Effect of massed v. standard prolonged exposure therapy on PTSD in military personnel and veterans: a non-inferiority randomised controlled trial.

BACKGROUND: A short, effective therapy for posttraumatic stress disorder (PTSD) could decrease barriers to implementation and uptake, reduce dropout, and ameliorate distressing symptoms in military personnel and veterans. This non-inferiority RCT evaluated the efficacy of 2-week massed prolonged exposure (MPE) therapy compared to standard 10-week prolonged exposure (SPE), the current gold standard treatment, in reducing PTSD severity in both active serving and veterans in a real-world health service system. METHODS: This single-blinded multi-site non-inferiority RCT took place in 12 health clinics across Australia. The primary outcome was PTSD symptom severity measured by the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) at 12 weeks. 138 military personnel and veterans with PTSD were randomised. 71 participants were allocated to SPE, with 63 allocated to MPE. RESULTS: The intention-to-treat sample included 138 participants, data were analysed for 134 participants (88.1% male, M = 46 years). The difference between the mean MPE and SPE group PTSD scores from baseline to 12 weeks-post therapy was 0.94 [95% confidence interval (CI) -4.19 to +6.07]. The upper endpoint of the 95% CI was below +7, indicating MPE was non-inferior to SPE. Significant rates of loss of PTSD diagnosis were found for both groups (MPE 53.8%, SPE 54.1%). Dropout rates were 4.8% (MPE) and 16.9% (SPE). CONCLUSIONS: MPE was non-inferior to SPE in significantly reducing symptoms of PTSD. Significant reductions in symptom severity, low dropout rates, and loss of diagnosis indicate MPE is a feasible, accessible, and effective treatment. Findings demonstrate novel methods to deliver gold-standard treatments for PTSD should be routinely considered.

Massed v. standard prolonged exposure therapy for PTSD in military personnel and veterans: 12-month follow-up of a non-inferiority randomised controlled trial.

BACKGROUND: The utilisation of massed therapy for treating posttraumatic stress disorder (PTSD) is gaining strength, especially prolonged exposure. However, it is unknown whether massed prolonged exposure (MPE) is non-inferior to standard prolonged exposure (SPE) protocols in the long term. The current study aimed to assess whether MPE was non-inferior to SPE at 12 months post-treatment, and to ascertain changes in secondary measure outcomes. METHODS: A multi-site non-inferiority randomised controlled trial (RCT) compared SPE with MPE in 12 clinics. The primary outcome was PTSD symptom severity (CAPS-5) at 12 months post-treatment commencement. Secondary outcome measures included symptoms of depression, anxiety, anger, disability, and quality of life at 12 weeks and 12 months post-treatment commencement. Outcome assessors were blinded to treatment allocation. The intention-to-treat sample included 138 Australian military members and veterans and data were analysed for 134 participants (SPE = 71, MPE = 63). RESULTS: Reductions in PTSD severity were maintained at 12 months and MPE remained non-inferior to SPE. Both treatment groups experienced a reduction in depression, anxiety, anger, and improvements in quality of life at 12 weeks and 12 months post-treatment commencement. Treatment effects for self-reported disability in the SPE group at 12 weeks were not maintained, with neither group registering significant effects at 12 months. CONCLUSIONS: The emergence of massed protocols for PTSD is an important advancement. The current study provides RCT evidence for the longevity of MPE treatment gains at 12 months post-treatment commencement and demonstrated non-inferiority to SPE. Promisingly, both treatments also significantly reduced the severity of comorbid symptoms commonly occurring alongside PTSD.

Attention-control training as an early intervention for veterans leaving the military: A pilot randomized controlled trial.

Transitioning out of the military can be a time of change and challenge. Research indicates that altered threat monitoring in military populations may contribute to the development of psychopathology in veterans, and interventions that adjust threat monitoring in personnel leaving the military may be beneficial. Australian Defence Force personnel (N = 59) transitioning from the military were randomized to receive four weekly sessions of either attention-control training or a placebo attention training. The primary outcome was symptoms of posttraumatic stress disorder (PTSD), as measured using the PTSD Checklist for DSM-5 (PCL-5) at posttreatment. Following training, participants who received attention-control training reported significantly lower levels of PTSD symptoms, Hedges' g = 0.86, 95% CI [0.37, 1.36], p = .004, and significantly improved work and social functioning, Hedges' g = 0.93, 95% CI [0.46, 1.39], p = .001, relative to those in the placebo condition. Moreover, no participants who received attention-control training worsened with regard to PTSD symptoms, whereas 23.8% of those who received the placebo attention training experienced an increase in PTSD symptoms. The preliminary findings from this pilot study add to a small body of evidence supporting attention-control training as a viable indicated early intervention approach for PTSD that is worthy of further research.

