A Preliminary Study of an Internet‐Based Intervention for OEF/OIF Veterans Presenting for VA Specialty PTSD Care

This preliminary study sought to evaluate the feasibility and potential effectiveness of a cognitive–behavioral, web‐based intervention for posttraumatic stress in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans who are not able to participate, or not eligible to participate, in evidence‐based posttraumatic stress disorder (PTSD) treatments. The study used an uncontrolled pre‐posttest design with a sample of 24 OEF/OIF veterans presenting to a VA PTSD specialty clinic. Participants used the afterdeployment.org, Post‐Traumatic Stress (PTS) Workshop, which was supplemented with brief weekly telephone calls. Half of the participants (n = 12) completed at least 5 of the 8 workshop sessions. At posttreatment, 40.0% of completers demonstrated reliable reductions on PTSD symptoms and overall d = 1.04. Treatment satisfaction and acceptability was generally positive based on Likert ratings. This web‐based intervention for PTS appears to be a feasible and potentially helpful intervention for veterans who may not otherwise receive psychosocial interventions. Given the minimal resources required and the potential reach, this web‐based intervention could be a viable addition to services provided to OEF/OIF veterans seeking PTSD specialty care. Efforts to further develop and more rigorously evaluate this approach are warranted.     

Trauma‐Related Correlates of Alcohol Use in Recently Deployed OEF/OIF Veterans

The co‐occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorders (AUDs) is well documented. Little is known about the factors that contribute to alcohol use and the development of AUDs among military personnel following deployment. The primary aim of this study was to examine trauma‐related correlates of alcohol use in recently deployed Operation Enduring Freedom/Operation Iraqi Freedom veterans. Members of the Rhode Island National Guard and Army Reserves (N = 238) completed an in‐person, initial assessment an average of 6 months postdeployment. Multiple regression analyses examined predictors of drinking outcomes (combat exposure, total PTSD symptoms, and PTSD symptom clusters) after accounting for gender, age, and history of AUD. Results indicated that total PTSD symptoms, but not combat exposure, significantly predicted alcohol use at the initial assessment. When PTSD symptom clusters were considered separately, reexperiencing symptoms (Cluster B) were the strongest predictor of total alcohol use (B = 3.58, p = .002) and heavy drinking episodes (B = 0.31, p = .005). Implications for these findings include early identification of risk factors that could lead to the development of AUDs, and the importance of integrated treatment approaches for co‐occurring PTSD and AUD among veterans postdeployment.     

Mild Traumatic Brain Injury,PTSD, and Psychosocial Functioning Among Male and Female U.S. OEF/OIF Veterans

This study examined the unique and combined relationship between mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) with psychosocial functioning in a cohort of 1,312 U.S. male and female veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) enrolled in the Veterans After‐Discharge Longitudinal Registry (Project VALOR). We assessed mTBI with structured screening questions reflective of current TBI classification standards and PTSD via the SCID‐IV PTSD module; all other variables were assessed by self‐report questionnaires. We identified significant diagnostic group differences in psychosocial functioning for both sexes. Individuals with PTSD, with or without a history of mTBI, reported significantly worse psychosocial functioning than individuals with mTBI alone or neither mTBI nor PTSD (males, η²_p = .11, p < .001; females, η²_p = .14, p < .001), even after adjusting for demographics and severity of chronic pain. The results suggested that veterans experiencing PTSD, regardless of whether they had a history of mTBI, were at increased risk for long‐term psychosocial impairment. Further research examining possible benefits from improved access to resources and treatment to address these needs would be valuable.     

