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.     

Brief report: Comparison of methods to identify Iraq and Afghanistan war veterans using Department of Veterans Affairs administrative data

The Department of Veterans Affairs (VA) has made treatment and care of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans a priority. Researchers face challenges identifying the OIF/OEF population because until fiscal year 2008, no indicator of OIF/OEF service was present in the Veterans Health Administration (VHA) administrative databases typically used for research. In this article, we compare an algorithm we developed to identify OIF/OEF veterans using the Austin Information Technology Center administrative data with the VHA Support Service Center OIF/OEF Roster and veterans' self-report of military service. We drew data from two different institutional review board-approved funded studies. The positive predictive value of our algorithm compared with the VHA Support Service Center OIF/OEF Roster and self-report was 92% and 98%, respectively. However, this method of identifying OIF/OEF veterans failed to identify a large proportion of OIF/OEF veterans listed in the VHA Support Service Center OIF/OEF Roster. Demographic, diagnostic, and VA service use differences were found between veterans identified using our method and those we failed to identify but who were in the VHA Support Service Center OIF/OEF Roster. Therefore, depending on the research objective, this method may not be a viable alternative to the VHA Support Service Center OIF/OEF Roster for identifying OIF/OEF veterans.     

Prevalence and characteristics of driving difficulties in Operation Iraqi Freedom/Operation Enduring Freedom combat returnees

We studied the prevalence and characteristics of self-reported driving difficulties and examined their association with traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans who were seen at a Department of Veterans Affairs outpatient polytrauma clinic. In this study, we used a brief driving questionnaire and chart reviews to assess the prevalence and characteristics of driving difficulties in the following four groups of patients: TBI only, PTSD only, TBI + PTSD, and Neither (neither TBI nor PTSD). Compared with before deployment, 93% of OIF/OEF veterans seen in the polytrauma clinic reported more difficulties with driving in at least one domain, with the most common areas of difficulty being (1) problems with anger or impatience (82%), (2) general driving difficulties (65%), and (3) experiences with near misses (57%). Patients with PTSD (with or without TBI) reported the most significant driving impairments, whereas respondents with a history of only TBI endorsed driving difficulties similar to veterans without either diagnosis. Qualitative analysis of veterans' comments also revealed similar patterns. Self-reported driving problems were common among OIF/OEF returnees. Respondents who had a diagnosis of PTSD (with or without TBI) reported the most severe driving difficulties since returning from deployment. The association between PTSD and driving problems warrants further investigation.     

"There's more to this pain than just pain": how patients' understanding of pain evolved during a randomized controlled trial for chronic pain

Chronic pain is prevalent, is costly, and exerts an emotional toll on patients and providers. Little is known about chronic pain in veterans of the recent military conflicts in Afghanistan and Iraq (OEF/OIF/OND [Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn] veterans). This study's objective was to ascertain veterans' perceptions of a multicomponent intervention tested in a randomized controlled trial for OEF/OIF/OND veterans with chronic musculoskeletal pain (ESCAPE: Evaluation of Stepped Care for Chronic Pain). Qualitative interviews were conducted with patients in the intervention arm of ESCAPE. Questions related to veterans' experiences with trial components, overall perceptions of the intervention, strengths, and suggestions for improvement. Twenty-six veterans (21% of total intervention patients) participated. Patients were purposefully sampled to include treatment responders (defined as ≥30% reduction in pain-related disability or pain severity) and non-responders. Non-completers (completed <50% of the trial) were also sampled. Qualitative analysis was guided by grounded theory, using constant comparative methodology. Both responders and non-responders spoke about their evolving understanding of their pain experience during the trial, and how this new understanding helped them to manage their pain more effectively. This evolution is reported under 2 themes: 1) learning to recognize physical and psychosocial factors related to pain; and 2) learning to manage pain through actions and thoughts. PERSPECTIVE: Responders and non-responders both described making connections between their pain and other factors in their lives, and how these connections positively influenced how they managed their pain. Traditional quantitative measures of response to pain interventions may not capture the full benefits that patients report experiencing.     

