Survivors of violence-related facial injury: psychiatric needs and barriers to mental health care

OBJECTIVE: This study examined mental health needs, receptivity to psychosocial aftercare, and barriers to care among survivors of violence-related facial injuries. METHODS: Face-to-face interviews were conducted with 25 consecutively treated individuals at a hospital-based specialty outpatient clinic one month after a violence-related facial injury. To participate in the study, patients had to screen positive for an alcohol use disorder (AUD), major depression or posttraumatic stress disorder (PTSD). Participants were questioned about receptivity to an aftercare program and perceived barriers to care. RESULTS: Of those screened for study eligibility (n=62), a substantial proportion met probable criteria for AUD (31%), PTSD (34%) and major depression (35%). Among those completing the core interview (n=25), 80% met probable criteria for two or more psychiatric disorders. The majority (84%) expressed interest in psychosocial aftercare. However, barriers such as cost, insufficient information about counseling and obtaining services, transportation and preferences for self-reliance were commonly endorsed. CONCLUSIONS: Survivors of violence-related facial injuries have substantial mental health needs and appear receptive to psychosocial aftercare. However, significant treatment barriers must be addressed. Findings underscore the value of a collaborative care model for treating violence-related facial trauma patients seeking care in specialty outpatient oral and maxillofacial clinics.     

Validating administrative records in post‐traumatic stress disorder

There is insufficient data on the accuracy of administrative coding data (ACD) for post‐traumatic stress disorder (PTSD). Medical records were reviewed for (1) a diagnosis of PTSD; (2) treatment for PTSD. The records were compared against the Veterans Health Administration (VHA) data in order to determine the positive predictive value (PPV) and negative predictive value (NPV) of three commonly used approaches. The PPV and NPV varied according to the ACD approach. Relative to a medical records review, the ACD approach of one or two PTSD coded outpatient encounters had a PPV of 78% and an NPV of 91%; whereas the PPV was 97% and the NPV was 98% for three or more PTSD codes. For pharmacotherapy, the ACD approach with one or two codes for PTSD had a PPV of 33% (NPV = 93%), whereas three or more PTSD coded encounters improved the PPV to 85% (NPV = 100%). When using VHA data, we recommend tailoring the identification strategy according to the research aims. An ACD approach identifying one or more PTSD outpatient encounters should be considered sufficient for a diagnosis of PTSD. Assessments for PTSD associated pharmacotherapy require using an ACD approach that identifies veterans with the presence ≥ 3 outpatient PTSD encounters. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.     

Relationships between insomnia and alcohol and cocaine use frequency with aggression among veterans engaged in substance use treatment

BackgroundVeterans with substance use problems have rates of partner and non-partner violence that typically exceed the general population. Sleep problems may exacerbate violence and maintain addictive behaviors in non-veterans, but requires study in veterans. Therefore, we examine the interrelationships between substance use, insomnia, and violence in veterans.MethodsVeterans (N = 762) screened for a randomized controlled trial at veterans affairs mental health and substance use clinics. Participants completed modified Conflict Tactics Scales to quantify past-year violence and the Insomnia Symptom Questionnaire to assess sleep disturbance. We evaluated associations between substance use and sleep in predicting the target of aggression (partner or non-partner) and degree of violence (aggression or injury) using binomial logistic regressions.ResultsHalf of participants endorsed symptoms suggestive of insomnia, 23.2% endorsed physical aggression toward partners (PA-P) and 33.9% non-partners (PA-NP), and 9.7% endorsed physical injury of partners (PI-P) and 17.6% of non-partners (PI-NP). Regressions revealed significant models for PA-P, PA-NP, and PI-NP, whereas the PI-P model was not significant. PA-P was higher among non-Caucasian race and older veterans. PA-NP was more common in those with insomnia and increased with frequency of cocaine use. Insomnia moderated the relationship between cocaine use and PA-NP; there was a weaker relationship between cocaine use and PA-NP in those with insomnia. PI-NP was more common with higher frequency of alcohol and cocaine use, and in those with insomnia.ConclusionsThis study finds sleep disturbances are meaningful predictors of violence among veterans with differential relationships with aggression severity, victims, and substance use concurrence.     

