High Rates Of Posttraumatic Stress Disorder Research Articles

Use of Mental Health Services by Survivors of Intimate Partner Violence

Fifty women survivors of intimate partner violence (IPV) were recruited from a legal advocacy program to participate in a study designed to assess current rates of posttraumatic stress disorder (PTSD), depression, and alcohol and substance abuse among a sample of abused women and to examine the types of services survivors of IPV had used in the previous 12 months. In addition, the authors sought to understand how the presence of substance abuse, PTSD, and/or depression affects access and utilization of services by IPV survivors. Fifty-four percent of these IPV survivors were experiencing either PTSD, clinical depression, or both. While women with either PTSD or depression used a significantly larger number of services overall, the majority had not used any mental health services, even though they frequently reported services were accessible. Given the high rates of PTSD and depression in this sample, these abused women were clearly not receiving adequate mental health care. Furthermore, many reported having trouble accessing housing, legal services, crisis lines, and medical care—services that are fundamental to safety. Practitioners working with abused women should assess for PTSD and depression, and be prepared to either treat each condition or provide effective referrals.

The role of social support in exposure therapy for Operation Iraqi Freedom/Operation Enduring Freedom veterans: A preliminary investigation.

The lack of social support has consistently been identified as a relevant factor in the development, maintenance, and treatment of posttraumatic stress disorder (PTSD). Prospective studies with combat veterans have supported the erosion model of social support in the development of PTSD. This model posits that increased PTSD symptoms lead to diminished social support over time. Additional epidemiological work that has investigated mental health and functional impairment in recently returning Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) veterans has suggested that interpersonal problems coincide with the onset of PTSD. Despite research that suggests OIF/OEF veterans experience high rates of PTSD and associated interpersonal problems, no studies have examined social support in relation to treatment response in this group. The current study examined the role of four theorized functional aspects of social support- emotional/informational support, positive social interactions, affectionate support, and tangible support- on pretreatment PTSD symptom severity and treatment response in a sample of OIF/OEF veterans receiving exposure-based psychotherapy. Findings showed that positive social interactions were negatively correlated with pretreatment symptom severity, and emotional/informational support was positively related to increased treatment response. Together, these findings suggest that specific types of social support may have an important influence on the course of exposure treatment.

Risk of Incarceration and Other Characteristics of Iraq and Afghanistan Era Veterans in State and Federal Prisons

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.

Risk of Incarceration and Other Characteristics of Iraq and Afghanistan Era Veterans in State and Federal Prisons

Objective 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. Methods 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. Results 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). Conclusions 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.

The Prevalence of Mental Health Problems in Men Arrested for Domestic Violence

The problem of male perpetrated intimate partner violence (IPV) is widespread. In an effort to identify risk factors for perpetrating IPV, researchers have examined mental health problems among perpetrators. However, the majority of research in this area has examined personality psychopathology and/or limited their investigation to posttraumatic stress disorder (PTSD) or depression. Thus, the present study examined self-reported Axis I psychopathology among men arrested for domestic violence (N = 308). Results replicated past research showing high rates of PTSD and depression. In addition, the prevalence of generalized anxiety disorder (GAD), panic disorder, social phobia, and alcohol and drug disorders were very high. All types of mental health problems were positively associated with aggression perpetration. Males meeting probable diagnostic classification reported significantly more frequent aggression than males not meeting diagnostic classification, even after controlling for social desirability. Directions for future research and implications of these findings are discussed.

Posttraumatic Stress Disorder among Paramedics

Paramedics have the highest rate of posttraumatic stress disorder (PTSD) among emergency service workers, higher than police or firefighters. This disorder can be detrimental to their personal and family lives, as well as their careers. Current biomedical, behavioral, and socioenvironmental interventions do not address paramedics' work environment, which contributes to the high rate of PTSD. Occupational health nurses can influence the triad of factors contributing to PTSD among paramedics by facilitating social support and emotional expression while advocating for reduced job exposure to traumatic events. This goal can be accomplished by using a component of the Ottawa Charter, creating a supportive work environment, as a framework. Occupational health nurses, together with management and paramedics, can facilitate a sustainable and supportive work environment that initiates change from within the trauma membrane of paramedics' workplaces to prevent PTSD.