Sexual Trauma and Combat During Deployment: Associations With Suicidal Ideation Among OEF/OIF/OND Veterans

Compelling evidence has emerged on the association between military sexual trauma and suicide attempt; however, research investigating how sexual trauma during deployment relates to suicidal ideation has received considerably less attention and has yielded mixed findings. Furthermore, such research has not accounted for other types of trauma that may occur during deployment. Our objectives were to examine whether sexual trauma during deployment was associated with recent suicidal ideation, adjusting for exposure to combat. Our sample included 199 Operation Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) veterans entering inpatient trauma‐focused treatment who completed the Beck Scale for Suicide Ideation (Beck & Steer, 1991) and the Deployment Risk and Resilience Inventory Sexual Harassment and Combat Experiences Scales (King, King, Vogt, Knight, & Samper, 2006). Deployment‐related sexual trauma was significantly associated with recent suicidal ideation, adjusting for age and gender (β = .18, η_p² = .03) and additionally for combat (β = .17, η_p² = .02). These findings underscore the importance of assessing for deployment‐related sexual trauma when assessing suicide risk in OEF/OIF/OND veterans in inpatient settings.     

Gender Differences in Posttraumatic Stress Symptoms Among OEF/OIF Veterans: An Item Response Theory Analysis

Establishing whether men and women tend to express different symptoms of posttraumatic stress in reaction to trauma is important for both etiological research and the design of assessment instruments. Use of item response theory (IRT) can reveal how symptom reporting varies by gender and help determine if estimates of symptom severity for men and women are equally reliable. We analyzed responses to the PTSD Checklist (PCL) from 2,341 U.S. military veterans (51% female) who completed deployments in support of operations in Afghanistan and Iraq (Operation Enduring Freedom/Operation Iraqi Freedom [OEF/OIF]), and tested for differential item functioning by gender with an IRT‐based approach. Among men and women with the same overall posttraumatic stress severity, women tended to report more frequent concentration difficulties and distress from reminders whereas men tended to report more frequent nightmares, emotional numbing, and hypervigilance. These item‐level gender differences were small (on average d = 0.05), however, and had little impact on PCL measurement precision or expected total scores. For practical purposes, men's and women's severity estimates had similar reliability. This provides evidence that men and women veterans demonstrate largely similar profiles of posttraumatic stress symptoms following exposure to military‐related stressors, and some theoretical perspectives suggest this may hold in other traumatized populations.     

Deliberate Self‐Harm and Suicidal Ideation Among Male Iraq/Afghanistan‐Era Veterans Seeking Treatment for PTSD

The objectives of the present research were to examine the prevalence of deliberate self‐harm (DSH) among 214 U.S. male Iraq/Afghanistan‐era veterans seeking treatment for posttraumatic stress disorder (PTSD) and to evaluate the relationship between DSH and suicidal ideation within this population. Approximately 56.5% (n = 121) reported engaging in DSH during their lifetime; 45.3% (n = 97) reported engaging in DSH during the previous 2 weeks. As hypothesized, DSH was a significant correlate of suicidal ideation among male Iraq/Afghanistan‐era veterans, OR = 3.88, p < .001, along with PTSD symptom severity, OR = 1.03, p < .001, and combat exposure, OR = 0.96, p = .040. A follow‐up analysis identified burning oneself, OR = 17.14, p = .017, and hitting oneself, OR = 7.93, p < .001, as the specific DSH behaviors most strongly associated with suicidal ideation. Taken together, these findings suggest that DSH is quite prevalent among male Iraq/Afghanistan‐era veterans seeking treatment for PTSD and is associated with increased risk for suicidal ideation within this population. Routine assessment of DSH is recommended when working with male Iraq/Afghanistan veterans seeking treatment for PTSD.     

