Ilan Harpaz-Rotem

The Role of Coping, Resilience, and Social Support in Mediating the Relation Between PTSD and Social Functioning in Veterans Returning from Iraq and Afghanistan

Abstract Posttraumatic stress disorder (PTSD) is one of the most common psychiatric disorders among veterans returning tfrom Iraq and Afghanistan. Little research has examined variables that may mediate the relation between PTSD and aspects of social functioning, such as relationship satisfaction and family functioning. In this cross-sectional study, a total of 164 veterans who were seeking VA primary care or mental health care within one year after returning from Iraq and/or Afghanistan were screened for PTSD and completed a series of questionnaires that assessed social functioning, coping, and life satisfaction. Results showed that the 86 (52%) veterans who screened positive for PTSD reported greater difficulties in their relationships with romantic partners, less cohesion in their families, less social support, poorer social functioning, and lower life satisfaction compared to other treatment-seeking veterans. Less social support from the community, excessive worry, decreased acceptance of change, and lower availability of secure relationships mediated the association between PTSD and poor social functioning. The relation between PTSD and lower partner satisfaction was mediated by greater cognitive social avoidance and lower availability of secure relationships. These results suggest that psychotherapeutic interventions that address these mediating variables may help improve social functioning in treatment-seeking veterans with PTSD.

Serving Those Who Served: Retention of Newly Returning Veterans From Iraq and Afghanistan in Mental Health Treatment

OBJECTIVE There are growing concerns about the mental health status of returning veterans from the recent conflicts in Iraq (Operation Iraq Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]) and about retention in mental health treatment of veterans with posttraumatic stress disorder (PTSD). This study obtained data from veterans who had a new diagnosis of PTSD from fiscal year (FY) 2004 to FY 2007 and determined whether retention in PTSD treatment and the number of mental health visits were comparable among OIF-OEF veterans and veterans from other service eras. METHODS Data from the Department of Veterans Affairs and the Department of Defense were combined to identify veterans who were newly diagnosed as having PTSD (N=204,184) and their service era. Survival analysis assessed dropout from mental health treatment within one year from initial diagnosis, and Poisson regression assessed the association between war era and number of mental health visits. RESULTS Although a smaller proportion of OIF-OEF veterans than Vietnam-era veterans remained in treatment for more than one year (37.6% versus 46.0%), when the analyses adjusted for demographic characteristics and comorbid diagnoses, OIF-OEF veterans were less likely than Vietnam-era veterans to discontinue psychiatric treatment for PTSD within one year. OIF-OEF veterans attended fewer mental health visits than Vietnam-era veterans did (8.15 versus 13.37). However, multivariate analysis indicated that, after the analyses adjusted for confounding factors, OIF-OEF veterans had significantly more visits than Vietnam-era veterans associated with PTSD treatment. CONCLUSIONS Retention and numbers of visits were found to be lower among OIF-OEF veterans primarily as a function of age and comorbid conditions and not as a function of the particular war era. Interventions should be designed to target specific barriers to care that may interfere with continued engagement in mental health services.

Dimensional structure of DSM-5 posttraumatic stress disorder symptoms: results from the National Health and Resilience in Veterans Study.

OBJECTIVE To evaluate the prevalence of DSM-5 posttraumatic stress disorder (PTSD) and factor structure of PTSD symptomatology in a nationally representative sample of US veterans and examine how PTSD symptom clusters are related to depression, anxiety, suicidal ideation, hostility, physical and mental health-related functioning, and quality of life. METHOD Data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative survey of 1,484 US veterans conducted from September through October 2013. Confirmatory factor analyses were conducted to evaluate the factor structure of PTSD symptoms, and structural equation models were constructed to examine the association between PTSD symptom clusters and external correlates. RESULTS 12.0% of veterans screened positive for lifetime PTSD and 5.2% for past-month PTSD. A 5-factor dysphoric arousal model and a newly proposed 6-factor model both fit the data significantly better than the 4-factor model of DSM-5. The 6-factor model fit the data best in the full sample, as well as in subsamples of female veterans and veterans with lifetime PTSD. The emotional numbing symptom cluster was more strongly related to depression (P < .001) and worse mental health-related functioning (P < .001) than other symptom clusters, while the externalizing behavior symptom cluster was more strongly related to hostility (P < .001). CONCLUSIONS A total of 5.2% of US veterans screened positive for past-month DSM-5 PTSD. A 6-factor model of DSM-5 PTSD symptoms, which builds on extant models and includes a sixth externalizing behavior factor, provides the best dimensional representation of DSM-5 PTSD symptom clusters and demonstrates validity in assessing health outcomes of interest in this population.

