[Show abstract][Hide abstract] ABSTRACT: 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.
To examine the effectiveness of psychotherapies for PTSD in military and veteran populations.
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.
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.
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.
JAMA The Journal of the American Medical Association 08/2015; 314(5):489-500. DOI:10.1001/jama.2015.8370 · 35.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
Published by Elsevier Inc.
Journal of Psychosomatic Research 11/2014; 78(5). DOI:10.1016/j.jpsychores.2014.11.017 · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
The goal of this study was to identify factors affecting timely, quality mental health and substance abuse treatment for service members and characterize patients at the greatest risk of having problems accessing treatment.
An electronic survey was emailed to 2,310 Army mental healthcare providers. After providers with undeliverable emails and who self-reported not being behavioral health providers were excluded, 543 (26%) of the remaining 2,104 providers responded. This represented approximately a quarter of all Army behavioral health providers at the time of the survey. Of these 543 providers, 399 (73%) reported treating at least one service member during their last typical work week and provided clinically detailed data on one systematically selected service member.
The majority of the clinicians reported being able to spend sufficient time with patients (91.8%) and schedule encounters to meet patients' needs (82.4%). The clinicians also identified services where treatment access was more limited and patient subgroups with an unmet need for additional clinical care or services. Specifically, a significant proportion of clinicians reported that they were "never, rarely, or sometimes" able to provide or arrange for mental health treatment for the sampled service member's children (52.0%), provide or arrange for marriage and family therapy (40.1%), coordinate care effectively with primary care (36.7%), provide or arrange for care/case management (28.3%), or provide or arrange for substance abuse treatment (24.9%). Patients with more severe symptoms and diagnostic and clinical complexity had higher rates of problems with treatment access.
Our findings highlight opportunities to improve access to timely, quality treatment for service members and their families.
Journal of Psychiatric Practice 11/2014; 20(6):448-59. DOI:10.1097/01.pra.0000456593.58739.61 · 1.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: As the longest war in American history draws to a close, an unprecedented number of service members and veterans are seeking care for health challenges related to transitioning home and to civilian life. Congressionally mandated screening for mental health concerns in the Department of Defense (DoD), as well as screening efforts Veterans Affairs (VA) facilities, has been established with the goal of decreasing stigma and ensuring service members and veterans with depression and posttraumatic stress disorder (PTSD) receive needed treatment. Both the DoD and VA have also developed integrated behavioral health in primary-care based initiatives, which emphasize PTSD screening, treatment, and care coordination. This article discusses the rationale for population-level deployment-related mental health screening, recent changes to screening frequency, commonly used screening instruments such as the primary care PTSD screen (PC-PTSD), PTSD checklist (PCL), and Davidson Trauma Scale (DTS); as well as the strengths/limitations of each, and recommended cut-off scores based on expected PTSD prevalence.
Current Psychiatry Reports 09/2014; 16(9):467. DOI:10.1007/s11920-014-0467-7 · 3.24 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The definition of post-traumatic stress disorder (PTSD) underwent substantial changes in the 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). How this will affect estimates of prevalence, whether clinical utility has been improved, and how many individuals who meet symptom criteria according to the previous definition will not meet new criteria is unknown. Updated screening instruments, including the PTSD checklist (PCL), have not been compared with previously validated methods through head-to-head comparisons.
The Lancet Psychiatry 09/2014; 1(4). DOI:10.1016/S2215-0366(14)70235-4
[Show abstract][Hide abstract] ABSTRACT: Measurement of functional impairment is a priority for the military and other professional work groups routinely exposed to stressful traumatic events as part of their occupation. Standard measures of impairment used in general or chronically ill populations contain many items not suitable for these populations, and include mental health symptoms items that are not true measures of functioning. We created a new, 14-item scale-the Walter Reed Functional Impairment Scale-to assess functioning in 4 domains (physical, occupational, social, and personal). We asked 3,380 soldiers how much difficulty they currently have in each of the 4 domains on a 5-point scale. Behaviorally based psychosocial and occupational performance measures and general health questions were used to validate the scale. The utility of the scale was assessed against clinical measures of psychopathology and physical health (depression, posttraumatic stress disorder [PTSD], general health, generalized physical symptoms). We utilized Cronbach's alpha, item response theory, and the score test for trend to establish consistency of items and the validity of the scale. The scale exhibited excellent reliability (Cronbach's α= 0.92) and validity. The individual items and quartiles of sum scores were strongly correlated with negative occupational and social performance, and the utility of the scale was demonstrated by strong correlations with depression, PTSD, and high levels of generalized physical symptoms. This scale exhibits excellent psychometric properties in this sample of U.S. soldiers and, pending future research, is likely to have utility for other healthy occupational groups. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
[Show abstract][Hide abstract] ABSTRACT: Objectives:
We characterized trends in mental health services utilization and stigma over the course of the Afghanistan and Iraq wars among active-component US soldiers.
We evaluated trends in mental health services utilization and stigma using US Army data from the Health-Related Behavior (HRB) surveys from 2002, 2005, and 2008 (n = 12,835) and the Land Combat Study (LCS) surveys administered to soldiers annually from 2003 to 2009 and again in 2011 (n = 22,627).
