A Pilot Randomized Controlled Trial of the Insomnia Coach Mobile App to Assess Its Feasibility, Acceptability, and Potential Efficacy.

Insomnia is highly prevalent among military veterans but access to cognitive-behavioral therapy for insomnia (CBT-I) is limited. Thus, this study examined the feasibility, acceptability, and potential efficacy of Insomnia Coach, a CBT-I-based, free, self-management mobile app. Fifty U.S. veterans, who were mostly male (58%) and mean age 44.5 (range = 28-55) years with moderate insomnia symptoms were randomized to Insomnia Coach (n = 25) or a wait-list control condition (n = 25) for 6 weeks. Participants completed self-report measures and sleep diaries at baseline, posttreatment, and follow-up (12 weeks postrandomization), and app participants (n = 15) completed a qualitative interview at posttreatment. Findings suggest that Insomnia Coach is feasible to use, with three quarters of participants using the app through 6 weeks and engaging with active elements. For acceptability, perceptions of Insomnia Coach were very favorable based on both self-report and qualitative interview responses. Finally, for potential efficacy, at posttreatment, a larger proportion of Insomnia Coach (28%) than wait-list control participants (4%) achieved clinically significant improvement (p = .049) and there was a significant treatment effect on daytime sleep-related impairment (d = -0.6, p = .044). Additional treatment effects emerged at follow-up for insomnia severity (d = -1.1, p = .001), sleep onset latency (d = -0.6, p = .021), global sleep quality (d = -0.9, p = .002), and depression symptoms (d = -0.8, p = .012). These findings provide preliminary evidence that among veterans with moderate insomnia symptoms, a CBT-I-based self-management app is feasible, acceptable, and promising for improving insomnia severity and other sleep-related outcomes. Given the vast unmet need for insomnia treatment in the population, Insomnia Coach may provide an easily accessible, convenient public health intervention for individuals not receiving care.

Validating military culture: The factor analysis of a military-related adaptation of acculturation in veterans.

Differences between military and civilian culture can impact a veteran's ability to effectively navigate the transition to the civilian setting after separating from military service. However, systems providing psychological services to veterans lack reliable and valid methods of identifying the extent to which the dissonance between military and civilian cultures is associated with postseparation adjustment (e.g., ability to integrate profound deployment experiences into civilian life) and psychological outcomes. Utilization of a theory-driven, acculturation framework to assess military and civilian cultural affiliation may address this gap. While several quantitative measures exist for evaluating acculturation in reference to different ethnocultural experiences and that evaluate military culture-related adjustment or reintegration, there are no existing validated measures rooted in cultural theory that explicitly assess military-related acculturation. The aim of the present study was to develop and examine the psychometric properties of theoretically grounded, military-related adaptations of validated acculturation measures. Data from 364 veterans were collected with an online survey including four military-related adaptations of acculturation measures. Results suggest that the proposed adaptation of the original ethnocultural measurement model was not a good fit to the data, χ² = 2396.99, p < .001, TLI = .73. An evaluation of localized areas of strain in the confirmatory model and results from an exploratory factor analysis suggest support for the continued development of a military-related model of acculturation after considering further measure restructuring and validation. Opportunities for future research and measure validation are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Military acculturation and readjustment to the civilian context.

OBJECTIVE: Attitudes and beliefs related to immersion in military culture can affect postseparation transition to the civilian setting. The etiology and complexity of these reactions are often overlooked by mental health providers, which can result in negative consequences for treatment. This qualitative study examined veterans' perceptions of military culture and the impact of military service on veterans' values, beliefs, and behaviors. The goal of this research was to identify aspects of military culture that are important for health care providers to consider as they care for veterans and to inform culturally sensitive mental health care for veterans. METHOD: Fifty-two military veterans completed a self-report survey and participated in semistructured focus groups. RESULTS: Participants reported diverse military experiences, and many endorsed a high level of continuing identification with aspects of military culture. Seven broad themes related to military culture emerged from qualitative analyses: (a) military values, beliefs, and behaviors; (b) relationships; (c) occupational habits and practices; (d) acquired skills; (e) communication; (f) affiliation; and (g) psychological health and well-being. CONCLUSION: This thematic analysis elucidated strategies to improve mental health services for veterans, using a nuanced model that encourages providers to better distinguish aspects of cultural transition from psychopathology. Results underscored the importance of training mental health providers to ensure sensitivity to military culture. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Serving Veterans in their Communities: Evaluation of an Online Resource for Behavioral Health Care Providers.

