Staying Relevant in the Digital Age: Exploring the Evolving Frontier of Telehealth for Mental Health in the Military Health System and Veterans Health Administration

To determine the relations between obstructive sleep apnea (OSA) diagnosis, the likelihood of being diagnosed with a psychological condition, among obese veterans, after accounting for severity of obesity and the correlated nature of patients within facility. We hypothesized that (1) individuals with a diagnosis of OSA would be more likely to receive a diagnosis of a (a) mood disorder and (b) anxiety disorder, but not (c) substance use disorder. Cross-sectional retrospective database review of outpatient medical records between October 2009 and September 2010, conducted across all 140 Veterans Health Administration (VHA) facilities. The entire VA Health Care System. Population-based sample of veterans with obesity (N = 2,485,658). Physician- or psychologist-determined diagnosis of psychological conditions including mood, anxiety, and substance use disorders. Using generalized linear mixed modeling, after accounting for the correlated nature of patients within facility and the severity of obesity, individuals with a diagnosis of sleep apnea had increased odds of receiving a mood disorder diagnosis (OR = 1.85; CI = 1.71-1.72; p < 0.001), anxiety disorder diagnosis (OR = 1.82; CI = 1.77-1.84; p < 0.001), but not a diagnosis of substance use disorder. Among obese veterans within VA, OSA is associated with increased risk for having a mood and anxiety disorder, but not substance use disorder, with the strongest associations observed for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). In addition, this relation remained after accounting for severity of BMI.

Pharmacotherapy of Alcohol Use Disorders in the Veterans Health Administration

Reintegration Problems and Treatment Interests Among Iraq and Afghanistan Combat Veterans Receiving VA Medical Care

To the Editor: Posttraumatic stress disorder and alcohol use disorder often co-occur. We report a case in which combination treatment with naltrexone and prazosin was effective for both disorders. Case report. Mr A, a 37-year-old married man diagnosed with major depressive disorder and alcohol use disorder, was admitted in August 2013 to the co-occurring inpatient unit at Sheppard Pratt Health System, Baltimore, Maryland. He endorsed having hypomanic episodes in the past, and the diagnosis was changed from major depressive disorder to bipolar II disorder (DSM-5 criteria). Mr A was physically abused as a child by his father. He reported posttraumatic stress disorder (PTSD) symptoms that were experienced only during daytime, without PTSD-related nightmares or sleep problems. He was diagnosed with PTSD (DSM-5 criteria) during this admission. His active medications included fluoxetine 40 mg daily and quetiapine 50 mg for sleep (which was not related to PTSD). These medications were discontinued because they were not indicated for bipolar depression and insomnia, respectively. Oral tablets of lithium 600 mg, prazosin 1 mg, and naltrexone 25 mg daily were started. On day 2, prazosin was increased to 1 mg twice daily, and naltrexone was increased to 50 mg at bedtime. Lithium was increased from 900 mg to 1,200 mg (lithium level 0.99 mEq/L) at bedtime after the lithium level was found to be low with 900 mg. Alcohol craving and flashbacks decreased in 4 days. There was a complete remission of alcohol craving and flashbacks in 2 and 4 weeks, respectively. To date, Mr A has been abstinent from alcohol for 6 months. There is a high comorbidity between PTSD and alcohol use disorder. More than 50% of Vietnam combat war veterans with PTSD subsequently developed alcohol use disorder.1 Woman with PTSD from childhood rape often self-medicate with alcohol to reduce symptoms of PTSD.2 Naltrexone is an opioid antagonist used for the treatment of alcohol use disorder. In an animal study, naltrexone prevented increased alcohol consumption following trauma.3 Prazosin, an α1-adrenergic antagonist, is effective for nightmares in PTSD.4 In a recently published review, patients with PTSD treated with prazosin reported almost complete remission of daytime symptoms such as hyperarousal, flashbacks, and daytime reexperiencing of the trauma.5 Prazosin reduced alcohol self-administration in rodents.6 Prazosin decreased stress and cue-induced alcohol craving in people with alcohol use disorder.7 In humans, there is evidence to support that prazosin reduces consumption of alcohol.8 In a randomized controlled trial, prazosin was shown to be efficacious for alcohol use disorder.9 There is evidence to support the use of naltrexone for PTSD.10 Both medications have been approved by the US Food and Drug Administration. Individual pharmacotherapy is effective for the treatment of PTSD and alcohol use disorder; however, no medications have been proven to be effective for these co-occurring disorders. Individuals with co-occurring PTSD and alcohol use disorder report increased alcohol craving following exposure to personalized trauma cues, in the absence of cues related to alcohol.11 This co-occurring disorder may be associated with severe clinical impairment with more relapses. Alcohol-preferring rats were fed naltrexone and prazosin alone or in combination for 4 weeks, and the effect of drug treatment on alcohol was assessed.12 The combination of naltrexone and prazosin was significantly more effective in reducing alcohol intake than either drug alone. The authors concluded that naltrexone and prazosin combination reduced alcohol consumption.12 This novel treatment with naltrexone and prazosin, which may have a synergistic effect, was effectively used in the management of our patient. This combination was safe, effective, and tolerable. To our knowledge, this is the first case report on the use of the combination of naltrexone and prazosin for PTSD and alcohol use disorder. This therapeutic strategy should be considered by clinicians in the management of these challenging co-occurring disorders, as it may lead to better outcomes. Future randomized clinical trials are warranted to validate this finding.

