Rachel Kimerling

The primary care PTSD screen (PC-PTSD): development and operating characteristics

Posttraumatic stress disorder (PTSD) is a frequently unrecognized anxiety disorder in primary care settings. This study reports on the development and operating characteristics of a brief 4-item screen for PTSD in primary care (PC-PTSD). 188 VA primary care patients completed the PC-PTSD, the PTSD Symptom Checklist (PCL) and the Clinician Administered Scale for PTSD (CAPS). The prevalence of PTSD was 24.5%. Signal detection analyses showed that with this base rate, the PC-PTSD had an optimally efficient cutoff score of 3 for both male and female patients. A cutoff score of 2 is recommended when sensitivity rather than efficiency is optimized. The PC-PTSD outperformed the PCL in terms of overall quality, sensitivity, specificity, efficiency, and quality of efficiency. The PC-PTSD appears to be a psychometrically sound screen for PTSD with comparable operating characteristtics to other screens for mental disorders.

The Veterans Health Administration and Military Sexual Trauma

OBJECTIVES We examined the utility of the Veterans Health Administration (VHA) universal screening program for military sexual violence. METHODS We analyzed VHA administrative data for 185,880 women and 4139888 men who were veteran outpatients and were treated in VHA health care settings nationwide during 2003. RESULTS Screening was completed for 70% of patients. Positive screens were associated with greater odds of virtually all categories of mental health comorbidities, including posttraumatic stress disorder (adjusted odds ratio [AOR]=8.83; 99% confidence interval [CI] = 8.34, 9.35 for women; AOR = 3.00; 99% CI = 2.89, 3.12 for men). Associations with medical comorbidities (e.g., chronic pulmonary disease, liver disease, and for women, weight conditions) were also observed. Significant gender differences emerged. CONCLUSIONS The VHA policies regarding military sexual trauma represent a uniquely comprehensive health care response to sexual trauma. Results attest to the feasibility of universal screening, which yields clinically significant information with particular relevance to mental health and behavioral health treatment. Womens health literature regarding sexual trauma will be particularly important to inform health care services for both male and female veterans.

Military-Related Sexual Trauma Among Veterans Health Administration Patients Returning From Afghanistan and Iraq

We examined military-related sexual trauma among deployed Operation Enduring Freedom and Operation Iraqi Freedom veterans. Of 125 729 veterans who received Veterans Health Administration primary care or mental health services, 15.1% of the women and 0.7% of the men reported military sexual trauma when screened. Military sexual trauma was associated with increased odds of a mental disorder diagnosis, including posttraumatic stress disorder, other anxiety disorders, depression, and substance use disorders. Sexual trauma is an important postdeployment mental health issue in this population.

BRIEF REPORT: Utility of a Short Screening Scale for DSM-IV PTSD in Primary Care

OBJECTIVE: To evaluate Breslau’s 7-item screen for posttraumatic stress disorder (PTSD) for use in primary care.DESIGN: One hundred and thirty-four patients were recruited from primary care clinics at a large medical center. Participants completed the self-administered 7-item PTSD screen. Later, psychologists blinded to the results of the screen-interviewed patients using the Clinician Administered PTSD Scale (CAPS). Sensitivity, specificity, and likelihood ratios (LR) were calculated using the CAPS as the criterion for PTSD.RESULTS: The screen appears to have test-retest reliability (r=.84), and LRs range from 0.04 to 13.4.CONCLUSIONS: Screening for PTSD in primary care is time efficient and has the potential to increase the detection of previously unrecognized PTSD.

Gender differences in military sexual trauma and mental health diagnoses among Iraq and Afghanistan veterans with posttraumatic stress disorder.

OBJECTIVE We examined correlates of posttraumatic stress disorder (PTSD), including military sexual trauma (MST), in Iraq and Afghanistan veterans. We also compared mental health comorbidities by gender among veterans with PTSD, with and without MST. METHODS Retrospective data analyses were conducted using Department of Veterans Affairs (VA) administrative data from 213,803 Iraq and Afghanistan veterans and the subset diagnosed with PTSD from April 1, 2002, to October 1, 2008. We used descriptive statistics and multivariate logistic regression compared by gender to investigate independent correlates and mental health comorbidities associated with PTSD, with and without MST. RESULTS Among women with PTSD, 31% screened positive for MST; 1% of men with PTSD screened positive for MST. Among those with PTSD, veterans with MST had more comorbid mental health diagnoses than those without MST. Women with PTSD and MST were more likely to receive comorbid depression, anxiety, and eating disorder diagnoses, and men were more likely to receive comorbid substance use disorder diagnoses. CONCLUSIONS MST is associated with an increased prevalence of mental health disorders comorbid with PTSD. Better understanding comorbidity patterns will allow for targeted evaluation and treatment of returning veterans with MST.

