PTSD symptoms are differentially associated with general distress and physiological arousal: Implications for the conceptualization and measurement of PTSD.

BACKGROUND: The primary purpose of this study was to examine the place of posttraumatic stress disorder (PTSD) vis-à-vis the external dimensions of general distress and physiological arousal. METHODS: Using data collected from veterans of the wars in Iraq and Afghanistan (N = 1350), latent variable covariance structure modeling was employed to compare correlations of PTSD symptom clusters and individual PTSD symptoms with general distress and physiological arousal. RESULTS: Each PTSD symptom cluster, and 17 of 20 individual PTSD symptoms were more strongly associated with general distress than with physiological arousal. However, moderate to strong associations were also found between physiological arousal and both PTSD clusters and symptoms. LIMITATIONS: Findings are based on self-reported data elicited from a single sample of veterans with substantial PTSD symptoms. Replication, particularly by clinician interview, is necessary. Generalizability to other traumatized populations is unknown. CONCLUSIONS: Results offer support, with caveats, for viewing PTSD as a distress disorder. Findings are not consistent with the position that PTSD is a hybrid disorder with some features reflecting hyperarousal and others indicative of general distress. Results have implications for the conceptualization and measurement of PTSD.

Recruitment and retention of young adult veteran drinkers using Facebook.

The objective of this study was to describe the feasibility of using Facebook as a platform to recruit and retain young adult veteran drinkers into an online-alcohol use intervention study. Facebook's wide accessibility and popularity among the age group that comprises the majority of veterans from the conflicts in Iraq and Afghanistan make it a compelling resource through which research can extend its reach to this otherwise hard-to-reach group. We developed a series of Facebook advertisement campaigns to reach veteran drinkers not specifically searching for alcohol treatment. In doing so, we recruited 793 valid veteran participants in approximately two weeks for an advertising cost of $4.53 per obtained participant. The study sample consisted primarily of male veterans, between 19 and 34 years of age, who were drinking at moderate to heavy levels. Although about half of the sample reported mental health comorbidity, few had received any mental health or substance use treatment in the past year. Facebook appears to be a valuable mechanism through which to recruit young veterans with unmet behavioral health needs, although more specific efforts may be needed to engage certain types of veterans after initial study enrollment.

A randomized controlled trial of a web-based, personalized normative feedback alcohol intervention for young-adult veterans.

OBJECTIVE: Young-adult American veterans are at risk for problematic alcohol use. However, they are unlikely to seek care and may drop out from lengthy, multicomponent treatments when they do get care. This randomized controlled trial tested a very brief alcohol intervention delivered over the Internet to reach the population of young-adult veterans to help reduce their drinking. METHOD: Veterans (N = 784) were recruited from Facebook and randomized to either a control condition or a personalized normative feedback (PNF) intervention seeking to correct drinking perceptions of gender-specific veteran peers. RESULTS: At immediate postintervention, PNF participants reported greater reductions in their perceptions of peer drinking and intentions to drink over the next month, compared with control participants. At 1-month follow-up, PNF participants reduced their drinking behavior and related consequences to a significantly greater extent than controls. Specifically, PNF participants drank 3.4 fewer drinks per week, consumed 0.4 fewer drinks per occasion, binge drank on 1.0 fewer days, and experienced about 1.0 fewer consequences than control participants in the month after the intervention. Intervention effects for drinks per occasion were most pronounced among more problematic drinkers. Changes in perceived norms from baseline to 1-month follow-up mediated intervention efficacy. CONCLUSION: Though effects were assessed after only 1 month, findings have potential to inform broader, population-level programs designed for young veterans to prevent escalation of drinking and development of long-term alcohol problems. Given the simplicity of the PNF approach and ease of administration, this intervention has the potential for a substantial impact on public health. (PsycINFO Database Record

Behavioral Health Treatment Receipt Among a Community Sample of Young Adult Veterans.

