Longitudinal Examination of Posttraumatic Stress Disorder as a Long-Term Outcome of Iraq War Deployment.

The mental health toll of the Iraq and Afghanistan Wars on military veterans has been considerable, yet little is known about the persistence of these adverse outcomes, especially relative to predeployment status. We prospectively examined posttraumatic stress disorder (PTSD) as a long-term consequence of warzone deployment, integrating data collected from 2003-2014. In the Neurocognition Deployment Health Study, we measured PTSD symptoms in US Army soldiers before and shortly after Iraq War deployment. We used the PTSD Checklist-Civilian Version and a structured clinical interview (i.e., Clinician-Administered PTSD Scale) to reassess PTSD in 598 service members and military veterans a median of 7.9 years (interquartile range, 7.2-8.5 years) after an index Iraq deployment. At long-term follow-up, 24.7% (95% confidence interval (CI): 21.5, 28.4) of participants met the case definition for PTSD, which was an absolute increase of 14.2% from the percentage assessed postdeployment (10.5%; 95% CI: 7.8, 13.7) and of 17.3% from the percentage assessed predeployment (7.4%; 95% CI: 5.5, 9.8). These findings highlight that PTSD is an enduring consequence of warzone participation among contemporary military personnel and veterans. The largest increase in PTSD cases occurred between the postdeployment and long-term follow-up assessments, which suggests that adverse stress reactions cannot necessarily be expected to dissipate over time and actually may increase.

A pilot trial of telephone-based collaborative care management for PTSD among Iraq/Afghanistan war veterans.

BACKGROUND: Collaborative care and care management are cornerstones of Primary Care-Mental Health Integration (PC-MHI) and have been shown to reduce depressive symptoms. Historically, the standard of Veterans Affairs (VA) collaborative care was referring patients with posttraumatic stress disorder (PTSD) to specialty care. Although referral to evidence-based specialty care is ideal, many veterans with PTSD do not receive such care. To address this issue and reduce barriers to care, VA currently recommends veterans with PTSD be offered treatment within PC-MHI as an alternative. The current project outlines a pilot implementation of an established telephone-based collaborative care model-Translating Initiatives for Depression into Effective Solutions (TIDES)-adapted for Iraq/Afghanistan War veterans with PTSD symptoms (TIDES/PTSD) seen in a postdeployment primary care clinic. MATERIALS AND METHODS: Structured medical record extraction and qualitative data collection procedures were used to evaluate acceptability, feasibility, and outcomes. RESULTS: Most participants (n=17) were male (94.1%) and white (70.6%). Average age was 31.2 (standard deviation=6.4) years. TIDES/PTSD was successfully implemented within PC-MHI and was acceptable to patients and staff. Additionally, the total number of care manager calls was positively correlated with number of psychiatry visits (r=0.63, p<0.05) and amount of reduction in PTSD symptoms (r=0.66, p<0.05). Overall, participants in the pilot reported a significant reduction in PTSD symptoms over the course of the treatment (t=2.87, p=0.01). CONCLUSIONS: TIDES can be successfully adapted and implemented for use among Iraq/Afghanistan veterans with PTSD. Further work is needed to test the effectiveness and implementation of this model in other sites and among veterans of other eras.

Posttraumatic stress and stigma in active-duty service members relate to lower likelihood of seeking support.

Posttraumatic stress disorder (PTSD) is a common mental health concern for returning service members. Social support is a robust predictor of resiliency and recovery from PTSD; however, barriers to seeking support are understudied. PTSD and anticipated enacted stigma from family and friends were explored as correlates of the likelihood of seeking support among 153 Iraq/Afghanistan U.S. service members. Results showed that PTSD (r = -.31, p < .001) and anticipated enacted stigma (r = -.22, p ≤ .01) were negatively associated with likelihood of seeking support. Post hoc analyses showed that only dysphoria (r = -.32, p < .001) was significantly related to the likelihood of seeking support after accounting for anticipated enacted stigma and other PTSD clusters. Implications of these findings and ways to increase likelihood of seeking support are discussed.

Unique PTSD clusters predict intention to seek mental health care and subsequent utilization in US veterans with PTSD symptoms.