Identification of domains and measures for assessment battery to examine well-being of spouses of OIF/OEF veterans with PTSD

Family members play an important role in the physical and mental recovery of soldiers returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Posttraumatic stress disorder (PTSD) has been associated with strained marital and family relations and parenting difficulties, and many veterans with PTSD experience difficulty finding and maintaining employment. Family members who assist with the veteran's recovery also experience significant strain and may have to leave employment to care for the veteran. Our objective was to identify appropriate assessment measures for examining the well-being of spouses assisting with veterans' recovery and to identify opportunities for supporting veterans' spouses. We used a combination of expert panel input and qualitative methods (focus group interviews) to develop a battery of instruments for use in future research with OIF/OEF family members to examine well-being. Research is needed to elucidate and refine the special needs and issues surrounding PTSD in current and future OIF/OEF veterans and their families. This study provides a first step toward understanding appropriate measures. Expert panel methods and focus group interviews yielded valuable input on the domains and measures that should be included in the assessment battery as well as opportunities for assisting spouses.     

Psychological Stress–Induced Immune Response and Risk of Alzheimer's Disease in Veterans from Operation Enduring Freedom and Operation Iraqi Freedom

PurposePsychological stress is a significant health problem in veterans and their family members. Traumatic brain injury (TBI) and stress lead to the onset, progression, and worsening of several inflammatory and neurodegenerative diseases in veterans and civilians. Alzheimer's disease (AD) is a progressive, irreversible neuroinflammatory disease that causes problems with memory, thinking, and behavior. TBIs and chronic psychological stress cause and accelerate the pathology of neuroinflammatory diseases such as AD. However, the precise molecular and cellular mechanisms governing neuroinflammation and neurodegeneration are currently unknown, especially in veterans. The purpose of this review article was to advance the hypothesis that stress and TBI-mediated immune response substantially contribute and accelerate the pathogenesis of AD in veterans and their close family members and civilians.MethodsThe information in this article was collected and interpreted from published articles in PubMed between 1985 and 2020 using the key words stress, psychological stress, Afghanistan war, Operation Enduring Freedom (OEF), Iraq War, Operation Iraqi Freedom (OIF), Operation New Dawn (OND), traumatic brain injury, mast cell and stress, stress and neuroimmune response, stress and Alzheimer's disease, traumatic brain injury, and Alzheimer's disease.FindingsChronic psychological stress and brain injury induce the generation and accumulation of beta-amyloid peptide, amyloid plaques, neurofibrillary tangles, and phosphorylation of tau in the brain, thereby contributing to AD pathogenesis. Active military personnel and veterans are under enormous psychological stress due to various war-related activities, including TBIs, disabilities, fear, new environmental conditions, lack of normal life activities, insufficient communications, explosions, military-related noise, and health hazards. Brain injury, stress, mast cell, and other immune cell activation can induce headache, migraine, dementia, and upregulate neuroinflammation and neurodegeneration in veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. TBIs, posttraumatic stress disorder, psychological stress, pain, glial activation, and dementia in active military personnel, veterans, or their family members can cause AD several years later in their lives. We suggest that there are increasing numbers of veterans with TBIs and stress and that these veterans may develop AD late in life if no appropriate therapeutic intervention is available.ImplicationsPer these published reports, the fact that TBIs and psychological stress can accelerate the pathogenesis of AD should be recognized. Active military personnel, veterans, and their close family members should be evaluated regularly for stress symptoms to prevent the pathogenesis of neurodegenerative diseases, including AD.     

Using International Classification of Functioning, Disability and Health to understand challenges in community reintegration of injured veterans

This pilot study used the framework of the World Health Organization's International Classification of Functioning, Disability and Health (ICF) to understand the challenges faced by Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans as they reintegrate into the community. We conducted semistructured interviews with 14 injured veterans, 12 caregivers, and 14 clinicians. We used ICF taxonomy to code data and identify issues. We identified challenges in the following ICF domains: learning and applying knowledge; general tasks and demands; communication; mobility; self-care; domestic life; interpersonal interactions, major life areas; and community, social, and civic life. We found many similarities between the challenges faced by veterans with and without polytraumatic injuries, although veterans with polytraumatic injuries faced challenges of greater magnitude. Identifying community reintegration challenges early and promoting reintegration are important mandates for the Department of Veterans Affairs. The findings of this study are useful in understanding the needs of OEF/OIF veterans.     

