Military-related Posttraumatic Stress Disorder Research Articles

Harsh parenting among veterans: parents' military-related PTSD, mentalization, and pre-military trauma.

Veteran parents experiencing posttraumatic stress disorder (PTSD) may resort to harsh parenting. The indirect pathway from parental military-related PTSD to harsh parenting, and the moderating role of parents' pre-military trauma histories, has been less explored. Informed by mentalization theory, as well as trauma-sensitive and posttraumatic growth perspectives, we aim to explore the associations between veteran parents' military-related PTSD, mentalization, harsh parenting, and prior trauma before military service. Data were collected from an online research panel of 509 veteran parents with children under 10. We employed Structural Equation Models to test indirect and moderating effects. We identified an indirect effect of parental pre-mentalization from military PTSD to harsh parenting [corporal punishment: b = 0.35, p < 0.001, 95% CI (0.23, 0.46); psychological aggression: b = 0.14, p < 0.001, 95% CI (0.09, 0.19)]. Multi-group analysis on four parent groups (parents with only pre-military physical trauma, parents with only pre-military psychological trauma, parents with both pre-military physical and psychological trauma, and parents with no pre-military physical or psychological trauma) highlighted differences in these associations, particularly between parents with only pre-military physical trauma and those without any physical and psychological trauma. The military-related PTSD effects on psychological aggression, corporal punishment, and pre-mentalization were all significantly higher for parents without pre-military physical and psychological trauma. Modifying parents' interpretation of their child's mental states can potentially counteract the effects of veterans' military PTSD on harsh parenting. Family-based programs should be created considering veteran parents' pre-military trauma histories.

Hidden Challenges Experienced by Families With Military-Related Post-Traumatic Stress Disorder

Family systems theory explains how post-traumatic stress disorder (PTSD) in the family affects family members who must cope with disturbing behaviors from the military member. Although military-related PTSD has been studied in the United States for over a decade, Canadian research is in its infancy. This article focuses on the challenges military families face for both active military members and retired veterans. Corbin and Strauss’ (2015) grounded theory was used to guide this study. Following theoretical sampling, semi-structured in-depth interviews were conducted with 21 non-military parents and 4 adult children in Alberta. The findings have important implications for military families, as well as practice, policy, and research on the topic. Further research could expand the sample to include military members/veterans and families across Canada.

Posttraumatic stress, visual working memory, and visual imagery in military personnel

Posttraumatic stress disorder (PTSD) is characterized by disruptions to cognitive functioning. Two studies were conducted to examine the relevance of military-related PTSD to two cognitive functions – visual working memory and visual imagery. Participants were military personnel who reported their PTSD diagnosis history and completed a self-administered screening tool for PTSD, the PTSD Checklist – Military Version. In Study 1, 138 personnel also completed a memory span task and a 2-back task using colored words in which Stroop interference was introduced via the semantic content of the words. In Study 2, a separate group of 211 personnel completed measures of perceived imagery vividness and spontaneous use of visual imagery. Interference effects on working memory in PTSD-diagnosed military personnel were not replicated. However, ANCOVA and structural equation modelling revealed that PTSD-intrusions were associated with poorer working memory whereas PTSD-arousal was associated with spontaneous use of visual imagery. We interpret these results as evidence that intrusive flashbacks disrupt working memory performance not by limiting memory capacity nor by interfering directly with memory functions such as inhibition, but by adding internal noise in the form of task-irrelevant memories and emotions. Visual imagery appears to be unrelated to these flashbacks but with arousal symptoms of PTSD, perhaps in the form of flashforwards about feared/anticipated threats.

It Is Time to Flip the Script and Leverage the Point of Care to Discover Ways of Improving Treatment Outcomes for Posttraumatic Stress Disorder: Commentary on “A Sobering Look at Treatment Effectiveness of Military-Related Posttraumatic Stress Disorder” (Levi et al., 2021)

Levi et al. (2021) reported posttreatment outcomes of 709 Israeli veterans seeking treatment for service-related distress and concluded that their results reveal the “limited overall effectiveness” of treatments for posttraumatic stress disorder (PTSD). In this commentary, I critically appraise the categorical/diagnostic, model-based methods Levi et al. employed to examine effectiveness and use their observational study as a point of departure to describe an approach that uses benchmarked, repeated assessments of individual and aggregated outcomes (measurement-based care) to leverage these types of observational results to improve outcomes at the point of care as a way of advancing knowledge about how to best treat PTSD.

Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans

IMPORTANCEPosttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness.OBJECTIVETo compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans.DESIGN, SETTING, AND PARTICIPANTSThis randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021.INTERVENTIONSParticipants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions.MAIN OUTCOMES AND MEASURESThe primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life.RESULTSAnalyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21–80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1–40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5–41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89–1.08]) and CPT (SMD, 0.71 [95% CI, 0.61–0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53–4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00–1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12–1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24–2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events.CONCLUSIONS AND RELEVANCEThis randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment.TRIAL REGISTRATIONClinicalTrials.gov Identifier: NCT01928732

\u201cYou can\u2019t un-ring the bell\u201d: a mixed methods approach to understanding veteran and family perspectives of recovery from military-related posttraumatic stress disorder

BackgroundMilitary-related posttraumatic stress disorder (PTSD) is a complex diagnosis with non-linear trajectories of coping and recovery. Current approaches to the evaluation of PTSD and treatment discontinuation often rely on biomedical models that dichotomize recovery based on symptom thresholds. This approach may not sufficiently capture the complex lived experiences of Veterans and their families. To explore conceptualizations of recovery, we sought perspectives from Veterans and their partners in a pilot study to understand: 1) how Veterans nearing completion of treatment for military-related PTSD and their partners view recovery; and 2) the experience of progressing through treatment towards recovery.MethodsWe employed a concurrent mixed methods design. Nine Veterans nearing the end of their treatment at a specialized outpatient mental health clinic completed quantitative self-report tools assessing PTSD and depressive symptom severity, and an individual, semi-structured interview assessing views on their treatment and recovery processes. Veterans’ partners participated in a separate interview to capture views of their partners’ treatment and recovery processes. Descriptive analyses of self-report symptom severity data were interpreted alongside emergent themes arising from inductive content analysis of qualitative interviews.ResultsWhile over half of Veterans were considered “recovered” based on quantitative assessments of symptoms, individual reflections of “recovery” were not always aligned with these quantitative assessments. A persistent narrative highlighted by participants was that recovery from military-related PTSD was not viewed as a binary outcome (i.e., recovered vs. not recovered); rather, recovery was seen as a dynamic, non-linear process. Key components of the recovery process identified by participants included a positive therapeutic relationship, social support networks, and a toolkit of adaptive strategies to address PTSD symptoms.ConclusionsFor participants in our study, recovery was seen as the ability to navigate ongoing issues of symptom management, re-engagement with meaningful roles and social networks, and a readiness for discontinuing intensive, specialized mental health treatment. The findings of this study highlight important considerations in balancing the practical utility of symptom severity assessments with a better understanding of the treatment discontinuation-related needs of Veterans with military-related PTSD and their families, which align with a contemporary biopsychosocial approach to recovery.

Four Decades of Military Posttraumatic Stress: Protocol for a Meta-analysis and Systematic Review of Treatment Approaches and Efficacy.

