Post-traumatic growth among veterans in the USA: results from the National Health and Resilience in Veterans Study.

BACKGROUND: There is increasing recognition that, in addition to negative psychological consequences of trauma such as post-traumatic stress disorder (PTSD), some individuals may develop post-traumatic growth (PTG) following such experiences. To date, however, data regarding the prevalence, correlates and functional significance of PTG in population-based samples are lacking. METHOD: Data were analysed from the National Health and Resilience in Veterans Study, a contemporary, nationally representative survey of 3157 US veterans. Veterans completed a survey containing measures of sociodemographic, military, health and psychosocial characteristics, and the Posttraumatic Growth Inventory-Short Form. RESULTS: We found that 50.1% of all veterans and 72.0% of veterans who screened positive for PTSD reported at least 'moderate' PTG in relation to their worst traumatic event. An inverted U-shaped relationship was found to best explain the relationship between PTSD symptoms and PTG. Among veterans with PTSD, those with PTSD reported better mental functioning and general health than those without PTG. Experiencing a life-threatening illness or injury and re-experiencing symptoms were most strongly associated with PTG. In multivariable analysis, greater social connectedness, intrinsic religiosity and purpose in life were independently associated with greater PTG. CONCLUSIONS: PTG is prevalent among US veterans, particularly among those who screen positive for PTSD. These results suggest that there may be a 'positive legacy' of trauma that has functional significance for veterans. They further suggest that interventions geared toward helping trauma-exposed US veterans process their re-experiencing symptoms, and to develop greater social connections, sense of purpose and intrinsic religiosity may help promote PTG in this population.

Self-concept changes related to war captivity.

A questionnaire was mailed to all US Air Force repatriated prisoners of the Vietnam was (POWs) still on active duty, and to matched controls, in the fall of 1976. Results were analyzed to determine long-term consequences of the war imprisonment experience. We hypothesized that individuals experiencing the greatest stress and frustration might believe they gained more psychologically than those less stressed. The questionnaire results indicated a distinct subgroup of POWs for which this was particularly true, although the subjective sense of feeling somehow "benefited" by the experience was by no means universal. This study supports the hypothesis that the subjective sense of having benefited from the experience of war imprisonment is positively correlated with the harshness of the experience.

Training and career activity. The experience of the Yale Advanced Track Program.

The Advanced Track Program of the Yale psychiatric residency is examined by a study of the career patterns of 132 graduates of the program over a 9-year period (1973 to 1982). The findings demonstrate that specific track training sequences are associated with subsequent career activities and that track graduates differ significantly from each other along dimensions of professional activities, work settings, treatment modalities, and patient characteristics. These differences are discussed from the vantage of the relationship between training and professional activity.

Effect of patient gender on evaluation of intern performance.

To explore the effect of patient gender on the perceptions of intern performance, 366 patients were interviewed during hospitalization in acute medical services. Women reported being more satisfied with the care they received than did men. In particular, women were more satisfied than men with their intern's demonstration of personal concern. The women placed more importance on personal manner and concern, and their greater satisfaction with these behaviors may have contributed to higher ratings of overall satisfaction. In contrast, the men seemed less satisfied with their intern's personal concern; they also tended to weigh such concern less in determining overall satisfaction. Men considered the presentation of information by the physician and the establishment of dialogue with the physician as more important. The amount of such dialogue may have been inadequate to generate higher levels of overall satisfaction for the men patients.

Audiotape playback as a technique in the treatment of schizophrenic patients.

The authors report on the use of playing back audiotaped portions of the speech of two schizophrenic patients during psychotherapy. They believe that this audiotape replay was instrumental in organizing the patients' thoughts and spoken communications and that it might also have facilitated the patients' participation in psychotherapy. The usefulness of this strategy is illustrated with clinical material.

The psychiatrist's role in aerospace operations.

This paper presents two unique aspects of aerospace psychiatry: the influence of the specialized stressors and occupational requirements of an aviation career and the ambiguous role of the aerospace psychiatrist. Aerospace psychiatrists have multiple, sometimes conflicting, responsibilities to the organization and society (the social control task) and to the individual aviator (the humanistic and medical tasks). In the two case reports below the authors describe airmen who had vasovagal syncope and how the psychiatrist intervened and resolved these conflicting tasks.

