Acute stress disorder, depression, and tobacco use in disaster workers following 9/11.

Early posttraumatic psychiatric disorders have not been well studied in disaster workers. This study examined the rates of probable acute stress disorder (ASD), probable depression, increased tobacco use, and their associated risk factors in 9/11 World Trade Center disaster workers. Surveys were obtained from 90 disaster workers (e.g., medical personnel, police, firefighters, search and rescue) 2-3 weeks after 9/11. Nearly 15% of disaster workers had probable ASD and 26% had probable depression. Probable ASD and depression were highly related to functional impairment. The risk for ASD was increased for those with 9/11-specific disaster exposures, more pre-9/11 trauma exposures, and the peritraumatic dissociative symptom of altered sense of time. Disaster workers who were younger, non-White, or who had increasing numbers of peritraumatic dissociative symptoms were more likely to have probable depression. More than half of tobacco users increased their tobacco use after 9/11. Additionally, all tobacco users with probable ASD and almost all tobacco users with probable depression increased tobacco use. Rapid mobilization of resources for early screening and intervention and health promotion campaigns aimed at improving adverse health-related behaviors may be helpful for this high-risk group.

Ethical considerations in military psychiatry.

Military psychiatrists are faced with multiple, difficult questions that shape the context for ethical patient care. These questions are difficult to answer and future efforts, including policy and evidence-based treatment practices, should aim at reducing the ambiguity faced by military psychiatrists. New research should focus on issues as diverse as optimal approaches to informed consent, evidence-derived approaches to protecting confidentiality, outcomes of care for individuals in widely varying military roles, and medication use in the field. Training for mental health care providers who deal with military patients should be provided not only in military graduate medical education but also in job-specific courses and in ethics. This should include specific training for personnel who will be dealing with specific populations, such as the US Army's current "Dealing with Detainee course" and the Army Medical Department's "Combat Operational Stress Course" for deploying military psychiatrists and psychologists.

Models of PTSD and traumatic stress: the importance of research "from bedside to bench to bedside".

The epidemiology and psychology of PTSD noted above is not often considered in neurobiological models of PTSD. Neurobiological models tend to focus on symptoms. This is an important perspective but it does not capture the brains total response to traumatic events. Similarly, neurobiologists have rarely used the extensive knowledge of animal behavioral responses to stress as a means to define the human stress phenomenology, looking for the human equivalent (rather than the other way around). The development of animal models for PTSD and other traumatic stress-related brain changes is an important part of advancing our neurobiological understanding of the disease process as well as recovery, resilience, and possible therapeutic targets. Animal models should address symptoms but also other aspects of PTSD that are seen in clinical care including the waxing and waning of symptoms, Understanding "forgetting", toxic exposure, failure to recover and how the neural systems fail rather than function are important perspectives on developing animal models. The cognitive process of identification is another important animal model to develop. Using these perspectives recent work has shown new avenues for understanding the trauma response in animal models and human brain tissue of individuals with PTSD. The 5-HT2A receptor and p11 protein and associated regulators are avenues of new investigation that warrant study and consideration in models of PTSD.

Depression in entry-level military personnel.

OBJECTIVE: The goal was to determine the prevalence of, and risk factors for, depression in an entry-level U.S. Army population. METHOD: A cross-sectional survey of U.S. Army soldiers in advanced individual training was performed by using an anonymous self-report survey including demographic data, history (including abuse and psychiatric treatment), and the Patient Health Questionnaire-9. RESULTS: Soldiers in advanced individual training (n = 1,184) were approached, and 1,090 (91.2%; 955 male soldiers and 135 female soldiers) voluntarily chose to participate. Eleven percent reported a psychiatric history, 26% reported a history of abuse, and 15.9% endorsed moderate or more severe current depressive symptoms (male, 15.0%; female, 22.2%). A history of psychiatric treatment (odds ratio, 2.08; 95% confidence interval, 1.21-3.59; p = 0.009) and a history of verbal abuse (odds ratio, 4.11; 95% confidence interval, 2.45-6.90; p = 0.000) placed soldiers at higher risk for depression. CONCLUSIONS: Our study shows a higher than expected rate of depression in entry-level training soldiers and identifies some risk factors for depression. This indicates an important need for further study, effective screening, preventive counseling, and early intervention.

Post-traumatic stress disorder and depression in health care providers returning from deployment to Iraq and Afghanistan.

OBJECTIVE: This study examines risk factors for post-traumatic stress disorder (PTSD), depression, and mental health care use among health care workers deployed to combat settings. METHODS: Anonymous surveys were administered to previously deployed workers at a military hospital. PTSD and depression were assessed by using the PTSD Checklist and the Patient Health Questionnaire depression scale, respectively. Deployment exposures and perceived threats during deployment were also assessed. RESULTS: There were 102 respondents (36% response rate). Nine percent (n=9) met the criteria for PTSD and 5% (n=5) met the criteria for depression. Direct and perceived threats of personal harm were risk factors for PTSD; exposure to wounded or dead patients did not increase risk. Those who met the criteria for PTSD were more likely to seek mental health care after but not before their deployment. CONCLUSIONS: For health care workers returning from a warfare environment, threat of personal harm may be the most predictive factor in determining those with subsequent PTSD.

