Changes in perceived social support and PTSD symptomatology among Danish army military personnel.

PURPOSE: Previous research has identified social support to be associated with risk of posttraumatic stress disorder (PTSD) symptoms among military personnel. While the lack of social support influences PTSD symptomatology, it is unknown how changes in perceived social support affect the PTSD symptom level in the aftermath of deployment. Furthermore, the influence of specific sources of social support from pre- to post-deployment on level of PTSD symptoms is unknown. We aim to examine how changes in perceived social support (overall and from specific sources) from pre- to 2.5 year post-deployment are associated with the level of post-deployment PTSD symptoms. METHODS: Danish army military personnel deployed to Afghanistan in 2009 and 2013 completed questionnaires at pre-deployment and at 2.5 year post-deployment measuring perceived social support and PTSD symptomatology and sample characteristics of the two cohorts. Data were analyzed using univariate and multivariate nominal logistic regression. RESULTS: Negative changes in perceived social support from pre- to post-deployment were associated with both moderate (OR 1.99, CI 1.51-2.57) and high levels (OR 2.71, CI 1.94-3.78) of PTSD symptoms 2.5 year post-deployment (adjusted analysis). Broadly, the same direction was found for specific sources of social support and level of PTSD symptoms. In the adjusted analyses, pre-deployment perceived social support and military rank moderated the associations. CONCLUSIONS: Deterioration in perceived social support (overall and specific sources) from pre- to 2.5 year post-deployment increases the risk of an elevated level of PTSD symptoms 2.5 year post-deployment.

Low-level cognitive ability in young adulthood and other risk factors of depression in an observational cohort study among deployed Danish soldiers.

PURPOSE: Evidence exists of an association between pre-morbid lower cognitive ability and higher risk of hospitalization for depressive disorder in civilian cohorts. The purpose of this study was to examine the relationship of cognitive ability at conscription with post-deployment depression and the influence of (1) baseline factors: age, gender, and pre-deployment educational level, (2) deployment-related factors: e.g., war-zone stress and social support, and (3) co-morbid PTSD. METHODS: An observational cohort study linking conscription board registry data with post-deployment self-report data. The study population consisted of Danish Army military personnel deployed to different war zones from 1997 to 2015. The association between cognitive ability at conscription and post-deployment depression was analyzed using repeated-measure logistic regression models. RESULTS: Study population totaled 9716 with a total of 13,371 deployments. Low-level cognitive ability at conscription was found to be weakly associated with post-deployment probable depression after adjustment for more important risk factors like gender, education, and deployment-related factors [odds ratio (OR) 0.93, 95% confidence interval (CI) 0.88-0.99]. The co-occurrence rate with PTSD was nearly 60%. When adding co-morbid PTSD as an independent variable, the association between cognitive ability and probable depression became insignificant, OR 0.95, CI 0.89-1.02. CONCLUSIONS: Low cognitive ability at conscription is a risk factor for depression among returning military personnel, but unimportant compared to gender, education, and deployment-related factors. Part of this effect may be related to co-morbid PTSD. Use of cognitive ability score as an isolated selection tool cannot be recommended because of low predictive performance.

Neurofeedback Treatment and Posttraumatic Stress Disorder: Effectiveness of Neurofeedback on Posttraumatic Stress Disorder and the Optimal Choice of Protocol.

Neurofeedback is an alternative, noninvasive approach used in the treatment of a wide range of neuropsychiatric disorders, including posttraumatic stress disorder (PTSD). Many different neurofeedback protocols and methods exist. Likewise, PTSD is a heterogeneous disorder. To review the evidence on effectiveness and preferred protocol when using neurofeedback treatment on PTSD, a systematic search of PubMed, PsychInfo, Embase, and Cochrane databases was undertaken. Five studies were included in this review. Neurofeedback had a statistically significant effect in three studies. Neurobiological changes were reported in three studies. Interpretation of results is, however, limited by differences between the studies and several issues regarding design. The optimistic results presented here qualify neurofeedback as probably efficacious for PTSD treatment.

Mental healthcare utilisation among Danish formerly deployed military personnel and their civilian counterparts: a cohort study.