Ethnic differences in symptoms among female veterans diagnosed with PTSD

Among U.S. male Vietnam veterans, Hispanics have been shown to have higher rates of posttraumatic stress disorder (PTSD) than African Americans and non-Hispanic Whites (Kulka et al., 1990). In terms of gender, Tolin and Foa's (2006) meta-analysis suggested women experience higher rates of PTSD than men. This study examined ethnic differences in PTSD and other symptomatology among 398 female veterans (63% non-Hispanic White, 28% Hispanic, 9% African American) seeking treatment for PTSD from 1995 to 2009 at a Veterans Administration (VA) behavioral health clinic. The following symptom clusters were examined: anxiety/PTSD, depression, anger/hostility, and psychotic/dissociative symptoms. Few differences were found among the groups, suggesting the 3 ethnic groups studied were more similar than different. African American female veterans, however, scored higher on measuring ideas of persecution/paranoia, although this may reflect an adaptive response to racism. These findings warrant further investigation to elucidate this relationship.

POST‐TRAUMATIC STRESS DISORDER AND NEUROANTHROPOLOGY: STOPPING PTSD BEFORE IT BEGINS

Post‐traumatic stress disorder (PTSD) is a problem that affects many combatants in war, including a high percentage of military personnel serving in Iraq and Afghanistan. The high rates of PTSD among veterans has pushed research and intervention to address the serious mental and behavioral health problems associated with wartime trauma. However, these efforts have largely proceeded using biomedical and psychological approaches, without recognizing the institutional and social contexts of trauma, adaptation, and recovery. Moreover, biomedical and psychological approaches have serious shortcomings in recognizing how individual–environment interactions, meaningful interpretations, and sense of identity play a key role in the impact of trauma and development (or not) of PTSD. A neuroanthropological approach can use ideas of neural plasticity and the encultured brain to link culture, interpretation and identity, and the impact of trauma. This synthetic approach then permits a critique of present efforts in the U.S. military to increase resilience and prevent PTSD, and propose alternative strategies and research approaches to more effectively understand and address PTSD.

Effect of Dwell Time on the Mental Health of US Military Personnel With Multiple Combat Tours

We investigated the association of the length of time spent at home between deployments, or dwell time, with posttraumatic stress disorder (PTSD) and other mental health disorders. We included US Marine Corps personnel identified from military deployment records who deployed to Operation Iraqi Freedom once (n = 49,328) or twice (n = 16,376). New-onset mental health diagnoses from military medical databases were included. We calculated the ratio of dwell-to-deployment time (DDR) as the length of time between deployments divided by the length of the first deployment. Marines with 2 deployments had higher rates of PTSD than did those with 1 deployment (2.1% versus 1.2%; P < .001). A DDR representing longer dwell times at home relative to first deployment length was associated with reduced odds of PTSD (odds ratio [OR] = 0.47; 95% confidence interval [CI] = 0.32, 0.70), PTSD with other mental health disorder (OR = 0.56; 95% CI = 0.33, 0.94), and other mental health disorders (OR = 0.62; 95% CI = 0.51, 0.75). Longer dwell times may reduce postdeployment risk of PTSD and other mental health disorders. Future research should focus on the role of dwell time in adverse health outcomes.