Young adult veterans are at risk for behavioral health problems such as depression, posttraumatic stress disorder (PTSD), and substance misuse. Despite this, studies of veterans within the Veterans Affairs Healthcare System (VA) indicate that about half of those warranting treatment receive it in any form, with few receiving an adequate dose of care. For this study, the behavioral health screening status and behavioral health usage (including care outside of VA settings) among a community sample of 812 young adult veterans recruited from the Internet is described. Although approximately 70% of the sample screened positive for behavioral health problems, only one fifth to three fifths of those screening positive reported any mental health or substance use treatment in the past year, with one third or less receiving a dose of minimally adequate psychotherapy or psychotropic care. Findings expand on prior work and suggest that more effort is necessary to engage young veterans in behavioral health services.

Combat experience and problem drinking in veterans: Exploring the roles of PTSD, coping motives, and perceived stigma.

PURPOSE: The current investigation sought to illustrate the etiology of adverse alcohol consequences in young adult veterans using a path analytic framework. METHODS: A total of 312 veterans aged 19-34 were enrolled in a larger intervention study on alcohol use. At baseline, participants completed measures of combat severity, PTSD symptom severity, and drinking motives to cope. At one month follow-up, participants completed measures of perceived stigma of behavioral health treatment seeking and past 30-day alcohol consequences. RESULTS: After entering the covariates of age, gender, race/ethnicity, and past year behavioral health treatment utilization, a path analytic model demonstrated a good fit to the data predicting alcohol consequences in this population. Further, a separate exploratory analysis confirmed that both drinking motives to cope and perceived stigma of behavioral health treatment seeking mediated the link between PTSD symptom severity and alcohol consequences. CONCLUSIONS: The current model expands upon prior research showing the relationship between combat severity and alcohol use behavior in young adult veterans. Results support the notion that veterans with PTSD symptoms may drink to cope and that perceived stigma surrounding help seeking may further contribute to alcohol related problems.

Study protocol for a web-based personalized normative feedback alcohol intervention for young adult veterans.

BACKGROUND: Young adult veterans from the wars in Iraq and Afghanistan represent a population at-risk for heavy and problematic alcohol use. Unfortunately, few seek treatment for alcohol concerns and those that do seek care may drop out from lengthy multicomponent treatments. Additionally, veterans who live in rural areas and those who are not engaged in the Veterans Affairs Healthcare System are often overlooked, difficult to engage in treatment, and may not be actively seeking treatment for heavy patterns of use that may develop into an alcohol use disorder. The objective of this proposed randomized controlled trial is to develop and pilot test a brief, stand-alone Internet-based alcohol intervention with young adult veterans to help them reduce their drinking and prevent the development of problematic alcohol use. METHODS/DESIGN: Recruitment and intervention is delivered entirely over the Internet to address barriers to seeking care among this at-risk group. The online intervention consists of an assessment followed by a single module of personalized normative feedback (PNF), which provides individuals with accurate information to reduce misperceptions regarding the frequency and acceptability of risky peer behavior. PNF has established efficacy as included within multicomponent interventions targeting military populations or as a stand-alone intervention with young adult college students, but has not yet been empirically supported for the at-risk veteran population. This paper describes the development of the PNF intervention content and details the protocol for the intervention study, which will utilize a sample of 600 young adult veterans to examine the efficacy of the brief PNF intervention targeted toward reducing perceived norms, intentions to drink, actual drinking behavior, and consequences. Specific subpopulations of this veteran population, including those with mental health concerns and those differentiated by level of drinking problems, reasons for drinking, and connection to peers, will be examined to support generalizability of the intervention. DISCUSSION: This intervention has the potential to improve veteran health care by utilizing a novel approach to increase access to care, assist with drinking reductions, and prevent alcohol-related problems. Trial registration ClinicalTrials.gov Identifier NCT02187887.

Young adult veteran perceptions of peers' drinking behavior and attitudes.

