Posttraumatic Stress Disorder Clinic Research Articles

Relationship between anxiety, depression, and health satisfaction among veterans with PTSD

Objectives Depression and anxiety are associated with significantly increased healthcare costs that include costs of non-psychiatric medical care. PTSD has been found to be related to many negative health perceptions and outcomes (e.g., [Resnick, H.S., Acierno, R., Kilpatrick, D.G., 1997. Health impact of interpersonal violence: II. Medical and mental health outcomes. Behavioral Medicine 23, 65–78]). The presence of comorbid depression and anxiety disorders in patients with posttraumatic stress disorder (PTSD) is well documented. This study aims to examine the effects of depression and anxiety on health satisfaction in veterans with PTSD. Methods The current study utilizes archival data from a clinical sample of combat veterans ( N = 249) with and without PTSD in order to examine the unique contributions of anxiety and depression to reported health satisfaction. Results After controlling for PTSD severity, combat exposure, and age, when both anxiety and depression are examined simultaneously in a regression to predict health satisfaction only depression significantly contributed and accounted for 10% of model variance. Conclusions While both depression and anxiety are related to more negative reported health satisfaction among veterans in a PTSD clinic, depression appears to be a main contributor. Limitations Evaluation and treatment seeking veterans may differ from a full range of veterans with PTSD. Closer examination with measures of depression and anxiety that more precisely separate these constructs is warranted. Finally, it is not known whether reported health satisfaction is related to an objective difference in health status or is more indicative of subjective expression of distress.

A New Engagement Strategy in a VA-Based Family Psychoeducation Program

This brief report describes the engagement strategy used in the Reaching out to Educate and Assist Caring, Healthy Families (REACH) program, a nine-month family psychoeducation program for veterans with serious mental illness or posttraumatic stress disorder (PTSD). A motivational interviewing-based strategy was created and implemented in a Veterans Affairs hospital to engage providers and veterans and their families into the intervention. Of the 1,539 veterans told about the program, 41% had a family member living nearby and were willing to meet with a provider to learn more. REACH providers met with 505 veterans for a motivational-interviewing session to explore family participation. Of the 436 veterans who were eligible to participate in REACH, 28% of veterans with PTSD, 34% of veterans with an affective disorder, and 25% of veterans with a schizophrenia spectrum disorder went on to participate in at least one session of the REACH program with a family member; these rates compare favorably with those for programs requiring a much shorter commitment. This engagement strategy shows promise as an effective tool in recruiting veterans and their families into family psychoeducation.

Prolonged exposure for PTSD in a Veterans Health Administration PTSD clinic

With the move toward dissemination of empirically supported treatments in the Veterans Health Administration (VHA), dissemination of additional data concerning the effectiveness of prolonged exposure (PE) among veterans is important. The authors present clinical treatment data from veterans with chronic posttraumatic stress disorder (PTSD) treated in a VHA PTSD clinic (N = 10). Veterans demonstrated significant reductions in total PTSD symptoms from pre- to posttreatment. Returning veterans from the conflicts in Afghanistan and Iraq and other era veterans (Vietnam Veterans and military sexual trauma veterans) demonstrated significant reductions in PTSD. In addition, veterans demonstrated significant reductions in depression from pre- to posttreatment. In conclusion, PE is effective in reducing the symptoms of PTSD in veterans.

Structural equation modeling of associations among combat exposure, PTSD symptom factors, and Global Assessment of Functioning

This study used structural equation modeling (SEM) to evaluate the relative strength of associations between combat exposure, four posttraumatic stress disorder (PTSD) symptom factors, and functional impairment as indexed by Global Assessment of Functioning (GAF) scores in a sample of 315 veterans assessed at a Department of Veterans Affairs PTSD clinic. Results showed that the association between combat exposure and GAF scores was fully mediated by PTSD severity. The best-fitting model included direct paths from combat exposure to reexperiencing symptoms and from avoidance and numbing symptoms to GAF. However, only 17% of variance in GAF was accounted for by PTSD. The results raise concern about the use of the GAF score as a benchmark for quantifying combat PTSD-related functional impairment.

