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DESCRIPTION: The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline (CPG) and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against. METHODS: Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed. RECOMMENDATIONS: The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder (PTSD) with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.
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Transtornos de Estresse Pós-Traumáticos , Transtornos de Estresse Traumático Agudo , Humanos , Transtornos de Estresse Pós-Traumáticos/terapia , Estados Unidos , Transtornos de Estresse Traumático Agudo/terapia , United States Department of Veterans Affairs , United States Department of Defense , Psicoterapia , Terapia Cognitivo-ComportamentalRESUMO
A clinical practice guideline (CPG) is a rigorously established set of recommendations based on currently available evidence about the efficacy, safety, acceptability, and feasibility of interventions to assist with clinical decision-making. The 2023 Department of Veterans Affairs /Department of Defense Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder is described herein. The CPG recommendations are accompanied by a clinical algorithm, which incorporates principles of evidence-based practice, shared decision-making, and functional and contextual assessments of goals and outcomes. An overview of the CPG recommendations is combined with a discussion of questions that clinicians and patients may face in implementing the CPG and suggestions for how to effectively work with the CPG.
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Transtornos de Estresse Pós-Traumáticos , Transtornos de Estresse Traumático Agudo , Veteranos , Estados Unidos , Humanos , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/terapia , United States Department of Veterans AffairsRESUMO
BACKGROUND: Transgender and/or gender-diverse (TGD) persons are vulnerable to stigma and health care inequities; however, data are particularly limited among TGD active duty military service members despite ongoing changes to service policies. TGD-related stressors may impede access to and utilization of health care due to fear of potential discrimination and distress, thereby adversely impacting military readiness. METHODS: We examined stigma and barriers in health care and associations with physical and mental health in an online sample of 177 active duty service members who self-identified as TGD. To assess associations between stigma and barriers in health care with mental and physical health, linear regressions were conducted adjusting for age, gender identity, race, and rank. RESULTS: Over half (65%) of the participants reported at least 1 instance of stigma and/or barrier in health care. Stigma and barriers to health care were significantly associated with greater self-reported depressive symptoms (ß=0.20, P =0.03), anxiety (ß=0.21, P =0.03), stress (ß=0.30, P =0.001), and poorer overall mental health (ß=-0.23, P =0.007), after adjusting for covariates. Nearly one-quarter of participants had not disclosed their gender identity to their primary care clinician. CONCLUSIONS: Findings suggested that stigma and barriers to affirming health care were prevalent among active duty service members identifying as TGD, specifically, difficulty accessing gender-affirming care and negative assumptions from clinicians. These experiences may adversely affect mental health and impede the quality of health care received by a population already vulnerable to health inequities. Given recent changes to military policy, efforts may be warranted to improve access to timely, affirming care and clinician training.
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Militares , Pessoas Transgênero , Humanos , Masculino , Feminino , Pessoas Transgênero/psicologia , Identidade de Gênero , Estigma Social , Acessibilidade aos Serviços de Saúde , Militares/psicologiaRESUMO
Since September 11, 2001, over 2.7 million United States service members have deployed to South-West Asia and the Middle East and have been exposed to environmental hazards and psychological trauma. Many of these service members have returned with medical and psychological illnesses, some of which have proved complex and resistant to treatment. One notable constellation of symptoms is post-deployment respiratory illness, which has become a focus of research and policy efforts. The present study sought to examine the impact of post-deployment psychological distress on respiratory symptom severity. Data were obtained from the Veterans Affairs Airborne Hazards and Open Burn Pit Registry (AHOBPR) health surveillance database (N =107,403). Psychological factors were compared against common organic and environmental predictors of post-deployment respiratory distress. Psychological distress following deployment was a stronger predictor of 12-month shortness of breath severity than general respiratory pathology or level of exposure to environmental hazards, controlling for gender, age, race, and tobacco use. Additionally, psychological distress was a better predictor of shortness of breath severity than documented respiratory illnesses including asthma, chronic obstructive pulmonary disease, and chronic bronchitis. Implications and directions for future research are discussed, as well as potential alterations to existing treatment and health surveillance paradigms.