Many veterans return from deployment with posttraumatic stress disorder (PTSD), but most attend only a limited number of mental health care visits. Although global PTSD relates to seeking mental health care, it is unclear whether specific features of PTSD inform the low rates of mental health care utilization. This study examined PTSD cluster severities of avoidance, reexperiencing, dysphoria, and hyperarousal as predictors of intention to seek mental health care and prospective treatment utilization. US veterans with at least subthreshold PTSD (N = 189) completed a PTSD symptom measure and indicated whether they intended to seek mental health care. Prospective Department of Veterans Affairs mental health care utilization was extracted from the medical record. At the bivariate level, each cluster was positively associated with a positive intention to seek mental health care and prospective treatment utilization. In multivariate models, however, dysphoria severity (OR = 1.16, 95% CI [1.06, 1.26]) was uniquely and positively correlated with intention to seek mental health care, whereas higher avoidance severity (IRR = 0.86, 95% CI [0.76, 0.98]) predicted lower treatment utilization, and higher reexperiencing severity (IRR = 1.07, 95% CI [1.01, 1.14]) predicted greater treatment utilization. It is critical to tailor interventions to target specific features of PTSD and to meet patients where they are.

Readiness for change predicts VA Mental Healthcare utilization among Iraq and Afghanistan war veterans.

Many veterans present to Veteran Affairs (VA) care intending to seek mental health treatment for symptoms of posttraumatic stress disorder (PTSD), depression, and/or alcohol misuse, yet most subsequently underutilize mental health care. This study examined the association of readiness for change with outpatient VA mental health care utilization in 104 treatment-seeking Iraq and Afghanistan war veterans who screened positive for PTSD, depression, and/or alcohol misuse at intake. Multivariate analyses demonstrated that readiness for change assessed at intake was positively associated (Incident Rate Ratio [IRR] = 1.22) with prospective outpatient mental health care utilization with demographic factors, military characteristics, and mental health burden in the model. Results suggest that interventions that target readiness to change, such as motivational interviewing, may improve treatment utilization in veterans presenting for mental health care.

Mental health and somatic symptom severity are associated with reduced physical activity among US Iraq and Afghanistan veterans.

OBJECTIVE: Ensuring that Iraq and Afghanistan veterans engage in adequate physical activity is essential to prevent metabolic and cardiovascular diseases, and promote psychological well-being. Identifying factors associated with physical activity in this population will yield areas for targeted interventions aimed at increasing activity. METHOD: Correlates of meeting physical activity recommendations (≥ 150 min/week of moderate-to-vigorous physical activity [MVPA]) were examined in Iraq/Afghanistan veterans assessed at intake to VA Puget Sound Healthcare System's post-deployment health clinic (May, 2005-August, 2009; N=266). RESULTS: The majority were male (94.3%) and Caucasian (70.7%), with an average age of 29.8 (SD=7.3) years. Participants engaged in a median of 180 weekly MVPA minutes. Among those meeting (59%) and not meeting (41%) recommendations, median weekly MVPA minutes were 540 and 0, respectively. In multivariate regression models, higher levels of depression (p=.042) and somatic (p=.018) symptom severity were associated with significantly decreased odds of meeting physical activity recommendations. CONCLUSION: Overall, physical activity engagement among Iraq/Afghanistan veteran VA patients was above the level specified in national recommendations. Those with higher depressive and somatic symptoms were less likely to meet physical activity recommendations and may benefit from targeted physical activity promotion interventions.

Modeling PTSD symptom clusters, alcohol misuse, anger, and depression as they relate to aggression and suicidality in returning U.S. veterans.

Suicidal ideation and aggression are common correlates of posttraumatic stress disorder (PTSD) among U.S. Iraq and Afghanistan war veterans. The existing literature has established a strong link between these factors, but a more nuanced understanding of how PTSD influences them is needed. The current study examined the direct and indirect relationships between PTSD symptom clusters and suicidal ideation in general aggression (without a specified target) regarding depression, alcohol misuse, and trait anger. Participants were 359 (92% male) U.S. Iraq/Afghanistan war veterans. Path analysis results suggested that the PTSD numbing cluster was directly (ß = .28, p < .01) and indirectly (ß = .17, p = .001) related through depression. The PTSD hyperarousal cluster was indirectly related to suicidal ideation through depression (ß = .13, p < .001). The PTSD reexperiencing cluster was directly related to aggression (ß = .17, p < .05), whereas the PTSD numbing and hyperarousal clusters were indirectly related to aggression through trait anger (ß = .05, p < .05; ß = .20, p < .001). These findings indicate that adjunct treatments aimed at stabilizing anger, depression, and alcohol misuse may help clinicians ameliorate the maladaptive patterns often observed in veterans. These results also point to specific manifestations of PTSD and co-occurring conditions that may inform clinicians in their attempts to identify at risk veterans and facilitate preventative interventions.