Mental Health Beliefs and Their Relationship With Treatment Seeking Among U.S. OEF/OIF Veterans

Many veterans who would benefit from mental health care do not seek treatment. The current study provided an in‐depth examination of mental health‐related beliefs and their relationship with mental health and substance abuse service use in a national sample of 640 U.S. Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans. Both concerns about mental health stigma from others and personal beliefs about mental illness and mental health treatment were examined. Data were weighted to adjust for oversampling of women and nonresponse bias. Results revealed substantial variation in the nature of OEF/OIF veterans’ mental health beliefs, with greater anticipated stigma in the workplace (M = 23.74) than from loved ones (M = 19.30), and stronger endorsement of negative beliefs related to mental health treatment‐seeking (M = 21.78) than either mental illness (M = 18.56) or mental health treatment (M = 20.34). As expected, individuals with probable mental health problems reported more negative mental health‐related beliefs than those without these conditions. Scales addressing negative personal beliefs were related to lower likelihood of seeking care (ORs = 0.80–0.93), whereas scales addressing anticipated stigma were not associated with service use. Findings can be applied to address factors that impede treatment seeking.     

Deployment‐Related Psychiatric and Behavioral Conditions and Their Association with Functional Disability in OEF/OIF/OND Veterans

Understanding the factors that influence veterans’ functional outcome after deployment is critical to provide appropriately targeted care. Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) have been related to disability, but other psychiatric and behavioral conditions are not as well examined. We investigated the impact of deployment‐related psychiatric and behavioral conditions on disability among 255 OEF/OIF/OND service members and veterans. Structured clinical interviews assessed TBI and the psychiatric conditions of depression, PTSD, anxiety, and substance use. Self‐report questionnaires assessed disability and the behavioral conditions of sleep disturbance and pain. Over 90% of participants had a psychiatric and/or behavioral condition, with approximately half presenting with ≥ 3 conditions. Exploratory factor analysis revealed 4 clinically relevant psychiatric and behavioral factors which accounted for 76.9% of the variance: (a) depression, PTSD, and military mTBI (deployment trauma factor); (b) pain and sleep (somatic factor); (c) anxiety disorders, other than PTSD (anxiety factor); and (d) substance abuse or dependence (substance use factor). Individuals with the conditions comprising the deployment trauma factor were more likely to be substantially disabled than individuals with depression and PTSD, but no military mTBI, OR = 3.52; 95% CI [1.09, 11.37]. Depression, PTSD, and a history of military mTBI may comprise an especially harmful combination associated with high risk for substantial disability.     

Feasibility and Desirability of Web‐Based Mental Health Screening and Individualized Education for Female OEF/OIF Reserve and National Guard War Veterans

Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Reserve and National Guard (RNG) service members have an increased risk for postdeployment mental health (MH) and readjustment problems, yet most do not access needed care. It is unknown if RNG servicewomen experiencing postdeployment readjustment symptoms are aware these may signify treatable MH concerns or if this knowledge activates care‐seeking. The aims of this proof‐of‐concept study were to determine the feasibility of web‐based MH screening for postdeployment MH symptoms to inform individualized psychoeducation, and to assess user perceptions about the online instrument and process, MH care access, and VA and other MH care. A midwestern sample (N = 131) of recently deployed (past 24 months) OEF/OIF RNG Army and Air Force servicewomen participated. High rates of combat experiences (95%) and military sexual trauma (50%) were reported. Positive screens for key symptoms of MH problems were prevalent. One third (31%) of satisfaction survey completers indicated online information reduced discomfort with seeking MH care; 42% reported they would subsequently seek MH assessment. Participants interviewed by telephone indicated that stigma and limited knowledge about women‐specific services were key reasons servicewomen do not use MH care. This study demonstrated web‐based screenings with individualized psychoeducation are implementable and favorable to RNG servicewomen.     

