Karen H Seal

University of California, San Francisco, San Francisco, California, United States

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Publications (65)356.95 Total impact

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    ABSTRACT: Suicide rates among U.S. military personnel and veterans are a public health concern, and those with mental health conditions are at particular risk. We examined demographic, military, temporal, and diagnostic associations with suicidality in veterans. We conducted a population-based, retrospective cohort study of all Iraq and Afghanistan war veterans who screened positive for posttraumatic stress disorder (PTSD) and/or depression, received a suicide risk assessment, and endorsed hopelessness about the present or future after their last deployment and between January 1, 2010 and June 29, 2014 (N = 45,741). We used bivariate and multivariate logistic regression analyses to examine variables associated with having endorsed suicidal thoughts and a plan. Multiple factors were associated with suicidality outcomes, including longer time from last deployment to screening (proxy for time to seeking VA care), an alcohol use disorder diagnosis, further distance from VA (rurality), and being active duty during military service. Hispanic veterans were at decreased risk of having suicidal ideation and a plan, compared to their white counterparts. In high-risk veterans, some of the strongest associations with suicidality were with modifiable risk factors, including time to VA care and alcohol use disorder diagnoses. Promising avenues for suicide prevention efforts can include early engagement/intervention strategies with a focus on amelioration of high-risk drinking. Published by Elsevier Ltd.
    Journal of Psychiatric Research 09/2015; 68:120-124. DOI:10.1016/j.jpsychires.2015.06.013 · 4.09 Impact Factor
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    ABSTRACT: Veterans who served in Operation Enduring Freedom (OEF; predominantly in Afghanistan) and Operations Iraqi Freedom and New Dawn (OIF and OND; predominantly in Iraq) and are enrolled in the VA are comprised of a growing cohort of women and higher proportions of racial/ethnic minorities than civilians. To compare rates of mental health disorders by race/ethnicity and gender for this diverse cohort, we conducted a retrospective analysis of existing records from OEF/OIF/OND veterans who were seen at the VA 10/7/01-8/1/2013 (N=792,663). We found that race/ethnicity was related to diagnoses of mental health disorders. Asian/Pacific Islanders (A/PIs) were diagnosed with all disorders at lower rates than whites, and American Indian/Alaska Native (AI/AN) males were diagnosed with most disorders at higher rates than white males. Research is needed to identify contributing factors to differential rates of diagnoses based on race/ethnicity and gender. A/PIs and AI/ANs have unique patterns of mental health diagnoses indicating they should be considered separately to present a comprehensive picture of veteran mental health. Published by Elsevier Ireland Ltd.
    08/2015; DOI:10.1016/j.psychres.2015.08.013
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    ABSTRACT: Antipsychotic medications have been increasingly prescribed for off-label uses, including treatment of posttraumatic stress disorder (PTSD). Given limited knowledge about their use in returning Iraq and Afghanistan veterans with PTSD, we explored rates of antipsychotic use in this population and correlations with sociodemographic, military service, and psychiatric factors. Iraq and Afghanistan veterans with a PTSD diagnosis based on ICD-9-CM codes enrolled in Veterans Administration care between January 1, 2007, and September 30, 2011, were followed through September 30, 2012. Patients with a comorbid diagnosis of schizophrenia or bipolar disorder were excluded. Poisson regression models evaluated factors associated with prescriptions for antipsychotic versus other psychiatric medications (primary outcome). The mean age of our study population was 29.3 years, and 9.4% were women. Of 186,460 veterans with PTSD diagnoses examined, 19.9% received no psychiatric medications, and the remainder received psychiatric medications that excluded (61.2%) or included (18.9%) antipsychotics. In adjusted models, several factors were independently associated with antipsychotic use, including male sex (adjusted relative risk = 1.25; 95% CI, 1.20-1.30) and enlisted rank (1.44; 95% CI, 1.35-1.53). Increased likelihood of antipsychotic prescribing was associated with suicidal ideation (4.77; 95% CI, 4.59-4.95) and comorbid psychiatric diagnoses including personality disorder (4.27; 95% CI, 4.09-4.46), drug use disorder (3.56; 95% CI, 3.43-3.69), and alcohol use disorder (2.75; 95% CI, 2.65-2.84). A substantial minority of Iraq and Afghanistan veterans diagnosed with PTSD received antipsychotics. Male veterans, those of enlisted rank, and those with suicidal ideation and psychiatric comorbidities were more likely to receive antipsychotics than other types of psychiatric medications. Providers should be cautious about antipsychotic use, given their known metabolic risks and questionable benefits for PTSD. © Copyright 2015 Physicians Postgraduate Press, Inc.
