Initial Validation of the Mid-Atlantic Mental Illness Research, Education, and Clinical Center Assessment of Traumatic Brain Injury.

With the increasing prevalence of traumatic brain injury (TBI), the need for reliable and valid methods to evaluate TBI has also increased. The purpose of this study was to establish the validity and reliability of a new comprehensive assessment of TBI, the Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) Assessment of TBI (MMA-TBI). The participants in this study were post-deployment, combat exposed veterans. First, MMA-TBI outcomes were compared with those of independently conducted clinical TBI assessments. Next, MMA-TBI outcomes were compared with those of a different validated TBI measure (the Ohio State University TBI Identification method [OSU-TBI-ID]). Next, four TBI subject matter experts independently evaluated 64 potential TBI events based on both clinical judgment and Veterans Administration/Department of Defense (VA/DoD) Clinical Practice Guidelines. Results of the MMA-TBI algorithm (based on VA/DoD clinical guideline) were compared with those of the subject matter experts. Diagnostic correspondence with independently conducted expert clinical evaluation was 96% for lifetime TBI and 92% for deployment-acquired TBI. Consistency between the MMA-TBI and the OSU-TBI-ID was high (κ = 0.90; Kendall Tau = 0.94). Comparison of MMA-TBI algorithm results with those of subject matter experts was high (κ = 0.97-1.00). The MMA-TBI is the first TBI interview to be validated against an independently conducted clinical TBI assessment. Overall, results demonstrate the MMA-TBI is a highly valid and reliable instrument for determining TBI based on VA/DoD clinical guidelines. These results support the need for application of standardized TBI criteria across all diagnostic contexts.

Common Data Elements in the Assessment of Military-Related PTSD Research Applied in the Consortium to Alleviate PTSD.

INTRODUCTION: Driven by the need to share data, sufficiently power studies, and allow for cross-study comparisons of medical and psychiatric diseases, the President's National Research Action Plan issued in 2013 called for the use of state-of-the-art common data elements (CDEs) for research studies. CDEs are variables measured across independent studies that facilitate methodologically sound data aggregation and study replication. Researchers in the field of military-related post-traumatic stress disorder (PTSD) have suggested applicable CDEs; however, to date, these recommendations have been conceptual and not field-tested. The Consortium to Alleviate PTSD (CAP) - an interdisciplinary and multi-institutional, military-related PTSD research consortium funded by the Departments of Defense and Veterans Affairs - generated and applied CDEs that can be used to combine data from disparate studies to improve the methodological and statistical capabilities of study findings. We provide a description and rationale for the CAP CDEs and details about administration with two main goals: (1) to encourage military-related PTSD researchers to use these measures in future studies and (2) to facilitate comparison, replication, and data aggregation. MATERIALS AND METHODS: The CAP compiled mandated (core) and optional CDEs based on the following criteria: (1) construct applicability to military-related PTSD; (2) precedence (use) in prior, related research; (3) published and strong psychometric evidence; (4) no cost (public domain); and (5) brevity, to limit participant burden. We provided descriptive statistics and internal consistency reliabilities for mandated measures from an initial cohort of around 400 participants enrolled in CAP studies. RESULTS: Mandated CDEs in the CAP were found to have very good internal consistency reliability. CONCLUSION: Although further research is needed to determine the incremental validity of these CDEs, preliminary analyses indicated that each mandated measure has very good internal consistency reliability. Investigators designing military-related PTSD research should consider using these field-tested CDEs to facilitate future data aggregation. Feedback based on empirical evidence or practical concerns to improve these CDEs is welcome.

"The Cango Lyec Project - Healing the Elephant": HIV related vulnerabilities of post-conflict affected populations aged 13-49 years living in three Mid-Northern Uganda districts.

