Risk factors, comorbidity and social impairment of ICD-11 PTSD and complex PTSD in Danish treatment-seeking military veterans.

PURPOSE: While a number of studies have investigated risk factors and comorbidities of ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) in various trauma exposed samples, few studies have been conducted in military samples. Existing studies with military samples have included rather small samples. The aim of the present study was to identify risk factors and comorbidities of ICD-11 PTSD and CPTSD in a large sample of previously deployed, treatment-seeking soldiers and veterans. METHODS: Previously deployed, treatment-seeking Danish soldiers and veterans (N = 599), recruited from the Military Psychology Department of the Danish Defense, completed the International Trauma Questionnaire (ITQ), as well as questionnaires of common mental health difficulties, trauma exposure, functioning and demographics. Multivariate multinomial logistic regression analysis explored differences in self-reported exposure to adversity and health outcomes between those meeting ICD-11 criteria for probable PTSD, CPTSD and no trauma disorder. RESULTS: A total of 13.0% met probable ICD-11 criteria for PTSD and 31.4% for CPTSD. Risk factors for CPTSD (compared to those with no trauma disorder) included exposure to warfare or combat, longer duration since the traumatic event and being single. Those with CPTSD were more likely than those with PTSD or no trauma disorder to endorse symptoms of depression, anxiety, stress, use of psychotropic medication, and suicide attempts. CONCLUSION: CPTSD is a more common and debilitating condition compared to PTSD in treatment-seeking soldiers and veterans. Further research should focus on testing existing and novel interventions for CPTSD in the military.

Changes in perceived social support and PTSD symptomatology among Danish army military personnel.

PURPOSE: Previous research has identified social support to be associated with risk of posttraumatic stress disorder (PTSD) symptoms among military personnel. While the lack of social support influences PTSD symptomatology, it is unknown how changes in perceived social support affect the PTSD symptom level in the aftermath of deployment. Furthermore, the influence of specific sources of social support from pre- to post-deployment on level of PTSD symptoms is unknown. We aim to examine how changes in perceived social support (overall and from specific sources) from pre- to 2.5 year post-deployment are associated with the level of post-deployment PTSD symptoms. METHODS: Danish army military personnel deployed to Afghanistan in 2009 and 2013 completed questionnaires at pre-deployment and at 2.5 year post-deployment measuring perceived social support and PTSD symptomatology and sample characteristics of the two cohorts. Data were analyzed using univariate and multivariate nominal logistic regression. RESULTS: Negative changes in perceived social support from pre- to post-deployment were associated with both moderate (OR 1.99, CI 1.51-2.57) and high levels (OR 2.71, CI 1.94-3.78) of PTSD symptoms 2.5 year post-deployment (adjusted analysis). Broadly, the same direction was found for specific sources of social support and level of PTSD symptoms. In the adjusted analyses, pre-deployment perceived social support and military rank moderated the associations. CONCLUSIONS: Deterioration in perceived social support (overall and specific sources) from pre- to 2.5 year post-deployment increases the risk of an elevated level of PTSD symptoms 2.5 year post-deployment.

Combat Exposure and Risk of Suicide Attempt Among Danish Army Military Personnel.

Objective: The aim of this study was to estimate the association between self-reported perceived danger during deployment, measured as combat exposure or witnessing the consequences of war, and post-deployment suicide attempts among military personnel. Furthermore, the effect of post-deployment symptoms of posttraumatic stress disorder (PTSD) and/or depression on the risk of suicide attempts was also evaluated.Methods: This observational cohort study included Danish Army military personnel who returned from deployment in international missions from 1998 to 2016 and had completed a post-deployment questionnaire. Perceived exposure to danger was ascertained by self-report. Data on suicide attempt were retrieved from national registers. Adjusted Cox regression analyses were used to evaluate if military personnel indicating high level of combat exposure were more likely to have attempted suicides post-deployment than military personnel with lower levels of combat exposure.Results: Eighty-three suicide attempts were registered after homecoming among 12,218 military personnel. Perceived higher exposure to combat was associated with the risk of suicide attempt (hazard ratio = 1.08; 95% CI, 1.01-1.16). Furthermore, the association between combat exposure and suicide attempt was fully mediated by post-deployment symptoms of PTSD and/or depression. No association was found between witnessing consequences of war and the risk of post-deployment suicide attempt.Conclusions: This nationwide study found that combat exposure was associated with an increased risk of suicide attempt among military personnel. This association was, however, fully mediated by mental disorders (PTSD and/or depression). These findings suggest that better psychological follow-up of military personnel identified as having PTSD and/or depression may be warranted.

PTSD and complex PTSD in treatment-seeking Danish soldiers: a replication of Folke et al. (2019) using the International Trauma Questionnaire.

