Miles McFall

Screening for post-traumatic stress disorder in female Veteran’s Affairs patients: validation of the PTSD checklist

We evaluated the screening validity of a self-report measure for post traumatic stress disorder (PTSD), the PTSD Checklist (PCL), in female Veterans Affairs (VA) patients. All women seen for care at the VA Puget Sound Health Care system from October 1996-January 1999 (n=2,545) were invited to participate in a research interview. Participants (n=282) completed the 17-item PCL, followed by a gold standard diagnostic interview for PTSD, the Clinician Administered PTSD Scale (CAPS). Thirty-six percent of the participants (n=100) met CAPS diagnostic criteria for current PTSD. Receiver Operating Characteristic (ROC) analysis was used to evaluate the screening performance of the PCL. The area under the ROC curve was 0.86 (95% CI 0.82-0.90). A PCL score of 38 optimized the performance of the PCL as a screening test (sensitivity 0.79, specificity 0.79). The PCL performed well as a screening measure for the detection of PTSD in female VA patients.

Post-traumatic stress disorder and smoking: a systematic review.

We conducted a systematic review of what is known about the relationship between post-traumatic stress disorder (PTSD) and smoking to guide research on underlying mechanisms and to facilitate the development of evidence-based tobacco treatments for this population of smokers. We searched Medline, PsychINFO, and the Cochrane Central Register of Controlled Trials and identified 45 studies for review that presented primary data on PTSD and smoking. Smoking rates were high among clinical samples with PTSD (40%-86%) as well as nonclinical populations with PTSD (34%-61%). Most studies showed a positive relationship between PTSD and smoking and nicotine dependence, with odds ratios ranging between 2.04 and 4.52. Findings also suggest that PTSD, rather than trauma exposure itself, is more influential for increasing risk of smoking. A small but growing literature has examined psychological factors related to smoking initiation and maintenance and the overlapping neurobiology of PTSD and nicotine dependence. Observational studies indicate that smokers with PTSD have lower quit rates than do smokers without PTSD. Yet a few tobacco cessation treatment trials in smokers with PTSD have achieved quit rates comparable with controlled trials of smokers without mental disorders. In conclusion, the evidence points to a causal relationship between PTSD and smoking that may be bidirectional. Specific PTSD symptoms may contribute to smoking and disrupt cessation attempts. Intervention studies that test behavioral and pharmacological interventions designed specifically for use in patients with PTSD are needed to reduce morbidity and mortality in this population.

Integrating Tobacco Cessation Into Mental Health Care for Posttraumatic Stress Disorder: A Randomized Controlled Trial

CONTEXT Most smokers with mental illness do not receive tobacco cessation treatment. OBJECTIVE To determine whether integrating smoking cessation treatment into mental health care for veterans with posttraumatic stress disorder (PTSD) improves long-term smoking abstinence rates. DESIGN, SETTING, AND PATIENTS A randomized controlled trial of 943 smokers with military-related PTSD who were recruited from outpatient PTSD clinics at 10 Veterans Affairs medical centers and followed up for 18 to 48 months between November 2004 and July 2009. INTERVENTION Smoking cessation treatment integrated within mental health care for PTSD delivered by mental health clinicians (integrated care [IC]) vs referral to Veterans Affairs smoking cessation clinics (SCC). Patients received smoking cessation treatment within 3 months of study enrollment. MAIN OUTCOME MEASURES Smoking outcomes included 12-month bioverified prolonged abstinence (primary outcome) and 7- and 30-day point prevalence abstinence assessed at 3-month intervals. Amount of smoking cessation medications and counseling sessions delivered were tested as mediators of outcome. Posttraumatic stress disorder and depression were repeatedly assessed using the PTSD Checklist and Patient Health Questionnaire 9, respectively, to determine if IC participation or quitting smoking worsened psychiatric status. RESULTS Integrated care was better than SCC on prolonged abstinence (8.9% vs 4.5%; adjusted odds ratio, 2.26; 95% confidence interval [CI], 1.30-3.91; P = .004). Differences between IC vs SCC were largest at 6 months for 7-day point prevalence abstinence (78/472 [16.5%] vs 34/471 [7.2%], P < .001) and remained significant at 18 months (86/472 [18.2%] vs 51/471 [10.8%], P < .001). Number of counseling sessions received and days of cessation medication used explained 39.1% of the treatment effect. Between baseline and 18 months, psychiatric status did not differ between treatment conditions. Posttraumatic stress disorder symptoms for quitters and nonquitters improved. Nonquitters worsened slightly on the Patient Health Questionnaire 9 relative to quitters (differences ranged between 0.4 and 2.1, P = .03), whose scores did not change over time. CONCLUSION Among smokers with military-related PTSD, integrating smoking cessation treatment into mental health care compared with referral to specialized cessation treatment resulted in greater prolonged abstinence. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00118534.