Many veterans receive behavioral health care services from providers in their communities. The Community Provider Toolkit (the Toolkit) is a website developed by the National Center for PTSD and the Department of Veterans Affairs intended to provide community mental health care providers with key veteran-focused educational resources. This mixed-methods study examined the potential impact of the Toolkit on provider knowledge and behaviors. Sixty-four clinicians in the community who currently or plan to provide services to veterans were surveyed. The majority of providers found the website useful and easy to navigate. After visiting the site, many providers found additional online and educational resources that they would add to a hypothetical treatment plan. Forty-five providers completed a 1-month follow-up survey focused on use of the Toolkit. Results indicate that the Toolkit may be a valuable tool for increasing provider knowledge about veteran-specific resources.

A Qualitative Examination of Stay Quit Coach, A Mobile Application for Veteran Smokers With Posttraumatic Stress Disorder.

INTRODUCTION: Smoking is a lethal public health problem that is common in US military veterans, particularly those with posttraumatic stress disorder (PTSD). Mobile applications (apps) to promote smoking cessation are a scalable and low-cost approach that may facilitate treatment engagement. METHODS: This qualitative study examined the acceptability, user experience, and perceptions of a smoking cessation app, Stay Quit Coach (SQC), when incorporated into evidence-based smoking cessation treatment. US military veterans with PTSD who smoked at least five cigarettes per day for 15 of the past 30 days and stated an interested in cessation were eligible to participate. Participants' baseline comfort levels with mobile technology was measured using the Perceptions of Mobile Phone Interventions Questionnaire-Patient version (PMPIQ-P). At treatment end, semi-structured qualitative interviews were conducted. RESULTS: Twenty participants were enrolled and 17 (85.0%) participated in the qualitative interview at treatment end. PMPIQ-P scores at baseline ranged from 4.97 to 5.25 (SDs = 0.73-1.04), reflecting moderately high comfort with mobile technology among participants. Qualitative analyses indicated that most participants: (1) endorsed mobile technology as an appealing format for smoking cessation treatment, due to convenience and instantaneous access; and (2) expressed highest perceived helpfulness for interactive app features. Recommendations to improve SQC clustered into four thematic areas: (1) increasing personalization, (2) including more self-tracking features, (3) increasing visual cues, and (4) sharing progress with peers. CONCLUSIONS: SQC was perceived as an acceptable and useful tool to support smoking cessation in a sample of veteran smokers with PTSD. Qualitative data provided valuable insights that can inform the continued development of SQC and other apps for smoking cessation. IMPLICATIONS: Given the high lethality associated with cigarette smoking, it is crucial to identify scalable, low-risk strategies to promote smoking cessation, particularly in high-risk populations. Mobile technology is a promising approach that can be used to augment evidence-based smoking cessation treatment. Results of this qualitative study support the use of the SQC mobile app when incorporated into evidence-based smoking cessation treatment for veterans with PTSD and provide future directions for refinement of the SQC app. These findings also highlight the importance of using a patient-centered approach in designing apps intended for a clinical population.

Predictors of multiple domains of functioning in Veterans with posttraumatic stress disorder: Results from the Mind Your Heart Study.