Background: While empirical support for the ICD-11 distinction between posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) is growing, empirical research into the ICD-11 model of CPTSD in military populations is scarce and inconsistent. Objective: To replicate a study from our own group identifying distinct classes based on CPTSD symptoms using the International Trauma Questionnaire (ITQ) and to identify predictors and functional outcomes associated with a potential distinction between PTSD and CPTSD. Method: Formerly deployed treatment-seeking Danish soldiers (N = 294) completed the ITQ and self-report measures of traumatic life events prior to treatment. Latent profile analysis (LPA) was used to extract classes based on CPTSD symptoms. Results: LPA revealed four classes; (1) high CPTSD symptoms ('CPTSD', 28.7%); (2) high PTSD symptoms and lower DSO symptoms ('PTSD', 23.5%); (3) high DSO symptoms ('DSO', 17.3%); and (4) low symptoms ('Low Symptoms', 30.5%). In comparison to the PTSD-class, CPTSD-class membership was not predicted by traumatic events in adult life and in childhood. The CPTSD class was more often single/divorced/widowed compared to the PTSD class. Moreover, the CPTSD class more often used psychotropic medicine compared to the DSO-class and Low Symptoms-class. Conclusion: Using the ITQ, this study yields empirical support for the ICD-11 model of CPTSD within a clinical sample of veterans. The results replicate findings from our previous study that also identified distinct profiles of ICD-11 PTSD and CPTSD.

Antecedentes: Si bien, el soporte empírico de la clasificación de la CIE-11 para la distinción entre el trastorno de estrés postraumático (TEPT) y TEPT complejo (TEPTC) está creciendo, la investigación empírica sobre el modelo del TEPTC según la CIE-11 en poblaciones militares es escasa e inconsistente.Objetivo: Replicar un estudio de nuestro propio grupo identificando distintas clases basadas en los síntomas del TEPTC utilizando el Cuestionario Internacional de Trauma (ITQ por sus siglas en inglés) e identificar los predictores y las consecuencias funcionales asociadas a una posible distinción entre TEPT y TEPTC.Método: Los soldados daneses que estuvieron en despliegue y en búsqueda de tratamiento (N= 294) completaron el cuestionario de la ITQ y medidas de auto-reporte en relación a eventos traumáticos a lo largo de la vida antes del tratamiento. Se utilizó el análisis de perfil latente (APL) para extraer clases basadas en los síntomas del TEPTC.Resultados: El APL reveló cuatro clases; (1) síntomas elevados de TEPTC ('TEPTC', 28.7%); (2) síntomas elevados de TEPT y síntomas más bajos de Alteraciones en la Auto-Organización (DSO por sus siglas en inglés) ('TEPT', 23.5%); (3) síntomas elevados de DSO ('DSO', 17.3%); y (4) síntomas bajos ('Síntomas bajos', 30.5%). En comparación con la clase de TEPT, la afiliación a la clase del TEPTC no estuvo predicha por eventos traumáticos en la adultez y en la infancia. La clase TEPTC era más frecuentemente soltero/divorciado/viudo, en comparación con la clase TEPT. Además, la clase TEPTC utilizó con mayor frecuencia medicamentos psicotrópicos en comparación con la clase DSO y la clase de Síntomas bajos.Conclusiones: Utilizando el cuestionario ITQ, este estudio proporciona apoyo empírico para el modelo de TEPTC de la CIE-11 dentro de una muestra clínica de veteranos. Los resultados replican los hallazgos de nuestro estudio anterior, que tambien identificó distintos perfiles de TEPT y TEPTC según la clasificación de la CIE-11.

Measuring Social Support among Soldiers with the Experienced Post-Deployment Social Support Scale (EPSSS): A Rasch-Based Construct Validity Study.

Perceived social support following deployment is a known buffer against post-deployment adverse mental health outcomes. Given contextual sensitivity of social support measures, scales that address specific social support needs of soldiers in the first months after home coming should be developed and validated. In a sample of 553 soldiers deployed to Afghanistan at two different time points (2009 and 2013, respectively), we selected items for and tested the construct validity of an 8-item measure of experienced post-deployment social support (experienced post-deployment social support scale; EPSSS). Within the item response theory framework, we used Rasch models (RM) to conduct item analysis with an emphasis on testing for differential item functioning (DIF) across background variables such as previous deployments and cohort. In short, we found that the scale did not fit the Rasch model, but with exclusion of two items, a 6-item version of the scale did fit an extended graphical loglinear Rasch model (GLLRM) with only one instance of DIF, for which the score can be adjusted. We also demonstrated that when applied as a scale, the DIF will not affect the results substantially. Hence, we conclude that the constructed 6-item EPSSS can be validly applied without score correction to assess the level of social support in Danish soldiers after home coming.

Effect of Predeployment Psychiatric Diagnoses on Postdeployment Long-Term Sickness Absence and Mental Health Problems Among Danish Military Personnel.

