanced medication management in the treatment of PTSD. Design, Setting, and Participants The Prolonged Exposure and Sertraline Trial was a randomized, multisite, 24-week clinical trial conducted at the Veterans Affairs Ann Arbor Healthcare System, Veterans Affairs San Diego Healthcare System, Ralph H. Johnson Veterans Affairs Medical Center, and Massachusetts General Hospital Home Base Veterans Program between January 26, 2012, and May 9, 2016. Participants and clinicians were blinded to pill condition, and outcome evaluators were blinded to assignment. Participants completed assessments at weeks 0 (intake), 6, 12, 24, and 52 (follow-up). Participants (N = 223) were service members or veterans of the Iraq and/or Afghanistan wars with combat-related PTSD and significant impairment (Clinician-Administered PTSD Scale score, ≥50) of at least 3 months' duration. Analyses were on an intent-to-treat basis. Intervention Participants completed up to thirteen 90-minute sessions of prolonged exposure therapy by week 24. Sertraline dosage was titrated during a 10-week period and continued until week 24; medication management was manualized. Main Outcomes and Measures The primary outcome was symptom severity of PTSD in the past month as assessed by the Clinician-Administered PTSD Scale score at week 24. Results Of 223 randomized participants, 149 completed the study at 24 weeks, and 207 (180 men and 27 women; mean [SD] age, 34.5 [8.3 years]) were included in the intent-to-treat analysis. Modified intent-to-treat analysis using a mixed model of repeated measures showed that PTSD symptoms decreased significantly during the 24 weeks (sertraline plus enhanced medication management, 33.8 points; prolonged exposure therapy plus sertraline, 32.7 points; and prolonged exposure therapy plus placebo, 29.4 points; β,-9.39; 95% CI, -11.62 to -7.16; P < .001); however, slopes did not differ by treatment group (prolonged exposure therapy plus placebo group, -9.39; sertraline plus enhanced medication management group, -10.37; and prolonged exposure therapy plus sertraline group, -9.99; P = .81). Conclusions and Relevance No difference in change in PTSD symptoms or symptom severity at 24 weeks was found between sertraline plus enhanced medication management, prolonged exposure therapy plus placebo, and prolonged exposure therapy plus sertraline. Trial Registration ClinicalTrials.gov Identifier: NCT01524133.
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Affiliation(s)
- Sheila A. M. Rauch
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - H. Myra Kim
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor
| | - Corey Powell
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor
| | - Peter W. Tuerk
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
- Department of Psychiatry, Medical University of South Carolina, Charleston
| | - Naomi M. Simon
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Psychiatry, New York University School of Medicine, New York
| | - Ron Acierno
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
- College of Nursing, Medical University of South Carolina, Charleston
| | - Carolyn B. Allard
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
| | - Sonya B. Norman
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
- Veterans Affairs Center of Excellence for Stress and Mental Health, San Diego, California
| | - Margaret R. Venners
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
| | - Barbara O. Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Murray B. Stein
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
| | - Katherine Porter
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - Brian Martis
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
| | - Anthony P. King
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - Israel Liberzon
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - K. Luan Phan
- Department of Psychiatry, University of Illinois at Chicago
- Mental Health Service Line, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
| | - Charles W. Hoge
- Walter Reed Army Institute of Research, Silver Spring, Maryland
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21
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Affiliation(s)
- Wendi M Waits
- From Walter Reed National Military Medical Center, Bethesda, Md.; and Walter Reed Army Institute of Research, Silver Spring, Md
| | - Charles W Hoge
- From Walter Reed National Military Medical Center, Bethesda, Md.; and Walter Reed Army Institute of Research, Silver Spring, Md
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22
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Toblin RL, Adrian AL, Hoge CW, Adler AB. Energy Drink Use in U.S. Service Members After Deployment: Associations With Mental Health Problems, Aggression, and Fatigue. Mil Med 2018; 183:e364-e370. [DOI: 10.1093/milmed/usy205] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Amanda L Adrian
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD
| | - Charles W Hoge
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD
| | - Amy B Adler
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD
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23
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Porter KE, Stein MB, Martis B, Avallone KM, McSweeney LB, Smith ER, Simon NM, Gargan S, Liberzon I, Hoge CW, Rauch SAM. Postconcussive symptoms (PCS) following combat-related traumatic brain injury (TBI) in Veterans with posttraumatic stress disorder (PTSD): Influence of TBI, PTSD, and depression on symptoms measured by the Neurobehavioral Symptom Inventory (NSI). J Psychiatr Res 2018; 102:8-13. [PMID: 29554536 DOI: 10.1016/j.jpsychires.2018.03.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 02/05/2018] [Accepted: 03/09/2018] [Indexed: 11/28/2022]
Abstract
Mild traumatic brain injury (mTBI) is commonly reported in recent combat Veterans. While the majority resolve, some Veterans develop postconcussive symptoms (PCS). Previous research suggests these symptoms are not specific to head injury and are often associated with psychiatric symptoms. The current study examines the relative contributions of posttraumatic stress, depressive symptoms, and TBI on postconcussive symptoms, and explores whether the relationship remains after controlling for symptom overlap. Two hundred eighteen combat Veterans from Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) provided the data for this study as part of a baseline evaluation for inclusion into larger treatment study for posttraumatic stress disorder (PTSD). Participants completed the Brief Traumatic Brain Injury Screen (BTBIS), Neurobehavioral Symptom Inventory (NSI), PTSD Checklist-Stressor Version (PCL-S), Beck Depression Inventory-II (BDI-II). Significant differences in NSI total score between individuals with and without history of TBI were not found. A series of regression analyses demonstrated that Depression and PTSD were significant predictors of NSI score even after removal of NSI symptoms that overlap with PTSD or depression. TBI status was also a significant predictor of PCS in most models, but its relative contribution was much smaller than that of depression and PTSD. Within PTSD symptoms, hyperarousal cluster was a significant predictor of NSI scores. Findings demonstrate that depression and PTSD are related to PCS beyond similarities in construct. Further, within a primarily PTSD treatment-seeking population, these psychiatric symptoms appear to be a stronger contributor than TBI.