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Asma , Militares , Síndrome do Desconforto Respiratório , Veteranos , Humanos , Estados Unidos/epidemiologia , Veteranos/psicologia , Dispneia/epidemiologia , Asma/epidemiologiaRESUMO
TBI and PTSD occur in a significant number of service members and can each result in considerable distress and cognitive challenges. Past research has established the individual impact of mild TBI (mTBI) and PTSD on cognitive performance; however, findings regarding the combined effects of mTBI and PTSD on cognitive performance are inconsistent. The present study examined the potentially synergistic effects of mTBI and PTSD symptoms on cognitive performance in a sample of 180 treatment-seeking active duty service members. As part of a larger clinical study, participants completed several self-report measures and an objective cognitive assessment via computer-based testing. Compared to norms, service members with mTBI-only, PTSD-symptoms-only, and comorbid TBI and PTSD performed significantly worse on cognitive tests, and there was a significant effect of group on cognitive performance, even when controlling for performance validity. Notably, individuals experiencing both mTBI and PTSD performed worse than those with either condition alone; service members with mTBI-only and those with PTSD symptoms-only did not differ. Findings further illustrate the complexity of the relationship between these two conditions, indicating comorbid mTBI and PTSD may represent a unique challenge to cognitive performance. Additional research is needed to clarify their combined impact on post-injury functioning.
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Much of the prior research on variables impacting spouses' perceptions of reunion stress have focused on individual variables and have not examined these variables within their shared context, despite the indication from some research and theory that this is a key component of understanding couple's responses to stressors. The present study examined the impact of various family stressors and resources, both independently and in conjunction with each other, on spouses' perceptions of reunion stress. To examine these variables, the present study utilized cross-sectional data from a representative sample of 1,558 military service members and their spouses participating in the Millennium Cohort Family Study. Results indicated that poorer mental health among spouses and service members was associated with increased reunion stress as reported by spouses across all models tested. In addition, stressful communication during deployment was significantly associated with spouses' perceptions of reunion stress. These results can help guide more targeted prevention and intervention efforts to decrease spouses' sense of reunion stress.
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Over the last two decades, treatment guidelines have become major aids in the delivery of evidence-based care and improvement of clinical outcomes. The International Society for Traumatic Stress Studies (ISTSS) produced the first guidelines for the prevention and treatment of posttraumatic stress disorder (PTSD) in 2000 and published its latest recommendations, along with position papers on complex PTSD (CPTSD), in November 2018. A rigorous methodology was developed and followed; scoping questions were posed, systematic reviews were undertaken, and 361 randomized controlled trials were included according to the a priori agreed inclusion criteria. In total, 208 meta-analyses were conducted and used to generate 125 recommendations (101 for adults and 24 for children and adolescents) for specific prevention and treatment interventions, using an agreed definition of clinical importance and recommendation setting algorithm. There were eight strong, eight standard, five low effect, 26 emerging evidence, and 78 insufficient evidence to recommend recommendations. The inclusion of separate scoping questions on treatments for complex presentations of PTSD was considered but decided against due to definitional issues and the virtual absence of studies specifically designed to clearly answer possible scoping questions in this area. Narrative reviews were undertaken and position papers prepared (one for adults and one for children and adolescents) to consider the current issues around CPTSD and make recommendations to facilitate further research. This paper describes the methodology and results of the ISTSS Guideline process and considers the interpretation and implementation of the recommendations.
Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Nuevas guías para la prevención y el tratamiento del trastorno de estrés postraumático de la Sociedad Internacional de Estudios de Estrés Traumático: metodología y proceso de desarrollo GUIAS DE LA ISTSS PARA EL TEPT En las últimas dos décadas, las guías de tratamiento se han convertido en una ayuda importante para la prestación de atención basada en la evidencia y la mejora de los resultados clínicos. La Sociedad Internacional de Estudios de Estrés Traumático (ISTSS en sus siglas en inglés) produjo las primeras guías para la prevención y tratamiento del trastorno de estrés postraumático (TEPT) en 2000 y publicó sus últimas recomendaciones, junto con los documentos de posición sobre el TEPT complejo (TEPT-C), en noviembre de 2018. Se desarrolló y siguió una metodología rigurosa; se plantearon preguntas de alcance, se realizaron revisiones sistemáticas y se incluyeron 361 ensayos controlados aleatorizados de acuerdo con los criterios de inclusión acordados a priori. En total, se realizaron 208 metanálisis y fueron utilizados para generar 125 recomendaciones (101 para adultos y 24 para niños y adolescentes) para intervenciones específicas de prevención y tratamiento, utilizando una definición acordada de la importancia clínica y un algoritmo de configuración de recomendaciones. Hubo ocho estudios con pruebas sólidas, ocho como estándar, cinco con bajo efecto, 26 con evidencia emergente y 78 fueron evaluados como con evidencia insuficiente para ser recomendados en las recomendaciones. Se consideró la inclusión de preguntas de alcance separadas sobre tratamientos para presentaciones complejas de TEPT, pero se decidió en contra debido a cuestiones de definición y ausencia virtual de estudios diseñados específicamente para responder con claridad las posibles preguntas de alcance en esta área. Se realizaron revisiones narrativas y se prepararon documentos de posición (uno para adultos y otro para niños y adolescentes) para considerar los problemas actuales en torno al TEPT-C y hacer recomendaciones para facilitar la investigación adicional. Este documento describe la metodología y los resultados del proceso de la Guía de la ISTSS y considera la interpretación y la implementación de las recomendaciones.
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Guias de Prática Clínica como Assunto , Transtornos de Estresse Pós-Traumáticos/prevenção & controle , Feminino , Humanos , Masculino , Metanálise como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Sociedades Médicas , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Revisões Sistemáticas como AssuntoRESUMO
BACKGROUND: Prolonged Exposure (PE) therapy is an efficacious treatment for PTSD; despite this, many clinicians do not utilize it due to concerns it could cause patient decompensation. METHOD: Data were pooled from four published well-controlled studies of female assault survivors with chronic PTSD (n = 361) who were randomly assigned to PE, waitlist (WL), or another psychotherapy, including cognitive processing therapy (CPT), Eye Movement and Desensitization Reprocessing (EMDR), or the combination of PE plus stress inoculation training (SIT) or PE plus cognitive restructuring. PTSD and depression severity scores were converted to categorical outcomes to evaluate the proportion of participants who showed reliable symptom change (both reliable worsening and reliable improvement). RESULTS: The majority of participants completing one of the active treatments showed reliable improvement on both PTSD and depression compared to WL. Among treatment participants in general, as well as those who received PE, reliable PTSD worsening was nonexistent and the rate of reliable worsening of depression was low. There were no differences on any outcome measures among treatments. By comparison, participants in WL had higher rates of reliable symptom worsening for both PTSD and depression. Potential alternative explanations were also evaluated. CONCLUSIONS: PE and a number of other empirically supported therapies are efficacious and safe treatments for PTSD, reducing the frequency of which symptom worsening occurs in the absence of treatment.
