Vietnam veteran perceptions of delayed onset and awareness of posttraumatic stress disorder.

Although 40 years have passed since the Vietnam War, demand for treatment of posttraumatic stress disorder (PTSD) among veterans from this conflict has increased steadily. This study investigates the extent to which two factors, delayed onset or awareness of PTSD symptoms, may influence this demand. Using data from two studies of Vietnam Veterans in outpatient (n = 353) and inpatient (n = 721) PTSD treatment, this analysis examines retrospective perceptions of the time of symptom onset and awareness of the connection between symptoms and war-zone stress. The association of these two constructs with pre-war, wartime, and post-war clinical variables are analyzed. Delay in onset of symptoms was reported by 50% of outpatients and 35% of inpatients. Delay in awareness was reported by 60% of outpatients and 65% of inpatients. Onset of symptoms occurred within six years and onset of awareness within 20 years in 90% of individuals. Reported delays in onset and awareness were associated with more numerous negative life events after military service and before the onset of symptoms. Findings suggest that providers, administrators, and policy makers should be aware of the potential for protracted treatment demand among veterans from current conflicts, due in part by delay in onset and awareness of symptoms.

Does PTSD moderate the relationship between social support and suicide risk in Iraq and Afghanistan War Veterans seeking mental health treatment?

OBJECTIVE: This study examined posttraumatic stress disorder (PTSD) as a potential moderating variable in the relationship between social support and elevated suicide risk in a sample of treatment-seeking Iraq and Afghanistan War Veterans. METHOD: As part of routine care, self-reported marital status, satisfaction with social networks, PTSD, and recent suicidality were assessed in Veterans (N=431) referred for mental health services at a large Veteran Affairs Medical Center. Logistic regression analyses were conducted using this cross-sectional data sample to test predictions of diminished influence of social support on suicide risk in Veterans reporting PTSD. RESULTS: Thirteen percent of Veterans were classified as being at elevated risk for suicide. Married Veterans were less likely to be at elevated suicide risk relative to unmarried Veterans and Veterans reporting greater satisfaction with their social networks were less likely to be at elevated risk relative to Veterans reporting lower satisfaction. Satisfaction with social networks was protective for suicide risk in PTSD and non-PTSD cases, but was significantly less protective for veterans reporting PTSD. CONCLUSIONS: Veterans who are married and Veterans who report greater satisfaction with social networks are less likely to endorse suicidal thoughts or behaviors suggestive of elevated suicide risk. However, the presence of PTSD may diminish the protective influence of social networks among treatment-seeking Veterans.

War zone veterans returning to treatment: effects of social functioning and psychopathology.

Patients with mental illness often return for further treatment after an initial episode of care. Two processes that may contribute to the return for further treatment are the severity of patients' initial social and clinical status; and/or deterioration in their status over time, regardless of their initial status. This study examined these processes in an administrative database of war zone veterans who had received outpatient treatment from a Veterans Affairs specialized posttraumatic stress disorder program. The results suggest that both initial severity and deterioration of status contribute to return to treatment and involve changes in both social functioning and psychopathology. Determination of the direction of effects between social functioning and psychopathology showed that psychopathology in the form of PTSD, other Axis I disorder or violent behavior generally affected subsequent social functioning, but not vice versa. Psychopathology in the form of alcohol or drug abuse/dependence, however, showed reciprocal effects with social functioning. These results point to the importance of emphasizing interventions that address social dysfunction and that address psychopathology, from the beginning of treatment as a way of maximizing the benefits and minimizing the need for recurrent care.

Influence of PTSD symptom clusters on smoking status among help-seeking Iraq and Afghanistan veterans.