Social norms-based interventions have shown promise in reducing drinking behavior and the resulting consequences in young adults. Although most research has focused on young civilians (i.e., college students), some studies have investigated social norms-based interventions with active-duty military and veteran samples. Yet, research has not yet determined how to maximize the effectiveness of social norms-based interventions in this heavy-drinking population. As an initial step toward this goal, the current study utilized a community sample of 1,023 young adult veterans to examine (a) whether veteran perceptions of the drinking behavior of their veteran peers differ from their perceptions of civilian drinking behavior, (b) whether perceptions of specific veteran groups differ from the actual drinking behavior of veterans within those groups, (c) what levels of specificity in reference groups (same-gender civilians, same-branch veterans, same-gender veterans, or same-branch-and-gender veterans) are most strongly associated with veterans' own drinking, and (d) whether perceptions about others' attitudes toward drinking also contribute independently of perceived behavioral norms to veteran drinking. Findings indicated that participants perceived that other veterans drank more than civilians and that veteran groups drank more than veterans in the sample actually drank. Veteran-specific perceived behavioral norms were similar in their associations with drinking outcomes, whereas same-gender civilian perceived behavioral norms exhibited little or no associations with drinking. Veteran-specific perceived attitudinal norms exhibited little or no association with drinking behavior after controlling for perceived behavioral norms. These findings can be used to inform the development of social norms interventions for young adult veterans.

Diabetes and Cardiovascular Disease Risk in Cambodian Refugees.

UNLABELLED: To determine rates of diabetes, hypertension, and hyperlipidemia in Cambodian refugees, and to assess the proportion whose conditions are satisfactorily managed in comparison to the general population. Self-report and laboratory/physical health assessment data obtained from a household probability sample of U.S.-residing Cambodian refugees (N = 331) in 2010-2011 were compared to a probability sample of the adult U.S. population (N = 6,360) from the 2009-2010 National Health and Nutrition Examination Survey. Prevalence of diabetes, hypertension and hyperlipidemia in Cambodian refugees greatly exceeded rates found in the age- and gender-adjusted U.S. POPULATION: Cambodian refugees with diagnosed hypertension or hyperlipidemia were less likely than their counterparts in the general U.S. population to have blood pressure and total cholesterol within recommended levels. Increased attention should be paid to prevention and management of diabetes and cardiovascular disease risk factors in the Cambodian refugee community. Research is needed to determine whether this pattern extends to other refugee groups.

Using facebook to recruit young adult veterans: online mental health research.

BACKGROUND: Veteran research has primarily been conducted with clinical samples and those already involved in health care systems, but much is to be learned about veterans in the community. Facebook is a novel yet largely unexplored avenue for recruiting veteran participants for epidemiological and clinical studies. OBJECTIVE: In this study, we utilized Facebook to recruit a sample of young adult veterans for the first phase of an online alcohol intervention study. We describe the successful Facebook recruitment process, including data collection from over 1000 veteran participants in approximately 3 weeks, procedures to verify participation eligibility, and comparison of our sample with nationally available norms. METHODS: Participants were young adult veterans aged 18-34 recruited through Facebook as part of a large study to document normative drinking behavior among a large community sample of veterans. Facebook ads were targeted toward young veterans to collect information on demographics and military characteristics, health behaviors, mental health, and health care utilization. RESULTS: We obtained a sample of 1023 verified veteran participants over a period of 24 days for the advertising price of approximately US $7.05 per verified veteran participant. Our recruitment strategy yielded a sample similar to the US population of young adult veterans in most demographic areas except for race/ethnicity and previous branch of service, which when we weighted the sample on race/ethnicity and branch a sample better matched with the population data was obtained. The Facebook sample recruited veterans who were engaged in a variety of risky health behaviors such as binge drinking and marijuana use. One fourth of veterans had never since discharge been to an appointment for physical health care and about half had attended an appointment for service compensation review. Only half had attended any appointment for a mental health concern at any clinic or hospital. Despite more than half screening positive for current probable mental health disorders such as post-traumatic stress disorder, depression, anxiety, only about 1 in 3 received mental health care in the past year and only 1 in 50 received such care within the past month. CONCLUSIONS: This work expands on the work of other studies that have examined clinical samples of veterans only and suggests Facebook can be an adequate method of obtaining samples of veterans in need of care. TRIAL REGISTRATION: Clinicaltrials.gov NCT02187887; http://clinicaltrials.gov/ct2/show/NCT02187887 (Archived by WebCite at http://www.webcitation.org/6YiUKRsXY).

Characterizing the Mental Health Care of U.S. Cambodian Refugees.

