American Civil War medical practice, the post-bellum opium crisis and modern comparisons.

The American Civil War resulted in massive numbers of injured and ill soldiers. Throughout the conflict, medical doctors relied on opium to treat these conditions, giving rise to claims that the injudicious use of the narcotic caused America's post-bellum opium crisis. Similar claims of medical misuse of opioids are now made as America confronts the modern narcotic crisis. A more nuanced thesis based on a broader base of Civil War era research suggests a more complex set of interacting factors that collectively contributed to America's post-war opium crisis.

Nutraceutical Augmentation Strategies for Depression: A Narrative Review.

Context: Depression is one of the most commonly diagnosed psychiatric disorders, but antidepressant pharmacotherapy often fails to achieve remission, leading health care professionals and researchers to consider various augmentation strategies to improve clinical outcomes. Objective: To assess the safety, tolerability, and efficacy of nutraceutical augmentation for depression. Methods: Nutraceutical-focused systematic reviews and clinical practice guidelines identified the more commonly studied augmentation strategies for depression. Results: S-adenosylmethionine, l-methylfolate, omega-3 fatty acids, and hydroxyvitamin D have sufficient scientific evidence to support their clinical consideration in the stepped care approach to the management of depression. Conclusions: Clinical remission is the goal in the management of depression, and nutraceuticals may be part of an overall treatment approach to achieve that outcome.

Prospective Study of Brain Wave Changes Associated With Cranial Electrotherapy Stimulation.

OBJECTIVE: To explore brain wave changes associated with cranial electrotherapy stimulation (CES) among subjects receiving psychiatric care. METHODS: Quantitative electroencephalogram data were obtained before and after a 20-minute session of CES. The investigators recruited active-duty military subjects from Walter Reed National Military Medical Center's Psychiatry Continuity Service, Bethesda, Maryland. Fifty subjects participated in this prospective, convenience sample study from August 2016 through March 2017. The main outcome measures were changes in brain wave activity and the Subjective Units of Distress Scale. RESULTS: The typical subject was mildly depressed and had severe trauma-related symptoms and sleep problems. There was a significant increase (P = .000) in the higher beta frequencies (18-21 Hz, 21-33 Hz, and 33-48 Hz) and a strong effect (with the Cohen d around 1.5) immediately following the 20-minute CES. Ten minutes after CES, slower wave activity (4-8 Hz and 8-12 Hz) significantly decreased (P < .05), while higher beta wave activity (13-15 Hz, 18-21 Hz, and 21-33 Hz) increased. A strong effect (with the Cohen d around 1.5) persisted in the beta brain wave bands 18-21 Hz and 21-33 Hz. CONCLUSIONS: Brain wave measurements taken immediately after the 20-minute CES session showed a significant and strong effect in the beta region, suggesting an increase in mental alertness, focus, and concentration. Ten minutes after the CES session, an even more marked change in brain wave activity occurred. The significant and strong effect in the beta region persisted but was joined by a reduction in slower wave activity, indicating an increase in mental alertness. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT03298308.

Alcohol Biomarkers Associated with Obstructive Sleep Apnea.

The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of the Army/Navy/Air Force or the Department of Defense The identification of specific products or scientific instrumentation does not constitute an endorsement or implied endorsement on the part of the authors, DoD, or any component agency. While we generally excise references to products, companies, manufacturers, organizations, etc. in government produced works, the abstracts produced and other similarly situated researchers presents a special circumstance when such product inclusions become an integral part of the scientific endeavor.

The Reasons for Living Scale-Military Version: Assessing Protective Factors Against Suicide in a Military Sample.