Symptom severity and lifetime and prospective health service use among military veterans evaluated for PTSD

We used structural equation modeling with 174 treatment-seeking military trauma survivors evaluated for posttraumatic stress disorder (PTSD) at a VA Medical Center PTSD clinic to examine relationships among lifetime mental health service use, PTSD symptom severity and medical problems (from self-report), as well as prospective (1-year) mental health and medical care use visit counts extracted from medical records. We discovered an adequate statistical fit to a hypothesized model of previous and prospective health service use, and current PTSD severity and health-related problems. Previous inpatient mental health treatment was significantly related to PTSD severity and prospective outpatient mental health use. However, PTSD severity was unrelated to prospective use of mental health or medical services. Health problems were related to prospective medical service use. Clinical and administrative implications in predicting health care use among trauma survivors are discussed.

Lifetime Trauma Exposure in Veterans With Military-Related Posttraumatic Stress Disorder

This study examined whether trauma exposure before, during, and/or after military service contributed to current levels of post-traumatic stress disorder (PTSD) and adjustment. Further, we investigated whether trauma exposure before military service was mediated or moderated by military trauma in its effects on current PTSD and adjustment. In this retrospective study, archival data from the medical records of 422 male veterans diagnosed with PTSD between December 2001 and July 2004 at a Veterans Administration Medical Center PTSD clinic were analyzed. Measures included the Clinician-Administered PTSD Scale interview as well as self-report measures assessing trauma history, health problems, and general psychopathology (including PTSD). Findings indicated that nonmilitary-related trauma was prevalent in this sample (90%). Regression analyses for PTSD symptom severity revealed that age, greater combat exposure, and a history of physical assault after military service were significantly associated with more severe PTSD symptoms. Childhood physical abuse, adult sexual trauma, and a history of being physically assaulted during military service were also significantly associated with PTSD symptom severity. Mediational analyses indicated that childhood trauma was associated with both adult trauma and increased symptomatology on various outcome measures. Moderational analyses indicated that adult trauma exposure moderated the effect of childhood trauma exposure on health complaints. Results suggest that several variables, including age, greater combat exposure, and premilitary and postmilitary traumas, are associated with increased PTSD symptomatology. This finding underscores the importance of conducting a thorough assessment of trauma when diagnosing PTSD.

A pilot study of behavioral activation for veterans with posttraumatic stress disorder

A pilot study was conducted to investigate the feasibility and effectiveness of behavioral activation (BA) therapy for veterans with posttraumatic stress disorder (PTSD). Eleven veterans seeking treatment at a Veterans Administration outpatient PTSD clinic were enrolled in the study protocol, consisting of 16-weekly individual sessions of BA. Nine veterans completed the protocol, one participant completed 15 sessions, and one dropped out after one session. Clinician-rated PTSD symptom severity showed significant pre- to posttreatment improvement and was associated with a moderate effect size. A number of participants also were improved on measures of depression and quality of life, but changes did not reach statistical significance. Findings suggest that BA is a well-tolerated, potentially beneficial intervention for veterans with chronic symptoms of PTSD.

Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder

There are concerns regarding the validity of combat exposure reports of veterans seeking treatment for combat-related post-traumatic stress disorder (PTSD) within US Veterans Affairs Medical Centers. To verify combat exposure history for a relevant sample through objective historical data. Archival records were reviewed from the US National Military Personnel Records Center for 100 consecutive veterans reporting Vietnam combat in a Veterans Affairs PTSD clinic. Cross-sectional clinical assessment and 12-month service use data were also examined. Although 93% had documentation of Vietnam war-zone service, only 41% of the total sample had objective evidence of combat exposure documented in their military record. There was virtually no difference between the Vietnam 'combat' and 'no combat' groups on relevant clinical variables. A significant number of treatment-seeking Veterans Affairs patients may misrepresent their combat involvement in Vietnam. There are implications for the integrity of the PTSD database and the Veterans Affairs healthcare system.

Psychiatric symptoms and health service utilization in rural and urban combat veterans with posttraumatic stress disorder.

This study investigated differences in rural/urban mental health and service use in veterans with combat-related posttraumatic stress disorder (PTSD). Data were obtained from 48 urban and 52 rural residing combat veterans diagnosed with PTSD at a Veterans Affairs Medical Center's outpatient PTSD clinic. Rural and urban groups were compared on health service utilization indices (PTSD, primary and specialty care clinic visits), the Minnesota Multiphasic Personality Inventory-2, the Mississippi Combat PTSD Scale, the Beck Depression Inventory, and the Dissociative Experiences Scale. Results indicated a lack of substantive differences between rural and urban combat PTSD patients. The sole difference involved higher dissociation scores among rural patients. Rural combat PTSD patients therefore seem to have similar mental health needs compared with their urban counterparts, with important service delivery implications.