The influence of combat and interpersonal trauma on PTSD, depression, and alcohol misuse in U.S. Gulf War and OEF/OIF women veterans.

The present study evaluated the impact of combat and interpersonal trauma exposure in a sample of 115 U.S. women veterans from Gulf War I and the Iraq and Afghanistan wars on 3 postdeployment trauma-related mental health outcomes: posttraumatic stress disorder symptoms (PSS), depressive symptom severity (DSS), and alcohol misuse. Patients presenting for healthcare services at a Veterans Affairs postdeployment health specialty clinic completed screening questionnaires that assessed combat exposure, lifetime interpersonal trauma history of childhood neglect, physical, or sexual abuse, and adult sexual and physical assault. In a regression model, combat exposure was the only significant independent variable associated with PSS, DSS, and alcohol misuse (ß = .42, .27 and B = 1.58, respectively) even after adding lifetime interpersonal assault exposure to the model. Results highlight the negative effects of combat exposure on treatment-seeking women veterans' postdeployment mental health. Incorporating combat exposure into routine screening procedures for Gulf War and Iraq and Afghanistan war women veterans can aid in mental health treatment planning.

Engaging stakeholders for change: A learning community methodology for implementing evidence-based, trauma-focused care on college campuses.

OBJECTIVE: Advances in implementation science have encouraged novel methods for disseminating and implementing evidence-based treatments. Mental health services offered to trauma-exposed students on college campuses are characterized by unique contextual, developmental, and cultural factors that must be considered to effectively disseminate and implement trauma-focused, evidence-based treatments (TF-EBTs). Informed by novel implementation designs, this project utilized a strategic stakeholder engagement method of creating a learning community to identify and adapt a TF-EBT for use in university counseling centers (UCCs). METHOD: Project leads convened campus and community stakeholders included UCC clinicians, administrators, student life professionals, and students, to join researchers in a reciprocal collaboration to work toward dissemination and implementation. These stakeholders participated in a learning community that reviewed, selected, and adapted a TF-EBT and other tools for dissemination and implementation to UCCs and other campus professionals. RESULTS: There were a number of benefits and challenges of using the learning community as a method of dissemination and implementation. Benefits included context-specific knowledge sharing, clarification of the scope of trauma among college students, creation of helpful tools, emphasis on cultural competence in TF-EBTs, and facilitating connections between professionals. Challenges included balancing flexibility with progress toward project goals and recruitment and retention of stakeholders. CONCLUSIONS: Stakeholder engagement is an integral component of dissemination and implementation efforts. The learning community method allowed for stakeholders to take an active part in adapting a TF-EBT for UCCs and can be utilized in other settings to aid in adoption and utilization of evidence-based treatments. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Access and attitudinal barriers to engagement in integrated primary care mental health treatment for rural populations.

PURPOSE: Compared to urban areas, rural populations are less likely to engage in mental health care. Using data from the Study to Promote Innovation in Rural Integrated Telepsychiatry, we examined the effect of rurality on engagement in mental health treatment as well as the role of potential mediators. METHODS: Data were obtained from medical records and surveys. We defined rurality using the rural-urban commuting area codes. Baseline mediators included the Endorsed and Anticipated Stigma Inventory and the Assessment of Perceived Access to Care. Engagement outcomes included number of psychotherapy visits and self-reported medication use. We used path analysis to examine the relationship between rurality and engagement and the influence of mediating variables. FINDINGS: Rural participants were less likely to initiate psychotherapy (OR = 0.49; adjusted P = .036), although rurality was not associated with number of psychotherapy sessions or medication use. Rurality was associated with a small elevation in negative beliefs about mental health, but this potential mediator was not associated with engagement. Rurality was negatively associated with lower perceived need for treatment (OR = 0.67, adjusted P = .040), which was in turn positively associated with initiating psychotherapy (OR = 1.99, adjusted P = .001). CONCLUSIONS: Neither rurality itself nor the potential mediators had a large effect on engagement. Federally Qualified Health Centers offering colocated and/or integrated mental health care appear to be mostly mitigating rural-urban disparities in mental health engagement. Improving rates of psychotherapy initiation for rural patients should remain a policy goal.