Post‐traumatic stress disorder symptoms in emotionally distressed individuals referred for a depression prevention intervention: relationship to problem‐solving skills

This study examined the rates of syndromal and subthreshold post-traumatic stress disorder (PTSD) and PTSD symptom scores in participants with symptoms of emotional distress, subsyndromal depression, and a history of traumatic exposure. Participants had been referred to a study of an indicated depression prevention intervention using problem-solving therapy in primary care. We hypothesized that higher severity of PTSD symptom scores would predict poorer problem-solving skills. In addition, some reports have suggested that there are higher rates of PTSD in minority populations relative to Caucasians; thus we hypothesized that race would also predict problem-solving skills in these individuals. We examined the rates of traumatic exposure, syndromal, and subthreshold PTSD. In those exposed to trauma, we performed a multiple linear regression to examine the effects of PTSD symptoms, depression symptoms, race, age, and gender on social problem-solving skills. Of the 244 participants, 64 (26.2%) reported a traumatic event; 6/234 (2.6%) had syndromal PTSD, and 14/234 (6.0%) had subthreshold PTSD. By way of regression analysis, higher PTSD symptom scores predicted poorer problem-solving skills. In addition, racial status (Caucasian vs. African American) predicted problem-solving skills; Caucasians exhibited lower levels of problem-solving skills. Individuals presenting with subsyndromal depressive symptoms may also have a history of traumatic exposure, subthreshold and syndromal PTSD. Thus, screening these individuals for PTSD symptoms is important and may inform clinical management decisions because problem-solving skills are lower in those with more severe PTSD symptoms (even after adjusting for race, age, gender, and depressive symptoms).

9/11 Tragedy Spurs Advances in PTSD Research

9/11 Tragedy Spurs Advances in PTSD Research

Exploring gender differences in trauma exposure and the emergence of symptoms of PTSD among incarcerated men and women

Our study examines gender differences in traumatic exposure and associated posttraumatic stress disorder (PTSD) symptoms reported by a 266 male and female inmates. In our sample, 94.7% of the inmates had experienced at least one traumatic event identified in Trauma History Questionnaire – Modified. Male inmates reported higher rates of witnessing harm to others in childhood (22.4%) and adolescence (43.25) and female inmates, higher rates of interpersonal sexual trauma in childhood (31.2%), adolescence (35.3%), and adulthood (27.7%). Women showed higher rates of PTSD (40.2%) when compared to men (12.5%), as measured by the total PTSD score of the Impact of Event Scale – Revised. The combined trauma types explained 12% and 16% of the total PTSD score in the female and male samples, respectively. In the female model, interpersonal sexual trauma was a significant predictor of PTSD symptoms; whereas in the male model, interpersonal nonsexual trauma was a significant predictor. We discuss these findings as they inform our understanding of gender differences in trauma response and psychiatric morbidity in adulthood.

Posttraumatic stress disorder and HIV risk among poor, inner-city women receiving care in an emergency department.

We examined the associations between posttraumatic stress disorder (PTSD) and HIV risk behaviors among a random sample of 241 low-income women receiving care in an urban emergency department. We recruited participants from the emergency department waiting room during randomly selected 6-hour blocks of time. Multivariate analyses and propensity score weighting were used to examine the associations between PTSD and HIV risk after adjustment for potentially confounding sociodemographic variables, substance use, childhood sexual abuse, and intimate partner violence. A large majority of the sample self-identified as Latina (49%) or African American (44%). Almost one third (29%) of the participants met PTSD criteria. Women who exhibited symptoms in 1 or more PTSD symptom clusters were more likely than women who did not to report having had sex with multiple sexual partners, having had sex with a risky partner, and having experienced partner violence related to condom use in the preceding 6 months. The high rate of PTSD found in this sample and the significant associations between PTSD symptom clusters and partner-related risk behaviors highlight the need to take PTSD into account when designing HIV prevention interventions for low-income, urban women.