Sleep Quality and Reexperiencing Symptoms of PTSD Are Associated With Current Pain in U.S. OEF/OIF/OND Veterans With and Without mTBIs

Pain, a debilitating condition, is frequently reported by U.S. veterans returning from Afghanistan and Iraq. This study investigated how commonly reported clinical factors were associated with pain and whether these associations differed for individuals with a history of chronic pain. From the Boston metropolitan area, 171 veterans enrolled in the Veterans Affairs Center of Excellence were assessed for current posttraumatic stress disorder (PTSD) symptom severity, current mood and anxiety diagnoses, lifetime traumatic brain injury, combat experiences, sleep quality, and alcohol use. Hierarchical regression models were used to determine the association of these conditions with current pain. Average pain for the previous 30 days, assessed with the McGill Pain Questionnaire, was 30.07 out of 100 (SD = 25.43). Sleep quality, PTSD symptom severity, and alcohol use were significantly associated with pain (R² = .24), as were reexperiencing symptoms of PTSD (R² = .25). For participants with a history of chronic pain (n = 65), only PTSD symptoms were associated with pain (R² = .19). Current pain severity was associated with increased PTSD severity (notably, reexperiencing symptoms), poor sleep quality, and increased alcohol use. These data support the hypothesis that PTSD symptoms influence pain, but suggest that problems with sleep and alcohol use may exacerbate the relationship.     

Long‐Term Trajectories of PTSD in Vietnam‐Era Veterans: The Course and Consequences of PTSD in Twins

We estimated the temporal course of posttraumatic stress disorder (PTSD) in Vietnam‐era veterans using a national sample of male twins with a 20‐year follow‐up. The complete sample included those twins with a PTSD diagnostic assessment in 1992 and who completed a DSM‐IV PTSD diagnostic assessment and a self‐report PTSD checklist in 2012 (n = 4,138). Using PTSD diagnostic data, we classified veterans into 5 mutually exclusive groups, including those who never had PTSD, and 4 PTSD trajectory groups: (a) early recovery, (b) late recovery, (c) late onset, and (d) chronic. The majority of veterans remained unaffected by PTSD throughout their lives (79.05% of those with theater service, 90.85% of those with nontheater service); however, an important minority (10.50% of theater veterans, 4.45% of nontheater veterans) in 2012 had current PTSD that was either late onset (6.55% theater, 3.29% nontheater) or chronic (3.95% theater, 1.16% nontheater). The distribution of trajectories was significantly different by theater service (p < .001). PTSD remains a prominent issue for many Vietnam‐era veterans, especially for those who served in Vietnam.     

Diagnostic Accuracy of the Composite International Diagnostic Interview (CIDI 3.0) PTSD Module Among Female Vietnam‐Era Veterans

The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) posttraumatic stress disorder (PTSD) module is widely used in epidemiological studies of PTSD, yet relatively few data attest to the instrument's diagnostic utility. The current study evaluated the diagnostic utility of the CIDI 3.0 PTSD module with U. S. women Vietnam‐era veterans. The CIDI and the Clinician‐Administered PTSD Scale (CAPS) were independently administered to a stratified sample of 160 women, oversampled for current PTSD. Both lifetime PTSD and recent (past year) PTSD were assessed within a 3‐week interval. Forty‐five percent of the sample met criteria for a CAPS diagnosis of lifetime PTSD, and 21.9% of the sample met criteria for a CAPS diagnosis of past‐year PTSD. Using CAPS as the diagnostic criterion, the CIDI correctly classified 78.8% of cases for lifetime PTSD (κ = .56) and 82.0% of past year PTSD cases (κ = .51). Estimates of diagnostic performance for the CIDI were sensitivity of .61 and specificity of .91 for lifetime PTSD and sensitivity of .71 and specificity of .85 for past‐year PTSD. Results suggest that the CIDI has good utility for identifying PTSD, though it is a somewhat conservative indicator of lifetime PTSD as compared to the CAPS.     

