Julia M. Whealin

Cognitive–Behavioral Theory and Preparation for Professionals at Risk for Trauma Exposure

Military personnel, emergency first responders, and others whose work environments include exposure to traumatic events are at risk for developing posttraumatic stress disorder (PTSD). To help prevent negative sequelae, there is a strong need to identify well-operationalized, empirically supported, theoretically framed models of healthy adaptation to potentially traumatic events. Cognitive–behavioral theories (CBTs) describe etiological factors in trauma, guide research that has identified risk for PTSD, and help develop interventions that can effectively reduce posttrauma symptomatology. In this article, the authors draw on CBT and empirical research on post-traumatic stress to propose possible cognitive–behavioral mechanisms in trauma adaptation. They then suggest directions for future research, including areas for prevention interventions for at-risk professionals.

Examining the Relation Between Combat-Related Concussion, a Novel 5-Factor Model of Posttraumatic Stress Symptoms, and Health-Related Quality of Life in Iraq and Afghanistan Veterans

OBJECTIVE This study examined demographic, military, and clinical characteristics associated with combat-related concussion and persistent postconcussive symptoms; and how combat-related concussion and persistent postconcussive symptoms and a novel 5-factor model of posttraumatic stress disorder (PTSD) symptoms are related to physical and mental health-related quality of life in veterans who served in Iraq and Afghanistan. METHOD 233 veterans recruited from the Veterans Affairs Hawaii Program Registry who served in Iraq and Afghanistan completed a survey in 2010 that assessed combat-related concussion and persistent postconcussive symptoms, PTSD (DSM-IV criteria), alcohol use problems, and physical and mental health-related quality of life. The primary measure was physical and mental health-related quality of life as assessed by the 12-item Short-Form Health Survey, version 2. RESULTS Veterans who screened positive for combat-related concussion and persistent postconcussive symptoms were more likely than those who did not to report direct combat exposure (χ2 = 15.46, P < .001), living in a rural area (χ2 = 6.86, P < .01), and screening positive for PTSD (χ2 = 37.67, P < .001) and alcohol use problems (χ2 = 11.62, P < .01); 57.3% of veterans who screened positive for combat-related concussion and persistent postconcussive symptoms screened positive for PTSD. In bivariate analyses, combat-related concussion and persistent postconcussive symptoms were associated with lower scores on measures of physical and mental health-related quality of life (r = -0.27 to -0.45, P < .001). In multivariate analyses, combat-related concussion and persistent postconcussive symptoms were no longer related to these outcomes, with PTSD-related dysphoric arousal symptoms as the strongest predictor of physical health-related quality of life (β = -0.55, P < .001) and PTSD-related emotional numbing symptoms (β = -0.56, P < .001) as the strongest predictor of mental health-related quality of life. CONCLUSIONS Results of this study suggest that a 5-factor model of PTSD symptoms may provide greater specificity in understanding the relation between combat-related concussion and persistent postconcussive symptoms, PTSD symptoms, and health-related physical and mental quality of life in Iraq/Afghanistan veterans. Psychiatric clinicians should consider this heterogeneity of PTSD symptoms when assessing and treating symptomatic veterans.

Deployment-related sequelae and treatment utilization in rural and urban war veterans in Hawaii.

This study compared common deployment-related health issues and correlates of mental health service utilization among rural and urban veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) living in Hawaii. Frequency of utilization of a broad range of mental health resources, including clergy/spiritual leaders, videoconference/online programs, and traditional/alternative healers, was also characterized. A random sample of 116 rural and 117 urban ethnoracially diverse veterans completed a mail survey. Rural veterans were more likely than urban veterans to meet screening criteria for posttraumatic stress disorder (PTSD), deployment-related concussion with persistent postconcussive symptoms, and alcohol use problems. Over one third of veterans who desired help for a mental health problem reported no current use of any services. Rural veterans were more likely than urban veterans to have accessed Veteran Readjustment Centers, but they did not differ with respect to utilization of other services. Correlates of mental health service utilization included higher education, PTSD, and lower mental-health-related quality of life. Results of this study underscore the need for dissemination efforts to enable OEF/OIF/OND veterans to access mental health resources.