INTRODUCTION: Military suicide rates have been rising over the past decade and continue to challenge military treatment facilities. Assessing suicide risk and improving treatments are a large part of the mission for clinicians who work with uniformed service members. This study attempts to expand the toolkit of military suicide prevention by focusing on protective factors over risk factors. In 1983, Marsha Linehan published a checklist called the Reasons for Living Scale, which asked subjects to check the reasons they choose to continue living, rather than choosing suicide. The authors of this article hypothesized that military service members may have different or additional reasons to live which may relate to their military service. They created a new version of Linehan's inventory by adding protective factors related to military life. The purpose of these additions was to make the inventory more acceptable and relevant to the military population, as well as to identify whether these items constitute a separate subscale as distinguished from previously identified factors. MATERIALS AND METHODS: A commonly used assessment tool, the Reasons for Living Inventory (RFL) designed by Marsha Linehan, was expanded to offer items geared to the military population. The RFL presents users with a list of items which may be reasons to not commit suicide (e.g., "I have a responsibility and commitment to my family"). The authors used focus groups of staff and patients in a military psychiatric partial hospitalization program to identify military-centric reasons to live. This process yielded 20 distinct items which were added to Linehan's original list of 48. This expanded list became the Reasons for Living-Military Version. A sample of 200 patients in the military partial hospitalization program completed the inventory at time of or close to admission. This study was approved by the Institutional Review Board at Walter Reed National Military Center for adhering to ethical principles related to pursuing research with human subjects. RESULTS: The rotated factor matrix revealed six factors that have been labeled as follows: Survival and Coping Beliefs, Military Values, Responsibility to Family, Fear of Suicide/Disability/Unknown, Moral Objections and Child-Related Concerns. The subscale of Military Values is a new factor reflecting the addition of military items to the original RFL. CONCLUSIONS: Results suggest that formally assessing protective factors in a military psychiatric population has potential as a useful tool in the prevention of military suicide and therefore warrants further research. The latent factor we have entitled "Military Values" may help identify those service members for whom military training or "esprit de corps" is a reason for living. Further research can focus on further validation, pre/post-treatment effects on scores, expanded clinical use to stimulate increased will to live, or evaluation of whether scores on this scale, or the subscale of Military Values, can predict future suicidal behavior by service members. Finally, a larger sample size may produce more robust results to support these findings.

Seeking Safety Pilot Outcome Study at Walter Reed National Military Medical Center.

Post-traumatic stress disorder (PTSD) and substance use disorder are two of the most prominent psychiatric disorders among military service members. Seeking Safety (SS) is an evidence-based behavioral therapy model for this comorbidity. This article reports results of a study of SS conducted in a military setting. Our pilot trial addressed outcomes, feasibility, and satisfaction. SS was conducted as is to evaluate its impact without adaptation for military culture. The sample was 24 outpatient service members (from the Army, Navy, Air Force, and Marines) with 33% minority representation. Inclusion criteria were current PTSD and/or SUD. Ten clinicians participated in this study after receiving SS training. Results showed significant improvements on most outcomes, including substance use on the Brief Addiction Monitor; PTSD symptoms on the PTSD Checklist-Military Version (total and criterion D); and the Trauma Symptom Checklist-40 (sexual abuse trauma index and anxiety subscale); functioning on the Sheehan Disability Scale (total and family subscale); psychopathology on the Zung Depression Scale total; the Behavior and Symptom Identification Scale (BASIS)-24 (total and subscales depression functioning, emotional liability, and psychosis); and the Brief Symptom Inventory-18 (total and anxiety subscale); and coping on the Coping Self-Efficacy Scale (total). Satisfaction was strong. Discussion includes methodology limitations and next steps.

Components and Characteristics of a Psychiatric Partial Hospital Military Program.

This article describes the components of a psychiatric partial hospital military program and the characteristics of referrals received over the 5-year period from 2009 to 2013. The 5-year study period included ongoing combat operations in Iraq and Afghanistan along with their subsequent troop withdrawals and change in mission. A total of 1,194 service members were referred for this level of care, and even with the changing battlefield conditions, the number of psychiatric referrals remained steady throughout the 5-year period, with a significant spike in admissions in 2013. The principal diagnoses were major depressive disorder and post-traumatic stress disorder. One-third of the admissions came from service members with 4 to 8 years' time in service and slightly more than one-third were employed in direct combat roles or medical support. In terms of gender, females accounted for one-quarter of the admissions.

