Charles W Hoge

Walter Reed Army Institute of Research, Silver Spring, Maryland, United States

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Publications (113)814.05 Total impact

  • Charles W Hoge, Christopher H Warner
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    ABSTRACT: Having an accurate estimate of the prevalence of posttraumatic stress disorder (PTSD) is critically important for projecting health care needs for veterans now and in coming years. However, prevalence studies in US veterans have produced widely varying estimates, due in large part to lack of representative samples of the entire population, including those who deployed to war zones as well as the large proportion with service not involving war zone deployment. The article by Wisco et al in this issue of the Journal of Clinical Psychiatry provides the most comprehensive estimate to date of PTSD prevalence in a national veteran sample, as well as other important findings on trauma exposure, risk factors, and comorbidities useful to clinicians, researchers, and health care administrators. © Copyright 2014 Physicians Postgraduate Press, Inc.
    The Journal of clinical psychiatry. 12/2014; 75(12):e1439-41.
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    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; · 2.84 Impact Factor
  • Charles W Hoge, Wayne B Jonas
    JAMA Internal Medicine 11/2014; · 13.25 Impact Factor
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    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. Methods. 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. Results. 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. Conclusions. Our findings highlight opportunities to improve access to timely, quality treatment for service members and their families. (Journal of Psychiatric Practice 2014;20:448-459).
    Journal of psychiatric practice. 11/2014; 20(6):448-59.
  • Charles W Hoge, Carl A Castro
    JAMA. 10/2014; 312(16):1685-6.
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    ABSTRACT: Background 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. Methods We compared the new 20-item PCL, mapped to DSM-5 (PCL-5), with the original validated 17-item specific stressor version (PCL-S) in 1822 US infantry soldiers, including 946 soldiers who had been deployed to Iraq or Afghanistan. Surveys were administered in November, 2013. Soldiers alternately received either of two surveys that were identical except for the order of the two PCL versions (911 per group). Standardised scales measured major depression, generalised anxiety, alcohol misuse, and functional impairment. Results In analysis of all soldiers, 224 (13%) screened positive for PTSD by DSM-IV-TR criteria and 216 (12%) screened positive by DSM-5 criteria (κ 0·67). In soldiers exposed to combat, 177 (19%) screened positive by DSM-IV-TR and 165 (18%) screened positive by DSM-5 criteria (0·66). However, of 221 soldiers with complete data who met DSM-IV-TR criteria, 67 (30%) did not meet DSM-5 criteria, and 59 additional soldiers met only DSM-5 criteria. PCL-5 scores from 15–38 performed similarly to PCL-S scores of 30–50; a PCL-5 score of 38 gave optimum agreement with a PCL-S of 50. The two definitions showed nearly identical association with other psychiatric disorders and functional impairment. Conclusions Our findings showed the PCL-5 to be equivalent to the validated PCL-S. However, the new PTSD symptom criteria do not seem to have greater clinical utility, and a high percentage of soldiers who met criteria by one definition did not meet the other criteria. Clinicians need to consider how to manage discordant outcomes, particularly for service members and veterans with PTSD who no longer meet criteria under DSM-5. Funding US Army Military Operational Medicine Research Program (MOMRP), Fort Detrick, MD.
    The Lancet Psychiatry 09/2014;
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    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. · 3.05 Impact Factor
  • JAMA Psychiatry 08/2014; 71(8):965-966. · 12.01 Impact Factor
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    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).
    Psychological Services 08/2014; 11(3):254-64. · 1.08 Impact Factor
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    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. Methods. 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). Results. 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. Conclusions. 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. (Am J Public Health. Published online ahead of print July 17, 2014: e1-e9. doi:10.2105/AJPH.2014.301971).
    American Journal of Public Health 07/2014; · 4.23 Impact Factor
  • JAMA Internal Medicine 06/2014; · 13.25 Impact Factor
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    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. METHODS 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). RESULTS 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. CONCLUSIONS 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.
    Psychiatric services (Washington, D.C.) 05/2014; · 2.81 Impact Factor
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    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; · 6.62 Impact Factor
  • JAMA The Journal of the American Medical Association 12/2013; 310(23):2565-2566. · 29.98 Impact Factor
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    ABSTRACT: Posttraumatic stress disorder (PTSD) occurs in an estimated 8% of men and 20% of women who are exposed to traumatic events. PTSD is a trauma- and stress-related disorder associated with significant psychosocial morbidity, substance abuse, and other negative physical health outcomes. The hallmarks of PTSD include exposure to a traumatic event; reexperiencing the event or intrusion symptoms; avoidance of people, places, or things that serve as a reminder of the trauma; negative mood and thoughts associated with the trauma; and chronic hyperarousal symptoms. Self-report questionnaires can assist clinicians in identifying anxiety problems associated with traumatic events. For patients who meet criteria for PTSD, trauma-focused psychotherapy and pharmacotherapy improve symptoms. Benzodiazepines and atypical antipsychotics are not recommended because studies have shown that adverse effects outweigh potential health benefits. Primary care physicians should monitor patients with PTSD for comorbid conditions such as substance abuse, mood disorders, and suicidality, and should refer patients to behavioral health specialists and support groups when appropriate.
