Posttraumatic stress disorder, depression, and suicide in veterans

Suicidal behavior is a critical problem in war veterans. Combat veterans are not only more likely to have suicidal ideation, often associated with posttraumatic stress disorder (PTSD) and depression, but they are more likely to act on a suicidal plan. Especially since veterans may be less likely to seek help from a mental health professional, non-mental-health physicians are in a key position to screen for PTSD, depression, and suicidal ideation in these patients. The authors discuss the association of PTSD, depression, and suicide in veterans, keys to assessment of suicide risk, and interventions.     

Posttraumatic Stress Disorder and the States-of-Mind Model: Evidence of Specificity

We conducted a study to examine whether the states-of-mind (SOM) model (Schwartz & Garamoni, 1986) could successfully differentiate between Vietnam combat veterans who suffered from posttraumatic stress disorder (PTSD) and Vietnam combat veterans who did not. Veterans completed a battery of questionnaires that assessed the balance of cognitions (SOM ratios), extent of combat exposure, and symptomatology. The results supported our predictions: After matching the groups according to combat exposure and controlling general psychopathology, we found that (a) the combat veterans who suffered from PTSD reported more maladaptive SOM than combat veterans who did not suffer from PTSD, and (b) maladaptive SOM related to intrusive, but not avoidant, PTSD symptomatology.     

Childhood trauma differentially impacts depression and stress associations with reintegration challenges among post-9/11 U.S. veterans

BackgroundPost-9/11 veterans exhibit high prevalence of deployment stress, psychological conditions, and traumatic brain injury (TBI) which impact reintegration, especially among those with a history of interpersonal early life trauma (I-ELT). The relative importance of each risk factor is unclear.PurposeWe examined major deployment and clinical exposures of reintegration challenges among veterans with and without I-ELT.MethodWe analyzed cross-sectional data of 155 post-9/11 veterans from the Translational Research Center for TBI and Stress Disorders study.FindingsDepression severity had the strongest association with reintegration challenges, followed by posttraumatic stress disorder (PTSD) severity, post-deployment stress, and deployment safety concerns. Deployment safety concerns had a stronger, significant association among veterans with I-ELT. In nearly every model, PTSD and depression severities were weaker for veterans with I-ELT, compared to those without.DiscussionClinicians should consider the relative risk of concurrent clinical conditions and trauma histories when considering veterans’ reintegration needs.     

Shared Cognitive Features of Posttraumatic Cognitions and Obsessive–Compulsive Symptoms

Obsessive–compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) frequently co-occur. However, the shared features of these conditions have been under-examined. Evaluation of the common aspects of posttraumatic and obsessive–compulsive (OC) symptoms could improve treatment responsivity for individuals with comorbid PTSD and OCD, for whom outcome is typically poorer than for those with either disorder alone. This study examined intolerance of uncertainty, inflated responsibility, and a global measure of posttraumatic cognitions as potential shared cognitive constructs that moderate distress associated with OC symptoms. A total of 211 undergraduate students reporting significant trauma histories participated. All participants completed measures of obsessive–compulsive symptoms and beliefs, as well as posttraumatic cognitions. Results indicated that posttraumatic cognitions moderated the relationship between inflated responsibility and intolerance of uncertainty, which in turn predicted all domains of obsessive–compulsive symptom distress (all βs > 0.41, all zs > 3.44). Further, posttraumatic cognitions alone significantly predicting OC symptoms related to doubting, obsessions, and neutralizing. These findings suggest that shared cognitive constructs play a role in co-occurring posttraumatic stress and OC symptoms, and thus may be a relevant treatment target when these disorders present simultaneously.     

