Intergenerational transmission of post-traumatic stress disorder in Australian Vietnam veterans' families.

OBJECTIVE: To assess the association between parental post-traumatic stress disorder (PTSD) and offspring PTSD and its specificity for other disorders in a non-clinical epidemiological cohort of Australian Vietnam veterans, their partners and their sons and daughters. METHOD: Veterans were interviewed twice, in 1992-1994 and 2005-2006; partners were interviewed in 2006-2007, and their offspring in 2012-2014. A total of 125 sons and 168 daughters were interviewed from 197 families, 137 of which also included partners who were the mothers of the children. Statistical analysis used multi-level modelling to compute odds ratios and 95% confidence intervals while controlling for clustering effects within families. Parent PTSD diagnoses were examined for associations with offspring trauma exposure, PTSD and other psychiatric diagnoses. RESULTS: Veteran PTSD increased the risk of PTSD and no other disorder in both sons and daughters; partner PTSD did not. Veteran depression was also a risk factor for sons' PTSD, and alcohol disorder was linked to alcohol dependence in sons and PTSD in daughters, but not when controlling for veteran PTSD. CONCLUSION: We conclude that PTSD in a Vietnam veteran father increases the risk specifically for PTSD in his sons and daughters.

Cancer incidence in patients with schizophrenia and their first-degree relatives - a meta-analysis.

OBJECTIVE: Controversy concerning cancer incidence in schizophrenia exists because of heterogeneous study findings. METHOD: A meta-analysis was performed on standardized incidence ratios (SIR) of cancer in patients with schizophrenia and first-degree relatives and compared with general population samples. RESULTS: The pooled overall cancer incidence in patients was not significantly increased (SIR = 1.05, CI 0.95-1.15). Lung cancer incidence was slightly increased (SIR = 1.31, CI 1.01-1.71), but was reduced after adjusting for smoking prevalence. The incidence of several cancers unrelated to smoking was reduced in patients. Breast cancer rates were significantly increased in female patients. The pooled overall cancer incidence in siblings (SIR = 0.89, CI 0.84-0.94) and parents (SIR = 0.90, CI 0.88-0.93) was significantly reduced. A meta-regression detected a significant relationship between cancer risk in the general population and relative risk in patients. CONCLUSION: The meta-analysis aided exploration of inconsistent study findings. There is a discrepancy between cancer risk exposure and cancer incidence in schizophrenia consistent with a protective effect.

Acute effects of low levels of ambient ozone on peak expiratory flow rate in a cohort of Australian children.

BACKGROUND: We enrolled a cohort of primary schoolchildren with a history of wheeze (n = 148) in an 11-month longitudinal study to examine the relationship between ambient ozone concentrations and peak expiratory flow rate. METHODS: Enrolled children recorded peak expiratory flow rates (PEFR) twice daily. We obtained air pollution, meteorological and pollen data. In all, 125 children remained in the final analysis. RESULTS: We found a significant negative association between daily mean deviation in PEFR and same-day mean daytime ozone concentration (beta-coefficient = 0.88; P = 0.04) after adjusting for co-pollutants, time trend, meteorological variables, pollen count and ALTERNARIA: count. The association was stronger in a subgroup of children with bronchial hyperreactivity and a doctor diagnosis of asthma (beta-coefficient = -2.61; P = 0.001). There was no significant association between PEFR and same-day daily daytime maximum ozone concentration. We also demonstrated a dose-response relationship with mean daytime ozone concentration. CONCLUSIONS: Moderate levels of ambient ozone have an adverse health effect on children with a history of wheezing, and this effect is larger in children with bronchial hyperreactivity and a doctor diagnosis of asthma.

The Australian Vietnam Veterans Health Study: I. study design and response bias.

BACKGROUND: The Australian Vietnam Veterans Health Study was set up to examine the post-war health of former soldiers 20 or more years after service and to examine the relation of combat exposure to physical and mental health. METHOD: A prospective cohort study of a simple random sample of 1000 male Australian Army Vietnam veterans used information gathered from Army records, from personnel interview and questionnaires. Military records were used to examine response bias by determining the differences between 641 interviewed veterans, 50 known deceased veterans and 309 non-respondents (including 48 refusers and 213 non-traceable). RESULTS: Differences were evident between respondents and non-respondents, with logistic regression modelling pointing to pre-enlistment employment, antisocial behaviour, intelligence and post-Vietnam AWOL (absent without leave) as the most important discriminants with non-respondents performing worse. Compared to respondents, deceased left school earlier, had higher rank in Vietnam and at discharge, had a higher overall number of charges but not a higher rate overall, and were less likely to have gone AWOL. Deceased also received more casualty reports than respondents and non-respondents, were better behaved during service, and were better emotionally adjusted than non-respondents. Respondents compared with the Australian population had equivalent or better current socioeconomic status. CONCLUSION: There seems little bias due to non-response, but deceased tend to come from and older cohort than in the other two groups.