Background: Prior studies comparing the mental healthcare utilisation (MHU) of Danish formerly deployed military personnel (FDP) with the general population have not included data on psychotherapy through the Defence or talking therapy with the general practitioner. This study included these and several other data sources in a comprehensive comparison of MHU between Danish FDP and civilians.Methods: First-time deployed military personnel (N = 10,971) who had returned from a mission to Kosovo, Afghanistan, Iraq or Lebanon between January 2005 and July 2017 were included. A sex and birth-year-matched civilian reference group was randomly drawn from the entire Danish non-deployed population (N = 253,714). Furthermore, a sub-cohort, including male FDP and civilians deemed eligible for military service, was defined. These cohorts were followed up in military medical records and registers covering the primary and secondary civilian health sectors from 2005 to 2018, and the rates of MHU were compared.Results: Approximately half of the initial help-seeking for FDP took place through the Defence (49.4%), and the remainder through the civilian healthcare system. When help-seeking through the Defence was not included, MHU was significantly lower among FDP in the main cohort during the first two years (IRR = 0.84, 95% CI: [0.77, 0.92]) compared to civilians. When help-seeking through the Defence was included, MHU was significantly higher among FDP compared to civilians both in the first two years of follow-up (IRR = 2.01, 95% CI: [1.89, 2.13]) and thereafter (IRR = 1.18, 95% CI: [1.13, 1.23]). In the sub-cohort, these differences were even more pronounced both in the first two years of follow-up and thereafter.Conclusions: MHU was higher among Danish FDP compared to civilians only when data from the Defence was included. The inclusion of data on both civilian and military healthcare services is necessary to evaluate the full impact of deployment on MHU among Danish FDP.

This study compared mental healthcare utilisation among Danish deployed military personnel and civilians.Most personnel sought help first through the Defence.When all data sources were included, mental healthcare utilisation was significantly higher among military personnel.

Risk factors, comorbidity and social impairment of ICD-11 PTSD and complex PTSD in Danish treatment-seeking military veterans.

PURPOSE: While a number of studies have investigated risk factors and comorbidities of ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) in various trauma exposed samples, few studies have been conducted in military samples. Existing studies with military samples have included rather small samples. The aim of the present study was to identify risk factors and comorbidities of ICD-11 PTSD and CPTSD in a large sample of previously deployed, treatment-seeking soldiers and veterans. METHODS: Previously deployed, treatment-seeking Danish soldiers and veterans (N = 599), recruited from the Military Psychology Department of the Danish Defense, completed the International Trauma Questionnaire (ITQ), as well as questionnaires of common mental health difficulties, trauma exposure, functioning and demographics. Multivariate multinomial logistic regression analysis explored differences in self-reported exposure to adversity and health outcomes between those meeting ICD-11 criteria for probable PTSD, CPTSD and no trauma disorder. RESULTS: A total of 13.0% met probable ICD-11 criteria for PTSD and 31.4% for CPTSD. Risk factors for CPTSD (compared to those with no trauma disorder) included exposure to warfare or combat, longer duration since the traumatic event and being single. Those with CPTSD were more likely than those with PTSD or no trauma disorder to endorse symptoms of depression, anxiety, stress, use of psychotropic medication, and suicide attempts. CONCLUSION: CPTSD is a more common and debilitating condition compared to PTSD in treatment-seeking soldiers and veterans. Further research should focus on testing existing and novel interventions for CPTSD in the military.

Applicability of an Automated Model and Parameter Selection in the Prediction of Screening-Level PTSD in Danish Soldiers Following Deployment: Development Study of Transferable Predictive Models Using Automated Machine Learning.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a relatively common consequence of deployment to war zones. Early postdeployment screening with the aim of identifying those at risk for PTSD in the years following deployment will help deliver interventions to those in need but have so far proved unsuccessful. OBJECTIVE: This study aimed to test the applicability of automated model selection and the ability of automated machine learning prediction models to transfer across cohorts and predict screening-level PTSD 2.5 years and 6.5 years after deployment. METHODS: Automated machine learning was applied to data routinely collected 6-8 months after return from deployment from 3 different cohorts of Danish soldiers deployed to Afghanistan in 2009 (cohort 1, N=287 or N=261 depending on the timing of the outcome assessment), 2010 (cohort 2, N=352), and 2013 (cohort 3, N=232). RESULTS: Models transferred well between cohorts. For screening-level PTSD 2.5 and 6.5 years after deployment, random forest models provided the highest accuracy as measured by area under the receiver operating characteristic curve (AUC): 2.5 years, AUC=0.77, 95% CI 0.71-0.83; 6.5 years, AUC=0.78, 95% CI 0.73-0.83. Linear models performed equally well. Military rank, hyperarousal symptoms, and total level of PTSD symptoms were highly predictive. CONCLUSIONS: Automated machine learning provided validated models that can be readily implemented in future deployment cohorts in the Danish Defense with the aim of targeting postdeployment support interventions to those at highest risk for developing PTSD, provided the cohorts are deployed on similar missions.