Care managers' experiences in a collaborative care program for the treatment of bipolar disorder and PTSD in underserved communities.

OBJECTIVES: To understand care managers' experiences treating primary care patients with bipolar disorder and PTSD in a telepsychiatry collaborative care (TCC) program, as part of a large pragmatic trial. METHODS: We conducted individual qualitative interviews with 12 care managers to evaluate barriers and facilitators to implementation of a previously completed TCC intervention for patients with bipolar disorder and/or PTSD. We used directed and conventional content analysis and Consolidated Framework for Implementation Research (CFIR) constructs to organize care manager experiences. RESULTS: Participants described clinical and medication management support from telepsychiatrists and satisfaction with the TCC model as facilitators of success for patients with bipolar disorder and PTSD in underserved communities. Participants also described onboarding of primary care providers and clinic leadership as keys to successful team-care and credited satisfaction with providing Behavioral Activation as essential to sustained delivery of the psychotherapy component of TCC. CONCLUSIONS: Participants described high satisfaction with TCC for patients with bipolar disorder and PTSD. Challenges included lack of clinic leadership and PCP engagement. Early and ongoing promotion of integrated care and prioritizing telepsychiatry consultation with patients, behavioral health professionals and PCPs, may improve patient care, provide ongoing training and improve workforce satisfaction.

Hopelessness and suicidal ideation in Iraq and Afghanistan War Veterans reporting subthreshold and threshold posttraumatic stress disorder.

We examined hopelessness and suicidal ideation in association with subthreshold and threshold posttraumatic stress disorder (PTSD) in a sample of Iraq and Afghanistan War Veterans (U.S., N = 275) assessed within a specialty VA postdeployment health clinic. Veterans completed paper-and-pencil questionnaires at intake. The military version of the PTSD Checklist was used to determine PTSD levels (No PTSD; subthreshold PTSD; PTSD), and endorsement of hopelessness or suicidal ideation were used as markers of elevated suicide risk. Veterans were also asked if they received mental health treatment in the prior 6 months. Veterans reporting subthreshold PTSD were 3 times more likely to endorse these markers of elevated suicide risk relative to the Veterans without PTSD. We found no significant differences in likelihood of endorsing hopelessness or suicidal ideation comparing subthreshold and threshold PTSD groups, although the subthreshold PTSD group was less likely to report prior mental health treatment. Clinicians should be attentive to suicide risk in returned Veterans reporting both subthreshold and threshold PTSD.

Outcomes of a health informatics technology-supported behavioral activation training for care managers in a collaborative care program.

INTRODUCTION: Health informatics-supported strategies for training and ongoing support may aid the delivery of evidence-based psychotherapies. The objective of this study was to describe the development, implementation, and practice outcomes of a scalable health informatics-supported training program for behavioral activation for patients who screened positive for posttraumatic stress disorder and/or bipolar disorder. METHOD: We trained 34 care managers in 12 rural health centers. They used a registry checklist to document the delivery of 10 behavioral activation skills for 4,632 sessions with 455 patients. Care managers received performance feedback based on registry data. Using encounter-level data reported by care managers, we described the implementation outcomes of patient reach and care manager skill adoption. We used cross-classified multilevel modeling to explore variation in skill delivery accounting for patient characteristics, provider characteristics, and change over time. RESULTS: Care managers engaged 88% of patients in behavioral activation and completed a minimum course for 57%. The average patient received 5.9 skills during treatment, with substantial variation driven more by providers (63%) than patients (29%). Care managers significantly increased the range of skills offered to patients over time. DISCUSSION: The registry-based checklist was a feasible training and support tool for community-based providers to deliver behavioral activation. Providers received data-driven performance feedback and demonstrated skill improvement over time, promoting sustainment. Future research will examine patient-level outcomes. Results underscore the potential public health impact of a simple registry-based skills checklist coupled with a scalable remote training program for evidence-based psychotherapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Posttraumatic stress disorder collaborative care: A quality improvement study in veterans affairs primary care.

