Patrick S. Calhoun

The diagnostic accuracy of the PTSD checklist: a critical review.

The PTSD Checklist (PCL) is the most frequently used self-report measure of PTSD symptoms. Although the PCL has been in use for nearly 20 years and over a dozen validation studies have been conducted, this paper provides the first comprehensive review of its diagnostic utility. Eighteen diagnostic accuracy studies of the PCL are presented, followed by an examination of the potential roles of spectrum effects, bias, and prevalence in understanding the variation in sensitivity, specificity, and other operating characteristics across these studies. Two related issues as to the interchangeability of the PCLs three versions (civilian, military, and specific) and various scoring methods are also discussed. Findings indicate that the PCL has several strengths as a PTSD screening test and suggest that it can be a useful tool when followed by a second-tier diagnostic test such as a standardized interview. However, the PCLs operating characteristics demonstrate significant variation across populations, settings, and research methods and few studies have examined such factors that may moderate the PCLs utility. Recommendations and cautions regarding the use of the PCL as a clinical screening test, a diagnostic tool in research, and as an estimator of PTSD population prevalence are provided.

Caregiver burden and psychological distress in partners of veterans with chronic posttraumatic stress disorder

Caregiver burden and psychological distress were examined in a sample of 71 partners of Vietnam War combat veterans. Partners of patients (n = 51) diagnosed with posttraumatic stress disorder (PTSD) experienced more caregiver burden and had poorer psychological adjustment than did partners of veterans without PTSD (n = 20). Among PTSD caregivers, patient PTSD symptom severity and level of interpersonal violence were associated with increased caregiver burden. When accounting for patient PTSD symptom severity, hostility, presence of major depression, level of interpersonal violence, and health complaints, only PTSD severity was uniquely associated with caregiver burden. Caregiver sociodemographic factors including age, race, education, and the availability of social support, did not moderate the relationship between PTSD symptom severity and caregiver burden. Caregiver burden was strongly related to spouse psychological adjustment.

Posttraumatic Stress Disorder, Cardiovascular, and Metabolic Disease: A Review of the Evidence

BackgroundPosttraumatic stress disorder (PTSD) is a significant risk factor for cardiovascular and metabolic disease.PurposeThe purpose of the current review is to evaluate the evidence suggesting that PTSD increases cardiovascular and metabolic risk factors, and to identify possible biomarkers and psychosocial characteristics and behavioral variables that are associated with these outcomes.MethodsA systematic literature search in the period of 2002–2009 for PTSD, cardiovascular disease, and metabolic disease was conducted.ResultsThe literature search yielded 78 studies on PTSD and cardiovascular/metabolic disease and biomarkers.ConclusionsAlthough the available literature suggests an association of PTSD with cardiovascular disease and biomarkers, further research must consider potential confounds, incorporate longitudinal designs, and conduct careful PTSD assessments in diverse samples to address gaps in the research literature. Research on metabolic disease and biomarkers suggests an association with PTSD, but has not progressed as far as the cardiovascular research.

The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans: A meta-analysis

Literature on posttraumatic stress disorder (PTSD) prevalence among Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans report estimates ranging from 1.4% to 60%. A more precise estimate is necessary for projecting healthcare needs and informing public policy. This meta-analysis examined 33 studies published between 2007 and 2013 involving 4,945,897 OEF/OIF veterans, and PTSD prevalence was estimated at 23%. Publication year and percentage of Caucasian participants and formerly active duty participants explained significant variability in prevalence across studies. PTSD remains a concern for a substantial percentage of OEF/OIF veterans. To date, most studies have estimated prevalence among OEF/OIF veterans using VA medical chart review. Thus, results generalize primarily to the prevalence of PTSD in medical records of OEF/OIF veterans who use VA services. Additional research is needed with randomly selected, representative samples administered diagnostic interviews. Significant financial and mental health resources are needed to promote recovery from PTSD.

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.

Association of trauma exposure with psychiatric morbidity in military veterans who have served since September 11, 2001

OBJECTIVE This study examined the association of lifetime traumatic stress with psychiatric diagnostic status and symptom severity in veterans serving in the US military after 9/11/01. METHOD Data from 356 US military veterans were analyzed. Measures included a standardized clinical interview measure of psychiatric disorders, and paper-and-pencil assessments of trauma history, demographic variables, intellectual functioning, posttraumatic stress disorder (PTSD) symptoms, depression, alcohol misuse, and global distress. RESULTS Ninety-four percent of respondents reported at least one traumatic stressor meeting DSM-IV criterion A for PTSD (i.e., life threatening event to which the person responded with fear, helplessness or horror), with a mean of four criterion A traumas. Seventy-one percent reported serving in a war-zone, with 50% reporting occurrence of an event meeting criterion A. The rate of current psychiatric disorder in this sample was: 30% PTSD, 20% major depressive disorder, 6% substance abuse or dependence and 10% for the presence of other Axis I psychiatric disorders. After accounting for demographic covariates and combat exposure, childhood physical assault and accident/disasters were most consistently associated with increased likelihood of PTSD. However, PTSD with no comorbid major depressive disorder or substance use disorder was predicted only by combat exposure and adult physical assault. Medical/unexpected-death trauma and adult physical assault were most consistently associated with more severe symptomatology. CONCLUSIONS Particular categories of trauma were differentially associated with the risk of psychiatric diagnosis and current symptom severity. These findings underscore the importance of conducting thorough assessment of multiple trauma exposures when evaluating recently post-deployed veterans.