Australian veterans - Identification of mental health issues.

BACKGROUND: To ensure the early identification and effective treatment of mental health disorders in the veteran population, general practitioners (GPs) need to be aware that the traditional profile of an Australian veteran has changed, and that more than combat service can give rise to mental health issues. OBJECTIVE: This article uses findings that have emerged from research undertaken with participants from three veteran cohorts to highlight mental health issues that should be considered in general practice. DISCUSSION: GPs have a key role to play in the diagnosis and treatment of mental health issues among the veteran population for several reasons. First, mental health issues may emerge at any point during a veteran's lifespan and among any veteran cohort. Second, mental health issues may have a significant trans-generational impact on a veteran's family. Third, GPs are uniquely positioned to break down barriers to help-seeking, such as stigma. Importantly, there is a comprehensive system of support available to assist GPs in providing effective and culturally appropriate care for veterans.

The Well-Being of Australian Service Mothers.

In recent years servicewomen with dependent children have for the first time in history been deployed into conflict zones in support of Australian Defence Force operations. This represents a significant social change, and the implications of deployment on the health of these service mothers are not fully understood. Data from women who participated in the Middle East Area of Operations Census study were analyzed to compare the psychological and physical symptoms reported by service mothers with service women who had no dependent children at the time of deploying to Afghanistan and/or Iraq. Of the 921 women who were included in this analysis, 235 had dependent children and 686 had no dependent children (comparison group). Service mothers were significantly older and were more likely to have served in the Air Force than women in the comparison group. Findings demonstrate that serving mothers were not at any significantly higher risk of psychological distress, post-traumatic stress symptoms, alcohol misuse, or reporting of somatic symptoms, than women who had no dependent children. A number of possible explanations for these findings are discussed, including the healthy soldier/mother effect, support from partners and extended family members, and collegial networks.

Gambling problems predict suicidality in recently transitioned military veterans.

OBJECTIVE: This study investigated associations between gambling problems and suicidality in Australian veterans. METHODS: Data drawn from n = 3,511 Australian Defence Force veterans who had recently transitioned to civilian life. Gambling problems were assessed using the Problem Gambling Severity Index (PGSI) and suicidal ideation and behaviour were assessed using items adapted from the National Survey of Mental Health and Wellbeing. RESULTS: At-risk gambling and problem gambling were associated with increased odds of suicidal ideation [at-risk gambling: odds ratio (OR), 1.93; 95% confidence interval (CI), 1.47‒2.53; problem gambling: OR, 2.75; 95% CI 1.86‒4.06] and suicide planning or attempts (at-risk gambling: OR, 2.07; 95% CI, 1.39‒3.06; problem gambling: OR 4.22, 95% CI, 2.61‒6.81). The association with total scores on the PGSI and any suicidality was substantially reduced and became non-significant when controlling for the effects of depressive symptoms, but not financial hardship or social support. CONCLUSIONS: Gambling problems and harms are important risk factors for suicide in veterans, and should be recognised in veteran-specific suicide prevention policies and programs, along with co-occurring mental health problems. IMPLICATIONS FOR PUBLIC HEALTH: A comprehensive public health approach to reducing gambling harm should feature in suicide prevention efforts in veteran and military populations.

Problem anger in veterans and military personnel: Prevalence, predictors, and associated harms of suicide and violence.

BACKGROUND: Problem anger is increasingly identified as an important issue, and may be associated with suicidality and violence. This study investigates the relationship between problem anger, suicidality, and violence amongst veterans and military personnel. METHODS: Cross-sectional survey data from n = 12,806 military personnel and veterans were subject to analyses. These considered the weighted prevalence of problem anger, while further analyses of veterans (n = 4326) considered risk factors and co-occurrence with other psychiatric conditions. Path analyses examined inter-relationships involving anger, violence and suicidality. RESULTS: There were 30.7% of veterans and 16.4% of military personnel that reported past month problem anger, while 14.9% of veterans and 7.4% of military personnel reported physical violence. There were higher levels of suicidality among veterans (30.3%), than military personnel (14.3%). Logistic regression models indicated that PTSD was the strongest risk factor for problem anger (PCL-5, OR = 21.68), while there were small but substantial increases in anger rates associated with depression (OR = 15.62) and alcohol dependence (OR = 6.55). Path models indicated that problem anger had an influence on suicide attempts, occurring primarily through suicidal ideation, and an influence on violence. Influences of problem anger on suicidal ideation and violence remained significant when controlling for co-occurring mental health problems. CONCLUSIONS: Problem anger, violence, and suicidality are common and inter-related issues among military personnel and veterans. Problem anger is a unique correlate of suicidality, supporting the need for anger to be included as part of violence and suicide risk assessment, and clinician training.