Mental health diagnosis and occupational functioning in National Guard/Reserve veterans returning from Iraq

Occupational functioning represents both an important outcome for military service members returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom and a predictor for long-term mental health functioning. We investigated the role of mental health diagnoses, determined by structured clinical interviews, on occupational functioning in a group of 262 National Guard/Reserve service members within 1 year of returning from a 16-month OIF combat deployment. We assessed occupational functioning at the time of diagnostic interviews and 1 year later. We hypothesized that service members with diagnoses of posttraumatic stress disorder (PTSD), depression, and/or alcohol abuse or dependence would exhibit lower rates of employment at both time points and lower rates of reported work and/or school role functioning. Service members with a diagnosis of PTSD (5%, n = 13), subthreshold PTSD (6%, n = 15), a major depressive disorder (11%, n = 29), or alcohol abuse or dependence (11%, n = 28) did not differ on employment status from service members without a diagnosis at either time point. However, those with a diagnosis of PTSD, depression, and/or alcohol abuse or dependence reported lower levels of work role functioning. In addition, service members with a diagnosis of PTSD reported greater rates of deterioration in work role functioning over time.     

A multimodal imaging study in U.S. veterans of Operations Iraqi and Enduring Freedom with and without major depression after blast-related concussion

Although the exact number of affected individuals is unknown, it has been estimated that approximately 20% of U.S. veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) have experienced mild traumatic brain injury (mTBI) (i.e., concussion), which is defined as a brief loss or alteration of consciousness from a blow or jolt to the head. Blast exposure is among the most common causes of concussion in OEF–OIF warriors. Although the mechanism is unknown, major depressive disorder (MDD) after head injury is common. The purpose of this study was to use diffusion tensor imaging (DTI) and functional magnetic resonance imaging (fMRI) to examine the structural and functional neural correlates of MDD in OEF–OIF combat veterans with a self-reported history of blast-related concussion. We hypothesized that subjects in the MDD group (i.e., individuals with a history of blast-related concussion who were experiencing current MDD) relative to individuals in the non-MDD group (i.e., individuals with a history of blast-related concussion but no current or lifetime history of MDD) would show amygdala hyperactivity and disruption of white matter tracts connecting prefrontal and limbic brain regions. To test these hypotheses, 11 MDD and 11 non-MDD individuals underwent DTI and performed a validated emotional face matching task during fMRI. MDD relative to non-MDD individuals showed greater activity during fear matching trials in the amygdala and other emotion processing structures, lower activity during fear matching trials in emotional control structures such as the dorsolateral prefrontal cortex and lower fractional anisotropy (FA) in several white matter tracts including the superior longitudinal fasciculus (SLF). Greater depressive symptom severity correlated negatively with FA in the SLF. These results suggest a biological basis of MDD in OEF–OIF veterans who have experienced blast-related concussion, and may contribute to the development of treatments aimed at improving the clinical care of this unique population of wounded warriors.     

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.     