Disordered eating in entry-level military personnel.

OBJECTIVE: The goal was to determine the prevalence of and risk factors for disordered eating in an entry-level U.S. Army population. METHODS: A cross-sectional survey of advanced individual training U.S. Army soldiers at Aberdeen Proving Ground, Maryland, was performed with an anonymous self-report survey containing demographic factors, history (including abuse and psychiatric treatment), and Eating Attitudes Test-26. RESULTS: Of 1,184 advanced individual training soldiers approached, 1090 participated. The response rate was 91.2% (955 men and 135 women). Forty percent were overweight (body mass index of > or =25), 11% reported a psychiatric history, 26% reported a history of abuse, and 9.8% endorsed disordered eating (male, 7.0%; female, 29.6%), as defined by Eating Attitudes Test-26. Factors that placed soldiers at higher risk for disordered eating were female gender (odds ratio, 5.63; 95% confidence interval, 3.32-9.57; p < 0.00005), overweight (odds ratio, 3.06; 95% confidence interval, 1.92-4.89; p < 0.00005), previous psychiatric treatment (odds ratio, 1.87; 95% confidence interval, 1.04-3.36; p = 0.035), and history of verbal abuse (odds ratio, 2.02; 95% confidence interval, 1.16-3.51; p = 0.014). CONCLUSIONS: Our study shows a higher than expected rate of disordered eating in advanced individual training soldiers with identifiable risk factors. This indicates an important need for further study, effective screening, preventive counseling, and early intervention for treatment.

Posttraumatic stress disorder and depression in battle-injured soldiers.

OBJECTIVE: This study examined rates, predictors, and course of probable posttraumatic stress disorder (PTSD) and depression among seriously injured soldiers during and following hospitalization. METHOD: The patients were 613 U.S. soldiers hospitalized following serious combat injury. Standardized screening instruments were administered 1, 4, and 7 months following injury; 243 soldiers completed all three assessments. Cross-sectional and longitudinal analyses of risk factors were performed. PTSD was assessed with the PTSD Checklist; depression was assessed with the Patient Health Questionnaire. Combat exposure, deployment length, and severity of physical problems were also assessed. RESULTS: At 1 month, 4.2% of the soldiers had probable PTSD and 4.4% had depression; at 4 months, 12.2% had PTSD and 8.9% had depression; at 7 months, 12.0% had PTSD and 9.3% had depression. In the longitudinal cohort, 78.8% of those positive for PTSD or depression at 7 months screened negative for both conditions at 1 month. High levels of physical problems at 1 month were significantly predictive of PTSD (odds ratio=9.1) and depression at 7 months (odds ratio=5.7) when the analysis controlled for demographic variables, combat exposure, and duration of deployment. Physical problem severity at 1 month was also associated with PTSD and depression severity at 7 months after control for 1-month PTSD and depression severity, demographic variables, combat exposure, and deployment length. CONCLUSIONS: Early severity of physical problems was strongly associated with later PTSD or depression. The majority of soldiers with PTSD or depression at 7 months did not meet criteria for either condition at 1 month.

Follow-up of Pentagon employees two years after the terrorist attack of September 11, 2001.

OBJECTIVE: This study examined probable posttraumatic stress disorder (PTSD) and probable depression, degree of psychological distress, and rates of mental health treatment in a sample of Pentagon staff two years after the terrorist attack of September 11, 2001. METHODS: Anonymous surveys were administered to staff at one Pentagon work center. Respondents were asked about exposure to the attack; injuries; exposure to dead bodies or families of the deceased; psychological distress; and use of mental health services. Probable PTSD and depression were assessed with the PCL-17 and the PHQ-9. RESULTS: A total of 267 responses were received. Fourteen percent of the sample had probable PTSD, and 7 percent had probable depression. Staff who were at the Pentagon on the day of the attack were more likely to have probable PTSD and probable depression. Exposure through watching television was not associated with a higher frequency of probable PTSD, probable depression, or distress. Injury during the attack was associated with a higher frequency of probable PTSD, probable depression, and distress. Respondents who were exposed to dead bodies or who acted as lay counselors to families of the deceased were more likely to have probable PTSD and depression and to report chronic distress. Of those with probable PTSD, 70 percent made at least one mental health visit during the next two years. Of those with probable depression, 74 percent reported at least one mental health visit. CONCLUSIONS: Direct exposure to the September 11 terrorist attack on the Pentagon, injury during the attack, and exposure to dead bodies or acting as a lay counselor to families of persons who were killed during the attack were all associated with higher frequencies of probable psychiatric illness and higher levels of psychological distress two years after the attack. Among survivors who had probable psychiatric illness, more than two-thirds received mental health treatment after the attack.

Psychiatric symptoms and cognitive appraisal following the near sinking of a research submarine.