Prevalence of gambling problems, help-seeking, and relationships with trauma in veterans.

BACKGROUND AND AIMS: Veterans who have recently left the military (i.e., transitioned) may be vulnerable to the development of psychiatric disorders, but little is known about gambling problems in this population. This study investigated the prevalence and risk factors of gambling problems, help-seeking amongst veterans with gambling problems, and relationships with trauma and posttraumatic psychopathology. METHODS: Cross-sectional self-report survey data from 3,511 Australian Defence Force members who left the military within the past five years. Surveys included measures of gambling problems (PGSI); depressive symptoms (PHQ-9); posttraumatic stress disorder (PCL-5); help-seeking behaviours; military and non-military-related trauma. RESULTS: Prevalence rates for problem gambling (PGSI ≥ 5) were 4.6%, while an additional 8.8% were classified in terms of at-risk gambling (PGSI = 1-4). Time since leaving the military was not associated with gambling problems. Only 2.1% of veterans with problem gambling reported help-seeking for their gambling. While trauma exposure, depression, and Posttraumatic Stress Disorder (PTSD) were all related to gambling problems at the bivariate level, only arousal and dysphoric-related affect were uniquely associated with gambling problems when adjusting for covariates. DISCUSSION: Gambling problems may be under-recognised relative to other psychiatric issues. Posttraumatic mental health problems, rather than trauma exposure per se, may explain the relationship between trauma and gambling problems. CONCLUSIONS: Some veterans are in a period of vulnerability during transition out of military service, and harms associated with gambling problems may be exacerbated during this period.

Massed versus standard prolonged exposure for posttraumatic stress disorder in Australian military and veteran populations (RESTORE trial): Study protocol for a non-inferiority randomized controlled trial.

Posttraumatic stress disorder (PTSD) can be a severe problem, affecting veterans and military personnel at higher rates than the general community. First-line treatment for PTSD, prolonged exposure (PE), is typically delivered weekly for 10-12 weeks, however this duration can pose a barrier to accessing and completing the treatment, particularly for current serving military. This paper presents the RESTORE trial protocol, the first randomized controlled trial of massed PE therapy outside of the United States and by an independent research group. One hundred and thirty-five Australian Defence Force members and veterans (18-80 years) who meet criteria for PTSD related to a military trauma will be randomly allocated to one of two conditions: standard PE (SPE; 10 weekly 90-min sessions) or massed PE (MPE; 10 daily 90-min sessions). Across eight sites, patients will be assessed at pre-treatment, and at 4 weeks, 12 weeks, and 12 months post-treatment commencement. The primary outcome is clinician-measured and self-reported PTSD symptom severity at the 12 week assessment. We hypothesize that MPE will be as effective as SPE in reducing PTSD severity at 12 weeks post-treatment commencement. The adaptation and testing of evidence-based interventions is critical to reduce barriers to treatment uptake among veterans and military personnel. Outcomes of this study have the potential to result in international, cross-service uptake and delivery of this rapid treatment for veterans and military members, as well as civilians, thereby improving clinical outcomes for patients and their families.

Psychosocial factors associated with psychological distress and functional difficulties in recently transitioned and current serving regular Australian Defence Force members.

The transition period from military-to-civilian life can be one of the most significant and stressful periods in the military life cycle. We explore the psychosocial factors associated with psychological distress and functional impairment among those who recently transitioned from the Australian Defence Force (ADF) and those currently serving in 2015. Using data from the Transition and Wellbeing Research Programme, multinomial logistic regression models were used to analyze the associations between a combined measure of psychological distress and functional impairment (K10/SDS) with various psychosocial, lifestyle, and physical health factors. There were 10,210 in the final analytic cohort (Transitioned=3,254; Regular 2015 ADF=6,956). Overall, the odds of belonging to the highly distressed/impaired group were greatest among those with insomnia (Odds Ratio 18.53), low resilience (OR 7.67), physical health symptoms (OR 7.16), and alcohol risk (OR 4.67). Other factors included pain (OR 3.36), financial issues (OR 2.38), and social strain (OR 1.98). The associations with insomnia and physical health symptoms were stronger among the Transitioned compared to the Regular 2015 ADF. Results of this research highlights the importance of taking a multi-dimensional perspective of symptoms in military populations, particularly in those recently transitioned from permanent service, as predictors of future risk of disorder.