Post-traumatic Stress Disorder in Older U.S. Military Veterans: Prevalence,Characteristics, and Psychiatric and Functional Burden

ObjectiveTo characterize the prevalence, characteristics, and comorbidities of subthreshold and full post-traumatic stress disorder (PTSD) in older U.S. military veterans.Design and SettingA nationally representative web-based survey of older U.S. military veterans who participated in the National Health and Resilience in Veterans Study (NHRVS) between November 18, 2019 and March 8, 2020.ParticipantsU.S. veterans aged 60 and older (n = 3,001; mean age = 73.2, SD: 7.9, range: 60–99).MeasurementsPTSD was assessed using the PTSD Checklist for DSM-5. Self-report measures assessed sociodemographic characteristics, trauma exposures, suicidal behaviors, psychiatric and substance use disorders, as well as mental, cognitive, and physical functioning. Multivariable analyses examined correlates of subthreshold and full PTSD.ResultsThe vast majority of the sample (n = 2,821; 92.7%) reported exposure to one or more potentially traumatic events. Of those exposed to such events, 262 (9.6%, 95% confidence interval [CI]: 8.4%–10.9%) and 68 (1.9%, 95% CI: 1.3%–2.6%) screened positive for subthreshold and full PTSD, respectively. The prevalence of subthreshold and full PTSD was significantly higher in female veterans and veterans who use VA as their primary healthcare. Subthreshold and full PTSD groups endorsed more adverse childhood experiences and total traumas than the no/minimal PTSD symptom group, the most common traumatic experiences endorsed were combat exposure, physical or sexual assault, and life-threatening illness or injury. Veterans with subthreshold and full PTSD were also more likely to screen positive for depression, substance use disorders, suicide attempts, nonsuicidal self-injury, and suicidal ideation, and reported lower mental, cognitive, and physical functioning.ConclusionSubthreshold PTSD and full PTSD are prevalent and associated with substantial clinical burden in older U.S. veterans. Results underscore the importance of assessing both subthreshold and full PTSD in this population.     

Medical service utilization by veterans seeking help for posttraumatic stress disorder

OBJECTIVE: 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. METHOD: 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. RESULTS: 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. CONCLUSIONS: 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.     

Multimorbidity among Veterans Diagnosed with PTSD in the Veterans Health Administration Nationally

Psychiatric Quarterly - Over 30% of veterans treated for psychiatric disorders in the Veterans Health Administration (VHA) are diagnosed with Post-Traumatic Stress Disorder (PTSD), with most...     

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.     

Evaluating treatment of posttraumatic stress disorder with cognitive processing therapy and prolonged exposure therapy in a VHA specialty clinic

This retrospective chart review evaluates the effectiveness of manualized cognitive processing therapy (CPT) protocols (individual CPT, CPT group only, and CPT group and individual combined) and manualized prolonged exposure (PE) therapy on veterans’ posttraumatic stress disorder (PTSD) symptoms in one Veterans Health Administration (VHA) specialty clinic. A total of 517 charts were reviewed, and analyses included 178 charts for CPT and 85 charts for PE. Results demonstrated CPT and PE to significantly reduce PTSD Checklist (PCL) scores. However, PE was significantly more effective than CPT after controlling for variables of age, service era, and ethnicity. Additional findings included different outcomes among CPT formats, decreased treatment dropouts for older veterans, and no significant differences in outcome between Hispanic and White veterans. Study limitations and future research directions are discussed.     

Correlates of Obtaining Employment among Veterans Receiving Treatment for Severe PTSD in Specialized Intensive Programs

Severe Post-Traumatic Stress Disorder (PTSD) has been identified as a significant impediment to employment. However, little is known about correlates of employment recovery after a period of not working among veterans with severe PTSD treated in specialized intensive treatment programs. This study examines rates and correlates of transitioning from not being employed at admission to working four months after discharge using national Veterans Health Administration (VHA) program evaluation data on veterans engaged in specialized intensive PTSD treatment (N?=?27,339). Results suggest that only 5.68% of the sample made the transition to employment while 10.6% lost employment, 8.9% worked both at admission and following discharge, and 74.9%, did not work either at admission or following discharge. Multinomial regression analysis found that compared to other groups, veterans who became employed were younger, less likely to receive service-connected disability payments, and experienced a significantly greater reduction in PTSD symptoms. Findings from this study highlight that this distinct population has very poor employment outcomes and deserves more attention, and that reducing PTSD symptoms can lead to improved employment outcomes. Efforts to integrate evidence-based vocational rehabilitation practice into residential PTSD treatment targeting PTSD symptoms is encouraged.

