Ann Marie Hernandez

Sleep disturbances in fibromyalgia syndrome: Relationship to pain and depression

OBJECTIVE This study is an examination of sleep, pain, depression, and physical functioning at baseline and 1-year followup among patients with fibromyalgia syndrome (FMS). Although it is clear that these symptoms are prevalent among FMS patients and that they are related, the direction of the relationship is unclear. We sought to identify and report sleep problems in this population and to examine their relationship to pain, depression, and physical functioning. METHODS Patients diagnosed with fibromyalgia were recruited from a Southern California health maintenance organization and evaluated according to American College of Rheumatology criteria in the research laboratory. Six hundred patients completed the baseline assessment and 492 completed the 1-year assessment. Measures included the Center for Epidemiologic Studies Depression Scale, the McGill Pain Questionnaire, the Pittsburgh Sleep Quality Index, and the Fibromyalgia Impact Questionnaire. RESULTS The majority of the sample (96% at baseline and 94.7% at 1 year) scored within the range of problem sleepers. Path analyses examined the impact of baseline values on 1-year values for each of the 4 variables. No variable of interest predicted sleep, sleep predicted pain (beta = 0.13), pain predicted physical functioning (beta = -0.13), and physical functioning predicted depression (beta = -0.10). CONCLUSION These findings highlight the high prevalence of sleep problems in this population and suggest that they play a critical role in exacerbating FMS symptoms. Furthermore, they support limited existing findings that sleep predicts subsequent pain in this population, but also extend the literature, suggesting that sleep may be related to depression through pain and physical functioning.

Combat Exposure and Suicide Risk in Two Samples of Military Personnel

OBJECTIVE In light of increased suicidal behaviors among military personnel and veterans since the initiation of combat operations in Afghanistan and Iraq, questions have been raised about the potential causal role of combat. The objective of the current study was to identify any direct or indirect effects of combat exposure on suicide risk through depression symptom severity, posttraumatic stress disorder (PTSD) symptom severity, thwarted belongingness, perceived burdensomeness, and fearlessness about death, consistent with the interpersonal-psychological theory of suicide (Joiner, 2005). METHOD Structural equation modeling was utilized with two separate samples of deployed military personnel, 1 nonclinical (n = 348; 89.7% male, mean age = 24.50) and 1 clinical (n = 219; 91.8% male, mean age = 27.88), to test the effects of combat exposure on suicide risk. RESULTS Greater combat exposure was directly associated with fearlessness about death and PTSD symptom severity in both samples, but failed to show either a direct or indirect effect on suicide risk. PTSD symptom severity was strongly associated with depression symptom severity, which in turn was related to suicide risk directly (in the nonclinical sample) or indirectly through low belongingness and perceived burdensomeness (in the clinical sample). CONCLUSIONS In both samples of deployed active duty military personnel, combat exposure was either unrelated to suicide risk or was too distally related to have a measurable effect. Results do not support the interpersonal-psychological theorys hypothesis that combat exposure should be indirectly related to suicide risk through acquired fearlessness of death.

Loss of consciousness, depression, posttraumatic stress disorder, and suicide risk among deployed military personnel with mild traumatic brain injury

Objective:To identify clinical variables associated with suicidality in military personnel with mild traumatic brain injury (mTBI) while deployed to Iraq. Setting:Outpatient TBI clinic on a US military base in Iraq. Participants:Military personnel (N = 158) referred to an outpatient TBI clinic for a standardized intake evaluation, 135 (85.4%) who had a diagnosis of mTBI and 23 (14.6%) who did not meet criteria for TBI. Main Measures:Suicidal Behaviors Questionnaire–Revised, Depression subscale of the Behavioral Health Measure-20, Posttraumatic Stress Disorder Checklist-Military Version, Insomnia Severity Index, self-report questionnaire, and clinical interview addressing TBI-related symptoms. Results:Among patients with mTBI, increased suicidality was significantly associated with depression and the interaction of depression with posttraumatic stress disorder symptoms. Longer duration of loss of consciousness was associated with decreased likelihood for any suicidality. Conclusion:Assessment after TBI in a combat zone may assist providers in identifying those at risk for suicidality and making treatment recommendations for service members with mTBI.

The associations of physical and sexual assault with suicide risk in nonclinical military and undergraduate samples

The associations of various forms of sexual and physical assault with a history of suicide attempts and recent suicide ideation were studied in two distinct samples: active duty military and undergraduate students. A total of 273 active duty Air Force personnel and 309 undergraduate students anonymously completed self-report surveys of assault victimization, emotional distress, belongingness, recent suicide ideation, and previous suicide attempts. Among military personnel, rape, robbery, or violent assault was associated with a nonsignificant trend toward increased risk for suicide attempts, whereas physical abuse or battering as an adult was significantly associated with recent suicide ideation. Among undergraduates, unwanted sexual experiences as an adult and physical or sexual abuse as a child were significantly associated with increased risk for suicide attempt, but only unwanted experiences as an adult was significantly associated with increased risk for suicide ideation. Experiencing multiple forms of assault increased risk for suicide attempts and ideation in both groups. Results suggest that different types of assault contribute differentially to suicide risk in military versus undergraduate populations, but experiencing multiple types of assault is associated with increased risk in both groups.