Technology-Enabled Mental Health Service Reform for Open Arms - Veterans and Families Counselling: Participatory Design Study.

BACKGROUND: The impact of mental ill-health on every aspect of the lives of a large number of Australian Defence Force (ADF) personnel, their partners, and their families is widely recognized. Recent Senate inquiries have highlighted gaps in service delivery as well as the need for service reform to ensure appropriate care options for individuals who are currently engaged with mental health and support services as well as for those who, for a variety of reasons, have not sought help. To that end, successive Australian governments generally and the Department of Veterans' Affairs specifically have prioritized veteran-centric reform. Open Arms is an Australia-wide service that provides counseling and support to current and former ADF personnel, and their family members, for mental health conditions. OBJECTIVE: The aim of this study was to develop and configure a prototypic Web-based platform for Open Arms - Veterans & Families Counselling (formerly Veterans and Veterans Families Counselling Service) with the Open Arms community to enhance the quality of mental health services provided by Open Arms. METHODS: The study aimed to recruit up to 100 people from the Open Arms community (current and former ADF personnel and their families, health professionals, service managers, and administrators) in regions of New South Wales, including Sydney, Canberra, Maitland, Singleton, and Port Stephens. Participants were invited to participate in 4-hour participatory design workshops. A variety of methods were used within the workshops, including prompted discussion, review of working prototypes, creation of descriptive artifacts, and group-based development of user journeys. RESULTS: Seven participatory design workshops were held, including a total of 49 participants. Participants highlighted that the prototype has the potential to (1) provide the opportunity for greater and better-informed personal choice in relation to options for care based on the level of need and personal preferences; (2) ensure transparency in care by providing the individual with access to all of their personal health information; and (3) improve collaborative care and care continuity by allowing information to be shared securely with current and future providers. CONCLUSIONS: Our findings highlight the value of actively engaging stakeholders in participatory design processes for the development and configuration of new technologies.

Screening for Depression and Psychological Distress in a Currently Serving Military Population: The Diagnostic Accuracy of the K10 and the PHQ9.

This study is the first to examine the diagnostic accuracy of two depression screening scales-the Kessler Psychological Distress Scale (K10) and the Patient Health Questionnaire (PHQ)-in an entire regular-serving military population. Currently serving Australian Defence Force personnel (n = 24,481) completed the K10 and PHQ9. Then a targeted subsample (i.e., the analysis sample, n = 1,730) completed a diagnostic interview to identify DSM-IV 30-day disorder. Weighted results represented the entire population (N = 50,049). Both scales similarly showed a good ability to discriminate between personnel with and without depressive disorders. Optimal cutoffs (19 for K10, 6 for PHQ9) showed high sensitivity and good specificity, and were similar to though slightly lower than those recommended in civilian populations. Both scales appear to be valid screens for depressive disorder in the military, using the cutoffs identified. As both performed similarly, scale choice may depend on other factors (e.g., availability of norms).

Mental Health Care for Service Members and Their Families Across the Globe.

The U.S. Defense Department partnered with the International Initiative for Mental Health Leadership on effective leadership and operational practices for delivery of mental health (MH) as well as addiction services throughout the world for Service Members (SM) and beneficiaries. A Military Issues Work Group (MIWG) was established in 2011 to focus on challenges experienced by military SM and beneficiaries among countries. The MIWG found common concerns related to MH care delivery to rural and remote beneficiaries. Gaps in access to care were identified and prioritized to explore. This led to better collaboration and understanding of telemental health (TMH) practices and technology applications (apps) which increase access to care for rural and remote SMs and beneficiaries. An assessment of the number of SMs and dependents distant from MH care services in the USA was conducted, as well as an environmental scan for psychological health-focused mobile apps and TMH services geared toward SM, veterans, and beneficiaries. The MIWG is developing a compendium of existing military TMH programs and apps that address MH concerns and extant literature on use of technology to extend global access to care for military members and their families across the world.

Effective and ineffective coping strategies in a low-autonomy work environment.