OBJECTIVE: This study assessed the stress reactions of a submarine crew forced to abandon their vessel in high seas after flooding and fire damaged their ship. METHODS: The remaining crew members (n = 22) were surveyed 7 months after the incident regarding exposures, initial emotional responses, peritraumatic dissociation, subsequent life events, current safety appraisal, and current symptoms of posttraumatic stress disorder (PTSD) and depression. RESULTS: At 7 months, 9.1% met criteria for PTSD and none met criteria for depression. Higher levels of depressive symptoms were associated with previous traumatic exposures, subsequent life events, and higher levels of PTSD symptoms; higher levels of PTSD symptoms were associated with greater peritraumatic dissociation and initial emotional response. CONCLUSION: Acute exposures of highly trained professionals to potentially fatal events may not result in high levels of posttraumatic symptoms. Previous and subsequent life events may play a more significant role in the level of postdisaster symptoms.

Posttraumatic stress disorder, depression, and perceived safety 13 months after September 11.

This study assessed relationships between exposure to the September 11, 2001, terrorist attack, current posttraumatic stress disorder (PTSD), current major depression, and current safety perceptions in a sample of 212 Pentagon staff members 13 months after the attack. Forty-eight respondents (23 percent) had possible PTSD; eight (4 percent) had probable major depression. Respondents who were directly exposed to the attack were more likely to have PTSD and major depression and were less likely to have a perception of safety at work and in usual activities and travel only. In contrast, respondents with PTSD reported a lower perception of safety at home, at work, and in usual activities and travel.

Posttraumatic stress disorder, alcohol use, and perceived safety after the terrorist attack on the pentagon.

OBJECTIVE: The authors examined posttraumatic stress disorder (PTSD), alcohol use, and perceptions of safety in a sample of survivors of the September 11, 2001, terrorist attack on the Pentagon. METHODS: Analyses were conducted to examine the effect of past traumatic experience, trauma exposure, initial emotional response, and peritraumatic dissociation on probable PTSD, substance use, and perceived safety among 77 survivors seven months after the attack. RESULTS: Eleven respondents (14 percent) had PTSD. Those with PTSD reported higher levels of initial emotional response and peritraumatic dissociation. Ten respondents (13 percent) reported increased use of alcohol. Women were more than five times as likely as men to have PTSD and almost seven times as likely to report increased use of alcohol. Persons with higher peritraumatic dissociation were more likely to develop PTSD and report increased alcohol use. Those with lower perceived safety at seven months had higher initial emotional response and greater peritraumatic dissociation and were more likely to have PTSD, to have increased alcohol use, and to be female. CONCLUSIONS: The association of perceived safety with gender, the presence of PTSD, and increased alcohol use among survivors of the terrorist attack on the Pentagon warrants further study.

Acute stress disorder, alcohol use, and perception of safety among hospital staff after the sniper attacks.

OBJECTIVE: This study examined emotional and behavioral effects on hospital staff after a series of sniper shootings in the Washington, D.C., area. METHODS: Employees of a large tertiary care military hospital were anonymously surveyed about their perceptions of safety and threat, changes in activities, and peritraumatic dissociation as possible risk factors for acute stress disorder, depression, and increased alcohol use the week after the sniper suspects were captured. RESULTS: Of 382 study participants, whose average age was 39 years, 24 (6 percent) met criteria for acute stress disorder, 13 (3 percent) reported increased alcohol use, and 31 (8 percent) met criteria for depression. Risk factors for acute stress disorder were female sex (odds ratio [OR]=2.59), increased alcohol use (OR=5.1), comorbid depression (OR=7.28), lower perceived safety, higher perceived threat, higher levels of peritraumatic dissociation, and greater numbers of decreased activities. Risk factors for increased alcohol use were comorbid depression (OR=4.02), lower perceived safety, higher perceived threat, and higher levels of peritraumatic dissociation. Risk factors for depression were lower perceived safety and higher levels of peritraumatic dissociation. CONCLUSIONS: The sniper shootings were associated with substantial changes in perceived safety and threat assessment as well as decreased activities outside the home among highly educated hospital employees. Levels of acute stress disorder were similar to levels of posttraumatic stress disorder in New York City after the terrorist attacks of September 11, 2001. Peritraumatic dissociation was associated not only with acute stress disorder but also with depression and increased alcohol use after the attacks.

Pharmacologic treatment of hospitalized patients with schizoaffective disorder.

This study examined changes in the pharmacologic treatment of 70 patients who were hospitalized with a diagnosis of schizoaffective disorder at some time during a six-year period. An increasing use of divalproex sodium and atypical antipsychotics instead of lithium and conventional antipsychotics was observed. The use of a combination of an antipsychotic and a thymoleptic medication was more common than monotherapy, and physicians tended to continue antidepressants if patients had a history of depression. Patients with a new diagnosis of schizoaffective disorder were stabilized less quickly than those with a previous diagnosis. The use of divalproex sodium and newer antipsychotics did not reduce the time to stabilization in routine clinical practice.