PTSD

The Geriatric Research Education and Clinical Center (GRECC) Memory Disorders Clinic at the VA Puget Sound Health Care System (VAPSHCS) in Seattle, Washington, receives referrals from primary and specialty care. About a decade ago, this clinic began to see an influx of Vietnam-era veterans who presented with a variety of symptoms: not remembering where they were going when driving, forgetting why they went into another room, not remembering what their spouse told them, and feeling “out of it.” These symptoms were not associated with the loss of independence, but they were cause for concern. Family members and care providers typically corroborated the symptom description and perception of decline. Yet during workups, these veterans showed no primary medical causes for cognitive impairments and on neuropsychological evaluation demonstrated essentially normal cognition.

Memory Disorders Clinic staff largely were at a loss to know how to care for these patients. The simple reassurance, “You do not have dementia now,” seemed unsatisfactory given the patients’ ongoing concerns and the established risk factors for neurodegenerative disease.^1,2 One theme emerged when talking with these veterans and their families: They all had a diagnosis of or history of treatment for posttraumatic stress disorder (PTSD).

To help these veterans, the VAPSHCS GRECC sought to address their key areas of concern related to memory. With input from veterans and their families, a quality improvement project was developed with the following goals: (1) to educate veterans and their families about PTSD and cognitive changes; (2) to build and field test a psychoeducational class to teach memory skills in this population; and (3) to inform VA staff about PTSD and cognitive change. In this article, the authors focus on how the first 2 goals were addressed and present preliminary results related to quality improvement.

Memory Skills Classes

The VAPSHCS GRECC Memory Disorders Clinic sought to use an approach that would be readily accepted, efficient, and effective. To that end, the authors developed a clinical model for enhancing memory skills and self-management for veterans with a history of PTSD by adapting existing clinical and educational tools.

Several strategies might promote memory skills, including printed materials for self-directed learning, individual sessions, interactive technologies, or groups. Given the patients’ reports about concentration problems, asking them to work through structured materials independently seemed unproductive. Individual clinical evaluations and cognitive interventions likely would not meet the demand or be cost-effective. Groups have long been used to treat PTSD, and Norrie and colleagues reported that at-risk adults benefited from a group psychoeducation program targeting healthy brain aging.³ At the same time, the Memory Disorders Clinic sought to distinguish itself from PTSD groups, because these groups tend to focus on treating active PTSD.

A better fit for this offering was the description of the sessions as classes. Although the focus was on promoting memory skills among those capable of learning them, the authors were mindful that some veterans might truly have prodromal dementia or acute PTSD symptoms that would require clinical management. The classes were not intended to address all these issues, and there was a plan to refer participants either before or during the class if warranted.

There was no formal evaluation of memory prior to starting the class. These classes were not developed as a research intervention and were exempt from institutional review board (IRB) approval requirements, according to prescreening by the VAPSHCS IRB and a memo from the GRECC director.

Core Components of Memory Skills

It may not be evident at first glance that PTSD or a history of PTSD influences memory. The symptom criteria for PTSD (involving reexperiencing, hyperarousal, and avoidance) might be described as “too much remembering” rather than forgetting. Yet problems with attention and concentration often occur in the setting of intrusive memories and alterations in reactivity. Research has found that older adults with PTSD have deficits of memory, especially new learning.⁴ In other words, while older memories may be “stuck,” PTSD seems to impair the processing of information in the here and now.

To appreciate these effects, it was important for participants in the memory skills classes to have some understanding of how memory works. The authors developed the Memory Model (Figure) as a visual aid and reference point to discuss the stages of new learning and how different aspects of brain activity are required for new learning and for memory to occur. This straightforward model is based on cognitive science and presented in layman’s terms. An important part of this model is the “filter” stage, which controls the information and stimuli that are available to the brain. Posttraumatic stress disorder involves involuntary emotional responses and efforts to avoid them and selects and colors the information that is processed in some situations (eg, avoidance of situations associated with trauma or dissociation of extreme memories). At other times, such as when a powerful stimulus is presented (eg, a helicopter flying close overhead), the filter may try to block out all inputs in order to preserve safety. The Memory Model also served as a visual aid during class discussions of normal cognitive aging.

Class sessions incorporated specific, measurable, attainable, realistic, and timely (SMART) goals, regular exercises based on mindfulness-based stress reduction approaches, and principles of behavioral activation.⁵ The SMART goals structure the sessions and permit customization of learning for participants. Class leaders record a goal for each participant and use these throughout the sessions to build rapport, develop communication, and teach memory skills.

Mindfulness-based stress reduction is an evidence-based treatment used in PTSD.⁶ It provides a counterpoint to the more didactic memory skills and is a method that even those with objective memory impairments can practice and apply successfully. Being in the current moment and emotional regulation are important skills to teach veterans as they learn to exert

Organization

Class sessions occurred weekly for 1 hour for a total of 8 sessions. The weekly class topics included introduction to memory; mood disorders, cognition, and cognitive disorders; barriers to effective memory: assessing readiness for change; developing a routine and becoming organized; attention and concentration; memory improvement (strategies internal and external aids); and reassessing goals.

Over the 3 years of classes reported in this article, the class sizes varied from 4 to 12 participants based on veteran interest, retention, and room size. The classes were structured so that important content areas were covered but with enough elasticity so leaders and veterans would develop a rapport and explore in greater depth the topics that resonated most for the attendees. Group participation was strongly encouraged. Veterans were expressly informed that the class was not for treatment of PTSD and that evidence-based therapies were encouraged to address PTSD especially if their symptoms flared up when compared with previous levels. The attendees also understood that they did not receive formal cognitive or memory testing but were encouraged to pursue testing if they showed significant deficits.

Preliminary Findings

From spring 2012 until spring 2015, 69 veterans agreed to participate and attended at least 1 memory skills class. Eighty-seven percent of participants (n = 60) attended 4 or more classes. The mean age (SD) was 67.3 years (4.2). All the participants were men, and the race/ethnic distribution was similar to that of the aging veteran population and very close to racial demographics for Washington state: 80% white, 14% African American, 2% Asian/Pacific Islander, 2% Native American, and 2% unknown.

Attendees were asked, but not required, to complete questionnaires before the classes began and again at completion. These questionnaires included self-assessments of cognitive strategies and compensatory methods used; an assessment of concern regarding cognition, life satisfaction, and community integration; the PTSD CheckList-Civilian Version (PCL-C); and the Geriatric Depression Scale (GDS).^7,8 The questionnaire also included open response questions to providefeedback on what attendees liked about the classes and recommendations for improvements. The majority of comments for improvement focused on attendees’ desire for longer sessions and repeat offerings. Five veterans did not complete the full set of questionnaires at the beginning of the classes, and 7 did not complete the questionnaires at completion (the 2 subsets did not perfectly overlap).

At the start of the class, on average, veteran participants were experiencing mild depression and moderate symptoms of PTSD as measured by the GDS (n = 54) and the PCL-C (n = 56), respectively. Preliminary comparisons of ratings pre- and post-classes, using simple paired t tests, indicated a reduction in symptoms of depression on the GDS, improved sense of mastery over their memory symptoms, as well as improved quality of life ratings (all P < .01, no corrections). There was no evidence for a significant reduction in PTSD symptoms or report of elimination of cognitive difficulties. With the small sample and modest effects, the clinical significance of these scores cannot be determined. The authors are planning more detailed analyses on a larger set of participants, including measures of health care utilization before and after the class.

Future Directions

The cohort of Vietnam-era veterans likely will manifest more geriatric mental health issues over time, and the number of veterans with a history of PTSD and memory concerns will increase. There is mounting evidence that PTSD alone can be associated with cognitive difficulties across the lifespan, and aspects of aging can both exacerbate and highlight these changes.^9-12 In addition, there is roughly a doubled dementia risk in older veterans with chronic PTSD.¹³ A variety of clinical interventions will be needed to address these issues. For those who have cognitive concerns, teaching older veterans self-management skills while also monitoring their cognition and keeping them engaged in proactive health care are worthy endeavors. The authors hope that by making the program and materials broadly available, more veterans can address their cognitive concerns in a productive, engaging manner. To learn more about the project or to receive class materials, please contact the authors (emily.trittschuh@va.gov).

The Geriatric Research Education and Clinical Center (GRECC) Memory Disorders Clinic at the VA Puget Sound Health Care System (VAPSHCS) in Seattle, Washington, receives referrals from primary and specialty care. About a decade ago, this clinic began to see an influx of Vietnam-era veterans who presented with a variety of symptoms: not remembering where they were going when driving, forgetting why they went into another room, not remembering what their spouse told them, and feeling “out of it.” These symptoms were not associated with the loss of independence, but they were cause for concern. Family members and care providers typically corroborated the symptom description and perception of decline. Yet during workups, these veterans showed no primary medical causes for cognitive impairments and on neuropsychological evaluation demonstrated essentially normal cognition.

Memory Disorders Clinic staff largely were at a loss to know how to care for these patients. The simple reassurance, “You do not have dementia now,” seemed unsatisfactory given the patients’ ongoing concerns and the established risk factors for neurodegenerative disease.^1,2 One theme emerged when talking with these veterans and their families: They all had a diagnosis of or history of treatment for posttraumatic stress disorder (PTSD).

To help these veterans, the VAPSHCS GRECC sought to address their key areas of concern related to memory. With input from veterans and their families, a quality improvement project was developed with the following goals: (1) to educate veterans and their families about PTSD and cognitive changes; (2) to build and field test a psychoeducational class to teach memory skills in this population; and (3) to inform VA staff about PTSD and cognitive change. In this article, the authors focus on how the first 2 goals were addressed and present preliminary results related to quality improvement.

Memory Skills Classes

The VAPSHCS GRECC Memory Disorders Clinic sought to use an approach that would be readily accepted, efficient, and effective. To that end, the authors developed a clinical model for enhancing memory skills and self-management for veterans with a history of PTSD by adapting existing clinical and educational tools.

Several strategies might promote memory skills, including printed materials for self-directed learning, individual sessions, interactive technologies, or groups. Given the patients’ reports about concentration problems, asking them to work through structured materials independently seemed unproductive. Individual clinical evaluations and cognitive interventions likely would not meet the demand or be cost-effective. Groups have long been used to treat PTSD, and Norrie and colleagues reported that at-risk adults benefited from a group psychoeducation program targeting healthy brain aging.³ At the same time, the Memory Disorders Clinic sought to distinguish itself from PTSD groups, because these groups tend to focus on treating active PTSD.

A better fit for this offering was the description of the sessions as classes. Although the focus was on promoting memory skills among those capable of learning them, the authors were mindful that some veterans might truly have prodromal dementia or acute PTSD symptoms that would require clinical management. The classes were not intended to address all these issues, and there was a plan to refer participants either before or during the class if warranted.

There was no formal evaluation of memory prior to starting the class. These classes were not developed as a research intervention and were exempt from institutional review board (IRB) approval requirements, according to prescreening by the VAPSHCS IRB and a memo from the GRECC director.

Core Components of Memory Skills

It may not be evident at first glance that PTSD or a history of PTSD influences memory. The symptom criteria for PTSD (involving reexperiencing, hyperarousal, and avoidance) might be described as “too much remembering” rather than forgetting. Yet problems with attention and concentration often occur in the setting of intrusive memories and alterations in reactivity. Research has found that older adults with PTSD have deficits of memory, especially new learning.⁴ In other words, while older memories may be “stuck,” PTSD seems to impair the processing of information in the here and now.

To appreciate these effects, it was important for participants in the memory skills classes to have some understanding of how memory works. The authors developed the Memory Model (Figure) as a visual aid and reference point to discuss the stages of new learning and how different aspects of brain activity are required for new learning and for memory to occur. This straightforward model is based on cognitive science and presented in layman’s terms. An important part of this model is the “filter” stage, which controls the information and stimuli that are available to the brain. Posttraumatic stress disorder involves involuntary emotional responses and efforts to avoid them and selects and colors the information that is processed in some situations (eg, avoidance of situations associated with trauma or dissociation of extreme memories). At other times, such as when a powerful stimulus is presented (eg, a helicopter flying close overhead), the filter may try to block out all inputs in order to preserve safety. The Memory Model also served as a visual aid during class discussions of normal cognitive aging.

Class sessions incorporated specific, measurable, attainable, realistic, and timely (SMART) goals, regular exercises based on mindfulness-based stress reduction approaches, and principles of behavioral activation.⁵ The SMART goals structure the sessions and permit customization of learning for participants. Class leaders record a goal for each participant and use these throughout the sessions to build rapport, develop communication, and teach memory skills.

Mindfulness-based stress reduction is an evidence-based treatment used in PTSD.⁶ It provides a counterpoint to the more didactic memory skills and is a method that even those with objective memory impairments can practice and apply successfully. Being in the current moment and emotional regulation are important skills to teach veterans as they learn to exert

Organization

Class sessions occurred weekly for 1 hour for a total of 8 sessions. The weekly class topics included introduction to memory; mood disorders, cognition, and cognitive disorders; barriers to effective memory: assessing readiness for change; developing a routine and becoming organized; attention and concentration; memory improvement (strategies internal and external aids); and reassessing goals.

Over the 3 years of classes reported in this article, the class sizes varied from 4 to 12 participants based on veteran interest, retention, and room size. The classes were structured so that important content areas were covered but with enough elasticity so leaders and veterans would develop a rapport and explore in greater depth the topics that resonated most for the attendees. Group participation was strongly encouraged. Veterans were expressly informed that the class was not for treatment of PTSD and that evidence-based therapies were encouraged to address PTSD especially if their symptoms flared up when compared with previous levels. The attendees also understood that they did not receive formal cognitive or memory testing but were encouraged to pursue testing if they showed significant deficits.

Preliminary Findings

From spring 2012 until spring 2015, 69 veterans agreed to participate and attended at least 1 memory skills class. Eighty-seven percent of participants (n = 60) attended 4 or more classes. The mean age (SD) was 67.3 years (4.2). All the participants were men, and the race/ethnic distribution was similar to that of the aging veteran population and very close to racial demographics for Washington state: 80% white, 14% African American, 2% Asian/Pacific Islander, 2% Native American, and 2% unknown.

