Treatment of military-related post-traumatic stress disorder: challenges, innovations, and the way forward.

Post-traumatic stress disorder (PTSD) is one of the common mental disorders in military and veteran populations. Considerable research and clinical opinion has been focused on understanding the relationship between PTSD and military service and the implications for prevention, treatment, and management. This paper examines factors associated with the development of PTSD in this population, considers issues relating to engagement in treatment, and discusses the empirical support for best practice evidence-based treatment. The paper goes on to explore the challenges in those areas, with particular reference to treatment engagement and barriers to care, as well as treatment non-response. The final section addresses innovative solutions to these challenges through improvements in agreed terminology and definitions, strategies to increase engagement, early identification approaches, understanding predictors of treatment outcome, and innovations in treatment. Treatment innovations include enhancing existing treatments, emerging non-trauma-focused interventions, novel pharmacotherapy, personalized medicine approaches, advancing functional outcomes, family intervention and support, and attention to physical health.

The long-term psychiatric sequelae of severe injury: a 6-year follow-up study.

OBJECTIVE: The impact of mental health on disease burden associated with injury represents a major public health issue, yet almost no information is available on the associated long-term mental health outcomes. The primary aim of this study was to assess the psychiatric outcomes 6 years after a severe injury and their subsequent impact on long-term disability. The secondary aim was to investigate the relationship between a mild traumatic brain injury (mTBI) and long-term psychiatric disorder and its impact on disability. METHODS: From April 2004 to February 2006, randomly selected injury patients admitted to 4 hospitals across Australia were assessed during hospitalization and at 72 months after trauma (N = 592). Injury characteristics, the presence of an mTBI (ICD-9 criteria), and previous psychiatric history were assessed during hospitalization. Structured clinical interviews for psychiatric disorders (DSM-IV and DSM-5) and a self-report measure of disability (WHODAS II) were administered at 72 months. RESULTS: At 72 months after a severe injury, 28% of patients met criteria for at least 1 psychiatric disorder, with 45% of those presenting with comorbid diagnoses. The most prevalent psychiatric disorder was a major depressive episode (11%) followed by substance use disorder (9%), agoraphobia (9%), posttraumatic stress disorder (6%), and generalized anxiety disorder (6%). The presence of any psychiatric disorder was found to increase the risk for disability (P < .001, odds ratio = 6.04). An mTBI was found to increase the risk for having some anxiety disorders but not to increase disability by itself. CONCLUSIONS: The long-term psychiatric consequences of severe injury are substantial and represent a significant contributor to long-term disability. This study points to an important intersection between injury and psychiatric disorder as a leading contributor to disease burden and suggests this growing burden will impose new challenges on health systems.

Support mechanisms and vulnerabilities in relation to PTSD in veterans of the Gulf War, Iraq War, and Afghanistan deployments: a systematic review.

Pretrauma factors of psychiatric history and neuroticism have been important in highlighting vulnerability to posttraumatic stress disorder (PTSD), whereas posttrauma support mechanisms have been associated with positive health and well-being outcomes, particularly in veterans. The relationship between these factors and PTSD has not been the subject of a systematic review in veterans. An online search was conducted, supplemented by reference list and author searches. Two investigators systematically and independently examined eligible studies. From an initial search result of 2,864, 17 met inclusion criteria. A meta-analysis of unit cohesion involving 6 studies found that low unit cohesion was associated with PTSD, standardised mean difference of -1.62, 95% confidence interval (CI) [-2.80, -0.45]. A meta-analysis of social support involving 7 studies found that low social support was associated with PTSD, standardised mean difference of - 12.40, 95% CI [-3.42, -1.38]. Three of 5 studies found a significant relationship between low-family support and PTSD; insufficient data precluded a meta-analysis. Regarding pretrauma vulnerability, 2 studies on psychiatric history and 1 on neuroticism found positive relationships with PTSD. Posttrauma factors of low support were associated with higher reporting of PTSD. Cross-sectional methodology may be inadequate to capture complex relationships between support and PTSD; more longitudinal research is required.