Predictors of veterans' participation in cognitive-behavioral group treatment for PTSD.

Increasingly effective treatments for posttraumatic stress disorder (PTSD) have led to dramatic improvements in the lives of many trauma survivors; however, a significant subgroup of individuals with PTSD avoids mental health treatment. Little is known about the features distinguishing those who participate in treatment from those who do not. We analyzed archival clinical data from 197 male veterans who were evaluated in a Veterans Affairs Medical Center PTSD clinic. We found greater PTSD severity associated with initial enrollment and continued participation in a PTSD group treatment program, and we noted few differences on other background and symptom measures. These preliminary findings suggest possible directions for future research in this area, which may have implications for enhancing service delivery to individuals with PTSD.

Enhancing Patient Satisfaction and Increasing Treatment Compliance: Patient Education as a Fundamental Component of PTSD Treatment

Posttraumatic Stress Disorder (PTSD) is the modal mental health problem afflicting combat veterans. In addition to the significant distress resulting from the disorder itself, PTSD has been associated with significant medical comorbidity and increased utilization of medical services. Interventions have historically focused on targeting symptoms directly, with comparatively little attention to systematically educating patients about the etiology and maintenance of the disorder and associated features and treatment issues. This descriptive study summarizes an eight-week PTSD patient education and orientation group. Seventeen patients admitted consecutively to the PTSD Clinic at a large VA hospital completed surveys of patient satisfaction with services and motivation to comply with treatment regimens upon completion of the group. Participants reported very high satisfaction with services, increased awareness of PTSD treatment options, greater optimism and symptom improvement and enhanced motivation to continue with treatment as a result of attending the group.

Predictors of Mental Health and Medical Service Use in Veterans Presenting With Combat-Related Posttraumatic Stress Disorder.

Predictors of health service use were assessed using archival data of 87 male combat veterans with combat posttraumatic stress disorder (PTSD) at an outpatient Veterans Affairs Medical Center PTSD clinic. Predictor variables included predisposing demographic, illness/need, and enabling resource variables. Criterion variables included indexes of health service use. Results revealed no significant predictors of PTSD-related or primary care health service consumption. Lower scores on measures of symptom overreporting and anxiety predicted specialty care service use. Race (Caucasian) and marital status (currently married) predicted prescription of psychiatric medications. Clinical implications are considered, with a focus on the impact of racial group status as well as symptom exaggeration on health service utilization in PTSD patients.

Medical service utilization by veterans seeking help for posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) has been associated with higher rates of health complaints and medical conditions diagnosed by physicians, yet research examining the relationship between PTSD and health care utilization has been limited. This study compared the health service use of veterans with PTSD to that of help-seeking veterans without PTSD. The relationship between severity of PTSD and service utilization was also examined. Data were collected from 996 veterans seeking an evaluation at a Veterans Affairs (VA) Medical Center specialty PTSD clinic in the southeastern United States between March 1992 and September 1998. Data included sociodemographic characteristics, severity of PTSD, and disability status. The outcome variable, VA health service utilization, was prospectively assessed 1 year from the date of the initial PTSD assessment. Although the use of VA mental health services by patients with PTSD was substantial (a median of seven clinic stops), these patients used more services in general physical health clinics that provided predominantly nonmental health services (a median of 18 clinic stops). Negative binomial regression models revealed that younger veterans with PTSD had greater health care utilization than those without PTSD who also sought services. Greater severity of PTSD was related to higher rates of mental and physical health service use among veterans without a service-connected disability. PTSD is associated with substantial health service use. The results highlight the importance of increased collaboration between primary care and mental health specialists, given that patients with PTSD are more likely to receive treatment in nonmental health clinics.

Racial differences in psychotic symptoms among combat veterans with PTSD.

We tested the hypothesis that race may influence clinical presentation and symptomatology in combat veterans with posttraumatic stress disorder (PTSD). African-American and Caucasian veterans were administered the Psychotic Screen Module of the Structured Clinical Interview for DSM, Minnesota Multiphasic Personality Inventory-2 (MMPI-2), and other psychometric measures at a Veterans Affairs outpatient PTSD clinic. Subjects were consecutive referrals who were not matched for level of combat trauma or preexisting trauma; however, there were no group differences in other relevant demographic or diagnostic variables. Significant racial differences, with modest effect sizes, were found on clinician ratings of psychotic symptoms, MMPI-2 scale 6 ("paranoia"), and a measure of dissociation. No significant differences were found for the MMPI-2 scale 8 ("schizophrenia"), or on measures that might suggest comorbid depression or anxiety. African-Americans with PTSD endorsed more items suggesting positive symptoms of psychosis, without higher rates of primary psychosis, depression, or anxiety than Caucasians.

