Michael E Clark’s research while affiliated with University of South Florida and other places

This study aimed to (1) identify the prevalence and severity of pain and psychiatric comorbidities among personnel who had been deployed during Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) and (2) assess whether the Department of Veterans Affairs (VA) Polytrauma System of Care and an OIF/OEF/OND registry reflect real differences among patients. Participants (N = 359) were recruited from two VA hospitals. They completed a clinical interview, structured diagnostic interview, and self-report measures. Results indicated pain was the most common complaint, with 87% experiencing pain during the prior week and 56% reporting moderate or severe pain. Eighty percent of participants met criteria for at least one of seven assessed comorbid problems (moderate or severe pain, postconcussional disorder, posttraumatic stress disorder [PTSD], anxiety disorder, mood disorder, substance use disorder, psychosis), and 59 percent met criteria for two or more problems. PTSD and postconcussional disorder rarely occurred in the absence of pain or other comorbidities (0.3% and 0%, respectively). The Polytrauma group had more comorbid psychiatric conditions (χ2 = 48.67, p< 0.05) and reported greater severity of symptoms (p < 0.05) than the Registry group. This study confirmed the high prevalence of pain and concurrent mental health problems among personnel returning from military deployment. © 2016, Journal of Rehabilitation Research and Development. All rights reserved.

Objectives: Optimal depression screening necessitates measurement tools that are valid across varied populations and in the presence of comorbidities. Methods: This study assessed the test properties of two versions of the Center for Epidemiologic Studies Depression scale against psychiatric diagnoses established by the Mini International Neuropsychiatric Interview among a clinical sample of US Veterans deployed during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. Participants (N = 359) recruited from two Department of Veterans Affairs hospitals completed a clinical interview, structured diagnostic interview, and self-reported measures. Results: Based on diagnostic interview and the Diagnostic and Statistical Manual of Mental Disorders 4th Edition criteria, 29.5% of the sample met diagnostic criteria for major depressive disorder and 26.5% met diagnostic criteria for post-traumatic stress disorder. Both Center for Epidemiologic Studies Depression-20 and Center for Epidemiologic Studies Depression-10 scales performed well and almost identically against the Mini International Neuropsychiatric Interview-major depressive disorder in identifying Veterans with major depressive disorder (Center for Epidemiologic Studies Depression-20 area under the Receiver Operating Characteristic curve 91%; Center for Epidemiologic Studies Depression-10 area under the ROC curve 90%). Overall, higher cut points for the Center for Epidemiologic Studies Depression scales performed better in correctly identifying true positives and true negatives for major depressive disorder (Center for Epidemiologic Studies Depression-20 cut point 18+ sensitivity 92% specificity 72%; Center for Epidemiologic Studies Depression-10 cut point 10+ sensitivity 92% specificity 69%). Conclusions: The specificity of the Center for Epidemiologic Studies Depression scales was poor among Veterans with co-occurring post-traumatic stress disorder (13% and 16%). Veterans with post-traumatic stress disorder who have a positive depression screen should have a more thorough assessment of mental health symptoms and comorbidities, rather than immediate diagnosis of and treatment for depression.

Background: Veterans and active duty service members returning from Operation New Dawn and those having returned from Operations Iraqi and Enduring Freedom frequently report the presence of overlapping, co-morbid symptom clusters consisting of chronic pain, mild cognitive complaints, and posttraumatic stress symptoms/disorder or mood disturbance. This presentation has been called Post-deployment Multi-symptom Disorder (PMD) and its implications not only impact various functional domains, but have also influenced a system/continuum of care to rise to meet the challenges of treating PMD. This continuum is based on innovation informed by evidence-based therapies, systemic limitations, and a focus on functional improvement rather than diagnostic classification. Objective: The purpose of this paper is to describe the symptomatic, functional and systemic challenges inherent to PMD conceptualization and treatment. Method: The constituent clusters of PMD are defined and exemplified, its functional impact is illustrated, and a continuum of care at a large southeastern Veterans Affairs (VA) hospital offering an interdisciplinary approach to integrated rehabilitation is described. Three case examples are provided that that underscore the importance of vocation for improved behavioral health and quality of life. Conclusion: The case examples demonstrate how vocational rehabilitation services are an integral component of PMD treatment.}

The primary aim of this study was to assess smoking characteristics and cessation motivation prior to and after initiation of multidisciplinary chronic pain treatment. A secondary aim was to identify predictors of cessation motivation among smokers initiating treatment for chronic pain. We used a prospective, nonrandomized, repeated measures design. The study was conducted in a multidisciplinary specialty pain treatment program at a veterans hospital. Smokers (N = 90) referred to a multidisciplinary pain program for the treatment of chronic pain. Patients completed questionnaires assessing pain-related and smoking-related factors prior to (baseline) and 8 weeks post (follow-up) specialty pain treatment initiation. Primary outcome measures were the Contemplation Ladder and the Stages of Change (SOC) algorithm. At baseline, patients reported moderate levels of cessation motivation, and 69% were in the contemplation stage or higher on the SOC. Motivation to quit smoking was higher at follow-up compared with baseline on both continuous, t(89) = 2.11, P < 0.05, and stage-based, z = 3.69, P < 0.01, measures. At follow-up, participants reported greater interest in receiving cessation interventions, and 7.8% of patients had quit smoking. Pain-related predictors of motivation (e.g., pain intensity) were subsumed by more general predictors (e.g., nicotine dependence). Patients in this sample were more motivated to quit smoking a few weeks after, as compared with before initiating specialty pain treatment. Future research into pain-specific predictors of cessation motivation is warranted to inform the development of interventions that address pain patients' unique needs.