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Vítimas de Crime/psicologia , Terapia Implosiva/métodos , Estupro/psicologia , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/terapia , Violência/psicologia , Adolescente , Criança , Terapia Combinada , Progressão da Doença , Feminino , Humanos , Entrevista Psicológica , Determinação da Personalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Listas de Espera , Adulto JovemRESUMO
INTRODUCTION: Posttraumatic nightmares (PTNs) are common among service members with a history of combat or mission-related trauma and are associated with decreased well-being. Unfortunately, beyond establishing an association between mental health symptoms and PTNs, the existing literature fails to provide a more comprehensive understanding of factors associated with PTNs. The effectiveness of current recommended treatments is frequently debated, with the literature varying in levels of support. Treatment of PTN is complicated, given their association with a number of mental health difficulties including posttraumatic stress disorder (PTSD), anxiety, and depression. The present study sought to better delineate the association of these difficulties with PTNs, in an effort to inform and improve treatments for the nation's service members. MATERIALS AND METHODS: This study utilized de-identified data collected during standard procedures for an interdisciplinary intensive outpatient program for service members with a history of traumatic brain injury and/or psychological health conditions (N = 1,550). Study analyses were performed under a Walter Reed National Military Medical Center institutional review board-approved protocol. Three cross-sectional forward likelihood ratio logistic regressions predicting the presence of PTNs were conducted while controlling for the alpha-blocker prazosin, as it is recommended for the treatment of PTSD-associated nightmares. Separate models were created for posttraumatic stress symptoms (PTSS), depression, and anxiety because of multicollinearity concerns. Additional variables considered for inclusion were psychological symptoms (e.g., suicide ideation, postconcussive symptoms), satisfaction with life, sleep (e.g., pain that disrupts sleep, early awakenings, sleepiness), demographics (e.g., sex, race/ethnicity, marital status, age), and military characteristics (e.g., rank, branch, special operator status, time in service). RESULTS: PTSS (odds ratio [OR]: 1.13), anxiety (OR: 1.19), and depression (OR: 1.19) were associated with increased odds of PTNs when controlling for prazosin. Each of the final models accounted for a significant amount of variance in the presence/absence of PTN. The included variables differed across models. The PTSS model included pain that disrupted sleep, postconcussive symptoms, special operator status, and early awakenings. The anxiety model included postconcussive symptoms, pain that disrupted sleep, special operator status, and prazosin use. The depression model included postconcussive symptoms, pain that disrupted sleep, special operator status, difficulty falling asleep within 30 min, and prazosin use. Although most variables were associated with an increased odds of PTNs, postconcussive symptoms in the PTSS model and special operator status in all 3 models were associated with decreased odds of PTNs. These findings are illustrated in Tables 2 to 4. CONCLUSIONS: Findings support the association of PTSS, anxiety, and depression to PTNs, and, importantly, suggest that other factors may be equally or more important in understanding PTNs. Notably, increased odds of PTNs were observed among patients with pain that disrupts their sleep. The cross-sectional nature of the study allows examination of these co-occurring symptoms as they would present in the clinic, potentially informing assessment and treatment strategies; however, it precludes consideration of temporal relationships. Results highlight the importance of considering comorbid symptoms and relevant military characteristics to gain a more complete understanding of PTNs. Future research utilizing longitudinal methods are needed to inform the temporal/causal aspects of these relationships.
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Military personnel and veterans are at heightened risk for exposure to traumatic events and posttraumatic stress disorder (PTSD), as well as intimate relationship problems associated with PTSD.The purpose of this study was to evaluate the relative efficacy of CBCT and PE in improving intimate relationship functioning in active duty military personnel or veterans and their intimate partners; both conditions were hypothesized to significantly improve PTSD. Method: In this study, 32 military service members or veterans with PTSD and their intimate partners were randomized to receive either Cognitive-Behavioral Conjoint Therapy for PTSD (n = 15; CBCT; [Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for posttraumatic stress disorder: Harnessing the healing power of relationships. Guilford]), a trauma-focused couple therapy, or Prolonged Exposure (n = 17; PE; [Foa, E. B., Hembree, E. A., Dancu, C. V., Peterson, A. L., Cigrang, J. A., & Riggs, D. S. (2008). Prolonged exposure treatment for combat-related stress disorders - provider's treatment manual [unpublished]. Department of Psychiatry, University of Pennsylvania]), a front-line evidence-based individual treatment for PTSD.There were significant challenges with recruitment and a significant difference in dropout from treatment for the two therapies (65% for PE; 27% for CBCT). Treatment dropout was differentially related to pre-treatment relationship functioning; those with below average relationship functioning had higher dropout in PE compared with CBCT, whereas those with above average relationship functioning did not show differential dropout. In general, CBCT led to relational improvements, but this was not consistently found in PE. Clinician- and self-reported PTSD symptoms improved with both treatments.This study is the first to test a couple or family therapy against a well-established, front-line recommended treatment for PTSD, with expected superiority of CBCT over PE on relationship outcomes. Lessons learned in trial design, including considerations of equipoise, and the effects of differential dropout on trial analyses are discussed. This trial provides further support for the efficacy of CBCT in the treatment of PTSD and enhancement of intimate relationships.