Functional significance of a novel 7-factor model of DSM-5 PTSD symptoms: Results from the National Health and Resilience in Veterans Study

BACKGROUND While posttraumatic stress disorder (PTSD) symptoms in the recently published Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are clustered into four factors, emerging confirmatory factor analytic studies suggest that this disorder is best characterized by seven symptom clusters, including re-experiencing, avoidance, negative affect, anhedonia, externalizing behaviors, and anxious and dysphoric arousal symptoms. To date, however, data are lacking regarding the relation between this novel model of DSM-5 PTSD symptoms and measures of clinical significance in this population (e.g., functioning). METHODS Using data from the National Health and Resilience in Veterans Study (NHRVS), a contemporary, nationally representative sample of 1484 U.S. veterans, we evaluated clinical and functional correlates of a novel 7-factor model of DSM-5 PTSD symptoms. RESULTS Differential patterns of associations were observed between DSM-5 PTSD symptom clusters, and psychiatric comorbidities, suicidal ideation, hostility, and functioning and quality of life. Anhedonia symptoms, in particular, were strongly related to current depression, as well as reduced mental functioning and quality of life. Externalizing behaviors were most strongly related to hostility, supporting the convergent validity of this construct. LIMITATIONS Cross-sectional design and employment of self-report measures. CONCLUSIONS These results suggest that a more refined 7-factor model of DSM-5 PTSD symptoms may provide greater specificity in understanding associations with comorbid psychopathology, suicidal ideation, and functioning and quality of life in U.S. veterans. They further suggest that prevention and treatment efforts that target distinct aspects of the PTSD phenotype may be more effective in mitigating key clinical and functional outcomes in this population.

Changes in child and adolescent inpatient psychiatric admission diagnoses between 1995 and 2000.

This study examined changes in the prevalence of psychiatric diagnoses at admission among children and adolescents treated for mental health problems in psychiatric inpatient settings between 1995 and 2000. Using a large, nationwide database (MarketScan) of private health insurance claims, our sample consisted of 5,346 children under the age of 18 who received psychiatric inpatient services, out of a total of 1,723,681 covered children. Odds ratios were used to measure changes in the prevalence of specific mental health disorders between 1995 and 2000. The study identified several significant changes, most notably, that the proportion of hospitalized children treated for bipolar or eating disorder doubled between 1995 and 2000. Significant decreases were observed for adjustment, anxiety, oppositional, and substance abuse disorders. This study lends support to recent concerns that the prevalence of bipolar disorder among the youth is increasing. Further research is needed to identify the underlying reasons for these observed changes.

Tracing the Flow of Knowledge: Geographic Variability in the Diffusion of Prazosin Use for the Treatment of Posttraumatic Stress Disorder Nationally in the Department of Veterans Affairs

CONTEXT Passive diffusion of new medical innovations is an important mechanism by which knowledge transitions from research to clinical practice. Preliminary evidence has emerged about the effectiveness of the alpha(1)-adrenergic blocker prazosin hydrochloride in the treatment of nightmares and hyperarousal among patients with posttraumatic stress disorder (PTSD). This treatment has been neither widely accepted nor the subject of active dissemination efforts, and its efficacy was discovered in a discrete geographic location. OBJECTIVES To evaluate the pace and reach of the passive dissemination of a promising technology within a national health care system. DESIGN Geographic surveillance data study. SETTING Academic research. PATIENTS We tracked the use of prazosin in the treatment of patients diagnosed as having PTSD in the Department of Veterans Affairs during fiscal years 2004 (n = 203 414) and 2006 (n = 319 670). MAIN OUTCOME MEASURE The percentage of patients diagnosed as having PTSD who received a prescription for prazosin. RESULTS Whereas 37.6% of patients with PTSD treated within the Veterans Affairs Puget Sound Health Care System, Tacoma, Washington, in 2004 were prescribed prazosin, only 18.2% were treated with prazosin at medical centers up to 499 miles (to convert miles to kilometers, multiply by 1.6) away, 6.7% at centers 500 to 999 miles away, 4.0% at centers 1000 to 2499 miles away, and 1.9% at centers 2500 miles away or farther. Adjusting for patient characteristics, patients with PTSD treated up to 499 miles from Puget Sound were about 49% less likely in 2006 and about 63% less likely in 2004 to be prescribed prazosin than their counterparts treated within Puget Sound, while those who were treated 2500 miles away or farther were about 94% less likely in 2006 and about 97% less likely in 2004 to be treated with prazosin than patients within Puget Sound. CONCLUSION Passive diffusion of a new treatment can be rapid in the immediate area in which it is developed, but the geographic gradient of use seems to be steep and enduring even when cost and organizational barriers are minimal.

Cognitive-behavioral coping strategies associated with combat-related PTSD in treatment-seeking OEF-OIF Veterans.