Stepped early psychological intervention for posttraumatic stress disorder, other anxiety disorders, and depression following serious injury.

The best approach for implementing early psychological intervention for anxiety and depressive disorders after a traumatic event has not been established. This study aimed to test the effectiveness of a stepped model of early psychological intervention following traumatic injury. A sample of 683 consecutively admitted injury patients were screened during hospitalization. High-risk patients were followed up at 4-weeks postinjury and assessed for anxiety and depression symptom levels. Patients with elevated symptoms were randomly assigned to receive 4-10 sessions of cognitive-behavioral therapy (n = 24) or usual care (n = 22). Screening in the hospital identified 89% of those who went on to develop any anxiety or affective disorder at 12 months. Relative to usual care, patients receiving early intervention had significantly improved mental health at 12 months. A stepped model can effectively identify and treat injury patients with high psychiatric symptoms within 3 months of the initial trauma.

Guidelines for peer support in high-risk organizations: an international consensus study using the Delphi method.

Despite widespread adoption of peer-support programs in organizations around the world whose employees are at high risk of exposure to potentially traumatic incidents, little consensus exists regarding even the most basic concepts and procedures for these programs. In this article, consensus refers to a group decision-making process that seeks not only agreement from most participants, but also resolution of minority objections. The aim of the current study was to develop evidence-informed peer-support guidelines for use in high-risk organizations, designed to enhance consistency around goals and procedures and provide the foundation for a systematic approach to evaluation. From 17 countries, 92 clinicians, researchers, and peer-support practitioners took part in a 3-round web-based Delphi process rating the importance of statements generated from the existing literature. Consensus was achieved for 62 of 77 (81%) statements. Based upon these, 8 key recommendations were developed covering the following areas: (a) goals of peer support, (b) selection of peer supporters, (c) training and accreditation, (d) role of mental health professionals, (e) role of peer supporters, (f) access to peer supporters, (g) looking after peer supporters, and (h) program evaluation. This international consensus may be used as a starting point for the design and implementation of future peer-support programs in high-risk organizations.

Posttraumatic stress disorder and hypertension in Australian veterans of the 1991 Gulf War.

OBJECTIVE: Military veterans experience a high prevalence of psychopathologies such as posttraumatic stress disorder (PTSD). Relationships between physical and psychological health are increasingly recognised. This study investigated associations between PTSD and hypertension in male Australian Gulf War veterans. METHODS: In 2000-02, 1456 veterans underwent medical and psychological assessments. Medical practitioners rated self-reported medical conditions as probable diagnoses, possible, unlikely or non-medical. The Composite International Diagnostic Interview (CIDI) assessed psychological symptomatology present in the 12 months preceding evaluation, and lifetime prevalence. Odds of hypertension among those with and without PTSD were calculated for each timeframe using logistic regression. RESULTS: Analysis was restricted to the 1381 veterans for whom CIDI and medical data were available. Hypertension was considered probable in 100 subjects (7.2%). Adjusted odds ratios of hypertension were 2.90 (95% CI 1.19-7.09) amongst veterans with PTSD in the past 12 months and 2.27 (95% CI 1.01-5.10) for lifetime prevalence, compared with those without PTSD. Hypertension was over seven times more likely amongst veterans with PTSD alone than those with no mental illness in the past 12 months. CONCLUSIONS: Veterans with a history of PTSD had increased odds of having hypertension. Given the array of disabling psychosocial associations of PTSD, and the numerous potential clinical sequelae of hypertension, co-existence of these conditions may have implications for prevention and management at the individual, clinical, and public health policy and practice level. Early identification of PTSD in military samples may help to ameliorate longer-term adverse physical health outcomes.

Does access to compensation have an impact on recovery outcomes after injury?