BackgroundOver 85% of active members of the Canadian Armed Forces have been exposed to potentially traumatic events linked to the development of posttraumatic stress disorder (PTSD). At the time of transition to civilian life, as high as 1 in 8 veterans may be diagnosed with PTSD. Given the high prevalence of PTSD in military and veteran populations, the provision of effective treatment considering their unique challenges and experiences is critical for mental health support and the well-being of these populations.ObjectiveThis paper presents the protocol for a meta-analysis and systematic review that will examine the effectiveness of treatment approaches for military-related PTSD.MethodsThis PROSPERO-preregistered meta-analysis is being conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Cochrane guidelines. A comprehensive search of the literature was conducted using the databases PsycInfo, Medline, Embase, CINAHL, and ProQuest Dissertation & Theses. Effect sizes will be computed based on changes in PTSD symptom scores over time across studies using validated PTSD scales. A multilevel meta-analysis will examine the overall effects, between-study effects, and within-study effects of available evidence for PTSD treatments in military populations. Effect sizes will be compared between pharmacotherapeutic, psychotherapeutic, and alternative/emerging treatment interventions. Finally, meta-regression and subgroup analyses will explore the moderating roles of clinical characteristics (eg, PTSD symptom clusters), treatment approaches (eg, therapeutic orientations in psychotherapy and alternative therapies and classifications of drugs in pharmacotherapy), as well as treatment characteristics (eg, length of intervention) on treatment outcomes.ResultsThe literature search was completed on April 14, 2021. After the removal of duplicates, a total of 12,002 studies were screened for inclusion. As of July 2021, title and abstract screening has been completed, with 1469 out of 12,002 (12.23%) studies included for full-text review. Full review is expected to be completed in the summer of 2021, with initial results expected for publication by early winter of 2021.ConclusionsThis meta-analysis will provide information on the current state of evidence on the efficacy and effectiveness of various treatment approaches for military-related PTSD and identify factors that may influence treatment outcomes. The results will inform clinical decision-making for service providers and service users. Finally, the findings will provide insights into future treatment development and practice recommendations to better support the well-being of military and veteran populations.Trial RegistrationPROSPERO CRD42021245754; https://tinyurl.com/y9u57c59International Registered Report Identifier (IRRID)DERR1-10.2196/33151

A Sobering Look at Treatment Effectiveness of Military-Related Posttraumatic Stress Disorder

Approximately two thirds of veterans with posttraumatic stress disorder (PTSD) remain with the disorder following treatment. Pinpointing the per-symptom effectiveness of treatments in real-world clinical settings can highlight relevant domains for treatment augmentation and development. Baseline and posttreatment assessments of PTSD and depression were performed in 709 veterans with PTSD. PTSD remission was 39.4%. Treatment was least effective for intrusion symptoms and had no effect on flashbacks or on poor recall of traumatic features. Of veterans who remitted, 72.8% still met diagnostic criteria for at least one cluster. Poor clinical effectiveness was noted for depression; only 4.1% of the patients remitted following treatment. Treatments for veterans with PTSD show limited overall effectiveness in real-world settings. Enhancing treatment response may require enhancing provider fidelity and patient compliance with extant treatments or the development of new treatments that specifically target the symptoms of PTSD that do not respond well to extant treatments.

A trauma-focused intensive outpatient program integrating elements of exposure therapy with acceptance and commitment therapy: Program development and initial outcomes

A Performance Improvement project conducted within Army Behavioral Health identified significant challenges associated with treating service members diagnosed with posttraumatic stress disorder (PTSD) including unavailability of frequent and consistent therapy, a low completion rate of evidence-based treatment, and a high non-response rate. In response to these findings, clinical staff at Brooke Army Medical Center developed an intensive outpatient program for the treatment of PTSD and combined Acceptance and Commitment Therapy with Prolonged Exposure therapy to create an integrative and uniquely tailored intervention. This project included 311 active duty service members who had not made significant progress in individual outpatient therapy for PTSD. Each participant completed pre- and post-treatment measures of symptoms, functioning, and processes related to psychological flexibility. Program evaluation also included participant interviews, survey responses, and clinician reports. Overall, the program was tolerable and reviewed favorably by participants. Preliminary pre-post treatment analyses revealed, on average, large reductions in PTSD symptoms as well as significant changes in the target direction on nine of ten outcome measures. These findings encourage further investigation of process-outcome relationships and future, rigorous implementation studies of ACT and exposure integration and culturally and contextually sensitive treatments for military-related PTSD.