Four-year evaluation of a psychiatric clerkship: 1982-1986.

The authors describe a psychiatric clerkship organized to achieve goals relevant to all medical students, regardless of their future specialty choice. The clerkship had been in place for 8 years in 1986, and standardized program evaluations were available for 4 years. A survey of the diverse clinical settings used for the clerkship showed that each had unique strengths and weaknesses but that each could meet the core goals of the clerkship, indicating that this clerkship design would also be feasible in a smaller department with any one or two of the settings available.

Health and disability costs of depressive illness in a major U.S. corporation.

OBJECTIVE: Employers are playing an increasingly influential role in determining the scope and character of health coverage in the United States. This study compares the health and disability costs of depressive illness with those of four other chronic conditions among employees of a large U.S. corporation. METHOD: Data from the health and employee files of 15,153 employees of a major U.S. corporation who filed health claims in 1995 were examined. Analyses compared the mental health costs, medical costs, sick days, and total health and disability costs associated with depression and four other conditions: heart disease, diabetes, hypertension, and back problems. Regression models were used to control for demographic differences and job characteristics. RESULTS: Employees treated for depression incurred annual per capita health and disability costs of $5,415, significantly more than the cost for hypertension and comparable to the cost for the three other medical conditions. Employees with depressive illness plus any of the other conditions cost 1.7 times more than those with the comparison medical conditions alone. Depressive illness was associated with a mean of 9.86 annual sick days, significantly more than any of the other conditions. Depressed employees under the age of 40 years took 3.5 more annual sick days than those 40 years old or older. CONCLUSIONS: The cost of depression to employers, particularly the cost in lost work days, is as great or greater than the cost of many other common medical illnesses, and the combination of depressive and other common illnesses is particularly costly. The strong association between depressive illness and sick days in younger workers suggests that the impact of depression may increase as these workers age.

Day hospital/crisis respite care versus inpatient care, Part II: Service utilization and costs.

OBJECTIVE: The authors compared service utilization and costs for acutely ill psychiatric patients treated in a day hospital/crisis respite program or in a hospital inpatient program. METHOD: The patients (N = 197) were randomly assigned to one of the two programs and followed for 10 months after discharge. Both programs were provided by a community mental health center (CMHC) in a poor urban community. Data were collected for developing service utilization profiles and estimates of per-unit costs of the inpatient, day hospital, and outpatient services provided by the CMHC. RESULTS: On average, the day hospital/crisis respite program cost less than inpatient hospitalization. The average saving per patient was +7,100, or roughly 20% of the total direct costs. There were no significant differences between programs in service utilization or costs during the follow-up phase. Cost savings accrued in the index episode because per-unit costs were lower for day hospital/crisis respite and the average stay was shorter. Significant differences in cost were found among patient groups with psychosis, affective disorders, and dual diagnoses; psychotic patients had the highest costs in both programs. The two programs had roughly equal direct service staff and capital costs but significantly different operating costs (day hospital/crisis respite operating costs were 51% of inpatient hospital costs). CONCLUSIONS: The programs were equally effective, but day hospital/crisis respite treatment was less expensive for some patients. Potential cost savings are higher for nonpsychotic patients. Cost differences between the programs are driven by the hospital's relatively higher overhead costs. The roughly equal expenditures for direct service staff costs in the two programs may be an important clue for understanding why these programs provided equally effective acute care.

Effect of time-limited psychotherapy on patient dropout rates.

The authors conducted an archival study of 149 new clinic patients at a large community mental health center. The dropout rate for patients in brief psychotherapy in which the length of therapy was specified at the outset of treatment (time-limited psychotherapy) (32%) was about one-half the dropout rate for patients in brief (67%) and long-term (61%) individual psychotherapy. The difference in dropout rates could not be explained by patient demographic or diagnostic variables or by therapist characteristics measured in the study. The results suggest that setting a specific time limit on individual psychotherapy at the outset of treatment can reduce the patient dropout rate in a public mental health clinic.

Educational objectives in psychiatric residency training: a survey of training directors and residents.