Deployment experiences and mental health problems as predictors of post-deployment unemployment length: a prospective, register-based study among Danish soldiers.

OBJECTIVES: To test responses of formerly deployed soldiers (FDS) to a questionnaire on deployment experiences in combination with screening levels of post-traumatic stress disorder (PTSD) and depression approximately 6 months after homecoming as predictors of the subsequent probability of gaining employment when unemployed within 5 years post-deployment. DESIGN, SETTING AND PARTICIPANTS: Danish FDS responders (n=3935) and non-responders (n=3046) to a 6-month post-deployment screening questionnaire after returning from a first-ever deployment to Kosovo, Iraq or Afghanistan (2002 to 2012) were included in the study and followed in public registers from 6 months to 5 years post-deployment. PRIMARY AND SECONDARY OUTCOME MEASURES: We tested Cox regression models including deployment experiences (1a), screening levels of PTSD and depressive symptoms (1b), and their combination (2) for FDS responders. For all FDS, a secondary model included a measure on whether they responded to the questionnaire (3). RESULTS: Neither the deployment experiences (1a) of exposure to danger and combat (HR=1.00, 95% CI=0.97 to 1.03) and witnessing consequences of war (HR=1.01, 95% CI=0.96 to 1.06), or the screening levels (1b) of PTSD (HR=1.06, 95% CI=0.84 to 1.33) and depressive symptoms (HR=0.82, 95% CI=0.64 to 1.06) were significant predictors of transitioning from unemployment to employment. Similar results were found for the combined model (2). A tendency among non-respondents (3) to have a lower probability of transitioning from unemployment to employment was found (HR=0.90, 95% CI=0.81 to 1.00). CONCLUSION: Deployment experiences, PTSD and depressive symptoms, as measured at 6-month screening questionnaire, did not predict differences in the probability of gaining employment when unemployed within 5 years post-deployment. However, the findings suggest that those with the least probability of transitioning from unemployment to employment can be found among the non-responders to the post-deployment screening questionnaire.

ICD-11 PTSD and complex PTSD in treatment-seeking Danish veterans: a latent profile analysis.

Background: The WHO International Classification of Diseases, 11th version (ICD-11), includes a trauma-related diagnosis of complex posttraumatic stress disorder (CPTSD) distinct from posttraumatic stress disorder (PTSD). Results from previous studies support the validity of this distinction. However, no studies to date have evaluated the ICD-11 model of PTSD and CPTSD in treatment-seeking military veterans. Objective: To determine if the distribution of symptoms in treatment-seeking Danish veterans was consistent with the ICD-11 PTSD and CPTSD symptom profiles. Based on previous studies, we hypothesized that separate classes representing PTSD and CPTSD would be found that membership of a potential CPTSD-class would be predicted by a larger number of childhood traumas, and that a potential distinction between PTSD and CPTSD would be supported by differences in sociodemographic and functional outcomes. Method: Participants (N = 1,541) were formerly deployed Danish soldiers who completed proxy measures of ICD-11 PTSD and disturbances in self-organization (DSO) symptoms, along with self-report measures of traumatic life events, prior to starting treatment at the Military Psychology Department of the Danish Defence. Results: All hypotheses were supported. Latent profile analysis (LPA) revealed separate classes representing PTSD and CPTSD. In comparison to the PTSD-class, membership of the CPTSD-class was predicted by more childhood traumatic experiences, and members of this class were more likely being single/divorced/widowed and more likely to use psychotropic medication. Besides a PTSD-class and a CPTSD-class, LPA revealed a Low Symptoms-class, a Moderate DSO-class, a Hyperarousal-class, and a High DSO-class, with clear differences in functional outcomes between classes. Conclusion: Findings replicate previous studies supporting the distinction between ICD-11 PTSD and CPTSD. In addition, there seem to be groups of treatment-seeking military veterans that do not fulfil full criteria for a trauma-related disorder. Further research should explore subsyndromal PTSD and CPTSD profiles in veterans and other populations.