OBJECTIVE: To conduct a descriptive study investigating the effect of access to motor vehicle accident (MVA) compensation on recovery outcomes at 24 months after injury. DESIGN AND SETTING: Longitudinal cohort study conducted in two Level 1 trauma hospitals in Victoria, Australia. Participants were 391 randomly selected injury patients with moderate-to-severe injuries. Compensable and non-compensable patients were compared at 24 months after injury on a number of health outcomes. MAIN OUTCOME MEASURES: Health outcomes at 24 months, including anxiety and depression severity, quality of life and disability. RESULTS: Medical records identified two groups of compensation patients: MVA-compensable and non-compensable patients. After controlling for baseline variables, the MVA-compensable patients, at 24 months, had higher levels of post-traumatic stress disorder, anxiety and depression, and were less likely to have returned to their pre-injury number of work hours. However, some patients in the non-compensable group had accessed other forms of compensation (eg, private health care or compensation for victims of crime). When these were removed from the non-compensable group, the differences between MVA-compensable and non-compensable groups all but disappeared. CONCLUSION: Our findings do not support previous research showing that access to compensation is associated with poor recovery outcomes. The relationship between access to compensation and health outcomes is complex, and more high-level research is required.

Comorbidity of PTSD and depression in Korean War veterans: prevalence, predictors, and impairment.

BACKGROUND: Rates of PTSD and depression are high in Korean War veterans. The prevalence and impact of the two disorders occurring comorbidly, however, has not been investigated. This paper aims to investigate the extent to which PTSD and depression co-occur in Australian veterans of the Korean War, the symptom severity characteristics of comorbidity, the impact on life satisfaction and quality, and the association with war-related predictors. METHODS: Veterans (N=5352) completed self-report questionnaires including the Posttraumatic Stress Disorder Checklist, the Hospital Anxiety and Depression Scale, the Life Satisfaction Scale, the brief World Health Organisation Quality of Life questionnaire and the Combat Exposure Scale. RESULTS: Seventeen percent of veterans met criteria for comorbid PTSD and depression, 15% had PTSD without depression, and a further 6% had depression without PTSD. Compared with either disorder alone, comorbidity was associated with impaired life satisfaction, reduced quality of life, and greater symptom severity. Several war-related factors were associated with comorbidity and with PTSD alone, but not with depression alone. LIMITATIONS: The reliance on self-reported measures and the necessity for retrospective assessment of some deployment-related factors renders some study data vulnerable to recall bias. CONCLUSIONS: Comorbid PTSD and depression, and PTSD alone, are prevalent among Korean War veterans, are both associated with war-related factors 50 years after the Korean War, and may represent a single traumatic stress construct. The results have important implications for understanding complex psychopathology following trauma.

The role of post-traumatic stress disorder and depression in predicting disability after injury.

OBJECTIVES: To examine the relationship between psychological response to injury at 1 week and 3 months, and disability at 12 months. DESIGN: Multisite, longitudinal study. PARTICIPANTS AND SETTING: 802 adult patients admitted to trauma services at four Australian hospitals from 13 March 2004 to 21 February 2006 were assessed before discharge and followed up at 3 and 12 months. MAIN OUTCOME MEASURE: Disability, measured with the 12-item version of the World Health Organization Disability Assessment Schedule II. RESULTS: Logistic regression identified the degree to which high levels of depression and post-traumatic stress disorder (PTSD) at 1 week and at 3 months predicted disability at 12 months. After controlling for demographic variables and characteristics of the injury, patients with PTSD or subsyndromal PTSD at 1 week were 2.4 times more likely, and those with depression at 1 week were 1.9 times more likely to have high disability levels at 12 months. PTSD at 3 months was associated with 3.7 times, and depression at 3 months with 3.4 times the risk of high disability at 12 months. CONCLUSIONS: PTSD and depression at 1 week and at 3 months after injury significantly increased the risk of disability at 12 months. Routine assessment of symptoms of depression and PTSD in patients who have been physically injured may facilitate triage to evidence-based treatments, leading to improvement in both physical and psychological outcomes.

A predictive screening index for posttraumatic stress disorder and depression following traumatic injury.