The authors surveyed 200 physicians completing their psychiatric residencies on the importance and achievement of 124 core training objectives. One hundred thirty (65%) of the residents and all 23 of the training directors of the programs selected responded. As a group, residents viewed a substantial number of the objectives as less important, and less well accomplished, than did their training directors. The discordantly rated objectives fell in several basic areas of psychiatric competence, such as the management of schizophrenia and drug side effects. Certain objectives were rated at a lower level of accomplishment by residents from smaller programs. Possible factors accounting for these differences are briefly considered.

Applicants' choice of a residency training program.

The authors present results from a survey of senior medical students in the class of 1981 concerning their selection of residency training programs in psychiatry. Generally, students were more influenced by clinical training opportunities and quality of life factors and not much influenced by the philosophy of the program. The implications of the findings are discussed from the perspectives of both advising and recruiting medical students.

Beginning careers in academic psychiatry for women--"Bermuda Triangle"?

OBJECTIVE: The proportion of women in leadership positions in academic psychiatry has not kept pace with the increase in the number of women entering the field. This study examines differences in career activities between women and men who graduated from the Yale University psychiatric residency training program and explores whether these differences can be explained by preresidency expectations, residency experiences, or training immediately after residency. METHOD: Departmental educational records of the Yale residency program were reviewed to determine professional interests expressed before psychiatric residency and training focus during residency for 355 residents in the 1970-1983 graduating classes. A 1984 follow-up study focused on their postresidency career activities. Differences in preresidency interests and experiences, training activities, and career paths between all female and male graduates and between women and men who chose academic careers were examined. RESULTS: After residency, the female graduates' marital status differed from men's--more had never married or were divorced. Women's professional activities diverged from men's; their practice pattern was different, they spent more hours teaching, and they had fewer publications in peer-reviewed journals. This divergence was not accounted for by differences in pretraining interests or in training focus during residency. The authors present possible explanations. CONCLUSIONS: Further research is indicated to determine the underlying causes of career differences between women and men in psychiatric practice and academia so that effective strategies for correcting the present inequality of women in senior faculty positions can be implemented.

Case management in psychiatry: an analysis of tasks.

OBJECTIVE: The authors analyze the concept of case management from the perspective of the task areas of psychiatry and demonstrate the importance of case management in the organization of psychiatric services. METHOD: The relevant literature was reviewed, and a functional analysis of current practices is provided. RESULTS: Case management is an ambiguous concept without a clear base in a professional discipline, and thus there is ongoing uncertainty about its mission, practice, and training, as well as authority and accountability issues. The activities of the case manager in both the private and the public sectors entail work in the task areas of medical care, rehabilitation, social control, growth and development, and social welfare. In all of these areas, the case manager may function in boundary management and in system enhancement and development as well as provide clinical services. CONCLUSIONS: Case management has considerable potential as a means of organizing and delivering mental health services in a cost-effective manner as long as its purpose, practice, and organizational structures are consistent. Psychiatrists should be involved in the organization of case management services.

Day hospital/crisis respite care versus inpatient care, Part I: Clinical outcomes.

OBJECTIVE: The authors investigated the clinical feasibility and the outcome for patients of a program designed as an alternative to acute hospitalization. METHOD: This was a random-design study comparing a conventional inpatient program for urban, poor, severely ill voluntary patients who usually require hospitalization to an alternative experimental program consisting of a day hospital linked to a crisis residence. Patients were assessed with standardized measures of symptoms, functioning, social adjustment, quality of life, and satisfaction with clinical services upon admission to the study, at discharge from the index admission, and at follow-ups 2, 5, and 10 months after discharge. RESULTS: One hundred ninety-seven patients were enrolled in the 2-year research program and followed for 10 months. Of the voluntary patients who would have been admitted to the hospital, 83% were appropriate for the experimental program. The clinical, functional, social adjustment, quality of life, and satisfaction outcome measures were not statistically different for the patients in the two treatment conditions; however, there was a slightly more positive effect of the experimental program on measures of symptoms, overall functioning, and social functioning. CONCLUSIONS: The experimental condition, a combined day hospital/crisis respite community residence, seems to have had the same treatment effectiveness as acute hospital care for urban, poor, acutely ill voluntary patients with severe mental illness.

A curriculum for education in geriatric psychiatry.

