Monoamine oxidase A regulates antisocial personality in whites with no history of physical abuse.

OBJECTIVE: Preclinical and human family studies clearly link monoamine oxidase A (MAOA) to aggression and antisocial personality (ASP). The 30-base pair variable number tandem repeat in the MAOA promoter regulates MAOA levels, but its effects on ASP in humans are unclear. METHODS: We evaluated the association of the variable number tandem repeat of the MAOA promoter with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, ASP disorder (ASPD) traits in a community sample of 435 participants from the Hopkins Epidemiology of Personality Disorders Study. RESULTS: We did not find an association between the activity of the MAOA allele and ASPD traits; however, among whites, when subjects with a history of childhood physical abuse were excluded, the remaining subjects with low-activity alleles had ASPD trait counts that were 41% greater than those with high-activity alleles (P < .05). CONCLUSION: The high-activity MAOA allele is protective against ASP among whites with no history of physical abuse, lending support to a link between MAOA expression and antisocial behavior.

Child neglect in Army families: a public health perspective.

Military families include 2.9 million people, with approximately 40% of all service members having at least one child. Rates of child neglect in this population have increased in recent years, but little is known about the characteristics of the neglect. To better identify targets for intervention, it is necessary that we refine our understanding of child neglect in the military. In this review, we examine definitions of child neglect and the specific definitions used by the U.S. Army. We identify domains of neglect and caregiver behaviors and affiliated. We suggest that this approach can inform prevention efforts within the Institute of Medicine's framework for preventive interventions. Understanding risk and protective factors in the military family are important to interventions for child neglect in military families.

Combat-injured service members and their families: the relationship of child distress and spouse-perceived family distress and disruption.

Combat injury in military service members affects both child and family functioning. This preliminary study examined the relationship of child distress postinjury to preinjury deployment-related family distress, injury severity, and family disruption postinjury. Child distress postinjury was assessed by reports from 41 spouses of combat-injured service members who had been hospitalized at two military tertiary care treatment centers. Families with high preinjury deployment-related family distress and high family disruption postinjury were more likely to report high child distress postinjury. Spouse-reported injury severity was unrelated to child distress. Findings suggest that early identification and intervention with combat-injured families experiencing distress and disruption may be warranted to support family and child health, regardless of injury severity.

Approach-avoidance coping conflict in a sample of burn patients at risk for posttraumatic stress disorder.

BACKGROUND: Following an acute burn injury, higher distress is consistently observed among individuals exhibiting a conflict between approach coping (e.g., processing) and avoidance coping (e.g., suppression) relative to those individuals who use only one of these methods. Study objectives were to determine if contradictory coping messages would lead to such approach-avoidance coping conflict and to determine if experiment-induced coping conflict is also associated with higher distress. METHODS: Participants (n=59 adults hospitalized with acute burn injuries) were assigned randomly to experimental conditions differing in the order in which training was provided in two ways of coping with posttrauma re-experiencing symptoms (i.e., process-then-suppress versus suppress-then-process). The primary dependent variable was coping behavior during the 24-hr posttraining period. Coping behavior was categorized as approach coping (processing), avoidance coping (suppressing), or approach-avoidance coping conflict (both) on the basis of median splits on subscales assessing these behaviors. Secondary analyses examined the relationship between this experiment-induced coping conflict and re-experiencing symptoms. RESULTS: Results indicated that participants in the process-then-suppress condition, relative to the suppress-then-process condition, were significantly more likely to exhibit approach-avoidance coping conflict (i.e., above median split on both processing and suppressing) during the next 24 hr. Furthermore, approach-avoidance coping conflict was associated with greater re-experiencing symptoms assessed via self-report and by blinded coding of recorded speech. CONCLUSIONS: It is concluded that the order of coping skill training can influence treatment outcome, success of coping methods, and overall levels of distress. therefore, training in stabilizing and calming methods should precede training in active processing following stressful life events.

Epidemiology of burn injuries II: psychiatric and behavioural perspectives.

