Robert K. Gifford

Predicting suicides after outpatient mental health visits in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

The 2013 US Veterans Administration/Department of Defense Clinical Practice Guidelines (VA/DoD CPG) require comprehensive suicide risk assessments for VA/DoD patients with mental disorders but provide minimal guidance on how to carry out these assessments. Given that clinician-based assessments are not known to be strong predictors of suicide, we investigated whether a precision medicine model using administrative data after outpatient mental health specialty visits could be developed to predict suicides among outpatients. We focused on male nondeployed Regular US Army soldiers because they account for the vast majority of such suicides. Four machine learning classifiers (naive Bayes, random forests, support vector regression and elastic net penalized regression) were explored. Of the Army suicides in 2004–2009, 41.5% occurred among 12.0% of soldiers seen as outpatient by mental health specialists, with risk especially high within 26 weeks of visits. An elastic net classifier with 10–14 predictors optimized sensitivity (45.6% of suicide deaths occurring after the 15% of visits with highest predicted risk). Good model stability was found for a model using 2004–2007 data to predict 2008–2009 suicides, although stability decreased in a model using 2008–2009 data to predict 2010–2012 suicides. The 5% of visits with highest risk included only 0.1% of soldiers (1047.1 suicides/100 000 person-years in the 5 weeks after the visit). This is a high enough concentration of risk to have implications for targeting preventive interventions. An even better model might be developed in the future by including the enriched information on clinician-evaluated suicide risk mandated by the VA/DoD CPG to be recorded.

Stress and stressors of the early phases of the Persian Gulf War

Soldiers who deployed to Saudi Arabia in support of Operation Desert Shield were exposed to a wide variety of stressors. These stressors from the pre-combat phase of the deployment undoubtedly affect the current health of Gulf War veterans, but the exact mechanisms and linkages are not known. This article examines the nature of those stressors and possible effects on later health of veterans.

The psychological burden of bioterrorism.

Summary Planning for the publics psychological and behavioral reactions to a bioterrorist attack must address individual and community preparedness, response, and recovery. Bioterrorism raises issues requiring skilled risk communication and education including isolation, quarantine, administering vaccinations and distributing medications. The United States anthrax attacks, the international outbreak of Severe Acute Respiratory Syndrome (SARS), and the U.S. smallpox vaccination program offer useful lessons. The Iraqi missile attacks on Israel and the Tokyo sarin gas attacks highlight challenges of emergency medical evaluation and triage. Early public health interventions should identify symptoms and behaviors linked to psychological distress and suggest strategies to restore well-being.

Anger and Posttraumatic Stress Disorder Symptom Severity in a Trauma-Exposed Military Population: Differences by Trauma Context and Gender

Studies have found a stronger association between anger and posttraumatic stress disorder (PTSD) severity in military populations than in nonmilitary populations. Two hypotheses have been proposed to explain this difference: Military populations are more prone to anger than nonmilitary populations, and traumas experienced on deployment create more anger than nondeployment traumas. To examine these hypotheses, we evaluated the association between anger and PTSD severity among never-deployed military service members with nondeployment traumas (n = 226) and deployed service members with deployment traumas (n = 594) using linear regression. We further examined these associations stratified by gender. Bivariate associations between anger and PTSD severity were similar for nondeployment and deployment events; however, gender modified this association. For men, the association for deployment events was stronger than for nondeployment events (β = .18, r = .53 vs. β = .16, r = .37, respectively), whereas the reverse was true for women (deployment: β = .20, r = .42 vs. nondeployment: β = .25, r = .65). Among men, findings supported the hypothesis that deployment traumas produce stronger associations between PTSD and anger and are inconsistent with hypothesized population differences. In women, however, there was not a clear fit with either hypothesis.

Trajectories of posttraumatic stress symptoms after civilian or deployment traumatic event experiences.

Objective: Growth mixture model studies have observed substantial differences in the longitudinal patterns of posttraumatic stress symptom (PTSS) trajectories. This variability could represent chance iterations of some prototypical trajectories or measurable variability induced by some aspect of the source population or traumatic event experience. Testing the latter, the authors analyzed a nationally representative sample of U.S. Reserve and National Guard members to identify the influence of civilian versus deployment trauma on the number of PTSS trajectories, the nature of these trajectories, and the proportion of respondents in each trajectory. Method: Data were collected from 2010 to 2013 and latent class growth analysis was used to identify different patterns of PTSS in persons exposed to both a civilian and a deployment trauma and to test whether respondents’ exposure to civilian trauma developed similar or distinct patterns of response compared to respondents exposed to deployment trauma. Results: PTSS were found to follow 3 trajectories, with respondents predominantly clustered in the lowest symptom trajectory for both trauma types. Covariates associated with each trajectory were similar between the 2 traumas, except number of civilian-related traumatic events; specifically, a higher number of civilian traumatic events was associated with membership in the borderline-stable, compared to low-consistent, trajectory, for civilian traumas and associated with the preexisting chronic trajectory for military traumas. Conclusions: Holding the source population constant, PTSS trajectory models were similar for civilian and deployment-related trauma, suggesting that irrespective of traumatic event experienced there might be some universal trajectory patterns. Thus, the differences in source populations may have induced the heterogeneity observed among prior PTSS trajectory studies.

