Thomas J. Metzler

Trends and Risk Factors for Mental Health Diagnoses Among Iraq and Afghanistan Veterans Using Department of Veterans Affairs Health Care, 2002–2008

OBJECTIVES We sought to investigate longitudinal trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans. METHODS We determined the prevalence and predictors of mental health diagnoses among 289,328 Iraq and Afghanistan veterans entering Veterans Affairs (VA) health care from 2002 to 2008 using national VA data. RESULTS Of 289,328 Iraq and Afghanistan veterans, 106,726 (36.9%) received mental health diagnoses; 62,929 (21.8%) were diagnosed with posttraumatic stress disorder (PTSD) and 50 432 (17.4%) with depression. Adjusted 2-year prevalence rates of PTSD increased 4 to 7 times after the invasion of Iraq. Active duty veterans younger than 25 years had higher rates of PTSD and alcohol and drug use disorder diagnoses compared with active duty veterans older than 40 years (adjusted relative risk = 2.0 and 4.9, respectively). Women were at higher risk for depression than were men, but men had over twice the risk for drug use disorders. Greater combat exposure was associated with higher risk for PTSD. CONCLUSIONS Mental health diagnoses increased substantially after the start of the Iraq War among specific subgroups of returned veterans entering VA health care. Early targeted interventions may prevent chronic mental illness.

Predicting symptomatic distress in emergency services personnel.

This study identified predictors of symptomatic distress in emergency services (EMS) personnel exposed to traumatic critical incidents. A replication was performed in 2 groups: 154 EMS workers involved in the 1989 Interstate 880 freeway collapse during the San Francisco Bay area earthquake, and 213 counterparts from the Bay area and from San Diego. Evaluated predictors included exposure, social support, and psychological traits. Replicated analyses showed that levels of symptomatic distress were positively related to the degree of exposure to the critical incident. Level of adjustment was also related to symptomatic distress. After exposure, adjustment, social support, years of experience on the job, and locus of control were controlled, 2 dissociative variables remained strongly predictive of symptomatic response. The study strengthens the literature linking dissociative tendencies and experiences to distress from exposure to traumatic stressors.

VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses

Little is known about mental health services utilization among Iraq and Afghanistan veterans receiving care at Department of Veterans Affairs (VA) facilities. Of 49,425 veterans with newly diagnosed posttraumatic stress disorder (PTSD), only 9.5% attended 9 or more VA mental health sessions in 15 weeks or less in the first year of diagnosis. In addition, engagement in 9 or more VA treatment sessions for PTSD within 15 weeks varied by predisposing variables (age and gender), enabling variables (clinic of first mental health diagnosis and distance from VA facility), and need (type and complexity of mental health diagnoses). Thus, only a minority of Iraq and Afghanistan veterans with new PTSD diagnoses received a recommended number and intensity of VA mental health treatment sessions within the first year of diagnosis.

Stress responses of emergency services personnel to the loma prieta earthquake interstate 880 freeway collapse and control traumatic incidents

A three-group quasi-experimental design contrasted the responses of rescue workers to the 1989 Loma Prieta earthquake Interstate 880 freeway collapse (n = 198) with responses to critical incident exposure of Bay Area Controls (n = 140) and San Diego Controls (n = 101). The three groups were strikingly similar with respect to demographics and years of emergency service. The I-880 group reported higher exposure, greater immediate threat appraisal, and more sick days. The three groups did not differ on current symptoms. For the sample as a whole EMT/Paramedics reported higher peritraumatic dissociation compared with Police. EMT/Paramedics and California road workers reported higher symptoms compared with Police and Fire personnel. Nine percent of the sample were characterized as having symptom levels typical of psychiatric outpatients. Compared with lower distress responders, those with greater distress reported greater exposure, greater peritraumatic emotional distress, greater peritraumatic dissociation, greater perceived threat, and less preparation for the critical incident.

Longitudinal course and predictors of continuing distress following critical incident exposure in emergency services personnel

This study examines the longitudinal course and predictors of stress-specific and general symptomatic distress in emergency services personnel. A three-group quasi-experimental design was used to determine the responses of 322 rescue workers to the Loma Prieta earthquake Interstate 880 Freeway collapse and to unrelated control critical incidents. Self-report questionnaires, including measures of incident exposure, peritraumatic dissociation and emotional distress, and current symptoms, were administered 1.9 years (initial) and 3.5 years (follow-up) after the freeway collapse. Despite modest symptom improvement at follow-up, rescue workers were at risk for chronic symptomatic distress after critical incident exposure. Peritraumatic dissociation accounted for significant increments in current posttraumatic stress disorder symptoms, over and above exposure, adjustment, years of experience, locus of control, social support, and general dissociative tendencies. The results suggest that rescue workers, particularly those with more catastrophic exposure and those prone to dissociate at the time of the critical incident, are at risk for chronic symptomatic distress.