Post-traumatic stress disorder in physicians from an underserviced area

Studies suggest a high prevalence of mental illness in physicians. The rate of post-traumatic stress disorder (PTSD) has been examined in physicians exposed to traumatic circumstances and physicians in training but never in physicians in regular practice. To estimate the prevalence of PTSD in physicians practicing in a predominantly rural and remote and medically underserviced region of Canada. The PTSD Checklist-Civilian Version (PCL-C) was mailed to all 331 physicians in Northwestern Ontario, Canada. A PCL-C score of >or=50 was used to define 'probable' PTSD and >or=30 defined 'possible' PTSD. Additional comments and demographic information were also requested. Completed questionnaires were received from 159 physicians (48%). The prevalence of probable PTSD was 4.4%. No differences between demographic groups were observed for probable PTSD, but possible PTSD was more frequent in males than females (47.3% versus 20.4%, chi-square = 10.59, P = 0.001). Mean scores were also higher for males than for females (30.4 versus 25.4, 95% confidence interval for the difference: 1.4-8.5, P = 0.006). Respondents identified overwork, insufficient resources and relationships with colleagues and patients as common stressors. Results suggest a high rate of PTSD in Northwestern Ontario physicians. The prevalence of possible PTSD and mean PCL-C scores are higher in men than in women in this region, which may relate to differences in practice characteristics and the opportunity for exposure to traumatic events.

Salivary cortisol and psychopathology in adults bereaved by the September 11, 2001 terror attacks.

This prospective study aimed to describe the nature and time course of HPA axis dysregulation and psychopathology among terror-bereaved spouses. Twenty-three spouses bereaved from September 11, 2001 terror attacks and 22 nonbereaved spouses were compared using a psychiatric diagnostic interview (SCID), 3 days of salivary cortisol collection, and a dexamethasone suppression test. Most subjects had repeated assessments at 6 month intervals during the 2 year study. After September 11, 2001, bereaved compared to nonbereaved had significantly higher rates ofposttraumatic stress disorder (PTSD; 68.1% versus 0%) and major depressive disorder (MDD; 45.5% versus 9.5%). Bereaved had significantly higher morning basal cortisol and less afternoon postdexamethasone cortisol suppression than nonbereaved. Among bereaved, those with PTSD without comorbid MDD had significantly greater afternoon postdexamethasone cortisol suppression than those without psychiatric disorders. Terror-related spouse death is a severe stressor associated with persistent HPA axis activation, PTSD, and MDD. However, bereaved spouses who developed PTSD and were not depressed had enhanced postdexamethasone cortisol suppression, evidence of heightened glucocorticoid receptor sensitivity.

APA Prepares Members for Change in Certification Requirements

Back to table of contents Previous article Next article Professional NewsFull AccessAPA Prepares Members for Change in Certification RequirementsJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:21 Aug 2009https://doi.org/10.1176/pn.44.16.0002Five years from now, the American Board of Psychiatry and Neurology (ABPN) will implement a new feature in its maintenance-of-certification program. Psychiatrists will have to evaluate themselves on the quality of the patient care they provide. The rationale for implementing this feature is that a number of studies have demonstrated a gap between recommended evidence-based best practices and the actual care that psychiatrists provide.To give psychiatrists experience in assessing the quality of the care they provide to patients with posttraumatic stress disorder (PTSD) before the ABPN requirement kicks in, APA has developed two Performance in Practice tools. They were published in the spring FOCUS: The Journal of Lifelong Learning in Psychiatry.The first tool is a traditional chart-review approach to assessment. It allows psychiatrists to evaluate the care that they have given to five patients with PTSD. Some questions relate to initial assessment and treatment, others to subsequent care. They can then see how the various aspects of their patient care match up with evidence-based recommendations and where they might want to make improvements.The second tool allows psychiatrists to evaluate the quality of their care for patients with PTSD in real time. They can complete the self-assessment form immediately after a patient's first visit and see how their care compares with the recommendations, and then, if there are disparities, they can adjust their treatment plan.Both tools highlight aspects of care that have substantial public-health implications, such as suicide risk and substance abuse, or for which disparities between clinical care and recommended guidelines are common.The evidence-based recommendations included in the two practice tools are derived from the “APA Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder” and“ Clinical Practice Guideline for the Management of Posttraumatic Stress,” a publication of the U.S. departments of Defense and Veterans Affairs.One of the recommendations, for example, is the following: “SSRIs are considered the first-line psychopharmacologic intervention. However, SSRIs are no longer recommended with the same level of confidence for combat-related PTSD as for non-combat-related PTSD.” Another recommendation states:“ Exposure-based therapies . . . are considered first-line evidence-based psychotherapeutic interventions. However, exposure therapies are not indicated and should be used with caution for patients living in dangerous situations (e.g., domestic violence) or for patients with current suicidal ideation, substance abuse not in stable remission, comorbid psychosis, or health problems that preclude exposure to intense physiological arousal.”The PTSD practice tools were designed by Farifteh Duffy, Ph.D., director of quality-of-care research at the American Psychiatric Institute for Research and Education (APIRE), in conjunction with APIRE colleagues and a consultant. The reason they decided to design practice tools for PTSD rather than for another disorder, Duffy explained to Psychiatric News, is that“ this is an area of significant interest given the high rates of PTSD among service members and veterans of the Iraq and Afghanistan wars, the availability of practice guidelines and recent updates through APA's Guideline Watch for PTSD, as well as APIRE's obtaining the Department of Defense PTSD Research Program Concept Award in September 2008.”Duffy and her colleagues published their first practice tools—for depression—last year. “The majority of the psychiatrists who completed the tools found them to be well designed and of value in improving practice or verifying that their current care was appropriate,” she said. “Some two-thirds reported that they identified at least one way in which they could improve their care of patients with depression.”Duffy and her team hope to develop more practice tools “depending on the availability of updates for practice guidelines, interest in the field, and funding support,” she noted.The PTSD practice tools, as well as more information about them, are posted at<http://focus.psychiatryonline.org/cgi/content/abstract/7/2/186>.▪ ISSUES NewArchived

