Alan Fontana

Posttraumatic Stress Disorder as a Risk Factor for Suicidal Ideation in Iraq and Afghanistan War Veterans

Posttraumatic stress disorder (PTSD) was examined as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans (N = 407) referred to Veterans Affairs mental health care. The authors also examined if risk for suicidal ideation was increased by the presence of comorbid mental disorders in veterans with PTSD. Veterans who screened positive for PTSD were more than 4 times as likely to endorse suicidal ideation relative to non-PTSD veterans. Among veterans who screened positive for PTSD (n = 202), the risk for suicidal ideation was 5.7 times greater in veterans who screened positive for two or more comorbid disorders relative to veterans with PTSD only. Findings are relevant to identifying risk for suicide behaviors in Iraq and Afghanistan War veterans.

An empirical conceptualization of the recovery orientation

OBJECTIVE The recovery movement is having a growing impact on policy for people with severe mental illness. The empirical literature on the recovery orientation, however, is scant, and no empirical conceptualization of recovery has been published. METHOD We identified items reflecting recovery themes and measuring aspects of subjective experience, and used principle components and confirmatory factor analyses to develop an empirical conceptualization of the recovery orientation, using data from a large, systematic study of schizophrenia. RESULTS We identified four domains of the recovery orientation: empowerment, hope and optimism, knowledge and life satisfaction. CONCLUSIONS We propose here an initial approach to measuring and conceptualizing recovery attitudes. We also suggest that the evidence-based practice (EBP) movement may help to identify interventions that promote the recovery orientation and help to advance recovery attitudes. We suggest that there is a bidirectional relationship between recovery attitudes and the positive clinical outcomes that are the goals of EBPs. Through the use of empirically derived conceptualizations of recovery, EBPs can provide a mechanism for identifying treatments that promote the recovery orientation. The conceptualization proposed here can, thus, serve as a tool to assess changes in recovery attitudes during participation in specific EBPs.

The role of denial in recovery from coronary heart disease.

&NA; This longitudinal study investigated the relationship between denial of illness and the course of recovery in patients with coronary heart disease. Using a newly developed interview instrument, the Levine Denial of Illness Scale (LDIS), the level and modes of denial were assessed in 45 male patients who were hospitalized for myocardial infarction or for coronary bypass surgery, of whom 30 were followed for 1 year after discharge. The reliability, internal consistency, and validity of the LDIS were found to be satisfactory. Furthermore, the LDIS showed discriminant validity from trait measures of denial. LDIS scores were not associated with severity of illness or risk factors. High deniers spent fewer days in intensive care and had fewer signs of cardiac dysfunction during their hospitalization relative to low deniers. However, in the year following discharge, high deniers adapted more poorly than low deniers: high deniers were more noncompliant with medical recommendations and required more days of rehospitalization. The findings suggest that denial of illness is adaptive during acute hospital recovery, but is maladaptive in the long‐run after hospital discharge.

Trauma, change in strength of religious faith, and mental health service use among veterans treated for PTSD.

One of the most pervasive effects of traumatic exposure is the challenge that people experience to their existential beliefs concerning the meaning and purpose of life. Particularly at risk is the strength of their religious faith and the comfort that they derive from it. The purpose of this study is to examine a model of the interrelationships among veterans’ traumatic exposure, posttraumatic stress disorder (PTSD), guilt, social functioning, change in religious faith, and continued use of mental health services. Data are drawn from studies of outpatient (N = 554) and inpatient (N = 831) specialized treatment of PTSD in Department of Veterans Affairs programs. Structural equation modeling is used to estimate the parameters of the model and evaluate its goodness of fit to the data. The model achieved acceptable goodness of fit and suggested that veterans’ experiences of killing others and failing to prevent death weakened their religious faith, both directly and as mediated by feelings of guilt. Weakened religious faith and guilt each contributed independently to more extensive use of VA mental health services. Severity of PTSD symptoms and social functioning played no significant role in the continued use of mental health services. We conclude that veterans’ pursuit of mental health services appears to be driven more by their guilt and the weakening of their religious faith than by the severity of their PTSD symptoms or their deficits in social functioning. The specificity of these effects on service use suggests that a primary motivation of veterans’ continuing pursuit of treatment may be their search for a meaning and purpose to their traumatic experiences. This possibility raises the broader issue of whether spirituality should be more central to the treatment of PTSD, either in the form of a greater role for pastoral counseling or of a wider inclusion of spiritual issues in traditional psychotherapy for PTSD.