Intensity dependence of auditory P2 in monozygotic twins discordant for Vietnam combat: associations with posttraumatic stress disorder

Two studies have reported decreased intensity dependence of the P2 event-related potential (ERP) in male combat veterans with posttraumatic stress disorder (PTSD), a response pattern presumed to reflect central nervous system-induced protective inhibition and heightened central serotonergic activity. We used an identical twin, case-control design to investigate whether intensity dependence abnormalities reflect pretrauma vulnerability or are an acquired consequence of PTSD. ERPs were measured in male Vietnam combat veterans and their noncombat-exposed monozygotic twin brothers during a four-tone, stimulus-intensity modulation procedure. Contrary to previous findings in male veterans, the PTSD group had significantly steeper P2 amplitude intensity slopes, similar to those reported for female veterans and abused children with PTSD. Additionally, increased P2 amplitude intensity slope was associated with increased PTSD symptom severity, particularly the severity of reexperiencing symptoms. A mixed-model, random-effects analysis that included the combat-unexposed twins revealed a significant diagnosis by combat exposure interaction. Inspection of group means suggests that the observed increased P2 intensity dependence is a consequence of PTSD. Our findings further suggest that low serotonergic tone may emerge as one potential consequence of this disorder.     

Posttraumatic stress disorder and employment in veterans participating in Veterans Health Administration Compensated Work Therapy

Few studies have examined employment outcomes in individuals with a primary diagnosis of posttraumatic stress disorder (PTSD). The current study used multivariate modeling to examine the relationship between PTSD, other aspects of military service, and employment among 5,862 veterans in a national Department of Veterans Affairs (VA) vocational rehabilitation program. Veterans with PTSD were 19% less likely to be employed at discharge (odds ratio = 0.81, p = 0.02) after controlling for potentially confounding variables. Individuals with substance use diagnoses or who were homeless at program entry were more likely to be employed at discharge, while receipt of public support income and severe mental illness decreased the likelihood of being competitively employed. This study supports current VA efforts to expand and improve the effectiveness of vocational rehabilitation services for veterans with PTSD.     

Preliminary analysis of posttraumatic stress disorder screening within specialty clinic setting for OIF/OEF veterans seeking care for neck or back pain

Escalating prevalence estimates of posttraumatic stress disorder (PTSD) among recently returning Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans highlight the need for early detection and management for reducing chronic mental illness and disability. Because PTSD and chronic pain are common comorbid conditions among veterans, PTSD screening within specialty clinic settings addressing musculoskeletal pain may be of value. This retrospective study evaluated measures of diagnostic value for the PTSD Checklist (PCL) for a sample (n = 79) of OIF/OEF veterans seeking care for neck or back pain within a Department of Veterans Affairs specialty clinic. Because published accounts of optimal PCL cutoff scores vary considerably, we used receiver operating characteristic curves to identify whether the optimal PCL cutoff score for the sample differed from a conventional cutoff score of 50. A clinical psychologist experienced in diagnosing and managing PTSD confirmed the diagnosis of PTSD for 37 veterans through a review of clinical records. The prevalence of diagnosed PTSD was 46.8%, with an optimal PCL cutoff score of 44. These findings may guide future research and influence clinical practice regarding PTSD screening for recently returning veterans with chronic pain.     

Influence of Depression on State and Trait Anger in Veterans with Posttraumatic Stress Disorder

Anger is one of the most important symptoms of posttraumatic stress disorder (PTSD), and is associated with many of the adverse correlates of PTSD. Researchers have proposed theories to explain the relationship between anger and PTSD, but no study to date has examined the mediating role of depression. The purpose of this study was to explore the mediating effects of current major depression disorder (MDD), as well as PTSD numbing and dysphoria symptom clusters (King et al. 1998; Simms et al. 2002) on the relationship between PTSD and anger. There were 98 participants in the study, and all were male veterans with combat-related PTSD taking part in a clinical trial. Results indicated that MDD partially mediated the relationship between PTSD and state anger, while numbing and dysphoria clusters partially mediated the relationships between other PTSD symptom clusters and trait anger. Implications for the treatment of anger in veterans with PTSD are discussed.     