Natural Course of Co‐Occurring PTSD and Alcohol Use Disorder Among Recent Combat Veterans

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) commonly co‐occur in veterans, yet little is known about the longitudinal course of PTSD and drinking in comorbid populations. This study assessed the natural course of daily alcohol consumption and weekly changes in PTSD symptoms in 112 recent combat veterans over the course of 11 months. Latent class growth mixture modeling was used to classify individuals into distinct classes with similar PTSD symptom and alcohol use growth trajectories. We then investigated theorized predictors of class membership including sociodemographics; pre‐, peri‐, and postdeployment factors; coping; symptom severity; and number of mental health/substance use appointments attended. Results revealed that most participants had severe and nonremitting PTSD. Trajectories for alcohol use included gradual and drastic declines, and chronic low‐level drinking. The use of behavioral health services (odds ratio = 2.47) and fewer current stressors (odds ratio = 0.42) predicted AUD remission. Because little variation was observed in the PTSD course, our study did not observe coordinated fluctuations of PTSD symptoms and heavy drinking. Our findings suggest that treatment impacts the course of AUD and that recent combat veterans who do not seek PTSD treatment may have chronic and severe PTSD symptoms.     

The Incidence of Cancer in a Population‐Based Cohort of Canadian Heart Transplant Recipients

To assess the long‐term risk of developing cancer among heart transplant recipients compared to the Canadian general population, we carried out a retrospective cohort study of 1703 patients who received a heart transplant between 1981 and 1998, identified from the Canadian Organ Replacement Register database. Vital status and cancer incidence were determined through record linkage to the Canadian Mortality Database and Canadian Cancer Registry. Cancer incidence rates among heart transplant patients were compared to those of the general population. The observed number of incident cancers was 160 with 58.9 expected in the general population (SIR = 2.7, 95% CI = 2.3, 3.2). The highest ratios were for non‐Hodgkin's lymphoma (NHL) (SIR = 22.7, 95% CI = 17.3, 29.3), oral cancer (SIR = 4.3, 95% CI = 2.1, 8.0) and lung cancer (SIR = 2.0, 95% CI = 1.2, 3.0). Compared to the general population, SIRs for NHL were particularly elevated in the first year posttransplant during more recent calendar periods, and among younger patients. Within the heart transplant cohort, overall cancer risks increased with age, and the 15‐year cumulative incidence of all cancers was estimated to be 17%. There is an excess of incident cases of cancer among heart transplant recipients. The relative excesses are most marked for NHL, oral and lung cancer.     

Associations Between Perceived Social Reactions to Trauma‐Related Experiences With PTSD and Depression Among Veterans Seeking PTSD Treatment

The Social Acknowledgment Questionnaire (SAQ; Maercker & Mueller, 2004 ) is a measure of trauma survivors’ perceptions of social acknowledgment and disapproval from others, and these factors are shown to be associated with posttraumatic stress disorder (PTSD) among civilian trauma survivors. This study seeks to validate the structure of the SAQ among U.S. military veterans and test the hypothesis that family and general disapproval are associated with PTSD and depression among veterans. Participants were 198 U.S. veterans who experienced military trauma and completed an intake evaluation through a Veterans Affairs PTSD treatment program. Structural equation modeling (SEM) results supported a well‐fitting 3‐factor model for the SAQ that was similar to prior studies in capturing the constructs of social acknowledgment, general disapproval, and family disapproval. SEM results also showed that all 3 of the SAQ factors were associated with veterans’ depression (?.31, .22, and .39, respectively), whereas only general disapproval was related to veterans’ PTSD. This is the first study of which we are aware to investigate the factor structure of the SAQ in a veteran sample and to investigate the relationship between SAQ factors and trauma survivors’ depression. Results build upon prior findings by showing the importance of positive and negative social reactions to veterans’ traumatic experiences.     