Military personnel may withhold information on mental health problems (MHPs) for fear of not being permitted to deploy. Past or current MHPs may, however, increase the risk of postdeployment MHPs. Using psychiatric diagnoses rather than self-report assessments in predeployment screening may be a more effective screening strategy for determining deployment fitness. This retrospective follow-up study investigated (a) the extent to which predeployment childhood and adult psychiatric diagnoses predicted postdeployment MHPs, measured as psychiatric diagnosis and the purchase of psychiatric drugs, and long-term sickness absence among formerly deployed Danish military personnel and (b) whether perceived combat exposure moderated or mediated the effect of predeployment psychiatric diagnoses. Complete data were available for 7,514 Danish military personnel who answered questions on perceived combat exposure between 6-8 months after returning from their first deployment to the Balkans, Iraq, or Afghanistan. Data on all psychiatric diagnoses given at Danish hospitals, all medicine purchases, and all sickness absences were retrieved from nationwide research registers. Personnel with predeployment psychiatric diagnoses had a statistically significant higher risk for both postdeployment long-term sickness absence, hazard ratio (HR) = 2.06, 95% CI [1.52, 2.80]; and postdeployment MHPs, HR = 2.38, 95% CI [1.73, 3.27], than personnel without a predeployment psychiatric diagnosis. Personnel with a predeployment psychiatric diagnosis demonstrated a higher risk of reporting high levels of perceived combat exposure. Perceived combat exposure was not found to moderate or mediate the effect of a predeployment psychiatric diagnosis on the two outcomes. Additional findings, limitations, and implications are discussed.

Trajectories of depression symptoms from pre- to post- deployment: Does previous trauma predict symptom increase?

BACKGROUND: A significant minority of individuals experience depression following military deployment. The course of depression symptoms varies over time and across individuals; several factors including combat exposure influence depressions incidence and course. Importantly, previous trauma, especially in childhood, have been found increase the risk of post-deployment depression. METHODS: In a prospective sample of 530 soldiers deployed to Afghanistan in 2009, we used latent growth mixture modeling (LGMM) to estimate trajectories of depression symptoms from before through 6.5 years after deployment. In a multinomial logistic regression model, we tested if childhood and adult life trauma predicted trajectory membership in combination with combat exposure and neuroticism. RESULTS: We identified a large trajectory of few depression symptoms from before through 6.5 years after deployment (Low-stable, 86.5%), a trajectory with somewhat elevated symptoms (Medium-fluctuating, 4.0%), and a trajectory with few symptoms before deployment and a steep increase to a severe symptom level 6.5 years after deployment (Low-increasing, 9.4%). The Low-increasing trajectory was predicted by lower rank and childhood trauma, while the Medium-fluctuating trajectory was predicted by neuroticism, adult life trauma, and post-deployment PTSD symptoms. LIMITATIONS: Attrition and use of self-report measures for depression and trauma. CONCLUSIONS: Depression symptoms follow a heterogeneous course from before through 6.5 years after deployment with 9.4% experiencing symptom increase, resulting in severe symptoms 6.5 years after deployment. Trajectories are differentially predicted by rank, childhood and adult life trauma as well as neuroticism and PTSD symptoms, illustrating the clinical importance of taking individual differences of symptom course into account.

ICD-11 PTSD and complex PTSD in treatment-seeking Danish veterans: a latent profile analysis.

Background: The WHO International Classification of Diseases, 11th version (ICD-11), includes a trauma-related diagnosis of complex posttraumatic stress disorder (CPTSD) distinct from posttraumatic stress disorder (PTSD). Results from previous studies support the validity of this distinction. However, no studies to date have evaluated the ICD-11 model of PTSD and CPTSD in treatment-seeking military veterans. Objective: To determine if the distribution of symptoms in treatment-seeking Danish veterans was consistent with the ICD-11 PTSD and CPTSD symptom profiles. Based on previous studies, we hypothesized that separate classes representing PTSD and CPTSD would be found that membership of a potential CPTSD-class would be predicted by a larger number of childhood traumas, and that a potential distinction between PTSD and CPTSD would be supported by differences in sociodemographic and functional outcomes. Method: Participants (N = 1,541) were formerly deployed Danish soldiers who completed proxy measures of ICD-11 PTSD and disturbances in self-organization (DSO) symptoms, along with self-report measures of traumatic life events, prior to starting treatment at the Military Psychology Department of the Danish Defence. Results: All hypotheses were supported. Latent profile analysis (LPA) revealed separate classes representing PTSD and CPTSD. In comparison to the PTSD-class, membership of the CPTSD-class was predicted by more childhood traumatic experiences, and members of this class were more likely being single/divorced/widowed and more likely to use psychotropic medication. Besides a PTSD-class and a CPTSD-class, LPA revealed a Low Symptoms-class, a Moderate DSO-class, a Hyperarousal-class, and a High DSO-class, with clear differences in functional outcomes between classes. Conclusion: Findings replicate previous studies supporting the distinction between ICD-11 PTSD and CPTSD. In addition, there seem to be groups of treatment-seeking military veterans that do not fulfil full criteria for a trauma-related disorder. Further research should explore subsyndromal PTSD and CPTSD profiles in veterans and other populations.