Attendees were asked, but not required, to complete questionnaires before the classes began and again at completion. These questionnaires included self-assessments of cognitive strategies and compensatory methods used; an assessment of concern regarding cognition, life satisfaction, and community integration; the PTSD CheckList-Civilian Version (PCL-C); and the Geriatric Depression Scale (GDS).^7,8 The questionnaire also included open response questions to providefeedback on what attendees liked about the classes and recommendations for improvements. The majority of comments for improvement focused on attendees’ desire for longer sessions and repeat offerings. Five veterans did not complete the full set of questionnaires at the beginning of the classes, and 7 did not complete the questionnaires at completion (the 2 subsets did not perfectly overlap).

At the start of the class, on average, veteran participants were experiencing mild depression and moderate symptoms of PTSD as measured by the GDS (n = 54) and the PCL-C (n = 56), respectively. Preliminary comparisons of ratings pre- and post-classes, using simple paired t tests, indicated a reduction in symptoms of depression on the GDS, improved sense of mastery over their memory symptoms, as well as improved quality of life ratings (all P < .01, no corrections). There was no evidence for a significant reduction in PTSD symptoms or report of elimination of cognitive difficulties. With the small sample and modest effects, the clinical significance of these scores cannot be determined. The authors are planning more detailed analyses on a larger set of participants, including measures of health care utilization before and after the class.

Future Directions

The cohort of Vietnam-era veterans likely will manifest more geriatric mental health issues over time, and the number of veterans with a history of PTSD and memory concerns will increase. There is mounting evidence that PTSD alone can be associated with cognitive difficulties across the lifespan, and aspects of aging can both exacerbate and highlight these changes.^9-12 In addition, there is roughly a doubled dementia risk in older veterans with chronic PTSD.¹³ A variety of clinical interventions will be needed to address these issues. For those who have cognitive concerns, teaching older veterans self-management skills while also monitoring their cognition and keeping them engaged in proactive health care are worthy endeavors. The authors hope that by making the program and materials broadly available, more veterans can address their cognitive concerns in a productive, engaging manner. To learn more about the project or to receive class materials, please contact the authors (emily.trittschuh@va.gov).

The Geriatric Research Education and Clinical Center (GRECC) Memory Disorders Clinic at the VA Puget Sound Health Care System (VAPSHCS) in Seattle, Washington, receives referrals from primary and specialty care. About a decade ago, this clinic began to see an influx of Vietnam-era veterans who presented with a variety of symptoms: not remembering where they were going when driving, forgetting why they went into another room, not remembering what their spouse told them, and feeling “out of it.” These symptoms were not associated with the loss of independence, but they were cause for concern. Family members and care providers typically corroborated the symptom description and perception of decline. Yet during workups, these veterans showed no primary medical causes for cognitive impairments and on neuropsychological evaluation demonstrated essentially normal cognition.

Memory Disorders Clinic staff largely were at a loss to know how to care for these patients. The simple reassurance, “You do not have dementia now,” seemed unsatisfactory given the patients’ ongoing concerns and the established risk factors for neurodegenerative disease.^1,2 One theme emerged when talking with these veterans and their families: They all had a diagnosis of or history of treatment for posttraumatic stress disorder (PTSD).

To help these veterans, the VAPSHCS GRECC sought to address their key areas of concern related to memory. With input from veterans and their families, a quality improvement project was developed with the following goals: (1) to educate veterans and their families about PTSD and cognitive changes; (2) to build and field test a psychoeducational class to teach memory skills in this population; and (3) to inform VA staff about PTSD and cognitive change. In this article, the authors focus on how the first 2 goals were addressed and present preliminary results related to quality improvement.

Memory Skills Classes

The VAPSHCS GRECC Memory Disorders Clinic sought to use an approach that would be readily accepted, efficient, and effective. To that end, the authors developed a clinical model for enhancing memory skills and self-management for veterans with a history of PTSD by adapting existing clinical and educational tools.

Several strategies might promote memory skills, including printed materials for self-directed learning, individual sessions, interactive technologies, or groups. Given the patients’ reports about concentration problems, asking them to work through structured materials independently seemed unproductive. Individual clinical evaluations and cognitive interventions likely would not meet the demand or be cost-effective. Groups have long been used to treat PTSD, and Norrie and colleagues reported that at-risk adults benefited from a group psychoeducation program targeting healthy brain aging.³ At the same time, the Memory Disorders Clinic sought to distinguish itself from PTSD groups, because these groups tend to focus on treating active PTSD.

A better fit for this offering was the description of the sessions as classes. Although the focus was on promoting memory skills among those capable of learning them, the authors were mindful that some veterans might truly have prodromal dementia or acute PTSD symptoms that would require clinical management. The classes were not intended to address all these issues, and there was a plan to refer participants either before or during the class if warranted.

There was no formal evaluation of memory prior to starting the class. These classes were not developed as a research intervention and were exempt from institutional review board (IRB) approval requirements, according to prescreening by the VAPSHCS IRB and a memo from the GRECC director.

Core Components of Memory Skills

It may not be evident at first glance that PTSD or a history of PTSD influences memory. The symptom criteria for PTSD (involving reexperiencing, hyperarousal, and avoidance) might be described as “too much remembering” rather than forgetting. Yet problems with attention and concentration often occur in the setting of intrusive memories and alterations in reactivity. Research has found that older adults with PTSD have deficits of memory, especially new learning.⁴ In other words, while older memories may be “stuck,” PTSD seems to impair the processing of information in the here and now.

To appreciate these effects, it was important for participants in the memory skills classes to have some understanding of how memory works. The authors developed the Memory Model (Figure) as a visual aid and reference point to discuss the stages of new learning and how different aspects of brain activity are required for new learning and for memory to occur. This straightforward model is based on cognitive science and presented in layman’s terms. An important part of this model is the “filter” stage, which controls the information and stimuli that are available to the brain. Posttraumatic stress disorder involves involuntary emotional responses and efforts to avoid them and selects and colors the information that is processed in some situations (eg, avoidance of situations associated with trauma or dissociation of extreme memories). At other times, such as when a powerful stimulus is presented (eg, a helicopter flying close overhead), the filter may try to block out all inputs in order to preserve safety. The Memory Model also served as a visual aid during class discussions of normal cognitive aging.

Class sessions incorporated specific, measurable, attainable, realistic, and timely (SMART) goals, regular exercises based on mindfulness-based stress reduction approaches, and principles of behavioral activation.⁵ The SMART goals structure the sessions and permit customization of learning for participants. Class leaders record a goal for each participant and use these throughout the sessions to build rapport, develop communication, and teach memory skills.

Mindfulness-based stress reduction is an evidence-based treatment used in PTSD.⁶ It provides a counterpoint to the more didactic memory skills and is a method that even those with objective memory impairments can practice and apply successfully. Being in the current moment and emotional regulation are important skills to teach veterans as they learn to exert

Organization

Class sessions occurred weekly for 1 hour for a total of 8 sessions. The weekly class topics included introduction to memory; mood disorders, cognition, and cognitive disorders; barriers to effective memory: assessing readiness for change; developing a routine and becoming organized; attention and concentration; memory improvement (strategies internal and external aids); and reassessing goals.

Over the 3 years of classes reported in this article, the class sizes varied from 4 to 12 participants based on veteran interest, retention, and room size. The classes were structured so that important content areas were covered but with enough elasticity so leaders and veterans would develop a rapport and explore in greater depth the topics that resonated most for the attendees. Group participation was strongly encouraged. Veterans were expressly informed that the class was not for treatment of PTSD and that evidence-based therapies were encouraged to address PTSD especially if their symptoms flared up when compared with previous levels. The attendees also understood that they did not receive formal cognitive or memory testing but were encouraged to pursue testing if they showed significant deficits.

Preliminary Findings

From spring 2012 until spring 2015, 69 veterans agreed to participate and attended at least 1 memory skills class. Eighty-seven percent of participants (n = 60) attended 4 or more classes. The mean age (SD) was 67.3 years (4.2). All the participants were men, and the race/ethnic distribution was similar to that of the aging veteran population and very close to racial demographics for Washington state: 80% white, 14% African American, 2% Asian/Pacific Islander, 2% Native American, and 2% unknown.

Attendees were asked, but not required, to complete questionnaires before the classes began and again at completion. These questionnaires included self-assessments of cognitive strategies and compensatory methods used; an assessment of concern regarding cognition, life satisfaction, and community integration; the PTSD CheckList-Civilian Version (PCL-C); and the Geriatric Depression Scale (GDS).^7,8 The questionnaire also included open response questions to providefeedback on what attendees liked about the classes and recommendations for improvements. The majority of comments for improvement focused on attendees’ desire for longer sessions and repeat offerings. Five veterans did not complete the full set of questionnaires at the beginning of the classes, and 7 did not complete the questionnaires at completion (the 2 subsets did not perfectly overlap).

At the start of the class, on average, veteran participants were experiencing mild depression and moderate symptoms of PTSD as measured by the GDS (n = 54) and the PCL-C (n = 56), respectively. Preliminary comparisons of ratings pre- and post-classes, using simple paired t tests, indicated a reduction in symptoms of depression on the GDS, improved sense of mastery over their memory symptoms, as well as improved quality of life ratings (all P < .01, no corrections). There was no evidence for a significant reduction in PTSD symptoms or report of elimination of cognitive difficulties. With the small sample and modest effects, the clinical significance of these scores cannot be determined. The authors are planning more detailed analyses on a larger set of participants, including measures of health care utilization before and after the class.

Future Directions

The cohort of Vietnam-era veterans likely will manifest more geriatric mental health issues over time, and the number of veterans with a history of PTSD and memory concerns will increase. There is mounting evidence that PTSD alone can be associated with cognitive difficulties across the lifespan, and aspects of aging can both exacerbate and highlight these changes.^9-12 In addition, there is roughly a doubled dementia risk in older veterans with chronic PTSD.¹³ A variety of clinical interventions will be needed to address these issues. For those who have cognitive concerns, teaching older veterans self-management skills while also monitoring their cognition and keeping them engaged in proactive health care are worthy endeavors. The authors hope that by making the program and materials broadly available, more veterans can address their cognitive concerns in a productive, engaging manner. To learn more about the project or to receive class materials, please contact the authors (emily.trittschuh@va.gov).

SILVER SPRING, MD. – Tending to the psychiatric and physical needs of military servicemen, servicewomen, and veterans must include attention to their sexual functioning, according to Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH.

“Think of sexual activity as an activity of daily living,” Dr. Ritchie said at the Trauma Treatment from the Trenches meeting at the Forest Glen Annex in Silver Spring, Md., organized by Sawsan Ghurani, MD, a psychiatrist and Navy captain, and sponsored by the Walter Reed National Military Medical Center in Bethesda, Md.

ghenderson@frontlinemedcom.com

On Twitter @ginalhenderson

SILVER SPRING, MD. – Tending to the psychiatric and physical needs of military servicemen, servicewomen, and veterans must include attention to their sexual functioning, according to Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH.

“Think of sexual activity as an activity of daily living,” Dr. Ritchie said at the Trauma Treatment from the Trenches meeting at the Forest Glen Annex in Silver Spring, Md., organized by Sawsan Ghurani, MD, a psychiatrist and Navy captain, and sponsored by the Walter Reed National Military Medical Center in Bethesda, Md.

ghenderson@frontlinemedcom.com

On Twitter @ginalhenderson

SILVER SPRING, MD. – Tending to the psychiatric and physical needs of military servicemen, servicewomen, and veterans must include attention to their sexual functioning, according to Col. (Ret.) Elspeth Cameron Ritchie, MD, MPH.

“Think of sexual activity as an activity of daily living,” Dr. Ritchie said at the Trauma Treatment from the Trenches meeting at the Forest Glen Annex in Silver Spring, Md., organized by Sawsan Ghurani, MD, a psychiatrist and Navy captain, and sponsored by the Walter Reed National Military Medical Center in Bethesda, Md.

ghenderson@frontlinemedcom.com

On Twitter @ginalhenderson

Over the past decade, nationwide attention has focused on mental health conditions associated with military service. Recent legal mandates have led to changes in the DoD, VA, and HHS health systems aimed at increasing access to care, decreasing barriers to care, and expanding research on mental health conditions commonly seen in service members and veterans. On August 31, 2012, President Barack Obama signed the Improving Access to Mental Health Services for Veterans, Service Members, and Military Families executive order, establishing an interagency task force from the VA, DoD, and HHS.¹ The task force was charged with addressing quality of care and provider training in the management of commonly comorbid conditions, including (among other conditions) posttraumatic stress disorder (PTSD) and depression.

Depression and PTSD present major health burdens in both military and veteran cohorts. Overlap in clinical presentation and significant rates of comorbidity complicate effective management of these conditions. This article offers a brief review of the diagnostic and epidemiologic complexities associated with PTSD and depression, a summary of research relevant to these issues, and a description of recent system-level developments within the Military Health System (MHS) designed to improve care through better approaches in identification, management, and research of these conditions.

Diagnostic Uncertainty

Both PTSD and major depressive disorder (MDD) have been recognized as mental health disorders since the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) discarded its previous etiologically based approach to diagnostic classification in 1980 in favor of a system in which diagnosis is based on observable symptoms.^2,3 With the release of DSM-5 in 2013, the diagnostic criteria for PTSD underwent a substantial transformation.⁴ Previously, PTSD was described as an anxiety disorder, and some of its manifestations overlapped descriptively (and in many cases, etiologically) with anxiety and depressive illnesses.⁵

Clinicians also often described shorter-lived, developmental, formes fruste, or otherwise subsyndromal manifestations of trauma associated with PTSD. In DSM-5, PTSD was removed from the anxiety disorders section and placed in a new category of disorders labeled Trauma and Stressor-Related Disorders. This new category also included reactive attachment disorder (in children), acute stress disorder, adjustment disorders, and unspecified or other trauma and stressor-related disorders. Other major changes to the PTSD diagnostic criteria included modification to the DSM-IV-TR (text revision) trauma definition (making the construct more specific), removal of the requirement for explicit subjective emotional reaction to a traumatic event, and greater emphasis on negative cognitions and mood. Debate surrounds the updated symptom criteria with critics questioning whether there is any improvement in the clinical utility of the diagnosis, especially in light of the substantial policy and practice implications the change engenders.⁶

Recently, Hoge and colleagues examined the psychometric implications of the diagnostic changes (between DSM-IV-TR and DSM-5) in the PTSD definition.⁶ The authors found that although the 2 definitions showed nearly identical association with other psychiatric disorders (including depression) and functional impairment, 30% of soldiers who met DSM-IV-TR criteria for PTSD failed to meet criteria in DSM-5, and another 20% met only DSM-5 criteria. Recognizing discordance in PTSD and associated diagnoses, the U.S. Army Medical Command mandated that its clinicians familiarize themselves with the controversies surrounding the discordant diagnoses and coding of subthreshold PTSD.⁷

Adding to the problem of diagnostic uncertainty, the clinical presentation of MDD includes significant overlap with that of PTSD. Specifically, symptoms of guilt, diminished interests, problems with concentration, and sleep disturbances are descriptive of both disorders. Furthermore, the criteria set for several subthreshold forms of MDD evidence considerable overlap with PTSD symptoms. For example, diagnostic criteria for disruptive mood dysregulation disorder include behavioral outbursts and irritability, and diagnostic criteria for dysthymia include sleep disturbances and concentration problems.