Military-related posttraumatic stress disorder and mindfulness meditation: A systematic review and meta-analysis

PurposePosttraumatic stress disorder (PTSD) is a significant global mental health concern, especially in the military. This study aims to estimate the efficacy of mindfulness meditation in the treatment of military-related PTSD, by synthesizing evidences from randomized controlled trials. MethodsFive electronic databases (Pubmed, EBSCO Medline, Embase, PsychINFO and Cochrane Library) were searched for randomized controlled trials focusing on the treatment effect of mindfulness meditation on military-related PTSD. The selection of eligible studies was based on identical inclusion and exclusion criteria. Information about study characteristics, participant characteristics, intervention details, PTSD outcomes, as well as potential adverse effects was extracted from the included studies. Risk of bias of all the included studies was critically assessed using the Cochrane Collaboration's tool. R Statistical software was performed for data analysis. ResultsA total of 1902 records were initially identified and screened. After duplicates removal and title & abstract review, finally, 19 articles in English language with 1326 participants were included through strict inclusion and exclusion criteria. The results revealed that mindfulness meditation had a significantly larger effect on alleviating military-related PTSD symptoms compared with control conditions, such as treatment as usual, present-centered group therapy and PTSD health education (standardized mean difference (SMD) = −0.33; 95% CI [−0.45, −0.21]; p < 0.0001). Mindfulness interventions with different control conditions (active or non-active control, SMD = −0.33, 95% CI [−0.46, −0.19]; SMD = −0.49, 95% CI [−0.88, −0.10], respectively), formats of delivery (group-based or individual-based, SMD = −0.30, 95% CI [−0.42, −0.17], SMD = −0.49, 95% CI [−0.90, −0.08], respectively) and intervention durations (short-term or standard duration, SMD = −0.27, 95% CI [−0.46, −0.08], SMD = −0.40, 95% CI [−0.58, −0.21], respectively) were equally effective in improving military-related PTSD symptoms. ConclusionFindings from this meta-analysis consolidate the efficacy and feasibility of mindfulness meditation in the treatment of military-related PTSD. Further evidence with higher quality and more rigorous design is needed in the future.

Randomized clinical trial of bedtime sublingual cyclobenzaprine (TNX-102 SL) in military-related PTSD and the role of sleep quality in treatment response

Effective posttraumatic stress disorder (PTSD) pharmacotherapy is needed. This 12-week randomized multicenter trial evaluated efficacy and safety of TNX-102 SL, a bedtime sublingual formulation of cyclobenzaprine, in patients with military-related PTSD randomized to TNX-102 SL 2.8 mg or 5.6 mg, or placebo. Primary analysis comparing change from baseline in Clinician-Administered PTSD Scale-5 score between 2.8 mg (n=90) and placebo (n=92) was not significant. Secondary analysis of 5.6 mg (n=49) vs placebo demonstrated a mean difference of -4.5 units, p=.05, or, accounting for missing data by multiple imputation, -5.0 units, p=.03. Clinician Global Impression – Improvement responder rate was greater in 5.6 mg than placebo (p=0.04), as was mean functional improvement in Sheehan Disability Scale social domain (p=.03) and trended in work domain (p=.05). Post-hoc analyses showed early sleep improvement predicted improvement in PTSD after 12 weeks for TNX-102 SL (p<.01), not for placebo. Most common administration site reaction in TNX-102 SL groups was oral hypoaesthesia (5.6 mg, 36%; 2.8 mg, 39%; placebo, 2%), while most common systemic adverse event was somnolence (5.6 mg, 16%; 2.8 mg, 12%; placebo, 6%). This provides preliminary evidence that TNX-102 SL 5.6 mg reduces PTSD symptoms, improves sleep and psychosocial function, and is well tolerated.Clinicaltrials.gov Identifier: NCT02277704

Utilization of machine learning for identifying symptom severity military-related PTSD subtypes and their biological correlates

We sought to find clinical subtypes of posttraumatic stress disorder (PTSD) in veterans 6–10 years post-trauma exposure based on current symptom assessments and to examine whether blood biomarkers could differentiate them. Samples were males deployed to Iraq and Afghanistan studied by the PTSD Systems Biology Consortium: a discovery sample of 74 PTSD cases and 71 healthy controls (HC), and a validation sample of 26 PTSD cases and 36 HC. A machine learning method, random forests (RF), in conjunction with a clustering method, partitioning around medoids, were used to identify subtypes derived from 16 self-report and clinician assessment scales, including the clinician-administered PTSD scale for DSM-IV (CAPS). Two subtypes were identified, designated S1 and S2, differing on mean current CAPS total scores: S2 = 75.6 (sd 14.6) and S1 = 54.3 (sd 6.6). S2 had greater symptom severity scores than both S1 and HC on all scale items. The mean first principal component score derived from clinical summary scales was three times higher in S2 than in S1. Distinct RFs were grown to classify S1 and S2 vs. HCs and vs. each other on multi-omic blood markers feature classes of current medical comorbidities, neurocognitive functioning, demographics, pre-military trauma, and psychiatric history. Among these classes, in each RF intergroup comparison of S1, S2, and HC, multi-omic biomarkers yielded the highest AUC-ROCs (0.819–0.922); other classes added little to further discrimination of the subtypes. Among the top five biomarkers in each of these RFs were methylation, micro RNA, and lactate markers, suggesting their biological role in symptom severity.