The Australian Vietnam Veterans Health Study: II. self-reported health of veterans compared with the Australian population.

BACKGROUND: Self-reported physical health status of Australian Vietnam veterans was determined 20-25 years after the war and its relation to combat was investigated. METHOD: An epidemiological cohort study of a simple random sample of Army veterans posted to Vietnam between 1964 and 1972 was conducted with personal interviews using the Australian Bureau of Statistics Health Interview Survey questionnaire to compare veterans with the Australian population and a 21-item combat exposure index used to measure the relationship of combat to physical health. RESULTS: Veterans reported greater health service usage and more recent health actions than population expectations. They also reported excess health problems in almost all recent illness disease categories except endocrine conditions and cardiovascular conditions; only 6 of 37 chronic disease groups were not elevated compared to the population. Adjustment for non-response changed estimates only slightly. Combat exposure was significantly related to reports of recent and chronic mental disorders, recent hernia and chronic ulcer, recent eczema and chronic rash, deafness, chronic infective and parasitic disease, chronic back disorders and symptoms, signs and ill-defined conditions. CONCLUSION: Combat exposure may have significantly increased reports of only some health problems. A general position to complain as a result of psychological conditions due to combat is not consistent with the lack of relationship between combat and reports of physical conditions.

The Australian Vietnam Veterans Health Study: III. psychological health of Australian Vietnam veterans and its relationship to combat.

BACKGROUND: Self-reported psychiatric status of Australian Vietnam war veterans was determined 20-25 years after the war and its relation to combat was investigated. METHOD: A simple random sample of Australian Army Vietnam veterans was interviewed nationally using standardized interviews and self-completion tests to assess the prevalence of lifetime and current psychiatric illness and its relationship to combat. Army records were used to extract data on the cohort for use in regression-based adjustment for non-response. RESULTS: The conditions mainly affecting the Australian veterans were alcohol abuse or dependence, post-traumatic stress disorder, somatization disorder were significantly related to combat exposure but not with posting to a combat unit. Less than half of the current one-month diagnoses were related to combat, possibly because of low power conferred by the relative rarity of these conditions. CONCLUSIONS: The results confirm a range of psychological problems in former warriors may linger 20 or more years from their war exposure and may be directly affected by exposure to war trauma.

Five years after child sexual abuse: persisting dysfunction and problems of prediction.

OBJECTIVE: To assess change in behavior, depression, and self-esteem in sexually abused children after 5 years and to determine which factors predict later functioning. METHOD: Sixty-eight of 84 children and their nonoffending parents were reassessed after 5 years for depression, self-esteem, and behavior problems in the children; parental mental health; and family functioning. RESULTS: There were no significant changes in depression, self-esteem, or behavior over 5 years. Forty-three percent of the children were now sad or depressed, 43% had low self-esteem, and 46% had behavioral dysfunction. While some children improved, a nearly equal number deteriorated, with no clear pattern of change. The only abuse-related variables associated with 5-year functioning were further contact with the abuser, which was significantly associated with depression and self-esteem, and sexual abuse prior to intake, which was related to an increased incidence of behavior problems. Older children showed more depression and lower self-esteem but less behavioral dysfunction. Poor family functioning at 5 years was associated with low self-esteem and behavior problems. Treatment had no effect on depression, self-esteem, or behavior. Multivariate analysis showed that depression and self-esteem at intake were prognostic indicators of 5-year outcome. CONCLUSION: Many sexually abused children have continuing problems with behavior, self-esteem, and depression. Family and abuse-related variables do not appear to be good predictors of outcome, although sexually abused children who are sad or depressed and have low self-esteem at intake are likely to have continuing problems in these areas.

Stability and change in outcomes for sexually abused children.

