Actuarial prediction of psychotherapy retention among Iraq-Afghanistan veterans with posttraumatic stress disorder.

The present study aimed to identify predictors of treatment retention in a sample of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veterans with posttraumatic stress disorder (PTSD) who were referred for PTSD-focused treatment through completion of a Veterans Affairs (VA) specialty clinic introductory information session. A total of 124 returning veterans (89% male, 53% Caucasian, 40% African American, 2% Latino; average age = 37 years) participated in an introductory session intended to facilitate informed decision making about treatment selection for PTSD. To evaluate patient, therapist, and system characteristics that were associated with risk of prematurely dropping out of psychotherapy for PTSD, we used recursive partitioning or "classification tree" methods commonly used to derive actuarial models of risk for high or low scores on a particular outcome when the set of independent or predictor variables is large. Findings revealed interactions among predictors involving access to care, readiness for change, histories of traumatic brain injury, and previous PTSD treatment. Results from the exploratory recursive model indicated that participation in therapy was highest when veterans entered psychotherapy within 68 days of the information session, believed that they needed help, and had a history of traumatic brain injury, while participation was lowest when entry into treatment exceeded 68 days and belief in needing help was low. Effects associated with partitions in the recursive model were substantial, with Cohen's d statistics ranging from .60 to 1.75. Results of the present effectiveness study implicate the importance of access to care as well as motivation for treatment in the returning cohort of OEF/OIF/OND veterans seeking help for PTSD. (PsycINFO Database Record

An Investigation of Treatment Engagement Among Returning Veterans With Problematic Anger.

Anger is a commonly reported problem among returning veterans, yet little attention has been devoted to studying treatment engagement among veterans who report anger problems but do not have posttraumatic stress disorder (PTSD). This study compares Iraq-Afghanistan veterans with anger/no PTSD (n = 159) to others reporting significant PTSD symptoms (n = 285) and those reporting neither anger nor PTSD (n = 716) on rates of treatment utilization, perceived barriers to treatment, and preferences for care. Relative to the PTSD group, the anger/no-PTSD group was significantly less likely to have received mental health treatment in the last year, despite endorsing barriers to treatment at a lower rate. Furthermore, the anger/no-PTSD group endorsed fewer preferences than the PTSD group. Results suggest that the anger/no-PTSD group is a unique subgroup that may be less likely to identify a need for treatment. Implications are discussed.

An RCT of Effects of Telephone Care Management on Treatment Adherence and Clinical Outcomes Among Veterans With PTSD.

OBJECTIVE: This study assessed whether adding telephone care management to usual outpatient mental health care improved treatment attendance, medication compliance, and clinical outcomes of veterans with posttraumatic stress disorder (PTSD). METHODS: In a multisite randomized controlled trial, 358 veterans were assigned to either usual outpatient mental health treatment (N=165) or usual care plus twice-a-month telephone care management (TCM) and support in the first three months of treatment (N=193). Treatment utilization and medication refills were determined from U.S. Department of Veterans Affairs administrative data. PTSD, depression, quality of life, aggressive behavior, and substance use were assessed with self-report questionnaires at intake, four months, and 12 months. RESULTS: Telephone care managers reached 95% of TCM participants (N=182), completing an average 5.1 of 6.0 planned telephone calls. During the three-month intervention period, TCM participants completed 43% more mental health visits (M±SD=5.9±6.8) than did those in usual care (4.1±4.2) (incident rate ratio=1.36, χ2=6.56, df=1, p<.01). Treatment visits in the nine-month follow-up period and medication refills did not differ by condition. Only 9% of participants were scheduled to receive evidence-based psychotherapy. Slopes of improvement in PTSD, depression, alcohol misuse, drug problems, aggressive behavior, and quality of life did not differ by condition or treatment attendance. CONCLUSIONS: TCM improved PTSD patients' treatment attendance but not their outcomes. TCM can enhance treatment engagement, but outcomes depend on the effectiveness of the treatments that patients receive.

Nature and Treatment of Comorbid Alcohol Problems and Post Traumatic Stress Disorder Among American Military Personnel and Veterans.

Many service members and veterans seeking treatment for alcohol problems also have post-traumatic stress disorder (PTSD). This article considers the effectiveness of treating alcohol problems and PTSD simultaneously. The authors begin by summarizing the extent of excessive alcohol use among military service members and veterans. They then explore the relationship between combat exposure and subsequent alcohol use; identify and briefly describe evidence-based treatments for alcohol problems and PTSD, separately; and review research on the effects of single treatments for both PTSD symptoms and alcohol use.

Veterans' Preferences for Receiving Information About VA Services: Is Getting the Information You Want Related to Increased Health Care Utilization?