Magnitudes of decline on Automated Neuropsychological Assessment Metrics subtest scores relative to predeployment baseline performance among service members evaluated for traumatic brain injury in Iraq.

Objective:Identify the proportion of service members demonstrating declines in Automated Neuropsychological Assessment Metrics (ANAM) scores as part of a traumatic brain injury (TBI) evaluation conducted while deployed to Iraq. Background:Although TBI has been associated with poorer performance on cognitive test in the general population and military combatants, little is known about the proportion of service members demonstrating declines in ANAM scores after TBI. Methods:Military personnel (N = 116) referred to a combat support hospital for TBI evaluation in Iraq underwent a standardized intake evaluation including computerized neurocognitive testing, psychological and physical health questionnaires, a clinical interview, and a physical examination by a physician. Predeployment and postinjury cognitive performance among service members with and without a TBI diagnosis was compared. Results:A significantly larger proportion of patients with TBI demonstrated greater declines in speed across all ANAM subtests compared with patients with no TBI. Differences in accuracy scores among patients with TBI relative to patients without TBI were nonsignificant. Patients with TBI also demonstrated greater than minimal declines on throughput Simple Reaction Time, Procedural Reaction Time, Code Substitution-Learning, and Spatial Memory scores, with no significant differences on Code Substitution-Delayed or Mathematical Processing (MATH). A similar pattern was seen among individuals examined within 72 hours of index injury. Conclusion:Assessment of cognitive impairment following TBI in a combat zone may assist providers in making treatment recommendations for service members with mild TBI.

Predictors of Post-Traumatic Headache Severity Among Deployed Military Personnel

(Headache 2011;51:945‐953)

EVALUATING POTENTIAL IATROGENIC SUICIDE RISK IN TRAUMA-FOCUSED GROUP COGNITIVE BEHAVIORAL THERAPY FOR THE TREATMENT OF PTSD IN ACTIVE DUTY MILITARY PERSONNEL.

To determine whether group cognitive processing therapy‐cognitive only version (CPT‐C) is associated with iatrogenic suicide risk in a sample of active duty US Army personnel diagnosed with posttraumatic stress disorder (PTSD). Possible iatrogenic effects considered include the incidence and severity of suicide ideation, worsening of preexisting suicide ideation, incidence of new‐onset suicide ideation, and incidence of suicide attempts among soldiers receiving group CPT‐C. Comparison with group present‐centered therapy (PCT) was made to contextualize findings.

Depression among older Mexican American caregivers.

The authors compared depression levels between older Mexican American caregivers and noncaregivers while controlling for confounds identified but not controlled in past research. Mexican American caregivers and noncaregivers (N = 114) ages 65 and older were matched on age, gender, socioeconomic status, self-reported health, and acculturation. Caregivers reported higher scores on the Center for Epidemiologic Studies Depression scale (CES-D) and were more likely to score in the depressed range than noncaregivers. In a regression model with all participants, group classification (caregiver vs. noncaregiver) and health significantly predicted CES-D scores. A model with only caregivers that included caregiver burden, self-rated health, and gender significantly predicted CES-D scores, with only caregiver burden entering the regression equation. These results suggest that older Mexican American caregivers are more depressed than noncaregivers, as has been found in younger populations.

Meaning in life, emotional distress, suicidal ideation, and life functioning in an active duty military sample

The present study examined the relationship of meaning in life with emotional distress, suicidal ideation, and life functioning in a sample of 273 active duty Security Forces personnel assigned to two US Air Force bases. Results of regression analyses indicated that stronger meaning in life was significantly associated with less severe emotional distress (p < 0.001, ΔR 2 = 0.047) and suicidal ideation (p = 0.043, ΔR 2 = 0.017), and better functioning at work and in intimate relationships, nonfamily relationships, and recreational activities (p < 0.001, ΔR 2 = 0.073). Meaning in life showed stronger associations with outcomes relative to other predictors and covariates and explained the relationship between belonging and life functioning. Findings suggest that meaning in life is associated with less emotional distress and suicide risk, and greater success and performance across multiple domains in life among military personnel.

Work-Related Musculoskeletal Disorders and Pain

Work-related musculoskeletal disorders (WRMDs) comprise a unique subset of pain disorders. These musculoskeletal disorders are distinctive in their etiology, presentation, and influence on industry and employees. The primary objective of this chapter is to provide an overview of the most commonly diagnosed WRMDs in a manner that is useful to clinicians, researchers, and health care administrators. The chapter integrates research findings within the occupational health literature into a comprehensive compendium that will update the reader on epidemiological, assessment, and therapeutic issues salient to WRMDs. Limitations and recommendations regarding the current state of the literature are also highlighted.