Modern technological advances have decreased the incidence and severity of burn injuries, and medical care improvements of burn injuries have significantly increased survival rates, particularly in developed countries. Still, fire-related burn injuries are responsible for 300,000 deaths and 10 million disability-adjusted life years lost annually worldwide. The extent to which psychiatric and behavioural factors contribute to the incidence and outcomes of these tragedies has not been systematically documented, and the available data is often insufficient to reach definitive conclusions. Accordingly, this article reviews the evidence of psychiatric and behavioural risk factors and prevention opportunities for burn injuries worldwide. Psychiatric prevalence rates and risk factors for burn injuries, prevalence and risks associated with 'intentional' burn injuries (self-immolation, assault, and child maltreatment), and prevention activities targeting the general population and those with known psychiatric and behavioural risk factors are discussed. These issues are substantially interwoven with many co-occurring risk factors. While success in teasing apart the roles and contributions of these factors rests upon improving the methodology employed in future research, the nature of this entanglement increases the likelihood that successful interventions in one problem area will reap benefits in others.

Psychological distress after major burn injury.

OBJECTIVE: To track the prevalence and stability of clinically significant psychological distress and to identify potentially modifiable in-hospital symptoms predictive of long-term distress (physical, psychological, and social impairment). METHOD: We obtained data from the Burn Model Systems project, a prospective, multisite, cohort study of major burn injury survivors. The Brief Symptom Inventory (BSI) was used to assess symptoms in-hospital (n = 1232) and at 6 (n = 790), 12 (n = 645), and 24 (n = 433) months post burn. Distress was examined dimensionally (BSI's Global Severity Index (GSI)) and categorically (groups formed by dichotomizing GSI: T score > or =63). Attrition was unrelated to in-hospital GSI score. RESULTS: Significant in-hospital psychological distress occurred in 34% of the patients, and clinically significant and reliable change in symptom severity by follow-up visits occurred infrequently. Principal components analysis of in-hospital distress symptoms demonstrated "alienation" and "anxiety" factors that robustly predicted distress at 6, 12, and 24 months, controlling for correlates of baseline distress. CONCLUSIONS: This is the largest prospective, multisite, cohort study of patients with major burn injury. We found that clinically significant in-hospital psychological distress was common and tends to persist. Two structural components of in-hospital distress seemed particularly predictive of long-term distress. Research is needed to determine if early recognition and treatment of patients with in-hospital psychological distress can improve long-term outcomes.

Sleep deprivation and adverse health effects in United States Coast Guard responders to Hurricanes Katrina and Rita.

OBJECTIVE: Disaster responders are increasingly called upon to assist in various natural and manmade disasters. A critical safety concern for this population is sleep deprivation; however, there are limited published data regarding sleep deprivation and disaster responder safety. DESIGN: We expanded upon a cross-sectional study of 2695 United States Coast Guard personnel who responded to Hurricanes Katrina and Rita. Data were collected via survey on self-reported timing and location of deployment, missions performed, health effects, medical treatment sought, average nightly sleep, and other lifestyle variables. We created a 4-level sleep deprivation metric based on both average nightly reported sleep (d5hours; >5hours) and length of deployment (d2weeks; >2weeks) to examine the association between sustained sleep deprivation and illnesses, injuries, and symptoms using logistic regression to calculate odds ratios (ORs) and 95% confidence intervals. RESULTS: The strongest, statistically significant positive ORs for the highest sleep deprivation category compared with the least sleep-deprived category were for mental health and neurologic effects, specifically depression (OR=6.76), difficulty concentrating (OR=8.33), and confusion (OR=11.34), and for dehydration (OR=9.0). Injuries most strongly associated with sleep deprivation were twists, sprains, and strains (OR=6.20). Most health outcomes evaluated had monotonically increasing ORs with increasing sleep deprivation, and P tests for trend were statistically significant. CONCLUSION: Agencies deploying disaster responders should understand the risks incurred to their personnel by sustained sleep deprivation. Improved planning of response efforts to disasters can reduce the potential for sleep deprivation and lead to decreased morbidity in disaster responders.