     

Advancing health equity by understanding race disparities and other factors associated with PTSD symptom improvement following evidence-based psychotherapy

Several studies found that Black veterans demonstrate less posttraumatic stress disorder (PTSD) symptom improvement than White veterans following PTSD evidence-based psychotherapies (EBPs). We aimed to understand this disparity among veterans receiving EBPs by modeling race with demographic, clinical, and service utilization factors. Using electronic health records, we employed a cohort study of Iraq and Afghanistan War Veterans who initiated PTSD EBP treatment and completed > 2 PTSD symptom measures (N = 21,751). Using hierarchical Bayesian logistic regressions, we modeled the probability of PTSD symptom improvement. Black race was associated with less PTSD improvement (mean posterior odds ratio [MPOR] = 0.92; 95 % plausibility interval [PI] = 0.84, 1.0), as was group therapy (MPOR = 0.67; 95 % PI = 0.62, 0.73). Factors associated with greatest improvement included prolonged exposure (MPOR = 1.35; 95 % PI = 1.25, 1.45) and treatment density (MPOR = 1.40; 95 % PI = 1.36, 1.45). On average, Black veterans evidenced PTSD EBP improvement disparities. Clinical and utilization did not fully account for these disparities, although disproportionate representation of Black veterans in group CPT may explain some of these differences. Understanding experiences such as race-based trauma and chronic racism and discrimination is critical to provide Black veterans with the most effective PTSD care.     

The relative health related quality of life of veterans with Parkinson's disease

OBJECTIVES: To use databases of the US Veterans Health Administration (VHA) to describe the impact of Parkinson's disease on health related quality of life (HRQoL) of veterans; to compare the HRQoL of veterans with Parkinson's disease with that of veterans reporting eight other neurological or chronic conditions; and to estimate the unique effect of Parkinson's disease on HRQoL. METHODS: Respondents to the VHA 1999 large national health survey of veteran enrollees with a diagnosis of Parkinson's disease in VHA treatment files for the fiscal years 1997-1999 were identified by merging databases. The survey incorporated the Veterans SF-36, a well validated generic measure of HRQoL and functional status. This was used to compare patient groups. Mean physical (PCS) and mental (MCS) component summary scores were calculated for Parkinson's disease and eight other diseases by multivariable regressions that adjusted for age, sex, race, education, and 15 mental and physical co-morbid conditions that were self reported in the survey. RESULTS: Of 887 775 survey respondents, 14 530 (1.64%) had a Parkinson's disease diagnosis. Controlling for sociodemographic factors and co-morbidities, veterans with Parkinson's disease had PCS and MCS below veterans with angina/coronary heart disease, arthritis, chronic low back pain, congestive heart failure, diabetes, and stroke. Veterans with spinal cord injury reported slightly lower PCS than veterans with Parkinson's disease (32.38 v 32.72; 0.03 of 1 SD). Veterans with depression reported markedly lower MCS than veterans with Parkinson's disease (35.94 v 41.48; 0.55 of 1 SD). The unique effect of having Parkinson's disease on HRQoL was to lower PCS and MCS by 4.10 and 3.42 points (0.41 and 0.34 of 1 SD), respectively. CONCLUSIONS: The analysis quantifies the negative impact of Parkinson's disease on HRQoL, after controlling for sociodemographic factors and co-morbidities. Compared with eight other chronic conditions, Parkinson's disease imposes a relatively heavy burden on US veterans in the VHA health care system.     

Symptom patterns associated with chronic PTSD in male veterans: new findings from the National Vietnam Veterans Readjustment Study

A subsample of 255 male Vietnam veterans from the National Vietnam Veterans Readjustment Study received in-depth psychiatric diagnostic interviews. This paper focuses on the 88 veterans with a war-related onset of PTSD. Among these veterans, the avoidance cluster, especially its symptoms of numbing, was most strongly associated with chronic PTSD; less strongly but also significantly associated was the hyperarousal cluster. Further analyses show that these associations are not artifacts of the relationship of symptom patterns to prewar demographic factors (race/ethnicity, socioeconomic status, age at entry into Vietnam), comorbidity, treatment and compensation seeking, or probable severity of war-related trauma. We conclude that certain symptom profiles may predict enduring pathological responses to trauma and therefore provide targets for intervention efforts.     