Antecedentes: La Clasificación Internacional de Enfermedades de la OMS, 11ª versión (CIE-11), incluye un diagnóstico relacionado con el trauma para el trastorno de estrés postraumático complejo (TEPT-C) distinto del trastorno de estrés postraumático (TEPT). Los resultados de los estudios anteriores respaldan la validez de esta distinción. Sin embargo, ningún estudio hasta la fecha ha evaluado el modelo CIE-11 del TEPT y TEPT-C en veteranos militares en busca de tratamiento.Objetivo: Determinar si la distribución de los síntomas en los veteranos daneses en busca tratamiento fue consistente con los perfiles de los síntomas del TEPT y TEPT-C de la CIE-11. Basados en estudios previos, planteamos la hipótesis de que se encontrarían clases separadas que representan el TEPT y TEPT-C, que la pertenencia a la clase potencial del TEPT-C sería predicha por un mayor número de traumas infantiles, y que una posible distinción entre el TEPT y TEPT-C sería apoyada por las diferencias en los resultados sociodemográficos y funcionales.Método: Los participantes (N = 1,541) fueron soldados daneses desplegados anteriormente, que completaron medidas indirectas del TEPT CIE-11 y la alteración en los síntomas de autoorganización (DSO en su sigla en inglés), junto con medidas de autoinforme de los eventos traumáticos de la vida, antes de comenzar el tratamiento en el Departamento de Psicología Militar de la Defensa Danesa.Resultados: Todas las hipótesis fueron sustentadas. El análisis de perfil latente (APL) reveló clases separadas que representan el TEPT y TEPT-C. En comparación con la clase del TEPT, la pertenencia a la clase del TEPT-C fue predicha por más experiencias traumáticas infantiles, y los miembros de esta clase eran más propensos a ser solteros/divorciados/viudos y más propensos a usar medicamentos psicotrópicos. Además de una clase del TEPT y una clase del TEPT-C, el APL reveló una clase de Síntomas Bajos, una clase de DSO Moderado, una clase de Hiperactivación y una clase de DSO Alto, con claras diferencias en los resultados funcionales entre las clases.Conclusión: Los resultados replican los estudios previos que respaldan la distinción entre el TEPT y TEPT-C del CIE-11. Adicionalmente, parece haber grupos de veteranos militares en busca de tratamiento que no cumplen con los criterios completos para un trastorno relacionado con el trauma. Los estudios futuros deben explorar los perfiles del TEPT y TEPT-C sub-sindrómico en veteranos y otras poblaciones.

Perceived danger during deployment: a Rasch validation of an instrument assessing perceived combat exposure and the witnessing of combat consequences in a war zone.

The potential stressors associated with military deployment are related to an increased risk of adverse mental health outcomes. Perceived exposure to combat has been found to be proportional to the severity of post-deployment posttraumatic stress disorder (PTSD). However, other perceived adversities during deployment, such as witnessing danger, distress, and hardship in the war zone, have been less systematically studied, but might play an equally substantial role for post-deployment mental health. The development and validation of scales that assess these related constructs are needed to distinguish their contribution to post-deployment risk of PTSD. We evaluated the validity of 10 items measuring perceived danger distributed to all deployed personnel with the Danish Defense since 1998. We hypothesize two scales: Exposure to Danger and Combat (EDC) and Witnessing Consequences of War (WCW). Two military cohorts deployed to Afghanistan in 2009 (Cohort 1, N = 276) and 2013 (Cohort 2, N = 273) were included. Questionnaire data was collected six months after homecoming, including deployment experiences and post-deployment reactions. We tested the construct validity of the 10 items of perceived danger with Rasch models (RM), focusing specifically on presence of subscales, and differential item functioning (DIF) across cohorts. We confirmed the existence of two separate subscales, EDCS and WCWS, both with adequate reliability. None of the subscales fitted a pure RM, but adequate fit was found for graphical log-linear RMs with evidence of DIF for the ECDS. However, adjusting the score to account for DIF had practically no effect, suggesting that the total non-adjusted mean score can be used in future cohort comparisons. Perceived exposure to combat and danger and witnessing consequences of war are related, but essentially distinct, concepts, each providing unique information about deployment adversities. Future studies should evaluate their shared and unique contribution to the risk of post-deployment PTSD.

La percepción de exposición al combate ha resultado ser proporcional a la severidad del trastorno por estrés post-traumático (TEPT) posterior al despliegue militar. Sin embargo, otras adversidades percibidas durante el despliegue, tales como experimentar peligro, angustia, y dificultades en la zona de guerra, han sido menos sistemáticamente estudiadas, pero podrían jugar un rol sustancialmente equivalente para el impacto en la salud mental posterior al despliegue militar. Se requiere desarrollar y validar escalas que evalúen estos constructos relacionados para distinguir su contribución al riesgo de desarrollar TEPT posterior al despliegue. El objetivo es evaluar la validez de 10 ítems que miden el peligro percibido distribuido a todo el personal desplegado con la Defensa Danesa desde 1998. Se hipotetizan dos escalas; Exposición a Peligro y Combate (EDC) y Exposición a Consecuencias de Guerra (WCW). Se incluyó a dos cohortes militares, que se desplegaron en Afganistán el año 2009 (Cohorte 1, N=276), y el 2013 (Cohorte 2, N=273). Se recopiló datos a partir de cuestionarios seis meses después de regreso al país de origen, incluyendo experiencias dentro del despliegue y reacciones posteriores a éste. Se probó en las cohortes la validez de constructo de los 10 ítems de peligro percibido con modelos Rasch (RM), poniendo especial énfasis en la presencia de subescalas, e Ítem de funcionamiento diferencial (DIF). Se confirmó la existencia de dos subescalas separadas, EDC y WCW, ambas con fiabilidad adecuada. Ninguna de las subescales correspondía a un modelo Rasch puro, pero sí se encontró una relación adecuada para un modelo Rasch logarítmico-lineal con evidencia de DIF para EDC. No obstante, el ajustar el puntaje para explicar el IFD prácticamente no tuvo efectos, sugiriendo que la puntuación media total no ajustada puede ser utilizada en futuras comparaciones de cohortes. La exposición percibida al combate y el peligro y exposición a consecuencias de guerra son dos conceptos relacionados, pero esencialmente distintos, cada uno proveyendo información única sobre los efectos adversos del despliegue militar. Futuros estudios deberían evaluar su contribución compartida y única al riesgo de desarrollar TEPT posterior al despliegue militar.