The authors present recommendations for educating medical students and psychiatric residents in geropsychiatry. They are primarily concerned with the objectives and methods rather than the content of training. Proposals are structured in terms of training objectives and educational settings in which such training takes place. The proposals are intended to be specific enough to be truly useful and at the same time sufficiently generalizable to adapt to geropsychiatric training in a variety of institutions. Priority is given to integrating knowledge of normal and abnormal aging with the clinical skills and empathy necessary to approach patients with competence and understanding.

Evaluation of intern performance by medical inpatients.

Patients, as the recipients of medical care, have a unique and crucial perspective from which to judge the performance of physicians. In this study, 27 interns (postgraduate year 1 residents) were evaluated by a sample of 212 medical inpatients at two university-affiliated hospitals using a previously validated questionnaire constructed from patients' comments. Patients were generally very satisfied with the performance of their interns and valued traditional clinical skills and interpersonal skills equally. The most important and characteristic attributes of the interns as rated by patients were demonstrating personal concern, skill in treating disease, providing information about findings, preparation for impending events, availability, manner of communication, trust, and comforting and listening skills. Encouraging mutuality by the interns was not often done and was not believed to be particularly important by patients. Older patients and whites were more satisfied with their interns, whereas college-educated, employed, and male patients were less satisfied. Implications of the findings for understanding and teaching about the physician-patient relationship are discussed.

Working memory, attention, and communication disturbances in schizophrenia.

The authors hypothesized that schizophrenic communication disturbances reflect specific cognitive deficits in the areas of working memory and attention. They examined the cognitive correlates of communication disturbances, as measured by linguistic reference performance, in schizophrenic (n = 48), bipolar (n = 24), and nonpsychiatric control (n = 23) individuals. Reference performance ratings in the schizophrenic patients were associated with scores on tests of working memory and attention and were not related to performance on concept formation or verbal fluency tests. In contrast, in the bipolar and nonpsychiatric individuals, reference performance was associated with concept formation and verbal fluency test scores but was not related to performance on tests of working memory. Implications with respect to the processes underlying schizophrenic communication disturbances are discussed.

Reintroducing the internship: reactions of three departments of psychiatry.

The reintroduction of the internship requirement has caused a number of changes in psychiatric education in the past decade. Many psychiatric educators and departments of psychiatry have been faced with the challenges of organizing internships and establishing an internship curriculum. This has been especially challenging because the psychiatrists involved have seldom had full postgraduate training in the fields being organized and have not previously administrated clinical services in those areas. The authors discuss the goals of the internship for future psychiatrists and the pros and cons of university versus community general hospital based internships for future psychiatrists, and find several potential advantages to the latter. Also discussed are their consistent observations of internship programs for future psychiatrists over the past decade in three geographically separate regions and in state and private institutions. They and most other faculty members in their respective departments believe that the reinstitution of the internship has had largely beneficial effects on future psychiatrists.

Normative implications of the relationship between reading vocabulary and Boston Naming Test performance.

The 60-item Boston Naming Test (BNT) was published in 1983 with norms described as provisional. One recent finding (Thompson & Heaton, 1989) suggests that verbal intelligence, and the Wechsler Adult Intelligence Scale (WA1S)-Revised Vocabulary subtest, in particular, is strongly correlated with BNT performance, and that education is moderately so. High false-positive rates for naming deficit may conceivably result from the application of the published norms with subjects of lower verbal abilities or limited educational backgrounds. To further explore the relationship of naming to other verbal abilities, analyses were undertaken of the correlations between Level 7-9 Gates-MacGinite Reading Vocabulary Test (G-MRVT) and BNT data from 97 schizophrenic, bipolar, and normal subjects. Reading vocabulary is strongly correlated with BNT performance, and the nature of this relationship is essentially the same across the three diagnostic groups. Application of the published norms would have resulted in a high false-positive rate for naming deficit in all groups among subjects with reading vocabularies equivalent to twelfth grade or less. As a word-recognition based reading exercise, the G-MRVT is likely to provide a brain-compromise-resistant index against which the adequacy of naming performances can be assessed. Accordingly, G-MRVT based BNT performance expectation guidelines are presented for use as a complement to the published norms. Other implications are discussed.