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Affiliation(s)
- Katherine E Porter
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan, Ann Arbor, MI, USA.
| | - Murray B Stein
- University of California San Diego, La Jolla, CA, USA; VA San Diego Healthcare System, San Diego, CA, USA
| | - Brian Martis
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan, Ann Arbor, MI, USA
| | - Kimberly M Avallone
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan, Ann Arbor, MI, USA
| | - Lauren B McSweeney
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Emory University School of Medicine, Atlanta, GA, USA
| | - Erin R Smith
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan, Ann Arbor, MI, USA
| | - Naomi M Simon
- Massachusetts General Hospital, Boston, MA, USA; New York University School of Medicine, New York, NY, USA
| | | | - Israel Liberzon
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan, Ann Arbor, MI, USA
| | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Sheila A M Rauch
- Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Medical Center, Atlanta, GA, USA
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Porter B, Hoge CW, Tobin LE, Donoho CJ, Castro CA, Luxton DD, Faix D. Measuring Aggregated and Specific Combat Exposures: Associations Between Combat Exposure Measures and Posttraumatic Stress Disorder, Depression, and Alcohol-Related Problems. J Trauma Stress 2018; 31:296-306. [PMID: 29603393 DOI: 10.1002/jts.22273] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 12/27/2017] [Accepted: 01/05/2018] [Indexed: 11/09/2022]
Abstract
Research has shown combat exposure to be associated with negative mental health outcomes. Different combat exposure measures are not composed of the same combat experiences, and few combat exposure measures have been directly compared to another measure. Furthermore, research about the unique associations between specific combat experiences and mental health is lacking. We investigated associations between new-onset posttraumatic stress disorder (PTSD), new-onset depression, and alcohol-related problems and two commonly used measures of combat among a sample of 20,719 recently deployed U.S. military personnel. A 13-item measure assessed both direct and indirect combat exposures, and a 5-item measure assessed only indirect exposures. Both combat measures were associated with all outcomes in the same direction (e.g., PTSD, odds ratio [OR] = 2.97 vs. 4.01; depression, OR = 2.03 vs. 2.42; alcohol-related problems, OR = 1.41 vs. 1.62, respectively, for the 5- and 13-item measures). The 13-item measure had a stronger association with some outcomes, particularly PTSD. Each specific item had significant bivariate associations with all outcomes, ORs = 1.43-4.92. After adjusting for other combat exposures, items assessing witnessing abuse, feeling in danger, and knowing someone injured or killed remained associated with all outcomes, ORs = 1.18-2.72. After this adjustment, several items had unexpected protective associations with some mental health outcomes. Results indicated these two combat exposure measures were approximately equally effective for determining risk for negative mental health outcomes in a deployed population, despite having different content. Additional research is needed to replicate and understand how specific combat exposures affect health.