Health and Health Behavior Differences

BACKGROUND Little is known about health and health behavior differences among military service veterans, active duty service members, National Guard/Reserve members, and civilians. Several important differences were identified among U.S. women from these subpopulations; to identify areas for targeted intervention, studies comparing men from these subpopulations are needed. PURPOSE To compare veteran, military, and civilian men on leading U.S. health indicators. METHODS Data were from the 2010 Behavioral Risk Factor Surveillance Survey, a U.S. population-based study. In 2011, self-reported health outcomes were compared using multivariable logistic regression across male veterans (n=53,406); active duty service members (n=2144); National Guard/Reserve service members (n=3724); and civilians (n=110,116). RESULTS Multivariate logistic regression results are presented. Despite better healthcare access, veterans had poorer health and functioning than civilians and National Guard/Reserve members on several indicators. Veterans also were more likely than those on active duty to report diabetes. Veterans were more likely to report current smoking and heavy alcohol consumption than National Guard/Reserve members and civilian men, and lack of exercise compared to active duty men and National Guard/Reserve members. National Guard/Reserve men had higher levels of obesity, diabetes, and cardiovascular disease (versus active duty and veterans, active duty, and civilians, respectively). Active duty men were more likely to report current smoking and heavy alcohol consumption than civilians and National Guard/Reserve members, and reported more smokeless tobacco use than civilians. CONCLUSIONS Veterans have poorer health and health behaviors; increased prevention efforts are needed from veteran-serving organizations. Despite good health, active duty men reported unhealthy lifestyles, indicating an important area for prevention efforts.

Analysis of violent behavior in Vietnam combat veteran psychiatric inpatients with posttraumatic stress disorder

This study tested the hypothesis that male Vietnam veterans seeking inpatient treatment for PTSD (n = 228) exhibit more violent behavior compared with a mixed diagnostic group of male psychiatric Inpatients without PTSD (n = 64) and a community sample of Vietnam veterans with PTSD not undergoing inpatient treatment (n = 273). Violent acts assessed included property destruction, threats without a weapon, physical fighting, and threats with a weapon. PTSD inpatients engaged in more types of violent behavior than both comparison conditions. Correlates of violence among PTSD inpatients included PTSD symptom severity and, to a lesser degree, measures of substance abuse. These findings justify routine assessment of violent behavior among inpatients with PTSD, as well as application of specialized interventions for anger dyscontrol and aggression.

Research articleHealth and Health Behavior Differences: U.S. Military, Veteran, and Civilian Men

BACKGROUND Little is known about health and health behavior differences among military service veterans, active duty service members, National Guard/Reserve members, and civilians. Several important differences were identified among U.S. women from these subpopulations; to identify areas for targeted intervention, studies comparing men from these subpopulations are needed. PURPOSE To compare veteran, military, and civilian men on leading U.S. health indicators. METHODS Data were from the 2010 Behavioral Risk Factor Surveillance Survey, a U.S. population-based study. In 2011, self-reported health outcomes were compared using multivariable logistic regression across male veterans (n=53,406); active duty service members (n=2144); National Guard/Reserve service members (n=3724); and civilians (n=110,116). RESULTS Multivariate logistic regression results are presented. Despite better healthcare access, veterans had poorer health and functioning than civilians and National Guard/Reserve members on several indicators. Veterans also were more likely than those on active duty to report diabetes. Veterans were more likely to report current smoking and heavy alcohol consumption than National Guard/Reserve members and civilian men, and lack of exercise compared to active duty men and National Guard/Reserve members. National Guard/Reserve men had higher levels of obesity, diabetes, and cardiovascular disease (versus active duty and veterans, active duty, and civilians, respectively). Active duty men were more likely to report current smoking and heavy alcohol consumption than civilians and National Guard/Reserve members, and reported more smokeless tobacco use than civilians. CONCLUSIONS Veterans have poorer health and health behaviors; increased prevention efforts are needed from veteran-serving organizations. Despite good health, active duty men reported unhealthy lifestyles, indicating an important area for prevention efforts.

posttraumatic stress and its relationship to physical health functioning in a sample of Iraq and Afghanistan War veterans seeking postdeployment VA health care.