Exploring the Role of Negative Cognitions in the Relationship Between Ethnicity,Sleep, and Pain in Women With Temporomandibular Joint Disorder

Negative cognitions are central to the perpetuation of chronic pain and sleep disturbances. Patients with temporomandibular joint disorder (TMJD), a chronic pain condition characterized by pain and limitation in the jaw area, have a high comorbidity of sleep disturbances that possibly exacerbate their condition. Ethnic group differences are documented in pain, sleep, and coping, yet the mechanisms driving these differences are still unclear, especially in clinical pain populations. We recruited 156 women (79% white, 21% African American) diagnosed with TMJD as part of a randomized, controlled trial evaluating the effectiveness of interventions targeting sleep and pain catastrophizing on pain in TMJD. Analysis of baseline data demonstrated that, relative to white participants, African Americans exhibited higher levels of clinical pain, insomnia severity, and pain catastrophizing, yet there was no ethnic group difference in negative sleep-related cognitions. Mediation models revealed pain catastrophizing, but not sleep-related cognitions or insomnia severity, to be a significant single mediator of the relationship between ethnicity and clinical pain. Only the helplessness component of catastrophizing together with insomnia severity sequentially mediated the ethnicity–pain relationship. These findings identify pain catastrophizing as a potentially important link between ethnicity and clinical pain and suggest that interventions targeting pain-related helplessness could improve both sleep and pain, especially for African American patients.Perspective:Pain-related helplessness and insomnia severity contribute to ethnic differences found in clinical pain among woman with TMJD. Findings can potentially inform interventions that target insomnia and catastrophizing to assist in reducing ethnic disparities in clinical pain.     

Suicide ideation among parents bereaved by the violent deaths of their children

Suicidal behaviors of parents bereaved by a child's suicide have received considerable attention by researchers, but deaths by other violent causes have not. We observed 175 bereaved parents for five years following three types of violent death: accidents, homicides, and suicides. The results showed that the incidence of suicidal ideation (SI) among the study parents was 13% (n = 34) over the 5 years and 9% (n = 24) at the initial data collection four months after the death of an adolescent or young adult child. Comparisons of study parents grouped by the presence or absence of SI showed that after corrections were made for the number of t-tests conducted, statistically significant differences on three of four outcome variables remained (mental distress, depression, and posttraumatic stress disorder [PTSD], but not on acceptance of the child's death). The groups also differed significantly on four of seven mediating variables examined. The hypothesis that parents whose children died by suicide would report the highest incidence of suicidal ideation was not supported. Regression analyses showed that SI was a significant predictor of depression one year, but not five years, after the violent death of a child. The hypothesis that SI would predict both depression and PTSD one year postdeath was not supported. Clinical and policy recommendations are offered.     

Posttraumatic Stress and Suicidality Among Firefighters: The Moderating Role of Distress Tolerance

Firefighters report high rates of suicidality and posttraumatic stress disorder (PTSD). This investigation explored the moderating role of distress tolerance (DT) in the association between PTSD symptomatology and suicidality in firefighters. Covariates included trauma load, depressive symptom severity, gender, race, age, and education. The sample was comprised of 765 (94.0% male; M_age?=?38.8, SD?=?8.6) trauma-exposed firefighters who completed a questionnaire battery. Structural equation modeling was employed. PTSD symptom severity was significantly, positively associated with global suicide risk, suicidal ideation/attempt, frequency of suicidal ideation, lifetime threat of suicide, and perceived likelihood of future suicide attempts. Lower levels of DT were significantly associated with higher frequency of past-year suicidal ideation. Significant interactive effects were noted; firefighters with higher levels of PTSD symptom severity and low levels of DT had the highest levels of global suicide risk and perceived likelihood of future suicide attempt. Clinical and research implications are discussed.     