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Affiliation(s)
- Ben Porter
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Charles W Hoge
- Center for Military Psychiatry and Neuroscience Research, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Laura E Tobin
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Carrie J Donoho
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, USA
| | - Carl A Castro
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA
| | - David D Luxton
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, USA
| | - Dennis Faix
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, USA
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Armenta RF, Rush T, LeardMann CA, Millegan J, Cooper A, Hoge CW. Factors associated with persistent posttraumatic stress disorder among U.S. military service members and veterans. BMC Psychiatry 2018; 18:48. [PMID: 29452590 PMCID: PMC5816529 DOI: 10.1186/s12888-018-1590-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 01/04/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) can have long-term and far-reaching impacts on health and social and occupational functioning. This study examined factors associated with persistent PTSD among U.S. service members and veterans. METHODS Using baseline and follow-up (2001-2013) questionnaire data collected approximately every 3 years from the Millennium Cohort Study, multivariable logistic regression was conducted to determine factors associated with persistent PTSD. Participants included those who screened positive for PTSD using the PTSD Checklist-Civilian Version at baseline (N = 2409). Participants were classified as having remitted or persistent PTSD based on screening negative or positive, respectively, at follow-up. RESULTS Almost half of participants (N = 1132; 47%) met criteria for persistent PTSD at the first follow-up; of those, 804 (71%) also screened positive for PTSD at the second follow-up. Multiple factors were independently associated with persistent PTSD in an adjusted model at the first follow-up, including older age, deployment with high combat exposure, enlisted rank, initial PTSD severity, depression, history of physical assault, disabling injury/illness, and somatic symptoms. Among those with persistent PTSD at the first follow-up, additional factors of less sleep, separation from the military, and lack of social support were associated with persistent PTSD at the second follow-up. CONCLUSIONS Combat experiences and PTSD severity were the most salient risk factors for persistent PTSD. Comorbid conditions, including injury/illness, somatic symptoms, and sleep problems, also played a significant role and should be addressed during treatment. The high percentage of participants with persistent PTSD supports the need for more comprehensive and accessible treatment, especially after separation from the military.
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Affiliation(s)
- Richard F. Armenta
- 0000 0004 0587 8664grid.415913.bDeployment Health Research Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106-3521 USA ,0000 0004 0614 9826grid.201075.1The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD USA
| | - Toni Rush
- 0000 0001 2107 4242grid.266100.3Department of Family Medicine and Public Health, La Jolla, University of California, San Diego, School of Medicine, San Diego, CA USA
| | - Cynthia A. LeardMann
- 0000 0004 0587 8664grid.415913.bDeployment Health Research Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106-3521 USA ,0000 0004 0614 9826grid.201075.1The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD USA
| | - Jeffrey Millegan
- 0000 0001 0639 7318grid.415879.6Directorate of Mental Health, Naval Medical Center San Diego, San Diego, CA USA
| | - Adam Cooper
- 0000 0004 0587 8664grid.415913.bDeployment Health Research Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106-3521 USA
| | - Charles W. Hoge
- 0000 0001 0036 4726grid.420210.5Walter Reed Army Institute of Research, Silver Spring, MD USA
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Affiliation(s)
- Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Kathleen M Chard
- Trauma Recovery Center, Cincinnati VA Medical Center, Cincinnati, Ohio
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Wood MD, Adler AB, Bliese PD, McGurk D, Castro CA, Hoge CW, Koffman R. Psychological Adjustment after Combat Deployment: Decompression at Home Versus at Sea. ACTA ACUST UNITED AC 2018. [DOI: 10.1080/21635781.2017.1412842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Amy B. Adler
- Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Paul D. Bliese
- Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Dennis McGurk
- Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Carl A. Castro
- Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Charles W. Hoge
- Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Robert Koffman
- National Intrepid Center of Excellence, Bethesda, Maryland
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Rauch SA, Simon NM, Kim HM, Acierno R, King AP, Norman SB, Venners MR, Porter K, Phan KL, Tuerk PW, Allard C, Liberzon I, Rothbaum BO, Martis B, Stein MB, Hoge CW. Integrating biological treatment mechanisms into randomized clinical trials: Design of PROGrESS (PROlonGed ExpoSure and Sertraline Trial). Contemp Clin Trials 2018; 64:128-138. [DOI: 10.1016/j.cct.2017.10.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/21/2017] [Accepted: 10/23/2017] [Indexed: 01/07/2023]
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Affiliation(s)
- Charles W Hoge
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland.,Behavioral Health Division, Office of the Army Surgeon General, Falls Church, Virginia
| | - Christopher G Ivany