BACKGROUND: The protracted war between the Government of Uganda and the Lord's Resistance Army in Northern Uganda (1996-2006) resulted in widespread atrocities, destruction of health infrastructure and services, weakening the social and economic fabric of the affected populations, internal displacement and death. Despite grave concerns that increased spread of HIV/AIDS may be devastating to post conflict Northern Uganda, empirical epidemiological data describing the legacy of the war on HIV infection are scarce. METHODS: The 'Cango Lyec' Project is an open cohort study involving conflict-affected populations living in three districts of Gulu, Nwoya and Amuru in mid-northern Uganda. Between November 2011 and July 2012, 8 study communities randomly selected out of 32, were mapped and house-to-house census conducted to enumerate the entire community population. Consenting participants aged 13-49 years were enrolled and interviewer-administered data were collected on trauma, depression and socio-demographic-behavioural characteristics, in the local Luo language. Venous blood was taken for HIV and syphilis serology. Multivariable logistic regression was used to determine factors associated with HIV prevalence at baseline. RESULTS: A total of 2954 participants were eligible, of whom 2449 were enrolled. Among 2388 participants with known HIV status, HIV prevalence was 12.2% (95%CI: 10.8-13.8), higher in females (14.6%) than males (8.5%, p < 0.001), higher in Gulu (15.2%) than Nwoya (11.6%, p < 0.001) and Amuru (7.5%, p = 0.006) districts. In this post-conflict period, HIV infection was significantly associated with war trauma experiences (Adj. OR = 2.50; 95%CI: 1.31-4.79), the psychiatric problems of PTSD (Adj. OR = 1.44; 95%CI: 1.06-1.96), Major Depressive Disorder (Adj. OR = 1.89; 95%CI: 1.28-2.80) and suicidal ideation (Adj. OR = 1.87; 95%CI: 1.34-2.61). Other HIV related vulnerabilities included older age, being married, separated, divorced or widowed, residing in an urban district, ulcerative sexually transmitted infections, and staying in a female headed household. There was no evidence in this study to suggest that people with a history of abduction were more likely to be HIV positive. CONCLUSIONS: HIV prevalence in this post conflict-affected population is high and is significantly associated with age, trauma, depression, history of ulcerative STIs, and residing in more urban districts. Evidence-based HIV/STI prevention programs and culturally safe, gender and trauma-informed are urgently needed.

What does the literature say about the needs of veterans in the areas of health?

This paper reports on a systematic review undertaken in 2013 aimed at identifying evidence and dismissing some of the myths surrounding the needs of the veteran community. Papers were retrieved from a wide range of sources to ensure that literature covered the key areas of health concerns and focused also on time spent in service. Of the twenty eight papers reviewed categories relating to mental health (including PTSD and suicide), the use of alcohol, trauma, hearing loss, cancer and obesity were identified. Outcomes from the review established that while early service leavers were the most vulnerable there were also aspects within service that had an impact on future life events such as the type of leadership experienced, the cohesion of the unit and facing combat situations. The use of alcohol as a coping mechanism is also considered prevalent with adverse effects as is the worry of family situations at home. The impact of service life on the veteran, especially if suffering trauma will have long lasting psychological and physical outcomes, although it is recognised that veterans in the main have excellent physical and psychological strength and many physical illnesses are not greatly exaggerated from that of the general public.

[Sequential traumatization, trauma-related disorders and psychotherapeutic approaches in war-traumatized adult refugees and asylum seekers in Germany]. / Sequenzielle Traumatisierungen, Traumafolgestörungen und psychotherapeutische Behandlungsansätze bei kriegstraumatisierten erwachsenen Flüchtlingen in Deutschland.

The impact of war and violence on the mental and physical health of the civilian population is immense. Traumatization is often experienced sequentially, which leads to a higher risk for developing trauma-related disorders (PTSD, depression, chronic pain).Refugees traumatized by war experience specific stressors related to their status of residence (e. g., application hearing, length of the asylum procedure). Together with limited access to health care, these constitute additional risk factors for developing somatic and psychological illnesses.Adequate treatment for this highly vulnerable group requires a multimodal approach facilitated by translators. According to the S3 guidelines (S3-Richtlinien), trauma-adapted psychotherapeutic treatment has to be complemented by the activities of social workers, by medical treatment, and by legal advice.

Predicting symptom clusters of posttraumatic stress disorder (PTSD) in Croatian war veterans: the role of socio-demographics, war experiences and subjective quality of life.

BACKGROUND: Previous research has documented multiple chains of risk in the development of PTSD among war veterans. However, existing studies were mostly carried out in the West, while they also did not analyze specific symptom clusters of PTSD. The aim of this study was to examine the role of socio-demographic characteristics, war experiences and subjective quality of life in the prediction of three clusters of PTSD symptoms (i.e., avoidance, intrusion, hyperarousal). SUBJECTS AND METHODS: This study comprised 184 male participants who have survived war imprisonment during the Croatian Homeland War in the period from 1991 to 1995. The data was collected through several self-report measuring instruments: questionnaire on socio-demographic data, war experiences (Questionnaire on Traumatic Combat and War Experiences), subjective quality of life (WHO-Five Well-being Index), and PTSD symptoms (Impact of Events Scale - Revised). RESULTS: The level of three symptom clusters of PTSD was found to be moderate to high, as indicated by the scores on the IES-R. Results of the three hierarchical regression analyses showed the following: traumatic war experiences were significant predictors of avoidance symptoms; traumatic war experiences and subjective quality of life were significant predictors of hyperarousal symptoms; and traumatic war experiences, material status and subjective quality of life were significant predictors of intrusion symptoms. CONCLUSIONS: These findings support the widespread belief that the development of war-related PTSD is accounted for by multiple chains of risk, while traumatic war experiences seem to be the only predictor of all three symptom clusters. Future research should put more emphasis on specific PTSD symptom clusters when investigating the etiopathogenesis of this disorder among war-affected populations.

