General distress is more important than PTSD's cognition and mood alterations factor in accounting for PTSD and depression's comorbidity.

BACKGROUND: Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) are highly comorbid and exhibit strong correlations with each other at both the symptom level and latent factor level. Various theories have attempted to explain this relationship. Results have been inconsistent regarding whether PTSD's negative alterations in cognition and mood factor (NACM) is significantly more related to depression, in contrast to other factors of PTSD. METHODS: Confirmatory factor analysis was used to attempt to address the relationships between PTSD and MDD in a large sample of trauma-exposed combat veterans from the Ohio National Guard as part of a larger longitudinal study. RESULTS: Confirmatory factor analysis was used to test a bifactor model of PTSD symptoms, testing relations between PTSD's factors and a latent depressive factor. After partitioning out the common variance into the bifactor, we found that in contrast to other PTSD factors, PTSD's NACM factor was not significantly more related to depression. Instead, only the general bifactor predicted depressive symptoms. LIMITATIONS: The limitations of the present study include the following: the specific measures of PTSD and MDD used were based on self-report, and the sample consisted of non-clinical, non-treatment seeking veterans. CONCLUSIONS: The present study suggests that the high rate of comorbidity between posttraumatic stress disorder (PTSD) and major depressive disorder is more related to underlying general distress or negative affectivity than the symptom categories of the PTSD diagnostic criteria.

Incidence and Risk for Mood and Anxiety Disorders in a Representative Sample of Ohio Army National Guard Members, 2008-2012.

OBJECTIVE: We investigated the incidence of first-onset psychiatric disorders among Ohio Army National Guard members and the sociodemographic and military factors associated with these incident disorders. We aimed to identify potential risk factors and mitigating factors for a range of psychiatric disorders in a representative military sample. METHODS: We analyzed data on a representative sample of 528 Ohio Army National Guard members who were assessed in person annually for first-onset psychiatric disorders from 2008 through 2012 using structured clinical interviews. We used a multivariable discrete-time Cox proportional hazard model to determine risk factors of first-onset anxiety or mood disorders. RESULTS: The annualized incidence rate of any first-onset psychiatric disorder was 9.8 per 100 person-years at risk. Alcohol use disorder and major depressive disorder had the highest incidence rates among the unique disorders under study (5.0 and 4.2 per 100 person-years at risk, respectively). We found an association between respondents endorsing past-year deployment and a 29% increase in the risk of incident anxiety or mood disorder, whereas the past-year experience of any non-deployment traumatic event was associated with a 32% increase in risk of incident anxiety or mood disorder. CONCLUSION: Soldiers experience a substantial burden of first-onset alcohol use disorder and major depressive disorder annually; the experience of non-deployment-related traumatic events contributes substantially to increasing risk, suggesting that any effort aimed at mitigating mood and anxiety disorders in this population must consider the soldier's life experience and military experience.

Retrospective age-of-onset and projected lifetime prevalence of psychiatric disorders among U.S. Army National Guard soldiers.

BACKGROUND: The study of military-related mental health has been disproportionately focused on current symptomology rather than potentially more informative life course mental health. Indeed, no study has assessed age-of-onset and projected lifetime prevalence of disorders among reservists. METHODS: Age-of-onset and projected lifetime DSM-IV anxiety, mood, and substance use disorders were assessed in 671 Ohio Army National Guard soldiers aged 17-60 years. Between 2008 and 2012, face-to-face clinical assessments and surveys were conducted using the Structured Clinical Interview for DSM-IV and Clinician-Administered PTSD Scale. RESULTS: Lifetime prevalence of psychiatric disorders was 61%. Alcohol abuse/dependence (44%) and major depressive disorder (23%) were the most common disorders. The majority (64%) of participants reported disorders antedating enlistment. Median age-of-onset varied with anxiety disorders - particularly phobias and OCD - having the earliest (median=15 years) and mood disorders the latest median age-of-onset (median=21 years). LIMITATIONS: The study was limited by both the retrospective investigation of age-of-onset and the location of our sample. As our sample may not represent the general military population, our findings need to be confirmed in additional samples. CONCLUSIONS: Each psychiatric disorder exhibited a distinct age-of-onset pattern, such that phobias and OCD onset earliest, substance use disorders onset during a short interval from late-adolescence to early-adulthood, and mood disorders onset the latest. Our finding that the majority of participants reported disorders antedating enlistment suggests that an assessment of lifetime psychopathology is essential to understanding the mental health burden of both current and former military personnel.