BACKGROUND: Those with posttraumatic stress disorder (PTSD) have lower overall functioning than healthy controls. However, this population is not homogenous, and those with PTSD have a wide range of functional outcomes. To our knowledge, only one other study has evaluated the predictors of better functioning within patients with PTSD. METHODS: We examined 254 veterans with likely PTSD, using the Clinician-Administered PTSD Scale to assess PTSD symptom severity, and the SF-36 and single-item question to assess aspects of current functioning and quality of life. RESULTS: In fully adjusted models (controlling for age, gender, and PTSD score, and including all significant psychosocial predictors of the outcome of interest), greater sleep quality (p = .03), lower C-reactive protein (p < .01), and lower erythrocyte sedimentation rate (p = 0.04) were associated with greater physical functioning; lower depression (p < .01) and greater perceived social support (p = .05) were associated with greater social functioning; lower depression (p = .02) was associated with greater occupational functioning; and greater combat exposure (p = .04), greater optimism (p < .01) and greater perceived social support (p = .05) were associated with greater quality of life. CONCLUSIONS: These findings highlight the differential impact of psychosocial predictors on multiple functional outcomes. As such, they provide important information for clinicians about aspects of veterans' lives that can be targeted during the treatment to improve specific types of functioning.

Positive impact of IPS supported employment on PTSD-related occupational-psychosocial functional outcomes: Results from a VA randomized-controlled trial.

OBJECTIVE: Posttraumatic stress disorder (PTSD) has significant negative effects on occupational, interpersonal, and social functioning. Supported employment is highly effective in helping people with a diagnosis of PTSD obtain and maintain competitive employment. However, less is known about the impact of supported employment on functioning in work or school, social, and interpersonal areas as specifically related to the symptoms of PTSD. METHOD: The Veterans Individual Placement and Support Toward Advancing Recovery study was a prospective, multisite, randomized, controlled trial that compared Individual Placement and Support (IPS) supported employment with a stepwise vocational rehabilitation involving transitional work (TW) assignments with unemployed veterans with PTSD diagnoses (n = 541) at 12 Veterans Administration (VA) medical centers. This analysis focuses on the PTSD-related functional outcomes over the 18-month follow-up period. RESULTS: Compared with those randomized to TW, the PTSD Related Functioning Inventory (PRFI) total score significantly improved for participants randomized to IPS (LSMeans difference = -3.92, 95% CI [-7.49, -.36]; p = .03) over 18 months. When the Work/School subscale of the PRFI was removed from the analysis, the IPS group continued to show significant improvements compared with the TW group on the PRFI relationship and lifestyle domains (LSMeans difference = -2.37, 95% CI [-4.74, .00]; p = .05), suggesting a positive impact of IPS beyond work/school functioning. CONCLUSION: Compared with the usual-care VA vocational services for veterans with PTSD, IPS supported employment is associated with greater improvement in overall PTSD-related functioning, including occupational, interpersonal, and lifestyle domains. In addition to superior employment outcomes, IPS has a positive impact on occupational-psychosocial functioning outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Factors associated with high functioning despite distress in post-9/11 veterans.

OBJECTIVE: This study aimed to identify modifiable factors associated with perceived functioning among veterans with high symptoms of posttraumatic stress disorder (PTSD). METHOD: Two hundred fifty-one post-9/11 veterans completed a survey of psychosocial symptoms and functioning; a subset participated in a follow-up survey (n = 109). Latent profile analysis (LPA) at baseline identified groups that differed by level of functioning (high/low). Items utilized in the LPA analysis were derived from the World Health Organization Quality of Life-Bref self-report measure. Veterans with high PTSD symptoms in both groups were compared and logistic regression was utilized to predict group membership. RESULTS: Veterans with high functioning/high symptoms (n = 45) had significantly lower alcohol use and sleep problems, and higher postdeployment social support, posttraumatic growth, and optimism than veterans with low functioning/high symptoms (n = 100). Fewer sleep difficulties and higher postdeployment social support and optimism were associated with membership in the high functioning/high symptom group. CONCLUSIONS: These findings support the importance of identifying factors that can facilitate higher social, occupational, and general functional capacity for those with high levels of PTSD symptomatology. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Student veterans with posttraumatic stress symptoms: Perceived preferences for on-campus psychoeducation.