Depressive Symptom Severity and Community Collective Efficacy following the 2004 Florida Hurricanes.

There is a lack of research investigating community-level characteristics, such as community collective efficacy, mitigating the impact of disasters on psychological health, specifically depression. We examined the association of community collective efficacy with depressive symptom severity in Florida public health workers (n = 2249) exposed to the 2004 hurricane season using a multilevel approach. Cross-sectional anonymous questionnaires were distributed electronically to all Florida Department of Health (FDOH) personnel that assessed depressive symptom severity and collective efficacy nine months after the 2004 hurricane season. Analyses were conducted at the individual level and community level using zip codes. The majority of participants were female (81.9%), and ages ranged from 20 to 78 years (median = 49 years). The majority of participants (73.4%) were European American, 12.7% were African American, and 9.2% were Hispanic. Using multilevel analysis, our data indicate that higher community-level and individual-level collective efficacy were associated with significantly lower depressive symptom severity (b = -0.09 [95% CI: -0.13, -0.04] and b = -0.09 [95% CI: -0.12, -0.06], respectively) even after adjusting for individual sociodemographic variables, community socioeconomic characteristics, individual injury/damage, and community storm damage. Lower levels of depressive symptom severity were associated with communities with high collective efficacy. Our study highlights the possible importance of programs that enrich community collective efficacy for disaster communities.

Disaster-related exposures and health effects among US Coast Guard responders to Hurricanes Katrina and Rita: a cross-sectional study.

OBJECTIVE: Disaster responders work among poorly characterized physical and psychological hazards with little understood regarding health consequences of their work. METHODS: A survey administered to 2834 US Coast Guard responders to Hurricanes Katrina and Rita provided data on exposures and health effects. Prevalence odds ratios (PORs) evaluated associations between baseline characteristics, missions, exposures, and health effects. RESULTS: Most frequent exposures were animal/insect vector (n = 1309; 46%) and floodwater (n = 817; 29%). Most frequent health effects were sunburn (n = 1119; 39%) and heat stress (n = 810; 30%). Significant positive associations were for mold exposure and sinus infection (POR = 10.39); carbon monoxide and confusion (POR = 6.27); lack of sleep and slips, trips, falls (POR = 3.34) and depression (POR = 3.01); being a Gulf-state responder and depression (POR = 3.22). CONCLUSIONS: Increasing protection for disaster responders requires provisions for adequate sleep, personal protective equipment, and access to medical and psychological support.

Posttraumatic stress disorder and community collective efficacy following the 2004 Florida hurricanes.

There is a paucity of research investigating the relationship of community-level characteristics such as collective efficacy and posttraumatic stress following disasters. We examine the association of collective efficacy with probable posttraumatic stress disorder and posttraumatic stress disorder symptom severity in Florida public health workers (n = 2249) exposed to the 2004 hurricane season using a multilevel approach. Anonymous questionnaires were distributed electronically to all Florida Department of Health personnel nine months after the 2004 hurricane season. The collected data were used to assess posttraumatic stress disorder and collective efficacy measured at both the individual and zip code levels. The majority of participants were female (80.42%), and ages ranged from 20 to 78 years (median = 49 years); 73.91% were European American, 13.25% were African American, and 8.65% were Hispanic. Using multi-level analysis, our data indicate that higher community-level and individual-level collective efficacy were associated with a lower likelihood of having posttraumatic stress disorder (OR = 0.93, CI = 0.88-0.98; and OR = 0.94, CI = 0.92-0.97, respectively), even after adjusting for individual sociodemographic variables, community socioeconomic characteristic variables, individual injury/damage, and community storm damage. Higher levels of community-level collective efficacy and individual-level collective efficacy were also associated with significantly lower posttraumatic stress disorder symptom severity (b = -0.22, p<0.01; and b = -0.17, p<0.01, respectively), after adjusting for the same covariates. Lower rates of posttraumatic stress disorder are associated with communities with higher collective efficacy. Programs enhancing community collective efficacy may be an important part of prevention practices and possibly lead to a reduction in the rate of posttraumatic stress disorder post-disaster.

