Stigma, help-seeking attitudes, and use of psychotherapy in veterans with diagnoses of posttraumatic stress disorder.

Survey and medical record data from 482 Veterans Affairs (VA) patients who recently received diagnoses of posttraumatic stress disorder (PTSD) were examined to determine need and predisposing factors associated with utilization of psychotherapy and counseling. More than half (58%) of participants initiated VA psychotherapy for PTSD within a year of diagnosis. Of those, one third completed eight or more sessions. Roughly two thirds of participants initiated counseling at a Vet Center. Initiating PTSD psychotherapy was associated with greater impairment but not with stigma, concerns about fitting in, or satisfaction with care. The use of Vet Center counseling was associated with desire for help, concerns about fitting in, and satisfaction with care. Unexpectedly, veterans with greater stigma concerns completed more psychotherapy visits and Vet Center counseling. Negative attitudes about mental health treatment did not seem to be substantial barriers to engaging in psychotherapy among these VA patients. Future research should consider enabling treatment system factors in addition to predisposing patient characteristics.

Relationships among PTSD symptoms, social support, and support source in veterans with chronic PTSD.

The present study examined the temporal relationship between posttraumatic stress disorder (PTSD) and social support among 128 male veterans treated for chronic PTSD. Level of perceived interpersonal support and stressors were assessed at two time points (6 months apart) for four different potential sources of support: spouse, relatives, nonveteran friends, and veteran peers. Veteran peers provided relatively high perceived support and little interpersonal stress. Spouses were seen as both interpersonal resources and sources of interpersonal stress. More severe PTSD symptoms at Time 1 predicted greater erosion in perceived support from nonveteran friends, but not from relatives. Contrary to expectations, initial levels of perceived support and stressors did not predict the course of chronic PTSD symptoms.

Direct and indirect links between childhood maltreatment, posttraumatic stress disorder, and women's health.

The authors evaluated the relationships among childhood maltreatment, sexual trauma in adulthood, posttraumatic stress disorder (PTSD), and health functioning in women. Female Veterans' Affairs (VA) primary care patients (N = 200) completed self-report measures of childhood maltreatment, adult sexual trauma, PTSD symptoms, and current health functioning. The authors used structural equation modeling to test models of the relationship among these variables. Childhood nonsexual maltreatment and adult sexual assault were positively associated with PTSD. Childhood nonsexual maltreatment (beta = -.20) and PTSD (beta = -.75) were significantly associated with poorer physical and mental health functioning. Adult sexual assault negatively affected health functioning through its association with PTSD. Thus, poor health outcomes associated with childhood maltreatment in women may be conveyed through PTSD. These findings should strengthen efforts directed at identifying and treating PTSD in female victims of childhood maltreatment with the aim of preventing or attenuating poor health outcomes.

Predictors of 4-year outcome of community residential treatment for patients with substance use disorders.

AIMS: This study examined systematically how predictors of substance use disorder (SUD) treatment outcome worked together over time and identified mediators and moderators of outcome. DESIGN: The MacArthur model was applied in this naturalistic study to identify how baseline, discharge and 1-year follow-up factors worked together to predict 4-year improvement in substance-related problems. SETTING: Eighty-eight community residential facilities were selected based on geographic representativeness, number of patient referrals and type of treatment orientation. PARTICIPANTS: Of 2796 male patients who completed intake assessments, 2324 were assessed at the 1-year follow-up and 2023 at the 4-year follow-up. MEASUREMENTS: Self-report measures of symptom severity, functioning, social resources and coping, treatment and involvement in Alcoholics Anonymous (AA) were collected at baseline and at 1- and 4-year follow-ups. Provider-rated treatment participation measures were obtained at discharge. FINDINGS: Greater substance use severity, more psychiatric symptoms, more prior arrests and stronger belief in AA-related philosophy at treatment entry predicted improvement significantly in substance-related problems 4 years later. At the 1-year follow-up, being employed and greater use of AA-related coping predicted outcome significantly. AA-related coping at 1 year mediated the relationship partially between belief in AA philosophy at treatment entry and 4-year outcome. CONCLUSIONS: The findings highlight the unique and positive impact of AA involvement on long-term SUD treatment outcome and extend understanding of why AA is beneficial for patients.

An evaluation of the psychometric properties of the traumatic events questionnaire in primary care patients.