Differential dropout from trial of couple versus individual therapy for PTSD.General pattern of improvements in relationship outcomes in couple therapy for PTSD.PTSD symptoms improved in the individual and couple therapy for PTSD.Lessons learned in trial design, including considerations of equipoise, and the effects of differential dropout by condition on trial analyses are discussed.
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Militares , Transtornos de Estresse Pós-Traumáticos , Veteranos , Humanos , Transtornos de Estresse Pós-Traumáticos/terapia , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Resultado do Tratamento , CogniçãoRESUMO
Background: Symptom accommodation by family members (FMs) of individuals with posttraumatic stress disorder (PTSD) includes FMs' participation in patients' avoidance/safety behaviours and constraining self-expression to minimise conflict, potentially maintaining patients' symptoms. The Significant Others' Responses to Trauma Scale (SORTS) is the only existing measure of accommodation in PTSD but has not been rigorously psychometrically tested.Objective: We aimed to conduct further psychometric analyses to determine the factor structure and overall performance of the SORTS. Method: We conducted exploratory and confirmatory factor analyses using a sample of N = 715 FMs (85.7% female, 62.1% White, 86.7% romantic partners of individuals with elevated PTSD symptoms).Results: After dropping cross-loading items, results indicated good fit for a higher-order model of accommodation with two factors: an anger-related accommodation factor encompassed items related largely to minimising conflict, and an anxiety-related accommodation factor encompassed items related primarily to changes to the FM's activities. Accommodation was positively related to PTSD severity and negatively related to relationship satisfaction, although the factors showed somewhat distinct associations. Item Response Theory analyses indicated that the scale provided good information and robust coverage of different accommodation levels.Conclusions: SORTS data should be analysed as both a single score as well as two factors to explore the factors' potential differential performance across treatment and relationship outcomes.
We examined the Significant Others' Responses to Trauma Scale (SORTS), a measure of symptom accommodation in PTSD, among a large sample of family members.As measured by the SORTS, accommodation in PTSD could be broken down into two aspects: anger-related accommodation and anxiety-related accommodation.Accommodation was positively related to PTSD severity and negatively related to relationship satisfaction.
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Psicometria , Transtornos de Estresse Pós-Traumáticos , Humanos , Transtornos de Estresse Pós-Traumáticos/psicologia , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Feminino , Masculino , Análise Fatorial , Adulto , Inquéritos e Questionários , Família/psicologia , Pessoa de Meia-IdadeRESUMO
IMPORTANCE: Alcohol dependence comorbid with posttraumatic stress disorder (PTSD) has been found to be resistant to treatment. In addition, there is a concern that prolonged exposure therapy for PTSD may exacerbate alcohol use. OBJECTIVE: To compare the efficacy of an evidence-based treatment for alcohol dependence (naltrexone) plus an evidence-based treatment for PTSD (prolonged exposure therapy), their combination, and supportive counseling. DESIGN, SETTING, AND PARTICIPANTS: A single-blind, randomized clinical trial of 165 participants with PTSD and alcohol dependence conducted at the University of Pennsylvania and the Philadelphia Veterans Administration. Participant enrollment began on February 8, 2001, and ended on June 25, 2009. Data collection was completed on August 12, 2010. INTERVENTIONS: Participants were randomly assigned to (1) prolonged exposure therapy plus naltrexone (100 mg/d), (2) prolonged exposure therapy plus pill placebo, (3) supportive counseling plus naltrexone (100 mg/d), or (4) supportive counseling plus pill placebo. Prolonged exposure therapy was composed of 12 weekly 90-minute sessions followed by 6 biweekly sessions. All participants received supportive counseling. MAIN OUTCOMES AND MEASURES: The Timeline Follow-Back Interview and the PTSD Symptom Severity Interview were used to assess the percentage of days drinking alcohol and PTSD severity, respectively, and the Penn Alcohol Craving Scale was used to assess alcohol craving. Independent evaluations occurred prior to treatment (week 0), at posttreatment (week 24), and at 6 months after treatment discontinuation (week 52). RESULTS: Participants in all 4 treatment groups had large reductions in the percentage of days drinking (mean change, -63.9% [95% CI, -73.6% to -54.2%] for prolonged exposure therapy plus naltrexone; -63.9% [95% CI, -73.9% to -53.8%] for prolonged exposure therapy plus placebo; -69.9% [95% CI, -78.7% to -61.2%] for supportive counseling plus naltrexone; and -61.0% [95% CI, -68.9% to -53.0%] for supportive counseling plus placebo). However, those who received naltrexone had lower percentages of days drinking than those who received placebo (mean difference, 7.93%; P = .008). There was also a reduction in PTSD symptoms in all 4 groups, but the main effect of prolonged exposure therapy was not statistically significant. Six months after the end of treatment, participants in all 4 groups had increases in percentage of days drinking. However, those in the prolonged exposure therapy plus naltrexone group had the smallest increases. CONCLUSIONS AND RELEVANCE: In this study of patients with alcohol dependence and PTSD, naltrexone treatment resulted in a decrease in the percentage of days drinking. Prolonged exposure therapy was not associated with an exacerbation of alcohol use disorder. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00006489.
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Alcoolismo/tratamento farmacológico , Terapia Implosiva , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos de Estresse Pós-Traumáticos/tratamento farmacológico , Adulto , Aconselhamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Método Simples-Cego , Fatores de Tempo , Resultado do TratamentoRESUMO
Few service members with posttraumatic stress disorder (PTSD) receive evidence-based psychotherapy (EBP) in the military health system (MHS). Efforts to increase EBP implementation have focused on provider training but have not adequately addressed organizational barriers. Thus, although behavioral health providers are trained in EBPs, clinic-, facility-, and system-level barriers preclude widespread EBP implementation. Building on work examining barriers to EBP use for PTSD across eight military treatment facilities, we propose recommendations for increasing the implementation of EBPs for PTSD and improving the quality of behavioral health care in MHS outpatient behavioral health clinics. Increasing the use of EBPs for PTSD will require that their use is supported and prioritized through MHS policy. We recommend that psychotherapy appointments are scheduled at least once weekly, as clinically indicated, as this frequency of care is prerequisite for EBP delivery. We propose several recommendations designed to increase system capacity for weekly psychotherapy, including improved triaging of potential patients, incentivizing and supporting group psychotherapy, matching the modality (i.e., group vs. individual) and frequency of treatment to patients' needs, and using behavioral health technicians as clinician extenders. Additional recommendations include providing ongoing support for EBP implementation (e.g., protected time to participate in EBP consultation) and matching patients to providers based on patient's clinical needs and treatment preferences. The barriers to EBP implementation that these recommendations target are interrelated. Therefore, adopting multiple policy recommendations is likely necessary to yield a meaningful and sustained increase in the implementation of EBPs for PTSD in the MHS.
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In the past decade, military personnel supporting the wars in Iraq and Afghanistan have faced multiple deployments and repeated traumatic stressors. Despite efforts to prevent post-traumatic stress disorder (PTSD) and other combat-related emotional difficulties, a significant number of military personnel experience psychological injuries during and following their deployments. Despite increased attention to prevention and treatment of these problems, it is clear that substantially more work is required to fully understand the emotional impact of combat and to better intervene to prevent potentially chronic problems. In the present article, the authors discuss possible avenues for future research and interventions (clinical and otherwise) to better prevent the development of combat-related PTSD. We discuss screening, assessment, education, and intervention for PTSD throughout the deployment cycle. In this discussion, we attend to both the needs of the current cohort of combat veterans and the potential advances that may mitigate the severity and chronicity of post-traumatic problems arising from future conflicts.