Replicability and Generalizability of Posttraumatic Stress Disorder (PTSD) Networks: A Cross-Cultural Multisite Study of PTSD Symptoms in Four Trauma Patient Samples.

The growing literature conceptualizing mental disorders like posttraumatic stress disorder (PTSD) as networks of interacting symptoms faces three key challenges. Prior studies predominantly used (a) small samples with low power for precise estimation, (b) nonclinical samples, and (c) single samples. This renders network structures in clinical data, and the extent to which networks replicate across data sets, unknown. To overcome these limitations, the present cross-cultural multisite study estimated regularized partial correlation networks of 16 PTSD symptoms across four data sets of traumatized patients receiving treatment for PTSD (total N = 2,782). Despite differences in culture, trauma type, and severity of the samples, considerable similarities emerged, with moderate to high correlations between symptom profiles (0.43-0.82), network structures (0.62-0.74), and centrality estimates (0.63-0.75). We discuss the importance of future replicability efforts to improve clinical psychological science and provide code, model output, and correlation matrices to make the results of this article fully reproducible.

Does size really matter? A multisite study assessing the latent structure of the proposed ICD-11 and DSM-5 diagnostic criteria for PTSD.

Background: Researchers and clinicians within the field of trauma have to choose between different diagnostic descriptions of posttraumatic stress disorder (PTSD) in the DSM-5 and the proposed ICD-11. Several studies support different competing models of the PTSD structure according to both diagnostic systems; however, findings show that the choice of diagnostic systems can affect the estimated prevalence rates. Objectives: The present study aimed to investigate the potential impact of using a large (i.e. the DSM-5) compared to a small (i.e. the ICD-11) diagnostic description of PTSD. In other words, does the size of PTSD really matter? Methods: The aim was investigated by examining differences in diagnostic rates between the two diagnostic systems and independently examining the model fit of the competing DSM-5 and ICD-11 models of PTSD across three trauma samples: university students (N = 4213), chronic pain patients (N = 573), and military personnel (N = 118). Results: Diagnostic rates of PTSD were significantly lower according to the proposed ICD-11 criteria in the university sample, but no significant differences were found for chronic pain patients and military personnel. The proposed ICD-11 three-factor model provided the best fit of the tested ICD-11 models across all samples, whereas the DSM-5 seven-factor Hybrid model provided the best fit in the university and pain samples, and the DSM-5 six-factor Anhedonia model provided the best fit in the military sample of the tested DSM-5 models. Conclusions: The advantages and disadvantages of using a broad or narrow set of symptoms for PTSD can be debated, however, this study demonstrated that choice of diagnostic system may influence the estimated PTSD rates both qualitatively and quantitatively. In the current described diagnostic criteria only the ICD-11 model can reflect the configuration of symptoms satisfactorily. Thus, size does matter when assessing PTSD.

Planteamiento: Los investigadores y clínicos del campo del trauma pronto decidirán entre dos descripciones diagnósticas diferentes del trastorno de estrés postraumático (TEPT) en el DSM-5 y la propuesta CIE-11. Varios estudios apoyan diferentes modelos en competencia sobre la estructura del TEPT en función de ambos sistemas de diagnóstico; sin embargo, los resultados demuestran que la elección de los sistemas de diagnóstico puede afectar las tasas de prevalencia estimadas. Objetivos: y métodos. El presente estudio tenía como objetivo investigar el impacto potencial de usar una descripción del TEPT amplia (es decir, el DSM-5) en comparación con una pequeña (es decir, la CIE-11). En otras palabras, ¿el tamaño del TEPT importa realmente? El objetivo se investigó mediante el examen de las diferencias en las frecuencias de diagnóstico entre los dos sistemas de diagnóstico y examinando de forma independiente cómo se ajustaban los modelos en competencia para el TEPT del DSM-5 y la CIE-11 en tres muestras de trauma: estudiantes universitarios (N = 4213), pacientes con dolor crónico (N = 573) y personal militar (N = 118). Resultados: Las tasas diagnósticas del TEPT fueron significativamente más bajas según los criterios de la propuesta CIE-11 en la muestra universitaria, pero no se encontraron diferencias significativas para los pacientes con dolor crónico y el personal militar. El modelo de tres factores propuesto por la CIE-11 proporcionó el mejor ajuste de los modelos de la CIE-11 que fueron probados en todas las muestras. En cambio, el modelo híbrido de siete factores del DSM-5 proporcionó el mejor ajuste en las muestras universitaria y del dolor, y el modelo de Anhedonia de seis factores del DSM-5 en la muestra militar de los modelos probados del DSM-5. Conclusiones: Se pueden debatir las ventajas y desventajas de utilizar un conjunto amplio o reducido de síntomas para el TEPT; sin embargo, este estudio demostró que la elección del sistema de diagnóstico puede influir en las tasas estimadas del TEPT, tanto cualitativa como cuantitativamente. Al mismo tiempo, parece que, dados los criterios diagnósticos descritos actualmente, solo el modelo de la CIE-11 puede reflejar satisfactoriamente la configuración de los síntomas. Por lo tanto, el tamaño importa cuando se evalúa el TEPT.