Measuring Use of Evidence Based Psychotherapy for Posttraumatic Stress Disorder

To improve methods of estimating use of evidence-based psychotherapy for posttraumatic stress disorder in the Veteran’s health administration, we evaluated administrative data and note text for patients newly enrolling in six VHA outpatient PTSD clinics in New England during the 2010 fiscal year (n = 1,924). Using natural language processing, we developed machine learning algorithms that mimic human raters in classifying note text. We met our targets for algorithm performance as measured by precision, recall, and F-measure. We found that 6.3 % of our study population received at least one session of evidence-based psychotherapy during the initial 6 months of treatment. Evidence-based psychotherapies appear to be infrequently utilized in VHA outpatient PTSD clinics in New England. Our method could support efforts to improve use of these treatments.     

Reducing suicidal ideation through evidence-based treatment for posttraumatic stress disorder

BackgroundSuicide is a major public health concern in military and civilian contexts. Veteran populations are at increased risk for suicide, especially veterans with mental health disorders such as Posttraumatic Stress Disorder (PTSD). Suicidal ideation (SI) is a primary risk factor for suicide.MethodsWe investigated changes in SI in a multi-site sample of treatment seeking veterans from three separate Veterans Health Administration (VA) medical centers (n = 289) who received Prolonged Exposure (PE) therapy, an evidence-based treatment (EBT) for PTSD. SI and PTSD symptoms were assessed, using self-report instruments, throughout routine clinical care.ResultsBoth PTSD and SI symptoms reduced over the course of treatment (d-type effect sizes of 1.47 and 0.27, respectively). While SI was associated with PTSD symptoms at all time points, appropriately specified, time lagged models indicated that changes in PTSD symptoms were predictive of future declines in SI, while the converse was not true.ConclusionsResults indicate that treating PTSD symptoms with an EBT for PTSD can be an effective way to reduce SI, at least partially, and for some patients. These data are significant in light of the resources and programming devoted to addressing SI in the VA relative to available empirical evidence regarding the effectiveness of developed strategies. The findings demonstrate the importance of facilitating EBT referrals for specific disorders as a component of broad-based suicide outreach and preventions strategies.     

Replication and expansion of findings related to racial differences in veterans with combat-related PTSD

Racial differences in those seeking treatment at a Veterans Affairs Medical Center (VAMC) outpatient posttraumatic stress disorder (PTSD) treatment program were examined. One hundred eleven (71 Caucasian and 40 African American) veterans were compared on both self-report measures and interview measures of PTSD, depression, dissociation, and general psychopathology. Participants completed the following self-report measures: the Beck Depression Inventory, the Dissociative Experiences Scale, the Mississippi Combat PTSD Scale, and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Participants also completed the Clinician Administered PTSD Scale (CAPS-1), which is a structured interview for PTSD, and completed a non-structured clinical interview. The two groups did not differ on measured demographic variables, nor were there significant differences on self-report or interview measures of anxiety, depression, or PTSD symptomatology. Contrary to expectation, groups did not differ on self-report measures of dissociation, paranoia, or schizophrenia. African Americans were significantly more likely to endorse items of bizarre mentation from the MMPI-2. These results suggest that African American and Caucasian veterans with combat-related PTSD do not differ with regard to manifestation or severity of psychopathology.     

Does PTSD moderate the relationship between social support and suicide risk in Iraq and Afghanistan War Veterans seeking mental health treatment?