PTSD, Combat Injury, and Headache in Veterans Returning From Iraq/Afghanistan

Objective.— To examine the relationship between posttraumatic stress disorder, combat injury, and headache in Operation Iraqi Freedom and Operation Enduring Freedom veterans at the VA San Diego Healthcare System. Background.— Previous investigations suggest that a relationship between posttraumatic stress disorder and primary headache disorders exists and could be complicated by the contribution of physical injury, especially one that results in loss of consciousness. These associations have not been systematically examined in Operation Iraqi Freedom and Operation Enduring Freedom veterans. Methods.— In this observational cross‐sectional study, a battery of self‐report, standardized questionnaires was completed by 308 newly registered veterans between March and October 2006. The Davidson Trauma Scale was used to determine the degree of posttraumatic stress disorder symptoms and combat‐related physical injury was assessed by self‐report. The presence of headache was based on a symptom checklist measure and self‐reported doctor diagnoses. Logistic regression analysis was performed to predict presence of headache and determine odds ratios and 95% confidence intervals associated with demographic, military, in‐theatre, and mental health characteristics. Results.— About 40% of the veterans met the criteria for posttraumatic stress disorder; 40% self‐reported current headache, 10% reported a physician diagnosis of migraine, 12% a physician diagnosis of tension‐type headache, and 6% reported both types of headache. Results from the logistic regression model indicated that combat‐related physical injury (odds ratio: 2.25; 95% confidence interval: 1.17‐4.33) and posttraumatic stress disorder (odds ratio: 4.13; 95% confidence interval: 2.44‐6.99) were independent predictors of self‐reported headache. Additional analyses found that veterans with both tension and migraine headache had higher rates of posttraumatic stress disorder (chi‐square [d.f. = 3] = 15.89; P = .001) whereas veterans with migraine headache alone had higher rates of combat‐related physical injury (chi‐square [d.f. = 9] = 22.00; P = .009). Conclusion.— Posttraumatic stress disorder and combat‐related physical injury were related to higher rates of self‐reported headache in newly returning veterans. Our finding that posttraumatic stress disorder and injury during combat are differentially related to migraine and tension‐type headache, point to a complex relationship between physical and psychological trauma and headache. These findings have implications for a comprehensive approach to interventions for headache and the physical and psychological sequelae of trauma.     

Deployment-Related Traumatic Brain Injury and Risk of New Episodes of Care for Back Pain in Veterans

Traumatic brain injury (TBI) may be a predisposing factor to pain syndromes other than headache. We conducted a longitudinal cohort study among veterans evaluated for TBI in the US Department of Veterans Affairs (VA). Among 36,880 veterans at baseline, 55% reported back pain. TBI history was classified by trained clinicians according to VA-US Department of Defense criteria. 14,223 Veterans without back pain were followed for up to 6 years for new (incident) episodes of VA care for back pain. We estimated adjusted odds ratios (aORs), adjusted hazard ratios (aHRs), and 95% confidence intervals (CI), accounting for covariates. Deployment-related mild TBI was significantly associated with self-reported back pain in cross-sectional analyses (aOR?=?1.27, 95% CI?=?1.21–1.35), but not with incident episodes of VA care for back pain in longitudinal analysis (aHR?=?1.07, 95% CI?=?0.99–1.17). Deployment-related moderate to severe TBI was significantly associated with self-reported back pain in cross-sectional (aOR?=?1.74, 95% CI?=?1.58–1.91), and longitudinal analyses (aHR?=?1.20, 95% CI?=?1.05–1.38; P?=?.01). These findings indicate that deployment-related moderate to severe TBI confers increased back pain risk, but do not support a causal effect of deployment-related mild TBI on back pain.

Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: implications for research and practice

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have resulted in a growing number of seriously injured soldiers who are evacuated to the United States for comprehensive medical care. Trauma-related pain is an almost universal problem among these war-injured soldiers, and several military and Department of Veterans Affairs initiatives have been implemented to enhance pain care across the continuum of medical services. This article describes several innovative approaches for improving the pain care provided to OEF and OIF military personnel during acute stabilization, transport, medical-surgical treatment, and rehabilitation and presents summary data characterizing the soldiers, pain management services provided, and associated outcomes. We also identify some of the pain assessment, classification, and treatment challenges emerging from work with this population and provide recommendations for future research and practice priorities.     

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) military mental health issues. Information on the wars' signature wounds: posttraumatic stress disorder and traumatic brain injury

This topic can be related to the nursing profession and the need to be better educated on military mental health. Since mood disorder, suicide, alcohol abuse, PTSD and TBI are evident in actively serving and returning service members, it is imperative to educate nurses and healthcare providers about these conditions, the available evidence-based treatments and referrals to programs for these signature OEF/OIF wounds. The authors encourage nurse educators to consider ways to include military mental health and other service-related health issues into nursing curricula and to use Veterans Administration and veterans-related healthcare facilities for clinical courses. As the wars in Afghanistan and Iraq continue into the foreseeable future, many veterans will be seen not only in VA facilities, but they will self-refer to academic and community hospitals, and psychiatric and rehabilitation centers. It is important for all nurses to be aware of the effects of PTSD, depression, suicide, substance abuse and TBI on our patients and to be effective advocates for quality care of veterans in all settings. Nurses need to advocate for screening and provision of mental health services in primary care settings. When such services are offered in primary care settings, it normalizes the care and the service member will more likely allow themselves to receive the care (Jones, 2004). All nurses must understand the price of war experienced by U.S. service members and their families, and in particular, the invisible wounds of war.     