Disability Status Attenuates Treatment Effects in an Intensive Outpatient Program for PTSD.

The utilization of intensive outpatient programs for the treatment of military-related post-traumatic stress disorder (PTSD) has increased through initiatives both inside and outside the military health care system. However, research in veteran populations suggest that patients concurrently undergoing disability evaluation may not respond well to such interventions. This study evaluates the relationship between disability separation and endorsement of PTSD symptoms during treatment at an intensive outpatient program. Patients in this retrospective study were 81 service members enrolled in a half-day, 6-week intensive outpatient program for PTSD. Sixty-seven percent (n = 54) were concurrently enrolled in the integrated disability evaluation system and were pending medical separation. Fifty-two percent (n = 42) also received a 4-week skills training intervention before beginning PTSD treatment. Patients completed the PTSD Checklist before, during, and after the treatment program as an index of PTSD symptoms. A significant interaction effect was observed in which PTSD symptoms throughout program enrollment differed as a function of enrollment in the integrated disability evaluation system. Patients undergoing disability evaluations did not show significant changes in endorsed PTSD symptoms during program enrollment, whereas significant decreases in PTSD symptoms were observed in patients not undergoing disability evaluations. These effects controlled for lost treatment days as a result of training or other appointments. These results provide preliminary data indicating that participation in disability separation may attenuate the effect of PTSD treatment and endorsement of PTSD symptoms in an intensive outpatient setting.

Prevalence and treatment implications of ICD-11 complex PTSD in Australian treatment-seeking current and ex-serving military members

ABSTRACT Background: Despite growing support for the distinction between posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as separate diagnoses within the ICD-11 psychiatric taxonomy, the prevalence and treatment implications of CPTSD among current and ex-serving military members have not been established. Objective: The study aims were to a) establish the prevalence of provisional ICD-11 CPTSD diagnosis relative to PTSD in an Australian sample of treatment-seeking current and ex-serving military members, and b) examine the implications of CPTSD diagnosis for intake profile and treatment response. Methods: The study analysed data collected routinely from Australian-accredited treatment programmes for military-related PTSD. Participants were 480 current and ex-serving military members in this programmes who received a provisional ICD-11 diagnosis of PTSD or CPTSD at intake using proxy measures. Measures of PTSD symptoms, disturbances in self-organisation, psychological distress, mental health and social relationships were considered at treatment intake, discharge, and 3-month follow-up. Results: Among participants with a provisional ICD-11 diagnosis, 78.2% were classified as having CPTSD, while 21.8% were classified as having PTSD. When compared to ICD-11 PTSD, participants with CPTSD reported greater symptom severity and psychological distress at intake, and lower scores on relationship and mental health dimensions of the quality of life measure. These relative differences persisted at each post-treatment assessment. Decreases in PTSD symptoms between intake and discharge were similar across PTSD (d RM = −0.81) and CPTSD (d RM = −0.76) groups, and there were no significant post-treatment differences between groups when controlling for initial scores. Conclusions: CPTSD is common among treatment-seeking current and ex-serving military members, and is associated with initially higher levels of psychiatric severity, which persist over time. Participants with CPTSD were equally responsive to PTSD treatment; however, the tendency for those with CPTSD to remain highly symptomatic post-treatment suggests additional treatment components should be considered.