OBJECTIVE: This investigation aimed to better understand perceived barriers to academic success and preferences for a veteran-specific psychosocial course among veterans with symptoms of posttraumatic stress (PTS). METHOD: Ninety-three veterans participated in this investigation as part of a larger study examining psychosocial functioning among veterans with PTS symptoms. Participants completed a self-report survey focused on perceived barriers to academic success and psychoeducational preferences related to health and well-being. RESULTS: Perceived barriers to academic success reported as most problematic were sleep difficulties, stress, depression, and financial concerns. Results indicated that veterans would be interested in attending an on-campus course focusing on these areas. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These findings contribute to the understanding of student veterans with PTS symptoms' perceived needs and inform the development of campus programs for this population. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Deployment Anxiety Reduction Training: A Pilot Study of Acceptability and Feasibility in Current or Recent Active Duty Service Members.

Objectives: The Deployment Anxiety Reduction Training (DART) is a manualized tool that was developed and piloted with active duty service members and recently deployed veterans regarding their response to potential and experienced acute combat stress reactions. DART is low risk and has high potential to be beneficial. It is a brief, one-session, non-pharmacological approach designed to reduce symptoms of peritraumatic panic and increase resilience in the face of a potentially traumatic stressor. Methods: This study was a mixed-methods pilot study to assess the utility and acceptability of DART during deployment. Results: Self-report and interview responses indicated that participants generally found the DART techniques acceptable and easy to understand. Overall, the techniques were perceived as likely to be helpful with high utility, although there was variation in perceived helpfulness among the different techniques. Participants overwhelmingly positively endorsed delivery of the DART protocol through use of smartphone technology. Conclusions: Results indicate that the DART components were considered highly acceptable and feasible for use in the deployed environment.

Mobile Technology for Treatment Augmentation in Veteran Smokers With Posttraumatic Stress Disorder.

INTRODUCTION: The purpose of this study is to examine the feasibility and acceptability of incorporating a mobile application, Stay Quit Coach, into an integrated care smoking-cessation treatment protocol for veterans with posttraumatic stress disorder (PTSD). METHODS: Participants included veteran smokers aged 18-69 years with PTSD. The integrated care protocol includes eight weekly PTSD-informed cognitive behavioral therapy sessions for smoking cessation, followed by monthly booster sessions and a prescription for standard smoking-cessation medications if desired. Participants used Stay Quit Coach as desired. Outcome measures at 3-month follow-up included: adherence (sessions attended), 30-day point-prevalence abstinence bioverified with carbon monoxide <6 parts per million, past-30 day mean daily cigarette use, exhaled carbon monoxide, nicotine dependence, and PTSD symptom severity. Repeated outcomes were analyzed with random-intercept linear mixed models. Data were collected in 2015-2016 and analyses were conducted in 2016-2017. RESULTS: Participants (n=20) were 95% male and 5% female; mean age 41.4 (SD=16.2) years. Thirteen participants (65%) attended all scheduled sessions, four (20%) did not adhere to the protocol on schedule, and three (15%) were lost to follow-up. At 3-month follow-up, six of 17 completers (35.3%) had bioverified 30-day point-prevalence abstinence. Nicotine dependence, carbon monoxide levels, and past 30-day cigarette use significantly decreased and PTSD symptoms were unchanged from baseline to follow-up. Participants self-reported using Stay Quit Coach 2.5 (SD=2.2) days/week; 15 of 17 (88.2%) reported using Stay Quit Coach <30 minutes/week; two of 17 (11.8%) reported using Stay Quit Coach 30-60 minutes/week. CONCLUSIONS: Although results must be interpreted with caution given the lack of control group and small sample size, findings indicate that integrating Stay Quit Coach into integrated care was feasible and acceptable.

Impact of Engagement in Exercise on Sleep Quality Among Veterans With Posttraumatic Stress Disorder Symptoms.