Statistical procedures for analyzing mental health services data.

In mental health services research, analyzing service utilization data often poses serious problems, given the presence of substantially skewed data distributions. This article presents a non-technical introduction to statistical methods specifically designed to handle the complexly distributed datasets that represent mental health service use, including Poisson, negative binomial, zero-inflated, and zero-truncated regression models. A flowchart is provided to assist the investigator in selecting the most appropriate method. Finally, a dataset of mental health service use reported by medical patients is described, and a comparison of results across several different statistical methods is presented. Implications of matching data analytic techniques appropriately with the often complexly distributed datasets of mental health services utilization variables are discussed.

The validity and diagnostic efficiency of the Davidson Trauma Scale in military veterans who have served since September 11th, 2001

The present study examined the psychometric properties and diagnostic efficiency of the Davidson Trauma Scale (DTS), a self-report measure of posttraumatic stress disorder (PTSD) symptoms. Participants included 158 U.S. military veterans who have served since September 11, 2001 (post-9/11). Results support the DTS as a valid self-report measure of PTSD symptoms. The DTS demonstrated good internal consistency, concurrent validity, and convergent and divergent validity. Diagnostic efficiency was excellent when discriminating between veterans with PTSD and veterans with no Axis I diagnosis. However, although satisfactory by conventional standards, efficiency was substantially attenuated when discriminating between PTSD and other Axis I diagnoses. Thus, results illustrate that potency of the DTS as a diagnostic aid was highly dependent on the comparison group used for analyses. Results are discussed in terms of applications to clinical practice and research.

Smoking Cessation Interventions for Patients with Depression: A Systematic Review and Meta-analysis

OBJECTIVESWe conducted a systematic literature review of smoking cessation interventions for patients with histories of depressive disorders or current significant depressive symptoms. We examined the comparative effectiveness of smoking cessation strategies on abstinence rates, differential effects of cessation strategies by depression status (i.e., history positive vs. current depression), and differential effects by gender.DATA SOURCESPeer-reviewed literature in MEDLINE, Embase, PsycINFO, and Cochrane Library.Study eligibility criteria, participants, and interventionsRandomized controlled trials or secondary analysis of RCT data comparing two or more smoking cessation interventions or intervention to control, and reporting cessation outcomes in adults with depression.STUDY APPRAISAL AND SYNTHESIS METHODSTwo trained researchers screened articles for inclusion. When possible, we estimated pooled risk ratios with 95% confidence intervals by using a random effects model with the Mantel–Haenszel method. We synthesized other studies qualitatively. We classified each intervention as antidepressants, nicotine replacement therapy (NRT), brief smoking cessation counseling, smoking cessation behavioral counseling, or behavioral mood management.RESULTSWe identified 16 unique RCTs, of which, only three trials recruited participants with current depression. Meta-analysis demonstrated a small, positive effect of adding behavioral mood management (RR = 1.41, 95% CI 1.01–1.96). All included antidepressant trials showed small, positive effects, but risk ratio summary was not significant (RR = 1.31, 95% CI 0.73–2.34). Three NRT trials demonstrated small, positive effects on smoking cessation rates. We found insufficient evidence to examine gender and depression status moderator effects.LIMITATIONSFew RCTs exist that test smoking cessation interventions among adults with depression. To make meaningful comparisons, we created broad intervention categories that contained heterogeneity.CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGSFew trials enrolled smokers with current depression. Most of data identified were from subgroup analyses of patients history-positive for depression. However, several promising interventions exist. Healthcare providers should consider encouraging their patients with significant depressive symptoms or depression histories to seek smoking cessation services that include NRT and behavioral mood management.

Factorial Invariance of Posttraumatic Stress Disorder Symptoms Across Three Veteran Samples

Research generally supports a 4-factor structure of posttraumatic stress disorder (PTSD) symptoms. However, few studies have established factor invariance by comparing multiple groups. This study examined PTSD symptom structure using the Davidson Trauma Scale (DTS) across three veteran samples: treatment-seeking Vietnam-era veterans, treatment-seeking post-Vietnam-era veterans, and Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veteran research participants. Confirmatory factor analyses of DTS items demonstrated that a 4-factor structural model of the DTS (reexperiencing, avoidance, numbing, and hyperarousal) was superior to five alternate models, including the conventional 3-factor model proposed by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994). Results supported factor invariance across the three veteran cohorts, suggesting that cross-group comparisons are interpretable. Implications and applications for DSM-IV nosology and the validity of symptom measures are discussed.