Adjustment disorders are categorized as trauma and stressor-related disorders in DSM-5 and hold many emotional and behavioral symptoms in common with PTSD. The “acute” and “chronic” adjustment disorder specifiers contribute to problems in diagnostic certainty for PTSD. In general, issues pertaining to diagnostic uncertainty and overlap likely reflect the limits of using a diagnostic classification system that relies exclusively on observational and subjective reports of psychological symptoms.^8,9

In a treatment environment where a veteran or active-duty patient has presented for care, in the face of these shared symptom sets, clinicians frequently offer initial diagnoses. These diagnoses are often based on perceived etiologic factors derived from patients’ descriptions of stressors encountered during military service. This tendency likely contributes to considerable inconsistencies and potential inaccuracies in diagnoses, and much of the variance can be attributed to the clinicians’ degree of familiarity with military exposures, perceptions of what constitutes trauma, and outside pressure to assign or avoid specific diagnoses.

Importantly, the phenomenologic differences between PTSD and depressive disorders increase the likelihood of poorly aligned and inconsistent treatment plans, and this lack of clarity may, in turn, compromise effective patient care. To address some of these diagnostic challenges, the VA and DoD incorporate military culture training into clinicians’ curriculum to increase provider familiarity with the common stressors and challenges of military life, mandate the use of validated measures to support diagnostic decision making, and regularly review policies that influence diagnostic practices.

Epidemiology

The prevalence rates for PTSD are increasing in the military, possibly stemming from the demands on service members engaged in years’ long wars. Despite the increased attention on this phenomenon, research has demonstrated that the majority of service members who deploy do not develop PTSD or significant trauma-related functional impairment.¹⁰ Furthermore, many cases of PTSD diagnosed in the MHS stem from traumatic experiences other than combat exposure, including childhood abuse and neglect, sexual and other assaults, accidents and health care exposures, domestic abuse, and bullying. Depression arguably has received less attention despite comparable prevalence rates in military populations, high co-occurrence of PTSD and depression, and depression being associated with a greater odds ratio for mortality that includes death by suicide in military service members.¹¹

Estimates of the prevalence of PTSD from the U.S. Army suggest that it exists in 3% to 6% of military members who have not deployed and in 6% to 25% of service members with combat deployment histories. The frequency and intensity of combat are strong predictors of risk.⁷ A recent epidemiologic study using inpatient and outpatient encounter records showed that the prevalence of PTSD in the active military component was 2.0% in the middle of calendar year (CY) 2010; a two-thirds increase from 1.2% in CY 2007.¹² The incidence of PTSD

Epidemiologic studies and prevalence/incidence rates derived from administrative data rely on strict case definitions. Consequently, such administrative investigations include data only from service members

PTSD and Depression Treatment

Despite the high rates of PTSD and MDD comorbidity, few treatments have been developed for and tested on an exclusively comorbid sample of patients.¹³ However, psychopharmacologic agents targeting depression have been applied to the treatment of PTSD, and PTSD psychotherapy trials typically include depression response as a secondary outcome. The generalizability of findings to a truly comorbid population may be limited based on study sampling frames and the unique characteristics of patients with comorbid PTSD and depression.^14-16 Several psychopharmacologic treatments for depression have been evaluated as frontline treatments for PTSD. The 3 pharmacologic treatments that demonstrate efficacy in treating PTSD include fluoxetine, paroxetine, and venlafaxine.¹⁷

Although these pharmacologic agents represent good candidate treatments for comorbid patients, the effect size of pharmacologic treatments are generally smaller than those of psychotherapeutic treatments for PTSD.^17,18 This observation, however, is based on indirect comparisons, and a recent systematic review concluded that the evidence was insufficient to determine the comparative effectiveness between psychotherapy and pharmacotherapy for PTSD.¹⁹ Evidence indicates that trauma-focused cognitive behavioral therapies consistently demonstrate efficacy and effectiveness in treating PTSD.^19,20 These treatments also have been shown to significantly reduce depressive symptoms among PTSD samples.²¹

Based on strong bodies of evidence, these pharmacologic and psychological treatments have received the highest level of recommendation in the VA and DoD.^22,23 Accordingly, both agencies have invested considerable resources in large-scale efforts to improve patient access to these particular treatments. Despite these impressive implementation efforts, however, the limitations of relying exclusively on these treatments as frontline approaches within large health care systems have become evident.^24-26

Penetration of Therapies

Penetration of these evidence-based treatments (EBTs) within the DoD and VHA remains limited. For instance, one study showed that VA clinicians in mental health specialty care clinics may provide only about 4 hours of EBT per week.²⁷

Other reports suggest that only about 60% of treatment-seeking patients in PTSD clinics receive any type of evidence-based therapy and that within-session care quality is questionable based on a systematic review of chart notes.^28,29 Attrition in trauma-focused therapy is a recognized limitation, with 1 out of 3 treatment-seeking patients not completing a full dose of evidence-based treatment.^30-33 Large-scale analyses of VHA and DoD utilization data suggest that the majority of PTSD patients do not receive a sufficient number of sessions to be characterized as an adequate dose of EBT, with a majority of dropouts occur- ring after just a few sessions.^34-37

Hoge and colleagues found that < 50% of soldiers meeting criteria for PTSD received any mental health care within the prior 6 months with one-quarter of those patients dropping out of care prematurely.³⁸ Among a large cohort of soldiers engaged in care for the treatment of PTSD, only about 40% received a number of EBT treatment sessions that could qualify as an adequate dose.³⁸ Thus, although major advancements in the development and implementation of effective treatments for PTSD and depression have occurred, the penetration of these treatments is limited, and the majority of patients in need of treatment potentially receive inadequate care.³⁹

System level approaches that integrate behavioral health services into the primary care system have been proposed to address these care gaps for service members and veterans.^40-42 Fundamentally, system-level approaches seek to improve the reach and effectiveness of care through large-scale screening efforts, a greater emphasis on the quality of patient care, and enhanced care continuity across episodes of treatment.

Primary Care

With the primary care setting considered the de facto mental health system, integrated approaches enhance the reach of care by incorporating uniform mental health screening and referral for patients coming through primary care. Specific evidence-based treatments can be integrated into this approach within a stepped-care framework that aims to match patients strategically to the right type of care and leverage specialty care resources as needed. Integrated care approaches for the treatment of PTSD and depression have been developed and evaluated inside and outside of the MHS. Findings indicate that integrated treatment approaches can improve care access, care continuity, patient satisfaction, quality of care,and in several trials, PTSD and depression outcomes.^43-47

Recently, an integrated care approach targeting U.S. Army soldiers who screened positive for PTSD or depression in primary care was evaluated in a multisite effectiveness trial.⁴⁸ Patients randomized to the treatment approach experienced significant improvements in both PTSD and depression symptoms relative to patients in usual care.⁴³ In addition, patients treated in this care model received significantly more mental health services; the patterns of care indicated that patients with comorbid PTSD and depression were more likely to be triaged to specialty care, whereas patients with a single diagnosis were more likely to be managed in primary care.⁴⁹ This trial suggests that integrated care models feasibly can be implemented in the U.S. Army care system, yielding increased uptake of mental health care, more efficiently matched care based on patient comorbidities, and improved PTSD and depression outcomes.

Treatment Research

The MHS supports a large portfolio of research in PTSD and depression through DoD/VA research consortia (eg, the Congressionally Directed Medical Research Program, the Consortium to Alleviate PTSD, the Injury and Traumatic Stress Clinical Consortium). The U.S. Army Medical Research and Materiel Command (USAMRMC) executes and manages the portfolio of research, relying on a joint program committee of DoD and non-DoD experts to make funding recommendations based on identified research priorities, policy guidance, and knowledge translation needs.

Health systems research on PTSD and MDD in federal health care settings is expanding. For example, the RAND Corporation recently evaluated a candidate set of quality measures for PTSD and MDD, using an operational definition of an episode of care.³⁷ This work is intended to inform efforts to measure and improve the quality of care for PTSD and depression across the enterprise.

The DoD Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury is simultaneously completing an inferential assessment of adjunctive mental health care services, many focused on PTSD and depression, throughout the health care enterprise. Along with the substantial resources devoted to research on PTSD and depression, the MHS is implementing strategies to improve the system of care for service members with mental health conditions.

Army Care System Innovations

The U.S. Army is engaged in a variety of strategies to improve the identification of patients with mental health conditions, increase access to mental health services, and enhance the quality of care that soldiers receive for PTSD and depression. To improve the coordination of mental health care, the U.S. Army Medical Command implemented a wide-scale innovative transformation of its mental health care system through the establishment of the Behavioral Health Service Line program management office.

This move eliminated separate departments of psychiatry, psychology, and social work in favor of integrated behavioral health departments that are now responsible for all mental health care delivered to soldiers, including inpatient, outpatient, partial hospitalization, residential, embedded care in garrison, and primary care settings. This transformation ensured coordination of care for soldiers, eliminating potential miscommunication with patients, commands, and other clinicians while clearly defining performance indicators in process (eg, productivity, scheduling, access to care, and patient satisfaction) and outcome measures.⁴⁹ In conjunction with the development of its service line, the U.S. Army created a Behavioral Health Data Portal (BHDP), an electronic and standardized means to assess clinical outcomes for common conditions.

To promote higher quality mental health care, the Office of the Surgeon General of the U.S. Army provided direct guidance on the treatment of PTSD and depression. U.S. Army policy mandates that providers treating mental health conditions adhere to the VA/DoD clinical practice guidelines (CPGs) and that soldiers with PTSD and depression be offered treatments with the highest level of scientific support and that outcome measures be routinely administered. In line with the CPGs, U.S. Army policy also recommends the use of both integrated and embedded mental health care approaches to address PTSD, depression, and other common physical and psychological health conditions.

To reduce stigma and improve mental health care access, the U.S. Army began implementing integrated care approaches in 2007 with its Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) program, an evidence-based collaborative care model.^51-55 This approach included structured screening and diagnostic procedures, predictable follow-up schedules for patients, and the coordination of the divisions of responsibility among and between primary care providers, paraprofessionals, and behavioral health care providers. From 2007 to 2013, this collaborative care model was rolled out across 96 clinics worldwide and provided PTSD and depression screening to more than 1 million encounters per year.^52,53

More recently, the U.S. Army led DoD in integrating behavioral health personnel in patient centered medical homes (PCMH) in compliance with DoD Instruction 6490.15.⁵⁶ This hybrid integrated care model combines collaborative care elements developed in the RESPECT-Mil program with elements of the U.S. Air Force Behavioral Health Optimization project colocating behavioral health providers in primary care settings to provide brief consultative services.

MHS Care Enhancements

Many of the innovations deployed throughout the U.S. Army system of behavioral health care have driven changes across the MHS as a whole. The DoD and the VA have made substantive systemwide policy and practice changes to improve care for beneficiaries with PTSD, depression, and comorbid PTSD and depression. In particular, significant implementation efforts have addressed population screening strategies, outcome monitoring to support measurement-based care, increased access to effective care, and revision of the disability evaluation system.

To improve the identification and referral of soldiers with deployment-related mental health concerns, the DoD implemented a comprehensive program that screens service members prior to deployment, immediately on redeployment, and then again 6 months after returning from deployment. Additionally, annual primary care- based screening requirements have been instituted as part of the DoD PCMH initiative. Both deployment-related and primary care-based screenings include an instrumentation to detect symptoms of PTSD and depression and extend the reach of mental health screening to the entire MHS population.

Building on the success of BHDP, former Assistant Secretary of Defense for Health Affairs Jonathan Woodson mandated BHDP use across the MHS for all patients in DoD behavioral health clinics and the use of outcome measures for the treatment of PTSD, anxiety, depression, and alcohol use disorders.⁵⁷ A DoD-wide requirement to use the PTSD checklist and patient health questionnaire to monitor PTSD and depression symptoms at mental health intakes and regularly at follow-up visits is being implemented. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, through its Practice-Based Implementation Network (underwritten by a Joint Incentive Fund managed between DoD and VA), has worked across the MHS and the VA to facilitate the implementation, uptake, and adoption of this initiative.

The DoD established the Center for Deployment Psychology (CDP) in 2006 to promote clinician training in EBTs with the aim of increasing service members’ access to effective psychological treatments. Since its inception, the CDP has provided EBT training to more than 40,000 behavioral health providers. Although the impact of these and other efforts on improving the quality of care that patients receive is unknown, a recent study documented widespread self-reported usage of EBT components in U.S. Army clinics and that providers formally trained in EBTs were more likely to deliver EBTs.⁵⁸

Finally, systemwide changes to the VA Schedule of Ratings for Disability (VASRD) and integration of DoD and VA disability evaluation systems have led to shifts in diagnosis toward PTSD that usually merit a minimum 50% disability rating. Mandates in law require military clinicians to evaluate patients who have deployed for PTSD and TBI prior to taking any actions associated with administrative separation. The practice of attributing PTSD symptoms to character pathology or personality disorders, even when these symptoms did not clearly manifest or worsen with military service, has likely been eliminated from practice in military and veteran populations.