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Distúrbios de Guerra/terapia , Militares , Transtornos de Estresse Pós-Traumáticos/terapia , Adaptação Psicológica , Distúrbios de Guerra/prevenção & controle , Distúrbios de Guerra/psicologia , Humanos , Medicina Militar , Transtornos de Estresse Pós-Traumáticos/prevenção & controle , Transtornos de Estresse Pós-Traumáticos/psicologiaRESUMO
INTRODUCTION: Mental health disparities and differences have been identified amongst all age groups, including adolescents. However, there is a lack of research regarding adolescents within the Military Health System (MHS). The MHS is a universal health care system for military personnel and their dependents. Research has indicated that the MHS removes many of the barriers that contribute to health disparities. Additional investigations with this population would greatly contribute to our understanding of disparities and health services delivery without the barrier of access to care. MATERIALS AND METHODS: This study analyzed the diagnostic trends of anxiety, depression, and impulse control disorders and differences within a national sample of adolescents of active-duty military parents. The study utilized 2006 to 2014 data in the MHS Data Repository for adolescents ages 13-18. The study identified 183,409 adolescents with at least one diagnosis. Multivariable logistic regressions were conducted to assess the differences and risks for anxiety, depression, and impulse control disorders in the identified sample. RESULTS: When compared to White Americans, minority patients had a higher likelihood of being diagnosed with an impulse control disorder (odds ratio [OR] = 1.43; confidence interval [CI] 1.39-1.48) and a decreased likelihood of being diagnosed with a depressive disorder (OR = 0.98; CI 0.95-1.00) or anxiety disorder (OR = 0.80; CI 0.78-0.83). Further analyses examining the subgroups of minorities revealed that, when compared to White Americans, African American adolescents have a much higher likelihood of receiving a diagnosis of an impulse control disorder (OR = 1.66; CI 1.61-1.72) and a lower likelihood of receiving a diagnosis of a depressive disorder (OR = 0.93; CI 0.90-0.96) and an anxiety disorder (OR = 0.75; CI 0.72-0.77). CONCLUSION: This study provides strong support for the existence of race-based differences in adolescent mental health diagnoses. Adolescents of military families are a special population with unique experiences and stressors and would benefit from future research focusing on qualitative investigations into additional factors mental health clinicians consider when making diagnoses, as well as further exploration into understanding how best to address this special population's mental health needs.
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Saúde Mental , Militares , Adolescente , Negro ou Afro-Americano , Transtornos de Ansiedade/diagnóstico , Transtornos de Ansiedade/epidemiologia , Humanos , Militares/psicologia , População BrancaRESUMO
Deployed service members regularly undergo demanding and stressful experiences that can contribute to mental health difficulties; however, there is a scarcity of studies examining rates of mental health disorders in-theater. The current study examined case rates of mental health disorders among deployed U.S. Army Soldiers using diagnostic encounter data from the Theater Medical Data Store. Case rates were calculated across 12 categories of mental health disorders. While in theater, soldiers' highest rates were for stress reactions and adjustment disorders, depression, anxiety, and sleep disorders. The lowest rates in theater were for psychosis, bipolar, somatic, and eating disorders. Notably, female soldiers had higher rates than their male counterparts for disorders in each of the 12 diagnostic categories. Results provide crucial information to aid in decision making about necessary interventions and provider competencies in deployed settings. Knowledge gained from these data may improve force readiness, help lessen disease burden, and inform military policy and prevention efforts.