BACKGROUND: Exercise has beneficial effects for physical health outcomes and has also been shown to reduce the severity of psychological health symptoms. Recent studies have shown a potentially positive impact of exercise on posttraumatic stress disorder (PTSD). Prominent among those with PTSD, sleep disturbance and nightmares are among the top three PTSD symptoms commonly reported by treatment-seeking Veterans. Regular physical exercise has been consistently associated with better sleep. This study utilized a longitudinal design to explore the relationship between exercise and sleep among Veterans with PTSD symptoms at baseline and one-year follow-up. MATERIALS AND METHODS: Veterans (n = 76) who served in support of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn were recruited for this study. Correlations were assessed between PTSD symptoms, sleep, and engagement in exercise at each time point (baseline, one-year follow-up). Regression analyses were conducted to examine the relationship between engagement in exercise at baseline and PTSD symptoms at one-year follow-up, as well as sleep quality at one-year follow-up. Regression models controlled for demographic variables (age and gender), alcohol use, baseline PTSD symptoms, and baseline sleep quality. RESULTS: Multiple regression analyses demonstrated that engagement in exercise at baseline was significantly associated with better sleep quality at one-year follow-up while controlling for age, gender, alcohol use, baseline PTSD symptoms, and baseline sleep quality (ß = -0.128, p < 0.05). Multiple regression analyses examining the relationship between engagement in exercise at baseline and PTSD symptoms at one-year follow-up (controlling for age, gender, alcohol use, baseline PTSD symptoms, and baseline sleep quality) did not yield statistically significant results (ß = 0.053, p = 0.57). CONCLUSION: Results from the present study found that engagement in exercise at baseline was associated with better sleep quality at one-year follow-up. These findings were consistent with the current literature suggesting exercise can have a positive impact on sleep quality. Furthermore, our findings suggest that exercise could be considered as an adjunctive intervention for individuals with PTSD-particularly for those patients whose difficulties with sleep are predominant. Given that exercise is highly accessible and is embedded in the military culture, future research should examine the way in which exercise can be leveraged in PTSD treatment, specifically in ameliorating sleep difficulties. Exercise may also reap demonstrable public health benefits in multiple psychological and physical domains and reduce the psychiatric and medical morbidity and mortality associated with PTSD.

Assessing posttraumatic stress related impairment and well-being: The Posttraumatic Stress Related Functioning Inventory (PRFI).

Posttraumatic stress symptoms are associated with poorer social and occupational functioning and quality of life. However, general assessments of functioning do not determine the extent to which these difficulties are directly related to PTSD symptoms. This study examines the psychometric properties of a self-report measure, the 27-item Posttraumatic Stress Related Functioning Inventory (PRFI), which was developed to provide a self-report tool for clinicians and researchers to better understand the perceived impact of PTSD symptoms on functioning. The psychometric properties of the PRFI were examined utilizing data collected within a larger study examining quality of life and functioning in 251 veterans who had served in OEF/OIF/OND and endorsed the presence of subsyndromal or greater levels of PTSD symptoms at screening. One-year test-retest reliability of the measure was examined in a subset of the baseline sample who received a second administration of the PRFI (n = 109). Higher levels of PTSD symptoms were associated with poorer functioning in all domains. The PRFI demonstrated convergent validity with a measure of PTSD symptoms and was less correlated with measures of alcohol and drug use, good internal consistency and test-retest reliability from baseline to one-year follow-up. The PRFI provides self-report information regarding several domains of functioning. This initial examination of psychometric properties of the scale indicated that it may be useful for efficiently eliciting information about the ways in which PTSD symptoms in veterans impact everyday functioning.

Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: a randomized controlled trial.