Objective: This study examined posttraumatic stress disorder (PTSD) as a potential moderating variable in the relationship between social support and elevated suicide risk in a sample of treatment‐seeking Iraq and Afghanistan War Veterans. Method: As part of routine care, self‐reported marital status, satisfaction with social networks, PTSD, and recent suicidality were assessed in Veterans (N=431) referred for mental health services at a large Veteran Affairs Medical Center. Logistic regression analyses were conducted using this cross‐sectional data sample to test predictions of diminished influence of social support on suicide risk in Veterans reporting PTSD. Results: Thirteen percent of Veterans were classified as being at elevated risk for suicide. Married Veterans were less likely to be at elevated suicide risk relative to unmarried Veterans and Veterans reporting greater satisfaction with their social networks were less likely to be at elevated risk relative to Veterans reporting lower satisfaction. Satisfaction with social networks was protective for suicide risk in PTSD and non‐PTSD cases, but was significantly less protective for veterans reporting PTSD. Conclusions: Veterans who are married and Veterans who report greater satisfaction with social networks are less likely to endorse suicidal thoughts or behaviors suggestive of elevated suicide risk. However, the presence of PTSD may diminish the protective influence of social networks among treatment‐seeking Veterans. Depression and Anxiety, 2010. Published 2010 Wiley‐Liss, Inc.     

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.     

Measuring Use of Evidence Based Psychotherapy for Posttraumatic Stress Disorder in a Large National Healthcare System

To derive a method of identifying use of evidence-based psychotherapy (EBP) for post-traumatic stress disorder (PTSD), we used clinical note text from national Veterans Health Administration (VHA) medical records. Using natural language processing, we developed machine-learning algorithms to classify note text on a large scale in an observational study of Iraq and Afghanistan veterans with PTSD and one post-deployment psychotherapy visit by 8/5/15 (N?=?255,968). PTSD visits were linked to 8.1 million psychotherapy notes. Annotators labeled 3467 randomly-selected psychotherapy notes (kappa?=?0.88) to indicate receipt of EBP. We met our performance targets of overall classification accuracy (0.92); 20.2% of veterans received?≥?one session of EBP over the study period. Our method can assist with identifying EBP use and studying EBP-associated outcomes in routine clinical practice.     

Perceived Purpose in Life,Mental Health,and Suicidality in Older U.S. Military Veterans: Results From the National Health and Resilience in Veterans Study

ObjectiveTo determine the current prevalence of perceived purpose in life (PIL) and its association with screening positive for mental disorders and suicidality in a nationally representative sample of predominantly older U.S. veterans.MethodsData were analyzed from the 2019–2020 National Health and Resilience in Veterans Study (N = 4,069; M_age = 62.2). Veterans were classified into three groups based on perceived PIL level (i.e., low, average, and high). Self-report assessments were administered to screen for mental disorders and suicidality.ResultsMost veterans endorsed average PIL (71.7%), while 16.0% endorsed low PIL and 12.4% endorsed high PIL. A “dose-response” association was observed between PIL and outcomes. High PIL was associated with 42%–94% reduced odds of screening positive for major depressive, generalized anxiety, posttraumatic stress, and substance use disorders, as well as suicide attempts, ideation, and future intent.ConclusionHigher PIL is associated with lower odds of mental disorders and suicidality in U.S. veterans, underscoring the potential importance of interventions to bolster PIL in this population.     

Combat-related PTSD and psychosocial adjustment problems among substance abusing veterans

The purpose of this study were the following: a) to determine the prevalence of combat-related posttraumatic stress disorder (PTSD) symptoms among veterans seeking assistance at a Veterans Administration medical center substance abuse treatment facility, b) to examine the relative contribution of Vietnam war zone variables to PTSD symptom development, and c) to study psychosocial adjustment problems associated with Vietnam combat exposure and with PTSD symptoms among help-seeking substance abusing men. Of 489 male veterans presenting for treatment, 10.7% had significant Vietnam combat-related PTSD symptoms as measured by the Mississippi Scale for Combat-Related PTSD. Clinically significant PTSD symptoms occurred among 46% of the subsample of combat-exposed Vietnam veterans with substance abuse problems. Degree of combat exposure was the most important military stressor that distinguished Vietnam veterans with PTSD from those without PTSD, but the groups also differed on age of war zone duty, duration of war zone duty, and whether they were wounded. Veterans who served in Vietnam did not differ from veterans who had no war zone duty on various parameters of psychosocial adjustment. However, the subgroup of Vietnam veterans with PTSD symptoms reported significantly greater psychosocial adjustment problems than their counterparts who did not have PTSD. The deleterious effects associated with combat-related PTSD appeared to be confined to adjunctive psychiatric difficulties and unemployment and did not increase risk of arrests for antisocial conduct beyond that found for veterans without PTSD. Methodological and clinical implications of these findings are discussed.