A Racial Comparison of Combat Veterans Evaluated for PTSD

This study attempted to replicate the work of Frueh, Smith, and Libet (1996), which showed racial differences on psychological measures of dissociation/thought disturbance and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) F-K index in combat veterans evaluated for posttraumatic stress disorder (PTSD). Veterans completed the Beck Depression Inventory, Mississippi Scale for Combat-Related PTSD, a fixed-response format version of the Dissociative Experiences Scale (DES-FRF), and MMPI-2 prior to treatment at a Veterans Affairs hospital outpatient PTSD clinic. Contrary to expectation, significant racial differences on the DES-FRF, MMPI-2 validity scales, and MMPI-2 Scales 6 and 8 were not found. Consistent with the previous study, no racial differences on measures of anxiety, depression, or PTSD symptomatology were found; nor were there racial differences on clinician ratings of global assessment of functioning or on most categories of psychiatric diagnoses. This suggests that Black and White combat veterans evaluated for PTSD do not differ with regard to reported manifestation or severity of psychopathology.

Preliminary evaluation of sexual problems in combat veterans with PTSD

AbstractThis study evaluated the potential relationship between posttraumatic stress disorder (PTSD) and sexual problems. The Golombok Rust Inventory of Sexual Satisfaction was mailed to combat veterans currently in treatment at an outpatient PTSD clinic. Completed questionnaires were received from 90 patients. Results indicated that over 80% of subjects were experiencing clinically relevant sexual difficulties. Impotence and premature ejaculation were the most frequently reported problems that have corresponding psychological diagnoses. The rates of sexual problems for this sample of veterans with PTSD was similar to those reported in other studies and exceeded rates of similar problems found in samples from community samples. These data suggest that PTSD may be a risk factor for sexual problems.

Preliminary evaluation of sexual problems in combat veterans with PTSD.

This study evaluated the potential relationship between posttraumatic stress disorder (PTSD) and sexual problems. The Golombok Rust Inventory of Sexual Satisfaction was mailed to combat veterans currently in treatment at an outpatient PTSD clinic. Completed questionnaires were received from 90 patients. Results indicated that over 80% of subjects were experiencing clinically relevant sexual difficulties. Impotence and premature ejaculation were the most frequently reported problems that have corresponding psychological diagnoses. The rates of sexual problems for this sample of veterans with PTSD was similar to those reported in other studies and exceeded rates of similar problems found in samples from community samples. These data suggest that PTSD may be a risk factor for sexual problems.

Compensation seeking status and psychometric assessment of combat veterans seeking treatment for PTSD.

Examined differences between compensation seeking (CS) veterans and noncompensation seeking (NCS) veterans on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and other psychological measures in 142 combat veterans evaluated for posttraumatic stress disorder (PTSD) at an outpatient Veterans Affairs (VA) hospital PTSD clinic. Patients were grouped on the basis of their compensation seeking status, with 69% classified as CS for PTSD. The CS veterans achieved significantly more pathological scores across a wide range of psychological inventories and MMPI-2 validity indices, although they did not differ in frequency of PTSD diagnoses from NCS veterans. Implications of these findings are discussed, and clinicians are advised to be aware of the compensation seeking status of combat-veterans being evaluated for PTSD.

Compensation seeking status and psychometric assessment of combat veterans seeking treatment for PTSD

AbstractExamined differences between compensation seeking (CS) veterans and noncompensation seeking (NCS) veterans on the Minnesota Multiphasic Personality Inventory‐2 (MMPI‐2) and other psychological measures in 142 combat veterans evaluated for posttraumatic stress disorder (PTSD) at an outpatient Veterans Affairs (VA) hospital PTSD clinic. Patients were grouped on the basis of their compensation seeking status, with 69% classified as CS for PTSD. The CS veterans achieved significantly more pathological scores across a wide range of psychological inventories and MMPI‐2 validity indices, although they did not differ in frequency of PTSD diagnoses from NCS veterans. Implications of these findings are discussed, and clinicians are advised to be aware of the compensation seeking status of combat‐veterans being evaluated for PTSD.