Neuroendocrine biomarkers of prolonged exposure treatment response in military-related PTSD

Posttraumatic stress disorder (PTSD) is associated with dysregulation of the neuroendocrine system, including cortisol, allopregnanolone, and pregnanolone. Preliminary evidence from animal models suggests that baseline levels of these biomarkers may predict response to PTSD treatment. We report the change in biomarkers over the course of PTSD treatment. Biomarkers were sampled from individuals participating in (1) a randomized controlled trial comparing a web-version of Prolonged Exposure (Web-PE) therapy to in-person Present-Centered Therapy (PCT) and (2) from individuals participating in a nonrandomized effectiveness study testing PE delivered in-person as part of an intensive outpatient PTSD program. We found that higher cortisol reactivity during script-driven imagery was associated with higher baseline PTSD severity and that baseline allopregnanolone, pregnanolone, and cortisol reactivity were associated with degree of symptom change over the course of intensive outpatient treatment. These findings demonstrate that peripherally assessed biomarkers are associated with PTSD severity and likelihood of successful treatment outcome of PE delivered daily over two weeks. These assessments could be used to determine which patients are likely to respond to treatment and which patients require augmentation to increase the likelihood of optimal response to PTSD treatment.

The Development of a Brief Version of the Insomnia Severity Index (ISI-3) in Older Adult Veterans with Posttraumatic Stress Disorder

ABSTRACT Objective/Background: The Insomnia Severity Index (ISI) is an insomnia self-report measure used to identify individuals at risk for insomnia disorder. Although the full ISI is only seven questions, a briefer version would allow more efficient and pragmatic administration in routine practice settings. Reliable and valid brief measures can support measurement-based care. The present study was a proof-of-concept study that developed a brief version of the ISI, the ISI-3, in a sample of older adult veterans with posttraumatic stress disorder (PTSD), a group which is at increased risk for insomnia. Patients/Methods: Participants included 86 older veterans with combat- or military-related PTSD. Veterans completed a clinician-administered PTSD diagnostic interview, self-report measures of insomnia and other psychosocial questionnaires, and two neuropsychological assessments. The factor structure of the ISI was examined to reduce the measure into a brief version. The reliability and validity of the ISI-3 were examined. Results: Principal axis factoring yielded a one-factor solution, which reproduced 59% of the item variance. Item reduction procedures resulted in three items, which best represented this factor (“Insomnia Impact;” ISI-3). For the ISI-3, internal consistency was good (α =.89). Convergent validity was demonstrated via moderate to high positive correlations between the ISI-3 and other measures of sleep disturbance. Divergent validity was demonstrated via non-significant correlations between the ISI-3 and unrelated measures and moderate correlations with self-reported depression. Conclusions: The ISI-3 is a psychometrically valid brief version of the ISI. Clinicians can administer the ISI-3 to screen for insomnia and monitor changes in insomnia during treatment.

The Impact of Depression Severity on Treatment Outcomes Among Older Male Combat Veterans with Posttraumatic Stress Disorder.

Posttraumatic stress disorder (PTSD) and depression are highly comorbid within the veteran population. Research studies have yielded divergent findings regarding the effect of depression on PTSD treatment outcomes. The present study investigated the influence of pretreatment depression severity on PTSD and depression symptom trajectories among 85 older (i.e., ≥ 60 years) male veterans with military-related PTSD who received either prolonged exposure or relaxation training as part of a randomized controlled trial. Participants were categorized as having no/mild depression (n = 23) or moderate/severe depression (n = 62). The PTSD Checklist (PCL-S) and Patient Health Questionnaire (PHQ-9) were completed at pretreatment, each of 12 therapy sessions, posttreatment, and 6-month follow-up, for a total of up to 15 data points per participant. Multilevel modeling (MLM) was used to evaluate the impact of pretreatment depression severity on piecewise symptom trajectories (i.e., active treatment and follow-up periods) over time and to determine whether treatment condition moderated the trajectories. The final MLM results showed significant main effects of depression severity on PCL-S scores, B = 10.84, p = .043 and PHQ-9 scores, B = 7.09, p = .001, over time. No significant interactions emerged for either the PCL-S or PHQ-9, indicating that although older veterans with more severe depression endorsed higher PTSD and depression scores across time, the symptom trajectories were not moderated by depression severity, treatment condition, or their interaction.

