Patricia M. Kinneer

Correlates of Anger and Hostility in Iraq and Afghanistan War Veterans

OBJECTIVE As troops return from Iraq and Afghanistan to civilian life, clinicians are starting to grapple with how best to detect those at risk of postdeployment adjustment problems. Data reveal the presence of mental health problems in these soldiers, including posttraumatic stress disorder (PTSD), head injury, and alcohol abuse. Each of these conditions has been associated with elevated anger and hostility in veterans from previous conflicts. The authors sought to identify variables empirically related to anger and hostility in Iraq and Afghanistan veterans. METHOD A total of 676 veterans who served since September 11, 2001, and who volunteered to participate in research studies were interviewed with instruments designed to collect information on psychiatric symptoms, health, and possible postdeployment adjustment issues. The primary outcome measures were variables measuring aggressive impulses or urges, difficulty managing anger, and perceived problems controlling violent behavior. RESULTS The three outcome measures were each significantly associated with PTSD hyperarousal symptoms. Other PTSD symptoms were less strongly and less consistently linked to anger and hostility. Traumatic brain injury and alcohol misuse were related to the outcome variables in bivariate but not multivariate analyses. Distinct sets of demographic, historical, and military-related variables were associated with the different facets of anger and hostility measured. CONCLUSIONS The results underscore the need to tailor interventions individually to address anger and hostility effectively and to develop theoretically sophisticated, evidence-based knowledge to identify service members at risk of problematic postdeployment adjustment.

Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey

OBJECTIVE This study analyzed data from a national survey of Iraq and Afghanistan veterans to improve understanding of mental health services use and perceived barriers. METHODS The National Post-Deployment Adjustment Survey randomly sampled post-9/11 veterans separated from active duty or in the Reserves or National Guard. The corrected response rate was 56% (N=1,388). RESULTS Forty-three percent screened positive for posttraumatic stress disorder (PTSD), major depression, or alcohol misuse. Past-year psychiatric treatment was reported by 69% of the PTSD group, 67% of the depression group, and 45% of those with alcohol misuse. Most received care at Veterans Affairs (VA) facilities, although women were more likely than men to seek non-VA services. Veterans with more severe symptoms reported greater treatment utilization. Eighteen percent saw a pastoral counselor (chaplain) in the past year. Veterans with mental health needs who did not access treatment were more likely to believe that they had to solve problems themselves and that medications would not help. Those who had accessed treatment were more likely to express concern about being seen as weak by others. CONCLUSIONS Veterans in greatest need were more likely to access services. More than two-thirds with probable PTSD obtained past-year treatment, mostly at VA facilities. Treatment for veterans may be improved by increasing awareness of gender differences, integrating mental health and pastoral services, and recognizing that alcohol misuse may reduce utilization. Veterans who had and had not used services endorsed different perceptions about treatment, indicating that barriers to accessing care may be distinct from barriers to engaging in care.

Evaluation of the patient-reported outcomes measurement information system in a large cohort of patients with inflammatory bowel diseases.

BACKGROUND & AIMS Patient-reported outcomes (PROs) convey important aspects of health status, complementing physician-reported measures. The PRO Measurement Information System (PROMIS) provides valid, widely available measures applicable to patients with chronic illness and the general population. We sought to evaluate these measures in a large cohort of patients with inflammatory bowel disease (IBD). METHODS By using data from the Crohns and Colitis Foundation Association Partners internet cohort, we performed cross-sectional and longitudinal analyses to evaluate associations between PROMIS measures and validated disease activity indices (Short Crohns Disease Activity Index and Simple Clinical Colitis Activity Index) and the Short IBD Questionnaire quality-of-life instrument. RESULTS A total of 10,634 individuals (6689 with Crohns disease and 3945 with ulcerative colitis or indeterminate colitis) completed PRO testing. Compared with the general population (mean PROMIS score, 50), IBD patients in this cohort reported more depression (mean, 54), anxiety (mean, 52), fatigue (mean, 56), sleep disturbance (mean, 52), and pain interference (mean, 53); and they had less social satisfaction (mean, 48). In each PROMIS domain, there was worse functioning with increasing levels of disease activity and worsening Short IBD Questionnaire scores (P < .001 for all). Longitudinal analyses showed improved PROMIS scores with improved disease activity and worsening PROMIS scores with worsening disease (P < .001 for all comparisons). CONCLUSIONS In a cross-sectional and longitudinal study, we observed differences between patients with IBD and the general population in several important aspects of health. The improvement in diverse health outcome measures with improved disease control provides strong support for the construct validity of PROMIS measures in the IBD population. Their use should advance patient-centered outcomes research in IBD.