HRB and LCS data suggested increased mental health services utilization and decreased stigma in US soldiers between 2002 and 2011. These trends were evident in soldiers with and without posttraumatic stress disorder (PTSD), major depressive disorder (MDD), or PTSD and MDD. Despite the improving trends, more than half of soldiers with mental health problems did not report seeking care.
Mental health services utilization increased and stigma decreased over the course of the wars in Iraq and Afghanistan. Although promising, these findings indicate that a significant proportion of US soldiers meeting criteria for PTSD or MDD do not utilize mental health services, and stigma remains a pervasive problem requiring further attention.
American Journal of Public Health 07/2014; 104(9):e1-e9. DOI:10.2105/AJPH.2014.301971 · 4.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
Limited data exist on the adequacy of treatment for posttraumatic stress disorder (PTSD) after combat deployment. This study assessed the percentage of soldiers in need of PTSD treatment, the percentage receiving minimally adequate care, and reasons for dropping out of care.
Data came from two sources: a population-based cohort of 45,462 soldiers who completed the Post-Deployment Health Assessment and a cross-sectional survey of 2,420 infantry soldiers after returning from Afghanistan (75% response rate).
Of 4,674 cohort soldiers referred to mental health care at a military treatment facility, 75% followed up with this referral. However, of 2,230 soldiers who received a PTSD diagnosis within 90 days of return from Afghanistan, 22% had only one mental health care visit and 41% received minimally adequate care (eight or more encounters in 12 months). Of 229 surveyed soldiers who screened positive for PTSD (PTSD Checklist score ≥50), 48% reported receiving mental health treatment in the prior six months at any health care facility. Of those receiving treatment, the median number of visits in six months was four; 22% had only one visit, 52% received minimally adequate care (four or more visits in six months), and 24% dropped out of care. Reported reasons for dropout included soldiers feeling they could handle problems on their own, work interference, insufficient time with the mental health professional, stigma, treatment ineffectiveness, confidentiality concerns, or discomfort with how the professional interacted.
Treatment reach for PTSD after deployment remains low to moderate, with a high percentage of soldiers not accessing care or not receiving adequate treatment. This study represents a call to action to validate interventions to improve treatment engagement and retention.
[Show abstract][Hide abstract] ABSTRACT: This study examined the association between specific combat experiences and postdeployment hazardous drinking patterns on selected military populations that are considered high risk, such as personnel belonging to U.S. Army Special Operations Forces. Data collection were conducted in a 5-year span in which 1,323 Special Operations Forces Soldiers were surveyed anonymously from 3 to 6 months after returning from deployment to Iraq/Afghanistan regarding their combat experiences and mental health. Combat items were independently analyzed and placed into the following categories: (1) Fighting, (2) Killing, (3) Threat to oneself, (4) Death/Injury of others, and (5) Atrocities. Alcohol misuse was measured using the Alcohol Use Disorders Identification Test-Consumption. Of the Soldiers sampled, 15% (N = 201) screened positive for alcohol misuse 3 to 6 months postdeployment. Combat experiences relating to fighting, threat to oneself, and atrocities were significantly related to alcohol misuse when analyzed individually. However, when factors were analyzed simultaneously, combat experiences in the fighting category were significantly associated with a positive screen for alcohol misuse. In conclusion, Soldiers belonging to certain elite combat units are significantly more likely to screen positive for alcohol misuse if they are exposed to specific types of fighting combat experiences versus any other type of combat exposure.
[Show abstract][Hide abstract] ABSTRACT: Research of military personnel who deployed to the conflicts in Iraq or Afghanistan has suggested that there are differences in mental health outcomes between UK and US military personnel.
To compare the prevalence of post-traumatic stress disorder (PTSD), hazardous alcohol consumption, aggressive behaviour and multiple physical symptoms in US and UK military personnel deployed to Iraq.
Data were from one US (n = 1560) and one UK (n = 313) study of post-deployment military health of army personnel who had deployed to Iraq during 2007-2008. Analyses were stratified by high- and low-combat exposure.
Significant differences in combat exposure and sociodemographics were observed between US and UK personnel; controlling for these variables accounted for the difference in prevalence of PTSD, but not in the total symptom level scores. Levels of hazardous alcohol consumption (low-combat exposure: odds ratio (OR) = 0.13, 95% CI 0.07-0.21; high-combat exposure: OR = 0.23, 95% CI 0.14-0.39) and aggression (low-combat exposure: OR = 0.36, 95% CI 0.19-0.68) were significantly lower in US compared with UK personnel. There was no difference in multiple physical symptoms.
Differences in self-reported combat exposures explain most of the differences in reported prevalence of PTSD. Adjusting for self-reported combat exposures and sociodemographics did not explain differences in hazardous alcohol consumption or aggression.
The British journal of psychiatry: the journal of mental science 01/2014; 204(3). DOI:10.1192/bjp.bp.113.129569 · 7.99 Impact Factor