Edwin Shirley

PTSD comorbidity and suicidal ideation associated with PTSD within the Ohio Army National Guard

OBJECTIVE To study the relation between posttraumatic stress disorder (PTSD) psychiatric comorbidity and suicidal ideation in a representative sample of Ohio Army National Guard soldiers. METHOD Using retrospective data collected on the telephone from a random sample of 2,616 National Guard soldiers who enrolled in a 10-year longitudinal study (baseline data collected November 2008-November 2009), we examined (1) the prevalence of other psychopathologies among those with DSM-IV-diagnosed PTSD compared to those without PTSD and (2) the association between PTSD comorbidity and suicidal ideation (reporting thoughts of being better off dead or hurting themselves). All analyses were carried out using logistic regression. RESULTS Of guard members with PTSD in the last year, 61.7% had at least 1 other psychopathology; 20.2% had at least 2 other co-occurring conditions. The most common co-occurring psychopathology was depression. While those with PTSD overall were 5.4 (95% CI, 3.8-7.5) times more likely to report suicidality than those without PTSD, those who had at least 2 additional conditions along with PTSD were 7.5 (95% CI, 3.0-18.3) times more likely to report suicidal ideation at some point in their lifetime than those with PTSD alone. CONCLUSIONS Soldiers with PTSD were at increased risk for suicidality, and, among those with PTSD, those with at least 2 additional conditions were at the highest risk of suicidal ideation. Future research should address the mechanisms that contribute to multimorbidity in this population and the appropriate treatment methods for this high-risk group.

Relations between the underlying dimensions of PTSD and major depression using an epidemiological survey of deployed Ohio National Guard soldiers.

BACKGROUND In the present study, the authors investigated the relationship between the underlying symptom dimensions of posttraumatic stress disorder (PTSD) and dimensions of major depressive disorder (MDD). METHOD A sample of 1266 Ohio National Guard soldiers with a history of overseas deployment participated and were administered the PTSD Checklist (assessing PTSD) and Patient Health Questionnaire-9 (assessing depression). RESULTS Using confirmatory factor analysis, results demonstrated that both PTSDs dysphoria and hyperarousal factors were more related to depressions somatic than non-somatic factor. Furthermore, depressions somatic factor was more related to PTSDs dysphoria than hyperarousal factor. LIMITATIONS Limitations of this study include the use of self-report measures and a predominately male military sample. CONCLUSIONS Results indicate that PTSDs dysphoria factor is related to depression specifically by way of depressions somatic construct. Given PTSDs substantial dysphoria/distress component, these results have implications for understanding the nature of PTSDs high comorbidity with depression.

The factor structure of major depression symptoms: A test of four competing models using the Patient Health Questionnaire-9

Little research has examined the underlying symptom structure of major depressive disorder (MDD) symptoms based on DSM-IV criteria. Our aim was to analyze the symptom structure of major depression, using the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 was administered to a sample of 2615 Army National Guard soldiers from Ohio. A one-factor model of depression and three separate two-factor models previously established in the literature were evaluated using confirmatory factor analysis. Results demonstrated greater support for the two-factor models of depression than for the one-factor model. The best fitting model was the two-factor model of somatic and non-somatic symptoms supported previously by Krause et al. (2010) and Richardson and Richards (2008). Implications for understanding the components and mechanisms of MDD are discussed.

Psychoeducational Approaches to Medication Adherence in Patients with Bipolar Disorder

There is growing consensus that a major obstacle to good outcomes among individuals with bipolar disorder (BPD) is premature discontinuation of medications. This review summarizes the current literature on prevalence and consequences of non-adherence in BPD populations, measurement of adherence, risk factors for non-adherence, and general and psychoeducational interventions to enhance treatment adherence among bipolar populations, and suggests future directions in psychoeducational approaches with respect to treatment adherence. Risks associated with discontinuation of medication among individuals with BPD are well documented and include manic and depressive relapses, re-hospitalization, and more lengthy hospital stays. A relatively limited but growing literature suggests that it is possible to enhance treatment adherence among patients with BPD. The most positive evidence for the improvement of medication adherence among patients with BPD comes from specific psychosocial interventions used in conjunction with pharmacotherapies. It has been suggested that improved treatment adherence is at least a partial component of the observed positive outcomes of psychoeducational approaches among bipolar populations. Many individuals with BPD remain relatively uninformed regarding their illness, creating potential barriers to optimal treatment adherence, and limiting self-management skills. Psychoeducation is based on the premise that individuals have a fundamental right to have information regarding their illness, and individuals who are informed are more likely to take a more active role in managing their illness, which results in better health outcomes. Psychoeducation strategies for BPD that have contributed to positive outcomes have ranged from simple one-site, education-only interventions that improve lithium adherence and attitudes about medications to a more complex, multi-site, collaborative care system intervention that yielded shorter durations of affective episodes for patients, improved functioning and quality of life, and treatment satisfaction. Although psychological therapies that emphasize psychoeducation generally support benefits in achieving and maintaining remission from bipolar symptoms, the effects of these interventions on treatment adherence are not consistent and the way in which psychoeducation improves outcomes is not entirely clear. There is an urgent need for greater understanding of interventions that can be implemented in real-world settings that address patient, provider/system, and environmental/social factors that are critical to treatment adherence.