E-mental health preferences of Veterans with and without probable posttraumatic stress disorder

Mental health care practices supported by electronic communication, referred to as e-mental health, offer ways to increase access to mental health resources. In recent years, e-mental health interventions using clinical video teleconferencing, Internet-based interventions, social networking sites, and telephones have emerged as viable, cost-effective methods to augment traditional service delivery. Whereas some research evaluates attitudes about e-mental health, few studies have assessed interest in using these approaches in a contemporary sample of U.S. Veterans. This study sought to understand willingness to use e-mental health in a diverse group of Veterans residing in Hawaii. Mailed surveys were completed by 600 Operation Iraqi Freedom/Operation Enduring Freedom Veterans and National Guard members. Results suggest that overall willingness to use e-mental health ranged from 32.2% to 56.7% depending on modality type. Importantly, Veterans who screened positive for posttraumatic stress disorder (PTSD) were significantly less likely to report willingness to use each e-mental health modality than their peers without PTSD, despite their greater desire for mental health services. These results suggest that despite solutions to logistical barriers afforded via e-mental health services, certain barriers to mental health care may persist, especially among Veterans who screen positive for PTSD.

A pilot trial of telephone-based collaborative care management for PTSD among Iraq/Afghanistan war veterans

BACKGROUND Collaborative care and care management are cornerstones of Primary Care-Mental Health Integration (PC-MHI) and have been shown to reduce depressive symptoms. Historically, the standard of Veterans Affairs (VA) collaborative care was referring patients with posttraumatic stress disorder (PTSD) to specialty care. Although referral to evidence-based specialty care is ideal, many veterans with PTSD do not receive such care. To address this issue and reduce barriers to care, VA currently recommends veterans with PTSD be offered treatment within PC-MHI as an alternative. The current project outlines a pilot implementation of an established telephone-based collaborative care model-Translating Initiatives for Depression into Effective Solutions (TIDES)-adapted for Iraq/Afghanistan War veterans with PTSD symptoms (TIDES/PTSD) seen in a postdeployment primary care clinic. MATERIALS AND METHODS Structured medical record extraction and qualitative data collection procedures were used to evaluate acceptability, feasibility, and outcomes. RESULTS Most participants (n=17) were male (94.1%) and white (70.6%). Average age was 31.2 (standard deviation=6.4) years. TIDES/PTSD was successfully implemented within PC-MHI and was acceptable to patients and staff. Additionally, the total number of care manager calls was positively correlated with number of psychiatry visits (r=0.63, p<0.05) and amount of reduction in PTSD symptoms (r=0.66, p<0.05). Overall, participants in the pilot reported a significant reduction in PTSD symptoms over the course of the treatment (t=2.87, p=0.01). CONCLUSIONS TIDES can be successfully adapted and implemented for use among Iraq/Afghanistan veterans with PTSD. Further work is needed to test the effectiveness and implementation of this model in other sites and among veterans of other eras.

Asian American and Pacific Islander Military Veterans in the United States: Health Service Use and Perceived Barriers to Mental Health Services

OBJECTIVES We (1) compared use of various health services nationally between Asian American and Pacific Islander (AA/PI) veterans and veterans of other racial/ethnic groups and (2) specifically compared perceived barriers and stigma related to mental health services. METHODS Using bivariate and multivariable statistics, we analyzed a population-weighted sample of 8315 veterans from the 2010 National Survey of Veterans and a random sample of 567 recent veterans from Hawaii. RESULTS A total of 1.5% of veterans were AA/PI compared with 0.4% a decade ago. Compared with other veterans, AA/PI veterans reported higher socioeconomic status and better mental health, although these findings may be specific to AA veterans. Adjusting for sociodemographic and health differences, we found no differences in health service use or perceived barriers or stigma related to mental health services. CONCLUSIONS AA/PIs are a small but fast-growing racial/ethnic group within the veteran population that deserves attention. Although veteran status may be protective against some barriers to mental health care found in the general AA/PI population, efforts to reduce barriers to health care among veterans should be continued.

