Joseph Kulas

MRSI of the medial temporal lobe at 7 T in explosive blast mild traumatic brain injury

Up to 19% of veterans returning from the wars in Iraq and Afghanistan have a history of mild traumatic brain injury with 70% associated with blast exposure. Tragically, 20–50% of this group reports persistent symptoms, including memory loss. Unfortunately, routine clinical imaging is typically normal, making diagnosis and clinical management difficult. The goal of this work was to develop methods to acquire hippocampal MRSI at 7 T and evaluate their sensitivity to detect injury in veterans with mild traumatic brain injury.

Concussive brain injury from explosive blast

Explosive blast mild traumatic brain injury (mTBI) is associated with a variety of symptoms including memory impairment and posttraumatic stress disorder (PTSD). Explosive shock waves can cause hippocampal injury in a large animal model. We recently reported a method for detecting brain injury in soldiers with explosive blast mTBI using magnetic resonance spectroscopic imaging (MRSI). This method is applied in the study of veterans exposed to blast.

Incidence of Mental Health Diagnoses in Veterans of Operations Iraqi Freedom, Enduring Freedom, and New Dawn, 2001–2014

OBJECTIVES To evaluate gender, age, and race/ethnicity as predictors of incident mental health diagnoses among Operations Iraqi Freedom, Enduring Freedom, and New Dawn veterans. METHODS We used US Veterans Health Administration (VHA) electronic health records from 2001 to 2014 to examine incidence rates and sociodemographic risk factors for mental health diagnoses among 888 142 veterans. RESULTS Posttraumatic stress disorder (PTSD) was the most frequently diagnosed mental health condition across gender and age groups. Incidence rates for all mental health diagnoses were highest at ages 18 to 29 years and declined thereafter, with the exceptions of major depressive disorder (MDD) in both genders, and PTSD among women. Risk of incident bipolar disorder and MDD diagnoses were greater among women; risk of incident schizophrenia, and alcohol- and drug-use disorders diagnoses were greater in men. Compared with Whites, risk incident PTSD, MDD, and alcohol-use disorder diagnoses were lower at ages 18 to 29 years and higher at ages 45 to 64 years for both Hispanics and African Americans. CONCLUSIONS Differentiating high-risk demographic and gender groups can lead to improved diagnosis and treatment of mental health diagnoses among veterans and other high-risk groups.

Group cognitive-behavioral therapy for insomnia delivered to veterans with posttraumatic stress disorder receiving residential treatment is associated with improvements in sleep independent of changes in posttraumatic stress disorder.

This chart review examined the effects of a six-session cognitive-behavioral therapy for insomnia (CBT-I) group in a sample of veterans diagnosed with posttraumatic stress disorder (PTSD) receiving residential PTSD treatment. Earliest-session scores on self-report sleep variables were compared to final-session scores among the 47 veterans who received at least five group sessions. Separate analyses were performed for the 39 veterans for whom the PTSD Checklist (PCL-M) scores before and after CBT-I were available, with change in the PCL-M score (10-point decrease or not) as a factor. Repeated-measures analyses of variance indicated significant improvements in the time awake after sleep onset, F(1, 46) = 4.17, p < .05; time in bed, F(1, 46) = 4.06, p < .05; sleep efficiency, F(1, 46) = 4.71, p < .05; and Insomnia Severity Index score, F(1, 46) = 38.8, p < .001. There were no significant effects for sleep onset latency or total sleep time. For veterans with available PCL-M scores, there were no significant interactions between PTSD score change and any of the sleep variables analyzed. These results add to the literature indicating that CBT-I is an effective treatment for insomnia with veterans diagnosed with PTSD. The suitability of CBT-I in residential treatment settings is also discussed.