    The Journal of Clinical Psychiatry 03/2015; DOI:10.4088/JCP.13m08857 · 5.14 Impact Factor
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    ABSTRACT: Objective: This study examined demographic, military, temporal, and logistic variables associated with improvement of posttraumatic stress disorder (PTSD) among Iraq and Afghanistan veterans who received mental health outpatient treatment from the U.S. Department of Veterans Affairs (VA) health care system. The authors sought to determine whether time between last deployment and initiating mental health treatment was associated with a lack of improvement in PTSD symptoms. Methods: The authors conducted a retrospective analysis of existing medical records of Iraq and Afghanistan veterans who enrolled in VA health care, received a postdeployment PTSD diagnosis, and initiated treatment for one or more mental health problems between October 1, 2007, and December 31, 2011, and whose records contained results of PTSD screening at the start of treatment and approximately one year later (N=39,690). Results: At the start of treatment, 75% of veterans diagnosed as having PTSD had a positive PTSD screen. At follow-up, 27% of those with a positive screen at baseline had improved, and 43% of those with a negative screen at baseline remained negative. A negative PTSD screen at follow-up was associated with female gender, older age, white race, having never married, officer rank, non-Army service, closer proximity to the nearest VA facility, and earlier initiation of treatment after the end of the last deployment. Conclusions: Interventions to reduce delays in initiating mental health treatment may improve veterans' treatment response. Further studies are needed to test interventions for particular veteran subgroups who were less likely than others to improve with treatment.
    Psychiatric services (Washington, D.C.) 08/2014; 65(12). DOI:10.1176/appi.ps.201300453 · 1.99 Impact Factor
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    ABSTRACT: Background Women experience chronic pain and use pain-related health care at higher rates than men. It is not known whether the pain-related health care female veterans receive is consistent with clinical practice guideline recommendations or whether receipt of this care differs between men and women.Objective The aim of this study was to identify whether sex differences in chronic pain management care exist for patients served by the Veterans Health Administration (VHA).DesignData on patient demographics, diagnostic criteria, and health care utilization were extracted from VHA administrative databases for fiscal year 2010 (FY10).PatientsPatients in this study included all VHA patients (excluding metastatic cancer patients) who received more than 90 days of a short-acting opioid medication or a long-acting opioid medication prescription in FY10 study.MeasuresMultilevel logistic regressions were conducted to identify sex differences in receipt of guideline-recommended chronic pain management.ResultsA total of 480,809 patients met inclusion criteria. Female patients were more likely to receive most measures of guideline-recommended care for chronic pain including mental health assessments, psychotherapy, rehabilitation therapy, and pharmacy reconciliation. However, women were more likely to receive concurrent sedative prescriptions, which is inconsistent with guideline recommendations. Most of the observed sex differences persisted after controlling for key demographic and diagnostic differences.Conclusions Findings suggest that female VHA patients are more likely to receive an array of pain management practices than male patients, including both contraindicated and recommended polypharmacy. Quality improvement efforts to address underutilization of mental health and rehabilitative services for pain by male patients and polypharmacy in female patients should be considered.