Association of Spirituality With Mental Health Conditions in Ohio National Guard Soldiers.

Research exploring spirituality in military populations is a relatively new field with limited published reports. This study used the Spiritual Well-Being Scale to examine the association of spiritual well-being with suicidal ideation/behavior, posttraumatic stress disorder (PTSD), and depression and alcohol use disorders in a randomized sample of Ohio Army National Guard soldiers. The participants were 418 soldiers, mostly white and male, with nearly three-quarters indicating that they had been deployed at least once during their careers. Higher spirituality, especially in the existential well-being subscale, was associated with significantly less lifetime PTSD, depression, and alcohol use disorders and with less suicidal ideation over the past year. Future research in this area may benefit from a longitudinal design that can assess spirituality and mental health behaviors in addition to diagnoses at different time points, to begin to explore spirituality in a larger context.

Onset of Alcohol Use Disorders and Comorbid Psychiatric Disorders in a Military Cohort: Are there Critical Periods for Prevention of Alcohol Use Disorders?

Alcohol use disorders (AUD) are commonly comorbid with anxiety and mood disorders; however, a strategy for AUD prevention remains unclear in the presence of three competing etiological models that each recommends different high-risk groups. Therefore, the investigation of the three hypotheses in a characteristically unique cohort is critical to identifying pervasive characteristics of AUD that can inform a universal prevention strategy. The current study evaluated the temporality and onset of comorbid AUD and psychiatric disorders in a representative sample of 528 Ohio Army National Guard soldiers using structured clinical interviews from 2009 to 2012. We examined temporality both statistically and graphically to identify patterns that could inform prevention. General estimating equations with dichotomous predictor variables were used to estimate odds ratios between comorbid psychiatric disorders and AUDs. An annualized rate of 13.5 % persons per year was diagnosed with any AUD between 2010 and 2012. About an equal proportion of participants with comorbid psychiatric disorders and AUD initiated the psychiatric disorder prior to the AUD and half initiated the psychiatric disorder after the AUD. Regardless of onset, however, the majority (80 %) AUD initiated during a short interval between the ages of 16 and 23. Focused primary prevention during this narrow age range (16-23 years) may have the greatest potential to reduce population mental health burden of AUD, irrespective of the sequencing of comorbid psychiatric disorder.

Latent dimensions of posttraumatic stress disorder and their relations with alcohol use disorder.

PURPOSE: The objective of this study was to evaluate the relationship between factors of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) using confirmatory factor analysis (CFA) in order to further our understanding of the substantial comorbidity between these two disorders. METHODS: CFA was used to examine which factors of PTSD's dysphoria model were most related to AUD in a military sample. Ohio National Guard soldiers with a history of overseas deployment participated in the survey (n = 1215). Participants completed the PTSD Checklist and a 12-item survey from the National Survey on Drug Use used to diagnosis AUD. RESULTS: The results of the CFA indicated that a combined model of PTSD's four factors and a single AUD factor fit the data very well. Correlations between PTSD's factors and a latent AUD factor ranged from correlation coefficients of 0.258-0.285, with PTSD's dysphoria factor demonstrating the strongest correlation. However, Wald tests of parameter constraints revealed that AUD was not more correlated with PTSD's dysphoria than other PTSD factors. CONCLUSIONS: All four factors of PTSD's dysphoria model demonstrate comparable correlations with AUD. The role of dysphoria to the construct of PTSD is discussed.

Latent profile analyses of posttraumatic stress disorder, depression and generalized anxiety disorder symptoms in trauma-exposed soldiers.