Cognitive ability and risk of post-traumatic stress disorder after military deployment: an observational cohort study.

BACKGROUND: Studies of the association between pre-deployment cognitive ability and post-deployment post-traumatic stress disorder (PTSD) have shown mixed results. AIMS: To study the influence of pre-deployment cognitive ability on PTSD symptoms 6-8 months post-deployment in a large population while controlling for pre-deployment education and deployment-related variables. METHOD: Study linking prospective pre-deployment conscription board data with post-deployment self-reported data in 9695 Danish Army personnel deployed to different war zones in 1997-2013. The association between pre-deployment cognitive ability and post-deployment PTSD was investigated using repeated-measure logistic regression models. Two models with cognitive ability score as the main exposure variable were created (model 1 and model 2). Model 1 was only adjusted for pre-deployment variables, while model 2 was adjusted for both pre-deployment and deployment-related variables. RESULTS: When including only variables recorded pre-deployment (cognitive ability score and educational level) and gender (model 1), all variables predicted post-deployment PTSD. When deployment-related variables were added (model 2), this was no longer the case for cognitive ability score. However, when educational level was removed from the model adjusted for deployment-related variables, the association between cognitive ability and post-deployment PTSD became significant. CONCLUSIONS: Pre-deployment lower cognitive ability did not predict post-deployment PTSD independently of educational level after adjustment for deployment-related variables. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Assessment of depression in veterans across missions: a validity study using Rasch measurement models.

Background: Depression is a common psychopathological outcome following military deployment. Previous studies have reported differing rates of post-deployment depression, indicating that the toll of war differs across missions. However, it is unclear to what degree the varying prevalence is due methodological differences. Studies comparing rates of depression across cohorts using the same methodology and ensuring measurement invariance are rare, leaving us with limited knowledge on the actual depression prevalence variance across missions. Objective: Applying Rasch models (RM), we aim to validate a measure of depression distributed to all personnel deployed with the Danish Defense since 1998. The main focus was establishing a sufficient sum score and measurement invariance relative to deployment cohort. Method: Two cohorts of the International Security Assistance Force (ISAF) deployed to Afghanistan in 2009 (ISAF7, N = 265) and 2013 (ISAF15, N = 271) were included. Participants filled out a questionnaire concerning their Psychological Reactions to International Missions (PRIM) approximately seven months after home-coming. The questionnaire included a 10-item scale of depression symptoms (PRIM-Depression). The validity of the PRIM-Depression was tested using RM with specific focus on differential item functioning (DIF) across the two cohorts. Results: The PRIM-Depression scale displayed excellent overall consistency and showed no problems with monotonicity or homogeneity. However, the full PRIM-Depression scale did not fit a pure RM. We therefore tested the fit of items to a graphical log-linear RM and found evidence of DIF for two items relative to cohort. We proceeded without these two items and tested the resulting 8-item version which fitted a pure RM without DIF on any of the exogenous variables. Conclusions: Our results suggest that the 10-item PRIM-Depression scale should be used to compare cohorts only with appropriate score equation. The 8-item version provides a sufficient statistic and can as such be applied using the raw score.

Assessing PTSD in the military: Validation of a scale distributed to Danish soldiers after deployment since 1998.

Since 1998, soldiers deployed to war zones with the Danish Defense (≈31,000) have been invited to fill out a questionnaire on post-mission reactions. This provides a unique data source for studying the psychological toll of war. Here, we validate a measure of PTSD-symptoms from the questionnaire. Soldiers from two cohorts deployed to Afghanistan with the International Security Assistance Force (ISAF) in 2009 (ISAF7, N = 334) and 2013 (ISAF15, N = 278) filled out a standard questionnaire (Psychological Reactions following International Missions, PRIM) concerning a range of post-deployment reactions including symptoms of PTSD (PRIM-PTSD). They also filled out a validated measure of PTSD-symptoms in DSM-IV, the PTSD-checklist (PCL). We tested reliability of PRIM-PTSD by estimating Cronbach's alpha, and tested validity by correlating items, clusters, and overall scale with corresponding items in the PCL. Furthermore, we conducted two confirmatory factor analytic models to test the factor structure of PRIM-PTSD, and tested measurement invariance of the selected model. Finally, we established a screening and a clinical cutoff score by application of ROC analysis. We found high internal consistency of the PRIM-PTSD (Cronbach's alpha = 0.88; both cohorts), strong item-item (0.48-0.83), item-cluster (0.43-0.72), cluster-cluster (0.71-0.82) and full-scale (0.86-0.88) correlations between PRIM-PTSD and PCL. The factor analyses showed adequate fit of a one-factor model, which was also found to display strong measurement invariance across cohorts. ROC curve analysis established cutoff scores for screening (sensitivity = 1, specificity = 0.93) and clinical use (sensitivity = 0.71, specificity = 0.98). In conclusion, we find that PRIM-PTSD is a valid measure for assessing PTSD-symptoms in Danish soldiers following deployment.