Risk of Fracture in Primary Aldosteronism: A Population‐Based Cohort Study

Primary aldosteronism (PA) is associated with increased urinary calcium excretion and osteoporosis prevalence. We studied the long‐term effect of hyperaldosterone on fracture risk and possible risk mitigation via treatments, by comparing PA patients and their essential hypertension (EH) counterparts extracted by propensity score match. We used a longitudinal population database from the Taiwan National Health Insurance, and used a validated algorithm to identify PA patients diagnosed in 1997–2010. Our sample included 2533 PA patients, including 921 patients with aldosterone‐producing adenoma (APA). Our methods for assessing excessive fracture risk included multivariable Cox regression and the competing risk regression. The incidence rate of fracture at any site was 14.4 per 1000 person‐years for PA, and 11.2 per 1000 person‐years for APA. In contrast, the incidence rate of fracture at any site was 8.3 per 1000 person‐years in EH controls for PA, and 6.5 per 1000 person‐years in EH controls for APA. Mineralocorticoid receptor antagonist (MRA) treatment might be associated with higher risk of osteoporotic fracture in the whole female PA cohort (subdistribution hazard ratio [SHR] = 2.12, p = 0.008) as well as female APA patients (SHR = 1.15, p = 0.049). As to fracture at any site, MRA treatment was also associated with higher risk; the SHR was 1.88 (p < 0.001) in the whole female PA cohort, and 2.17 (p = 0.019) in female APA patients. PA is tightly associated with higher risk of bone fracture, even in the case where the competing risk of death was controlled. Particularly, female PA patients treated with MRA were confronted with significantly higher risk in bone fracture than their EH controls. © 2017 American Society for Bone and Mineral Research.     

Predictors of Excess Mortality After Fracture: A Population‐Based Cohort Study

To determine the extent to which excess mortality after fractures attributable to particular causes at specific skeletal sites can be predicted using data about all medical diagnoses, we conducted a historical cohort study among 1991 Olmsted County, Minnesota, residents aged ≥50 years who experienced any fracture in 1989 to 1991 and who were followed passively for up to 22 years for death from any cause. We used a machine learning approach, gradient boosting machine (GBM) modeling, to determine whether the comorbid conditions present at the time of fracture and those that arose subsequently could, in aggregate, identify patients at the greatest increased risk of death. During 21,867 person‐years of follow‐up, 1245 deaths were observed when 1061 were expected (standardized mortality ratio, 1.2; 95% confidence interval [CI] 1.1–1.2). Patients presented with a median history of 26 comorbid conditions each as assessed by the Clinical Classification Software system and 57 each over the total duration of follow‐up. Using all available information, the excess deaths could be predicted with good accuracy (c‐index ≥0.80) in 89% of the GBM models built for patients with different types of fracture; in one‐third of the models, the c‐index was ≥0.90. The conditions most prominent in the GBM prediction models were also reflected in the specific causes of death that were elevated, suggesting the influence of confounding on the relationship. However, the predominant comorbid conditions were mainly those responsible for mortality in the general population, rather than the specific diseases most closely associated with secondary osteoporosis. To reduce long‐term deaths in the fracture population as a whole, a more general approach to the fracture patient is indicated. © 2014 American Society for Bone and Mineral Research.     

Comparison of DSM‐IV and Proposed ICD‐11 Formulations of PTSD Among Civilian Survivors of War and War Veterans

The World Health Organization recently proposed a reformulation of posttraumatic stress disorder (PTSD) for the 11^th edition of the International Classification of Diseases (ICD‐11), employing only 6 symptoms. The aim of this study was to investigate the impact of this reformulation of PTSD as compared to criteria according to Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM‐IV; American Psychiatric Association, 1994) on the prevalence of current PTSD as well as comorbid major depressive episode and anxiety disorders other than PTSD. Study 1 involved previously collected interviews with 560 Kosovar civilian war survivors; Study 2 employed a previously collected sample of 142 British war veterans. Results revealed no change in the diagnostic status under the criteria proposed for ICD‐11 in 87.5% of civilian war survivors and 91.5% of war veterans. Participants who only met the newly proposed criteria showed lower rates of comorbid major depressive episode than participants who only met DSM‐IV criteria (13.6% vs. 43.8% respectively). Rates of comorbid anxiety disorders did not significantly differ between participants who lost or gained a PTSD diagnosis under the proposed criteria.