- Behavioral Health Division, Office of the Army Surgeon General, Falls Church, Virginia
| | - Amy B Adler
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
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Britt TW, Herleman HA, Odle-Dusseau HN, Moore D, Castro CA, Hoge CW. How the potential benefits of active combat events may partially offset their costs. International Journal of Stress Management 2017. [DOI: 10.1037/str0000026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Lee DJ, Hoge CW. Significant methodological flaws limit conclusions drawn by authors of a recent PTSD mindfulness study. Evid Based Ment Health 2017; 20:30. [PMID: 28104779 PMCID: PMC10699261 DOI: 10.1136/eb-2016-102308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 12/04/2016] [Accepted: 12/13/2016] [Indexed: 11/03/2022]
Affiliation(s)
- Daniel J Lee
- US Food and Drug Association, Silver Spring, Maryland, USA
- Uniformed Services, University of the Health Sciences, Bethesda, Maryland, USA
| | - Charles W Hoge
- Center for Psychiatry & Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
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Hoge CW, Lee DJ, Castro CA. Refining Trauma-Focused Treatments for Servicemembers and Veterans With Posttraumatic Stress Disorder: Progress and Ongoing Challenges. JAMA Psychiatry 2017; 74:13-14. [PMID: 27893037 DOI: 10.1001/jamapsychiatry.2016.2740] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Charles W Hoge
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Daniel J Lee
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Carl A Castro
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California
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Affiliation(s)
- Marjorie S Campbell
- From the Directorate of Mental Health and the Clinical Investigation Program, Naval Hospital Camp Pendleton, Camp Pendleton, Calif.; and the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Md
| | - Margaret Ryan
- From the Directorate of Mental Health and the Clinical Investigation Program, Naval Hospital Camp Pendleton, Camp Pendleton, Calif.; and the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Md
| | - Daniel Wright
- From the Directorate of Mental Health and the Clinical Investigation Program, Naval Hospital Camp Pendleton, Camp Pendleton, Calif.; and the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Md
| | - Maria D Devore
- From the Directorate of Mental Health and the Clinical Investigation Program, Naval Hospital Camp Pendleton, Camp Pendleton, Calif.; and the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Md
| | - Charles W Hoge
- From the Directorate of Mental Health and the Clinical Investigation Program, Naval Hospital Camp Pendleton, Camp Pendleton, Calif.; and the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Md
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34
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Affiliation(s)
- Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, Maryland
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Lee DJ, Schnitzlein CW, Wolf JP, Vythilingam M, Rasmusson AM, Hoge CW. PSYCHOTHERAPY VERSUS PHARMACOTHERAPY FOR POSTTRAUMATIC STRESS DISORDER: SYSTEMIC REVIEW AND META-ANALYSES TO DETERMINE FIRST-LINE TREATMENTS. Depress Anxiety 2016; 33:792-806. [PMID: 27126398 DOI: 10.1002/da.22511] [Citation(s) in RCA: 208] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 03/21/2016] [Accepted: 03/26/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Current clinical practice guidelines (CPGs) for posttraumatic stress disorder (PTSD) offer contradictory recommendations regarding use of medications or psychotherapy as first-line treatment. Direct head-to-head comparisons are lacking. METHODS Systemic review of Medline, EMBASE, PILOTS, Cochrane Central Register of Controlled Trials, PsycINFO, and Global Health Library was conducted without language restrictions. Randomized clinical trials ≥8 weeks in duration using structured clinical interview-based outcome measures, active-control conditions (e.g. supportive psychotherapy), and intent-to-treat analysis were selected for analyses. Independent review, data abstraction, and bias assessment were performed using standardized processes. Study outcomes were grouped around conventional follow-up time periods (3, 6, and 9 months). Combined effect sizes were computed using meta-analyses for medication versus control, medication pre-/posttreatment, psychotherapy versus control, and psychotherapy pre-/posttreatment. RESULTS Effect sizes for trauma-focused psychotherapies (TFPs) versus active control conditions were greater than medications versus placebo and other psychotherapies versus active controls. TFPs resulted in greater sustained benefit over time than medications. Sertraline, venlafaxine, and nefazodone outperformed other medications, although potential for methodological biases were high. Improvement following paroxetine and fluoxetine treatment was small. Venlafaxine and stress inoculation training (SIT) demonstrated large initial effects that decreased over time. Bupropion, citalopram, divalproex, mirtazapine, tiagabine, and topiramate failed to differentiate from placebo. Aripiprazole, divalproex, guanfacine, and olanzapine failed to differentiate from placebo when combined with an antidepressant. CONCLUSIONS Study findings support use of TFPs over nontrauma-focused psychotherapy or medication as first-line interventions. Second-line interventions include SIT, and potentially sertraline or venlafaxine, rather than entire classes of medication, such as SSRIs. Future revisions of CPGs should prioritize studies that utilize active controls over waitlist or treatment-as-usual conditions. Direct head-to-head trials of TFPs versus sertraline or venlafaxine are needed.