Robust policy changes to limit personality disorder discharges started in fiscal year 2007, when there were 4,127 personality disorder separations across DoD. This number was reduced to 300 within 5 years. Policy changes regarding separation not only seem to have affected discharges, but also may have shaped diagnostic practice. The incidence rate of personality disorder diagnoses declined from 513 per 100,000 person-years in 2007 to 284 per 100,000 person-years by 2011.⁵⁹ The VASRD recognizes chronic adjustment disorder as a disability, and the National Defense Authorization Act of 2008 mandated that DoD follow disability guidelines promulgated by VA.

As stated in the memorandum Clinical Policy Guidance for Assessment and Treatment of Post-Traumatic Stress Disorders (August 24, 2012), DoD recognizes chronic adjustment disorder as an unfitting condition that merits referral to its disability evaluation system.⁶⁰ Acute adjustment disorders may still lead to administrative separations, as many service members manifest emotional symptoms stemming from the failure to adjust to the routine vicissitudes of military life. Finally, many court jurisdictions, including veteran’s courts, military courts, and commanders empowered to adjudicate nonjudicial infractions under the Uniform Code of Military Justice, have recognized PTSD as grounds for the mitigation of penalties associated with a wide array of criminal and administrative infractions.

Conclusion

In response to the increased mental health burden following a decade of war and the associated pressures stemming from federal mandates, the MHS has invested unprecedented resources into improving care for military service members. The U.S. Army has played a prominent role in this endeavor by investing in clinical research efforts to accelerate discovery on the causes and cures for these conditions, enacting policies that mandate best practices, and implementing evidence-based care approaches across the system of care. Despite this progress, however, understanding and effectively treating the most prevalent mental health conditions remain a challenge across the DoD and VHA health care systems. Many service members and veterans still do not receive timely, high-quality care for PTSD, depression, and other common comorbidities associated with military experience, and controversies in diagnostic clarification abound.

In short, great strides have been made, yet there is still a large distance to go. The vision of an effective, efficient, comprehensive care system for mental health conditions will continue to be pursued and achieved through collaborations across key agencies and the scientific community, implementation of health system approaches that support population care, and the sustained efforts of dedicated clinicians, staff, and clinic leaders who deliver the care to our service members and veterans.

Over the past decade, nationwide attention has focused on mental health conditions associated with military service. Recent legal mandates have led to changes in the DoD, VA, and HHS health systems aimed at increasing access to care, decreasing barriers to care, and expanding research on mental health conditions commonly seen in service members and veterans. On August 31, 2012, President Barack Obama signed the Improving Access to Mental Health Services for Veterans, Service Members, and Military Families executive order, establishing an interagency task force from the VA, DoD, and HHS.¹ The task force was charged with addressing quality of care and provider training in the management of commonly comorbid conditions, including (among other conditions) posttraumatic stress disorder (PTSD) and depression.

Depression and PTSD present major health burdens in both military and veteran cohorts. Overlap in clinical presentation and significant rates of comorbidity complicate effective management of these conditions. This article offers a brief review of the diagnostic and epidemiologic complexities associated with PTSD and depression, a summary of research relevant to these issues, and a description of recent system-level developments within the Military Health System (MHS) designed to improve care through better approaches in identification, management, and research of these conditions.

Diagnostic Uncertainty

Both PTSD and major depressive disorder (MDD) have been recognized as mental health disorders since the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) discarded its previous etiologically based approach to diagnostic classification in 1980 in favor of a system in which diagnosis is based on observable symptoms.^2,3 With the release of DSM-5 in 2013, the diagnostic criteria for PTSD underwent a substantial transformation.⁴ Previously, PTSD was described as an anxiety disorder, and some of its manifestations overlapped descriptively (and in many cases, etiologically) with anxiety and depressive illnesses.⁵

Clinicians also often described shorter-lived, developmental, formes fruste, or otherwise subsyndromal manifestations of trauma associated with PTSD. In DSM-5, PTSD was removed from the anxiety disorders section and placed in a new category of disorders labeled Trauma and Stressor-Related Disorders. This new category also included reactive attachment disorder (in children), acute stress disorder, adjustment disorders, and unspecified or other trauma and stressor-related disorders. Other major changes to the PTSD diagnostic criteria included modification to the DSM-IV-TR (text revision) trauma definition (making the construct more specific), removal of the requirement for explicit subjective emotional reaction to a traumatic event, and greater emphasis on negative cognitions and mood. Debate surrounds the updated symptom criteria with critics questioning whether there is any improvement in the clinical utility of the diagnosis, especially in light of the substantial policy and practice implications the change engenders.⁶

Recently, Hoge and colleagues examined the psychometric implications of the diagnostic changes (between DSM-IV-TR and DSM-5) in the PTSD definition.⁶ The authors found that although the 2 definitions showed nearly identical association with other psychiatric disorders (including depression) and functional impairment, 30% of soldiers who met DSM-IV-TR criteria for PTSD failed to meet criteria in DSM-5, and another 20% met only DSM-5 criteria. Recognizing discordance in PTSD and associated diagnoses, the U.S. Army Medical Command mandated that its clinicians familiarize themselves with the controversies surrounding the discordant diagnoses and coding of subthreshold PTSD.⁷

Adding to the problem of diagnostic uncertainty, the clinical presentation of MDD includes significant overlap with that of PTSD. Specifically, symptoms of guilt, diminished interests, problems with concentration, and sleep disturbances are descriptive of both disorders. Furthermore, the criteria set for several subthreshold forms of MDD evidence considerable overlap with PTSD symptoms. For example, diagnostic criteria for disruptive mood dysregulation disorder include behavioral outbursts and irritability, and diagnostic criteria for dysthymia include sleep disturbances and concentration problems.

Adjustment disorders are categorized as trauma and stressor-related disorders in DSM-5 and hold many emotional and behavioral symptoms in common with PTSD. The “acute” and “chronic” adjustment disorder specifiers contribute to problems in diagnostic certainty for PTSD. In general, issues pertaining to diagnostic uncertainty and overlap likely reflect the limits of using a diagnostic classification system that relies exclusively on observational and subjective reports of psychological symptoms.^8,9

In a treatment environment where a veteran or active-duty patient has presented for care, in the face of these shared symptom sets, clinicians frequently offer initial diagnoses. These diagnoses are often based on perceived etiologic factors derived from patients’ descriptions of stressors encountered during military service. This tendency likely contributes to considerable inconsistencies and potential inaccuracies in diagnoses, and much of the variance can be attributed to the clinicians’ degree of familiarity with military exposures, perceptions of what constitutes trauma, and outside pressure to assign or avoid specific diagnoses.

Importantly, the phenomenologic differences between PTSD and depressive disorders increase the likelihood of poorly aligned and inconsistent treatment plans, and this lack of clarity may, in turn, compromise effective patient care. To address some of these diagnostic challenges, the VA and DoD incorporate military culture training into clinicians’ curriculum to increase provider familiarity with the common stressors and challenges of military life, mandate the use of validated measures to support diagnostic decision making, and regularly review policies that influence diagnostic practices.

Epidemiology

The prevalence rates for PTSD are increasing in the military, possibly stemming from the demands on service members engaged in years’ long wars. Despite the increased attention on this phenomenon, research has demonstrated that the majority of service members who deploy do not develop PTSD or significant trauma-related functional impairment.¹⁰ Furthermore, many cases of PTSD diagnosed in the MHS stem from traumatic experiences other than combat exposure, including childhood abuse and neglect, sexual and other assaults, accidents and health care exposures, domestic abuse, and bullying. Depression arguably has received less attention despite comparable prevalence rates in military populations, high co-occurrence of PTSD and depression, and depression being associated with a greater odds ratio for mortality that includes death by suicide in military service members.¹¹

Estimates of the prevalence of PTSD from the U.S. Army suggest that it exists in 3% to 6% of military members who have not deployed and in 6% to 25% of service members with combat deployment histories. The frequency and intensity of combat are strong predictors of risk.⁷ A recent epidemiologic study using inpatient and outpatient encounter records showed that the prevalence of PTSD in the active military component was 2.0% in the middle of calendar year (CY) 2010; a two-thirds increase from 1.2% in CY 2007.¹² The incidence of PTSD

Epidemiologic studies and prevalence/incidence rates derived from administrative data rely on strict case definitions. Consequently, such administrative investigations include data only from service members

PTSD and Depression Treatment

Despite the high rates of PTSD and MDD comorbidity, few treatments have been developed for and tested on an exclusively comorbid sample of patients.¹³ However, psychopharmacologic agents targeting depression have been applied to the treatment of PTSD, and PTSD psychotherapy trials typically include depression response as a secondary outcome. The generalizability of findings to a truly comorbid population may be limited based on study sampling frames and the unique characteristics of patients with comorbid PTSD and depression.^14-16 Several psychopharmacologic treatments for depression have been evaluated as frontline treatments for PTSD. The 3 pharmacologic treatments that demonstrate efficacy in treating PTSD include fluoxetine, paroxetine, and venlafaxine.¹⁷

Although these pharmacologic agents represent good candidate treatments for comorbid patients, the effect size of pharmacologic treatments are generally smaller than those of psychotherapeutic treatments for PTSD.^17,18 This observation, however, is based on indirect comparisons, and a recent systematic review concluded that the evidence was insufficient to determine the comparative effectiveness between psychotherapy and pharmacotherapy for PTSD.¹⁹ Evidence indicates that trauma-focused cognitive behavioral therapies consistently demonstrate efficacy and effectiveness in treating PTSD.^19,20 These treatments also have been shown to significantly reduce depressive symptoms among PTSD samples.²¹

Based on strong bodies of evidence, these pharmacologic and psychological treatments have received the highest level of recommendation in the VA and DoD.^22,23 Accordingly, both agencies have invested considerable resources in large-scale efforts to improve patient access to these particular treatments. Despite these impressive implementation efforts, however, the limitations of relying exclusively on these treatments as frontline approaches within large health care systems have become evident.^24-26

Penetration of Therapies

Penetration of these evidence-based treatments (EBTs) within the DoD and VHA remains limited. For instance, one study showed that VA clinicians in mental health specialty care clinics may provide only about 4 hours of EBT per week.²⁷

Other reports suggest that only about 60% of treatment-seeking patients in PTSD clinics receive any type of evidence-based therapy and that within-session care quality is questionable based on a systematic review of chart notes.^28,29 Attrition in trauma-focused therapy is a recognized limitation, with 1 out of 3 treatment-seeking patients not completing a full dose of evidence-based treatment.^30-33 Large-scale analyses of VHA and DoD utilization data suggest that the majority of PTSD patients do not receive a sufficient number of sessions to be characterized as an adequate dose of EBT, with a majority of dropouts occur- ring after just a few sessions.^34-37

Hoge and colleagues found that < 50% of soldiers meeting criteria for PTSD received any mental health care within the prior 6 months with one-quarter of those patients dropping out of care prematurely.³⁸ Among a large cohort of soldiers engaged in care for the treatment of PTSD, only about 40% received a number of EBT treatment sessions that could qualify as an adequate dose.³⁸ Thus, although major advancements in the development and implementation of effective treatments for PTSD and depression have occurred, the penetration of these treatments is limited, and the majority of patients in need of treatment potentially receive inadequate care.³⁹

System level approaches that integrate behavioral health services into the primary care system have been proposed to address these care gaps for service members and veterans.^40-42 Fundamentally, system-level approaches seek to improve the reach and effectiveness of care through large-scale screening efforts, a greater emphasis on the quality of patient care, and enhanced care continuity across episodes of treatment.

Primary Care

With the primary care setting considered the de facto mental health system, integrated approaches enhance the reach of care by incorporating uniform mental health screening and referral for patients coming through primary care. Specific evidence-based treatments can be integrated into this approach within a stepped-care framework that aims to match patients strategically to the right type of care and leverage specialty care resources as needed. Integrated care approaches for the treatment of PTSD and depression have been developed and evaluated inside and outside of the MHS. Findings indicate that integrated treatment approaches can improve care access, care continuity, patient satisfaction, quality of care,and in several trials, PTSD and depression outcomes.^43-47

Recently, an integrated care approach targeting U.S. Army soldiers who screened positive for PTSD or depression in primary care was evaluated in a multisite effectiveness trial.⁴⁸ Patients randomized to the treatment approach experienced significant improvements in both PTSD and depression symptoms relative to patients in usual care.⁴³ In addition, patients treated in this care model received significantly more mental health services; the patterns of care indicated that patients with comorbid PTSD and depression were more likely to be triaged to specialty care, whereas patients with a single diagnosis were more likely to be managed in primary care.⁴⁹ This trial suggests that integrated care models feasibly can be implemented in the U.S. Army care system, yielding increased uptake of mental health care, more efficiently matched care based on patient comorbidities, and improved PTSD and depression outcomes.

Treatment Research

The MHS supports a large portfolio of research in PTSD and depression through DoD/VA research consortia (eg, the Congressionally Directed Medical Research Program, the Consortium to Alleviate PTSD, the Injury and Traumatic Stress Clinical Consortium). The U.S. Army Medical Research and Materiel Command (USAMRMC) executes and manages the portfolio of research, relying on a joint program committee of DoD and non-DoD experts to make funding recommendations based on identified research priorities, policy guidance, and knowledge translation needs.

Health systems research on PTSD and MDD in federal health care settings is expanding. For example, the RAND Corporation recently evaluated a candidate set of quality measures for PTSD and MDD, using an operational definition of an episode of care.³⁷ This work is intended to inform efforts to measure and improve the quality of care for PTSD and depression across the enterprise.

The DoD Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury is simultaneously completing an inferential assessment of adjunctive mental health care services, many focused on PTSD and depression, throughout the health care enterprise. Along with the substantial resources devoted to research on PTSD and depression, the MHS is implementing strategies to improve the system of care for service members with mental health conditions.

Army Care System Innovations

The U.S. Army is engaged in a variety of strategies to improve the identification of patients with mental health conditions, increase access to mental health services, and enhance the quality of care that soldiers receive for PTSD and depression. To improve the coordination of mental health care, the U.S. Army Medical Command implemented a wide-scale innovative transformation of its mental health care system through the establishment of the Behavioral Health Service Line program management office.