INTRODUCTION: Despite the strong association between smoking and posttraumatic stress disorder (PTSD), mechanisms influencing smoking in this population remain unclear. Previous smoking research has largely examined PTSD as a homogenous syndrome despite the fact that PTSD is composed of four distinct symptom clusters (i.e., reexperiencing, effortful avoidance, emotional numbing, and hyperarousal). Examination of the relationship between smoking and PTSD symptom clusters may increase understanding of mechanisms influencing comorbidity between smoking and PTSD. The goals of the present study were to (a) examine the influence of overall PTSD symptom severity on likelihood of smoking and smoking heaviness and (b) examine the influence of each PTSD symptom cluster on smoking. METHODS: Participants (N = 439) were Operation Iraqi Freedom/Operation Enduring Freedom combat veterans referred to VA mental health services. RESULTS: Multinomial logistic regression was chosen to accommodate a three-level outcome, in which the likelihood of being a nonsmoker was compared with (a) light smoking (1-9 cigarettes/day), (b) moderate smoking (10-19 cigarettes/day), and (c) heavy smoking (> or =20 cigarettes/day). Results showed that veterans with higher levels of overall PTSD symptomatology were more likely to endorse heavy smoking (Wald = 4.56, p = .03, odds ratio [OR] = 1.65). Veterans endorsing high levels of emotional numbing were also more likely to endorse heavy smoking (Wald = 6.49, p = .01, OR = 1.81); all other PTSD symptom clusters were unrelated to smoking. DISCUSSION: The association between emotional numbing and heavy daily smoking suggests that veterans with PTSD may smoke to overcome emotional blunting following trauma exposure.

Evaluating the reliability of multiple assessments of PTSD symptomatology: multiple examiners, one patient.

The objective of this investigation was to assess the inter-examiner reliability of PTSD symptomatology by 12 clinical examiners who evaluated independently a single-case Vietnam-Era veteran, using videotaped clinician interviews with The Clinician Administered PTSD Scale-1 (CAPS-1). A second patient was utilized for cross-validation purposes. Data were analyzed using a specially designed Kappa statistic. In previous reliability assessments of the CAPS-1, a pair of examiners assessed multiple patients, and demonstrated evidence of high reliability and validity. As in previous reliability assessments, reliability was assessed both for frequency and intensity of PTSD symptomatology in both patients. Results indicated that the reliability levels of the CAPS-1 were consistently and almost exclusively in the excellent to perfect levels of inter-examiner agreement, as based upon both global assessments and on a symptom-by-symptom basis. The results of this investigation are interpreted in the broader framework of their applicability to assessing inter-examiner agreement in clinical trials or other large multi-site studies.

Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans.

Posttraumatic stress disorder (PTSD) was examined as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans (N = 407) referred to Veterans Affairs mental health care. The authors also examined if risk for suicidal ideation was increased by the presence of comorbid mental disorders in veterans with PTSD. Veterans who screened positive for PTSD were more than 4 times as likely to endorse suicidal ideation relative to non-PTSD veterans. Among veterans who screened positive for PTSD (n = 202), the risk for suicidal ideation was 5.7 times greater in veterans who screened positive for two or more comorbid disorders relative to veterans with PTSD only. Findings are relevant to identifying risk for suicide behaviors in Iraq and Afghanistan War veterans.

Treatment-seeking veterans of Iraq and Afghanistan: comparison with veterans of previous wars.

Differences in the characteristics and mental health needs of veterans of the Iraq/Afghanistan war when compared with those of veterans who served in the Persian Gulf war and in the Vietnam war may have important implications for Veterans Affairs (VA) program and treatment planning. Subjects were drawn from administrative data bases of veterans who sought treatment from specialized VA programs for treatment of posttraumatic stress disorder (PTSD). Current Iraq/Afghanistan veterans were compared with 4 samples of outpatient and inpatient Persian Gulf and Vietnam veterans whose admission to treatment was either contemporaneous or noncontemporaneous with their admission. A series of analyses of covariance was used hierachically to control for program site and age. In analyses of contemporaneous veterans uncontrolled for age, Iraq/Afghanistan veterans differed most notably from Vietnam veterans by being younger, more likely to be female, less likely to be either married or separated/divorced, more often working, less likely to have ever been incarcerated, and less likely to report exposure to atrocities in the military. Regarding clinical status, Iraq/Afghanistan veterans were less often diagnosed with substance abuse disorders, manifested more violent behavior, and had lower rates of VA disability compensation because of PTSD. Differences are more muted in comparisons with Persian Gulf veterans, particularly in those involving noncontemporaneous samples, or those that controlled for age differences. Among recent war veterans with PTSD, social functioning has largely been left intact. There is a window of opportunity, therefore, for developing and focusing on treatment interventions that emphasize the preservation of these social assets.