Relationships between polypharmacy and the sleep cycle among active-duty service members.

CONTEXT: Sleep disorders are frequent clinical presentations, especially among active-duty service members. Medications are one factor that can affect sleep in many ways. OBJECTIVE: To determine the effect of increasing numbers of medications on the sleep cycle of active-duty service members. METHODS: Medical records for active-duty service members who completed enhanced sleep assessments at the Psychiatry Continuity Service at Walter Reed National Military Medical Center from October 1, 2010, through November 30, 2013, were retrospectively reviewed. Data were collected on home sleep study findings, sleep-related self-report instrument scores, and active medications. RESULTS: A total of 135 medical records were reviewed. One hundred patients (74.07%) had an active prescription for a psychoactive drug. Among all patients, the mean (SD) number of active medications per participant was 2.52 (2.09), with 118 patients (82.96%) having an active medication for depression or insomnia. As the number of prescribed medications increased, the percentage of the sleep cycle in deep sleep decreased (P=.049), the percentage of light sleep increased (P=.016), the percentage of rapid eye movement sleep decreased (P=.083), and the first episode of deep sleep was delayed (P=.056). An increased number of medications had no significant impact on total sleep time (P>.05). CONCLUSION: An increasing number of medications did not influence total sleep time but negatively affected the sleep cycle.

WITHDRAWN: Brain computer interface technology: Usability and applications in psychiatry.

Ahead of Print article withdrawn by publisher.

Stress in service members.

Military service differs from civilian jobs in the stressors that service members experience, including frequent deployments (eg, to an area of combat operations), obedience, regimentation, subordination of self to the group, integrity, and flexibility. The military culture emphasizes teamwork and peer support. In some cases, service members cannot adapt to military life, become overwhelmed by stress, or cannot overcome a traumatic experience. Clinicians should conduct a thorough evaluation guided by an understanding of the military culture. Every effort should be made to identify the stress and the maladaptive response and provide early clinical interventions to prevent progression.

Sleep problems, posttraumatic stress, and mood disorders among active-duty service members.

CONTEXT: Sleep problems among active-duty service members are pervasive and complicate the recovery from comorbid posttraumatic stress and mood disorders. OBJECTIVE: To better understand chronic sleep problems among active-duty service members. METHODS: Medical records for active-duty service members who completed enhanced sleep assessments during an 18-month period beginning in October 2010 at the Walter Reed National Military Medical Centers' Psychiatry Continuity Service were retrospectively reviewed. Sleep assessment measures included the Pittsburgh Insomnia Rating Scale, the Alcohol Use Disorders Identification Test, the Zung Self-Rating Depression Scale, the Zung Self-Rating Anxiety Scale, the Posttraumatic Stress Disorder Checklist - Military Version, the Epworth Sleepiness Scale, the Pre-Sleep Arousal Scale, and a home sleep study. RESULTS: A total of 76 records met the study criteria. Twenty-two participants (29%) had an apnea/hypopnea index that suggested mild to moderate sleep apnea. Service members with higher self-reported posttraumatic stress scores also reported a higher degree of both somatic and cognitive factors interfering with sleep initiation. Compared with those who had low self-reported posttraumatic stress scores, service members with high posttraumatic stress scores also had less total sleep time (mean difference, 38 minutes) and higher scores on the apnea/hypopnea index, the respiratory disturbance index, and the oxygen saturation index. CONCLUSION: Enhanced sleep assessments that include traditional self-report tests and a home sleep study can help identify previously undiscovered behavioral and respiratory problems among service members, particularly those with higher posttraumatic stress scores.

A comparison of two alcohol biomarkers in clinical practice: ethyl glucuronide versus ethyl sulfate.