Improving risk assessment of violence among military Veterans: An evidence-based approach for clinical decision-making

Increased media attention to post-deployment violence highlights the need to develop effective models to guide risk assessment among military Veterans. Ideally, a method would help identify which Veterans are most at risk for violence so that it can be determined what could be done to prevent violent behavior. This article suggests how empirical approaches to risk assessment used successfully in civilian populations can be applied to Veterans. A review was conducted of the scientific literature on Veteran populations regarding factors related to interpersonal violence generally and to domestic violence specifically. A checklist was then generated of empirically-supported risk factors for clinicians to consider in practice. To conceptualize how these known risk factors relate to a Veterans violence potential, risk assessment scholarship was utilized to develop an evidence-based method to guide mental health professionals. The goals of this approach are to integrate science into practice, overcome logistical barriers, and permit more effective assessment, monitoring, and management of violence risk for clinicians working with Veterans, both in Department of Veteran Affairs settings and in the broader community. Research is needed to test the predictive validity of risk assessment models. Ultimately, the use of a systematic, empirical framework could lead to improved clinical decision-making in the area of risk assessment and potentially help prevent violence among Veterans.

Development of an internet-based cohort of patients with inflammatory bowel diseases (CCFA Partners): Methodology and initial results

Background: The widespread use of the Internet allows for unique research opportunities. We aimed to develop and follow an Internet‐based cohort (e‐cohort) of patients with self‐reported inflammatory bowel diseases (IBD) over time. Methods: We established an e‐cohort of adults with IBD (CCFA Partners) by recruiting through Crohns and Colitis Foundation of America (CCFA) email rosters, CCFA Website promotion, social media, and other publicity mechanisms. The baseline survey included modules on disease course and activity, diet and exercise, and patient‐reported outcomes (PROs). Baseline characteristics of the cohort are summarized using descriptive statistics. Results: A total of 7819 adults with IBD joined CCFA Partners through August, 2011. The median age was 42 years (interquartile range [IQR] 30–54), 5074 (72.3%) were female. A total of 4933 (63.1%) had Crohns disease (CD), 2675 (34.2%) had ulcerative colitis (UC), and 211 (2.7%) had IBD unspecified. For CD, the mean short CD Activity Index (CDAI) was 151.9 (standard deviation [SD] 106.4), with 2274 (59.4%) in remission. For UC, the mean simple clinical colitis activity index (SCCAI) was 3.6 (SD 2.8), with 937 (42.9%) in remission. The mean short IBD questionnaire (SIBDQ) score was 48.7 (SD 11.8). SIBDQ was inversely correlated with disease activity (P < 0.01). The mean Morisky medication adherence score (MMAS) was 5.7 (SD 2.0). MMAS scores were inversely correlated with disease activity (P < 0.01). Conclusions: CCFA Partners is a novel e‐cohort. Enrollment is ongoing, with surveys twice yearly. CCFA Partners represents a unique resource to study PROs and changes in disease management over time. (Inflamm Bowel Dis 2012;)

Association between Patient Race/Ethnicity and Perceived Interpersonal Aspects of Care in the Emergency Department

Objectives To determine if perceptions of interpersonal aspects of care in the emergency department (ED) vary by patient race/ethnicity. Methods Patients in a tertiary care academic ED responded to a 22-question survey focusing on interpersonal care aspects: affiliation, satisfaction, trust and participation. Scores for each of the four generated scales were compared in terms of race, ethnicity and other basic demographics. Results African-American patients demonstrated significantly lower mean scores for trust of healthcare providers than Caucasians and significantly lower levels of participation. African-American race/ethnicity continued to be a significant predictor of lower levels of trust (but not participation) after accounting for age, gender, education, household income, health insurance, healthcare received in last six months and route of referral to the ED. Conclusion Preliminary evidence suggests that African Americans may feel less trust toward their ED providers. Understanding this phenomenon and teaching providers how to reduce distrust may translate into better patient compliance/outcomes and reduce healthcare disparities.