Although the current cohort of returning veterans has engaged more fully with care from the Department of Veterans Affairs (VA) than have veterans from previous eras, concern remains regarding low engagement with VA services, particularly for specialty services for diagnoses that can most negatively impact quality of life. This study used the framework of the Andersen Model to examine factors related to VA health care use in Operation Enduring Freedom/Operation Iraqi Freedom veterans. Match between veterans' preferences for source of information about VA programs and veterans' actual sources of information about VA services was examined as an additional predictor of help seeking. The study included 1,161 veterans recruited from the southeast United States. Results suggested that veterans prefer to receive information from VA publications and the web, whereas they actually receive information from VA publications and other veterans. Logistic regression suggested that the number of deployments, income, distance to VA, VA disability rating, self-rated health, and match between preferred source of information and actual source of information were significantly related to the use of VA services since deployment. These results suggest that future outreach efforts should focus on targeting veterans' health needs and preferences for care and source of information.

Surveying treatment preferences in U.S. Iraq-Afghanistan Veterans with PTSD symptoms: a step toward veteran-centered care.

This study examined health care barriers and preferences among a self-selected sample of returning U.S. veterans drawn from a representative, randomly selected frame surveyed about posttraumatic stress disorder (PTSD) symptomatology and mental health utilization in the prior year. Comparisons between treated (n = 160) and untreated (n = 119) veterans reporting PTSD symptoms were conducted for measures of barriers and preferences, along with logistic models regressing mental health utilization on clusters derived from these measures. Reported barriers corroborated prior research findings as negative beliefs about treatment and stigma were strongly endorsed, but only privacy concerns were associated with lower service utilization (B = -0.408, SE = 0.142; p = .004). The most endorsed preference (91.0%) was for assistance with benefits, trailed by help for physical problems, and particular PTSD symptoms. Help-seeking veterans reported stronger preferences for multiple interventions, and desire for services for families (B = 0.468, SE = 0.219; p = .033) and specific PTSD symptoms (B = 0.659, SE = 0.302; p = .029) were associated with increased utilization. Outcomes of the study suggested PTSD severity drove help-seeking in this cohort. Results also support the integration of medical and mental health services, as well as coordination of health and benefits services. Finally, the study suggested that outreach about privacy protections and treatment options could well improve engagement in treatment.

Mental Health Among Military Personnel and Veterans.

This commentary describes the prevalence of mental health problems affecting military service members and veterans in North Carolina and the rest of the nation, with a special emphasis on those who served in the recent wars in Iraq and Afghanistan. Approximately 1.9 million of these veterans have become eligible for Veterans Affairs health care since 2002, and an estimated 1.16 million veterans have registered for this care.

Diagnostic efficiency of the AUDIT-C in U.S. veterans with military service since September 11, 2001.

BACKGROUND: Alcohol screening with the 3-item alcohol use disorders identification test (AUDIT-C) has been implemented throughout the U.S. Veterans Health Administration. Validation of the AUDIT-C, however, has been conducted with samples of primarily older veterans. This study examined the diagnostic efficiency of the AUDIT-C in a younger cohort of veterans who served during Operation Enduring Freedom and/or Operation Iraqi Freedom (OEF/OIF). METHODS: Veteran participants (N=1775) completed the alcohol use disorders identification test (AUDIT) and underwent the structured clinical interview for DSM-IV-TR for Axis I disorders (SCID) in research settings within four VA medical Centers. Areas under receiver operating characteristic curves (AUCs) measured the effiency of the full AUDIT and AUDIT-C in identifying SCID-based diagnoses of past year alcohol abuse or dependence. RESULTS: Both measures performed well in detecting alcohol use disorders. In the full sample, the AUDIT had a better AUC (.908; .881-.935) than the AUDIT-C (.859; .826-.893; p<.0001). It is notable that this same result was found among men but not women, perhaps due to reduced power. Diagnostic efficiency statistics for the AUDIT and AUDIT-C were consistent with results from older veteran samples. The diagnostic efficiency of both measures did not vary with race or age. CONCLUSIONS: Both the AUDIT and AUDIT-C appear to be valid instruments for identifying alcohol abuse or dependence among the most recent cohort of U.S. veterans with service during OEF/OIF within research settings.

Diagnostic efficiency of the personality assessment inventory LOGIT function for posttraumatic stress disorder in women.

In this study, we examined the diagnostic efficiency of the Personality Assessment Inventory (PAI; Morey, 1991) for the assessment of posttraumatic stress disorder (PTSD) in a community-based sample of women (n = 128). Receiver operating characteristic curves (ROC) were generated to examine the efficiency of the PAI PTSD LOGIT function as a tool for diagnosing PTSD. Using the Clinician Administered PTSD Scale as the reference standard, the PTSD LOGIT function performed well (area under the curve [AUC] = .856, standard error [SE] = .034). This represents performance consistent with more commonly used self-report PTSD scales, the Davidson Trauma Scale (AUC = .863, SE = .033) and the PAI Anxiety subscale Anxiety-Related Disorders Traumatic Experiences (AUC = .861; S.E. = .033). Results of this study suggest that the PAI PTSD LOGIT function may be a useful tool in assessing PTSD.