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Affiliation(s)
- Daniel J Lee
- Office of Evidence Based Practice, JBSA Fort Sam Houston, San Antonio, Texas. ,
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland. ,
| | - Carla W Schnitzlein
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Department of Behavioral Health, Bayne-Jones Army Community Hospital, Fort Polk, Louisiana
| | - Jonathan P Wolf
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Meena Vythilingam
- Headquarters U.S. Marine Corps, Health Services, Arlington, Virginia
| | - Ann M Rasmusson
- Women's Health Science Division, National Center for PTSD, VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts
- Department of Veterans Affairs, Boston University School of Medicine, Boston, Massachusetts
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Charles W Hoge
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
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Wilk JE, Herrell RK, Carr AL, West JC, Wise J, Hoge CW. Diagnosis of PTSD by Army Behavioral Health Clinicians: Are Diagnoses Recorded in Electronic Health Records? Psychiatr Serv 2016; 67:878-82. [PMID: 26975516 DOI: 10.1176/appi.ps.201500292] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The study sought to identify the extent to which posttraumatic stress disorder (PTSD) diagnoses are recorded in the electronic health record (EHR) in Army behavioral health clinics and to assess clinicians' reasons for not recording them and treatment factors associated with recording or not recording the diagnosis. METHODS A total of 543 Army mental health providers completed the anonymous, Web-based survey. Clinicians reported clinical data for 399 service member patients, of whom 110 (28%) had a reported PTSD diagnosis. Data were weighted to account for sampling design and nonresponses. RESULTS Of those given a diagnosis of PTSD by their clinician, 59% were reported to have the diagnosis recorded in the EHR, and 41% did not. The most common reason for not recording was reducing stigma or protecting the service member's career prospects. Psychiatrists were more likely than psychologists or social workers to record the diagnosis. CONCLUSIONS Findings indicate that for many patients presenting with PTSD in Army behavioral health clinics at the time of the survey (2010), clinicians did not record a PTSD diagnosis in the EHR, often in an effort to reduce stigma. This pattern may exist for other diagnoses. Recent Army policy has provided guidance to clinicians on diagnostic recording practice. An important implication concerns the reliance on coded diagnoses in PTSD surveillance efforts by the U.S. Department of Defense (DoD). The problem of underestimated prevalence rates may be further compounded by overly narrow DoD surveillance definitions of PTSD.
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Affiliation(s)
- Joshua E Wilk
- Except for Dr. West, the authors are with the Center for Military Psychiatry and Neurosciences, Walter Reed Army Institute of Research, Silver Spring, Maryland (e-mail: ). Dr. West is with the Psychiatric Research Network, American Psychiatric Institute for Research and Education, American Psychiatric Association, Arlington, Virginia
| | - Richard K Herrell
- Except for Dr. West, the authors are with the Center for Military Psychiatry and Neurosciences, Walter Reed Army Institute of Research, Silver Spring, Maryland (e-mail: ). Dr. West is with the Psychiatric Research Network, American Psychiatric Institute for Research and Education, American Psychiatric Association, Arlington, Virginia
| | - Abby L Carr
- Except for Dr. West, the authors are with the Center for Military Psychiatry and Neurosciences, Walter Reed Army Institute of Research, Silver Spring, Maryland (e-mail: ). Dr. West is with the Psychiatric Research Network, American Psychiatric Institute for Research and Education, American Psychiatric Association, Arlington, Virginia
| | - Joyce C West
- Except for Dr. West, the authors are with the Center for Military Psychiatry and Neurosciences, Walter Reed Army Institute of Research, Silver Spring, Maryland (e-mail: ). Dr. West is with the Psychiatric Research Network, American Psychiatric Institute for Research and Education, American Psychiatric Association, Arlington, Virginia
| | - Joseph Wise
- Except for Dr. West, the authors are with the Center for Military Psychiatry and Neurosciences, Walter Reed Army Institute of Research, Silver Spring, Maryland (e-mail: ). Dr. West is with the Psychiatric Research Network, American Psychiatric Institute for Research and Education, American Psychiatric Association, Arlington, Virginia
| | - Charles W Hoge
- Except for Dr. West, the authors are with the Center for Military Psychiatry and Neurosciences, Walter Reed Army Institute of Research, Silver Spring, Maryland (e-mail: ). Dr. West is with the Psychiatric Research Network, American Psychiatric Institute for Research and Education, American Psychiatric Association, Arlington, Virginia
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Hoge CW, Yehuda R, Castro CA, McFarlane AC, Vermetten E, Jetly R, Koenen KC, Greenberg N, Shalev AY, Rauch SAM, Marmar CR, Rothbaum BO. Unintended Consequences of Changing the Definition of Posttraumatic Stress Disorder in DSM-5: Critique and Call for Action. JAMA Psychiatry 2016; 73:750-2. [PMID: 27224895 DOI: 10.1001/jamapsychiatry.2016.0647] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Charles W Hoge
- Walter Reed Army Institute of Research, US Army Medical Research and Material Command, Silver Spring, Maryland
| | - Rachel Yehuda
- James J. Peters Veterans Affairs Medical Center, Bronx, New York3Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carl A Castro
- School of Social Work, University of Southern California, Los Angeles
| | - Alexander C McFarlane
- Centre for Traumatic Stress Studies, University of Adelaide, Adelaide, South Australia, Australia
| | - Eric Vermetten
- Military Mental Health Research Center, Ministry of Defense, Utrecht, the Netherlands7Department of Psychiatry, Leiden University Medical Center, Leiden, the Netherlands8Arq Psychotrauma Expert Group, Diemen, the Netherlands
| | - Rakesh Jetly
- Canadian Forces Health Services Group Headquarters, Directorate of Mental Health, Ottawa, Ontario, Canada
| | - Karestan C Koenen