Antecedentes: La Clasificación Internacional de Enfermedades de la OMS, 11ª versión (CIE-11), incluye un diagnóstico relacionado con el trauma para el trastorno de estrés postraumático complejo (TEPT-C) distinto del trastorno de estrés postraumático (TEPT). Los resultados de los estudios anteriores respaldan la validez de esta distinción. Sin embargo, ningún estudio hasta la fecha ha evaluado el modelo CIE-11 del TEPT y TEPT-C en veteranos militares en busca de tratamiento.Objetivo: Determinar si la distribución de los síntomas en los veteranos daneses en busca tratamiento fue consistente con los perfiles de los síntomas del TEPT y TEPT-C de la CIE-11. Basados en estudios previos, planteamos la hipótesis de que se encontrarían clases separadas que representan el TEPT y TEPT-C, que la pertenencia a la clase potencial del TEPT-C sería predicha por un mayor número de traumas infantiles, y que una posible distinción entre el TEPT y TEPT-C sería apoyada por las diferencias en los resultados sociodemográficos y funcionales.Método: Los participantes (N = 1,541) fueron soldados daneses desplegados anteriormente, que completaron medidas indirectas del TEPT CIE-11 y la alteración en los síntomas de autoorganización (DSO en su sigla en inglés), junto con medidas de autoinforme de los eventos traumáticos de la vida, antes de comenzar el tratamiento en el Departamento de Psicología Militar de la Defensa Danesa.Resultados: Todas las hipótesis fueron sustentadas. El análisis de perfil latente (APL) reveló clases separadas que representan el TEPT y TEPT-C. En comparación con la clase del TEPT, la pertenencia a la clase del TEPT-C fue predicha por más experiencias traumáticas infantiles, y los miembros de esta clase eran más propensos a ser solteros/divorciados/viudos y más propensos a usar medicamentos psicotrópicos. Además de una clase del TEPT y una clase del TEPT-C, el APL reveló una clase de Síntomas Bajos, una clase de DSO Moderado, una clase de Hiperactivación y una clase de DSO Alto, con claras diferencias en los resultados funcionales entre las clases.Conclusión: Los resultados replican los estudios previos que respaldan la distinción entre el TEPT y TEPT-C del CIE-11. Adicionalmente, parece haber grupos de veteranos militares en busca de tratamiento que no cumplen con los criterios completos para un trastorno relacionado con el trauma. Los estudios futuros deben explorar los perfiles del TEPT y TEPT-C sub-sindrómico en veteranos y otras poblaciones.

Are Posttraumatic Stress Symptoms Related to Mental Health Service Use? A Prospective Study of Danish Soldiers Deployed to Afghanistan.

BACKGROUND: Investigating the use of mental health services by combat veterans can help illuminate utilization and unmet needs of this population. The aims of this study were to estimate the use of mental health services and to examine how such use is associated with self-reported symptoms of posttraumatic stress disorder (PTSD) in soldiers before and after deployment to Afghanistan. METHODS: Prospectively, 703 Danish soldiers who deployed from January 2009 to August 2009 were followed up with 6 assessments from predeployment to 2.5 years postdeployment in 2012. At assessments, the soldiers responded to a comprehensive questionnaire including a measure of PTSD symptoms (the PTSD Checklist-Civilian version). These self-reported data were combined with individual-level records of receiving psychotherapy from the Military Psychological Division at the Danish Defense and psychiatric treatment from the Danish registers. RESULTS: The prevalence of PTSD symptoms increased over time, and almost 10% of the sample reported high levels of PTSD symptoms 2.5 years postdeployment. Overall, 37% of the soldiers utilized mental health services; 6% utilized psychiatric services, and 12.4% redeemed a prescription for psychiatric medicine. Approximately one-third received psychotherapy at the Military Psychological Division. In those reporting high PTSD symptomatology, 83% utilized 1 or more types of mental health service. At predeployment and homecoming, high PTSD symptomatology was significantly (P < .01) associated with attending psychotherapy, but not with psychiatric treatment or redemption of psychiatric medicine. CONCLUSIONS: With time, more soldiers report high PTSD symptoms. Among Danish soldiers with high symptomatology, the utilization of mental health services was high. Most frequently, soldiers with high PTSD symptomatology received psychotherapy at the Military Psychological Division and less frequently received psychiatric treatment.