The impact of gender on the long-term morbidity and mortality of patients with type 2 diabetes receiving structured personal care: a 13 year follow-up study.

AIMS/HYPOTHESIS: The aim of this study was to assess gender differences in mortality and morbidity during 13 follow-up years after 6 years of structured personal care in patients with type 2 diabetes mellitus. METHODS: In the Diabetes Care in General Practice (DCGP) multicentre, cluster-randomised, controlled trial (ClinicalTrials.gov registration no. NCT01074762), 1,381 patients newly diagnosed with type 2 diabetes were randomised to receive 6 years of either structured personal care or routine care. The intervention included regular follow-up, individualised goal setting and continuing medical education of general practitioners participating in the intervention. Patients were re-examined at the end of intervention. This observational analysis followed 970 patients for 13 years thereafter using national registries. Outcomes were all-cause mortality, incidence of diabetes-related death, any diabetes-related endpoint, myocardial infarction, stroke, peripheral vascular disease and microvascular disease. RESULTS: In women, but not men, a lower HR for structured personal care vs routine care emerged for any diabetes-related endpoint (0.65, p = 0.004, adjusted; 73.4 vs 107.7 events per 1,000 patient-years), diabetes-related death (0.70, p = 0.031; 34.6 vs 45.7), all-cause mortality (0.74, p = 0.028; 55.5 vs 68.5) and stroke (0.59, p = 0.038; 15.6 vs 28.9). This effect was different between men and women for diabetes-related death (interaction p = 0.015) and all-cause mortality (interaction p = 0.005). CONCLUSIONS/INTERPRETATION: Compared with routine care, structured personal diabetes care reduced all-cause mortality and diabetes-related death in women but not in men. This gender difference was also observed for any diabetes-related outcome and stroke but was not statistically significant after extensive multivariate adjustment. These observational results from a post hoc analysis of a randomised controlled trial cannot be explained by intermediate outcomes like HbA1c alone, but involves complex social and cultural issues of gender. There is a need to rethink treatment schemes for both men and women to gain benefit from intensified treatment efforts.

An intervention with access to C-reactive protein rapid test reduces antibiotic overprescribing in acute exacerbations of chronic bronchitis and COPD.

BACKGROUND: In acute exacerbation of chronic obstructive pulmonary disease (AECOPD) antibiotic overprescribing leads to antimicrobial resistance and underprescribing may cause poor patient outcomes. OBJECTIVE: This study aimed to evaluate changes in over- and underprescribing of antibiotics after two interventions to optimize antibiotic prescribing in AECOPD in Spain. METHODS: In 2008 and 2009, general practitioners (GPs) registered patients in a 3-week period before and after interventions. Two types of intervention were conducted: GPs in the full-intervention group (FIG) were exposed to a multifaceted intervention and given access to C-reactive protein (CRP) rapid test; partial-intervention group (PIG) was only exposed to the multifaceted intervention. Overprescribing was defined as antibiotic given to type III* exacerbation (≤ one Anthonisen Criteria); underprescribing was defined as no antibiotic given to type I exacerbation (three Anthonisen Criteria). A multivariate logistic regression model was used, considering antibiotic prescribing as the dependent variable. RESULTS: A total of 210 GPs and 70 GPs were assigned to FIG and PIG, respectively, and 952 AECOPD patients were eligible for main analysis. After adjusting for clustering at GP level and for patient age and sex, we found that GPs in FIG significantly reduced antibiotic overprescribing; odds ratio (OR) = 0.35 (95% CI: 0.18-0.68, P = 0.003) and underprescribing was not significantly increased; OR = 0.25 (95% CI: 0.06 to 1.0, P = 0.075). No statistically significant changes were found in the PIG. CONCLUSION: Antibiotic overprescribing was only reduced when CRP test was available. Simultaneously, underprescribing was not significantly increased, but this could be due to sample size limitations.

The predictive value of self-rated health in the presence of subjective memory complaints on permanent nursing home placement in elderly primary care patients over 4-year follow-up.