Suicidal behaviors and the use of mental health services among active duty Army soldiers.

OBJECTIVE: U.S. Army personnel experience a significant mental health burden, particularly during times of war and multiple deployments. This study identified rates of suicidality (seriously considering or attempting suicide) and types of mental health services used in the past 12 months by active duty Army soldiers. METHODS: This study used the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, which sampled 10,400 Army soldiers from a total population of 508,088 soldiers. Mental health service utilization included receiving counseling or therapy from a general medical doctor, receiving counseling or therapy from a mental health professional, and being prescribed medications for depression, anxiety, or sleep. Suicidality was assessed via self-report questions. RESULTS: Thirteen percent had seriously considered or attempted suicide at some point in their lives, 7% since joining the military. One percent who reported suicidality since joining the Army reported having considered or attempted suicide in the past year. After the analyses adjusted for sociodemographic factors, soldiers who seriously considered or attempted suicide since joining the military versus those who did not were 1.71 times more likely to have used a mental health service, 2.33 times more likely to have used two or more types of services, 1.82 times more likely to have seen a mental health specialist, and 1.67 times more likely to have received medication in the past year. CONCLUSIONS: Understanding the relationship between suicidal thoughts and behaviors and the specific levels and types of mental health services received in this military population is important for health care provision and planning.

Mental health service utilization in the U.S. Army.

OBJECTIVE: U.S. Army personnel experience significant burden from mental disorders, particularly during times of war and with multiple deployments. This study identified the rates and predictors of mental health service use by Army soldiers and examined the association of daily functioning with the various types of mental health service use. METHODS: This study used the U.S. Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, which sampled 10,400 Army soldiers, representing 508,088 soldiers. Mental health service utilization over a 12-month period included receiving counseling or therapy from a general medical doctor, receiving counseling or therapy from a mental health professional, and being prescribed medications for depression, anxiety, or sleep. Current functioning was assessed with the Health-Related Quality of Life-4 instrument. RESULTS: Of the active U.S. Army, 21% had used mental health services in the previous 12 months, and 48% of them had used two or more services. About 7% of soldiers saw a mental health specialist and were prescribed medication. Women (incidence rate ratio [IRR]=1.39, 95% confidence interval [CI]=1.19-1.63) and enlisted soldiers (IRR=1.93, CI=1.49-2.50) were more likely than others to use a greater number of services. Soldiers with higher versus lower levels of impaired functioning were 7.82 times more likely (CI=6.03-10.14) to use mental health services, 4.40 times more likely (CI=3.83-5.05) to use more services, and 3.18 times more likely (CI=1.85-5.49) to see a mental health specialist and to be prescribed medication. CONCLUSIONS: A substantial proportion of the Army accesses mental health services. Soldiers using the highest levels of care had the greatest impairment.

Posttraumatic stress disorder, depression, and alcohol and tobacco use in public health workers after the 2004 Florida hurricanes.

OBJECTIVE: We examined the relationship of probable posttraumatic stress disorder (PTSD), probable depression, and increased alcohol and/or tobacco use to disaster exposure and work demand in Florida Department of Health workers after the 2004 hurricanes. METHODS: Participants (N = 2249) completed electronic questionnaires assessing PTSD, depression, alcohol and tobacco use, hurricane exposure, and work demand. RESULTS: Total mental and behavioral health burden (probable PTSD, probable depression, increased alcohol and/or tobacco use) was 11%. More than 4% had probable PTSD, and 3.8% had probable depression. Among those with probable PTSD, 29.2% had increased alcohol use, and 50% had increased tobacco use. Among those with probable depression, 34% indicated increased alcohol use and 55.6% increased tobacco use. Workers with greater exposure were more likely to have probable PTSD and probable depression (ORs = 3.3 and 3.06, respectively). After adjusting for demographics and work demand, those with high exposure were more likely to have probable PTSD and probable depression (ORs = 3.21 and 3.13). Those with high exposure had increased alcohol and tobacco use (ORs = 3.01 and 3.40), and those with high work demand indicated increased alcohol and tobacco use (ORs = 1.98 and 2.10). High exposure and work demand predicted increased alcohol and tobacco use, after adjusting for demographics, work demand, and exposure. CONCLUSIONS: Work-related disaster mental and behavioral health burden indicate the need for additional mental health interventions in the public health disaster workforce.