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Transtornos Mentais , Militares , Transtornos do Sono-Vigília , Humanos , Masculino , Feminino , Estados Unidos/epidemiologia , Saúde Mental , Transtornos Mentais/epidemiologia , Transtornos de Ansiedade , Transtornos de AdaptaçãoRESUMO
Posttraumatic nightmares commonly occur after a traumatic experience. Despite significant deleterious effects on well-being and their role in posttraumatic stress disorder, posttraumatic nightmares remain understudied. The neuroanatomical structures of the amygdala, medial prefrontal cortex, hippocampus, and anterior cingulate cortex constitute the AMPHAC model (Levin and Nielsen, 2007), which is implicated in the neurophysiology of disturbing dreams of which posttraumatic nightmares is a part. However, this model has not been investigated using neuroimaging data. The present study sought to determine whether there are structural differences in the AMPHAC regions in relation to the occurrence of posttraumatic nightmares. Data were obtained from treatment-seeking male active duty service members (N = 351). Posttraumatic nightmares were not significantly related to gray matter volume, cortical surface area, or cortical thickness of any the AMPHAC regions when controlling for age and history of mild traumatic brain injury. Although the present analyses do not support an association between structural measures of AMPHAC regions and posttraumatic nightmares, we suggest that functional differences within and/or between these brain regions may be related to the occurrence of posttraumatic nightmares because functional and structural associations are distinct. Future research should examine whether functional differences may be associated with posttraumatic nightmares.
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Transtornos de Estresse Pós-Traumáticos , Veteranos , Masculino , Humanos , Sonhos , Transtornos de Estresse Pós-Traumáticos/diagnóstico por imagem , Transtornos de Estresse Pós-Traumáticos/etiologiaRESUMO
Barriers to mental healthcare services are reported among military service members. However, little is known about these barriers among the spouses of military personnel, who face unique stressors and may subsequently be at high-need for mental health services. Understanding barriers to care among this vulnerable population may help improve access to psychological services. The current study utilized data from the Millennium Cohort Family Study. Participants were referred by their military spouses or through targeted mailers. Participants completed self-report measures of mood, psychosocial functioning, and perceived barriers to mental healthcare via web- or paper-based surveys. A factor analysis was conducted to identify subscales of the barriers to mental healthcare measure, and logistic regressions were conducted adjusting for relevant sociodemographic variables, to determine psychosocial factors associated with likelihood of reporting barriers to mental healthcare. The sample comprised 9,666 military spouses (86% female; Mage: 27.73 ± 5.09; 29.2% racial/ethnic minority; 19.5% with prior/current military service). Logistic factors were the most frequently reported barrier to care (63%), followed by negative beliefs about mental healthcare (52%), fear of social/occupational consequences (35%), and internalized stigma (32%). Spouses with prior or current military service themselves and individuals with a psychiatric condition were most likely to report barriers to mental healthcare. A preponderance of military spouses reported barriers to mental healthcare services. Prospective data are needed to elucidate the associations between barriers to care and mental healthcare utilization. Efforts may be warranted to improve access to mental healthcare among the spouses of military personnel. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
Assuntos
Serviços de Saúde Mental , Militares , Etnicidade , Feminino , Humanos , Masculino , Militares/psicologia , Grupos Minoritários , Estudos Prospectivos , Cônjuges/psicologiaRESUMO
INTRODUCTION: Prolonged exposure therapy is an effective treatment for posttraumatic stress disorder that is underutilized in health systems, including the military health system. Organizational barriers to prolonged exposure implementation have been hypothesized but not systematically examined. This multisite project sought to identify barriers to increasing the use of prolonged exposure across eight military treatment facilities and describe potential solutions to addressing these barriers. MATERIALS AND METHODS: As part of a larger project to increase the use of prolonged exposure therapy in the military health system, we conducted a needs assessment at eight military treatment facilities. The needs assessment included analysis of clinic administrative data and a series of stakeholder interviews with behavioral health clinic providers, leadership, and support staff. Key barriers were matched with potential solutions using a rubric developed for this project. Identified facilitators, barriers, and potential solutions were summarized in a collaboratively developed implementation plan for increasing prolonged exposure therapy tailored to each site. RESULTS: There was a greater than anticipated consistency in the barriers reported by the sites, despite variation in the size and type of facility. The identified barriers were grouped into four categories: time-related barriers, provider-related barriers, barriers related to patient education and matching patients to providers, and scheduling-related barriers. Potential solutions to each barrier are described. CONCLUSIONS: The findings highlight the numerous organizational-level barriers to implementing evidence-based psychotherapy in the military health system and offer potential solutions that may be helpful in addressing the barriers.