Posttraumatic stress disorder (PTSD) is comorbid with major depressive disorder (MDD; Kessler et al., 1995) and generalized anxiety disorder (GAD; Brown et al., 2001). We aimed to (1) assess discrete patterns of post-trauma PTSD-depression-GAD symptoms using latent profile analyses (LPAs), and (2) assess covariates (gender, income, education, age) in defining the best fitting class solution. The PTSD Checklist (assessing PTSD symptoms), GAD-7 scale (assessing GAD symptoms), and Patient Health Questionnaire-9 (assessing depression) were administered to 1266 trauma-exposed Ohio National Guard soldiers. Results indicated three discrete subgroups based on symptom patterns with mild (class 1), moderate (class 2) and severe (class 3) levels of symptomatology. Classes differed in symptom severity rather than symptom type. Income and education significantly predicted class 1 versus class 3 membership, and class 2 versus class 3. In conclusion, there is heterogeneity regarding severity of PTSD-depression-GAD symptomatology among trauma-exposed soldiers, with income and education predictive of class membership.

Posttraumatic stress disorder's dysphoria dimension and relations with generalized anxiety disorder symptoms.

The present study investigated symptom relations between two highly comorbid disorders--posttraumatic stress disorder (PTSD) and generalized anxiety disorder (GAD)--by exploring their underlying dimensions. Based on theory and prior empirical research it was expected that the dysphoria factor of PTSD would be more highly related to GAD. As part of a longitudinal project of mental health among Ohio National Guard Soldiers, 1266 subjects were administered the Posttraumatic Stress Disorder Checklist (PCL) and Generalized Anxiety Disorder-7 scale (GAD-7). Confirmatory factor analyses (CFAs) were conducted to examine two models of PTSD and to determine which PTSD factors were more related to the GAD factor. The results indicate that the GAD factor was significantly more highly correlated with PTSD's dysphoria factor than with all other PTSD factors, including PTSD's reexperiencing factor, avoidance factor, and hyperarousal factor. Results indicate GAD was not significantly more highly correlated with numbing than most other factors of PTSD. The results are consistent with prior research. Implications of the results are discussed in regards to PTSD in DSM-5, comorbidity and diagnostic specificity.

Lifetime and 12-month use of psychiatric services among U.S. Army National Guard soldiers in Ohio.

OBJECTIVE: The individual and economic burden of psychiatric illnesses is substantial. Although treatment of psychiatric disorders mitigates the burden of illness, over half of military personnel with disorders do not receive mental health care. However, there is a paucity of research examining the relationship between psychiatric disorder categories and treatment-seeking behavior in representative military populations. This study aimed to document, by psychiatric disorder category, the annualized rate of Guard members who obtained psychiatric services and the factors associated with service utilization. METHODS: Face-to-face clinical assessments were conducted between 2008 and 2012 to assess lifetime and current psychiatric disorders and recent psychiatric service use among 528 Ohio Army National Guard soldiers. RESULTS: An annualized rate of 31% of persons per year accessed psychiatric services between 2010 and 2012. Persons with substance use disorders had the lowest annualized rate of service use, and these were the only disorders not predictive of accessing services. Current mood disorder, current anxiety disorder, and lifetime history of service use were the strongest predictors of recent service use. There were no socioeconomic or other group predictors of psychiatric service use. CONCLUSIONS: About half of the soldiers who could benefit from mental health services used them, yet soldiers with substance use disorders were predominantly going untreated. There were no differences in treatment utilization by group characteristics, suggesting no systematic barriers to care for particular groups. Efforts to encourage broader adoption of treatment seeking, particularly among persons with substance use disorders, are necessary to mitigate psychiatric health burden in this population.

Structural relations between DSM-5 PTSD and major depression symptoms in military soldiers.

BACKGROUND: Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) are frequently comorbid. One explanation for this comorbidity is that PTSD has a constellation of "dysphoria" symptoms resembling depression. METHOD: Using confirmatory factor analysis we tested the role of DSM-5 PTSD׳s dysphoria factor in relation to MDD symptom dimensions of somatic and non-somatic psychopathology. 672 Ohio National Guard soldiers completed DSM-5 measures of PTSD and MDD symptoms in an epidemiological study. RESULTS: Results indicated that in contrast to other PTSD factors, PTSD׳s dysphoria factor was more related to MDD׳s somatic and non-somatic factors. LIMITATIONS: Limitations include generalizability to the epidemiological population of trauma-exposed military veterans rather than civilians, and reliance on self-report measures. CONCLUSIONS: Implications concerning clinical psychopathology and comorbidity of PTSD are discussed, including whether PTSD should be refined by removing its non-specific symptoms.