An empirical conceptualization of the recovery orientation.

OBJECTIVE: The recovery movement is having a growing impact on policy for people with severe mental illness. The empirical literature on the recovery orientation, however, is scant, and no empirical conceptualization of recovery has been published. METHOD: We identified items reflecting recovery themes and measuring aspects of subjective experience, and used principle components and confirmatory factor analyses to develop an empirical conceptualization of the recovery orientation, using data from a large, systematic study of schizophrenia. RESULTS: We identified four domains of the recovery orientation: empowerment, hope and optimism, knowledge and life satisfaction. CONCLUSIONS: We propose here an initial approach to measuring and conceptualizing recovery attitudes. We also suggest that the evidence-based practice (EBP) movement may help to identify interventions that promote the recovery orientation and help to advance recovery attitudes. We suggest that there is a bidirectional relationship between recovery attitudes and the positive clinical outcomes that are the goals of EBPs. Through the use of empirically derived conceptualizations of recovery, EBPs can provide a mechanism for identifying treatments that promote the recovery orientation. The conceptualization proposed here can, thus, serve as a tool to assess changes in recovery attitudes during participation in specific EBPs.

Use of mental health services by veterans with PTSD after the terrorist attacks of September 11.

OBJECTIVE: Community surveys have demonstrated significant psychological distress since the terrorist attacks of Sept. 11, 2001. Since people with posttraumatic stress disorder (PTSD) and other mental illnesses are especially vulnerable to stressful events, the authors examined the use of PTSD treatment services and other mental health services at Department of Veterans Affairs (VA) medical centers in New York City and elsewhere after the attacks. METHOD: Analysis of variance was used to compare changes in average daily service use in the 6 months before and the 6 months after September 11, with changes in service use across the same months in the 2 previous years. Chi-square tests were used to examine differences from previous years in the proportion of new patients (i.e., who had not received treatment in the previous 6 months) entering treatment after September 11. RESULTS: There was no significant increase in the use of VA services for the treatment of PTSD or other mental disorders or in visits to psychiatric or nonpsychiatric clinics in New York City after September 11 and no significant change in the pattern of service use from previous years. Nor was there a significant increase in PTSD treatment in the greater New York area, Washington, D.C., or Oklahoma City or in the proportion of new patients. CONCLUSIONS: No increase was observed in the use of mental health services among VA patients with PTSD or other mental illnesses in response to the terrorist attacks of September 11.

Changing environments and alternative perspectives in evaluating the cost-effectiveness of new antipsychotic drugs.

This article examines the ways in which changes in the treatment environment and in measurement perspectives can affect the evaluation of cost-effectiveness of new medications. In three studies we reexamined data from a clinical trial of haloperidol and clozapine conducted from 1993 to 1996. The results of the studies are as follows: Study 1 found that clozapine treatment was associated with significantly reduced inpatient costs, and increased outpatient costs, suggesting that as systems use less inpatient care and more outpatient care, more effective medications may increase, rather than decrease, costs in sicker patients. Study 2 found that while provider assessments and standard measures favored clozapine over haloperidol, patient responses showed little evidence of a clinical advantage for clozapine and a less favorable side-effect profile. Study 3 found that while annual drug costs in the published trial were estimated to be dollars 4,545 for a full year of clozapine treatment, atypical antipsychotic costs in 2000 were estimated to range from dollars 1,254 to dollars 3,016 in the Department of Veterans Affairs system, and from dollars 2,221 to dollars 8,147 in the private sector. In conclusion, cost-effectiveness, as evaluated in studies like CATIE, will increasingly need to be tied to service system contingencies, environments, and evaluation perspectives.