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts11Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Neil Greenberg
- The King's Centre for Military Health Research, King's College London, London, England
| | - Arieh Y Shalev
- Department of Psychiatry, NYU Langone Medical Center, New York, New York14Hadassah and Hebrew University School of Medicine, Jerusalem, Israel
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia16Mental Health Services, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Charles R Marmar
- Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Traumatic Brain Injury, Department of Psychiatry, NYU Langone Medical Center, New York, New York
| | - Barbara O Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
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Affiliation(s)
- Rachel Yehuda
- James J. Peters Veterans Affairs Medical Center, Bronx, New York2Icahn School of Medicine at Mount Sinai, New York, New York
| | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, Maryland
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Affiliation(s)
- Rachel Yehuda
- Department of Psychiatry, James J. Peters Veterans Affairs Medical Center, Bronx, New York2Icahn School of Medicine at Mount Sinai, New York, New York
| | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, Maryland
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Hoge CW, Ivany CG, Brusher EA, Brown MD, Shero JC, Adler AB, Warner CH, Orman DT. Transformation of Mental Health Care for U.S. Soldiers and Families During the Iraq and Afghanistan Wars: Where Science and Politics Intersect. Am J Psychiatry 2016; 173:334-43. [PMID: 26552941 DOI: 10.1176/appi.ajp.2015.15040553] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The cumulative strain of 14 years of war on service members, veterans, and their families, together with continuing global threats and the unique stresses of military service, are likely to be felt for years to come. Scientific as well as political factors have influenced how the military has addressed the mental health needs resulting from these wars. Two important differences between mental health care delivered during the Iraq and Afghanistan wars and previous wars are the degree to which research has directly informed care and the consolidated management of services. The U.S. Army Medical Command implemented programmatic changes to ensure delivery of high-quality standardized mental health services, including centralized workload management; consolidation of psychiatry, psychology, psychiatric nursing, and social work services under integrated behavioral health departments; creation of satellite mental health clinics embedded within brigade work areas; incorporation of mental health providers into primary care; routine mental health screening throughout soldiers' careers; standardization of clinical outcome measures; and improved services for family members. This transformation has been accompanied by reduction in psychiatric hospitalizations and improved continuity of care. Challenges remain, however, including continued underutilization of services by those most in need, problems with treatment of substance use disorders, overuse of opioid medications, concerns with the structure of care for chronic postdeployment (including postconcussion) symptoms, and ongoing questions concerning the causes of historically high suicide rates, efficacy of resilience training initiatives, and research priorities. It is critical to ensure that remaining gaps are addressed and that knowledge gained during these wars is retained and further evolved.
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Affiliation(s)
- Charles W Hoge
- From the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Md.; the Behavioral Health Division, Office of the Army Surgeon General, Falls Church, Va.; the Behavioral Health Division, U.S. Army Medical Command Headquarters, Fort Sam Houston, Tex.; the Department of Defense and Veterans Affairs Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, Tex.; and the 61st Multifunctional Medical Battalion, Fort Hood, Tex
| | - Christopher G Ivany
- From the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Md.; the Behavioral Health Division, Office of the Army Surgeon General, Falls Church, Va.; the Behavioral Health Division, U.S. Army Medical Command Headquarters, Fort Sam Houston, Tex.; the Department of Defense and Veterans Affairs Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, Tex.; and the 61st Multifunctional Medical Battalion, Fort Hood, Tex
| | - Edward A Brusher
- From the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Md.; the Behavioral Health Division, Office of the Army Surgeon General, Falls Church, Va.; the Behavioral Health Division, U.S. Army Medical Command Headquarters, Fort Sam Houston, Tex.; the Department of Defense and Veterans Affairs Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, Tex.; and the 61st Multifunctional Medical Battalion, Fort Hood, Tex
| | - Millard D Brown
- From the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Md.; the Behavioral Health Division, Office of the Army Surgeon General, Falls Church, Va.; the Behavioral Health Division, U.S. Army Medical Command Headquarters, Fort Sam Houston, Tex.; the Department of Defense and Veterans Affairs Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, Tex.; and the 61st Multifunctional Medical Battalion, Fort Hood, Tex
| | - John C Shero
- From the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Md.; the Behavioral Health Division, Office of the Army Surgeon General, Falls Church, Va.; the Behavioral Health Division, U.S. Army Medical Command Headquarters, Fort Sam Houston, Tex.; the Department of Defense and Veterans Affairs Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, Tex.; and the 61st Multifunctional Medical Battalion, Fort Hood, Tex
| | - Amy B Adler
- From the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Md.; the Behavioral Health Division, Office of the Army Surgeon General, Falls Church, Va.; the Behavioral Health Division, U.S. Army Medical Command Headquarters, Fort Sam Houston, Tex.; the Department of Defense and Veterans Affairs Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, Tex.; and the 61st Multifunctional Medical Battalion, Fort Hood, Tex
| | - Christopher H Warner