    Pain Medicine 08/2014; 16(1). DOI:10.1111/pme.12501 · 2.24 Impact Factor
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    ABSTRACT: OBJECTIVE To describe returning veterans’ transition experience from military to civilian life and to educate health care providers about culture-centered communication that promotes readjustment to civilian life. METHODS Qualitative, in-depth, semi-structured interviews with 17 male and 14 female Iraq and Afghanistan veterans were audio recorded, transcribed verbatim, and analyzed using Grounded Practical Theory. RESULTS Veterans described disorientation when returning to civilian life after deployment. Veterans’ experiences resulted from an underlying tension between military and civilian identities consistent with reverse culture shock. Participants described challenges and strategies for managing readjustment stress across three domains: intrapersonal, professional/educational, and interpersonal. CONCLUSIONS To provide patient-centered care to returning Iraq and Afghanistan veterans, health care providers must be attuned to medical, psychological, and social challenges of the readjustment experience, including reverse culture shock. Culture-centered communication may help veterans integrate positive aspects of military and civilian identities, which may promote full reintegration into civilian life. PRACTICE IMPLICATIONS Health care providers may promote culture-centered interactions by asking veterans to reflect about their readjustment experiences. By actively eliciting challenges and helping veterans’ to identify possible solutions, health care providers may help veterans integrate military and civilian identities through an increased therapeutic alliance and social support throughout the readjustment process.
    Patient Education and Counseling 06/2014; 95(3). DOI:10.1016/j.pec.2014.03.016 · 2.60 Impact Factor
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    ABSTRACT: Background Posttraumatic stress disorder (PTSD) is associated with endocrine and immune abnormalities that could increase risk for autoimmune disorders. However, little is known about the risk for autoimmune disorders among individuals with PTSD. Methods We conducted a retrospective cohort study of 666,269 Iraq and Afghanistan veterans under age 55 who were enrolled in the Department of Veterans Affairs (VA) healthcare system between October 7, 2001 and March 31, 2011. Generalized linear models were used to examine if PTSD, other psychiatric disorders, and military sexual trauma exposure (MST) increase risk for autoimmune disorders, including thyroiditis, inflammatory bowel disease, rheumatoid arthritis, multiple sclerosis, and lupus erythematosus, adjusting for age, gender, race, and primary care visits. Results PTSD was diagnosed in 203,766 (30.6%) veterans, and psychiatric disorders other than PTSD were diagnosed in an additional 129,704 (19.5%) veterans. Veterans diagnosed with PTSD had significantly higher adjusted relative risk (ARR) for diagnosis with any of the autoimmune disorders alone or in combination compared to veterans with no psychiatric diagnoses (ARR = 2.00, 95% CI, 1.91, 2.09), and compared to veterans diagnosed with psychiatric disorders other than PTSD (ARR = 1.51, 95% CI, 1.43, 1.59, p < .001). The magnitude of the PTSD-related increase in risk for autoimmune disorders was similar in women and men, and MST was independently associated with increased risk in both women and men. Conclusions Trauma exposure and PTSD may increase risk for autoimmune disorders. Altered immune function, lifestyle factors, or shared etiology may underlie this association.
    Biological Psychiatry 06/2014; 77(4). DOI:10.1016/j.biopsych.2014.06.015 · 10.25 Impact Factor
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    ABSTRACT: BACKGROUND: Gastrointestinal disorders (GIDs) represent a large public health burden, affecting an estimated 60-70 million Americans annually. Our goal was to examine the relationship between GID and the most common mental health disorders in a national group of newly returning veterans. We also evaluated gender differences in the association of mental health disorders and GID. METHODS: We utilized a retrospective, longitudinal cohort analysis of veterans' health records. Participants were 603,221 Iraq and Afghanistan veterans who were new users of VA healthcare from October 7, 2001 (start of the war in Afghanistan) to December 31, 2010. RESULTS: The prevalence of GID in newly returning veterans was nearly 20%, and veterans with a mental health disorder were at least twice as likely to have a GID as those without mental health disorders. For women, the increased risk of all GIDs was greatest among those with depression. Among men, the increased risk of irritable bowel syndrome (IBS) was greatest among those with posttraumatic stress disorder. IBS was the GID most strongly associated with mental health conditions among both genders. CONCLUSIONS: The large proportion of newly returning veterans with GIDs and comorbid mental health diagnoses is concerning. Successful detection and treatment of GIDs associated with mental health disorders will require integrated efforts from primary care and mental health.