A Comparison of Veterans with Post-traumatic Stress Disorder, with Mild Traumatic Brain Injury and with Both Disorders: Understanding Multimorbidity

Introduction Mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) are common military service-related conditions diagnosed both singly and together in veterans returning from recent military conflicts overseas. The impact of these disorders in real-world Veterans Health Administration practice has not been studied extensively, and few studies have examined the association of these disorders both by themselves and together with sociodemographic characteristics, psychiatric and medical comorbidities, health service utilization, and psychotropic medication fills. This study aims to add to the broader study of multimorbidity and the impact it has on patient care. Materials and Methods This study used a national Veterans Health Administration sample (N = 164,884) to compare characteristics of veterans diagnosed with mTBI, PTSD, and with both disorders. Relative rates of diagnosis with psychiatric and medical disorders, utilization of medical and psychiatric services, and prescription rates of psychotropic medication fills were examined to determine the impact that the disorders had on these rates, both in isolation and together. Results With few exceptions, diagnosis with PTSD, both alone and in the presence of mTBI, was associated with greater risk of comorbid psychiatric diagnosis, higher service utilization, and greater psychotropic medication fills. Notable correlates specific to mTBI included headache, seizure disorder, paraplegia, and cerebrovascular accident. Conclusion PTSD thus plays the dominant role in the development of psychiatric difficulties and service use independently of mTBI. The recognition of the central importance of psychiatric difficulties in the functional outcomes of individuals who have experienced an mTBI suggests a need to assure access of veterans to psychiatric treatment services.

Increase in migraine diagnoses and guideline-concordant treatment in veterans, 2004-2012.

Background and aim Health administrators, policy makers, and educators have attempted to increase guideline adherence of migraine medications while reducing inappropriate use of opioid- and barbiturate-containing medications. We evaluated the burden of migraine and proportion of guideline-concordant care in a large, national health care system over time. Methods We conducted a time-series study using data from the Veterans Health Administration (VHA) electronic health record. Veterans with migraines were identified by ICD-9 code (346.X). Prescriptions and comorbid conditions were evaluated before and after migraine diagnosis. Chi-square tests and logistic regression were performed. Results A total of 57,064 veterans were diagnosed with migraine headache (5.3%), with women significantly more likely diagnosed (11.6% vs. 4.4%, p < 0.0001). The number of veterans diagnosed with migraine has significantly increased over the years. By 2012, triptans were prescribed to 43% of people with migraine, with no difference by gender. However, triptan prescriptions increased from 2004 to 2012 in men, but not women, veterans. Preventive medicines showed a significant increase with the year of migraine diagnosis, after controlling for age, sex, race, and for comorbidities treated with medications used for migraine prevention. Conclusions The burden of migraines is increasing within the VHA, with a corresponding increase in the delivery of guideline-concordant acute and prophylactic migraine-specific medication.

Clinical utility of the memory complaints inventory to detect invalid test performance

Abstract Objective: This investigation was designed to examine the classification statistics of Memory Complaints Inventory (MCI) scores relative to the Medical Symptom Validity Test (MSVT) and the Non-Verbal Medical Symptom Validity Test (NV-MSVT), as well as various validity scales on the Personality Assessment Inventory (PAI) and Minnesota Multiphasic Personality Inventory-2 Restructured Form(MMPI-2-RF). Method: The sample consisted of 339 active duty service members with a history of concussion who completed performance validity tests (PVTs), symptom validity tests (SVTs), and the MCI. Results: Those who failed the MSVT and NV-MSVT had significantly higher scores across all MCI scales. In addition, those who scored above specified cut scores on the evaluated PAI and MMPI-2-RF validity scales also had significantly higher MCI scale scores. Receiver operator characteristics analysis demonstrated acceptable area under the curve (AUC) across the evaluated SVTs for the mean of all MCI subtests with values ranging from (.77 to .86), with comparable findings for PVTs (MSVT AUC = .75; NV-MSVT AUC = .72). Conclusions: In general the MCI scales demonstrated better classification statistics relative to SVTs vs. PVTs, which is consistent with the nature of the MCI as a self-report instrument.