OBJECTIVE: This study examined U.S. Cambodian refugees' utilization of mental health services across provider types, levels of minimally adequate care, and mode of communication with providers. METHODS: Face-to-face household interviews about mental health service use in the past 12 months were conducted as part of a study of a probability sample of Cambodian refugees. The analytic sample was restricted to the 227 respondents who met past 12-month criteria for posttraumatic stress disorder (PTSD) or major depressive disorder or both. Analyses were weighted to account for complex sampling design effects and for attrition. RESULTS: Fifty-two percent of Cambodian refugees who met diagnostic criteria obtained mental health services in the past 12 months. Of those who obtained care, 75% visited a psychiatrist and 56% a general medical provider. Only 7% had obtained care from other mental health specialty providers. Virtually all respondents who had seen a psychiatrist (100%) or a general medical doctor (97%) had been prescribed a psychotropic medication. Forty-five percent had received minimally adequate care. Most relied on interpreters to communicate with providers. CONCLUSIONS: Cambodian refugees' rates of mental health service utilization and minimally adequate care were comparable to those of individuals in the general U.S. POPULATION: Cambodian refugees obtained care almost entirely from psychiatrists and general medical doctors, and nearly all were receiving pharmacotherapy; these findings differ from rates seen in a nationally representative sample. Given this pattern of utilization, and the persistently high levels of PTSD and depression found among Cambodian refugees, treatment improvements may require identification of creative approaches to delivering more evidence-based psychotherapy.

Access to Behavioral Health Care for Geographically Remote Service Members and Dependents in the U.S.

With many service members now returning to the United States from the recent conflicts in Iraq and Afghanistan, concern over adequate access to behavioral health care (treatment for mental, behavioral, or addictive disorders) has risen. Yet data remain very sparse regarding how many service members (and their dependents) reside in locations remote from behavioral health providers, as well as the resulting effect on their access to and utilization of care. Little is also known about the effectiveness of existing policies and other efforts to improve access to services among this population. To help fill these gaps, a team of RAND researchers conducted a geospatial analysis using TRICARE and other data, finding that roughly 300,000 military service members and 1 million dependents are geographically distant from behavioral health care, and an analysis of claims data indicated that remoteness is associated with lower use of specialty behavioral health care. A review of existing policies and programs discovered guidelines for access to care, but no systematic monitoring of adherence to those guidelines, limiting their value. RAND researchers recommend implementing a geospatial data portal and monitoring system to track access to care in the military population and mark progress toward improvements in access to care. In addition, the RAND team highlighted two promising pathways for improving access to care among remote military populations: telehealth and collaborative care that integrates primary care with specialty behavioral care.

A comparison of Cambodian-American adolescent substance use behavior to national and local norms.

INTRODUCTION: This study was designed to compare rates of alcohol, marijuana, and cigarette use in Cambodian-American adolescents with norms from nationally- and regionally-representative peers. METHODS: Substance use data from 439 10th grade Cambodian-American adolescents in Long Beach, California were compared to grade- and gender-matched nationally representative data from the Monitoring the Future study and data from the California Healthy Kids Survey of students within the same school district. RESULTS: Overall, the Cambodian-American youth were less likely than nationally- and regionally-representative youth to use alcohol, marijuana, and cigarettes. Specifically, relative to estimates obtained for the general population and students attending school in the same school district, Cambodian-American youth were significantly less likely to use alcohol and marijuana. Cambodian-American youth were also less likely than youth in the general population to smoke cigarettes, but did not differ statistically from youth within their same school district. CONCLUSIONS: As a group, Cambodian-American youth may not be at especially high risk for substance use. As is the case with virtually all populations, some individuals within the Cambodian-American group are likely to have more difficulty than others with substance use concerns. Thus, additional research is needed to identify factors that might help to identify high users with potential service needs.

Are mental disorders more common in urban than rural areas of the United States?