    Depression and Anxiety 02/2014; 31(2). DOI:10.1002/da.22072 · 4.29 Impact Factor
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    ABSTRACT: Veterans with posttraumatic stress disorder (PTSD) symptoms frequently present to primary care providers (PCPs) and are reluctant to seek out or accept referrals to specialty mental health care. Most PCPs have not been trained to assess for and manage symptoms of PTSD. Web-based programs are increasingly used for medical education, but there are no published evaluations of online PTSD trainings for PCPs. We developed a 70-min Web-based training that focused on military-related PTSD for PCPs practicing in Veterans Affairs (VA) hospitals, but was applicable to PCPs treating veterans and other trauma-exposed patients outside VA settings. The training consisted of four modules: (1) Detection and Assessment; (2) Comorbid Conditions and Related Problems; (3) Pharmacological Interventions; and (4) Psychotherapeutic Interventions. Clinical vignettes dramatized key training concepts. Seventy-three PCPs completed the training and assessments pre- and posttraining and 30 days later. Paired t tests compared change in PTSD-related knowledge and comfort with PTSD-related skills, and qualitative methods were used to summarize participant feedback. After the training, mean knowledge score improved from 46% to 75% items correct, with sustained improvement at 30 days. Thirty days posttraining, PCPs reported significantly greater comfort regarding PTSD-related skills assessed; 47% reported using training content in their clinical practice. Qualitatively, PCPs appreciated the flexibility of asynchronous, self-paced online modules, but suggested more interactive content. Given the numerous barriers to specialty mental health treatment, coupled with a preference among veterans with PTSD for accessing treatment through primary care, improving PTSD competency among PCPs may help better serve veterans' mental health needs. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
    Psychological Services 12/2013; 11(2). DOI:10.1037/a0034855 · 1.08 Impact Factor
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    ABSTRACT: To determine the prevalence and correlates of lower urinary tract symptoms (LUTS) among returned Iraq and Afghanistan veterans; in particular its association with mental health diagnoses and medication use. We performed a retrospective cohort study of Iraq and Afghanistan veterans who were new users of U.S. Department of Veterans Affairs health care. Mental health diagnoses were defined by International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) codes from medical records. LUTS was defined by ICD-9-CM code, use of prescription medication for LUTS, or procedure for LUTS. We determined the independent association of mental health diagnoses and LUTS after adjusting for sociodemographic and military service characteristics, comorbidities, and medications. Of 519,189 veterans, 88% were men and the mean age was 31.8 years (standard deviation ± 9.3). The overall prevalence of LUTS was 2.2% (11,237/519,189). Veterans with post-traumatic stress disorder (PTSD) were significantly more likely to have a LUTS diagnosis, prescription, or related procedure (3.5%) compared with veterans with no mental health diagnoses (1.3%) or a mental health diagnosis other than PTSD (3.1%, P <.001). In adjusted models, LUTS was significantly more common in veterans with PTSD with and without other mental health disorders vs those without mental health disorders (adjusted relative risk [ARR] = 2.04, 95% confidence interval [CI] = 1.94-2.15) and in veterans prescribed opioids (ARR = 2.46, 95% CI = 2.36-2.56). In this study of young returned veterans, mental health diagnoses and prescription for opioids were independently associated with increased risk of receiving a diagnosis, treatment, or procedure for LUTS. Provider awareness may improve the detection and treatment of LUTS, and improve patient care and quality of life.