Medical Care Needs of Returning Veterans with PTSD: Their Other Burden

ABSTRACTBACKGROUNDThere has been considerable focus on the burden of mental illness (including post-traumatic stress disorder, PTSD) in returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, but little attention to the burden of medical illness in those with PTSD.OBJECTIVES(1) Determine whether the burden of medical illness is higher in women and men OEF/OIF veterans with PTSD than in those with No Mental Health Conditions (MHC). (2) Identify conditions common in those with PTSD.DESIGNCross-sectional study using existing databases (Fiscal Year 2006–2007).SETTINGVeterans Health Administration (VHA) patients nationally.PATIENTSAll 90,558 OEF/OIF veterans using VHA outpatient care nationally, categorized into strata: PTSD, Stress-Related Disorders, Other MHCs, and No MHC.MEASUREMENTS(1) Count of medical conditions; (2) specific medical conditions (from ICD9 codes, using Agency for Health Research and Quality’s Clinical Classifications software framework).MAIN RESULTSThe median number of medical conditions for women was 7.0 versus 4.5 for those with PTSD versus No MHC (p < 0.001), and for men was 5.0 versus 4.0 (p < 0.001). For PTSD patients, the most frequent conditions among women were lumbosacral spine disorders, headache, and lower extremity joint disorders, and among men were lumbosacral spine disorders, lower extremity joint disorders, and hearing problems. These high frequency conditions were more common in those with PTSD than in those with No MHC.CONCLUSIONSBurden of medical illness is greater in women and men OEF/OIF veteran VHA users with PTSD than in those with No MHC. Health delivery systems serving them should align clinical program development with their medical care needs.

Associations among symptoms of depression and posttraumatic stress disorder and self-reported health in sexually assaulted women.

Symptoms of depression and posttraumatic stress disorder (PTSD) were examined for their association with health status in a sample of sexual assault victims. Hypotheses were that symptoms of each disorder would account for unique variance in health status among individuals exposed to traumatic stressors. Fifty-seven sexually assaulted college women were assessed for prior victimization history, assault characteristics, and depressive and PTSD symptoms. When prior history of sexual victimization, assault severity, and physical reactions during the assault were controlled, hierarchical multiple regression models indicated that symptoms of PTSD and depression were significantly associated with global health perceptions and severity of self-reported health symptoms. Only PTSD symptoms were significantly associated with reproductive health symptoms. The results suggest that both symptoms of PTSD and depression account for the relationship between exposure and health impairment among sexual assault victims.

Victimization experiences and HIV infection in women: associations with serostatus, psychological symptoms, and health status.

The present investigation evaluates the relationship between HIV infection and victimization with regard to the interplay of these two factors as they relate to mental and physical health. Eighty eight inner-city low income African-American women who are HIV-infected and a demographically similar comparison group of women who were not HIV-infected were assessed for victimization experiences (rape, physical assault, robbery/attack) via interview. Additionally, the psychological symptoms and health status correlates of victimization within the HIV-infected group are delineated. Results indicated that women in the HIV-infected sample were significantly more likely to report a victimization experience. Additionally, within the HIV-infected group, victims reported higher levels of global psychological distress, depressive symptomatology, and greater distress regarding physical symptoms than nonvictims. Furthermore, HIV-infected victims were diagnosed with higher rates of AIDS-defining conditions than HIV-infected nonvictims. These results underscore the importance of acknowledging the experience of violent victimization in the prevention and treatment of HIV infection in women.

Unemployment Among Women Examining the Relationship of Physical and Psychological Intimate Partner Violence and Posttraumatic Stress Disorder

Prior research has demonstrated that intimate partner violence (IPV) is associated with employment instability among poor women. The current study assesses the broader relationship between IPV and womens workforce participation in a population-based sample of 6,698 California women. We examined past-year IPV by analyzing specific effects of physical violence, psychological violence, and posttraumatic stress disorder (PTSD) symptoms as predictors of unemployment. Results indicated substantial rates of unemployment among women who reported IPV, with rates of 20% among women who experienced psychological violence, 18% among women who experienced physical violence, and 19% among women with PTSD symptoms. When the relationship was adjusted for demographic characteristics and educational attainment, PTSD (adjusted odds ratio [AOR] = 1.60; 95% confidence interval [CI] = 1.22, 2.09) and psychological violence (AOR = 1.78; 95% CI = 1.36, 2.32), but not physical violence, were associated with unemployment. Implications for supported employment programs and workplace responses to IPV are discussed.

Psychiatric Diagnoses and Neurobehavioral Symptom Severity among OEF/OIF VA Patients with Deployment-Related Traumatic Brain Injury: A Gender Comparison

BACKGROUND Traumatic brain injury (TBI) has substantial negative implications for the post-deployment adjustment of veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF); however, most research on veterans has focused on males. This study investigated gender differences in psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF veterans with deployment-related TBI. METHODS This population-based study examined psychiatric diagnoses and self-reported neurobehavioral symptom severity from administrative records for 12,605 United States OEF/OIF veterans evaluated as having deployment-related TBI. Men (n = 11,951) and women (n = 654) who were evaluated to have deployment-related TBI during a standardized comprehensive TBI evaluation in Department of Veterans Affairs facilities were compared on the presence of psychiatric diagnoses and severity of neurobehavioral symptoms. FINDINGS Posttraumatic stress disorder (PTSD) was the most common psychiatric condition for both genders, although women were less likely than men to have a PTSD diagnosis. In contrast, relative to men, women were 2 times more likely to have a depression diagnosis, 1.3 times more likely to have a non-PTSD anxiety disorder, and 1.5 times more likely to have PTSD with comorbid depression. Multivariate analyses indicated that blast exposure during deployment may account for some of these differences. Additionally, women reported significantly more severe symptoms across a range of neurobehavioral domains. CONCLUSION Although PTSD was the most common condition for both men and women, it is also critical for providers to identify and treat other conditions, especially depression and neurobehavioral symptoms, among women veterans with deployment-related TBI.