STUDY OBJECTIVES: Examine whether cognitive behavioral therapy for insomnia (CBT-I) improves sleep in posttraumatic stress disorder (PTSD) as well as nightmares, nonsleep PTSD symptoms, depression symptoms, and psychosocial functioning. DESIGN: RANDOMIZED CONTROLLED TRIAL WITH TWO ARMS: CBT-I and monitor-only waitlist control. SETTING: Department of Veterans Affairs (VA) Medical Center. PARTICIPANTS: Forty-five adults (31 females: [mean age 37 y (22-59 y)] with PTSD meeting research diagnostic criteria for insomnia, randomly assigned to CBT-I (n = 29; 22 females) or monitor-only waitlist control (n = 16; nine females). INTERVENTIONS: Eight-session weekly individual CBT-I delivered by a licensed clinical psychologist or a board-certified psychiatrist. MEASUREMENTS AND RESULTS: Measures included continuous monitoring of sleep with diary and actigraphy; prepolysomnography and postpolysomnography and Clinician-Administered PTSD Scale (CAPS); and pre, mid, and post self-report questionnaires, with follow-up of CBT-I participants 6 mo later. CBT-I was superior to the waitlist control condition in all sleep diary outcomes and in polysomnography-measured total sleep time. Compared to waitlist participants, CBT-I participants reported improved subjective sleep (41% full remission versus 0%), disruptive nocturnal behaviors (based on the Pittsburgh Sleep Quality Index-Addendum), and overall work and interpersonal functioning. These effects were maintained at 6-mo follow-up. Both CBT-I and waitlist control participants reported reductions in PTSD symptoms and CAPS-measured nightmares. CONCLUSIONS: Cognitive behavioral therapy for insomnia (CBT-I) improved sleep in individuals with posttraumatic stress disorder, with durable gains at 6 mo. Overall psychosocial functioning improved following CBT-I. The initial evidence regarding CBT-I and nightmares is promising but further research is needed. Results suggest that a comprehensive approach to treatment of posttraumatic stress disorder should include behavioral sleep medicine. CLINICAL TRIAL INFORMATION: TRIAL NAME: Cognitive Behavioral Treatment Of Insomnia In Posttraumatic Stress Disorder. URL: http://clinicaltrials.gov/ct2/show/NCT00881647. REGISTRATION NUMBER: NCT00881647.

Social support may protect against development of posttraumatic stress disorder: findings from the Heart and Soul Study.

PURPOSE: No prospective studies have examined the association of poor social support and development of posttraumatic stress disorder (PTSD) in patients with chronic illness. This study addresses this knowledge gap. DESIGN: This prospective study examines the relationship of social support to the subsequent development of PTSD during a 5-year period. SETTING: San Francisco Veterans Affairs Medical Center. SUBJECTS: A total of 579 participants with cardiovascular disease did not have PTSD at baseline and returned for the 5-year follow-up examination. MEASURES: PTSD measured by Computerized Diagnostic Interview Schedule for DSM-IV. Social support measured by Interpersonal Support Evaluation List (ISEL). ANALYSIS: Unconditional ordered logistic regression analyses were performed to yield the odds ratio of developing PTSD for a one-standard-deviation change in ISEL score. RESULTS: Of 579 participants who did not have PTSD at baseline, approximately 6.4% (n = 37) developed PTSD. Higher baseline perceived social support was strongly protective against development of PTSD (OR = .60, p = .001). Results remained significant after adjustment for age, sex, race, income, and depression (OR = .69, p = .04). Of social support types examined, the "tangible" and "belonging" domains were most strongly associated with future PTSD status. CONCLUSION: Social support may impact development of PTSD. Interventions that optimize social support may be part of a PTSD prevention program designed to help individuals at risk of developing PTSD.

Killing and latent classes of PTSD symptoms in Iraq and Afghanistan veterans.

BACKGROUND: Our goal was to better understand distinct PTSD symptom presentations in Iraq and Afghanistan Veterans (N=227) and to determine whether those who killed in war were at risk for being in the most symptomatic class. METHODS: We used latent class analysis of responses to the PTSD checklist and logistic regression of most symptomatic class. RESULTS: We found that a four-class solution best fit the data, with the following profiles emerging: High Symptom (34% of participants), Intermediate Symptom (41%), Intermediate Symptom with Low Emotional Numbing (10%), and Low Symptom (15%). The largest group of individuals who reported killing (45%) was in the High Symptom class, and those who killed had twice the odds of being in the most symptomatic PTSD class, compared to those who did not kill. Those who endorsed killing a non-combatant (OR=4.56, 95% CI [1.77, 11.7], p<0.01) or killing in the context of anger or revenge (OR=4.63, 95% CI=[1.89, 11.4], p<0.001) were more likely to belong to the most symptomatic PTSD class, compared to those who did not kill. LIMITATIONS: The study was retrospective and cross-sectional. The results may not generalize to veterans of other wars. CONCLUSIONS: Killing in war may be an important indicator of risk for developing frequent and severe PTSD symptoms. This has implications for the mental healthcare of veterans, providing evidence that a comprehensive evaluation of returning veterans should include an assessment of killing experiences and reactions to killing.