Diverse veterans’ pre- and post-intervention perceptions of home telemental health for posttraumatic stress disorder delivered via tablet

Objectives Home telemental health services have the potential to overcome many individual and systemic barriers to care facing military veterans with posttraumatic stress disorder. However, little is known about the home telemental health-related attitudes and experiences of highly underserved rural or ethnically, racially diverse veterans. This study evaluated whether ethnically/racially diverse U.S. veterans residing in the rural Pacific Islands would find the delivery of evidence-based treatment for posttraumatic stress disorder via home telemental health tablet devices useful and helpful. Method Clinicians located in a central urban location delivered Cognitive Processing Therapy for posttraumatic stress disorder directly into patients’ homes via a tablet device and secure WiFi connection. Pre- and post-treatment measures were collected from a clinical sample of 47 veterans (average age: 49.3 years). Most (74.4%) self-identified as being of ethnic/racial minority background. Attitudinal, satisfaction, and usability scales were collected from home telemental health engaging (n = 29) and non-engaging (n = 18) veterans. Results Ratings on measures of home telemental health comfort, satisfaction with care, and usability were uniformly positive. Veterans were equally open to receiving mental health services at home via home telemental health or in the clinic. In the case of services for a physical problem, however, veterans preferred in-clinic care. Following treatment, veterans’ attitudinal scores increased on items such as “There is enough therapist contact in home telemental health interventions.” However, a small portion of veterans (7%) reported having technical or privacy concerns. Conclusion The provision of evidence-based posttraumatic stress disorder treatment directly into the patients’ homes proved feasible and was well received by the large majority of rural ethnically/racially diverse veterans.

Risk and resilience factors associated with posttraumatic stress in ethno-racially diverse National Guard members in Hawai׳i

This study examinedrisk and resilience factors associated with posttraumatic stress symptomatology (PTSS) in an ethno-racially diverse sample of Hawai׳i National Guard members comprised of Native Hawaiians, Filipino Americans, Japanese Americans, and European Americans. In the full sample, identifying as Japanese American and higher scores on measures of perceived social support and psychological resilience were negatively associated with PTSS, while Army Guard (vs. Air Guard) status and stronger family norms against disclosing mental health problems were positively associated with PTSS. Exploratory analyses of ethno-racial subgroups identified different patterns of within and between-group correlates of PTSS. For example, when controlling for other factors, higher psychological resilience scores were negatively associated with PTSS only among Native Hawaiian and European Americans. Overall, results of this study suggest that some risk and resilience factors associated with posttraumatic stress disorder (PTSD) may extend to military populations with high numbers of Filipino American, Japanese American, and Native Hawaiian Veterans. Results further suggest differences in risk and resilience factors unique to specific ethno-racial subgroups.

Factors impacting rural Pacific Island veterans’ access to care: A qualitative examination.

Pacific Island veterans suffer from greater severity of posttraumatic stress disorder (PTSD) compared with Caucasian veterans but face substantial barriers to mental health care. However, the factors that may dissuade or facilitate veterans in the Pacific Islands from seeking mental health care are not known. The main aim of this study was to identify how internal and external factors interact to impact wounded warriors’ access to and use of mental health services. Veterans residing in 5 rural Pacific Island locations were mailed recruitment materials. Other veterans were made aware of the project by key stakeholders in their communities. Thirty-seven male veterans (across 5 focus groups) and 1 female veteran (via individual interview) participated. The study utilized an analytic design in which taped focus group discussions were transcribed verbatim and coded for major themes. Results indicated that most veterans identified Veterans Affairs (VA) as a positive source for health care. However, common concerns acknowledged were as follows: (a) difficulty navigating the VA system, (b) time associated with receiving care, (c) family stigma, (d) community stigma, (e) cultural differences, and (f) a lack of knowledge about VA services and benefits. Facilitators of care included the following: (a) individual knowledge and self-efficacy, (b) networking with other veterans, (c) family support, and (d) rural community support. All factor levels interacted in subtle ways to ultimately impact access to care. Next steps are described, including projects designed to better meet the needs of rural Pacific Island veterans.

Factors protecting against the development of suicidal ideation in military veterans

the 2013 National Survey on Drug Use and Health: summary of national findings. Rockville: Substance Abuse and Mental Health Services Administration, 2014. 2. Enggasser JL, Hermos JA, Rubin A et al. Addict Behav 2015;42:63-8. 3. Witkiewitz K, Pearson MR, Hallgren KA et al. Addiction (in press) 4. van Amsterdam J, van den Brink W. J Psychopharmacol 2013;27:987-97. 5. Charlet K, Heinz A. Addict Biol (in press) 6. Witkiewitz K, Hallgren KA, Kranzler HR et al. Alcohol Clin Exp Res 2017;41: 179-86. 7. Hasin DS, Wall M, Witkiewitz K et al. Lancet Psychiatry 2017;4:469-76.