Posttraumatic stress disorder (PTSD) is associated with intrusive trauma-related thoughts and avoidance behaviors that contribute to its severity and chronicity. This study examined thought control and avoidance coping strategies associated with both a probable diagnosis and symptom severity of combat-related PTSD in a sample of 167 treatment-seeking Operations Enduring Freedom and Iraqi Freedom (OEF-OIF) Veterans. Within one year of returning from deployment, Veterans completed a survey containing measures of combat exposure, coping strategies, psychopathology, and postdeployment social support. Veterans with a positive screen for PTSD scored higher than Veterans without a positive screen for PTSD on measures of worry, self-punishment, social control, behavioral distraction, and avoidance coping strategies. Worry and social avoidance coping were positively related to PTSD symptoms, and greater perceptions of understanding from others were negatively related to these symptoms. A structural equation model revealed that scores on a measure of postdeployment social support were negatively associated with scores on measures of maladaptive cognitive coping (i.e., worry, self-punishment) and avoidance coping (social and non-social avoidance coping) strategies, which were positively associated with combat-related PTSD symptoms. These results suggest that maladaptive thought control and avoidance coping may partially mediate the relation between postdeployment social support and combat-related PTSD symptoms in treatment-seeking OEF-OIF Veterans. Consistent with cognitive therapy models, these findings suggest that interventions that target maladaptive coping strategies such as worry, self-punishment, and social avoidance, and that bolster social support, most notably understanding from others, may help reduce combat-related PTSD symptoms in this population.

Determinants of prospective engagement in mental health treatment among symptomatic Iraq/Afghanistan veterans.

Abstract There is considerable public and professional concern about the mental health status of veterans deployed to Iraq and Afghanistan as well as how to engage and retain symptomatic veterans in treatment. This study examined demographic, psychiatric, and psychosocial determinants of prospective initiation and retention in mental health services among symptomatic Iraq/Afghanistan veterans. One hundred thirty-seven symptomatic veterans who were referred to mental health screening completed a survey at the time of their first mental health visit. Associations between survey variables and subsequent Veterans Affairs service utilization were evaluated. The most consistent determinants of mental health service initiation and retention were severity of posttraumatic stress disorder (PTSD) and depressive symptoms. Notably, whereas PTSD-related re-experiencing symptoms were independently associated with initiation of mental health treatment, PTSD-related numbing symptoms were independently associated with retention in treatment. Stigma, barriers to care, and beliefs about mental health treatment were not associated with either mental health initiation or retention.

Changes in Representations of a Self—Designated Significant Other in Long—Term Intensive Inpatient Treatment of Seriously Disturbed Adolescents and Young Adults

Abstract Blatt and colleagues (1996) found that severity of psychopathology in seriously disturbed, treatment-resistant, hospitalized adolescents at the beginning of treatment was positively correlated with the degree to which these adolescents were involved in describing their parents. At the end of long—term, intensive, psychodynamically oriented, inpatient treatment of these very troubled adolescents, reduction in the severity of psychopathology correlated significantly with increases in the development of the structural organization of descriptions of mother, father, self, and therapist. These findings suggested that treatment of seriously disturbed, treatment-resistant, adolescent and young adult inpatients seems to involve at least two primary dimensions: 1) disengagement from an intense involvement with parents and 2) development in the structural organization of representations of self and a significant new figure, the therapist. The present study extends these earlier findings by examining changes in the description of a “significant other” that each patient elected to describe at the beginning and the end of treatment. Clinical improvement over the course of treatment was significantly correlated with developmental progression of the significant figure each patient selected to describe (from a grandparent to a close friend) as well as with progression in the developmental organization in which this significant other was described. These findings suggest that treatment of seriously disturbed adolescents and young adults involves a disengagement from an intense involvement with primary caregivers to involvement with others outside the family matrix and the developmental elaboration of the representation of these figures.

Pharmacologic Treatment of Posttraumatic Stress Disorder Among Privately Insured Americans

OBJECTIVE Although psychological trauma affects millions of Americans, few studies have examined treatment of posttraumatic stress disorder (PTSD) in real-world service environments. This study explored pharmacological treatment of PTSD among privately insured individuals. METHODS Data were from the MarketScan database, which compiles claims from private health insurance plans nationwide. Descriptive statistics and multivariate logistic regression were used to identify predictors of any use of a psychotropic medication and use of three medication classes: antidepressants, anxiolytics or sedative-hypnotics, and antipsychotics. RESULTS Of 860,090 adult mental health care users in 2005, only 10,636 (1.2%) had a diagnosis of PTSD. Sixty percent of PTSD patients received any psychotropic medication: 74.3% of those received antidepressants, 73.7% received anxiolytics or sedative-hypnotics, and 21.3% received antipsychotics. Greater likelihood of any medication use was associated with greater use of mental health services and with several comorbid psychiatric disorders. Having a comorbid diagnosis of an indicated disorder was the most robust predictor of use of each of the three medication classes: major depressive disorder and dysthymia were most strongly associated with antidepressant use, schizophrenia and bipolar disorder were associated with antipsychotic use, and anxiety disorders were associated with use of anxiolytics or sedative-hypnotics. CONCLUSIONS Psychotropic medications were frequently used in the treatment of PTSD among privately insured clients. Although use targeted specifically to PTSD and to comorbid disorders was common, substantial use appeared to be unrelated to diagnosis and may be targeted at specific symptoms rather than diagnosed illnesses. Further research is needed to determine symptom-specific responses to medications across diagnoses.