OBJECTIVE: To evaluate sexually abused children and their families at intake and 18 months later, in comparison with a control group. METHODS: Eighty-four sexually abused children aged 5 to 15 years were assessed at intake, with 64 being able to be reassessed at 18 months, the assessment using measures of self-esteem relevant to their age; the Children's Depression Inventory, and the Achenbach Child Behavior Checklist. Parents were assessed with the McMaster Family Assessment Device and the General Health Questionnaire. Control children and families were similarly assessed. Additional measures at follow-up were a structured interview with the parents, the Indices of Coping Responses, and the Newcastle Child and Family Life Events Schedule. Therapists were contacted to obtain information on type and duration of therapy. RESULTS: While the control children's self-esteem, depression, and behavior scores showed little change over time, the abused children's scores were more likely to move toward the normal range although 56% remained in the dysfunctional range for self-esteem, 48% for behavior, and 35% for depression. Improvement in child behavior was related to improvement in family function. While there was no direct relationship between child outcome and the relationship of the abuser to the child, family dysfunction, which was related to child outcome, did correlate with the closeness of the abuser to the child. Sixty-five percent of abused children had received therapy for an average of 9 months. No relationship was found between therapy and outcome. CONCLUSIONS: The major variable relating to improvement in sexually abused children appears to be adequacy of family functioning. There is a need for increased emphasis on the evaluation of treatment.

Domestic violence in the Emergency Department: 2. Detection by doctors and nurses.

This study was conducted in 1991 and 1992 to determine the detection rates of domestic violence victims by doctors and nurses at the Emergency Department (ED) of Royal Brisbane Hospital, a major public hospital in Australia. The objective was to determine the outcome of an education program about domestic violence conducted in 1991 for doctors and nurses in the ED. As part of two case-control studies, the self-reports of those who disclosed domestic violence on a screening questionnaire were compared with the recording of domestic violence on each individual medical record. Subjects were drawn from two screening studies carried out 1 year apart which were conducted to assess the prevalence of domestic violence among attendees at the ED. An education program about domestic violence was conducted for doctors and nurses in the ED between the two screening studies. The examination of the medical records showed that detection rates of victims of domestic violence were unchanged between the two case-control studies. Both studies found that 50.0% of those who reported the experience of domestic violence within the 24 hours prior to index presentation, on the screening questionnaire in the prevalence studies, were recorded as such in their medical records. The low detection rates indicate the requirement for doctors and nurses to receive appropriate training to identify and record the psychosocial aspects of domestic violence victims. As well as training, referral systems need to be set in place to address the psychosocial aspects of domestic violence victims.

Domestic violence in the Emergency Department: I. Two case-control studies of victims.

The object of this study was to compare the diagnoses and characteristics of self-reported domestic violence victims with a random sample of nonvictim controls who were selected from attendees at the Emergency Department (ED) of a major public hospital in Australia. Comparisons were made at index presentation and for the 5 years prior to index presentation. Subjects were drawn from two screening studies carried out 1 year apart which were conducted to assess the prevalence of domestic violence among attendees at the ED. From these groups, the medical records of all individuals who had disclosed domestic violence were examined and compared with the medical records of a random sample of nondisclosers, matched for age (+/- 10 years), sex, and type of entry into the ED (acute vs nonacute). The two case-control studies, conducted 12 months apart, showed that there were statistically significant differences between the diagnoses and characteristics of victims and nonvictims. Victims made more visits to the ED and Outpatients' Department than nonvictims; victims had more psychiatric index presentations; more victims had evidence of treatment of psychiatric conditions, both as inpatients and outpatients, in the previous 5 years than nonvictims; victims had greater rates of attempted suicide and alcohol problems than nonvictims at index presentation and for the previous 5 years. The findings indicate the need for the prevention and treatment of psychiatric conditions of domestic violence victims, including drug and alcohol problems and suicidal ideation. The findings form the basis of hypotheses for further studies to investigate the association between domestic violence and psychiatric illness.

Posttraumatic stress disorder and other predictors of health care consumption by Vietnam veterans.

A total of 641 randomly selected Australian veterans of the Vietnam War were interviewed about their use of health care in the previous two weeks to determine what factors contributed to health care consumption. Seventy-three variables were examined by univariate linear regression and then grouped into seven categories relating to age, physical and mental health, predisposition to posttraumatic stress disorder (PTSD), deployment and repatriation experiences, and membership in veterans groups. PTSD was associated with an additional cost of $79 in health care for the two-week period. Each physical diagnosis was associated with an additional $28. Alcohol consumption was not related to health care costs. Other important variables contributing to costs were depression, educational status, the quality of the repatriation experience, and social support.

Intelligence and behaviour and motor vehicle accident mortality.