The relationships among premilitary vocational aptitude assessment, traumatic brain injury, and postdeployment cognitive functioning in combat veterans.

Traumatic brain injury (TBI) in Iraq and Afghanistan war veterans is frequently associated with a variety of complaints, including cognitive problems and posttraumatic stress disorder. In this study, the authors explored the predictive impact of premilitary cognitive abilities on postdeployment cognitive functioning, as mitigated by posttraumatic stress symptoms in a sample of veterans with and without history of TBI. Measures included clinical interview, neuropsychological tests, the PTSD Checklist-Military Version, and the Armed Services Vocational Aptitude Battery. In contrast to history of TBI, premilitary abilities and posttraumatic stress symptoms emerged as significant predictors of postdeployment cognitive deficits.

Assessment of plasma C-reactive protein as a biomarker of posttraumatic stress disorder risk.

IMPORTANCE: Posttraumatic stress disorder (PTSD) has been associated in cross-sectional studies with peripheral inflammation. It is not known whether this observed association is the result of PTSD predisposing to inflammation (as sometimes postulated) or to inflammation predisposing to PTSD. OBJECTIVE: To determine whether plasma concentration of the inflammatory marker C-reactive protein (CRP) helps predict PTSD symptoms. DESIGN, SETTING, AND PARTICIPANTS: The Marine Resiliency Study, a prospective study of approximately 2600 war zone-deployed Marines, evaluated PTSD symptoms and various physiological and psychological parameters before deployment and at approximately 3 and 6 months following a 7-month deployment. Participants were recruited from 4 all-male infantry battalions imminently deploying to a war zone. Participation was requested of 2978 individuals; 2610 people (87.6%) consented and 2555 (85.8%) were included in the present analysis. Postdeployment data on combat-related trauma were included for 2208 participants (86.4% of the 2555 included) and on PTSD symptoms at 3 and 6 months after deployment for 1861 (72.8%) and 1617 (63.3%) participants, respectively. MAIN OUTCOMES AND MEASURES: Severity of PTSD symptoms 3 months after deployment assessed by the Clinician-Administered PTSD Scale (CAPS). RESULTS: We determined the effects of baseline plasma CRP concentration on postdeployment CAPS using zero-inflated negative binomial regression (ZINBR), a procedure designed for distributions, such as CAPS in this study, that have an excess of zeroes in addition to being positively skewed. Adjusting for the baseline CAPS score, trauma exposure, and other relevant covariates, we found baseline plasma CRP concentration to be a highly significant overall predictor of postdeployment CAPS scores (P = .002): each 10-fold increment in CRP concentration was associated with an odds ratio of nonzero outcome (presence vs absence of any PTSD symptoms) of 1.51 (95% CI, 1.15-1.97; P = .003) and a fold increase in outcome with a nonzero value (extent of symptoms when present) of 1.06 (95% CI, 0.99-1.14; P = .09). CONCLUSIONS: AND RELEVANCE A marker of peripheral inflammation, plasma CRP may be prospectively associated with PTSD symptom emergence, suggesting that inflammation may predispose to PTSD.

War experiences, general functioning and barriers to care among former child soldiers in Northern Uganda: the WAYS study.

BACKGROUND: Exposure to war is associated with considerable risks for long-term mental health problems (MHP) and poor functioning. Yet little is known about functioning and mental health service (MHS) use among former child soldiers (FCS). We assessed whether different categories of war experiences predict functioning and perceived need for, sources of and barriers to MHS among FCS. METHODS: Data were drawn from an on-going War-affected Youths (WAYS) cohort study of FCS in Uganda. Participants completed questionnaires about war experiences, functioning and perceived need for, sources of and barriers to MHS. Regression analyses and parametric tests were used to assess between-group differences. RESULTS: Deaths, material losses, threat to loved ones and sexual abuse significantly predicted poor functioning. FCS who received MHS function better than those who did not. Females reported more emotional and behavioural problems and needed MHS more than males. FCS who function poorly indicated more barriers to MHS than those who function well. Stigma, fear of family break-up and lack of health workers were identified as barriers to MHS. CONCLUSIONS: Various war experiences affect functioning differently. A significant need for MHS exists amidst barriers to MHS. Nevertheless, FCS are interested in receiving MHS and believe it would benefit them.