Partners’ motivations for accommodating posttraumatic stress disorder symptoms in service members: The reasons for accommodation of PTSD scale

Emerging research reinforces the importance of partner accommodation in the interpersonal context of posttraumatic stress disorder (PTSD). A better understanding of partners’ motivations for accommodation is needed to help refine or design interventions that target accommodation. To explore partners’ motivations, we created the Reasons for Accommodation of PTSD Scale (RAPS) and evaluated it in 263 female partners of male Army soldiers who had returned from a deployment within the past 2 years. Soldiers completed a measure of military-related PTSD, and partners completed a measure of accommodation and the newly created RAPS. Factor analysis of the RAPS yielded a clear, 3-factor solution suggesting the following reasons for accommodating: (1) Relationship & Obligation, or a desire for positive relationship outcomes and a sense of duty or responsibility; (2) Helping Recovery, or a belief that avoidance was helpful for the service member; and (3) Conflict Avoidance/Helplessness, or a desire to avoid conflict or simply not knowing what else to do. Analyses of these factors in relation to soldiers’ PTSD clusters indicated that hyperarousal symptoms were uniquely associated with relationship and obligation motivations, re-experiencing symptoms were uniquely associated with helping recovery motivations, and emotional numbing symptoms were uniquely associated with conflict avoidance and helplessness motivations. Furthermore, conflict avoidance and helplessness accounted for the greatest variance in partners’ accommodation frequency and distress. Assessment of partners’ accommodative behaviors, as well as their motivations for engaging in accommodation, may aid in treatment planning and enhance outcomes for couples in which one individual has PTSD.

Trauma Management Therapy and Prolonged Exposure Therapy for PTSD in an active duty sample: Design and methodology of a randomized clinical trial

Posttraumatic stress disorder (PTSD) resulting from military service is a common, yet often chronic condition. Treatment outcome often is attenuated by programs that are (a) lengthy in nature and (b) constricted in their target outcomes. These limitations leave much of the emotional and behavioral impairment that accompanies PTSD unaddressed and/or unassessed. Typical PTSD treatment programs are 3–4 months in length, which is challenging for the pace of the nation's military. In this investigation, we will compare two treatments, Trauma Management Therapy (TMT) and Prolonged Exposure (PE), both redesigned to address the needs of active duty personnel (300 participants at 3 military installations). Specifically, we will compare the TMT Intensive Outpatient Program (IOP; 3 weeks) to PE's compressed (2 week) format. Both interventions will be compared to a standard course of PE (12 weeks). In addition to PTSD symptomatology, outcome measurement includes other aspects of psychopathology as well as changes in social, occupational, and familial impairment. Potential negative outcomes of massed treatment, such as increased suicidal ideation or increased alcohol use, will be assessed, as will genetic predictors of PTSD subtype and treatment outcome. This study will inform the delivery of care for military-related PTSD and particularly the use of intensive or compressed treatments for active duty personnel.

Military Posttraumatic Stress Disorder: A Qualitative Systematic Review of the Experience of Families, Parents and Children

Research into military-related posttraumatic stress disorder (PTSD) and the impact to families is growing. However, qualitative studies exploring the family life or parenting experiences of military/veteran families living with PTSD appears limited. The current paper aimed to systematically review research that explored different family members’ experiences of living in families where a parent had a military related PTSD. Adhering to the PRISMA guidelines for systematic reviews, six online databases were comprehensively searched, along with manual searches of relevant journals, reviews and reference lists. Interrater reliability for identifying papers was established through blind co-screening of 20% of search results, with minimal initial discrepancy. Eleven studies were identified. Each study was critically appraised for quality using the RATS (relevancy, appropriateness, transparency, soundness) qualitative research review guidelines. Thematic analysis identified six primary themes including: the absent parent; walking on eggshells; still part of the family; children and partners as care givers; making sense and understanding; and long-term impacts upon the family. Quality of the identified research was mixed. The existing literature is extended by presenting a systematic review of published qualitative research on the subjective experiences of the parent with military-related PTSD, their partner and children. Themes across veteran, partner and child focused papers illustrated interconnected elements of the family experience of PTSD. Future studies might integrate the views of family members. Clinicians need to be mindful of the relational context in which PTSD exists.