This move eliminated separate departments of psychiatry, psychology, and social work in favor of integrated behavioral health departments that are now responsible for all mental health care delivered to soldiers, including inpatient, outpatient, partial hospitalization, residential, embedded care in garrison, and primary care settings. This transformation ensured coordination of care for soldiers, eliminating potential miscommunication with patients, commands, and other clinicians while clearly defining performance indicators in process (eg, productivity, scheduling, access to care, and patient satisfaction) and outcome measures.⁴⁹ In conjunction with the development of its service line, the U.S. Army created a Behavioral Health Data Portal (BHDP), an electronic and standardized means to assess clinical outcomes for common conditions.

To promote higher quality mental health care, the Office of the Surgeon General of the U.S. Army provided direct guidance on the treatment of PTSD and depression. U.S. Army policy mandates that providers treating mental health conditions adhere to the VA/DoD clinical practice guidelines (CPGs) and that soldiers with PTSD and depression be offered treatments with the highest level of scientific support and that outcome measures be routinely administered. In line with the CPGs, U.S. Army policy also recommends the use of both integrated and embedded mental health care approaches to address PTSD, depression, and other common physical and psychological health conditions.

To reduce stigma and improve mental health care access, the U.S. Army began implementing integrated care approaches in 2007 with its Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) program, an evidence-based collaborative care model.^51-55 This approach included structured screening and diagnostic procedures, predictable follow-up schedules for patients, and the coordination of the divisions of responsibility among and between primary care providers, paraprofessionals, and behavioral health care providers. From 2007 to 2013, this collaborative care model was rolled out across 96 clinics worldwide and provided PTSD and depression screening to more than 1 million encounters per year.^52,53

More recently, the U.S. Army led DoD in integrating behavioral health personnel in patient centered medical homes (PCMH) in compliance with DoD Instruction 6490.15.⁵⁶ This hybrid integrated care model combines collaborative care elements developed in the RESPECT-Mil program with elements of the U.S. Air Force Behavioral Health Optimization project colocating behavioral health providers in primary care settings to provide brief consultative services.

MHS Care Enhancements

Many of the innovations deployed throughout the U.S. Army system of behavioral health care have driven changes across the MHS as a whole. The DoD and the VA have made substantive systemwide policy and practice changes to improve care for beneficiaries with PTSD, depression, and comorbid PTSD and depression. In particular, significant implementation efforts have addressed population screening strategies, outcome monitoring to support measurement-based care, increased access to effective care, and revision of the disability evaluation system.

To improve the identification and referral of soldiers with deployment-related mental health concerns, the DoD implemented a comprehensive program that screens service members prior to deployment, immediately on redeployment, and then again 6 months after returning from deployment. Additionally, annual primary care- based screening requirements have been instituted as part of the DoD PCMH initiative. Both deployment-related and primary care-based screenings include an instrumentation to detect symptoms of PTSD and depression and extend the reach of mental health screening to the entire MHS population.

Building on the success of BHDP, former Assistant Secretary of Defense for Health Affairs Jonathan Woodson mandated BHDP use across the MHS for all patients in DoD behavioral health clinics and the use of outcome measures for the treatment of PTSD, anxiety, depression, and alcohol use disorders.⁵⁷ A DoD-wide requirement to use the PTSD checklist and patient health questionnaire to monitor PTSD and depression symptoms at mental health intakes and regularly at follow-up visits is being implemented. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, through its Practice-Based Implementation Network (underwritten by a Joint Incentive Fund managed between DoD and VA), has worked across the MHS and the VA to facilitate the implementation, uptake, and adoption of this initiative.

The DoD established the Center for Deployment Psychology (CDP) in 2006 to promote clinician training in EBTs with the aim of increasing service members’ access to effective psychological treatments. Since its inception, the CDP has provided EBT training to more than 40,000 behavioral health providers. Although the impact of these and other efforts on improving the quality of care that patients receive is unknown, a recent study documented widespread self-reported usage of EBT components in U.S. Army clinics and that providers formally trained in EBTs were more likely to deliver EBTs.⁵⁸

Finally, systemwide changes to the VA Schedule of Ratings for Disability (VASRD) and integration of DoD and VA disability evaluation systems have led to shifts in diagnosis toward PTSD that usually merit a minimum 50% disability rating. Mandates in law require military clinicians to evaluate patients who have deployed for PTSD and TBI prior to taking any actions associated with administrative separation. The practice of attributing PTSD symptoms to character pathology or personality disorders, even when these symptoms did not clearly manifest or worsen with military service, has likely been eliminated from practice in military and veteran populations.

Robust policy changes to limit personality disorder discharges started in fiscal year 2007, when there were 4,127 personality disorder separations across DoD. This number was reduced to 300 within 5 years. Policy changes regarding separation not only seem to have affected discharges, but also may have shaped diagnostic practice. The incidence rate of personality disorder diagnoses declined from 513 per 100,000 person-years in 2007 to 284 per 100,000 person-years by 2011.⁵⁹ The VASRD recognizes chronic adjustment disorder as a disability, and the National Defense Authorization Act of 2008 mandated that DoD follow disability guidelines promulgated by VA.

As stated in the memorandum Clinical Policy Guidance for Assessment and Treatment of Post-Traumatic Stress Disorders (August 24, 2012), DoD recognizes chronic adjustment disorder as an unfitting condition that merits referral to its disability evaluation system.⁶⁰ Acute adjustment disorders may still lead to administrative separations, as many service members manifest emotional symptoms stemming from the failure to adjust to the routine vicissitudes of military life. Finally, many court jurisdictions, including veteran’s courts, military courts, and commanders empowered to adjudicate nonjudicial infractions under the Uniform Code of Military Justice, have recognized PTSD as grounds for the mitigation of penalties associated with a wide array of criminal and administrative infractions.

Conclusion

In response to the increased mental health burden following a decade of war and the associated pressures stemming from federal mandates, the MHS has invested unprecedented resources into improving care for military service members. The U.S. Army has played a prominent role in this endeavor by investing in clinical research efforts to accelerate discovery on the causes and cures for these conditions, enacting policies that mandate best practices, and implementing evidence-based care approaches across the system of care. Despite this progress, however, understanding and effectively treating the most prevalent mental health conditions remain a challenge across the DoD and VHA health care systems. Many service members and veterans still do not receive timely, high-quality care for PTSD, depression, and other common comorbidities associated with military experience, and controversies in diagnostic clarification abound.

In short, great strides have been made, yet there is still a large distance to go. The vision of an effective, efficient, comprehensive care system for mental health conditions will continue to be pursued and achieved through collaborations across key agencies and the scientific community, implementation of health system approaches that support population care, and the sustained efforts of dedicated clinicians, staff, and clinic leaders who deliver the care to our service members and veterans.

Over the past decade, nationwide attention has focused on mental health conditions associated with military service. Recent legal mandates have led to changes in the DoD, VA, and HHS health systems aimed at increasing access to care, decreasing barriers to care, and expanding research on mental health conditions commonly seen in service members and veterans. On August 31, 2012, President Barack Obama signed the Improving Access to Mental Health Services for Veterans, Service Members, and Military Families executive order, establishing an interagency task force from the VA, DoD, and HHS.¹ The task force was charged with addressing quality of care and provider training in the management of commonly comorbid conditions, including (among other conditions) posttraumatic stress disorder (PTSD) and depression.

Depression and PTSD present major health burdens in both military and veteran cohorts. Overlap in clinical presentation and significant rates of comorbidity complicate effective management of these conditions. This article offers a brief review of the diagnostic and epidemiologic complexities associated with PTSD and depression, a summary of research relevant to these issues, and a description of recent system-level developments within the Military Health System (MHS) designed to improve care through better approaches in identification, management, and research of these conditions.

Diagnostic Uncertainty

Both PTSD and major depressive disorder (MDD) have been recognized as mental health disorders since the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) discarded its previous etiologically based approach to diagnostic classification in 1980 in favor of a system in which diagnosis is based on observable symptoms.^2,3 With the release of DSM-5 in 2013, the diagnostic criteria for PTSD underwent a substantial transformation.⁴ Previously, PTSD was described as an anxiety disorder, and some of its manifestations overlapped descriptively (and in many cases, etiologically) with anxiety and depressive illnesses.⁵

Clinicians also often described shorter-lived, developmental, formes fruste, or otherwise subsyndromal manifestations of trauma associated with PTSD. In DSM-5, PTSD was removed from the anxiety disorders section and placed in a new category of disorders labeled Trauma and Stressor-Related Disorders. This new category also included reactive attachment disorder (in children), acute stress disorder, adjustment disorders, and unspecified or other trauma and stressor-related disorders. Other major changes to the PTSD diagnostic criteria included modification to the DSM-IV-TR (text revision) trauma definition (making the construct more specific), removal of the requirement for explicit subjective emotional reaction to a traumatic event, and greater emphasis on negative cognitions and mood. Debate surrounds the updated symptom criteria with critics questioning whether there is any improvement in the clinical utility of the diagnosis, especially in light of the substantial policy and practice implications the change engenders.⁶

Recently, Hoge and colleagues examined the psychometric implications of the diagnostic changes (between DSM-IV-TR and DSM-5) in the PTSD definition.⁶ The authors found that although the 2 definitions showed nearly identical association with other psychiatric disorders (including depression) and functional impairment, 30% of soldiers who met DSM-IV-TR criteria for PTSD failed to meet criteria in DSM-5, and another 20% met only DSM-5 criteria. Recognizing discordance in PTSD and associated diagnoses, the U.S. Army Medical Command mandated that its clinicians familiarize themselves with the controversies surrounding the discordant diagnoses and coding of subthreshold PTSD.⁷

Adding to the problem of diagnostic uncertainty, the clinical presentation of MDD includes significant overlap with that of PTSD. Specifically, symptoms of guilt, diminished interests, problems with concentration, and sleep disturbances are descriptive of both disorders. Furthermore, the criteria set for several subthreshold forms of MDD evidence considerable overlap with PTSD symptoms. For example, diagnostic criteria for disruptive mood dysregulation disorder include behavioral outbursts and irritability, and diagnostic criteria for dysthymia include sleep disturbances and concentration problems.

Adjustment disorders are categorized as trauma and stressor-related disorders in DSM-5 and hold many emotional and behavioral symptoms in common with PTSD. The “acute” and “chronic” adjustment disorder specifiers contribute to problems in diagnostic certainty for PTSD. In general, issues pertaining to diagnostic uncertainty and overlap likely reflect the limits of using a diagnostic classification system that relies exclusively on observational and subjective reports of psychological symptoms.^8,9

In a treatment environment where a veteran or active-duty patient has presented for care, in the face of these shared symptom sets, clinicians frequently offer initial diagnoses. These diagnoses are often based on perceived etiologic factors derived from patients’ descriptions of stressors encountered during military service. This tendency likely contributes to considerable inconsistencies and potential inaccuracies in diagnoses, and much of the variance can be attributed to the clinicians’ degree of familiarity with military exposures, perceptions of what constitutes trauma, and outside pressure to assign or avoid specific diagnoses.

Importantly, the phenomenologic differences between PTSD and depressive disorders increase the likelihood of poorly aligned and inconsistent treatment plans, and this lack of clarity may, in turn, compromise effective patient care. To address some of these diagnostic challenges, the VA and DoD incorporate military culture training into clinicians’ curriculum to increase provider familiarity with the common stressors and challenges of military life, mandate the use of validated measures to support diagnostic decision making, and regularly review policies that influence diagnostic practices.

Epidemiology

The prevalence rates for PTSD are increasing in the military, possibly stemming from the demands on service members engaged in years’ long wars. Despite the increased attention on this phenomenon, research has demonstrated that the majority of service members who deploy do not develop PTSD or significant trauma-related functional impairment.¹⁰ Furthermore, many cases of PTSD diagnosed in the MHS stem from traumatic experiences other than combat exposure, including childhood abuse and neglect, sexual and other assaults, accidents and health care exposures, domestic abuse, and bullying. Depression arguably has received less attention despite comparable prevalence rates in military populations, high co-occurrence of PTSD and depression, and depression being associated with a greater odds ratio for mortality that includes death by suicide in military service members.¹¹

Estimates of the prevalence of PTSD from the U.S. Army suggest that it exists in 3% to 6% of military members who have not deployed and in 6% to 25% of service members with combat deployment histories. The frequency and intensity of combat are strong predictors of risk.⁷ A recent epidemiologic study using inpatient and outpatient encounter records showed that the prevalence of PTSD in the active military component was 2.0% in the middle of calendar year (CY) 2010; a two-thirds increase from 1.2% in CY 2007.¹² The incidence of PTSD

Epidemiologic studies and prevalence/incidence rates derived from administrative data rely on strict case definitions. Consequently, such administrative investigations include data only from service members

PTSD and Depression Treatment

Despite the high rates of PTSD and MDD comorbidity, few treatments have been developed for and tested on an exclusively comorbid sample of patients.¹³ However, psychopharmacologic agents targeting depression have been applied to the treatment of PTSD, and PTSD psychotherapy trials typically include depression response as a secondary outcome. The generalizability of findings to a truly comorbid population may be limited based on study sampling frames and the unique characteristics of patients with comorbid PTSD and depression.^14-16 Several psychopharmacologic treatments for depression have been evaluated as frontline treatments for PTSD. The 3 pharmacologic treatments that demonstrate efficacy in treating PTSD include fluoxetine, paroxetine, and venlafaxine.¹⁷

Although these pharmacologic agents represent good candidate treatments for comorbid patients, the effect size of pharmacologic treatments are generally smaller than those of psychotherapeutic treatments for PTSD.^17,18 This observation, however, is based on indirect comparisons, and a recent systematic review concluded that the evidence was insufficient to determine the comparative effectiveness between psychotherapy and pharmacotherapy for PTSD.¹⁹ Evidence indicates that trauma-focused cognitive behavioral therapies consistently demonstrate efficacy and effectiveness in treating PTSD.^19,20 These treatments also have been shown to significantly reduce depressive symptoms among PTSD samples.²¹

Based on strong bodies of evidence, these pharmacologic and psychological treatments have received the highest level of recommendation in the VA and DoD.^22,23 Accordingly, both agencies have invested considerable resources in large-scale efforts to improve patient access to these particular treatments. Despite these impressive implementation efforts, however, the limitations of relying exclusively on these treatments as frontline approaches within large health care systems have become evident.^24-26

Penetration of Therapies

Penetration of these evidence-based treatments (EBTs) within the DoD and VHA remains limited. For instance, one study showed that VA clinicians in mental health specialty care clinics may provide only about 4 hours of EBT per week.²⁷

Other reports suggest that only about 60% of treatment-seeking patients in PTSD clinics receive any type of evidence-based therapy and that within-session care quality is questionable based on a systematic review of chart notes.^28,29 Attrition in trauma-focused therapy is a recognized limitation, with 1 out of 3 treatment-seeking patients not completing a full dose of evidence-based treatment.^30-33 Large-scale analyses of VHA and DoD utilization data suggest that the majority of PTSD patients do not receive a sufficient number of sessions to be characterized as an adequate dose of EBT, with a majority of dropouts occur- ring after just a few sessions.^34-37

Hoge and colleagues found that < 50% of soldiers meeting criteria for PTSD received any mental health care within the prior 6 months with one-quarter of those patients dropping out of care prematurely.³⁸ Among a large cohort of soldiers engaged in care for the treatment of PTSD, only about 40% received a number of EBT treatment sessions that could qualify as an adequate dose.³⁸ Thus, although major advancements in the development and implementation of effective treatments for PTSD and depression have occurred, the penetration of these treatments is limited, and the majority of patients in need of treatment potentially receive inadequate care.³⁹

System level approaches that integrate behavioral health services into the primary care system have been proposed to address these care gaps for service members and veterans.^40-42 Fundamentally, system-level approaches seek to improve the reach and effectiveness of care through large-scale screening efforts, a greater emphasis on the quality of patient care, and enhanced care continuity across episodes of treatment.