BACKGROUND: self-rated health (SRH) predicts nursing home (NH) placement; subjective memory complaints (SMC) too. However, the predictive value of SRH in the presence of SMC is unclear. METHODS: seven-hundred fifty-seven non-nursing home residents ≥65 years from general practices in Central Copenhagen were followed for 4 years (2002-2006). Patients gave information on SRH, cognition (SMC and MMSE), quality of life (EQ-5D) and socio-demographics. Information on comorbidities and permanent NH placement came from registries. The association between SRH (dichotomised into good versus poor) and SMC, and permanent NH placement was assessed using Cox proportional hazard regression adjusted for potential confounders. RESULTS: NH placement totaled 6.5% at 4-year follow-up. Poor SRH increased NH placement [hazard ratio (HR) = 2.07, 95% CI: 1.11-3.87] adjusted for age, SMC, MMSE, sex and comorbidities. SRH was not associated with NH placement if accounting for additional health information; however, SMC was (HR = 2.47, 95% CI: 1.26-4.86). Increased placement was seen for patients with good SRH and SMC (HR = 6.64, 95% CI: 2.31-19.12), but not among patients with poor SRH and SMC (HR = 1.37, 95% CI: 0.59-3.20) when compared with the reference group (good SRH and without SMC). CONCLUSIONS: both poor SRH and SMC were associated with permanent NH placement risk among elderly primary care patients. However, when SMC was present a reverse association was found for SRH: good SRH increased NH placement. Since SRH is integrated in widely used psychometric instruments, further research is needed to establish the mechanism and implications of this finding.

The relationship between HbA1c level, symptoms and self-rated health in type 2 diabetic patients.

OBJECTIVE: Improving glycaemic control is generally supposed to reduce symptoms experienced by type 2 diabetic patients, but the relationships between glycated haemoglobin (HbA(1c)), diabetes-related symptoms, and self-rated health (SRH) are unclarified. This study explored the relationships between these aspects of diabetes control. DESIGN: A cross-sectional study one year after diagnosis of type 2 diabetes. SUBJECTS: A population-based sample of 606 type 2 diabetic patients, median age 65.6 years at diagnosis, regularly reviewed in primary care. MAIN OUTCOME MEASURES: The relationships between HbA(1c), diabetes-related symptoms, and SRH. RESULTS: The patients' median HbA(1c) was 7.8 (reference interval: 5.4-7.4 % at the time of the study). 270 (45.2%) reported diabetes-related symptoms within the past 14 days. SRH was associated with symptom score (γ = 0.30, p < 0.001) and HbA(1c) (γ = 0.17, p = 0.038) after correction for covariates. The relation between HbA(1c) and symptom score was explained by SRH together with other confounders, e.g. hypertension (γ = 0.02, p = 0.40). The relation between the symptom fatigue and SRH was not explained by symptom score and significantly modified the direct association between symptom score and SRH. CONCLUSIONS: Symptom relief may not occur even when HbA(1c) level is at its lowest average level in the natural history of diabetes, and symptoms and SRH are closely linked. Monitoring symptoms in the clinical encounter to extend information on disease severity, as measured e.g. by HbA(1c), may help general practitioners and patients to understand the possible impact of treatments and of disease manifestations in order to obtain optimum disease control.

Self-rated health in patients with mild Alzheimer's disease: baseline data from the Danish Alzheimer Intervention Study.

In both epidemiological studies and in clinical trials the patients' own health perception, self-rated health (SRH), measured by a single question, is frequently used as an overall health assessment. Researchers have been encouraged to examine ways of assessing SRH in cognitively impaired persons, but the validity and the influence on other factors on SRH among cognitively impaired persons remain unknown. This study reports how patients with mild Alzheimer's disease (AD) report SRH and which factors influence SRH. The study was based on baseline data from 321 home living patients with mild AD who participated in the Danish Alzheimer Intervention Study (DAISY). Analysis using the generalized estimating equation (GEE) models revealed that good/excellent SRH among patients with mild AD were associated with longer education, lack of other chronic conditions, higher scores of quality of life (QOL), lower scores of mini mental state examination (MMSE), and loss of insight in own cognitive deficits. The present results indicate that SRH reported by patients with mild AD may differ from SRH among cognitively intact persons. Further research is needed in order to establish the validity and implication of SRH in this group of patients.

Structured personal diabetes care in primary health care affects only women's HbA1c.

OBJECTIVE: Diabetic men and women differ in lifestyle and attitudes toward diabetes and may benefit differently from interventions to improve glycemic control. We explored the relation between HbA1c (A1C), sex, treatment allocation, and their interactions with behavioral and attitudinal characteristics in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: Six years after their diabetes diagnosis, a population-based sample of 874 primary care patients cluster-randomized to receive structured personal care or routine care reported lifestyle, medication, social support, diabetes-related consultations, and attitudes toward diabetes. Multivariate analyses were applied, split by sex. RESULTS: A marked intervention effect on A1C was confined to the structured personal care women. The median A1C was 8.4% in structured personal care women and 9.2% in routine care women (P < 0.0001) and 8.5% in structured personal care men and 8.9% in routine care men (P = 0.052). Routine care women had a 1.10 times higher A1C than structured personal care women, (P < 0.0001, adjusted analysis). Structured personal care women had relatively more consultations than routine care women, but neither number of consultations nor other covariates helped to explain the sex difference in A1C. Irrespective of treatment allocation, women had more adaptive attitudes toward diabetes but lacked support compared with men. CONCLUSIONS: In this study, the observed effect of structured personal care on A1C was present only among women, possibly because they were more inclined to comply with regular follow-up and had a tendency to have a more adaptive attitude toward diabetes.