- From the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Md.; the Behavioral Health Division, Office of the Army Surgeon General, Falls Church, Va.; the Behavioral Health Division, U.S. Army Medical Command Headquarters, Fort Sam Houston, Tex.; the Department of Defense and Veterans Affairs Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, Tex.; and the 61st Multifunctional Medical Battalion, Fort Hood, Tex
| | - David T Orman
- From the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Md.; the Behavioral Health Division, Office of the Army Surgeon General, Falls Church, Va.; the Behavioral Health Division, U.S. Army Medical Command Headquarters, Fort Sam Houston, Tex.; the Department of Defense and Veterans Affairs Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, Tex.; and the 61st Multifunctional Medical Battalion, Fort Hood, Tex
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Affiliation(s)
| | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, Maryland
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Hourani L, Williams J, Bray RM, Wilk JE, Hoge CW. Gender Differences in Posttraumatic Stress Disorder and Help Seeking in the U.S. Army. J Womens Health (Larchmt) 2015; 25:22-31. [PMID: 26562624 DOI: 10.1089/jwh.2014.5078] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Inconsistent findings between studies of gender differences in mental health outcomes in military samples have left open questions of differential prevalence in posttraumatic stress disorder (PTSD) among all United States Army soldiers and in differential psychosocial and comorbid risk and protective factor profiles and their association with receipt of treatment. METHODS This study assesses the prevalence and risk factors of screening positive for PTSD for men and women based on two large, population-based Army samples obtained as part of the 2005 and 2008 U.S. Department of Defense Surveys of Health Related Behaviors among Active Duty Military Personnel. RESULTS The study showed that overall rates of PTSD, as measured by several cutoffs of the PTSD Checklist, are similar between active duty men and women, with rates increasing in both men and women between the two study time points. Depression and problem alcohol use were strongly associated with a positive PTSD screen in both genders, and combat exposure was significantly associated with a positive PTSD screen in men. Overall, active duty men and women who met criteria for PTSD were equally likely to receive mental health counseling or treatment, though gender differences in treatment receipt varied by age, race, social support (presence of spouse at duty station), history of sexual abuse, illness, depression, alcohol use, and combat exposure. CONCLUSIONS The study demonstrates that the prevalence of PTSD as well as the overall utilization of mental health services is similar for active duty men compared with women. However, there are significant gender differences in predictors of positive PTSD screens and receipt of PTSD treatment.
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Affiliation(s)
- Laurel Hourani
- 1 RTI International , Research Triangle Park, North Carolina
| | - Jason Williams
- 1 RTI International , Research Triangle Park, North Carolina
| | - Robert M Bray
- 1 RTI International , Research Triangle Park, North Carolina
| | - Joshua E Wilk
- 2 Center for Military Psychiatry and Neuroscience Research, Walter Reed Army Institute of Research , Silver Spring, Maryland
| | - Charles W Hoge
- 2 Center for Military Psychiatry and Neuroscience Research, Walter Reed Army Institute of Research , Silver Spring, Maryland
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Affiliation(s)
- Charles W Hoge
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
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Abstract
IMPORTANCE Posttraumatic stress disorder (PTSD) is a disabling psychiatric disorder common among military personnel and veterans. First-line psychotherapies most often recommended for PTSD consist mainly of "trauma-focused" psychotherapies that involve focusing on details of the trauma or associated cognitive and emotional effects. OBJECTIVE To examine the effectiveness of psychotherapies for PTSD in military and veteran populations. EVIDENCE REVIEW PubMed, PsycINFO, and PILOTS were searched for randomized clinical trials (RCTs) of individual and group psychotherapies for PTSD in military personnel and veterans, published from January 1980 to March 1, 2015. We also searched reference lists of articles, selected reviews, and meta-analyses. Of 891 publications initially identified, 36 were included. FINDINGS Two trauma-focused therapies, cognitive processing therapy (CPT) and prolonged exposure, have been the most frequently studied psychotherapies for military-related PTSD. Five RCTs of CPT (that included 481 patients) and 4 RCTs of prolonged exposure (that included 402 patients) met inclusion criteria. Focusing on intent-to-treat outcomes, within-group posttreatment effect sizes for CPT and prolonged exposure were large (Cohen d range, 0.78-1.10). CPT and prolonged exposure also outperformed waitlist and treatment-as-usual control conditions. Forty-nine percent to 70% of participants receiving CPT and prolonged exposure attained clinically meaningful symptom improvement (defined as a 10- to 12-point decrease in interviewer-assessed or self-reported symptoms). However, mean posttreatment scores for CPT and prolonged exposure remained at or above clinical criteria for PTSD, and approximately two-thirds of patients receiving CPT or prolonged exposure retained their PTSD diagnosis after treatment (range, 60%-72%). CPT and prolonged exposure were marginally superior compared with non-trauma-focused psychotherapy comparison conditions. CONCLUSIONS AND RELEVANCE In military and veteran populations, trials of the first-line trauma-focused interventions CPT and prolonged exposure have shown clinically meaningful improvements for many patients with PTSD. However, nonresponse rates have been high, many patients continue to have symptoms, and trauma-focused interventions show marginally superior results compared with active control conditions. There is a need for improvement in existing PTSD treatments and for development and testing of novel evidence-based treatments, both trauma-focused and non-trauma-focused.