Effects of the 2002 Sniper Attacks on the Homeless Population in Washington, DC

OBJECTIVE Despite the prevalence of homelessness, this population has rarely been included in disaster and terrorism planning. To better understand the mental health needs of the homeless during a terrorist event and to highlight the need to address methodological limitations in research in this area, we examined responses to the October 2002 Washington, DC, sniper attacks. METHODS We interviewed 151 homeless individuals 1 year after the Washington, DC, sniper attacks. RESULTS The majority (92.7%) was aware of the sniper events; 84.1% stayed informed through the media and 72.7% had someone to turn to for emotional support. Almost half (44%) reported identification with victims and 41% increased substance use during the attacks. More than half (61.7%) felt extremely frightened or terrified and 57.6% reported high perceived threat. Females, nonwhites, and participants with less than a high school education experienced greater threat. Women, nonwhites, and younger (<43 years old) participants were more likely to have decreased more activities and 32.7% increased confidence in local law enforcement; however, 32.7% became less confident. CONCLUSIONS During a terrorist attack the homeless population may be difficult to reach or reluctant to comply with public health programs. Addressing barriers to health care in vulnerable groups is critical to effective public health disaster response.

Responding to Workplace Terrorism: Applying Military Models of Behavioral Health and Public Health Response

Summary The behavioral health response to the September 11th, 2001, attack at the Pentagon illustrates the principles of a public health approach to the emotional and behavioral consequences of terrorism. This model applies public health principles and consultation. It addresses resiliency, illness, distress, and risk behaviors to maximize return to health and work productivity. In this approach, multidisciplinary teams conduct a program of health surveillance, health education and informational briefings at sites within the workplace and to key leaders. The composition of these teams would differ in other civilian settings and should include an integrated response from security, employee assistance, human resources, communications, and leadership. However, the principles of the approach would remain consistent: identify individuals and populations at high risk for post-attack distress reactions or illness, integrate family support into workplace support, promote individual and community resilience, and refer individuals as necessary for further assessment and treatment.

Resiliency Among People Who are Homeless During the Washington-Area Sniper Attacks of October 2002

The natural and man-made disasters in the first decade of the 21st century have raised issues of race, poverty, and inequality in federal, state, and local emergency response and recovery systems. In various studies, reports, and media accounts of these events, little is mentioned about people who were homeless at the time of the disaster, showing a further marginalization of some populations of people who are poor during such times. For this study, researchers interviewed 151 people who were homeless during the Washington, DC, sniper shootings of 2002 to ascertain how they behaved and coped during the shootings, and how long it took them to return to how they were before the shootings. Implications of the findings are drawn for social work research, education, and practice.

Workplace resources for crisis management: implications for public-private sector planning, policy and response to disasters

The interface and cooperation of the public and private sector is essential in disaster planning and response at the federal, state and local level. The resources of private industry and the integration of resources from multiple corporations have been proven necessary for effective community and regional responses to large-scale disasters (natural disasters, terrorism, bioterrorism and the threat of a pandemic). Large corporations often possess sophisticated crisis management capabilities that may exceed the disaster response capacities of the communities in which they are located. Important crisis management resources of large employers that have implications for community planning and response to disasters include the corporations security and threat assessment, communications, human resources and Employee Assistance Programmes (EAP). Workplace preparedness influences family and community preparedness and impacts population health, safety and resilience. Workplace crisis resources, often forgotten and untapped by public sector planners, need to be considered in the continued development and implementation of disaster planning and response policies.

Post-Traumatic Stress Disorder, Depression, and Binge Drinking in the Reserve Component of the U.S. Armed Forces

OBJECTIVES We documented the prevalence of post-traumatic stress disorder (PTSD), depression, and binge drinking in U.S. Reserve and National Guard (Reserve Component [RC]) personnel for each service and branch by rank, gender, and deployment status. METHODS Structured interviews were conducted with a nationally representative sample of RC personnel (n = 2,003). We used weighted descriptive statistics to examine the prevalence of PTSD, depression, and binge drinking. RESULTS The prevalence of PTSD was 6.7%, depression was 6.8%, and binge drinking was 11.5%. The prevalence of having one or more mental health problems investigated in this study was 19.8%. The prevalence of binge drinking was higher for enlisted men (14.8%) than enlisted women (2.6%). Having one or more mental health problems was nearly twice as high for enlisted men (23.4%) vs. enlisted women (12.9%). For deployed personnel, the prevalence of PTSD or having one or more mental health problems was approximately twice that of never-deployed personnel. CONCLUSIONS Prevalence of mental health problems can inform prevention and treatment for RC personnel. Further research is needed to identify risk factors for PTSD, depression, and binge drinking. Interventions for RC personnel should consider service and branch, rank, gender, and deployment status.