Post‐traumatic stress disorder and dementia in veterans: A scoping literature review

Emerging research has found an association between post‐traumatic stress disorder (PTSD) and dementia in veterans, yet little is known about the nature of this association and how it is conceptualized in the literature. The purpose of this scoping review is to understand how the relationship between PTSD and dementia in veterans is recognized and described in the peer‐reviewed literature. A scoping review was conducted using Arksey and O'Malley's (International Journal of Social Research Methodology, 8 , 19, 2005) framework. Articles are included if participants were veterans with a focus on PTSD and dementia. A total of six databases (CINAHL, MEDLINE, EMBASE, PsycINFO, HealthSTAR, and PubMed) were searched along with the reference lists of eligible sources in September 2018. Thematic analysis was used to summarize the data. Thirty‐six studies were included in this review. Three main themes emerged from the literature: (i) symptomatic expression of PTSD and dementia; (ii) aetiology underlying the relationship between PTSD and dementia; and (iii) implications of PTSD and dementia on healthcare providers, treatment, and resources. This study highlights the ongoing need to understand mechanisms underlying the association between PTSD and dementia, the need for definition of PTSD symptoms, and to sensitize healthcare providers to the presence of PTSD when caring for veterans with dementia.     

Racial disparities in VA service connection for posttraumatic stress disorder disability

BACKGROUND: "Service connected" veterans are those with documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the Veterans Affairs (VA) health care system. For some veterans, service connection represents the difference between access to VA health care facilities and no access. OBJECTIVES: To determine whether there are racial discrepancies in the granting of service connection for posttraumatic stress disorder (PTSD) by the Department of Veterans Affairs and, if so, to determine whether these discrepancies could be attributed to appropriate subject characteristics, such as differences in PTSD symptom severity or functional status. RESEARCH DESIGN: Mailed survey linked to administrative data. Claims audits were conducted on 11% of the sample. SETTING AND SUBJECTS: The study comprised 2700 men and 2700 women randomly selected from all veterans filing PTSD disability claims between January 1, 1994 and December 31, 1998. RESULTS: A total of 3337 veterans returned usable surveys, of which 17% were black. Only 16% of respondents carried private health insurance, and 44% reported incomes of 20,000 US dollars or less. After adjusting for respondents' sociodemographic characteristics, symptom severity, functional status, and trauma histories, black persons' rate of service connection for PTSD was 43% compared with 56% for other respondents (P = 0.003). CONCLUSION: Black persons' rates of service connection for PTSD were substantially lower than other veterans even after adjusting for differences in PTSD severity and functional status.     

Gender Differences in service connection for PTSD

BACKGROUND: Mentally ill female veterans obtain a smaller proportion of their care from Department of Veterans Affairs (VA) facilities than mentally ill male veterans do, possibly because women are less likely than men to be service connected for psychiatric disabilities. "Service connected" veterans have documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the VA healthcare system. OBJECTIVES: To see if there are gender discrepancies in rates of service connection for posttraumatic stress disorder (PTSD) and, if so, to see if these discrepancies could be attributed to appropriate subject characteristics (eg, differences in symptom severity or impairment). RESEARCH DESIGN: Mailed survey linked to administrative data. Claims audits were conducted on 11% of the sample. SUBJECTS: Randomly selected veterans seeking VA disability benefits for PTSD. Women were oversampled to achieve a gender ratio of 1:1. RESULTS: A total of 3337 veterans returned usable surveys (effective response rate, 68%). Men's unadjusted rate of service connection for PTSD was 71%; women's, 52% (P < 0.0001). Adjustment for veterans' PTSD symptom severity or functional impairment did not appreciably reduce this discrepancy, but adjustment for dissimilar rates of combat exposure did. Estimated rates of service connection were 53% for men and 56% for women after adjusting for combat exposure. This combat preference could not be explained by more severe PTSD symptoms or greater functional impairment. CONCLUSIONS: Instead of a gender bias in awards for PTSD service connection, we found evidence of a combat advantage that disproportionately favored men. The appropriateness of this apparent advantage is unclear and needs further investigation.     

The influence of family and social problems on treatment outcomes of persons with co-occurring substance use disorders and PTSD

Objective: Family and social problems may contribute to negative recovery outcomes in patients with co-occurring substance use and psychiatric disorders, yet few studies have empirically examined this relationship. This study investigates the impact of family and social problems on treatment outcomes among patients with co-occurring substance use and posttraumatic stress disorder (PTSD).