    Urology 10/2013; 83(2). DOI:10.1016/j.urology.2013.08.047 · 2.13 Impact Factor
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    ABSTRACT: Little is known about follow-up care for alcohol misuse in the Veterans Affairs (VA) health care system among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans with and without alcohol use disorders (AUD) and/or posttraumatic stress disorder (PTSD). Using data from 4725 OEF/OIF VA outpatients with alcohol screening (2006-2010), we compared the prevalence of follow-up for alcohol misuse-brief intervention (BI) or referral to treatment-among patients with and without AUD and/or PTSD. Among 933 (19.7%) patients with alcohol misuse (AUDIT-C ≥5), 77.0% had AUD and/or PTSD. Rates of BI or referral for alcohol misuse were higher among patients with AUD (76.9%) and both AUD and PTSD (70.1%) compared to those with PTSD only (53.1%) and neither AUD nor PTSD (52.3%). Among OEF/OIF VA outpatients with alcohol misuse, those with AUD had higher rates of follow-up for alcohol misuse than those without, but PTSD was not associated with differential follow-up.
    Journal of substance abuse treatment 07/2013; 45(5). DOI:10.1016/j.jsat.2013.04.007 · 2.90 Impact Factor
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    ABSTRACT: Obesity is a growing public health concern and is becoming an epidemic among veterans in the post-deployment period. To explore the relationship between body mass index (BMI) and posttraumatic stress disorder (PTSD) in a large cohort of Iraq and Afghanistan veterans, and to evaluate trajectories of change in BMI over 3 years. Retrospective, longitudinal cohort analysis of veterans' health records A total of 496,722 veterans (59,790 female and 436,932 male veterans) whose height and weight were recorded at the Department of Veterans Affairs (VA) healthcare system at least once after the end of their last deployment and whose first post-deployment outpatient encounter at the VA was at least 1 year prior to the end of the study period (December 31, 2011). BMI, mental health diagnoses. Seventy-five percent of Iraq and Afghanistan veterans were either overweight or obese at baseline. Four trajectories were observed: "stable overweight" represented the largest class; followed by "stable obese;" "overweight/obese gaining;" and "obese losing." During the 3-year ascertainment period, those with PTSD and depression in particular were at the greatest risk of being either obese without weight loss or overweight or obese and continuing to gain weight. Adjustment for demographics and antipsychotic medication attenuated the relationship between BMI and certain mental health diagnoses. Although BMI trajectories were similar in men and women, some gender differences were observed. For example, the risk of being in the persistently obese class in men was highest for those with PTSD, whereas for women, the risk was highest among those with depression. The growing number of overweight or obese returning veterans is a concerning problem for clinicians who work with these patients. Successful intervention to reduce the prevalence of obesity will require integrated efforts from primary care and mental health to treat underlying mental health causes and assist with engagement in weight loss programs.
    Journal of General Internal Medicine 07/2013; 28 Suppl 2(Suppl 2):563-70. DOI:10.1007/s11606-013-2374-8 · 3.42 Impact Factor
  • Karen H Seal · Murray B Stein
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    ABSTRACT: A selective opioid receptor agonist prevents fear memory consolidation in the amygdala in a mouse model of posttraumatic stress disorder (Andero et al.).