The association of PTSD with physical and mental health functioning and disability (VA Cooperative Study #569: the course and consequences of posttraumatic stress disorder in Vietnam-era veteran twins).

PURPOSE: To assess the relationship of posttraumatic stress disorder (PTSD) with health functioning and disability in Vietnam-era Veterans. METHODS: A cross-sectional study of functioning and disability in male Vietnam-era Veteran twins. PTSD was measured by the Composite International Diagnostic Interview; health functioning and disability were assessed using the Veterans RAND 36-Item Health Survey (VR-36) and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). All data collection took place between 2010 and 2012. RESULTS: Average age of the 5,574 participating Veterans (2,102 Vietnam theater and 3,472 non-theater) was 61.0 years. Veterans with PTSD had poorer health functioning across all domains of VR-36 and increased disability for all subscales of WHODAS 2.0 (all p < .001) compared with Veterans without PTSD. Veterans with PTSD were in poorer overall health on the VR-36 physical composite summary (PCS) (effect size = 0.31 in theater and 0.47 in non-theater Veterans; p < .001 for both) and mental composite summary (MCS) (effect size = 0.99 in theater and 0.78 in non-theater Veterans; p < .001 for both) and had increased disability on the WHODAS 2.0 summary score (effect size = 1.02 in theater and 0.96 in non-theater Veterans; p < .001 for both). Combat exposure, independent of PTSD status, was associated with lower PCS and MCS scores and increased disability (all p < .05, for trend). Within-pair analyses in twins discordant for PTSD produced consistent findings. CONCLUSIONS: Vietnam-era Veterans with PTSD have diminished functioning and increased disability. The poor functional status of aging combat-exposed Veterans is of particular concern.

Assessment of subthreshold and developing behavioral health concerns among U.S. army soldiers.

This study aimed to merge existing methodologies of identifying high-risk soldiers to create a comprehensive testable model to assist leaders in the identification, mitigation, and prevention of negative behavioral health (BH) issues. In 2011, a total of 2,664 active duty U.S. Army soldiers completed a survey of demographic and military characteristics, combat exposures, and BH diagnoses and symptoms. Multivariable linear and logistic regression models were fit to examine the relationship between demographic and military characteristics, subthreshold behavioral and social health issues, and positive screening for BH symptoms. The "recent loss of someone close" and self-reporting a history of BH issues were the strongest and most consistent predictors of subthreshold behavioral and social health issues. This study found that individual and occupational factors were associated with subthreshold behavioral and social health issues, which were in turn, associated with screening positive for BH symptoms. The recent loss of someone close (an indicator of grief and loss) was not the study's primary research question, but warrants further investigation to determine its impact on the mental well-being of soldiers.

Long-term trajectories and service needs for military families.

The deployment of US military personnel to recent conflicts has been a significant stressor for their families; yet, we know relatively little about the long-term family effects of these deployments. Using data from prior military service eras, we review our current understanding of the long-term functioning and needs of military families. These data suggest that overseas deployment, exposure to combat, experiencing or participating in violence during war deployment, service member injury or disability, and combat-related post-traumatic stress disorder (PTSD) all have profound impacts on the functioning of military families. We offer several recommendations to address these impacts such as the provision of family-centered, trauma-informed resources to families of veterans with PTSD and veterans who experienced high levels of combat and war violence. Recent efforts to address the needs of caregivers of veterans should be evaluated and expanded, as necessary. We should also help military families plan for predictable life events likely to challenge their resilience and coping capacities. Future research should focus on the following: factors that mediate the relationship between PTSD, war atrocities, caregiver burden, and family dysfunction; effective family-centered interventions that can be scaled-up to meet the needs of a dispersed population; and system-level innovations necessary to ensure adequate access to these interventions.

Critical concerns in Iraq/Afghanistan war veteran-forensic interface: veterans treatment court as diversion in rural communities.

The veteran-forensic interface is an emerging area of relevance to forensic clinicians assessing or treating returning Iraq and Afghanistan war veterans facing criminal sanctions. Veterans' Treatment Court (VTC) represents a recent diversion mechanism for low-level offenses that is based on a collaborative justice model. Thirty-nine percent of veterans who served in Iraq or Afghanistan and receiving VA services reside in rural areas. Rural veterans facing criminal justice charges may be at a disadvantage due to limited access to forensic psychiatrists with relevant expertise in providing veterans services for diversion. Therefore, widening the pool of forensic clinicians who have such expertise, as well as knowledge of the signature wounds of the wars as related to aggression and reckless behavior is necessary. This article presents an overview of VTCs and discusses the role of forensic clinicians as stakeholders in this process.