Predicting mortality in veterans with posttraumatic stress disorder thirty years after Vietnam.

Previous research has demonstrated elevated mortality rates among Vietnam-era veterans with posttraumatic stress disorder, especially deaths resulting from nonmedical causes. However, information on the relative contribution of particular risk factors to increased mortality is limited. We used receiver operating characteristics methodology to identify patient-level characteristics that predicted 7-year mortality in 79,551 middle-aged, male, posttraumatic stress disorder-diagnosed outpatients seeking mental health treatment within the Veterans Affairs Health Care System between April 1, 1998 and September 30, 1998. Receiver operating characteristics models indicated that the strongest predictor of mortality was a recent history of medical hospitalization, followed by severity of medical diagnoses and presence of a substance disorder. Results highlight the importance of addressing comorbid medical illnesses and addictive disorders when caring for this population.

The association of posttraumatic stress disorder and metabolic syndrome: a study of increased health risk in veterans.

BACKGROUND: There is accumulating evidence for a link between trauma exposure, posttraumatic stress disorder (PTSD) and diminished health status. To assess PTSD-related biological burden, we measured biological factors that comprise metabolic syndrome, an important established predictor of morbidity and mortality, as a correlate of long-term health risk in PTSD. METHODS: We analyzed clinical data from 253 male and female veterans, corresponding to five factors linked to metabolic syndrome (systolic and diastolic blood pressure, waist-to-hip ratio and fasting measures of high-density lipoprotein (HDL) cholesterol, serum triglycerides and plasma glucose concentration). Clinical cut-offs were defined for each biological parameter based on recommendations from the World Health Organization and the National Cholesterol Education Program. Controlling for relevant variables including sociodemographic variables, alcohol/substance/nicotine use and depression, we examined the impact of PTSD on metabolic syndrome using a logistic regression model. RESULTS: Two-fifths (40%) of the sample met criteria for metabolic syndrome. Of those with PTSD (n = 139), 43% met criteria for metabolic syndrome. The model predicted metabolic syndrome well (-2 log likelihood = 316.650, chi-squared = 23.731, p = 0.005). Veterans with higher severity of PTSD were more likely to meet diagnostic criteria for metabolic syndrome (Wald = 4.76, p = 0.03). CONCLUSION: These findings provide preliminary evidence linking higher severity of PTSD with risk factors for diminished health and increased morbidity, as represented by metabolic syndrome.

An evaluation of the psychometric properties of the traumatic events questionnaire in primary care patients.

This study examined the reliability of reports of traumatic experiences across the Traumatic Events Questionnaire (TEQ; S. Vrana & D. Lauterbach, 1994) and the Composite International Diagnostic Interview (CIDI; World Health Organization, 1998), and evaluated other psychometric properties of the TEQ in 154 primary care patients. Agreement rates for various traumatic experiences were moderate to substantial, with sexual abuse showing 87% agreement, and other forms of trauma exhibiting rates from 81-74%. The TEQ yields a trauma intensity score, which produced stronger correlations with self-reported PTSD symptoms and problematic anger than the sum of traumas experienced. Trauma intensity also proved to be a powerful predictor of posttraumatic stress disorder (PTSD) diagnostic status. Results support the TEQ as a measure of traumatic exposure in primary care populations.

Validity of the Personality Assessment Inventory Aggression scales and Violence Potential index in veterans with PTSD.

In this study, we examined the validity of the Personality Assessment Inventory (PAI; Morey, 1991) Aggression (AGG) scales and Violence Potential index (VPI) in 399 male combat veterans presenting for formal evaluation of posttraumatic stress disorder (PTSD). The AGG scales exhibited convergence with other measures of hostility and violence and demonstrated discriminant validity with alternative constructs. When we examined reports of interpersonal violence in the past year, the AGG composite scale displayed substantial incremental validity over the effects of PTSD severity, demographics, a simple dichotomous question regarding violence in the past 30 days, and MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) scales measuring aggression. The VPI, however, added no unique explanatory power over the AGG composite scale.

MMPI-2 assessment of malingered emotional distress related to a workplace injury: a mixed group validation.

In this study, we examined the capacity of MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 2001) validity indexes to identify malingered depression associated with a workplace injury. We compared 27 graduate students simulating depression with archival records of 33 inpatients diagnosed with major depressive disorder. We employed a mixed-group validation design to generate true positive rates (TPR) and false positive rates (FPR) for the various MMPI-2 validity scales [F, FB, F(p), FBS, F - K, Ds2] while we accounted for base rates of malingering in each sample. The Fake Bad scale (FBS) was the only validity measure that produced acceptable TPR and FPR or a significant correlation with malingering status.