Psychological Benefits and Liabilities of Traumatic Exposure in the War Zone

Data from the National Vietnam Veterans Readjustment Study on 1,198 Vietnam theater veterans were used to examine the psychological benefits and liabilities of traumatic exposure in the war zone. Psychological benefits and liabilities were found to be largely independent of one another and to be related positively to the dose of traumatic exposure. Additionally, there was a curvilinear trend in the form of an inverted U, such that psychological benefits, most notably solidarity with others, were stronger at intermediate compared to high and low levels of exposure. Psychological benefits counteracted and psychological liabilities passed through the effects of traumatic exposure on posttraumatic stress disorder (PTSD). The psychological benefit of self-improvement moderated the effects of the psychological liability of self-impoverishment on PTSD.

Analysis of violent behavior in Vietnam combat veteran psychiatric inpatients with posttraumatic stress disorder

This study tested the hypothesis that male Vietnam veterans seeking inpatient treatment for PTSD (n = 228) exhibit more violent behavior compared with a mixed diagnostic group of male psychiatric Inpatients without PTSD (n = 64) and a community sample of Vietnam veterans with PTSD not undergoing inpatient treatment (n = 273). Violent acts assessed included property destruction, threats without a weapon, physical fighting, and threats with a weapon. PTSD inpatients engaged in more types of violent behavior than both comparison conditions. Correlates of violence among PTSD inpatients included PTSD symptom severity and, to a lesser degree, measures of substance abuse. These findings justify routine assessment of violent behavior among inpatients with PTSD, as well as application of specialized interventions for anger dyscontrol and aggression.

Service system integration, access to services, and housing outcomes in a program for homeless persons with severe mental illness

OBJECTIVES This study evaluated the hypothesis that greater integration and coordination between agencies within service systems is associated with greater accessibility of services and improved client housing outcomes. METHODS As part of the Access to Community Care and Effective Services and Supports program, data were obtained on baseline client characteristics, service use, and 3-month and 12-month outcomes from 1832 clients seen at 18 sites during the first year of program operation. Data on interorganizational relationships were obtained from structured interviews with key informants from relevant organizations in each community (n = 32-82 at each site). RESULTS Complete follow-up data were obtained from 1340 clients (73%). After control for baseline characteristics, service system integration was associated with superior housing outcomes at 12 months, and this relationship was mediated through greater access to housing agencies. CONCLUSIONS Service system integration is related to improved access to housing services and better housing outcomes among homeless people with mental illness.

Posttraumatic Stress Disorder Among Vietnam Theater Veterans A Causal Model of Etiology in a Community Sample

Data from the National Vietnam Veterans Readjustment Study, conducted from 1986 to 1988, were used to develop and cross-validate a model of the etiology of posttraumatic stress disorder (PTSD) among a community sample of 1198 male Vietnam theater veterans. The initial model specified causal paths among five sets of variables, ordered according to their historical occurrence: a) premilitary risk factors and traumas, b) war-related and non-warrelated traumas during the military, c) homecoming reception, d) postmilitary traumas, and e) PTSD. The initial model was refined and then cross-validated, leading to the specification of a final model with highly satisfactory fit and parsimony. In terms of the magnitude of their contribution to the development of PTSD, lack of support from family and friends at the time of the homecoming and exposure to combat were the two most influential contributors. Other contributing factors, in order of importance, were Hispanic ethnicity, societal rejection at the time of homecoming, childhood abuse, participation in abusive violence and family instability. Exposure to war-related and non-war-related traumas occurred largely independently of each other, with war-related traumas contributing substantially more than non-war-related traumas to the development of PTSD. Limitations to interpretation of the results are noted due to the retrospective nature of the data and the inevitable omission of other etiological factors.

Transgenerational effects of abusive violence on the children of Vietnam combat veterans.

This study examined the relationship between participation in abusive violence in Vietnam and behavioral disturbances among children aged 6-16 in the next generation. As part of the National Vietnam Veterans Readjustment Study (NVVRS) detailed data were obtained on a national sample of male veterans who were living in households with children aged 6–16 (N = 257). Interviews with spouses/partners were used to evaluate current family relationships and child behavior. Children of veterans who participated in abusive violence showed more behavioral disturbance than children of other Vietnam veterans even after multivariate analysis was used to adjust for other factors such as PTSD symptoms, combat exposure, and postmilitary family relationships. Participation in abusive violence appears to affect parent-child relationships in a way that adversely influences children living at home.

A Computer Program for Assessing Specific Category Rater Agreement for Qualitative Data

This program computes specific category agreement levels for both nominally and ordinally scaled data. For ordinally scaled data, an option is available for collapsing the original scale to a smaller number of categories, with the goal of improving the level of inter-rater reliability for the rating scale.