Risk factors for mortality from motor vehicle accidents (MVAs) were examined in all Australian former National Service conscripts of the Vietnam conflict era, by comparing all those who had died from MVAs since the end of their basic training up until 1982 with a random sample of survivors, using data available from service records. Decedents were in their third and fourth decades. Risk of mortality was higher for men with lower scores on the army intelligence test, with poorer education, with lower preenlistment occupational status, with a history of juvenile offenses before army enlistment, and who went absent without leave (AWOL) during National Service. These factors were modelled using logistic regression, which showed that intelligence plus either lower levels of education or a history of offenses before army service were the most important of these factors in predicting mortality in MVAs.

Suicide risk factors among Australian Vietnam era draftees.

The cohort of all Australian former army conscripts of the Vietnam conflict ea was followed from 1965 to 1982 to determine mortality rates and causes of death following completion of their National Service. Suiciders were compared with a random sample of survivors using information contained in their military documents in a nested case-control study. Their military document information was recorded before men were selected for Vietnam service and is uncontaminated by "recall bias." Suicide victims had lower mean scores on the army general intelligence and mechanical comprehension tests, were less likely to have continued education beyond high school, were less likely to be employed in white-collar or skilled blue-collar jobs between leaving school and being drafted, and more likely to have volunteered for the draft. They were more likely to have committed a civilian offense before joining the army, more likely to have gone absent without leave (AWOL), and more likely to have committed other offenses during military service. Suiciders were more likely to have a history of diagnosis and treatment for psychological disorder during service and to be judged to be less than emotionally stable at discharge. Service in Vietnam was not associated with suicide. A log-linear regression model was used to analyze death rates associated with five types of variables: cognitive abilities, education, preservice employment, conduct while in service, and physical and mental health. This analysis produced a model containing only four variables: intelligence test score, postschool education, AWOL charge during service, and history of diagnosis and treatment of psychological problems. The difference in death rates between high scorers on these items and low scorers was 46-fold, from 5.2 to 240.9 per 10,000 person-years.

Prior childhood sexual abuse in mothers of sexually abused children.

OBJECTIVE: To see if mothers who were sexually abused in their own childhood are at increased risk of their children being sexually abused and to see if prior sexual abuse in mothers affects their parenting abilities. METHOD: Sixty-seven mothers whose children had been sexually abused by others and 65 control mothers were asked about sexual abuse in their own childhood. The sexually abused children of mothers who had been sexually abused in their own childhood were compared with the sexually abused children of mothers who had not suffered child sexual abuse as children. Comparisons were made on self-esteem, depression and behavior in the children. RESULTS: Thirty-four percent of mothers of sexually abused children gave a history of sexual abuse in their own childhoods, compared with 12% of control mothers. Assessment of the sexually abused children for self-esteem, depression and behavior at the time of diagnosis, after 18 months and after 5 years showed no difference in any of these measures at any of the three time intervals between those whose mothers had suffered child sexual abuse and those whose mothers had not been abused. CONCLUSION: In this study, sexual abuse in a mother's own childhood was related to an increased risk of sexual abuse occurring in the next generation, although prior maternal sexual abuse did not effect outcome in children who were sexually abused.

Communication across the divide. A trial of structured communication between general practice and emergency departments.

AIM: To evaluate the impact of structured form letters for general practitioner to emergency department (ED) communication. STUDY POPULATION: one hundred and fifty-five GPs with practices in the Liverpool local government area in metropolitan Sydney and patients referred by them to ED at Liverpool over five months from June to October 1998. DESIGN: randomised control trial of GPs as unit of randomisation; intervention GPs were encouraged to follow a structured proforma for their written communication with the ED. Control GPs were left to usual referral procedures. The ED was encouraged to fax a brief report back to GPs using the form. Impact measures: the quality of the referral letters was evaluated using a checklist that included: reason for referral; examination finding; medical history; investigations; psychosocial history; allergies; drugs given in the surgery and present medication. Surveys were sent every month to GPs to assess communication from the ED and adverse events observed by GPs. RESULTS: Most letters from GPs to the ED contained information on reasons for referral, medical history and examination findings. Reasons for referral were present in 95% of the intervention group GPs' letters compared with 99% of those of the control group. Investigations were included with 27% and present medications in 37%. Letters from GPs in the intervention group were more likely to contain a psychosocial history than those in the control group (13% compared with 1%). Most GPs reported receiving a letter from the ED although this was rarely by fax; most were brought to them by the patient. Phone calls were received by about one in five GPs each month. Most GPs found both of these to be useful. There were no differences between communication received by GPs in the intervention and control groups. CONCLUSION: This study demonstrates that improvements to communication between GPs and EDs are difficult and may require a systemic change within general practice and the hospital. Electronic systems may allow the sort of reciprocal communication required to establish and sustain improvement.