Latent profile analyses of posttraumatic stress disorder, depression and generalized anxiety disorder symptoms in trauma-exposed soldiers

Posttraumatic stress disorder (PTSD) is comorbid with major depressive disorder (MDD; Kessler et al., 1995) and generalized anxiety disorder (GAD; Brown et al., 2001). We aimed to (1) assess discrete patterns of post-trauma PTSD-depression-GAD symptoms using latent profile analyses (LPAs), and (2) assess covariates (gender, income, education, age) in defining the best fitting class solution. The PTSD Checklist (assessing PTSD symptoms), GAD-7 scale (assessing GAD symptoms), and Patient Health Questionnaire-9 (assessing depression) were administered to 1266 trauma-exposed Ohio National Guard soldiers. Results indicated three discrete subgroups based on symptom patterns with mild (class 1), moderate (class 2) and severe (class 3) levels of symptomatology. Classes differed in symptom severity rather than symptom type. Income and education significantly predicted class 1 versus class 3 membership, and class 2 versus class 3. In conclusion, there is heterogeneity regarding severity of PTSD-depression-GAD symptomatology among trauma-exposed soldiers, with income and education predictive of class membership.

Validation of lay-administered mental health assessments in a large Army National Guard cohort

To report the reliability and validity of key mental health assessments in an ongoing study of the Ohio Army National Guard (OHARNG). The 2616 OHARNG soldiers received hour‐long structured telephone surveys including the post‐traumatic stress disorder (PTSD) checklist (PCV‐C) and Patient Health Questionnaire – 9 (PHQ‐9). A subset (N = 500) participated in two hour clinical reappraisals, using the Clinician‐Administered PTSD Scale (CAPS) and the Structured Clinical Interview for DSM (SCID). The telephone survey assessment for PTSD and for any depressive disorder were both highly specific [92% (standard error, SE 0.01), 83% (SE 0.02)] with moderate sensitivity [54% (SE 0.09), 51% (SE 0.05)]. Other psychopathologies assessed included alcohol abuse [sensitivity 40%, (SE 0.04) and specificity 80% (SE 0.02)] and alcohol dependence [sensitivity, 60% (SE 0.05) and specificity 81% (SE 0.02)].The baseline prevalence estimates from the telephone study suggest alcohol abuse and dependence may be higher in this sample than the general population. Validity and reliability statistics suggest specific, but moderately sensitive instruments. Copyright

Posttraumatic stress disorder׳s dysphoria dimension and relations with generalized anxiety disorder symptoms

The present study investigated symptom relations between two highly comorbid disorders--posttraumatic stress disorder (PTSD) and generalized anxiety disorder (GAD)--by exploring their underlying dimensions. Based on theory and prior empirical research it was expected that the dysphoria factor of PTSD would be more highly related to GAD. As part of a longitudinal project of mental health among Ohio National Guard Soldiers, 1266 subjects were administered the Posttraumatic Stress Disorder Checklist (PCL) and Generalized Anxiety Disorder-7 scale (GAD-7). Confirmatory factor analyses (CFAs) were conducted to examine two models of PTSD and to determine which PTSD factors were more related to the GAD factor. The results indicate that the GAD factor was significantly more highly correlated with PTSDs dysphoria factor than with all other PTSD factors, including PTSDs reexperiencing factor, avoidance factor, and hyperarousal factor. Results indicate GAD was not significantly more highly correlated with numbing than most other factors of PTSD. The results are consistent with prior research. Implications of the results are discussed in regards to PTSD in DSM-5, comorbidity and diagnostic specificity.