The authors examined the effectiveness of different coping strategies in buffering the negative effects of uncontrollable stressors and predicting mental health symptoms in a low-autonomy work environment using a longitudinal design. Soldiers in training indicated the extent to which they engaged in various coping strategies to deal with stressors related to the training environment at 4 different points in time. Factor analyses of soldiers in 2 different countries (i.e., United States and Australia) yielded 5 coping dimensions: active coping, acceptance of demands, seeking social support, humor, and denial/self-criticism. Among U.S. soldiers in basic training, acceptance of demands and denial/self-criticism interacted with the magnitude of basic-training stressors to predict mental health symptoms (depression and anxiety) at 3 different points during training while controlling for symptoms at the immediate prior time period. Acceptance buffered soldiers from the negative effects of the stressors, whereas denial/self-criticism exacerbated the effects of the stressors. The results of LGC models also indicated that the slopes of acceptance and active coping were negatively related to the slope of mental health symptoms across training, whereas the slope for denial/self-criticism was positively related to the slope of symptoms. Active coping was less predictive of functioning in the face of stressors and in the prediction of symptoms over time. The results demonstrated that in a low-autonomy occupational setting, acceptance coping was more effective in facilitating good mental health outcomes compared with other coping strategies considered important in prior research (e.g., active coping).

Rapid evidence assessment: increasing the transparency of an emerging methodology.

RATIONALE, AIMS AND OBJECTIVES: Within the field of evidence-based practice, policy makers, health care professionals and consumers require timely reviews to inform decisions on efficacious health care and treatments. Rapid evidence assessment (REA), also known as rapid review, has emerged in recent years as a literature review methodology that fulfils this need. It highlights what is known in a clinical area to the target audience in a relatively short time frame. METHODS: This article discusses the lack of transparency and limited critical appraisal that can occur in REA, and goes on to propose general principles for conducting a REA. The approach that we describe is consistent with the principles underlying systematic review methodology, but also makes allowances for the rapid delivery of information as required while utilizing explicit and reproducible methods at each stage. RESULTS: Our method for conducting REA includes: developing an explicit research question in consultation with the end-users; clear definition of the components of the research question; development of a thorough and reproducible search strategy; development of explicit evidence selection criteria; and quality assessments and transparent decisions about the level of information to be obtained from each study. In addition, the REA may also include an assessment of the quality of the total body of evidence. CONCLUSIONS: Transparent reporting of REA methodologies will provide greater clarity to end-users about how the information is obtained and about the trade-offs that are made between speed and rigour.

The validity of military screening for mental health problems: diagnostic accuracy of the PCL, K10 and AUDIT scales in an entire military population.

Depression, alcohol use disorders and post-traumatic stress disorder (PTSD) are serious issues among military personnel due to their impact on operational capability and individual well-being. Several military forces screen for these disorders using scales including the Kessler Psychological Distress Scale (K10), Alcohol Use Disorders Identification Test (AUDIT), and Post-traumatic Stress Disorder Checklist (PCL). However, it is unknown whether established cutoffs apply to military populations. This study is the first to test the diagnostic accuracy of these three scales in a population-based military cohort. A large sample of currently-serving Australian Defence Force (ADF) Navy, Army and Air Force personnel (n = 24,481) completed the K10, AUDIT and PCL-C (civilian version). Then, a stratified sub-sample (n = 1798) completed a structured diagnostic interview detecting 30-day disorder. Data were weighted to represent the ADF population (n = 50,049). Receiver operating characteristic (ROC) analyses suggested all three scales had acceptable sensitivity and specificity, with areas under the curve from 0.75 to 0.93. AUDIT and K10 screening cutoffs closely paralleled established cutoffs, whereas the PCL-C screening cutoff resembled that recommended for US military personnel. These self-report scales represent a cost-effective and clinically-useful means of screening personnel for disorder. Military populations may need lower cutoffs than civilians to screen for PTSD.

The Australian Defence Force Mental Health Prevalence and Wellbeing Study: design and methods.

BACKGROUND: The Australian Defence Force (ADF) Mental Health Prevalence and Wellbeing Study (MHPWS) is the first study of mental disorder prevalence in an entire military population. OBJECTIVE: The MHPWS aims to establish mental disorder prevalence, refine current ADF mental health screening methods, and identify specific occupational factors that influence mental health. This paper describes the design, sampling strategies, and methodology used in this study. METHOD: At Phase 1, approximately half of all regular Navy, Army, and Air Force personnel (n=24,481) completed self-report questionnaires. At Phase 2, a stratified sub-sample (n=1,798) completed a structured diagnostic interview to detect mental disorder. Based on data from non-responders, data were weighted to represent the entire ADF population (n=50,049). RESULTS: One in five ADF members met criteria for a 12-month mental disorder (22%). The most common disorder category was anxiety disorders (14.8%), followed by affective (9.5%) and alcohol disorders (5.2%). At risk ADF sub-groups were Army personnel, and those in the lower ranks. Deployment status did not have an impact on mental disorder rates. CONCLUSION: This study has important implications for mental health service delivery for Australian and international military personnel as well as contemporary veterans.