The authors aim to delineate cognitive dysfunction associated with posttraumatic stress disorder (PTSD) by evaluating a well-defined cohort of former World War II prisoners of war (POWs) with documented trauma and minimal comorbidities. The authors studied a cross-sectional assessment of neuropsychological performance in former POWs with PTSD, PTSD with other psychiatric comorbidities, and those with no PTSD or psychiatric diagnoses. Participants who developed PTSD had average IQ, while those who did not develop PTSD after similar traumatic experiences had higher IQs than average (approximately 116). Those with PTSD performed significantly less well in tests of selective frontal lobe functions and psychomotor speed. In addition, PTSD patients with co-occurring psychiatric conditions experienced impairment in recognition memory for faces. Higher IQ appears to protect individuals who undergo a traumatic experience from developing long-term PTSD, while cognitive dysfunctions appear to develop with or subsequent to PTSD. These distinctions were supported by the negative and positive correlations of these cognitive dysfunctions with quantitative markers of trauma, respectively. There is a suggestion that some cognitive decrements occur in PTSD patients only when they have comorbid psychiatric diagnoses.

Dr. Jones declares no conflict of interests. Dr. Back is the first author of a behavioral therapy targeting the treatment of substance use disorder and comorbid PTSD.

The study compared delay of treatment for posttraumatic stress disorder (PTSD), major depressive disorder, and alcohol use disorder among post-9/11 veterans versus pre-9/11 veterans and civilians. The 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a nationally representative survey of U.S. noninstitutionalized adults, was used. Participants included 13,528 civilians, 1,130 pre-9/11 veterans, and 258 post-9/11 veterans with lifetime diagnoses of PTSD, major depression, or alcohol use disorder. Cox proportional hazard models, controlling for relevant demographic characteristics, were used to estimate differences in treatment delay (i.e., time between diagnosis and treatment). Post-9/11 veterans were less likely to delay treatment for PTSD and depression than pre-9/11 veterans (adjusted hazard ratios [AHRs]=0.69 and 0.74, respectively) and civilians (AHRs=0.60 and 0.67, respectively). No differences in treatment delay were observed between post-9/11 veterans and pre-9/11 veterans or civilians for alcohol use disorder. In an exploratory analysis, post-9/11 veterans with past-year military health care coverage (e.g., Veterans Health Administration) had shorter delays for depression treatment compared with post-9/11 veterans without military coverage, pre-9/11 veterans regardless of health care coverage, and civilians, although past-year coverage did not predict treatment delay for PTSD or alcohol use disorder. Post-9/11 veterans were less likely to delay treatment for some common psychiatric conditions compared with pre-9/11 veterans or civilians, which may reflect efforts to engage recent veterans in mental health care. All groups exhibited low initiation of treatment for alcohol use disorder, highlighting the need for further engagement efforts.

This study aimed to determine a pattern in the frequency with which individuals who manifested distress reactions resembling diagnostic syndromes of posttraumatic stress disorder (PTSD) and major depressive disorder accessed services provided by Project Liberty. Hierarchical cluster analysis was applied to 31 reactions to stress (event reactions) shown by 465,428 recipients of Project Liberty counseling, to determine how well event reactions mapped onto traditional diagnostic criteria. Service recipients were tracked when they first sought Project Liberty counseling during the 27 months after the attacks. Those who reported three or more reactions associated with these clusters were characterized as having possible diagnosable conditions. Strong consistent clusters corresponding to traumatic stress and depressive symptoms emerged, with 26 percent, 16 percent, and 8 percent of service recipients rated as having possible PTSD, major depressive disorder, or both, respectively. Taken together, this group constituted over 40 percent of service recipients served by Project Liberty almost every month throughout the 27 months of its existence. Event reactions, as reported by Project Liberty crisis counselors, many of whom were nonclinicians, mapped coherently onto diagnostic syndromes, suggesting that a checklist of such reactions may be useful to disaster counselors as a cost-effective screening and planning instrument. The steady entry over time into Project Liberty counseling by a substantial number of individuals experiencing high levels of distress underscores the need for providing long-term access to mental health services postdisaster.