Where's the common ground? A survey of hospitals, community health centres and divisions of general practice in Australia.

BACKGROUND: Divisions of general practice are key structures for integration between general practice and other health services in Australia. AIM: To compare the views of divisions of general practice toward integration of care with those of hospitals and community health services. METHOD: Representative national samples of public hospitals and community health centres (CHCs) and a census of divisions of general practice (DGP) were surveyed on their current collaborations and links as well as barriers to and factors that enhance integration between general practitioners and other health services. RESULTS: There is wide agreement on the need for greater integration. Personal links (via letter, phone and face to face) were thought to be useful. However, general practice liaison officers were seen as especially useful. All organizations rated different accountabilities and responsibilities as a highly significant barrier. Resources, structures for collaboration and high level organisational support were rated as being more useful in enabling greater integration. CONCLUSION: Formalizing collaboration will require changes to funding and accountability. However there is also a need for cultural change to support greater integration of patient care between general practice and both hospitals and community health services.

Screening for low prevalence disorders.

OBJECTIVE: To examine the epidemiologic theory of screening as it applies to low prevalence disorders, such as schizophrenia, in order to identify the tasks required for primary and secondary prevention. METHOD: Review of principles of screening, computation of prevented fraction for varying sensitivities, specificities and prevalences of disease, and review of prevalence of schizophrenia in Australian general practice. RESULTS: There is no currently available efficient method of screening for schizophrenia or for prodromal symptoms. From the genesis of disease to eventual outcome, the milestones that are passed in the case of schizophrenia are uncertain in their nature and the intervening time periods are of uncertain and possibly varying duration. The extent of false positives and negatives in low prevalence disorders is high unless the specificity is very high. CONCLUSION: It may be feasible to screen for behaviours that are precursors to schizophrenia; however, screening depends upon the existence of a reliable screening instrument that can be shown to discriminate accurately between diseased and disease-free individuals. Development of a method for screening requires comparison against formal clinical assessment of both screen positives and screen negatives. For low prevalence disorders the predictive values may be low unless specificity is high.

Exposure-time and spatial-frequency effects in the tilt illusion.

The exposure durations of a vertical test line and a tilted inducing grating were varied and the tilt illusion thus generated was found to change as a function of this variation. Significant direct effects (acute-angle expansion) and indirect effects (acute-angle contraction) were found to occur at times consistent with Andrew's estimate of the time course of inhibition in the visual system when the inducing grating had a spatial frequency of 10 cycles deg-1. However, a 2.71 cycles deg-1 grating gave significant effects at exposure durations of 10 as well as 1000 ms, while in a further experiment a 10.91 cycles deg-1 grating gave significant effects at 1000 ms only. These results seem to suggest that orientation interactions thought to be due to inhibition (direct effect) and disinhibition (indirect effect) may occur within both sustained and transient channels with concomitant differences in time constants.

Medical-care costs associated with posttraumatic stress disorder in Vietnam veterans.

OBJECTIVE: This study examined the relationship between medical-care costs of Vietnam veterans and predictor factors, including posttraumatic stress disorder (PTSD). METHOD: We merged medical-care cost data from the Department of Veterans' Affairs and the Health Insurance Commission with data from an epidemiological study of 641 Australian Vietnam veterans. Posttraumatic stress disorder and other factors were examined as predictors of medical-care cost using regression analysis. RESULTS: We found that a diagnosis of PTSD was associated with medical costs 60% higher than average. Those costs appeared to be partly associated with higher treatment costs for physical conditions in those with PTSD and also related mental health comorbidities. Major predictors of medical-care cost were age ($137 per year for each 5-year increase in age) and number of diagnoses reported ($81 to $112 per year for each diagnosis). Mental health factors such as depression ($14 per year for each symptom reported) and anxiety ($27 per year for each symptom reported) were also important predictors. CONCLUSIONS: The findings indicate that, however they are incurred, high healthcare and, presumably, also economic and personal costs are associated with PTSD. There is an important social obligation as well as substantial economic reasons to deal with these problems. From both perspectives, continued efforts to identify and implement effective prevention and treatment programs are warranted.