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

We sought to investigate longitudinal trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans. 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. 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. 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.

PTSD and Combat-Related Injuries: Functional Neuroanatomy

PTSD and Combat-Related Injuries: Functional Neuroanatomy

Abortion and anxiety: What's the relationship?

Using data from the United States National Survey of Family Growth (NSFG) and the National Comorbidity Survey (NCS), we conducted secondary data analyses to examine the relationship of abortion, including multiple abortions, to anxiety after first pregnancy outcome in two studies. First, when analyzing the NSFG, we found that pre-pregnancy anxiety symptoms, rape history, age at first pregnancy outcome (abortion vs. delivery), race, marital status, income, education, subsequent abortions, and subsequent deliveries accounted for a significant association initially found between first pregnancy outcome and experiencing subsequent anxiety symptoms. We then tested the relationship of abortion to clinically diagnosed generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and social anxiety disorder, using NCS data. Contrary to findings from our analyses of the NSFG, in the NCS analyses we did not find a significant relationship between first pregnancy outcome and subsequent rates of GAD, social anxiety, or PTSD. However, multiple abortions were found to be associated with much higher rates of PTSD and social anxiety; this relationship was largely explained by pre-pregnancy mental health disorders and their association with higher rates of violence. Researchers and clinicians need to learn more about the relations of violence exposure, mental health, and pregnancy outcome to avoid attributing poor mental health solely to pregnancy outcomes.

The stressor Criterion-A1 and PTSD: A matter of opinion?

Considerable controversy exists with regard to the interpretation and definition of the stressor “A1” criterion for Post Traumatic Stress Disorder (PTSD). At present, classifying an event as either traumatic (satisfying DSM-IV Criterion-A1 for PTSD), or non-traumatic (life event) is determined by the rater's subjective interpretation of the diagnostic criteria. This has implications in research and clinical practice. Utilizing a sample of 860 Australian adults, this study is the first to provide a detailed examination of the impact of event categorization on the prevalence of trauma and PTSD. Overall, events classified as non-traumatic were associated with higher rates of PTSD. Unanimous agreement between raters occurred for 683 (79.4%) events. As predicted, the categorization method employed (single rater, multiple rater-majority, multiple rater-unanimous) substantially altered the prevalence of Criterion-A1 events and PTSD, raising doubts about the functionality of PTSD diagnostic criteria. Factors impacting on the categorization process and suggestions for minimizing discrepancies in future research are discussed.