Our study examines the association between suicidal ideation and and self-reported symptoms of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), generalized anxiety disorder (GAD), and alcohol use disorder (AUD) in a sample of treatment-seeking Canadian combat and peacekeeping veterans; and identifies potential predictors of suicidal ideation. Actively serving Canadian Forces and Royal Canadian Mounted Police members and veterans seeking treatment at the Parkwood Hospital Operational Stress Injury Clinic (n = 250) completed measures including the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, the Alcohol Use Disorder Identification Test, and the PTSD Checklist-Military Version (PCL-M) between January 2002 and December 2010. Regression analyses were used to determine the respective impact of PTSD, and self-reported symptoms of MDD, GAD, AUD, and anxiety on suicidal ideation. Most people met PCL-M screening criteria for PTSD (73.6%, n = 184), while 70.8% (n = 177) screened positively for a probable major depressive episode. PTSD symptom was significantly associated with suicidal ideation (β = 0.412, P < 0.001). After controlling for self-reported depressive symptom severity, AUD severity, and generalized anxiety, PTSD severity was no longer significantly associated with suicidal ideation (β = 0.043, P = 0.58). Although PTSD alone is associated with suicidal ideation, after controlling for common comorbid psychiatric illnesses, self-reported depressive symptom severity emerged as the most significant predictor of suicidal ideation. These findings support the importance of screening for comorbidities, particularly an MDD, as potentially modifiable conditions that are strongly related to suicidal ideation in military personnel's endorsing criteria for PTSD.

The authors investigated the theoretical and clinical role of depression among cocaine abusers in treatment. Eighty-nine cocaine-abusing patients underwent 2 weeks of substance abuse treatment. Posttreatment major depressive disorder, depressive symptoms before and after substance abuse treatment, and alcohol diagnoses were assessed and their relation to pretreatment substance use, cravings in high-risk situations, and 3-month follow-up status was examined. High rates of major depressive disorder were found but were unrelated to pretreatment substance use. The decrease in depressive symptoms during treatment was independent of major depressive disorder or alcohol diagnoses and predicted treatment attrition. Higher levels of depressive symptoms during treatment were associated with greater urge to use cocaine, alcohol, and other drugs in high-risk situations. Concurrent major depressive disorder and depressive symptoms did not predict cocaine use at follow-up. However, patients who had an alcohol relapse episode experienced more depressive symptoms during treatment than did those who abstained. The results highlight the relationship of depression to alcohol use among cocaine abusers and suggest a need for further studies of the association between depression and substance use disorders.

The relationship between shame, rumination, self-compassion, and symptoms of post-traumatic stress disorder and major depressive disorder.

The Health Care for Reentry Veterans (HCRV) program provides Veterans Health Administration outreach services to veterans incarcerated in state and federal prisons. This study used HCRV data to compare risk of incarceration of veterans of Operations Enduring Freedom (OEF), Iraqi Freedom (OIF), and New Dawn (OND) and other veterans and to identify sociodemographic and clinical characteristics of incarcerated veterans of OEF/OIF/OND. Administrative national data were analyzed for 30,968 incarcerated veterans, including 1,201 OEF/OIF/OND veterans, contacted from October 2007 to April 2011. Odds ratios were calculated comparing the risk of incarceration among OEF/OIF/OND and other veterans in the HCRV sample and in a weighted sample of nonincarcerated veterans from the 2010 National Survey of Veterans. Stepwise logistic regressions of HCRV data examined characteristics of incarcerated veterans independently associated with OEF/OIF/OND service. Regardless of ethnicity or age, OEF/OIF/OND veterans were less than half as likely as other veterans to be incarcerated and constituted only 3.9% of the incarcerated veterans. Compared with other incarcerated veterans, OEF/OIF/OND veterans were younger, were more likely to be married, were more likely to report combat exposure, expected a shorter incarceration, were 26% less likely to have a diagnosis of drug abuse or dependence, and were three times more likely to have combat-related posttraumatic stress disorder (PTSD). OEF/OIF/OND veterans appeared to be at lower risk of incarceration than veterans of other service eras, but those who were incarcerated had higher rates of PTSD. Efforts to link these veterans to mental health services upon their release are warranted.

A model of suicidal behavior in war veterans with posttraumatic mood disorder

Men's Depression, Externalizing, and DSM-5-TR: Primary Signs and Symptoms or Co-occurring Symptoms?

Alcohol-related and mental health care for patients with unhealthy alcohol use and posttraumatic stress disorder in a National Veterans Affairs cohort