Peritraumatic heart rate and posttraumatic stress disorder in patients with severe burns.

OBJECTIVE: Previous studies have suggested a link between heart rate (HR) following trauma and the development of posttraumatic stress disorder (PTSD). This study expands on previous work by evaluating HR in burn patients followed longitudinally for symptoms of acute stress disorder (ASD) and PTSD. METHOD: Data were collected from consecutive patients admitted to the Johns Hopkins Burn Center, Baltimore, Maryland, between 1997 and 2002. Patients completed the Stanford Acute Stress Reaction Questionnaire (n = 157) to assess symptoms of ASD. The Davidson Trauma Scale was completed at 1 (n = 145), 6 (n = 106), 12 (n = 94), and 24 (n = 66) months postdischarge to assess symptoms of PTSD. Heart rate in the ambulance, emergency room, and burn unit were obtained by retrospective medical chart review. RESULTS: Pearson correlations revealed a significant relationship between HR in the ambulance (r = 0.32, P = .016) and burn unit (r = 0.30, P = .001) and ASD scores at baseline. Heart rate in the ambulance was related to PTSD avoidance cluster scores at 1, 6, 12, and 24 months. In women, HR in the ambulance was correlated with PTSD scores at 6 (r = 0.65, P = .005) and 12 (r = 0.78, P = .005) months. When covariates (gender, ß-blockers, Brief Symptom Inventory Global Severity Index score) were included in multivariate linear regression analyses, ambulance HR was associated with ASD and PTSD scores at baseline and 1 month, and the interaction of ambulance HR and gender was associated with PTSD scores at 6 and 12 months. Multivariate logistic regression results were similar at baseline and 12 months, which included an HR association yet no interaction at 6 months and a marginal interaction at 1 month. CONCLUSIONS: While peritraumatic HR is most robustly associated with PTSD symptom severity, HR on admission to burn unit also predicts the development of ASD. Gender and avoidance symptoms appear particularly salient in this relationship, and these factors may aid in the identification of subgroups for which HR serves as a biomarker for PTSD. Future work may identify endophenotypic measures of increased risk for PTSD, targeting subgroups for early intervention.

Sleep and arousal as risk factors for adverse health and work performance in public health workers involved in the 2004 Florida hurricane season.

BACKGROUND: We examined the relation of sleep disturbance and arousal to work performance, mental and physical health, and day-to-day functioning in Florida Department of Health (FDOH) employees 9 months after the 2004 Florida hurricane season. METHODS: FDOH employees were contacted via e-mail 9 months after the 2004 hurricanes. Participants (N = 2249) completed electronic questionnaires including measures of sleep disturbance, arousal, work performance, physical health, mental health, day-to-day function, hurricane injury, and work demand. RESULTS: More than 18% of FDOH employees reported ≥ 25% reduced work performance and 11% to 15.3% reported ≥ 7 "bad" mental or physical health days in the past month. Sleep disturbance and elevated arousal were strongly associated with impaired work performance (odds ratios [ORs] 3.33 and 3.34, respectively), "bad" mental health (ORs 3.01 and 3.64), "bad" physical health (ORs 3.21 and 2.01), and limited day-to-day function (ORs 4.71 and 2.32), even after adjusting for sex, race, age, education, and marital status. CONCLUSIONS: Among public health workers exposed to the 2004 hurricanes, sleep disturbance and arousal were associated with personal and work impairment. Future research should continue to examine the effect of repeated exposure to disasters in first responders.

Acute stress disorder and posttraumatic stress disorder: a prospective study of prevalence, course, and predictors in a sample with major burn injuries.