Diagnostic accuracy of the posttraumatic stress disorder checklist-civilian version in a representative military sample.

This study aimed to assess the diagnostic accuracy of the Posttraumatic Stress Disorder Checklist-Civilian Version (PCL-C; Weathers, Litz, Herman, Huska, & Keane, 1993) and to establish the most accurate cutoff for prevalence estimation of posttraumatic stress disorder (PTSD) in a representative military sample compared to a clinical interview. Danish soldiers (N = 415; 94.4% male, mean age 26.6 years) were assessed with the PCL-C and the Structured Clinical Interview for the DSM-IV (SCID; First, Spitzer, Gibbon, & Williams, 2002) 2.5 years after their return from deployment to Afghanistan. Diagnostic accuracy of the PCL-C was assessed through receiver operating characteristic curve analysis. The PCL-C displayed high overall accuracy (area under the curve = .95, confidence interval [.92, .98]) and performed well (sensitivity > .70 and specificity ≥ .90), with cutoff scores ranging from 37 to 44. When including sensitivity values a little below .70 (.69), the PCL-C performed well for cutoff levels up to 53. Prevalence of PTSD varied considerably with the application of different cutoff values and scoring methods. Our results show that the PCL-C is a relevant and valid tool for screening for probable PTSD in active military samples. However, it is of great importance that cutoff scores be chosen based on the sample and the purpose of the particular study or screening.

Postdeployment suicidal ideations and trajectories of posttraumatic stress disorder in Danish soldiers: a 3-year follow-up of the USPER study.

OBJECTIVE: Suicidal ideation in veterans is of great concern. The objective of this study is to examine how heterogeneous posttraumatic stress disorder (PTSD) trajectories are associated with postdeployment suicidal ideation in veterans 2.5 years postdeployment to a combat zone in Afghanistan. If PTSD trajectories are associated with postdeployment suicidal ideations, then the accumulative knowledge on what characterizes veterans falling into different PTSD trajectories may provide better opportunities for early identification of suicidal high-risk veterans. METHOD: In this prospective study of 743 Danish soldiers deployed to Afghanistan from February to August in 2009, we collected data at 6 time points from 6 weeks before deployment to 2.5 years after homecoming (total for this study: 456). At all assessments, the soldiers responded to a comprehensive questionnaire including measures of PTSD (measured by the PTSD Checklist, Civilian Version) and other mental and physical health variables, demographics, and social and combat-related factors. Suicidal ideation was measured by an item from the European Parasuicide Study Interview Schedule II. In a previous study based on soldiers from this cohort, we identified 6 PTSD trajectories using latent growth mixture modeling, which we have extracted and applied as independent variables in this study. Adjusted multivariable logistic regression analyses were applied to examine whether deployed soldiers with certain PTSD symptom trajectories were more likely to report suicidal ideation 2.5 years after homecoming. RESULTS: Two PTSD trajectories with high PTSD symptom level 2.5 years after return were significantly associated with suicidal ideation 2.5 years after homecoming. Thus, a relieved-worsening class, described by initial decreasing PTSD symptom levels followed by a steep increase in symptoms had higher risk of suicidal ideation (OR = 7.84; 95% CI, 1.68-36.6), which was also the case for a late-onset class (OR 5.2; 95% CI, 2.21-12.24) when compared to a low-stable class. CONCLUSIONS: Heterogeneous PTSD trajectories are associated with suicidal ideation in veterans 2.5 years after homecoming.

Latent trajectories of trauma symptoms and resilience: the 3-year longitudinal prospective USPER study of Danish veterans deployed in Afghanistan.