Urban vs. rural residence is commonly cited as a risk factor for depression and other mental disorders, but epidemiological evidence for this relationship in the US is inconclusive. We examined three consecutive annual samples (2009-2011) of adolescents (age 12-17, N = 55,583) and adults (age 18 and over, N = 116,459) from the National Survey of Drug Use and Health (NSDUH) to compare the prevalence of major depression and other serious mental illness across four categories of urbanicity: (1) large metropolitan areas, (2) small metropolitan areas, (3) semi-rural areas, and (4) rural areas, with and without adjustment for other demographic risk factors. For adolescents, no association was observed between urbanicity and the prevalence of major depression, with or without statistical adjustments. For adults, no differences were found in the prevalence of major depression or serious mental illness between large metropolitan areas and rural areas, but the prevalence of both was slightly higher in the two intermediate urbanicity categories than in large metropolitan areas, with statistically significant odds ratios after adjustment ranging from 1.12 to 1.19. Contrary to expectations, the prevalence of mental disorders was not higher in the most urban compared with the most rural areas, suggesting that the move to identify mechanistic explanations for risk associated with the urban environment is premature. Evidence of slightly higher prevalence in small urban and semi-rural areas relative to large urban areas, reported for the first time, requires additional investigation.

Prevalence of mental health problems among Iraq and Afghanistan veterans who have and have not received VA services.

OBJECTIVE: Roughly half of veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) have not received services from the Veterans Health Administration (VHA). This study assessed probable posttraumatic stress disorder (PTSD) and depression among OEF/OIF veterans by receipt of VHA services. METHODS: In 2010 a mixed-mode survey assessing symptoms and VHA services utilization was fielded in a random sample of 913 New York State OEF/OIF veterans. RESULTS: Probable PTSD and depression were roughly three times more common among veterans who had received VHA services (N=537) (PTSD, 23%; depression, 21%) than those who had not (N=376) (PTSD, 6%; depression, 8%). CONCLUSIONS: Studies of veterans receiving VHA services likely overstate the prevalence of mental health problems among the broader OEF/OIF veteran population. However, many veterans with mental health problems are not receiving VHA services. Policies that improve outreach to this population may improve health outcomes.

Mental health treatment experiences of U.S. service members previously deployed to Iraq and Afghanistan.

OBJECTIVE: This study examined the mental health treatment experiences of active-duty U.S. service members who received treatment from primary care or specialty mental health providers. METHODS: A national sample of active-duty service members (N=1,659) was surveyed about mental health treatment experiences. RESULTS: About 17% of respondents reported receipt of mental health care in the prior 12 months. Three times as many service members had seen a specialty mental health provider (14%) as had seen a primary care provider (5%). Of those who had seen a specialty provider, 79% thought treatment helped "a lot or some" and none stated that treatment was "not at all" helpful. Of those who had seen a primary care provider, only 51% thought treatment had helped a lot or some and 15% viewed treatment as not helping at all. CONCLUSIONS: Patterns of utilization and perceptions of treatment should be considered when addressing the unmet mental health needs of service members.

A multi-sample confirmatory factor analysis of PTSD symptoms: what exactly is wrong with the DSM-IV structure?

Within the DSM-IV, PTSD symptoms are rationally classified as assessing one of three symptom domains: reexperiencing, avoidance/numbing, or hyperarousal. However, two alternative four-factor models have been advocated as superior to the DSM-IV framework, based on confirmatory factor analysis. In the Numbing model, symptoms of emotional numbing are differentiated from avoidance. In the Dysphoria model, several symptoms of numbing and hyperarousal are combined to form a factor purported to assess general psychological distress. Examination of these models, within 29 separate data sets, supports two conclusions. First, contrary to its conceptual underpinnings, the Dysphoria model differs empirically from the Numbing model solely in the correlation predicted between two hyperarousal symptoms; all other predicted correlations made by the two models are substantively identical. Second, when the factor analytic presumption of simple structure is relaxed to allow for potential presentation order effects, other plausible symptom structures emerge. In particular, the fit of the DSM-IV model improved dramatically and was a better fit to the data than either four-factor model. The ostensible inferiority of the DSM-IV model may be due to a methodological artifact stemming from the order in which symptoms are typically assessed. The provisional decision to revise the structure of PTSD symptoms in the DSM-5 in light of confirmatory factor analytic results may be misguided.

Making Sense of Posttraumatic Stress Disorder: Illness Perceptions Among Traumatic Injury Survivors.