Childhood Trauma Associated with Short Leukocyte Telomere Length in Posttraumatic Stress Disorder

BACKGROUND Posttraumatic stress disorder (PTSD) is associated with increased risk for age-related diseases and early mortality. An accelerated rate of biological aging could contribute to this increased risk. To investigate, we assessed leukocyte telomere length (LTL), an emerging marker of biological age, in men and women with and without PTSD. We also examined childhood trauma, a risk factor for both PTSD and short LTL, as a potential contributor to short LTL in PTSD. METHODS Participants included 43 adults with chronic PTSD (n = 18 with multiple categories of childhood trauma) and 47 control subjects (none with multiple categories of childhood trauma) (mean age = 30.55, SD = 7.44). Exclusion criteria included physical illness, medication use, obesity, alcohol or substance abuse, and pregnancy. Structured clinical interviews were conducted to assess PTSD and other psychiatric disorders and childhood trauma exposure. LTL was measured with a quantitative polymerase chain reaction method. RESULTS As predicted, participants with PTSD had shorter age-adjusted LTL than control subjects. Exposure to childhood trauma was also associated with short LTL. In fact, childhood trauma seemed to account for the PTSD group difference in LTL; only participants with PTSD and exposure to multiple categories of childhood trauma had significantly shorter LTL than control subjects. CONCLUSIONS Childhood trauma is associated with short LTL in individuals with PTSD. Chronic exposure to the psychobiological sequelae of childhood trauma could increase risk for PTSD and short LTL. Thus, the lasting psychological impact of exposure to trauma in childhood might be accompanied by equally enduring changes at the molecular level.

Predictors of Posttraumatic Stress in Police and Other First Responders

Abstract:  We provide an overview of previous research conducted by our group on risk and resilience factors for PTSD symptoms in police and other first responders. Based on our work, the findings of other investigators on individual differences in risk for PTSD, and drawing on preclinical studies fear conditioning and extinction, we propose a conceptual model for the development of PTSD symptoms emphasizing the role of vulnerability and resilience to peritraumatic panic reactions. We tested this conceptual model in a cross‐sectional sample of police officers (n= 715). Utilizing an hierarchical linear regression model we were able to explain 39.7% of the variance in PTSD symptoms. Five variables remained significant in the final model; greater peritraumatic distress (β= 0.240, P < .001), greater peritraumatic dissociation (β= 0.174, P < .001), greater problem‐solving coping (β= 0.103, P < .01), greater routine work environment stress (β= 0.182, P < .001), and lower levels of social support (β=−0.246, P < .001). These results were largely consistent with the proposed conceptual model. Next steps in this line of research will be to test this model prospectively in a sample of 400 police academy recruits assessed during training and currently being followed for the first 2 years of police service.

Routine occupational stress and psychological distress in police

The relationship between routine work stress and psychological distress was investigated among 733 police officers in three US cities, during 1998‐1999. The Work Environment Inventory (WEI) was developed to assess exposure to routine work stressors, while excluding duty‐related traumatic stressors (critical incidents). The WEI and its general properties are presented. The relationship between routine work stress exposure and psychological distress is then explored. Exposure to routine work stressors predicted general psychological distress (r = 0.46), as well as post‐traumatic stress symptoms following officers’ most traumatic career incident (rs = 0.26 to 0.39). Multivariate analyses found that these effects were independent of, and larger than, the effects of cumulative critical incident exposure. (Time since the most traumatic event, social support, and social desirability effects were also controlled statistically.) Routine occupational stress exposure appears to be a significant risk factor for psychological distress among police officers, and a surprisingly strong predictor of post‐traumatic stress symptoms.

Why are hispanics at greater risk for PTSD

Several studies have found that Hispanic Americans have higher rates of posttraumatic stress disorder (PTSD) than non-Hispanic Caucasian and Black Americans. The authors identified predictors of PTSD symptom severity that distinguished Hispanic police officers (n=189) from their non-Hispanic Caucasian (n=317) and Black (n=162) counterparts and modeled them to explain the elevated Hispanic risk for PTSD. The authors found that greater peritraumatic dissociation, greater wishful thinking and self-blame coping, lower social support, and greater perceived racism were important variables in explaining the elevated PTSD symptoms among Hispanics. Results are discussed in the context of Hispanic culture and may be important for prevention of mental illness in the fastest growing ethnic group in the United States.

PTSD symptoms predict waking salivary cortisol levels in police officers

This study examines whether pre- or post-dexamethasone salivary cortisol is related to cumulative critical incident exposure, peritraumatic responses, or post-traumatic stress disorder (PTSD) symptom severity. Thirty active duty police officers completed the study protocol, which included measures of peritraumatic emotional distress, peritraumatic dissociation, duty-related trauma exposure, and PTSD symptoms. Salivary cortisol was consolidated into three outcome variables: (1) pre-dexamethasone free cortisol levels at 1, 30, 45, and 60 min after awakening, (2) post-dexamethasone cortisol levels at the identical wake times, and (3) percentage of cortisol suppression. Control variables included age, gender, average daily alcohol use, night shift work, routine work environment stressors, and salivary dexamethasone levels. Zero order correlations showed that greater levels of PTSD symptoms, peritraumatic distress, and peritraumatic dissociation were associated with lower levels of pre-dexamethasone cortisol levels on awakening, but were not associated with the other two cortisol variables. A trend was also noted for older subjects to have lower pre-dexamethasone cortisol on awakening. When these four predictors were entered simultaneously in a regression analysis, only age and PTSD symptom severity significantly predicted pre-dexamethasone awakening cortisol levels. These results replicate previous research indicating a relationship between greater PTSD symptoms and lower levels of basal cortisol on awakening, and extend this finding to a previously unstudied non-treatment seeking population, urban police.