Primary Care

With the primary care setting considered the de facto mental health system, integrated approaches enhance the reach of care by incorporating uniform mental health screening and referral for patients coming through primary care. Specific evidence-based treatments can be integrated into this approach within a stepped-care framework that aims to match patients strategically to the right type of care and leverage specialty care resources as needed. Integrated care approaches for the treatment of PTSD and depression have been developed and evaluated inside and outside of the MHS. Findings indicate that integrated treatment approaches can improve care access, care continuity, patient satisfaction, quality of care,and in several trials, PTSD and depression outcomes.^43-47

Recently, an integrated care approach targeting U.S. Army soldiers who screened positive for PTSD or depression in primary care was evaluated in a multisite effectiveness trial.⁴⁸ Patients randomized to the treatment approach experienced significant improvements in both PTSD and depression symptoms relative to patients in usual care.⁴³ In addition, patients treated in this care model received significantly more mental health services; the patterns of care indicated that patients with comorbid PTSD and depression were more likely to be triaged to specialty care, whereas patients with a single diagnosis were more likely to be managed in primary care.⁴⁹ This trial suggests that integrated care models feasibly can be implemented in the U.S. Army care system, yielding increased uptake of mental health care, more efficiently matched care based on patient comorbidities, and improved PTSD and depression outcomes.

Treatment Research

The MHS supports a large portfolio of research in PTSD and depression through DoD/VA research consortia (eg, the Congressionally Directed Medical Research Program, the Consortium to Alleviate PTSD, the Injury and Traumatic Stress Clinical Consortium). The U.S. Army Medical Research and Materiel Command (USAMRMC) executes and manages the portfolio of research, relying on a joint program committee of DoD and non-DoD experts to make funding recommendations based on identified research priorities, policy guidance, and knowledge translation needs.

Health systems research on PTSD and MDD in federal health care settings is expanding. For example, the RAND Corporation recently evaluated a candidate set of quality measures for PTSD and MDD, using an operational definition of an episode of care.³⁷ This work is intended to inform efforts to measure and improve the quality of care for PTSD and depression across the enterprise.

The DoD Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury is simultaneously completing an inferential assessment of adjunctive mental health care services, many focused on PTSD and depression, throughout the health care enterprise. Along with the substantial resources devoted to research on PTSD and depression, the MHS is implementing strategies to improve the system of care for service members with mental health conditions.

Army Care System Innovations

The U.S. Army is engaged in a variety of strategies to improve the identification of patients with mental health conditions, increase access to mental health services, and enhance the quality of care that soldiers receive for PTSD and depression. To improve the coordination of mental health care, the U.S. Army Medical Command implemented a wide-scale innovative transformation of its mental health care system through the establishment of the Behavioral Health Service Line program management office.

This move eliminated separate departments of psychiatry, psychology, and social work in favor of integrated behavioral health departments that are now responsible for all mental health care delivered to soldiers, including inpatient, outpatient, partial hospitalization, residential, embedded care in garrison, and primary care settings. This transformation ensured coordination of care for soldiers, eliminating potential miscommunication with patients, commands, and other clinicians while clearly defining performance indicators in process (eg, productivity, scheduling, access to care, and patient satisfaction) and outcome measures.⁴⁹ In conjunction with the development of its service line, the U.S. Army created a Behavioral Health Data Portal (BHDP), an electronic and standardized means to assess clinical outcomes for common conditions.

To promote higher quality mental health care, the Office of the Surgeon General of the U.S. Army provided direct guidance on the treatment of PTSD and depression. U.S. Army policy mandates that providers treating mental health conditions adhere to the VA/DoD clinical practice guidelines (CPGs) and that soldiers with PTSD and depression be offered treatments with the highest level of scientific support and that outcome measures be routinely administered. In line with the CPGs, U.S. Army policy also recommends the use of both integrated and embedded mental health care approaches to address PTSD, depression, and other common physical and psychological health conditions.

To reduce stigma and improve mental health care access, the U.S. Army began implementing integrated care approaches in 2007 with its Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) program, an evidence-based collaborative care model.^51-55 This approach included structured screening and diagnostic procedures, predictable follow-up schedules for patients, and the coordination of the divisions of responsibility among and between primary care providers, paraprofessionals, and behavioral health care providers. From 2007 to 2013, this collaborative care model was rolled out across 96 clinics worldwide and provided PTSD and depression screening to more than 1 million encounters per year.^52,53

More recently, the U.S. Army led DoD in integrating behavioral health personnel in patient centered medical homes (PCMH) in compliance with DoD Instruction 6490.15.⁵⁶ This hybrid integrated care model combines collaborative care elements developed in the RESPECT-Mil program with elements of the U.S. Air Force Behavioral Health Optimization project colocating behavioral health providers in primary care settings to provide brief consultative services.

MHS Care Enhancements

Many of the innovations deployed throughout the U.S. Army system of behavioral health care have driven changes across the MHS as a whole. The DoD and the VA have made substantive systemwide policy and practice changes to improve care for beneficiaries with PTSD, depression, and comorbid PTSD and depression. In particular, significant implementation efforts have addressed population screening strategies, outcome monitoring to support measurement-based care, increased access to effective care, and revision of the disability evaluation system.

To improve the identification and referral of soldiers with deployment-related mental health concerns, the DoD implemented a comprehensive program that screens service members prior to deployment, immediately on redeployment, and then again 6 months after returning from deployment. Additionally, annual primary care- based screening requirements have been instituted as part of the DoD PCMH initiative. Both deployment-related and primary care-based screenings include an instrumentation to detect symptoms of PTSD and depression and extend the reach of mental health screening to the entire MHS population.

Building on the success of BHDP, former Assistant Secretary of Defense for Health Affairs Jonathan Woodson mandated BHDP use across the MHS for all patients in DoD behavioral health clinics and the use of outcome measures for the treatment of PTSD, anxiety, depression, and alcohol use disorders.⁵⁷ A DoD-wide requirement to use the PTSD checklist and patient health questionnaire to monitor PTSD and depression symptoms at mental health intakes and regularly at follow-up visits is being implemented. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, through its Practice-Based Implementation Network (underwritten by a Joint Incentive Fund managed between DoD and VA), has worked across the MHS and the VA to facilitate the implementation, uptake, and adoption of this initiative.

The DoD established the Center for Deployment Psychology (CDP) in 2006 to promote clinician training in EBTs with the aim of increasing service members’ access to effective psychological treatments. Since its inception, the CDP has provided EBT training to more than 40,000 behavioral health providers. Although the impact of these and other efforts on improving the quality of care that patients receive is unknown, a recent study documented widespread self-reported usage of EBT components in U.S. Army clinics and that providers formally trained in EBTs were more likely to deliver EBTs.⁵⁸

Finally, systemwide changes to the VA Schedule of Ratings for Disability (VASRD) and integration of DoD and VA disability evaluation systems have led to shifts in diagnosis toward PTSD that usually merit a minimum 50% disability rating. Mandates in law require military clinicians to evaluate patients who have deployed for PTSD and TBI prior to taking any actions associated with administrative separation. The practice of attributing PTSD symptoms to character pathology or personality disorders, even when these symptoms did not clearly manifest or worsen with military service, has likely been eliminated from practice in military and veteran populations.

Robust policy changes to limit personality disorder discharges started in fiscal year 2007, when there were 4,127 personality disorder separations across DoD. This number was reduced to 300 within 5 years. Policy changes regarding separation not only seem to have affected discharges, but also may have shaped diagnostic practice. The incidence rate of personality disorder diagnoses declined from 513 per 100,000 person-years in 2007 to 284 per 100,000 person-years by 2011.⁵⁹ The VASRD recognizes chronic adjustment disorder as a disability, and the National Defense Authorization Act of 2008 mandated that DoD follow disability guidelines promulgated by VA.

As stated in the memorandum Clinical Policy Guidance for Assessment and Treatment of Post-Traumatic Stress Disorders (August 24, 2012), DoD recognizes chronic adjustment disorder as an unfitting condition that merits referral to its disability evaluation system.⁶⁰ Acute adjustment disorders may still lead to administrative separations, as many service members manifest emotional symptoms stemming from the failure to adjust to the routine vicissitudes of military life. Finally, many court jurisdictions, including veteran’s courts, military courts, and commanders empowered to adjudicate nonjudicial infractions under the Uniform Code of Military Justice, have recognized PTSD as grounds for the mitigation of penalties associated with a wide array of criminal and administrative infractions.

Conclusion

In response to the increased mental health burden following a decade of war and the associated pressures stemming from federal mandates, the MHS has invested unprecedented resources into improving care for military service members. The U.S. Army has played a prominent role in this endeavor by investing in clinical research efforts to accelerate discovery on the causes and cures for these conditions, enacting policies that mandate best practices, and implementing evidence-based care approaches across the system of care. Despite this progress, however, understanding and effectively treating the most prevalent mental health conditions remain a challenge across the DoD and VHA health care systems. Many service members and veterans still do not receive timely, high-quality care for PTSD, depression, and other common comorbidities associated with military experience, and controversies in diagnostic clarification abound.

In short, great strides have been made, yet there is still a large distance to go. The vision of an effective, efficient, comprehensive care system for mental health conditions will continue to be pursued and achieved through collaborations across key agencies and the scientific community, implementation of health system approaches that support population care, and the sustained efforts of dedicated clinicians, staff, and clinic leaders who deliver the care to our service members and veterans.

Identifying people who might be at risk for posttraumatic stress disorder (PTSD) before the trauma—and teaching them preventive coping skills—could reduce or prevent long-term effects, according to University of Oxford in Oxford, United Kingdom, and King’s College London, United Kingdom, researchers.

They assessed 453 newly recruited paramedics every 4 months for 2 years. Of those, 386 paramedics participated in follow-up interviews.

Related: Let’s Dance: A Holistic Approach to Treating Veterans With Posttraumatic Stress Disorder

Over the 2 years, 32 participants (8.3%) had an episode of PTSD, and 41 participants had (10.6%) an episode of major depression (MD). Most of the episodes were moderate and short lived. In most cases, the participant had recovered by the next 4-month assessment. However, at 2 years, those who had experienced episodes of PTSD or MD during the follow-up period reported more days off work, poorer sleep, poorer quality of life, and greater burn out as well as weight gain (mean gain, 6.9 kg) for those with PTSD.

Ten participants who developed PTSD received treatment during follow-up, as did 12 participants who developed MD. Five of 9 participants who had recurrent PTSD or MD received treatment during the follow-up period but did not recover.

Related: Telehealth for Native Americans With PTSD

The researchers tested a number of possible pretrauma predictors of PTSD and MD. They correlated several: cognitive style (eg, suppression, rumination, intentional numbing), coping style (eg, avoidant styles, such as wishful thinking), and psychological traits (eg, neuroticism). However, they found rumination about memories of stressful events uniquely predicted an episode of PTSD. Perceived resilience uniquely predicted an episode of MD.

Interestingly, about 42% of the study participants had a psychiatric history before training—more than the general population. That might be a factor that draws them to emergency work, the researchers suggest.

Related: Yoga-Based Classes for Veterans With Severe Mental Illness: Development, Dissemination, and Assessment

Some predictors, such as psychiatric history, are fixed, the researchers note. But others, such as cognitive styles, can be modified or taught. Studies have shown that rumination can be redirected through training in concrete thinking, for instance, and psychoeducation and cognitive behavioral techniques (eg, modifying interpretations of stressful events) have been used to strengthen resilience. The predictors they identified in their study could serve as targets, the researchers suggest, for modifying future resilience programs.

Source:
Wild J, Smith KV, Thompson E, Béar F, Lommen MJ, Ehlers A. Psychol Med. 2016;46(12):2571-2582. doi: 10.1017/S0033291716000532.

Identifying people who might be at risk for posttraumatic stress disorder (PTSD) before the trauma—and teaching them preventive coping skills—could reduce or prevent long-term effects, according to University of Oxford in Oxford, United Kingdom, and King’s College London, United Kingdom, researchers.

They assessed 453 newly recruited paramedics every 4 months for 2 years. Of those, 386 paramedics participated in follow-up interviews.

Related: Let’s Dance: A Holistic Approach to Treating Veterans With Posttraumatic Stress Disorder

Over the 2 years, 32 participants (8.3%) had an episode of PTSD, and 41 participants had (10.6%) an episode of major depression (MD). Most of the episodes were moderate and short lived. In most cases, the participant had recovered by the next 4-month assessment. However, at 2 years, those who had experienced episodes of PTSD or MD during the follow-up period reported more days off work, poorer sleep, poorer quality of life, and greater burn out as well as weight gain (mean gain, 6.9 kg) for those with PTSD.

Ten participants who developed PTSD received treatment during follow-up, as did 12 participants who developed MD. Five of 9 participants who had recurrent PTSD or MD received treatment during the follow-up period but did not recover.