    Science translational medicine 06/2013; 5(188):188fs22. DOI:10.1126/scitranslmed.3006635 · 14.41 Impact Factor
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    ABSTRACT: INTRODUCTION: Mental health disorders are prevalent in the United States, Iraq, and Afghanistan war veterans. Mental illness, including posttraumatic stress disorder (PTSD) with or without psychiatric medications, can increase the risk for male sexual dysfunction, threatening quality of life. AIMS: We sought to determine the prevalence and correlates of sexual dysfunction among male Iraq and Afghanistan veterans. METHODS: We performed a retrospective cohort study of 405,275 male Iraq and Afghanistan veterans who were new users of U.S. Department of Veterans Affairs healthcare from October 7, 2001 to September 30, 2009 and had 2-year follow-up. MAIN OUTCOME MEASURES: We determined the independent association of mental health diagnoses and sexual dysfunction after adjusting for sociodemographic and military service characteristics, comorbidities, and medications. RESULTS: Veterans with PTSD were more likely to have a sexual dysfunction diagnosis, be prescribed medications for sexual dysfunction, or both (10.6%), compared with veterans having a mental diagnosis other than PTSD (7.2%), or no mental health diagnosis (2.3%). In a fully adjusted model, PTSD increased the risk of sexual dysfunction by more than threefold (adjusted risk ratio = 3.61, 95% CI = 3.48-3.75). Veterans with mental health disorders, particularly PTSD, were at the highest risk of sexual dysfunction when prescribed psychiatric medications (adjusted risk ratio = 4.59, 95% CI = 4.41-4.77). CONCLUSIONS: Among U.S. combat veterans, mental health disorders, particularly PTSD, increased the risk of sexual dysfunction independent of the use of psychiatric medications. Breyer BN, Cohen BE, Bertenthal D, Rosen RC, Neylan TC, and Seal KH. Sexual dysfunction in male Iraq and Afghanistan war veterans: Association with posttraumatic stress disorder and other combat-related mental health disorders: A population-based cohort study. J Sex Med **;**:**-**.
    Journal of Sexual Medicine 05/2013; 11(1). DOI:10.1111/jsm.12201 · 3.15 Impact Factor
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    ABSTRACT: OBJECTIVE Although many risk behaviors peak during young adulthood, little is known about health risk factors and access to care. This study assessed health indicators and health care access in a national sample of young adult veterans and civilians. METHODS Data were from the 2010 Behavioral Risk Factor Surveillance System, a national telephone survey. Of 27,471 participants, ages 19-30 years, 2.2% were veterans (74.6% were male) and 97.7% were civilians (37.6% were male). Gender-stratified comparisons assessed health indicators and health care access by veteran status. Multivariate logistic regression was used to examine health indicators and health care access as a function of gender and veteran status. RESULTS In the overall sample, women were more likely than men to have insurance, to have a regular physician, and to have had a routine checkup and yet were more likely to report financial barriers to care. Women also were more likely than men to report general medical and mental distress and higher lifetime anxiety and depressive disorders, whereas men were more likely to be overweight or obese and to report tobacco use and high-risk drinking. Adjusted analyses revealed a higher likelihood of general medical distress and higher rates of lifetime anxiety disorders among veterans compared with civilians, although there were no differences between veterans and civilians regarding health care utilization and hazardous drinking. CONCLUSIONS Findings extend the literature on health care status and modifiable risk factors for young adults by identifying differences between men and women and between veterans and civilians. Interventions may need to be tailored on the bases of gender and veteran status because of several differences in mental health and general health needs.
    Psychiatric services (Washington, D.C.) 03/2013; 64(6). DOI:10.1176/appi.ps.003002012 · 1.99 Impact Factor