    American family physician 12/2013; 88(12):827-34. · 1.82 Impact Factor
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    ABSTRACT: Objective: To identify the extent to which evidence-based psychotherapy (EBP) and psychopharmacologic treatments for posttraumatic stress disorder (PTSD) are provided to U.S. service members in routine practice, and the degree to which they are consistent with evidence-based treatment guidelines. Method: We surveyed the majority of Army behavioral health providers (n = 2,310); surveys were obtained from 543 (26%). These clinicians reported clinical data on a total sample of 399 service member patients. Of these patients, 110 (28%) had a reported PTSD diagnosis. Data were weighted to account for sampling design and nonresponses. Results: Army providers reported 86% of patients with PTSD received evidence-based psychotherapy (EBP) for PTSD. As formal training hours in EBPs increased, reported use of EBPs significantly increased. Although EBPs for PTSD were reported to be widely used, clinicians who deliver EBP frequently reported not adhering to all core procedures recommended in treatment manuals; less than half reported using all the manualized core EBP techniques. Conclusions: Further research is necessary to understand why clinicians modify EBP treatments, and what impact this has on treatment outcomes. More data regarding the implications for treatment effectiveness and the role of clinical context, patient preferences, and clinical decision-making in adapting EBPs could help inform training efforts and the ways that these treatments may be better adapted for the military.
    Psychiatry Interpersonal & Biological Processes 12/2013; 76(4):336-48. · 3.18 Impact Factor
  • Comprehensive Psychiatry 11/2013; 54(8):e23. · 2.26 Impact Factor
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    ABSTRACT: Beginning in 2005, the incidence of suicide deaths in the US military began to sharply increase. Unique stressors, such as combat deployments, have been assumed to underlie the increasing incidence. Previous military suicide studies, however, have relied on case series and cross-sectional investigations and have not linked data during service with postservice periods. To prospectively identify and quantify risk factors associated with suicide in current and former US military personnel including demographic, military, mental health, behavioral, and deployment characteristics. Prospective longitudinal study with accrual and assessment of participants in 2001, 2004, and 2007. Questionnaire data were linked with the National Death Index and the Department of Defense Medical Mortality Registry through December 31, 2008. Participants were current and former US military personnel from all service branches, including active and Reserve/National Guard, who were included in the Millennium Cohort Study (N = 151,560). Death by suicide captured by the National Death Index and the Department of Defense Medical Mortality Registry. Through the end of 2008, findings were 83 suicides in 707,493 person-years of follow-up (11.73/100,000 person-years [95% CI, 9.21-14.26]). In Cox models adjusted for age and sex, factors significantly associated with increased risk of suicide included male sex, depression, manic-depressive disorder, heavy or binge drinking, and alcohol-related problems. None of the deployment-related factors (combat experience, cumulative days deployed, or number of deployments) were associated with increased suicide risk in any of the models. In multivariable Cox models, individuals with increased risk for suicide were men (hazard ratio [HR], 2.14; 95% CI, 1.17-3.92; P = .01; attributable risk [AR], 3.5 cases/10,000 persons), and those with depression (HR, 1.96; 95% CI, 1.05-3.64; P = .03; AR, 6.9/10,000 persons), manic-depressive disorder (HR, 4.35; 95% CI, 1.56-12.09; P = .005; AR, 35.6/10,000 persons), or alcohol-related problems (HR, 2.56; 95% CI, 1.56-4.18; P <.001; AR, 7.7/10,000 persons). A nested, matched case-control analysis using 20:1 control participants per case confirmed these findings. In this sample of current and former military personnel observed July 1, 2001-December 31, 2008, suicide risk was independently associated with male sex and mental disorders but not with military-specific variables. These findings may inform approaches to mitigating suicide risk in this population.
    JAMA The Journal of the American Medical Association 08/2013; 310(5):496-506. · 29.98 Impact Factor
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    ABSTRACT: Research involving military service members has shown a strong relationship between combat experiences and increased risk for posttraumatic stress disorder (PTSD) and other mental health problems. Comparatively little research has examined the relationship between combat experiences, PTSD, aggression, and unethical conduct on the battlefield, although news stories sometimes suggest links between unethical conduct and disorders such as PTSD. This study systematically examined whether unethical conduct is a proxy for aggression and whether specific combat experiences and PTSD are independently associated with unethical behavior. The results of this study indicate that aggression (β = 0.30) and specific combat experiences (particularly, witnessing war atrocities [β = 0.14] and fighting [β = 0.13]) are much more strongly associated with unethical conduct than is PTSD (β = 0.04).
    The Journal of nervous and mental disease 04/2013; 201(4):259-65. · 1.81 Impact Factor
  • Charles W Hoge, Carl A Castro
    JAMA The Journal of the American Medical Association 08/2012; 308(7):671-2. · 29.98 Impact Factor

Publication Stats

5k Citations
814.05 Total Impact Points


  • 2002–2014
    • Walter Reed Army Institute of Research
      • Center for Military Psychiatry and Neuroscience Research
      Silver Spring, Maryland, United States
    • Walter Reed National Military Medical Center
      Washington, Washington, D.C., United States
  • 2013
    • Naval Health Research Center
      San Diego, California, United States
  • 2010–2011
    • Uniformed Services University of the Health Sciences
      • Department of Psychiatry
      Bethesda, MD, United States
  • 2002–2011
    • United States Army
      • Department of Behavioral Health Sciences
      Washington, West Virginia, United States
  • 2009–2010
    • George Washington University
      Washington, Washington, D.C., United States