This is one of the largest prospective studies of patients with major burn injuries to use psychometrically sound methods to track and predict posttraumatic stress disorder (PTSD) across 2 years after burn. The principal objectives were to investigate the utility of self-report measures in detecting acute stress disorder (ASD) and PTSD, and in tracking and predicting PTSD. Participants were adult patients admitted for treatment of a major burn injury. The Stanford Acute Stress Reaction Questionnaire (SASRQ) was used to assess ASD symptomatology at discharge (n = 178), and the Davidson Trauma Scale was used to assess PTSD symptoms at scheduled follow-ups at 1 (n = 151), 6 (n = 111), 12 (n = 105), and 24 (n = 71) months after burn. The prevalence of in-hospital ASD was 23.6%, and 35.1, 33.3, 28.6, and 25.4% of the participants met PTSD criteria at 1, 6, 12, and 24 months, respectively. Clinically significant and reliable change in PTSD symptomatology during the 24 months was uncommon. SASRQ diagnostic cutoff and total scores each robustly predicted PTSD at the first three follow-ups and all four follow-ups, respectively. A SASRQ empirically derived cutoff score (> or =40) yielded moderate-high sensitivities (0.67-0.71) and specificities (0.75-0.80), and predicted PTSD at each follow-up. In conclusion, ASD and PTSD are prevalent following major burn injuries, ASD symptomatology can reliably predict PTSD up to 24 months later, and, once established, PTSD usually persists. Research is needed to determine whether early recognition and treatment of persons with in-hospital ASD can improve long-term outcomes.

Case identification in psychiatric epidemiology: a review.

BACKGROUND: Psychiatric epidemiologic surveys since 1980 have relied heavily on a small number of survey diagnostic instruments for case ascertainment, which encode reports of respondents to highly structured interview questions delivered by interviewers without clinical training. Many validations of these survey diagnostic instruments have been carried out. OBJECTIVE: This paper reviews the success of the survey diagnostic instruments, for eight diagnostic categories, in validations with a psychiatrist examination as the gold standard. METHOD: Public databases were searched for potentially relevant publications, of which more than 1000 were located. Tables show sensitivity, specificity, Kappa, sample source and size, survey instrument and validation method. RESULTS: The number of validation studies relevant to the eight disorders ranged from 8 for schizophrenia to 29 for major depressive disorder. Reported sensitivities ranged from zero to 100%, and specificities from 22% to 100%. CONCLUSION: Results for common mental disorders such as major depressive disorder, alcohol disorder, drug disorder, and agoraphobic disorder are better than for panic disorder, obsessive compulsive disorder, bipolar disorder, and schizophrenia. The validity of case ascertainment in psychiatric epidemiology is still in question.

Symptoms of depression and anxiety as unique predictors of pain-related outcomes following burn injury.

BACKGROUND: The adverse consequences of burn injuries include pain and psychological distress, which show bidirectional associations. However, much of the existing research has relied on global measures of distress that do not separate distinct symptoms of anxiety and depression. PURPOSE: The purpose is to assess the prospective effects of anxiety and depression on pain and functional outcomes following burn injury. METHODS: This article describes a 2-year cohort study in patients hospitalized for serious burn injuries (assessments at discharge and 6-month, 1-year, and 2-year follow-up). Linear mixed effects analyses were conducted to model anxiety and depression's unique longitudinal effects; at each time point, depressive and anxiety symptoms were studied as predictors of subsequent changes in pain, fatigue, and physical function. RESULTS: When studied in separate prediction models, both depression and anxiety were strong prospective predictors of greater pain, more fatigue, and physical dysfunction at the subsequent time point (ps < .01). However, when both were included in a single model to study their unique effects, depressive symptoms (but not anxiety) emerged as a significant predictor of subsequent increases in pain and reductions in physical functioning, whereas anxiety (but not depression) predicted subsequent elevations in fatigue. CONCLUSIONS: These findings suggest potentially distinct effects of depression and anxiety and imply that assessment and early treatment of both depressive and anxiety symptoms may help improve a broad range of long-term pain-related outcomes following burn injury.