Stephen C. Hunt

PTSD symptom clusters in relationship to alcohol misuse among Iraq and Afghanistan war veterans seeking post-deployment VA health care

Demographic factors, characteristics of military service, PTSD, and depression were examined as predictors of alcohol misuse in Iraq and Afghanistan War Veterans (N=287) presenting for post-deployment Veteran Affairs (VA) health care. Results indicated that alcohol misuse was more common among younger male Veterans who served in the Army or Marine Corps. Accounting for demographic factors and characteristics of service, Veterans who screened positive for PTSD or depression were two times more likely to report alcohol misuse relative to Veterans who did not screen positive for these disorders. The examination of specific PTSD symptom clusters suggested that emotional numbing symptoms were most strongly associated with alcohol misuse. The implications for interventions for alcohol misuse in returning Veterans are discussed.

Post deployment care for returning combat veterans

Since September 11, 2001, 2.4 million military personnel have deployed to Iraq and Afghanistan. To date, roughly 1.44 million have separated from the military and approximately 772,000 of these veterans have used VA health care. Combat deployments impact the physical, psychological, and social health of veterans. Given that many veterans are receiving care from non-VA providers, it is important that all community health care workers be familiar with the unique health care needs of this patient population, which include injuries associated with blast exposures (including mild traumatic brain injury), as well as a variety of mental health conditions, such as post-traumatic stress disorder. Other important health concerns are chronic musculoskeletal pain, medically unexplained symptoms, sequelae of environmental exposures, depression, suicide, substance abuse, sleep disturbances, and impairments in family, occupational and social functioning. Elevated rates of hypertension and tobacco use remind us that deployment may result not only in immediate impacts on health, but also increase risk for chronic disease, contributing to a growing public health burden. This paper provides a comprehensive review of these health concerns and offers practical management guidelines for primary care providers. In light of relationships between physical, psychological and psychosocial concerns in this population, we recommend an interdisciplinary approach to care directed toward mitigating the long-term health impacts of combat.

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.

Hopelessness and suicidal ideation in Iraq and Afghanistan war veterans reporting subthreshold and threshold posttraumatic stress disorder

We examined hopelessness and suicidal ideation in association with subthreshold and threshold posttraumatic stress disorder (PTSD) in a sample of Iraq and Afghanistan War Veterans (U.S., N = 275) assessed within a specialty VA postdeployment health clinic. Veterans completed paper-and-pencil questionnaires at intake. The military version of the PTSD Checklist was used to determine PTSD levels (No PTSD; subthreshold PTSD; PTSD), and endorsement of hopelessness or suicidal ideation were used as markers of elevated suicide risk. Veterans were also asked if they received mental health treatment in the prior 6 months. Veterans reporting subthreshold PTSD were 3 times more likely to endorse these markers of elevated suicide risk relative to the Veterans without PTSD. We found no significant differences in likelihood of endorsing hopelessness or suicidal ideation comparing subthreshold and threshold PTSD groups, although the subthreshold PTSD group was less likely to report prior mental health treatment. Clinicians should be attentive to suicide risk in returned Veterans reporting both subthreshold and threshold PTSD.

Association of Perceived Barriers With Prospective Use of VA Mental Health Care Among Iraq and Afghanistan Veterans

OBJECTIVE The relationship between perceived barriers and prospective use of mental health care among veterans was examined. METHODS The sample included Iraq and Afghanistan veterans (N=305) who endorsed symptoms of depression or posttraumatic stress disorder (PTSD) or alcohol misuse at intake to a postdeployment clinic between May 2005 and August 2009. Data on receipt of adequate treatment (nine or more mental health visits in the year after intake) were obtained from a VA database. RESULTS Adequate treatment was more likely for women (odds ratio [OR]=4.82, 95% confidence interval (CI)=1.37-16.99, p=.014) and for those with more severe symptoms of PTSD (OR=1.03, CI=1.01-1.05, p=.003) and depression (OR=1.06, CI=1.01-1.11, p=.01). Perceived barriers were not associated with adequate treatment. CONCLUSIONS Male veterans with mental health problems should be targeted with outreach to reduce unmet need. Research is needed to identify perceived barriers to treatment among veterans.

Feedback from recently returned veterans on an anonymous web-based brief alcohol intervention

BackgroundVeterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) are at increased risk for alcohol misuse, and innovative methods are needed to improve their access to alcohol screening and brief interventions (SBI). This study adapted an electronic SBI (e-SBI) website shown to be efficacious in college students for OEF/OIF veterans and reported findings from interviews with OEF/OIF veterans about their impressions of the e-SBI.MethodsOutpatient veterans of OEF/OIF who drank ≥3 days in the past week were recruited from a US Department of Veterans Affairs (VA) Deployment Health Clinic waiting room. Veterans privately pretested the anonymous e-SBI then completed individual semistructured audio-recorded interviews. Their responses were analyzed using template analysis to explore domains identified a priori as well as emergent domains.ResultsDuring interviews, all nine OEF/OIF veterans (1 woman and 8 men) indicated they had received feedback for risky alcohol consumption. Participants generally liked the standard-drinks image, alcohol-related caloric and monetary feedback, and the website’s brevity and anonymity (a priori domains). They also experienced challenges with portions of the e-SBI assessment and viewed feedback regarding alcohol risk and normative drinking as problematic, but described potential benefits derived from the e-SBI (emergent domains). The most appealing e-SBIs would ensure anonymity and provide personalized transparent feedback about alcohol-related risk, consideration of the context for drinking, strategies to reduce drinking, and additional resources for veterans with more severe alcohol misuse.ConclusionsResults of this qualitative exploratory study suggest e-SBI may be an acceptable strategy for increasing OEF/OIF veteran access to evidenced-based alcohol SBI.

Are veterans seeking Veterans Affairs' primary care as healthy as those seeking Department of Defense primary care? A look at Gulf War veterans' symptoms and functional status.

Objective This study compared Gulf War veterans seeking VA primary care with Gulf War veterans seeking treatment from a Department of Defense primary care clinic on measures of physical symptoms, psychiatric complaints, and functional status. Additionally, the association between employment status and health was examined. Methods Analysis was based on the responses of consecutive patients attending the Gulf War Primary Care clinics at either the VA Puget Sound Health Care System in Seattle, WA (N = 223), or the Walter Reed Army Medical Center in Washington, DC (N = 153), between March 1998 and September 1999. Results After controlling for demographic variables, Gulf War veterans who sought VA care reported significantly more anxiety and PTSD symptoms than active duty military personnel. The groups did not differ on somatic complaints or summary scores from the SF-36. Employment status was significantly, independently, and consistently associated with greater psychiatric symptoms, physical symptoms, and decreased functional status. Conclusions Our findings reveal important differences in health status between veterans seeking primary care at a VA and a Department of Defense facility, differences that are in part related to employment status. Both groups report symptoms of psychiatric distress and decreased functional status, though VA patients are more impaired. Research findings based on clinical samples of veterans at VA sites may not generalize to Gulf War veterans still on active duty (and vice versa).

Readiness for Change Predicts VA Mental Healthcare Utilization Among Iraq and Afghanistan War Veterans

Many veterans present to Veteran Affairs (VA) care intending to seek mental health treatment for symptoms of posttraumatic stress disorder (PTSD), depression, and/or alcohol misuse, yet most subsequently underutilize mental health care. This study examined the association of readiness for change with outpatient VA mental health care utilization in 104 treatment-seeking Iraq and Afghanistan war veterans who screened positive for PTSD, depression, and/or alcohol misuse at intake. Multivariate analyses demonstrated that readiness for change assessed at intake was positively associated (Incident Rate Ratio [IRR] = 1.22) with prospective outpatient mental health care utilization with demographic factors, military characteristics, and mental health burden in the model. Results suggest that interventions that target readiness to change, such as motivational interviewing, may improve treatment utilization in veterans presenting for mental health care.

Squamous cell carcinoma of the skin and coal tar creosote exposure in a railroad worker.

A 50-year-old male railroad worker presented to his primary care physician with an erythematous, tender skin lesion on the right knee; a biopsy of this lesion revealed squamous cell carcinoma in situ. The site of the lesion was sun-protected but had been associated with 30 years of creosote-soaked clothing. In this article, we review dermal and other malignancies associated with creosote, along with creosote occupational exposures and exposure limits. This is a unique case, given the lack of other, potentially confounding, polyaromatic hydrocarbons and the sun-protected location of the lesion.

Unique PTSD Clusters Predict Intention to Seek Mental Health Care and Subsequent Utilization in US Veterans with PTSD Symptoms

Many veterans return from deployment with posttraumatic stress disorder (PTSD), but most attend only a limited number of mental health care visits. Although global PTSD relates to seeking mental health care, it is unclear whether specific features of PTSD inform the low rates of mental health care utilization. This study examined PTSD cluster severities of avoidance, reexperiencing, dysphoria, and hyperarousal as predictors of intention to seek mental health care and prospective treatment utilization. US veterans with at least subthreshold PTSD (N = 189) completed a PTSD symptom measure and indicated whether they intended to seek mental health care. Prospective Department of Veterans Affairs mental health care utilization was extracted from the medical record. At the bivariate level, each cluster was positively associated with a positive intention to seek mental health care and prospective treatment utilization. In multivariate models, however, dysphoria severity (OR = 1.16, 95% CI [1.06, 1.26]) was uniquely and positively correlated with intention to seek mental health care, whereas higher avoidance severity (IRR = 0.86, 95% CI [0.76, 0.98]) predicted lower treatment utilization, and higher reexperiencing severity (IRR = 1.07, 95% CI [1.01, 1.14]) predicted greater treatment utilization. It is critical to tailor interventions to target specific features of PTSD and to meet patients where they are.