The relationship between posttraumatic stress and physical health functioning was examined in a sample of Iraq and Afghanistan War veterans seeking postdeployment VA care. Iraq and Afghanistan War veterans (N = 108) who presented for treatment to a specialty postdeployment care clinic completed self-report questionnaires that assessed symptoms of posttraumatic stress disorder (PTSD), chemical exposure, combat exposure, and physical health functioning. As predicted, PTSD symptom severity was significantly associated with poorer health functioning, even after accounting for demographic factors, combat and chemical exposure, and health risk behaviors. These results highlight the unique influence of PTSD on the physical health in treatment seeking Iraq and Afghanistan War veterans.

Behavioral Activation as a Primary Care-Based Treatment for PTSD and Depression Among Returning Veterans

This preliminary study examined treatment-satisfaction and potential therapeutic benefits of Behavioral Activation as a primary care-based treatment for posttraumatic stress disorder (PTSD) and depression among Iraq and Afghanistan War veterans. Eight veterans were enrolled, 6 completed at least 4 sessions, and 5 veterans completed posttreatment and 3-month follow-up assessments after receiving 5-8 weekly sessions of Behavioral Activation delivered in a specialty postdeployment primary care clinic. Significant and meaningful reductions in PTSD symptoms were found on structured clinical assessments and self-report measures. Posttraumatic stress disorder treatment gains (measured by structured clinical assessments) were maintained at 3-month follow-up. The majority of veterans demonstrated meaningful improvements on depression and quality of life and veterans reported a high satisfaction with treatment.

DOES PTSD MODERATE THE RELATIONSHIP BETWEEN SOCIAL SUPPORT AND SUICIDE RISK IN IRAQ AND AFGHANISTAN WAR VETERANS SEEKING MENTAL HEALTH TREATMENT

Objective: This study examined posttraumatic stress disorder (PTSD) as a potential moderating variable in the relationship between social support and elevated suicide risk in a sample of treatment‐seeking Iraq and Afghanistan War Veterans. Method: As part of routine care, self‐reported marital status, satisfaction with social networks, PTSD, and recent suicidality were assessed in Veterans (N=431) referred for mental health services at a large Veteran Affairs Medical Center. Logistic regression analyses were conducted using this cross‐sectional data sample to test predictions of diminished influence of social support on suicide risk in Veterans reporting PTSD. Results: Thirteen percent of Veterans were classified as being at elevated risk for suicide. Married Veterans were less likely to be at elevated suicide risk relative to unmarried Veterans and Veterans reporting greater satisfaction with their social networks were less likely to be at elevated risk relative to Veterans reporting lower satisfaction. Satisfaction with social networks was protective for suicide risk in PTSD and non‐PTSD cases, but was significantly less protective for veterans reporting PTSD. Conclusions: Veterans who are married and Veterans who report greater satisfaction with social networks are less likely to endorse suicidal thoughts or behaviors suggestive of elevated suicide risk. However, the presence of PTSD may diminish the protective influence of social networks among treatment‐seeking Veterans. Depression and Anxiety, 2010. Published 2010 Wiley‐Liss, Inc.

Characteristics of Deployed Operation Iraqi Freedom Military Personnel Who Seek Mental Health Care

INTRODUCTION This study reports on the feasibility of using validated mental health screening instruments for deployed Operation Iraqi Freedom military personnel. METHODS For a 3-month period in 2005, all service members (N=296) who initially presented to the U.S. Military Hospital Kuwait mental health clinic completed an intake questionnaire that gathered demographic information and contained validated instruments to screen for mental disorders and functional impairment. RESULTS A total of 19% of the sample subjects screened positive for post-traumatic stress disorder-related symptoms, 35% for a major depressive disorder, and 11% for severe misuse of alcohol. Significant levels of distress and functional impairment were reported by 58% of the sample. Women represented a disproportionately high percentage of those presenting for care (27%). CONCLUSIONS Screening instruments were well accepted and useful in detecting psychopathological conditions and functional impairment. Female service members might represent a high-risk group. These results are useful for those caring for service members during or after deployment.