This study examined the reliability of reports of traumatic experiences across the Traumatic Events Questionnaire (TEQ; S. Vrana & D. Lauterbach, 1994) and the Composite International Diagnostic Interview (CIDI; World Health Organization, 1998), and evaluated other psychometric properties of the TEQ in 154 primary care patients. Agreement rates for various traumatic experiences were moderate to substantial, with sexual abuse showing 87% agreement, and other forms of trauma exhibiting rates from 81-74%. The TEQ yields a trauma intensity score, which produced stronger correlations with self-reported PTSD symptoms and problematic anger than the sum of traumas experienced. Trauma intensity also proved to be a powerful predictor of posttraumatic stress disorder (PTSD) diagnostic status. Results support the TEQ as a measure of traumatic exposure in primary care populations.

Does compensation status influence treatment participation and course of recovery from post-traumatic stress disorder?

We reviewed the empirical literature to examine how seeking compensation and/or being awarded compensation for posttraumatic stress disorder-related disability are associated with participation in mental health treatment and course of recovery. The search for relevant literature was conducted using the PubMed, PsycINFO, Medline, and PILOTS databases and yielded seven studies on veterans and five on motor vehicle accident survivors. The literature indicates that veterans who are seeking or have been awarded compensation participate in treatment at similar or higher rates than do their non-compensation-seeking counterparts. Veteran treatment outcome studies produced either null or mixed findings, with no consistent evidence that compensation-seeking predicts worse outcomes. Studies of motor vehicle accident survivors found no association between compensation status and course of recovery. Recommendations to strengthen future research in this area are provided, including using clear and consistent definitions of compensation status that differentiate compensation-seeking status from award status.

Relationships among childhood maltreatment, PTSD, and health in female veterans in primary care.

OBJECTIVE: Women with histories of childhood maltreatment (CM) have higher rates of physical health problems and greater medical utilization compared to women without abuse histories. This study examined whether current post-traumatic stress disorder (PTSD) symptoms mediate the relationship between CM and indicators of physical health and medical utilization in female veterans. METHOD: Respondents were 221 female veterans (56% of the potential sample), who received medical care from the San Diego VA Healthcare System during a 12-month period. Respondents provided self-report information about CM, PTSD symptoms, use of pain medication, and physical symptoms and functioning. Additional information about medical utilization was extracted from respondents' medical charts. Regression-based models were conducted to test whether PTSD symptoms mediate the relationships between CM and physical symptoms and between CM and medical utilization. RESULTS: Emotional abuse was associated with poorer role-physical functioning, increased bodily pain and greater odds of using pain medication in the past 6 months. Physical abuse was associated with poorer general health. Contrary to prediction, emotional neglect was associated with better role-physical functioning, and CM was not associated with increased healthcare utilization. PTSD was shown to mediate the relationship between emotional and physical abuse and health outcomes. CONCLUSIONS: PTSD, or psychopathology more generally, appears to be an important factor in the negative health impact of CM. Given that several empirically supported interventions are available for PTSD, there may be physical health benefits in early identification and treatment of psychopathology related to CM.

Mental health and satisfaction with primary health care in female patients.

PURPOSE AND OBJECTIVES: Patient satisfaction is an important outcome in patient care and is increasingly being used as an indicator of quality of care within large health systems. This study examined whether consideration of specific mental health factors, including posttraumatic stress disorder (PTSD), can improve our understanding of patient satisfaction in primary care settings. METHODS: Questionnaires were mailed to all women who used the VA San Diego Healthcare System primary care clinic in 1998. Two hundred twenty-one (56%) women who were invited to participate in this study completed questionnaires. Participants provided information about physical and mental health and satisfaction with their primary medical care. RESULTS: Age and general mental health were negatively associated and PTSD was positively associated with overall satisfaction with care and satisfaction with the provider. General mental health was significantly related to satisfaction with the clinic. CONCLUSIONS: These findings support the importance of specific mental health symptoms, and trauma-related symptoms in specific, in determining satisfaction.

The impact of individual forms of childhood maltreatment on health behavior.