More than 1.5 million persons in the United States sustain traumatic physical injuries each year. A significant proportion of traumatic injury survivors develop serious mental health problems such as posttraumatic stress disorder (PTSD), yet few obtain professional mental health care. According to the commonsense model of self-regulation (Leventhal, Diefenbach, & Leventhal, 1992), illness-related perceptions can influence coping responses including the use of professional treatment. Using the commonsense model as a guiding framework, we conducted semi-structured interviews with non-treatment seeking trauma injury survivors with PTSD (N = 23). Illness perceptions regarding the following key conceptual dimensions were examined: PTSD symptoms (identity), experienced or perceived consequences of PTSD symptoms, and beliefs about the causes, controllability, and course of PTSD symptoms. Results revealed that no respondents identified their symptoms as indicative of PTSD. Common illness perceptions included believing that symptoms would be short-lived, that symptoms were reflective of poor physical health or were a natural reaction to life in a violent community, and that symptoms were functionally adaptive. Respondents also reported exerting some limited control over symptoms by relying on religious forms of coping. None of the respondents perceived professional treatment as being able to completely control symptoms. Findings indicated that respondents' conceptualizations of PTSD symptoms may have inhibited the recognition of symptoms as a serious mental health condition that warrants professional treatment.

The unusually poor physical health status of Cambodian refugees two decades after resettlement.

To better document the health status of Cambodian refugees, the physical health functioning, disability, and general health status of Cambodian refugees was compared to that of non-refugee Asian immigrants with similar demographic characteristics. Data were collected between October 2003 and February 2005, from 490 face-to-face interviews conducted with a stratified probability sample of households from the Cambodian community in Long Beach, California. Data on the health status of the general adult population (n = 56,270) was taken from the California Health Interview Survey, a telephone interview of a representative sample California residents. Cambodian refugees reported exceedingly poor health when compared to both the general population to the Asian participants. This disparity was only slightly reduced when Cambodian refugees were compared to the subsample of Asian immigrants who were matched on gender, age, income, and urbanicity. Although Cambodians refugees are older and poorer than the general population, their poor health cannot be fully attributed to these risk factors. Research is needed to guide health policy and practices aimed at eliminating this health disparity.

Prevalence and Correlates of Drinking Behaviors of Previously Deployed Military Personnel and Matched Civilian Population.

We examined drinking behaviors (frequency of use, quantity of use, and frequency of binge drinking) and correlates of frequency of use and binge drinking in a representative sample of previously deployed personnel from the US military (n = 1887). Drinking behaviors were compared with a matched sample of adults in U.S. households (n = 17,533). Comparable patterns of alcohol consumption were reported in both samples: 70% of previously deployed personnel and 69% of US adults reported drinking alcohol in the past 30 days though, civilians drank on average more drinks on the days that they drank than did previously deployed military personnel. Regression analyses indicated that among previously deployed military personnel, deployment-related experiences (e.g., combat-related traumas) and psychological distress (e.g., symptoms associated with posttraumatic stress disorder) were associated with frequency of drinking behaviors. We discuss the implication of our findings for developing interventions to modify drinking behaviors for military personnel.

A Needs Assessment of New York State Veterans: Final Report to the New York State Health Foundation.

Mental health disorders and other types of impairments resulting from deployment experiences are beginning to emerge, but fundamental gaps remain in our knowledge about the needs of veterans returning from Iraq and Afghanistan, the services available to meet those needs, and the experiences of veterans who have tried to use these services. This article highlights the findings of a study focused directly on the veterans living in New York state. The study included veterans who currently use U.S. Department of Veterans Affairs (VA) services as well as those who do not; and it looked at needs across a broad range of domains. The authors collected information and advice from a series of qualitative interviews with veterans of Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) residing in New York, as well as their family members. In addition, they conducted a quantitative assessment of the needs of veterans and their spouses from a sample that is broadly representative of OEF/OIF veterans in New York state. Finally, they conducted a review the services currently available in New York state for veterans. The study found substantially elevated rates of post-traumatic stress disorder (PTSD) and major depression among veterans. It also found that both VA and non-VA services are critically important for addressing veterans' needs, and that the health care systems that serve veterans are extremely complicated. Addressing veterans' mental health needs will require a multipronged approach: reducing barriers to seeking treatment; improving the sustainment of, or adherence to, treatment; and improving the quality of the services being delivered. Finally, veterans have other serious needs besides mental health care and would benefit from a broad range of services.