This study compared the characteristics of two direct alcohol biomarkers, ethyl glucuronide and ethyl sulfate. Both biomarkers were analyzed from urine specimens submitted by 58 active duty service members at Walter Reed National Military Medical Center's Addiction Treatment Service. These 58 individuals, as a result of serial testing, submitted a total of 374 urine specimens for laboratory analysis. Of 374 specimens, the paired tests were most often negative (n = 295, 78.9%).The paired tests were both positive less frequently (n = 38, 10.2%). In an interesting development ethyl sulfate produced more positive results than ethyl glucuronide (n = 32, 8.6%).

United States military service members and their tattoos: a descriptive study.

To explore the characteristics of military service tattoos a descriptive study was conducted at Walter Reed Army Medical Center to collect information from a convenience sample. An investigator-developed questionnaire provided the data for this study. Over the ensuing 12 month-period the researchers collected 126 questionnaires. Typical respondents were enlisted men with at least one deployment to an area of combat operations. Among the respondents, 57% acquired their tattoos before their deployment. One-quarter of the respondents reported only one tattoo, leaving the majority with multiple tattoos. Men received their first tattoo at an earlier age than women. The most common tattoo listed a person's name. Respondents did not regret their tattoos and rarely acquired the body art under the influence of alcohol or drugs. Little evidence was found to support a connection between tattoos and deployment. Few regretted their decisions and most all approached the tattoo experience free of any mind-altering substance. All this seems to suggest that military tattoos are a well-accepted means of self-expression.

Sleep trends of active-duty service members referred for psychiatric care: a descriptive study.

CONTEXT: Military service members have unique experiences that may contribute to sleep problems in this patient population. OBJECTIVE: To gather sleep habits and chronic sleep complaints among active-duty service members to identify common characteristics. METHODS: The investigators administered a detailed sleep log, the Pittsburgh Insomnia Rating Scale, the Zung Self-Rating Depression Scale, the Epworth Sleepiness Scale, and the Pre-Sleep Arousal Scale to consenting service members referred to a military psychiatric partial hospitalization program. RESULTS: A total of 57 service members participated in this study. Participants reported a mean of less than 5 total hours of sleep and sleep latencies of 30 minutes or more. Tobacco users (n=22) reported nearly a full hour less of total time slept. Service members with combat experience (n=26) reported qualitatively poorer sleep with less total sleep time (P=.05), greater presleep arousal (P=.01), and a substantially greater number of troubling dreams (P=.06) compared with service members without combat experience. CONCLUSION: Chronic sleep issues are common complaints among military personnel, an anecdotal finding confirmed by the results of this study. These results lend support for more detailed sleep assessments, particularly among combat veterans.

Efficacy of cranial electric stimulation for the treatment of insomnia: a randomized pilot study.

OBJECTIVES: This pilot study examined the potential efficacy of cranial electric stimulation for the treatment of insomnia. DESIGN: The researchers tested the hypothesis through a randomized, double-blind, and placebo controlled clinical trial. The researchers approached eligible subjects who scored 21 or above on the Pittsburgh Insomnia Rating Scale. The researchers then randomly assigned the subjects to receive either an active or sham device. Each study subject received 60min of active or sham treatment for five days. Following each intervention the subjects completed a sleep log, as well as three and ten days later. SETTING: The researchers conducted the study among active duty service members receiving mental health care on the Psychiatry Continuity Service (PCS), Walter Reed National Military Medical Center in Bethesda, MD. MAIN OUTCOME MEASURES: The study's primary outcome variables were the time to sleep onset, total time slept, and number of awakenings as reported by the subjects in the serial sleep logs. The researchers identified a nearly significant increase in total time slept after three cranial electric stimulation treatments among all study subjects. A closer examination of this group revealed an interesting gender bias, with men reporting a robust increase in total time slept after one treatment, decay in effect over the next two interventions, and then an increase in total time slept after the fourth treatment. The researchers speculate that the up and down effect on total time slept could be the result of an insufficient dose of cranial electric stimulation.