The U.S. Department of Veterans Affairs (VA) implemented the Polytrauma System of Care to meet the health care needs of military and veterans with multiple injuries returning from combat operations in Afghanistan and Iraq. Studies are needed to systematically assess barriers to use of comprehensive and exclusive VA healthcare services from the perspective of veterans with polytrauma and with other complex health outcomes following their service in Afghanistan and Iraq. These perspectives can inform policy with regard to the optimal delivery of care to returning veterans. We studied combat veterans (n = 359) from two polytrauma rehabilitation centers using structured clinical interviews and qualitative open-ended questions, augmented with data collected from electronic health records. Our outcomes included several measures of exclusive utilization of VA care with our primary exposure as reported access barriers to care. Nearly two thirds of the veterans reported one or more barriers to their exclusive use of VA healthcare services. These barriers predicted differences in exclusive use of VA healthcare services. Experiencing any barriers doubled the returnees' odds of not using VA exclusively, the geographic distance to VA barrier resulted in a 7 fold increase in the returnees odds of not using VA, and reporting a wait time barrier doubled the returnee's odds of not using VA. There were no striking differences in access barriers for veterans with polytrauma compared to other returning veterans, suggesting the barriers may be uniform barriers that predict differences in using the VA exclusively for health care. This study provides an initial description of utilization of VA polytrauma rehabilitation and other medical care for veteran returnees from all military services who were involved in combat operations in Afghanistan or Iraq. Our findings indicate that these veterans reported important stigmatization and barriers to receiving services exclusively from the VA, including mutable health delivery system factors.

The co-occurrence of chronic pain and traumatic brain injury (TBI) are 2 of the most common concerns among the Operations Enduring Freedom and Iraqi Freedom population and present unique challenges for evaluation and treatment. Previous research suggests that almost half the cohort report clinically significant pain, while up to 1 in 4 experiences some form of TBI. There is limited information regarding how TBI affects the presence and course of pain, and how pain impacts TBI and its symptoms. The present paper provides an overview of the range and degree of TBIs as well as a brief summary of current knowledge regarding the interaction between chronic pain and TBI, particularly in light of the numerous variables impacting it. Information on ways to best assess for and treat pain in the TBI population, including in those with multiple system injuries or associated affective symptoms, is provided. In addition, several innovative approaches for addressing the needs of this complex cohort of patients are described, which may stimulate further research and clinical innovation for this important subgroup.

Military Psychologists' Desk Reference is the authoritative guide in the field of military mental health, covering in a clear and concise manner the depth and breadth of this expanding area at a pivotal and relevant time. It brings together the field's top experts to provide concise and targeted reviews of the most salient aspects of military mental health and present the material in an easily digestible manner. It covers important topics, including military culture, working with Special Operations Forces, professional issues and ethical challenges, women in combat, posttraumatic stress, anxiety and sleep disorders, psychologists' involvement in interrogations, and how to build and sustain a resilient Force.

The abuse of prescription opioid analgesics has increased dramatically in the last ten years. An overview of the scope and response to the current problems, the numerous challenges inherent in the management of pain and opioid use, as well as recommendations for enhanced outcomes in the future are reviewed.

The purpose of this paper is to review the rationale for concurrent, evidence-based treatment of chronic pain and posttraumatic stress disorder (PTSD). To meet this end, we review pertinent definitions and extant theories related to the two conditions and their correlations with each other. We then synthesize theoretical components into a proposal of a comprehensive conceptual framework for understanding the relationship and clinical complexity of overlapping chronic pain and PTSD. We conclude with an example of an integrated treatment model designed specifically to address a fundamental factor associated with pain and PTSD: avoidance.

Objectives: Although the efficacy of interdisciplinary treatment for chronic noncancer pain has been well-established in the literature, there is limited research examining interdisciplinary programs that require opioid cessation. As the long-term use of opioid analgesics remains controversial, further investigation is warranted. The aim of this study was to evaluate the associations between opioid cessation and subsequent multidomain treatment outcomes among veterans admitted to a pain rehabilitation program at a large Veterans Affairs tertiary care hospital in the southeastern United States. Methods: A retrospective design examined the medical records of 705 consecutive admissions comparing those using opioids at admission with those who were not. Participants taking opioids agreed to taper off of these medications using a "pain cocktail" approach; otherwise patients received identical treatment. Outcome measures were administered at program admission and discharge. Results: Repeated measures analyses were used to compare responses across time. Those who completed the program (n=600) demonstrated improvement in all outcome measures from admission to discharge, and the opioid group improved as much or more than the nonopioid group on all measures despite opioid cessation during treatment. Discussion: Results indicated that both groups experienced significant improvement on outcome measures, and that opioid analgesic use at admission had no discernible impact on treatment outcome in this large sample of veterans with moderate to severe chronic pain syndrome. The clinical implications of these findings for long-term chronic pain treatment, in light of the risks associated with opioid analgesics, are discussed.