Introduction: Collaborative care improves depression and anxiety outcomes. In this naturalistic, observational case study, we adapted an evidence-based depression collaborative care protocol for the assessment and treatment of posttraumatic stress disorder (PTSD) and sought to demonstrate that the protocol could be implemented in Veterans Affairs (VA) primary care. Method: Based on feedback from a content expert panel, clinical stakeholders, and a pilot study conducted in a postdeployment clinic, the original depression collaborative care protocol was modified to include PTSD assessment and support for PTSD medication adherence, self-management, and engagement in evidence-based PTSD care. Results: The modified program was implemented from November 2012 to March 2017, and 239 patients with PTSD were referred. Nearly two thirds (n = 185) enrolled, and they participated in the program for an average of 4 to 5 months and completed calls approximately once per month. Among patients with more than one assessment of clinical outcomes, 53.4% (n = 94) reported clinically significant improvement in depression on the Patient Health Questionnaire-9 (≥ 5-point decrease), and 42.2% (n = 35) reported clinically significant improvement on the PTSD Checklist (≥ 10-point decrease). Veterans and clinical staff described the modified collaborative care program positively in qualitative interviews. Discussion: Our findings suggest that a depression collaborative care program can be modified to support treatment of PTSD in primary care. The modified program was acceptable to both veterans and clinical staff and showed potential for positive clinical change in an uncontrolled quality improvement study. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.

Behavioral activation as a primary care-based treatment for PTSD and depression among returning veterans.

This preliminary study examined treatment-satisfaction and potential therapeutic benefits of Behavioral Activation as a primary care-based treatment for posttraumatic stress disorder (PTSD) and depression among Iraq and Afghanistan War veterans. Eight veterans were enrolled, 6 completed at least 4 sessions, and 5 veterans completed posttreatment and 3-month follow-up assessments after receiving 5-8 weekly sessions of Behavioral Activation delivered in a specialty postdeployment primary care clinic. Significant and meaningful reductions in PTSD symptoms were found on structured clinical assessments and self-report measures. Posttraumatic stress disorder treatment gains (measured by structured clinical assessments) were maintained at 3-month follow-up. The majority of veterans demonstrated meaningful improvements on depression and quality of life and veterans reported a high satisfaction with treatment.

Emotion suppression: a preliminary experimental investigation of its immediate effects and role in subsequent reactivity to novel stimuli.

This study details a preliminary investigation of the subjective and physiological effects of emotion suppression, relative to the allowance of emotional experience, within one distressing situation on responses to another, unrelated situation. Thirty-four men were instructed to suppress or allow their emotional responses to a distressing film clip. Immediately following the film clip, participants responded to a mildly emotionally evocative interpersonal scenario. There was evidence of significantly different patterns of change in subjective distress and heart rate (HR) from one situation to the next as a function of whether participants received instructions to suppress or allow their emotional experience to the film clip. Specifically, allowance participants exhibited a significant decrease in subjective distress, whereas suppression participants exhibited no change in distress. Further, suppression participants' distress was significantly higher than that of allowance participants following the interpersonal scenario. Suppression participants also exhibited a significant increase in mean HR from one situation to the next, whereas allowance participants exhibited no change. Finally, allowance participants were significantly more likely to report being willing to watch the film clip again than were suppression participants. Results are discussed in terms of their implications for understanding the delayed negative consequences of emotion suppression.

Behavioral activation for treatment of PTSD and depression in an Iraqi combat veteran with multiple physical injuries.

BACKGROUND: Physical injury and psychological trauma associated with combat in the wars in Iraq and Afghanistan frequently lead to a constellation of symptoms including pain, post traumatic stress disorder (PTSD), and depression. METHOD: This single case study describes the application of a behaviorally-based psychotherapy known as behavioral activation for the treatment of post traumatic stress disorder (PTSD) and depressive symptoms in a recent combat veteran with multiple physical injuries sustained from a blast injury. Treatment was provided concurrently with other rehabilitation services and consisted of weekly individual sessions for 4 months, followed by monthly sessions for 4 months. RESULTS: Clinically significant reductions in PTSD and depressive symptoms were noted between baseline and 1 year follow-up. CONCLUSION: Preliminary evidence from this case suggests that behavioral activation may be a promising treatment for PTSD and depression, and can be readily tailored to individuals with physical limitations such as pain and mobility restriction. Treatment can be provided in the context of concurrent interdisciplinary medical and rehabilitation 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.

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.