OBJECTIVE: To identify trajectories of posttraumatic stress disorder (PTSD) symptoms from before to 2.5 years after deployment and to assess risk factors for symptom fluctuations and late-onset PTSD. METHOD: 743 soldiers deployed to Afghanistan in 2009 were assessed for PTSD symptoms using the PTSD Checklist (PCL) at 6 occasions from predeployment to 2.5 years postdeployment (study sample = 561). Predeployment vulnerabilities and deployment and postdeployment stressors were also assessed. RESULTS: Six trajectories were identified: a resilient trajectory with low symptom levels across all assessments (78.1%) and 5 trajectories showing symptom fluctuations. These included a trajectory of late onset (5.7%), independently predicted by earlier emotional problems (OR = 5.59; 95% CI, 1.57-19.89) and predeployment and postdeployment traumas (OR = 1.10; 95% CI, 1.04-1.17 and OR = 1.13; 95% CI, 1.00-1.26). Two trajectories of symptom fluctuations in the low-to-moderate range (7.5% and 4.1%); a trajectory of symptom relief during deployment, but with a drastic increase at the final assessments (2.0%); and a trajectory with mild symptom increase during deployment followed by relief at return (2.7%) were also found. Symptom fluctuation was predicted independently by predeployment risk factors (depression [OR = 1.27; 95% CI, 1.16-1.39], neuroticism [OR = 1.10; 95% CI, 1.00-1.21], and earlier traumas [OR = 1.09; 95% CI, 1.03-1.16]) and deployment-related stressors (danger/injury exposure [OR = 1.20; 95% CI, 1.04-1.40]), but not by postdeployment stressors. DISCUSSION: The results confirm earlier findings of stress response heterogeneity following military deployment and highlight the impact of predeployment, perideployment, and postdeployment risk factors in predicting PTSD symptomatology and late-onset PTSD symptoms.

Electrophysiological correlates of anxious rumination.

EEG coherence and EEG power response were recorded as 63 participants engaged in one of three experimental conditions: 'personal rumination', 'nominal rumination', and 'baseline counting'. The rumination conditions were separated by a neutral (counting) task to eliminate neural carry-over effects. For personal rumination, participants spent 2 min ruminating about something in their life about which they were in two minds (i.e., in a state of personal conflict). For nominal rumination, they were presented with a conflict scenario (concerning buying a car) and instructed to ruminate about that for 2 min. The baseline counting task simply involved counting forwards from 1 at a speed comfortable to the individual. Participants completed various questionnaires to measure mood and also traits of personality (including trait anxiety). EEG data were analysed in the following wavebands: 4-6 Hz, 6-8 Hz, 8-10 Hz, 10-12 Hz, 12-20 Hz and 20-30 Hz. Results revealed that the scalp-wide EEG theta (4-6 Hz and 6-8 Hz) coherence associated with personal rumination was significantly greater than that associated with nominal rumination and baseline counting. Similarly, the scalp-wide 6-8 Hz and parietal-occipital 4-6 Hz power associated with personal rumination were significantly greater than power associated with the nominal rumination and power for baseline counting. For alpha, the 10-12 Hz scalp-wide EEG coherence associated with personal rumination was significantly greater than that associated with baseline counting. Otherwise, the scalp-wide 10-12 Hz power related to both nominal rumination and personal rumination were significantly greater than in response to baseline counting. For 20-30 Hz scalp-wide EEG power, data in response to the nominal rumination condition were significantly increased compared to data associated with the baseline counting condition. In terms of questionnaire data, tense arousal, anger/frustration, hedonic tone and energetic arousal were all influenced by rumination. This was largely in line with expectation. Also, mood state was influenced by neuroticism and state anxiety. Our EEG results are consistent with Gray and McNaughton's [Gray, J.A., McNaughton, N., 2000. The neuropsychology of Anxiety: An Anquiry into the Functions of the Septo-Hippocampal System. 2nd ed. Oxford University Press, Oxford.] account of recursive processing between the septo-hippocampal system and neocortex during goal-conflict resolution inherent in rumination. Evidence of posterior cingulate involvement in this processing was also discussed. Recommendations for future research, aimed at further evaluating the role of the SHS and the posterior cingulated, were outlined. Effects found in alpha were linked to increased vigilance whilst effects in beta were linked to cognitive and emotional aspects of the task. We conclude that these data provide new information of the neural processes associated with the psychological state of anxious rumination and, thus, hold implications for understanding normal and pathological anxiety.