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Affiliation(s)
- Maria M Steenkamp
- Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, New York
| | - Brett T Litz
- VA Boston Healthcare System, Massachusetts Veterans Epidemiological Research and Information Center (MAVERIC), Boston University School of Medicine, Boston
| | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Charles R Marmar
- Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, New York
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Affiliation(s)
- Charles W Hoge
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
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Quartana PJ, Wilk JE, Balkin TJ, Hoge CW. Indirect associations of combat exposure with post-deployment physical symptoms in U.S. soldiers: roles of post-traumatic stress disorder, depression and insomnia. J Psychosom Res 2015; 78:478-483. [PMID: 25499887 DOI: 10.1016/j.jpsychores.2014.11.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 11/17/2014] [Accepted: 11/20/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To characterize the indirect associations of combat exposure with post-deployment physical symptoms through shared associations with post-traumatic stress disorder (PTSD), depression and insomnia symptoms. METHODS Surveys were administered to a sample of U.S. soldiers (N = 587) three months after a 15-month deployment to Iraq. A multiple indirect effects model was used to characterize direct and indirect associations between combat exposure and physical symptoms. RESULTS Despite a zero-order correlation between combat exposure and physical symptoms, the multiple indirect effects analysis did not provide evidence of a direct association between these variables. Evidence for a significant indirect association of combat exposure and physical symptoms was observed through PTSD, depression, and insomnia symptoms. In fact, 92% of the total effect of combat exposure on physical symptoms scores was indirect. These findings were evident even after adjusting for the physical injury and relevant demographics. CONCLUSION This is the first empirical study to suggest that PTSD, depression and insomnia collectively and independently contribute to the association between combat exposure and post-deployment physical symptoms. Limitations, future research directions, and potential policy implications are discussed.
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Affiliation(s)
- Phillip J Quartana
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, United States.
| | - Joshua E Wilk
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, United States
| | - Thomas J Balkin
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, United States
| | - Charles W Hoge
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, United States
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Hoge CW, Lies J. Posttraumatic Stress Disorder: Developments in Assessment and Treatment. Fed Pract 2015; 32:24S-28S. [PMID: 30766116 PMCID: PMC6375492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Diagnostic discordance between posttraumatic stress disorder definitions, treatment dropout rates, comorbidities, and varying policy approaches leave VA and DoD clinicians with unique concerns in providing effective treatment for many postwar health problems.
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Affiliation(s)
- Charles W Hoge
- is a senior scientist at the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research in Silver Spring, Maryland. is a counsellor advocate for the Victorian Foundation for Survivors of Torture Inc. in Brunswick, Victoria, Australia
| | - July Lies
- is a senior scientist at the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research in Silver Spring, Maryland. is a counsellor advocate for the Victorian Foundation for Survivors of Torture Inc. in Brunswick, Victoria, Australia
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Affiliation(s)
- Christopher G Ivany
- Behavioral Health Division, Office of the Army Surgeon General, Falls Church, Virginia
| | - Charles W Hoge
- Behavioral Health Division, Office of the Army Surgeon General, Falls Church, Virginia2Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
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Affiliation(s)
- Charles W Hoge
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
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Hoge CW, Warner CH. Estimating PTSD prevalence in US veterans: considering combat exposure, PTSD checklist cutpoints, and DSM-5. J Clin Psychiatry 2014; 75:e1439-41. [PMID: 25551241 DOI: 10.4088/jcp.14com09616] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 10/30/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Charles W Hoge
- Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, 20910
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