Mindfulness-Based Interdisciplinary Pain Management Program for Complex Polymorbid Pain in Veterans: A Randomized Controlled Trial

ObjectiveTo evaluate the effects of interdisciplinary pain management on pain-related disability and opioid reduction in polymorbid pain patients with 2 or more comorbid psychiatric conditions.DesignTwo-arm randomized controlled trial testing a 3-week intervention with assessments at pre-treatment, post-treatment, 6-month, and 12-month follow-up.SettingDepartment of Veterans Affairs medical facility.Participants103 military veterans (N=103) with moderate (or worse) levels of pain-related disability, depression, anxiety, and/or posttraumatic stress disorder randomly assigned to usual care (n=53) and interdisciplinary pain management (n=50). All participants reported recent persistent opioid use. Trial participants had high levels of comorbid medical and mental health conditions.InterventionsExperimental arm—a 3-week, interdisciplinary pain management program guided by a structured manual; comparison arm—usual care in a large Department of Veterans Affairs medical facility.Main Outcome MeasuresOswestry Disability Index (pain disability); Timeline Followback Interview and Medication Event Monitoring System (opioid use). Analysis used generalized linear mixed model with all posttreatment observations (posttreatment, 6-month follow-up, 12-month follow-up) entered simultaneously to create a single posttreatment effect.ResultsVeterans with polymorbid pain randomized to the interdisciplinary pain program reported significantly greater decreases in pain-related disability compared to veterans randomized to treatment as usual (TAU) at posttreatment, 6-month, and 12-month follow-up. Aggregated mean pain disability scores (ie, a summary effect of all posttreatment observations) for the interdisciplinary pain program were -9.1 (95% CI: -14.4, -3.7, P=.001) points lower than TAU. There was no difference between groups in the proportion of participants who resumed opioid use during trial participation (32% in both arms).ConclusionThese findings offer the first evidence of short- and long-term interdisciplinary pain management efficacy in polymorbid pain patients, but more work is needed to examine how to effectively decrease opioid use in this population.     

Functional self-efficacy and pain-related disability among older veterans with chronic pain in a primary care setting

We examined the relationship between functional self-efficacy and pain-related disability in a sample of older veterans with chronic pain. A total of 1045 veterans aged 65 years or older who received primary care at the VA Connecticut Healthcare System in West Haven, CT, were assessed for the presence of chronic pain (i.e. pain due to a non-cancer cause for >/=3 consecutive months in the past 12 months); 303 (26%) screened positive; and 245 (81%) participated. Using a ten-item functional self-efficacy questionnaire (scale: 0-40), participants were categorized into three functional self-efficacy groups: low, score 相似文献   

Barriers to PTSD treatment-seeking by women veterans who experienced military sexual trauma decades ago: The role of institutional betrayal

BackgroundWhile some barriers to PTSD treatment engagement among veterans are well-identified, e.g., stigma, little is known about the barriers to VA PTSD treatment-seeking among women veterans who experienced military sexual trauma (MST) decades ago.PurposeTo explore the barriers to PTSD treatment-seeking of women veterans with PTSD related to MST experienced prior to 2000.MethodData were collected from women veterans (n = 14) who had experienced MST and sought VA PTSD treatment. Data analyses utilized a constructivist grounded theory approach.FindingsThe context of the MST experience, including the military environment at the time, the era in which they experienced MST and the response of others to their reporting or disclosure of MST created decades-long barriers to PTSD treatment-seeking.DiscussionUnderstanding institutional betrayal as a barrier to PTSD treatment-seeking among women veterans who experienced MST decades ago is necessary to develop effective targeted outreach and programs for this population.