Baseline prevalence of Axis I diagnosis in the Ohio Army National Guard.

The goal of this study is to determine the pre-existing lifetime and current prevalence of DSM-IV Axis I disorders within the Ohio Army National Guard (OHARNG). Data was analyzed from the clinical subsample of the Ohio Army National Guard Mental Health Initiative (OHARNG MHI). Five hundred participants were provided with an in-depth clinical assessment using the Clinician-Administered PTSD Scale (CAPS) and the Structured Clinical Interview for DSM-IV-TR (SCID). Logistic regression examined the relationship between Axis I disorders and the number of deployments and gender. Prevalence of at least one DSM-IV lifetime disorder was 66.2%; substance use disorders were 52.2%, followed by mood disorders (30.0%) and anxiety disorders (22.0%). Prevalence of at least one current disorder was 24.8%; anxiety disorders (13.2%), mood disorders (7.6%), and substance use disorders (7.0%) were most frequent. Number of deployments was associated with PTSD (OR=8.27, 95% CI 2.10-32.59, p=0.003), alcohol use disorder (OR=1.77, 95% CI 1.07-2.92, p=0.025), and any substance use disorder (OR=1.85, 95% CI 1.12-3.05, p=0.016). Gender (OR=2.02, 95% CI 1.10-3.73, p=0.024) was associated with any mood disorder. The results provide baseline information on the most prevalent mental disorders within the OHARNG.

Validation of lay-administered mental health assessments in a large Army National Guard cohort.

To report the reliability and validity of key mental health assessments in an ongoing study of the Ohio Army National Guard (OHARNG). The 2616 OHARNG soldiers received hour-long structured telephone surveys including the post-traumatic stress disorder (PTSD) checklist (PCV-C) and Patient Health Questionnaire - 9 (PHQ-9). A subset (N = 500) participated in two hour clinical reappraisals, using the Clinician-Administered PTSD Scale (CAPS) and the Structured Clinical Interview for DSM (SCID). The telephone survey assessment for PTSD and for any depressive disorder were both highly specific [92% (standard error, SE 0.01), 83% (SE 0.02)] with moderate sensitivity [54% (SE 0.09), 51% (SE 0.05)]. Other psychopathologies assessed included alcohol abuse [sensitivity 40%, (SE 0.04) and specificity 80% (SE 0.02)] and alcohol dependence [sensitivity, 60% (SE 0.05) and specificity 81% (SE 0.02)].The baseline prevalence estimates from the telephone study suggest alcohol abuse and dependence may be higher in this sample than the general population. Validity and reliability statistics suggest specific, but moderately sensitive instruments.

Validation of the telephone-administered PHQ-9 against the in-person administered SCID-I major depression module.

BACKGROUND: We assessed item-to-item correspondence between the Patient Health Questionnaire-9 (PHQ-9) and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) major depression episode portion of the major depressive module. METHOD: Four hundred and ninety-eight soldiers in the Ohio National Guard were administered the PHQ-9 and SCID-I. Data were analyzed using chi-square analyses, logistic regression, receiver operating characteristic (ROC) curve analyses and diagnostic efficiency statistics. RESULTS: To screen for depression effectively, results indicate use of the cardinal first two items, items representing fatigue, appetite and sleep changes with an item level cut-off point of two, and the item representing suicidal ideation with item level cut-off point of one. Further, total PHQ-9 scores significantly predicted SCID-I major depressive episode (MDE) and diagnosis (MDD) with moderate accuracy. Lastly, the cut-off total score of 10 had the optimal balance of sensitivity and specificity compared to other PHQ-9 scoring options. LIMITATIONS: Differences in timeline of administration of the measures, differences in "worst episode" reference between the measures, and use of a specific military population are some of the limitations. CONCLUSIONS: This validation study provides guidelines for the use of the telephone-administered PHQ-9 in assessing the lifetime prevalence of a major depressive episode and diagnosis in non-clinical populations, with implications for clinical use.

