Using self-report surveys at the beginning of service to develop multi-outcome risk models for new soldiers in the U.S. Army.

BACKGROUND: The U.S. Army uses universal preventives interventions for several negative outcomes (e.g. suicide, violence, sexual assault) with especially high risks in the early years of service. More intensive interventions exist, but would be cost-effective only if targeted at high-risk soldiers. We report results of efforts to develop models for such targeting from self-report surveys administered at the beginning of Army service. METHODS: 21 832 new soldiers completed a self-administered questionnaire (SAQ) in 2011-2012 and consented to link administrative data to SAQ responses. Penalized regression models were developed for 12 administratively-recorded outcomes occurring by December 2013: suicide attempt, mental hospitalization, positive drug test, traumatic brain injury (TBI), other severe injury, several types of violence perpetration and victimization, demotion, and attrition. RESULTS: The best-performing models were for TBI (AUC = 0.80), major physical violence perpetration (AUC = 0.78), sexual assault perpetration (AUC = 0.78), and suicide attempt (AUC = 0.74). Although predicted risk scores were significantly correlated across outcomes, prediction was not improved by including risk scores for other outcomes in models. Of particular note: 40.5% of suicide attempts occurred among the 10% of new soldiers with highest predicted risk, 57.2% of male sexual assault perpetrations among the 15% with highest predicted risk, and 35.5% of female sexual assault victimizations among the 10% with highest predicted risk. CONCLUSIONS: Data collected at the beginning of service in self-report surveys could be used to develop risk models that define small proportions of new soldiers accounting for high proportions of negative outcomes over the first few years of service.

Mitochondria-focused gene expression profile reveals common pathways and CPT1B dysregulation in both rodent stress model and human subjects with PTSD.

Posttraumatic stress disorder (PTSD), a trauma-related mental disorder, is associated with mitochondrial dysfunction in the brain. However, the biologic approach to identifying the mitochondria-focused genes underlying the pathogenesis of PTSD is still in its infancy. Previous research, using a human mitochondria-focused cDNA microarray (hMitChip3) found dysregulated mitochondria-focused genes present in postmortem brains of PTSD patients, indicating that those genes might be PTSD-related biomarkers. To further test this idea, this research examines profiles of mitochondria-focused gene expression in the stressed-rodent model (inescapable tail shock in rats), which shows characteristics of PTSD-like behaviors and also in the blood of subjects with PTSD. This study found that 34 mitochondria-focused genes being upregulated in stressed-rat amygdala. Ten common pathways, including fatty acid metabolism and peroxisome proliferator-activated receptors (PPAR) pathways were dysregulated in the amygdala of the stressed rats. Carnitine palmitoyltransferase 1B (CPT1B), an enzyme in the fatty acid metabolism and PPAR pathways, was significantly over-expressed in the amygdala (P < 0.007) and in the blood (P < 0.01) of stressed rats compared with non-stressed controls. In human subjects with (n = 28) or without PTSD (n = 31), significant over-expression of CPT1B in PTSD was also observed in the two common dysregulated pathways: fatty acid metabolism (P = 0.0027, false discovery rate (FDR) = 0.043) and PPAR (P = 0.006, FDR = 0.08). Quantitative real-time polymerase chain reaction validated the microarray findings and the CPT1B result. These findings indicate that blood can be used as a specimen in the search for PTSD biomarkers in fatty acid metabolism and PPAR pathways, and, in addition, that CPT1B may contribute to the pathology of PTSD.

Forensic psychiatry in the United States military.

Members of the U.S. military and their families represent a unique subsection of the American culture. The U.S. Constitution, federal law, and military regulations establish guidance for the conduct of service members during peacetime and wartime. This same hierarchy of law and regulation sets forth the legal rights and directs the provision of medical care for service members and their families. The fact that the military population is concurrently subject to a body of military law, as well as to the broader guidelines of the civilian sector, creates distinct roles for the military forensic psychiatrist. An understanding of the medical and legal framework in which the military forensic psychiatrist operates will facilitate the interactions of the civilian expert witness with the military justice system. In this report, the legal issues most relevant to the practice of forensic psychiatry in the military are discussed. In addition, the roles and responsibilities for psychiatrists specifically trained in aspects of military medical and mental health law are identified.

Operational stress control in the former Yugoslavia: a joint endeavor.

The military has developed specialized mental health teams to evaluate and treat soldiers diagnosed with stress reactions and neuropsychiatric disorders. The response of these mental health teams in support of the year-long peace enforcement mission to Bosnia-Herzegovina is reviewed. Demographics and operational stressors are examined. Stress control doctrine is tested and revised. Credibility with leaders, chaplains, and medical personnel is achieved through rapid response to serious injury or fatality. Emphasis is placed on successful marketing strategies, stress management and suicide prevention classes, prompt access to care, and decreasing the stigma of mental health through education. Coordination of mental health assets promotes synergy and mission accomplishment.

Treatment of premenstrual dysphoric disorder with sertraline during the luteal phase: a randomized, double-blind, placebo-controlled crossover trial.

BACKGROUND: The authors designed a randomized, double-blind, crossover study to assess the efficacy of sertraline in the treatment of premenstrual dysphoric disorder (PMDD) when given only during the luteal phase of the menstrual cycle. METHOD: Thirty-one subjects were selected for a 7-month study period that included an initial 2 months of screening, 2 months of treatment with placebo or sertraline, 1 washout month, and 2 months of crossover treatment with either placebo or sertraline. Eleven subjects completed the study. Symptoms were monitored with daily reports using the Calendar of Premenstrual Experience (COPE). For each study phase, premenstrual COPE scores (7 days prior to menses) were examined using repeated measures analysis of variance. Scores were logarithmically transformed. Comparison of baseline scores between the luteal and follicular phases was examined using the paired t test. RESULTS: Analysis of COPE results during the treatment periods of the luteal phase showed a significant treatment effect, with higher scores during the placebo cycles compared with the sertraline-treated cycles (p = .0052 behavioral, p = .014 physical). CONCLUSION: This study is the first to demonstrate a significant response to a serotonin selective reuptake inhibitor used only during the luteal phase. The authors point out the importance of this finding both in terms of economic cost of patients as well as how it may add to the growing understanding of the etiology of PMDD.

Bedside stuffed animals and borderline personality.

We explored the relationship between psychiatric diagnosis and the presence of stuffed animals at the bedside in a population of adult female psychiatric inpatients. One of the authors made approximately weekly surveys of the wardrooms of adult psychiatric inpatients over twelve months for the presence of displayed stuffed animals. The observer was blind to the diagnosis of 80% of the patients, and the study or its hypothesis was not known to other physicians. The discharge diagnoses of patients displaying stuffed animals were recorded and compared with those of the ward population in general. Among 36 female patients who displayed stuffed animals in their rooms, Borderline Personality Disorder was diagnosed in 22 (61%) of these patients. Of 447 adult female patients admitted to the same unit over the same period, only 17% were noted to be diagnosed Borderline Personality Disorder. Stuffed animals as a bedside clinical clue may suggest evaluation for Borderline Personality Disorder.