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    ABSTRACT: Many veterans present to Veteran Affairs (VA) care intending to seek mental health treatment for symptoms of posttraumatic stress disorder (PTSD), depression, and/or alcohol misuse, yet most subsequently underutilize mental health care. This study examined the association of readiness for change with outpatient VA mental health care utilization in 104 treatment-seeking Iraq and Afghanistan war veterans who screened positive for PTSD, depression, and/or alcohol misuse at intake. Multivariate analyses demonstrated that readiness for change assessed at intake was positively associated (Incident Rate Ratio [IRR] = 1.22) with prospective outpatient mental health care utilization with demographic factors, military characteristics, and mental health burden in the model. Results suggest that interventions that target readiness to change, such as motivational interviewing, may improve treatment utilization in veterans presenting for mental health care. 標題:伊拉克和阿富汗戰後退役軍人中,求變心態預測軍醫精神健康服務的使用率 撮要:退役軍人到軍事醫療服務(VA)尋求治療創傷後壓力症(PTSD)、抑鬱症和酗酒的精神治療,但其後大多服務使用偏低。本研究在104位伊拉克和阿富汗戰後退役求醫軍人中(全都在初次面見時篩選為有PTSD、抑鬱或酗酒者),檢視「求變心態」與VA精神科門診使用率的關係。多重變量分析指出:使用人口特徵、軍事特性和精神健康負擔在模型內,初次面見時的求變心態與繼後精神科門診使用率有正面關連(IRR = 1.22)。研究亦建議尋求精神健康治療的退役軍人的介入治療應聚焦于「求變心態」,如激勵面見等,可改善治療的使用率。 标题:伊拉克和阿富汗战后退役军人中,求变心态预测军医精神健康服务的使用率 撮要:退役军人到军事医疗服务(VA)寻求治疗创伤后压力症(PTSD)、抑郁症和酗酒的精神治疗,但其后大多服务使用偏低。本研究在104位伊拉克和阿富汗战后退役求医军人中(全都在初次面见时筛选为有PTSD、抑郁或酗酒者),检视「求变心态」与VA精神科门诊使用率的关系。多重变量分析指出:使用人口特征、军事特性和精神健康负担在模型内,初次面见时的求变心态与继后精神科门诊使用率有正面关连(IRR = 1.22)。研究亦建议寻求精神健康治疗的退役军人的介入治疗应聚焦于「求变心态」,如激励面见等,可改善治疗的使用率。
    Journal of Traumatic Stress 02/2013; 26(1). DOI:10.1002/jts.21768 · 2.72 Impact Factor
  • Shira Maguen · Erin Madden · Karen M Lau · Karen H Seal
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    ABSTRACT: We compared mental health outpatient, primary care, and emergency care service utilization among veterans screening TBI-positive (S-TBI+) versus those screening TBI-negative (S-TBI-) and described associations between TBI-related symptoms and health service utilization. Our study population consisted of 1,746 Iraq and Afghanistan veterans in VA care screened for TBI between April 1, 2007 and June 1, 2010. Rates of mental health outpatient, primary care and emergency services utilization were greater for S-TBI+ veterans compared with S-TBI- veterans, even after adjusting for mental health screen results. Irritability on the initial TBI screen was associated with increased mental health outpatient utilization rates (IRR = 1.64, 95 % CI= 1.18-2.3, p<0.01). Reports of dizziness (IRR = 1.24, 95 % CI = 1.02-1.51, p <0.05) and headaches (IRR = 1.41, 95% CI = 1.16-1.7, p < 0.001) were associated with increased primary care utilization rates. Higher utilization rates among veterans who screened positive for TBI were not better explained by screening positive for comorbid mental health problems. Knowing that certain symptoms are more strongly associated with increased utilization in certain health service domains will help to better plan for the care of returning veterans who screen positive for TBI.
    Journal of neurotrauma 01/2013; 30(13). DOI:10.1089/neu.2012.2744 · 3.97 Impact Factor
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    ABSTRACT: OBJECTIVE: Early mental health treatment after military deployment may reduce chronic mental health problems. The authors described time to and predictors of time to initiation of a first primary care visit, a first mental health outpatient visit, and minimally adequate mental health care (eight or more outpatient visits within 12 months) among veterans with psychiatric diagnoses. METHODS: The authors conducted a retrospective cohort analysis of medical records of veterans of the conflicts in Iraq and Afghanistan who enrolled in Veterans Affairs (VA) health care, had a psychiatric diagnosis, and had used primary or mental health outpatient care between October 7, 2001, and September 30, 2011 (N=314,717). RESULTS: The median time from the end of the last deployment to engagement in mental health care was over two years. More than three years postdeployment, 75% of the veterans in the VA system for at least one year had not engaged in minimally adequate mental health care. There was a median lag of nearly 7.5 years between initial mental health treatment session and initiation of minimally adequate mental health care. Men waited nearly two years longer than women to initiate minimally adequate mental health care. Younger age and minority racial or ethnic status were also associated with greater time to initial mental health outpatient visit and to minimally adequate mental health care. CONCLUSIONS: Delays in initiating and completing minimally adequate mental health care by veterans using VA services highlight the importance of attending to the timing of care, particularly among newly returning veterans.