Cortisol awakening response prospectively predicts peritraumatic and acute stress reactions in police officers.

BACKGROUND: The hypothalamic-pituitary-adrenal axis is a major stress response system hypothesized to be involved in the pathogenesis of posttraumatic stress disorder (PTSD). However, few studies have prospectively examined the relationships among pre-exposure hypothalamic-pituitary-adrenal activity, acute stress reactions and PTSD. METHODS: Two hundred ninety-six police recruits were assessed during academy training before critical incident exposure and provided salivary cortisol at first awakening and after 30 minutes. A measure of cortisol awakening response (CAR) was computed as the change in cortisol level from the first to the second collection. At 12, 24, and 36 months following the start of active police service, officers were assessed for peritraumatic distress, peritraumatic dissociation, acute stress disorder (ASD) symptoms, and PTSD symptoms to their self-identified worst duty-related critical incident. Mixed models for repeated measures were used to analyze the effects of CAR on the outcome variables pooled across the three follow-up assessments. RESULTS: After controlling for time of awakening, first awakening cortisol levels, and cumulative critical incident stress exposure, CAR during academy training was associated with greater peritraumatic dissociation, ß = .14, z = 3.49, p < .0001, and greater ASD symptoms during police service assessed at 12, 24, and 36 months, ß = .09, Z = 2.03, p < .05, but not with peritraumatic distress, ß = .03, z = .81, p = .42, or PTSD symptoms, ß = -.004, z = -.09, p = .93. CONCLUSIONS: These findings suggest that greater cortisol response to awakening is a pre-exposure risk factor for peritraumatic dissociation and ASD symptoms during police service.

The impact of killing and injuring others on mental health symptoms among police officers.

This study examined the relationship between killing or seriously injuring someone in the line of duty and mental health symptoms in a sample of police officers (N = 400) who were first assessed during academy training and at five additional time points over three years. We found that nearly 10% of police officers reported having to kill or seriously injure someone in the line of duty in the first three years of police service. After controlling for demographics and exposure to life threat, killing or seriously injuring someone in the line of duty was significantly associated with PTSD symptoms (p < .01) and marginally associated with depression symptoms (p = .06). These results highlight the potential mental health impact of killing or seriously injuring someone in the line of duty. Greater attention to mental health services following these types of exposures can serve as a preventative measure for police officers who have been negatively impacted.

Pretraumatic prolonged elevation of salivary MHPG predicts peritraumatic distress and symptoms of post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) is associated with elevated catecholamines and increased sympathetic arousal. However, it is unknown whether this condition is a pre-existing vulnerability factor for PTSD or an acquired result of either trauma exposure or the development of PTSD symptoms. We sought to examine if salivary 3-methoxy-4-hydroxy-phenylglycol (MHPG) in response to a laboratory stressor prior to critical incident exposure predicts the development of PTSD symptoms and if early childhood trauma influences this relationship. In a prospective cohort study, 349 urban police officers were assessed during academy training (baseline) and 243 were reassessed 12 months after the start of active duty (follow-up). At baseline, participants observed a video consisting of police critical incidents. Salivary MHPG was measured before and immediately after the challenge, and after 20min recovery. At follow-up, peritraumatic distress and PTSD symptoms were assessed in relationship to the worst critical incident during the past year. Participants with childhood trauma showed a trend towards higher MHPG increase to the challenge. Higher MHPG levels after 20min recovery were associated with both higher levels of peritraumatic distress and PTSD symptoms at follow-up. In a path analysis, elevated MHPG levels predicted higher peritraumatic distress which in turn predicted higher levels of PTSD symptoms while the direct effect of elevated MHPG levels on PTSD symptoms was no longer significant. Prolonged elevation of salivary MHPG in response to a laboratory stressor marks a predisposition to experience higher levels of peritraumatic distress and subsequently more PTSD symptoms following critical incident exposure.