OBJECTIVE: This study examines the unique contribution of five types of maltreatment (sexual abuse, physical abuse, emotional abuse, physical neglect, emotional neglect) to adult health behaviors as well as the additive impact of exposure to different types of childhood maltreatment. METHOD: Two hundred and twenty-one women recruited from a VA primary care clinic completed questionnaires assessing exposure to childhood trauma and adult health behaviors. Regression models were used to test the relationship between childhood maltreatment and adult health behaviors. RESULTS: Sexual and physical abuse appear to predict a number of adverse outcomes; when other types of maltreatment are controlled, however, sexual abuse and physical abuse do not predict as many poor outcomes. In addition, sexual, physical, and emotional abuse and emotional neglect in childhood were all related to different adult health behaviors. The more types of childhood maltreatment participants were exposed to the more likely they were to have problems with substance use and risky sexual behaviors in adulthood. IMPLICATIONS: The results indicate that it is important to assess a broad maltreatment history rather than trying to relate specific types of abuse to particular adverse health behaviors or health outcomes.

Relationship of sexual assault history to somatic symptoms and health anxiety in women.

Prior reports have pointed to a link between traumatic experiences and health consequences in women. The objective of this study was to determine whether there is an association between sexual assault history and measures of somatic symptoms and illness attitudes in a sample of female Veterans Affairs primary care patients, a group in whom high rates of sexual trauma have been reported. We conducted a cross-sectional study of a representative sample of 219 women in a Veteran's Affairs primary care outpatient clinic. Sexual assault history, somatic symptoms and health anxiety were assessed by self-report questionnaire. Multivariate analyses were used to examine relationships between sexual assault exposure and these outcomes. Ninety-seven women (43.9%) reported experience(s) of sexual assault (i.e., rape, attempted rape or being made to perform any type of sexual act through force or threat of harm). Sexual assault was associated with a significant increase in somatization scores, physical complaints across multiple symptom domains and health anxiety. Sexual assault was also a significant statistical predictor of having multiple sick days in the prior 6 months and of being a high utilizer of primary care visits in the prior 6 months. These data confirm a strong association between sexual trauma exposure and somatic symptoms, illness attitudes and healthcare utilization in women. Causal mechanisms cannot be inferred from these data. Studies in other cohorts are warranted.

Sexual trauma, posttraumatic stress disorder, and health behavior.

The authors tested whether sexual traumatization is associated with poorer health behavior and also evaluated the role of posttraumatic stress disorder (PTSD) in this relationship. They mailed questionnaires to 419 women who had visited a San Diego Veterans Administration primary care clinic in 1998 and received 221 responses, a 56% return rate. They found that a history of sexual assault was associated with increased substance use, risky sexual behaviors, less vigorous exercise, and increased preventive healthcare. They then used regression-based techniques to test whether PTSD mediates the relationship between a history of sexual assault and health behaviors and discovered support for this hypothesis in relation to substance use. PTSD symptoms were also associated with less likelihood of conducting regular breast self-examinations. Findings from the study highlight the value of programs designed to (1) identify trauma victims, (2) screen for problematic behaviors, and (3) intervene to improve long-term health outcomes.

Post-traumatic stress disorder and health-related quality of life in female victims of intimate partner violence.

The association between post-traumatic stress disorder (PTSD) and health-related quality of life (QOL) in female victims of intimate partner violence (IPV) was examined. The Short-Form Health Survey (SF-36) was used to evaluate health-related QOL. IPV victims with PTSD (IPV/PTSD+; n = 18), IPV victims without PTSD (IPV/PTSD-; n = 22), and a non-abused control group (NA; n = 30) were compared. Multiple Analyses of Covariance (covarying for socioeconomic status and age) indicated that the three groups scored significantly differently on health-related QOL, and the IPV/PTSD- group was significantly more impaired than the NA group. IPV/PTSD+ subjects were significantly more impaired than IPV/PTSD- subjects on physical functioning, mental health, vitality, role limitations due to emotional health, and social functioning. Multiple regression analyses indicated that PTSD severity was a significant statistical predictor of SF-36 mental health composite scores (but not of physical health composite scores), after controlling for depressive symptomatology and extent of physical and psychological abuse.

Sensitivity and specificity of the PTSD checklist in detecting PTSD in female veterans in primary care.

PTSD affects a substantial number of women in medical settings and is associated with significant distress and impairment. There are effective methods of treating trauma-related distress, but a minority seek such care. Thus, primary care is an important setting in which to identify individuals with PTSD. We sent questionnaires, including the PTSD Checklist--Civilian Version (PCL-C), to 419 female veterans who were seen in our primary care clinic in 1998; 56% (N = 221) returned the measures. A random subset (n = 49) was interviewed to establish psychiatric diagnoses. The results provide qualified support for the use of the PCL-C total score with a lowered cutoff score as a screening measure for PTSD in female veterans in primary care.