Prevalence and characteristics of military malingering.

The authors' principle objective was determining the prevalence and characteristics of medical malingering in the military. The authors accessed an electronic database used by the Department of Defense to monitor and manage military health care activities worldwide. The authors searched the database from 2006 to 2011 in the Northern Regional Medical Command for all instances where a health care provider, consequent to an outpatient medical visit, diagnosed malingering, factitious disorder with psychological symptoms, or factitious disorder with physical symptoms. During the time period studied, the Northern Regional Medical Command reported 28,065,568 health care visits. During the same time period, clinicians diagnosed 1,074 individuals with malingering, factitious disorder with predominantly psychological signs and symptoms, or factitious disorder with predominantly physical signs and symptoms. The typical subject diagnosed with one of these disorders was young, male, nonmarried, and enlisted. Although most diagnoses came from a mental health clinic, other medical specialties also contributed to the total tally. These diagnoses are extremely rare based on the findings from this study of outpatient medical care visits.

Troublesome triad: trauma, insomnia, and alcohol.

The objective of this study was to examine the relationships between combat related trauma, insomnia, and alcohol misuse. The author reviewed the standardized tests results from 39 active duty service members, all of whom had recent deployments to either Iraq or Afghanistan. The battery of self-test instruments assessed the effects of military trauma, anxiety, depression, alcohol use, and insomnia. Among the study subjects, the entire group reported significant sleep problems, with bedtime arousals impeding sleep initiation. Male subjects' reported an average AUDIT score of 8.62. Service members with higher trauma scores also reported greater misuse of alcohol. The high trauma scores also correlated with specific pre-sleep cognitive and somatic factors. The findings of this study lend support for the use of standardized instruments for assessing sleep problems, along with similar tests for trauma and substance misuse, which together should help identify high risk military patients.

Felo De Se: soldier suicides in America's Civil War.

OBJECTIVE: This article examined the factors associated with suicide during America's Civil War and the years immediately following the cessation of armed conflict. METHODS: Contemporary newspaper reports, complemented by book and journal articles, provide an understanding of the incidence and motivations of suicide. RESULTS: The rate of suicide in the general population dramatically increased in the years following the war's end. During the Civil War, suicides occurred nearly every month, reliably peaking in the spring of each year. Depression and alcohol abuse were major factors associated with military suicides. CONCLUSION: Emotional disorders and alcohol misuse, when combined with the hardships of war, contributed to a steady rate of suicides during the Civil War.

Effectiveness of light therapy for depression among active duty service members: A nonrandomized controlled pilot trial.

OBJECTIVE: The authors investigated the potential effectiveness of light therapy as an augmentation treatment for depression among active duty service members. DESIGN: This pilot study recruited active duty service members deployed to an area of combat operations. Enrollment was offered to service members scoring 50 or greater on the Zung Self-Rating Depression Scale. The authors implemented a systematic sampling technique randomly assigning the first subject and then alternating each subsequent subject to either a reference group which received the usual standard of care plus light therapy at 10,000 lux or a control group which received the usual standard of care and light therapy at 50 lux. Both groups received 90 min light sessions for five days. SETTING: The study was conducted at Walter Reed Army Medical Center's Psychiatry Continuity Service. MAIN OUTCOME MEASURE: Zung Self-Rating Depression Scale collected at baseline, after five consecutive daily light sessions, and one week later. RESULTS: A repeated measures analysis of variance (RM ANOVA) was conducted to examine the change in Zung Depression results which showed a significant main effect for time F(2, 21)=5.05, p<0.02, indicating that depression scores reduced over time for both participant groups. Post hoc comparisons (with Bonferroni correction) demonstrated that the post-treatment Zung score was significantly lower indicating less depression than the baseline Zung score (p<0.004) and there was a statistical trend (p<0.05) for depression scores to be reduced halfway through the study in the treatment group. CONCLUSION: The post hoc analysis hints at the possibility of a reduction in depression during the active phase of light treatment.