Method: A secondary analysis was conducted using data collected from a randomized controlled trial of an integrated therapy for patients with co-occurring substance use and PTSD. Substance use, psychiatric symptoms and social problems were assessed. Longitudinal outcomes were analyzed using generalized estimating equations (GEEs) and multiple linear regression.

Results: At baseline, increased family and social problems were associated with more severe substance use and psychiatric symptoms. Over time, all participants had comparable decreases in substance use and psychiatric problem severity. However, changes in family and social problem severity were predictive of PTSD symptom severity, alcohol use and psychiatric severity at follow-up.

Conclusions: For patients with co-occurring substance use and PTSD, family and social problem severity is associated with substance use and psychiatric problem severity at baseline and over time. Targeted treatment for social and family problems may be optimal.     

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.     

Exploration of gender differences in how quality of life relates to posttraumatic stress disorder in male and female veterans

Significant gaps exist in our knowledge about gender differences in quality of life among individuals with posttraumatic stress disorder (PTSD). We addressed these gaps by using data from two randomized clinical trials of veterans treated in Department of Veterans Affairs settings: 358 male Vietnam veterans who received group therapy and 203 female veterans who received individual psychotherapy. Using confirmatory factor analysis, we found that a four-factor structure for the Quality of Life Inventory provided the best fit for both groups. Overall quality of life was poor in men and women, and in general, they did not differ in quality of life or in how PTSD was associated with quality of life; the few statistically significant differences were small and clinically insignificant. For both men and women, numbing was uniquely associated with reduced quality of life. We suggest that quality of life should receive increased attention in research and clinical efforts to help veterans with PTSD.     

Prevalence and patterns of posttraumatic stress disorder in abused and postabused women

This study examined the prevalence and patterns of posttraumatic stress disorder (PTSD) symptomatology in abused and postabused women. A convenience sample of 160 abused, postabused, and nonabused women completed measures related to physical and emotional abuse by an intimate partner, risk of homicide, and PTSD. Results indicated that PTSD symptoms were present in both the abused and postabused women and were positively correlated with the severity of abuse and risk of homicide that the women experienced. The postabused women were out of the abusive relationship an average of nine years, yet continued to experience PTSD symptoms.     

PREVALENCE AND PATTERNS OF POSTTRAUMATIC STRESS DISORDER IN ABUSED AND POSTABUSED WOMEN

This study examined the prevalence and patterns of posttraumatic stress disorder (PTSD) symptomatology in abused and postabused women. A convenience sample of 160 abused, postabused, and nonabused women completed measures related to physical and emotional abuse by an intimate partner, risk of homicide, and PTSD. Results indicated that PTSD symptoms were present in both the abused and postabused women and were positively correlated with the severity of abuse and risk of homicide that the women experienced. The postabused women were out of the abusive relationship an average of nine years, yet continued to experience PTSD symptoms.     

Dysfunctional Pain Modulation in Torture Survivors: The Mediating Effect of PTSD

Trauma survivors, and particularly torture survivors, suffer from high rates of chronic pain and posttraumatic stress disorder (PTSD) for years afterward, along with alterations in the function of the pain system. On the basis of longitudinal data on PTSD symptomatology, we tested whether exposure to torture, PTSD or PTSD trajectories accounted for chronic pain and altered pain perception. Participants were 59 torture survivors and 44 age-matched healthy control subjects. Chronic pain was characterized. Pain threshold, pain tolerance, conditioned pain modulation (CPM), and temporal summation of pain were measured. Three PTSD trajectories were identified among torture survivors; chronic, delayed, and resilient. Lack of CPM and more intense chronic pain was found among the chronic and delayed groups compared with the resilient and healthy control groups. Temporal summation of pain was strongest among the chronic group. PTSD trajectories mediated the relationship between torture and CPM. It appears that the duration and severity of posttraumatic distress, rather than the exposure to trauma, are crucial factors that mediate the association between trauma and chronic pain. Because PTSD and its resultant distress are measurable, their evaluation seems particularly important in the management of pain among trauma survivors. The results may be generalized to other instances in which chronic pain persists after traumatic events.