    Psychiatric services (Washington, D.C.) 10/2012; 63(12). DOI:10.1176/appi.ps.201200051 · 1.99 Impact Factor
  • Shira Maguen · Karen M Lau · Erin Madden · Karen Seal
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    ABSTRACT: This study used factor analytic techniques to differentiate distinct from overlapping screen-based symptoms of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and depression in Iraq and Afghanistan veterans. These symptoms were derived from screen results of 1,549 veterans undergoing Department of Veterans Affairs postdeployment screening between April 2007 and January 2010. Veterans with positive TBI screens were approximately twice as likely to also screen positive for depression and PTSD (adjusted relative risks = 1.9 and 2.1, respectively). Irritability was a shared symptom between TBI and PTSD, and emotional numbing was a shared symptom between PTSD and depression. Symptoms unique to TBI included dizziness, headaches, memory problems, and light sensitivity. Four separate constructs emerged: TBI, PTSD, depression, and a fourth construct consisting of hypervigilance and sleep problems. These findings illuminate areas of overlap between TBI and common postdeployment mental health problems. Discriminating symptoms of TBI from mental health problems may facilitate diagnosis, triage to specialty care, and targeted symptom management. The emergence of a fourth factor consisting of sleep problems and hypervigilance highlights the need to attend to specific symptoms in the postdeployment screening process.
    The Journal of Rehabilitation Research and Development 10/2012; 49(7):1115-26. DOI:10.1682/JRRD.2011.02.0015 · 1.69 Impact Factor
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    ABSTRACT: An increasing number of women serve in the military and are exposed to trauma during service that can lead to mental health problems. Understanding how these mental health problems affect reproductive and physical health outcomes will inform interventions to improve care for women veterans. We analyzed national Department of Veterans Affairs (VA) data from women Iraq and Afghanistan veterans who were new users of VA healthcare from October 7, 2001, through December 31, 2010 (n = 71,504). We used ICD-9 codes to categorize veterans into five groups by mental health diagnoses (MH Dx): Those with no MH Dx, posttraumatic stress disorder (PTSD), depression, comorbid PTSD and depression, and a MH Dx other than PTSD and depression. We determined the association between mental health category and reproductive and other physical health outcomes defined by ICD-9 codes. Categories included sexually transmitted infections, other infections (e.g., urinary tract infections), pain-related conditions (e.g., dysmenorrhea and dsypareunia), and other conditions (e.g., polycystic ovarian syndrome, infertility, sexual dysfunction). Models were adjusted for sociodemographic and military service factors. There were 31,481 patients (44%) who received at least one mental health diagnosis. Women veterans with any mental health diagnosis had significantly higher prevalences of nearly all categories of reproductive and physical disease diagnoses (p < .0001 for adjusted prevalences). There was a trend of increasing prevalence of disease outcomes in women with PTSD, depression, and comorbid PTSD and depression (p for trend <.0001 for all outcomes). Iraq and Afghanistan women veterans with mental health diagnoses had significantly greater prevalences of several important reproductive and physical health diagnoses. These results provide support for VA initiatives to address mental and physical health concerns and improve comprehensive care for women veterans.
    Women s Health Issues 09/2012; 22(5):e461-71. DOI:10.1016/j.whi.2012.06.005 · 1.61 Impact Factor

Publication Stats

2k Citations
356.95 Total Impact Points

Institutions

  • 2000–2015
    • University of California, San Francisco
      • • Department of Psychiatry
      • • Department of Medicine
      • • Division of Hospital Medicine
      • • Department of Family and Community Medicine
      San Francisco, California, United States
  • 2005–2014
    • San Francisco VA Medical Center
      San Francisco, California, United States
  • 2003
    • CSU Mentor
      Long Beach, California, United States
  • 2001
    • California State University
      • Department of Medicine
      Long Beach, California, United States