Retrospective age-of-onset and projected lifetime prevalence of psychiatric disorders among U.S. Army National Guard soldiers

BACKGROUND The study of military-related mental health has been disproportionately focused on current symptomology rather than potentially more informative life course mental health. Indeed, no study has assessed age-of-onset and projected lifetime prevalence of disorders among reservists. METHODS Age-of-onset and projected lifetime DSM-IV anxiety, mood, and substance use disorders were assessed in 671 Ohio Army National Guard soldiers aged 17-60 years. Between 2008 and 2012, face-to-face clinical assessments and surveys were conducted using the Structured Clinical Interview for DSM-IV and Clinician-Administered PTSD Scale. RESULTS Lifetime prevalence of psychiatric disorders was 61%. Alcohol abuse/dependence (44%) and major depressive disorder (23%) were the most common disorders. The majority (64%) of participants reported disorders antedating enlistment. Median age-of-onset varied with anxiety disorders - particularly phobias and OCD - having the earliest (median=15 years) and mood disorders the latest median age-of-onset (median=21 years). LIMITATIONS The study was limited by both the retrospective investigation of age-of-onset and the location of our sample. As our sample may not represent the general military population, our findings need to be confirmed in additional samples. CONCLUSIONS Each psychiatric disorder exhibited a distinct age-of-onset pattern, such that phobias and OCD onset earliest, substance use disorders onset during a short interval from late-adolescence to early-adulthood, and mood disorders onset the latest. Our finding that the majority of participants reported disorders antedating enlistment suggests that an assessment of lifetime psychopathology is essential to understanding the mental health burden of both current and former military personnel.

Lifetime and 12-Month Use of Psychiatric Services Among U.S. Army National Guard Soldiers in Ohio

OBJECTIVE The individual and economic burden of psychiatric illnesses is substantial. Although treatment of psychiatric disorders mitigates the burden of illness, over half of military personnel with disorders do not receive mental health care. However, there is a paucity of research examining the relationship between psychiatric disorder categories and treatment-seeking behavior in representative military populations. This study aimed to document, by psychiatric disorder category, the annualized rate of Guard members who obtained psychiatric services and the factors associated with service utilization. METHODS Face-to-face clinical assessments were conducted between 2008 and 2012 to assess lifetime and current psychiatric disorders and recent psychiatric service use among 528 Ohio Army National Guard soldiers. RESULTS An annualized rate of 31% of persons per year accessed psychiatric services between 2010 and 2012. Persons with substance use disorders had the lowest annualized rate of service use, and these were the only disorders not predictive of accessing services. Current mood disorder, current anxiety disorder, and lifetime history of service use were the strongest predictors of recent service use. There were no socioeconomic or other group predictors of psychiatric service use. CONCLUSIONS About half of the soldiers who could benefit from mental health services used them, yet soldiers with substance use disorders were predominantly going untreated. There were no differences in treatment utilization by group characteristics, suggesting no systematic barriers to care for particular groups. Efforts to encourage broader adoption of treatment seeking, particularly among persons with substance use disorders, are necessary to mitigate psychiatric health burden in this population.

General distress is more important than PTSD’s cognition and mood alterations factor in accounting for PTSD and depression’s comorbidity

BACKGROUND Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) are highly comorbid and exhibit strong correlations with each other at both the symptom level and latent factor level. Various theories have attempted to explain this relationship. Results have been inconsistent regarding whether PTSDs negative alterations in cognition and mood factor (NACM) is significantly more related to depression, in contrast to other factors of PTSD. METHODS Confirmatory factor analysis was used to attempt to address the relationships between PTSD and MDD in a large sample of trauma-exposed combat veterans from the Ohio National Guard as part of a larger longitudinal study. RESULTS Confirmatory factor analysis was used to test a bifactor model of PTSD symptoms, testing relations between PTSDs factors and a latent depressive factor. After partitioning out the common variance into the bifactor, we found that in contrast to other PTSD factors, PTSDs NACM factor was not significantly more related to depression. Instead, only the general bifactor predicted depressive symptoms. LIMITATIONS The limitations of the present study include the following: the specific measures of PTSD and MDD used were based on self-report, and the sample consisted of non-clinical, non-treatment seeking veterans. CONCLUSIONS The present study suggests that the high rate of comorbidity between posttraumatic stress disorder (PTSD) and major depressive disorder is more related to underlying general distress or negative affectivity than the symptom categories of the PTSD diagnostic criteria.