Related: Telehealth for Native Americans With PTSD

The researchers tested a number of possible pretrauma predictors of PTSD and MD. They correlated several: cognitive style (eg, suppression, rumination, intentional numbing), coping style (eg, avoidant styles, such as wishful thinking), and psychological traits (eg, neuroticism). However, they found rumination about memories of stressful events uniquely predicted an episode of PTSD. Perceived resilience uniquely predicted an episode of MD.

Interestingly, about 42% of the study participants had a psychiatric history before training—more than the general population. That might be a factor that draws them to emergency work, the researchers suggest.

Related: Yoga-Based Classes for Veterans With Severe Mental Illness: Development, Dissemination, and Assessment

Some predictors, such as psychiatric history, are fixed, the researchers note. But others, such as cognitive styles, can be modified or taught. Studies have shown that rumination can be redirected through training in concrete thinking, for instance, and psychoeducation and cognitive behavioral techniques (eg, modifying interpretations of stressful events) have been used to strengthen resilience. The predictors they identified in their study could serve as targets, the researchers suggest, for modifying future resilience programs.

Source:
Wild J, Smith KV, Thompson E, Béar F, Lommen MJ, Ehlers A. Psychol Med. 2016;46(12):2571-2582. doi: 10.1017/S0033291716000532.

Identifying people who might be at risk for posttraumatic stress disorder (PTSD) before the trauma—and teaching them preventive coping skills—could reduce or prevent long-term effects, according to University of Oxford in Oxford, United Kingdom, and King’s College London, United Kingdom, researchers.

They assessed 453 newly recruited paramedics every 4 months for 2 years. Of those, 386 paramedics participated in follow-up interviews.

Related: Let’s Dance: A Holistic Approach to Treating Veterans With Posttraumatic Stress Disorder

Over the 2 years, 32 participants (8.3%) had an episode of PTSD, and 41 participants had (10.6%) an episode of major depression (MD). Most of the episodes were moderate and short lived. In most cases, the participant had recovered by the next 4-month assessment. However, at 2 years, those who had experienced episodes of PTSD or MD during the follow-up period reported more days off work, poorer sleep, poorer quality of life, and greater burn out as well as weight gain (mean gain, 6.9 kg) for those with PTSD.

Ten participants who developed PTSD received treatment during follow-up, as did 12 participants who developed MD. Five of 9 participants who had recurrent PTSD or MD received treatment during the follow-up period but did not recover.

Related: Telehealth for Native Americans With PTSD

The researchers tested a number of possible pretrauma predictors of PTSD and MD. They correlated several: cognitive style (eg, suppression, rumination, intentional numbing), coping style (eg, avoidant styles, such as wishful thinking), and psychological traits (eg, neuroticism). However, they found rumination about memories of stressful events uniquely predicted an episode of PTSD. Perceived resilience uniquely predicted an episode of MD.

Interestingly, about 42% of the study participants had a psychiatric history before training—more than the general population. That might be a factor that draws them to emergency work, the researchers suggest.

Related: Yoga-Based Classes for Veterans With Severe Mental Illness: Development, Dissemination, and Assessment

Some predictors, such as psychiatric history, are fixed, the researchers note. But others, such as cognitive styles, can be modified or taught. Studies have shown that rumination can be redirected through training in concrete thinking, for instance, and psychoeducation and cognitive behavioral techniques (eg, modifying interpretations of stressful events) have been used to strengthen resilience. The predictors they identified in their study could serve as targets, the researchers suggest, for modifying future resilience programs.

Source:
Wild J, Smith KV, Thompson E, Béar F, Lommen MJ, Ehlers A. Psychol Med. 2016;46(12):2571-2582. doi: 10.1017/S0033291716000532.

WAIKOLOA, HAWAII – A new nine-item tool known as the Injured Trauma Survivor Screen demonstrated strong sensitivity and specificity for predicting posttraumatic stress disorder and depression in trauma patients.

At the annual meeting of the American Association for the Surgery of Trauma, Terri deRoon-Cassini, PhD, said that the rates of PTSD among trauma patients range from 10% to 42%, depending on the type of injury sustained. “There is significant life impairment, including an increased risk for suicide and an increased risk for morbidity and mortality,” said Dr. deRoon-Cassini, a clinical psychologist and associate professor with the division of trauma and critical care at the Medical College of Wisconsin, Milwaukee.

The ACS Committee on Trauma currently recommends PTSD screening by trauma centers, including the 20-item PTSD Checklist and the nine-item PHD-9 for depression. However, these symptom-based screens were not validated in hospitalized trauma patients. “This becomes important, because according to the symptom trajectory of PTSD after trauma, about 22% of people experience chronic disease and about 16%-18% of people who have symptoms at baseline do not translate to symptoms by 6 months, so screening with a symptom-based measure isn’t always the best route,” she said.

Doug Brunk/Frontline Medical News

• Did you think you were going to die? (risk factor being perceived life threat; odds ratio 6.32).

• Do you think this was done to you intentionally? (risk factor being intentionality; OR, 4.24).

• Have you felt more restless, tense, or jumpy than usual? (risk factor being assessment of arousal; OR, 5.31).

• Have you found yourself unable to stop worrying? (risk factor being worry/rumination; OR, 4.49).

• Do you find yourself thinking that the world is unsafe and that people are not to be trusted? (risk factor being negative alterations in cognition; OR, 5.52).

The five ITSS depression questions are:

• Have you ever taken medication for, or been given a mental health diagnosis? (risk factor being preexisting psychopathology; OR, 10.58).

• Has there ever been a time in your life you have been bothered by feeling down or hopeless or lost all interest in things you usually enjoyed for more than 2 weeks? (risk factor being premorbid depression; OR, 3.78).

• Did you think you were going to die? (risk factor being perceived life threat; OR, 9.69).

• Have you felt emotionally detached from your loved ones? (risk factor being negative alteration in mood; OR, 8.03).

• Do you find yourself crying and are unsure why? (risk factor being mood/depression; OR, 9.18).

The researchers administered the survey to 139 patients at two trauma centers. More than half (69%) were male, 48% were white, 40% were African American, and the remainder were from other ethnic backgrounds. The three most common mechanisms of injury were motor vehicle crashes (29%), motorcycle/all-terrain vehicle crashes (19%), and falls (13%). Dr. deRoon-Cassini reported that administration of the ITSS within 4 days of injury demonstrated a 75% sensitivity for identifying the risk for PTSD and depression, a 94% specificity for PTSD, and a 96% specificity for depression, with a cutoff score of 2 out of 5 for both subscales based on a receiver operating characteristic (ROC) curve analysis.

One month following administration of the ITSS, 20% of patients were diagnosed with depression and 29% were diagnosed with PTSD. Of those diagnosed with PTSD, 55% met criteria for concomitant depression “so we are seeing a high comorbidity between PTSD and depression, which is consistent with the medical literature,” she said.

“The ITSS represents a brief way that we can screen for PTSD and depression within a trauma system,” Dr. deRoon-Cassini said. “At our institution, social workers administer the tool. They have a flow sheet in our EMR system where they enter the responses. If someone screens positive, a best practice recommendation is put into the patient’s chart, which gets funneled to a trauma psychology consult. On the treatment side we try to intervene by triaging the severity of the current distress the person is experiencing, past comorbidities, and past trauma histories. From there we decide whether to do a brief intervention or more intensive evidence-based interventions for PTSD or depression together or separately.”

The study was funded by a grant from the Medical College of Wisconsin. Coauthors included Joshua Hunt, PhD, of the Medical College of Wisconsin, Milwaukee; Ann Marie Warren, PhD, of Baylor Medical Center, Dallas; and Karen Brasel, MD, FACS, of Oregon Health & Science University, Portland. Dr. deRoon-Cassini reported having no financial disclosures.

dbrunk@frontlinemedcom.com

WAIKOLOA, HAWAII – A new nine-item tool known as the Injured Trauma Survivor Screen demonstrated strong sensitivity and specificity for predicting posttraumatic stress disorder and depression in trauma patients.

At the annual meeting of the American Association for the Surgery of Trauma, Terri deRoon-Cassini, PhD, said that the rates of PTSD among trauma patients range from 10% to 42%, depending on the type of injury sustained. “There is significant life impairment, including an increased risk for suicide and an increased risk for morbidity and mortality,” said Dr. deRoon-Cassini, a clinical psychologist and associate professor with the division of trauma and critical care at the Medical College of Wisconsin, Milwaukee.

The ACS Committee on Trauma currently recommends PTSD screening by trauma centers, including the 20-item PTSD Checklist and the nine-item PHD-9 for depression. However, these symptom-based screens were not validated in hospitalized trauma patients. “This becomes important, because according to the symptom trajectory of PTSD after trauma, about 22% of people experience chronic disease and about 16%-18% of people who have symptoms at baseline do not translate to symptoms by 6 months, so screening with a symptom-based measure isn’t always the best route,” she said.

Doug Brunk/Frontline Medical News

• Did you think you were going to die? (risk factor being perceived life threat; odds ratio 6.32).

• Do you think this was done to you intentionally? (risk factor being intentionality; OR, 4.24).

• Have you felt more restless, tense, or jumpy than usual? (risk factor being assessment of arousal; OR, 5.31).

• Have you found yourself unable to stop worrying? (risk factor being worry/rumination; OR, 4.49).

• Do you find yourself thinking that the world is unsafe and that people are not to be trusted? (risk factor being negative alterations in cognition; OR, 5.52).

The five ITSS depression questions are:

• Have you ever taken medication for, or been given a mental health diagnosis? (risk factor being preexisting psychopathology; OR, 10.58).

• Has there ever been a time in your life you have been bothered by feeling down or hopeless or lost all interest in things you usually enjoyed for more than 2 weeks? (risk factor being premorbid depression; OR, 3.78).

• Did you think you were going to die? (risk factor being perceived life threat; OR, 9.69).

• Have you felt emotionally detached from your loved ones? (risk factor being negative alteration in mood; OR, 8.03).

• Do you find yourself crying and are unsure why? (risk factor being mood/depression; OR, 9.18).

The researchers administered the survey to 139 patients at two trauma centers. More than half (69%) were male, 48% were white, 40% were African American, and the remainder were from other ethnic backgrounds. The three most common mechanisms of injury were motor vehicle crashes (29%), motorcycle/all-terrain vehicle crashes (19%), and falls (13%). Dr. deRoon-Cassini reported that administration of the ITSS within 4 days of injury demonstrated a 75% sensitivity for identifying the risk for PTSD and depression, a 94% specificity for PTSD, and a 96% specificity for depression, with a cutoff score of 2 out of 5 for both subscales based on a receiver operating characteristic (ROC) curve analysis.

One month following administration of the ITSS, 20% of patients were diagnosed with depression and 29% were diagnosed with PTSD. Of those diagnosed with PTSD, 55% met criteria for concomitant depression “so we are seeing a high comorbidity between PTSD and depression, which is consistent with the medical literature,” she said.

“The ITSS represents a brief way that we can screen for PTSD and depression within a trauma system,” Dr. deRoon-Cassini said. “At our institution, social workers administer the tool. They have a flow sheet in our EMR system where they enter the responses. If someone screens positive, a best practice recommendation is put into the patient’s chart, which gets funneled to a trauma psychology consult. On the treatment side we try to intervene by triaging the severity of the current distress the person is experiencing, past comorbidities, and past trauma histories. From there we decide whether to do a brief intervention or more intensive evidence-based interventions for PTSD or depression together or separately.”

The study was funded by a grant from the Medical College of Wisconsin. Coauthors included Joshua Hunt, PhD, of the Medical College of Wisconsin, Milwaukee; Ann Marie Warren, PhD, of Baylor Medical Center, Dallas; and Karen Brasel, MD, FACS, of Oregon Health & Science University, Portland. Dr. deRoon-Cassini reported having no financial disclosures.

dbrunk@frontlinemedcom.com

WAIKOLOA, HAWAII – A new nine-item tool known as the Injured Trauma Survivor Screen demonstrated strong sensitivity and specificity for predicting posttraumatic stress disorder and depression in trauma patients.

At the annual meeting of the American Association for the Surgery of Trauma, Terri deRoon-Cassini, PhD, said that the rates of PTSD among trauma patients range from 10% to 42%, depending on the type of injury sustained. “There is significant life impairment, including an increased risk for suicide and an increased risk for morbidity and mortality,” said Dr. deRoon-Cassini, a clinical psychologist and associate professor with the division of trauma and critical care at the Medical College of Wisconsin, Milwaukee.

The ACS Committee on Trauma currently recommends PTSD screening by trauma centers, including the 20-item PTSD Checklist and the nine-item PHD-9 for depression. However, these symptom-based screens were not validated in hospitalized trauma patients. “This becomes important, because according to the symptom trajectory of PTSD after trauma, about 22% of people experience chronic disease and about 16%-18% of people who have symptoms at baseline do not translate to symptoms by 6 months, so screening with a symptom-based measure isn’t always the best route,” she said.

Doug Brunk/Frontline Medical News

• Did you think you were going to die? (risk factor being perceived life threat; odds ratio 6.32).

• Do you think this was done to you intentionally? (risk factor being intentionality; OR, 4.24).

• Have you felt more restless, tense, or jumpy than usual? (risk factor being assessment of arousal; OR, 5.31).

• Have you found yourself unable to stop worrying? (risk factor being worry/rumination; OR, 4.49).

• Do you find yourself thinking that the world is unsafe and that people are not to be trusted? (risk factor being negative alterations in cognition; OR, 5.52).

The five ITSS depression questions are:

• Have you ever taken medication for, or been given a mental health diagnosis? (risk factor being preexisting psychopathology; OR, 10.58).

• Has there ever been a time in your life you have been bothered by feeling down or hopeless or lost all interest in things you usually enjoyed for more than 2 weeks? (risk factor being premorbid depression; OR, 3.78).

• Did you think you were going to die? (risk factor being perceived life threat; OR, 9.69).

• Have you felt emotionally detached from your loved ones? (risk factor being negative alteration in mood; OR, 8.03).

• Do you find yourself crying and are unsure why? (risk factor being mood/depression; OR, 9.18).