Posttraumatic stress disorder (PTSD) and major depressive episode (MDE) are frequent and disabling consequences of surviving severe injury. The majority of those who develop these problems are not identified or treated. The aim of this study was to develop and validate a screening instrument that identifies, during hospitalization, adults at high risk for developing PTSD and/or MDE. Hospitalized injury patients (n = 527) completed a pool of questions that represented 13 constructs of vulnerability. They were followed up at 12 months and assessed for PTSD and MDE. The resulting database was split into 2 subsamples. A principal-axis factor analysis and then a confirmatory factor analysis were conducted on the 1st subsample, resulting in a 5-factor solution. Two questions were selected from each factor, resulting in a 10-item scale. The final model was cross-validated with the 2nd subsample. Receiver-operating characteristic curves were then created. The resulting Posttraumatic Adjustment Scale had a sensitivity of .82 and a specificity of .84 when predicting PTSD and a sensitivity of .72 and a specificity of .75 in predicting posttraumatic MDE. This 10-item screening index represents a clinically useful instrument to identify trauma survivors at risk for the later development of PTSD and/or MDE.

Treating adults with acute stress disorder and post-traumatic stress disorder in general practice: a clinical update.

General practitioners have an important role to play in helping patients after exposure to severe psychological trauma. In the immediate aftermath of trauma, GPs should offer "psychological first aid", which includes monitoring of the patient's mental state, providing general emotional support and information, and encouraging the active use of social support networks, and self-care strategies. Drug treatments should be avoided as a preventive intervention after traumatic exposure; they may be used cautiously in cases of extreme distress that persists. Adults with acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) should be provided with trauma-focused cognitive behaviour therapy (CBT). Eye movement desensitisation and reprocessing (EMDR) in addition to in-vivo exposure (confronting avoided situations, people or places in a graded and systematic manner) may also be provided for PTSD. Drug treatments should not normally replace trauma-focused psychological therapy as a first-line treatment for adults with PTSD. If medication is considered for treating PTSD in adults, selective serotonin reuptake inhibitor antidepressants are the first choice. Other new generation antidepressants and older tricyclic antidepressants should be considered as second-line pharmacological options. Monoamine oxidase inhibitors may be considered by mental health specialists for use in people with treatment-resistant symptoms.

War zone stress without direct combat: the Australian naval experience of the Gulf War.

This study examines psychological stressors reported by Australian Navy Gulf War veterans in relation to the 1991 Gulf War and other military service. Using a 44-item questionnaire, veterans reported few direct-combat encounters during the Gulf War; however, they reported many other stressful experiences, including fear of death and perceived threat of attack, more frequently in relation to the Gulf War than other military service. Reporting of stressful experiences was associated with younger age, lower rank, and deployment at the height of the conflict. These experiences may partly explain increased rates of psychological disorders previously demonstrated in this Navy veteran population. Findings highlight the importance of documenting war experiences in close proximity to deployment, and developing war exposure instruments which include naval activities and which reflect stressors other than those related to direct combat.

War-related psychological stressors and risk of psychological disorders in Australian veterans of the 1991 Gulf War.

BACKGROUND: Questions remain about the long-term health impacts of the 1991 Gulf War on its veterans. AIMS: To measure psychological disorders in Australian Gulf War veterans and a military comparison group and to explore any association with exposure to Gulf War-related psychological stressors. METHOD: Prevalences of DSM-IV psychological disorders were measured using the Composite International Diagnostic Interview. Gulf War-related psychological stressors were measured using a service experience questionnaire. RESULTS: A total of 31% of male Gulf War veterans and 21% of the comparison group met criteria for a DSM-IV disorder first present in the post-Gulf War period. The veterans were at greater risk of developing post-Gulf War anxiety disorders including post-traumatic stress disorder, affective disorders and substance use disorders. The prevalence of such disorders remained elevated a decade after deployment. The findings can be explained partly as a 'war-deployment effect'. There was a strong dose-response relationship between psychological disorders and number of reported Gulf War-related psychological stressors. CONCLUSIONS: Service in the 1991 Gulf War is associated with increased risk of psychological disorders and these are related to stressful experiences.