Critical concerns in Iraq/Afghanistan war veteran-forensic interface: combat-related postdeployment criminal violence.

Identifying whether there is a nexus between Iraq and Afghanistan combat injuries and civilian violence on return from deployment is complicated by differences in reactions of individuals to combat exposure, the overlapping effects of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), and the low base rate of civilian violence after combat exposure. Moreover, the overall prevalence of violence among returning Iraq and Afghanistan combat war veterans has not been well documented. Malingered symptoms and either exaggeration or outright fabrication of war zone exposure are challenges to rendering forensic opinions, with the risk reduced by accessing military documents that corroborate war zone duties and exposure. This article serves as a first step toward understanding what may potentiate violence among returning Iraq and Afghanistan veterans. We offer a systematic approach toward the purpose of forensic case formulation that addresses whether combat duty/war zone exposure and associated clinical conditions are linked to criminal violence on return to civilian life.

Adapting the multifamily group model for treating veterans with posttraumatic stress disorder.

The Department of Veterans Affairs (VA) health care system's leadership has endorsed family involvement in veterans' mental health care as an important component of treatment. Both veterans and families describe family participation as highly desirable, and research has documented that having healthy social support is a strong protective factor for posttraumatic stress disorder (PTSD). Family psychoeducation has been shown to be effective in preventing relapse among severely mentally ill, and preliminary evidence suggests that family interventions for PTSD may improve veteran and family outcomes. The multifamily group (MFG) treatment model incorporates psychoeducation, communication training, and problem-solving skill building, and it increases social support through its group format. This article describes the rationale for further adaptation of the MFG model for PTSD, and it reviews issues related to its implementation as a promising adjunctive treatment as part of the continuum of PTSD services available in VA.

Primary care-mental health integration and treatment retention among Iraq and Afghanistan war veterans.

Despite the high prevalence of posttraumatic stress disorder (PTSD) and medical comorbidity among veterans from Iraq/Afghanistan (OEF/OIF), keeping these patients engaged in health care is challenging. Primary Care-Mental Health Integration (PC-MHI), an initiative in the Veterans Health Administration (VA), sought to improve access to mental health care from within primary care. This study examined the lag between first PC-MHI visit and next mental/medical care visit, if any, and the relationship of PC-MHI with short-term (subsequent year) and long-term (4 years later) use of VA. We identified 2,470 OEF/OIF veterans receiving care during fiscal year 2006 (FY06) in a regional VA health care system. Unconditional survival analysis modeled time to next mental/medical visit and logistic regression modeled short- and long-term care as a function of PC-MHI, demographics, and clinical covariates. Of 181 patients in the PC-MHI program, 60%/18% returned for mental/medical care within 1 month, and 82%/74% within 1 year. Sixty-one percent (1,503) were still using the VA in FY09. Short-term mental care was related to prior-year PC-MHI. Consistent correlates of short- and long-term mental/medical care included physical comorbidity and Priority 1 status. Most patients attended mental health appointments subsequent to PC-MHI, and PC-MHI was correlated with mental health treatment retention in adjusted models for our cohort. Need for treatment, notably VA Priority 1 status and physical comorbidity, were the primary correlates of care-seeking. Developing innovative approaches to engaging new veterans in care remains imperative as multiple options will be necessary to meet the needs of these complex patients.

Effects of home on the mental health of British forces serving in Iraq and Afghanistan.

BACKGROUND: Most studies of the mental health of UK armed forces focus on retrospective accounts of deployment and few sample personnel while they are deployed. AIMS: This study reports the results of a survey of deployed personnel, examining the perceived impact of events at home and military support for the family on current mental health during the deployment. METHOD: Surveys were conducted with 2042 British forces personnel serving in Iraq and Afghanistan. Prevalence of common mental disorders was assessed with the 12-item General Health Questionnaire (GHQ-12) and post-traumatic stress disorder (PTSD) was assessed with the PTSD Checklist - Civilian version (PCL-C). RESULTS: The prevalence of common mental disorders was 17.8% and of probable PTSD was 2.8%. Perceived home difficulties significantly influenced the mental health of deployed personnel; the greater the perception of negative events in the home environment, the greater the reporting of adverse mental health effects. This finding was independent of combat exposure and was only partially mitigated by being well led and reporting subjectively good unit cohesion; however, the effect of the totality of home-front events was not improved by the latter. Poor perceived military support for the family had a detrimental impact on deployment mental health. CONCLUSIONS: The armed forces offer many support services to the partners and families of deployed personnel and ensuring that the efforts being made on their behalf are well communicated might improve the mental health of deployed personnel.