Relations between the underlying dimensions of PTSD and major depression using an epidemiological survey of deployed Ohio National Guard soldiers.

BACKGROUND: In the present study, the authors investigated the relationship between the underlying symptom dimensions of posttraumatic stress disorder (PTSD) and dimensions of major depressive disorder (MDD). METHOD: A sample of 1266 Ohio National Guard soldiers with a history of overseas deployment participated and were administered the PTSD Checklist (assessing PTSD) and Patient Health Questionnaire-9 (assessing depression). RESULTS: Using confirmatory factor analysis, results demonstrated that both PTSD's dysphoria and hyperarousal factors were more related to depression's somatic than non-somatic factor. Furthermore, depression's somatic factor was more related to PTSD's dysphoria than hyperarousal factor. LIMITATIONS: Limitations of this study include the use of self-report measures and a predominately male military sample. CONCLUSIONS: Results indicate that PTSD's dysphoria factor is related to depression specifically by way of depression's somatic construct. Given PTSD's substantial dysphoria/distress component, these results have implications for understanding the nature of PTSD's high comorbidity with depression.

The factor structure of major depression symptoms: a test of four competing models using the Patient Health Questionnaire-9.

Little research has examined the underlying symptom structure of major depressive disorder (MDD) symptoms based on DSM-IV criteria. Our aim was to analyze the symptom structure of major depression, using the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 was administered to a sample of 2615 Army National Guard soldiers from Ohio. A one-factor model of depression and three separate two-factor models previously established in the literature were evaluated using confirmatory factor analysis. Results demonstrated greater support for the two-factor models of depression than for the one-factor model. The best fitting model was the two-factor model of somatic and non-somatic symptoms supported previously by Krause et al. (2010) and Richardson and Richards (2008). Implications for understanding the components and mechanisms of MDD are discussed.

Potentially modifiable pre-, peri-, and postdeployment characteristics associated with deployment-related posttraumatic stress disorder among ohio army national guard soldiers.

PURPOSE: To evaluate potentially modifiable deployment characteristics-- predeployment preparedness, unit support during deployment, and postdeployment support-that may be associated with deployment-related posttraumatic stress disorder (PTSD). METHODS: We recruited a sample of 2616 Ohio Army National Guard (OHARNG) soldiers and conducted structured interviews to assess traumatic event exposure and PTSD related to the soldiers' most recent deployment, consistent with DSM-IV criteria. We assessed preparedness, unit support, and postdeployment support by using multimeasure scales adapted from the Deployment Risk and Resilience Survey. RESULTS: The prevalence of deployment-related PTSD was 9.6%. In adjusted logistic models, high levels of all three deployment characteristics (compared with low) were independently associated with lower odds of PTSD. When we evaluated the influence of combinations of deployment characteristics on the development of PTSD, we found that postdeployment support was an essential factor in the prevention of PTSD. CONCLUSIONS: Results show that factors throughout the life course of deployment-in particular, postdeployment support-may influence the development of PTSD. These results suggest that the development of suitable postdeployment support opportunities may be centrally important in mitigating the psychological consequences of war.

PTSD comorbidity and suicidal ideation associated with PTSD within the Ohio Army National Guard.

OBJECTIVE: To study the relation between posttraumatic stress disorder (PTSD) psychiatric comorbidity and suicidal ideation in a representative sample of Ohio Army National Guard soldiers. METHOD: Using retrospective data collected on the telephone from a random sample of 2,616 National Guard soldiers who enrolled in a 10-year longitudinal study (baseline data collected November 2008-November 2009), we examined (1) the prevalence of other psychopathologies among those with DSM-IV-diagnosed PTSD compared to those without PTSD and (2) the association between PTSD comorbidity and suicidal ideation (reporting thoughts of being better off dead or hurting themselves). All analyses were carried out using logistic regression. RESULTS: Of guard members with PTSD in the last year, 61.7% had at least 1 other psychopathology; 20.2% had at least 2 other co-occurring conditions. The most common co-occurring psychopathology was depression. While those with PTSD overall were 5.4 (95% CI, 3.8-7.5) times more likely to report suicidality than those without PTSD, those who had at least 2 additional conditions along with PTSD were 7.5 (95% CI, 3.0-18.3) times more likely to report suicidal ideation at some point in their lifetime than those with PTSD alone. CONCLUSIONS: Soldiers with PTSD were at increased risk for suicidality, and, among those with PTSD, those with at least 2 additional conditions were at the highest risk of suicidal ideation. Future research should address the mechanisms that contribute to multimorbidity in this population and the appropriate treatment methods for this high-risk group.

The relationship of personality traits to substance abuse in patients with bipolar disorder.

PURPOSE: The aim of this study is to determine if personality traits contribute to the likelihood of substance abuse in Bipolar Disorder (BD). SUBJECTS/MATERIALS AND METHODS: Fifty-nine patients meeting DSM-IV criteria for BD: 20 without any history of Substance Related Disorder (SRD), 21 with a lifetime history of SRD but without current SRD, and 18 with current SRD. Patients filled out the TCI, the differences were analyzed by ANOVA and the likelihood was obtained by Multinomial Logistic Regression. RESULTS: Only Novelty Seeking (NS) is statistically different between the groups. Patients with BD with current SRD have higher rates in NS than those with past SRD, and those without a history of SRD. NS was confirmed as a predicting variable, both to current SRD (OR [CI 95%]=1.039/1.351; p=0.011) and past SRD (OR [CI 95%]=1.004/1.277; p=0.042) on patients with BD. DISCUSSION: The results shown would appear to confirm the relationship of NS with the SRD, so long as there is no clear evidence that indicates the association of NS with BD. CONCLUSIONS: There appears a greater predisposition to develop SRD in those patients with a higher degree of NS. The use of the Cloninger's TCI could be used in BD to determine the risk of developing an SRD. Early detection might help improve prognosis.

Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhancement Program.

CONTEXT: Psychosocial interventions have been shown to enhance pharmacotherapy outcomes in bipolar disorder. OBJECTIVE: To examine the benefits of 4 disorder-specific psychotherapies in conjunction with pharmacotherapy on time to recovery and the likelihood of remaining well after an episode of bipolar depression. DESIGN: Randomized controlled trial. SETTING: Fifteen clinics affiliated with the Systematic Treatment Enhancement Program for Bipolar Disorder. Patients A total of 293 referred outpatients with bipolar I or II disorder and depression treated with protocol pharmacotherapy were randomly assigned to intensive psychotherapy (n = 163) or collaborative care (n = 130), a brief psychoeducational intervention. INTERVENTIONS: Intensive psychotherapy was given weekly and biweekly for up to 30 sessions in 9 months according to protocols for family-focused therapy, interpersonal and social rhythm therapy, and cognitive behavior therapy. Collaborative care consisted of 3 sessions in 6 weeks. MAIN OUTCOME MEASURES: Outcome assessments were performed by psychiatrists at each pharmacotherapy visit. Primary outcomes included time to recovery and the proportion of patients classified as well during each of 12 study months. RESULTS: All analyses were by intention to treat. Rates of attrition did not differ across the intensive psychotherapy (35.6%) and collaborative care (30.8%) conditions. Patients receiving intensive psychotherapy had significantly higher year-end recovery rates (64.4% vs 51.5%) and shorter times to recovery than patients in collaborative care (hazard ratio, 1.47; 95% confidence interval, 1.08-2.00; P = .01). Patients in intensive psychotherapy were 1.58 times (95% confidence interval, 1.17-2.13) more likely to be clinically well during any study month than those in collaborative care (P = .003). No statistically significant differences were observed in the outcomes of the 3 intensive psychotherapies. CONCLUSIONS: Intensive psychosocial treatment as an adjunct to pharmacotherapy was more beneficial than brief treatment in enhancing stabilization from bipolar depression. Future studies should compare the cost-effectiveness of models of psychotherapy for bipolar disorder. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00012558.