The researchers administered the survey to 139 patients at two trauma centers. More than half (69%) were male, 48% were white, 40% were African American, and the remainder were from other ethnic backgrounds. The three most common mechanisms of injury were motor vehicle crashes (29%), motorcycle/all-terrain vehicle crashes (19%), and falls (13%). Dr. deRoon-Cassini reported that administration of the ITSS within 4 days of injury demonstrated a 75% sensitivity for identifying the risk for PTSD and depression, a 94% specificity for PTSD, and a 96% specificity for depression, with a cutoff score of 2 out of 5 for both subscales based on a receiver operating characteristic (ROC) curve analysis.

One month following administration of the ITSS, 20% of patients were diagnosed with depression and 29% were diagnosed with PTSD. Of those diagnosed with PTSD, 55% met criteria for concomitant depression “so we are seeing a high comorbidity between PTSD and depression, which is consistent with the medical literature,” she said.

“The ITSS represents a brief way that we can screen for PTSD and depression within a trauma system,” Dr. deRoon-Cassini said. “At our institution, social workers administer the tool. They have a flow sheet in our EMR system where they enter the responses. If someone screens positive, a best practice recommendation is put into the patient’s chart, which gets funneled to a trauma psychology consult. On the treatment side we try to intervene by triaging the severity of the current distress the person is experiencing, past comorbidities, and past trauma histories. From there we decide whether to do a brief intervention or more intensive evidence-based interventions for PTSD or depression together or separately.”

The study was funded by a grant from the Medical College of Wisconsin. Coauthors included Joshua Hunt, PhD, of the Medical College of Wisconsin, Milwaukee; Ann Marie Warren, PhD, of Baylor Medical Center, Dallas; and Karen Brasel, MD, FACS, of Oregon Health & Science University, Portland. Dr. deRoon-Cassini reported having no financial disclosures.

dbrunk@frontlinemedcom.com

WASHINGTON – The role of ostracism in overall poor health outcomes in service personnel is a growing concern, according to a panel of military experts.

“Think about the primary mechanism of suicide in kids who are bullied: It’s ostracism,” Kate McGraw, PhD, said in an interview at the American Psychiatric Association’s Institute on Psychiatric Services. Dr. McGraw is the interim director of the Deployment Health Clinical Center, a Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.

Whitney McKnight/Frontline Medical News

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

WASHINGTON – The role of ostracism in overall poor health outcomes in service personnel is a growing concern, according to a panel of military experts.

“Think about the primary mechanism of suicide in kids who are bullied: It’s ostracism,” Kate McGraw, PhD, said in an interview at the American Psychiatric Association’s Institute on Psychiatric Services. Dr. McGraw is the interim director of the Deployment Health Clinical Center, a Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.

Whitney McKnight/Frontline Medical News

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

WASHINGTON – The role of ostracism in overall poor health outcomes in service personnel is a growing concern, according to a panel of military experts.

“Think about the primary mechanism of suicide in kids who are bullied: It’s ostracism,” Kate McGraw, PhD, said in an interview at the American Psychiatric Association’s Institute on Psychiatric Services. Dr. McGraw is the interim director of the Deployment Health Clinical Center, a Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.

Whitney McKnight/Frontline Medical News

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

SCOTTSDALE, ARIZ. – A sublingual formulation of cyclobenzaprine taken at bedtime was significantly better than placebo at reducing symptoms of military-related posttraumatic stress disorder, and study participants taking cyclobenzaprine also reported better sleep, a study showed.

After 12 weeks of nightly use at bedtime, 5.6 mg of sublingual cyclobenzaprine (CBP) resulted in a significant reduction on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), compared with placebo. Under several different analytic and data imputation methods, CAPS-5 values improved by 20.2 to 22.6 points from baseline for the 5.6-mg group, compared with reductions of 17.4 to 20.6 for the placebo group (P value range, 0.038-0.016). Improvement in the CAPS-5 was the study’s primary efficacy outcome measure.

Patients also saw significantly improved global symptoms, as assessed by the Clinician Global Impression – Improvement scale (CGI-I; 63.3% responders cyclobenzaprine versus 44.6% placebo, P = 0.041).

Significant reductions in hyperarousal (P less than 0.05) and exaggerated startle (P =0.015) symptoms also were seen in the 5.6-mg cyclobenzaprine group, and those participants also had significantly less symptom-related disruption in work/school, and in social/leisure activities, as measured by those domains on the Sheehan Disability Scale (for both, P less than 0.050).

Gregory M. Sullivan, MD, chief medical officer of Tonix Pharmaceuticals, presented these findings from AtEase, a randomized, placebo-controlled, double-blind study of sublingual cyclobenzaprine for military PTSD, at a meeting of the American Society of Clinical Psychopharmacology, formerly known as the New Drug Clinical Evaluation Unit meeting.

The phase II safety, efficacy, and dose-ranging study of 245 patients (231 in the modified intent-to-treat population, and 237 in the safety population) also compared 2.8- and 5.6-mg sublingual doses. At the end of the 12-week study period, those on the lower dose did not experience significantly improved sleep or PTSD symptoms.

The AtEase participants were current or former servicemembers with PTSD. Ninety-three percent of the patients were male and had been deployed an average of 2.3 times. The index trauma occurred a mean of 7 years ago. Demographic distribution was representative of the U.S. military, according to Dr. Sullivan. The mean CAPS-5 and Montgomery-Åsberg Depression Rating Scale (MADRS) scores were similar across treatment arms. The mean CAPS-5 score for participants in the study was 39.5 representing “severe” PTSD. “These people are quite ill,” said Seth Lederman, MD, Tonix CEO, in an interview.

Oral symptoms were the most frequent side effects reported in the safety analysis. Of those taking the 2.8-mg cyclobenzaprine dose, 38.7% (36/93) experienced oral hypoesthesia, as did 36% (18/50) of the 5.6-mg dosing group. This compared with 2.1% (2/94) of the placebo group. Somnolence was noted by 11.8% (11/93) of the lower dose group, by 16% (8/50) of the higher dose group, and by 6.4% (6/94) of the placebo group. No participants discontinued the study because of adverse events.

Military traumatic brain injury may be different from most civilian TBI, said Dr. Lederman, because of both the intensity and duration of the events that precipitated the condition. Most military-related trauma stems from combat, and most patients with military-related trauma are men; in the civilian population, PTSD patients are predominantly women. “Especially in today’s military, servicemembers are deploying multiple times,” he noted. “Everyone has their breaking point.”

Effective medical treatments for military PTSD are lacking, said Dr. Sullivan. One multicenter trial found that sertraline not effective for PTSD in military veterans (J Clin Psychiatry. 2007 May;68[5]:711-20), and selective serotonin reuptake inhibitors are associated with sexual dysfunction and insomnia for some patients.

Cyclobenzaprine is thought to interact with several receptors thought to be important for sleep, including 5-HT2A, alpha-1 adrenergic, and H1 histamine receptors.

Problems with sleep for individuals with PTSD may include nightmares, as well as sleep disturbances associated with the hyperarousal that characterizes the disorder. Sleep disruption may contribute to “attenuated extinction consolidation, or a delay in the processing of emotionally charged memories,” Dr. Sullivan said. Sleep disturbances in those with PTSD also are associated with depression, substance use disorders, and suicidal behavior.

“Processing memories is an essential part of learning and extinction,” Dr. Lederman said. “We saw startle improve” in the clinical trial of sublingual cyclobenzaprine, an indication of diminished hyperarousal, he said.

The sublingual formulation, said Dr. Lederman, avoids first-pass metabolism of cyclobenzaprine, which converts large amounts of the dose to norcyclobenzaprine. This metabolite has a much longer half-life than cyclobenzaprine and is responsible, in large part, for the persistent grogginess many patients report when taking the oral formulation of the medication. Previous work showed that the exposure ratio for cyclobenzaprine/norcyclobenzaprine for oral immediate-release cyclobenzaprine was 1.2, compared with 1.9 for sublingual cyclobenzaprine

“With the sublingual formulation, we hope to achieve a true ‘on-off’ effect, really helping sleep quality and improving sleep architecture,” Dr. Lederman said.

“Early effects on sleep and hyperarousal are consistent with the mechanistic hypothesis that TNX-102 SL’s primary actions on sleep architecture and autonomic balance underlie the observed PTSD treatment effect,” wrote Dr. Sullivan. The later reduction in exaggerated startle is consistent with the memory consolidation hypothesis, he said.

Sublingual cyclobenzaprine also is being trialed for fibromyalgia, another condition where significant sleep disruption can be a prominent symptom. Next steps for military PTSD include a larger clinical trial that plans to enroll 450 patients, said Dr. Lederman.

Dr. Lederman and Dr. Sullivan are both employed by Tonix Pharmaceuticals, which was the sponsor of the AtEase study.

koakes@frontlinemedcom.com

On Twitter @karioakes

SCOTTSDALE, ARIZ. – A sublingual formulation of cyclobenzaprine taken at bedtime was significantly better than placebo at reducing symptoms of military-related posttraumatic stress disorder, and study participants taking cyclobenzaprine also reported better sleep, a study showed.

After 12 weeks of nightly use at bedtime, 5.6 mg of sublingual cyclobenzaprine (CBP) resulted in a significant reduction on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), compared with placebo. Under several different analytic and data imputation methods, CAPS-5 values improved by 20.2 to 22.6 points from baseline for the 5.6-mg group, compared with reductions of 17.4 to 20.6 for the placebo group (P value range, 0.038-0.016). Improvement in the CAPS-5 was the study’s primary efficacy outcome measure.

Patients also saw significantly improved global symptoms, as assessed by the Clinician Global Impression – Improvement scale (CGI-I; 63.3% responders cyclobenzaprine versus 44.6% placebo, P = 0.041).

Significant reductions in hyperarousal (P less than 0.05) and exaggerated startle (P =0.015) symptoms also were seen in the 5.6-mg cyclobenzaprine group, and those participants also had significantly less symptom-related disruption in work/school, and in social/leisure activities, as measured by those domains on the Sheehan Disability Scale (for both, P less than 0.050).

Gregory M. Sullivan, MD, chief medical officer of Tonix Pharmaceuticals, presented these findings from AtEase, a randomized, placebo-controlled, double-blind study of sublingual cyclobenzaprine for military PTSD, at a meeting of the American Society of Clinical Psychopharmacology, formerly known as the New Drug Clinical Evaluation Unit meeting.

The phase II safety, efficacy, and dose-ranging study of 245 patients (231 in the modified intent-to-treat population, and 237 in the safety population) also compared 2.8- and 5.6-mg sublingual doses. At the end of the 12-week study period, those on the lower dose did not experience significantly improved sleep or PTSD symptoms.

The AtEase participants were current or former servicemembers with PTSD. Ninety-three percent of the patients were male and had been deployed an average of 2.3 times. The index trauma occurred a mean of 7 years ago. Demographic distribution was representative of the U.S. military, according to Dr. Sullivan. The mean CAPS-5 and Montgomery-Åsberg Depression Rating Scale (MADRS) scores were similar across treatment arms. The mean CAPS-5 score for participants in the study was 39.5 representing “severe” PTSD. “These people are quite ill,” said Seth Lederman, MD, Tonix CEO, in an interview.

Oral symptoms were the most frequent side effects reported in the safety analysis. Of those taking the 2.8-mg cyclobenzaprine dose, 38.7% (36/93) experienced oral hypoesthesia, as did 36% (18/50) of the 5.6-mg dosing group. This compared with 2.1% (2/94) of the placebo group. Somnolence was noted by 11.8% (11/93) of the lower dose group, by 16% (8/50) of the higher dose group, and by 6.4% (6/94) of the placebo group. No participants discontinued the study because of adverse events.

Military traumatic brain injury may be different from most civilian TBI, said Dr. Lederman, because of both the intensity and duration of the events that precipitated the condition. Most military-related trauma stems from combat, and most patients with military-related trauma are men; in the civilian population, PTSD patients are predominantly women. “Especially in today’s military, servicemembers are deploying multiple times,” he noted. “Everyone has their breaking point.”

Effective medical treatments for military PTSD are lacking, said Dr. Sullivan. One multicenter trial found that sertraline not effective for PTSD in military veterans (J Clin Psychiatry. 2007 May;68[5]:711-20), and selective serotonin reuptake inhibitors are associated with sexual dysfunction and insomnia for some patients.

Cyclobenzaprine is thought to interact with several receptors thought to be important for sleep, including 5-HT2A, alpha-1 adrenergic, and H1 histamine receptors.

Problems with sleep for individuals with PTSD may include nightmares, as well as sleep disturbances associated with the hyperarousal that characterizes the disorder. Sleep disruption may contribute to “attenuated extinction consolidation, or a delay in the processing of emotionally charged memories,” Dr. Sullivan said. Sleep disturbances in those with PTSD also are associated with depression, substance use disorders, and suicidal behavior.

“Processing memories is an essential part of learning and extinction,” Dr. Lederman said. “We saw startle improve” in the clinical trial of sublingual cyclobenzaprine, an indication of diminished hyperarousal, he said.

The sublingual formulation, said Dr. Lederman, avoids first-pass metabolism of cyclobenzaprine, which converts large amounts of the dose to norcyclobenzaprine. This metabolite has a much longer half-life than cyclobenzaprine and is responsible, in large part, for the persistent grogginess many patients report when taking the oral formulation of the medication. Previous work showed that the exposure ratio for cyclobenzaprine/norcyclobenzaprine for oral immediate-release cyclobenzaprine was 1.2, compared with 1.9 for sublingual cyclobenzaprine

“With the sublingual formulation, we hope to achieve a true ‘on-off’ effect, really helping sleep quality and improving sleep architecture,” Dr. Lederman said.

“Early effects on sleep and hyperarousal are consistent with the mechanistic hypothesis that TNX-102 SL’s primary actions on sleep architecture and autonomic balance underlie the observed PTSD treatment effect,” wrote Dr. Sullivan. The later reduction in exaggerated startle is consistent with the memory consolidation hypothesis, he said.

Sublingual cyclobenzaprine also is being trialed for fibromyalgia, another condition where significant sleep disruption can be a prominent symptom. Next steps for military PTSD include a larger clinical trial that plans to enroll 450 patients, said Dr. Lederman.

Dr. Lederman and Dr. Sullivan are both employed by Tonix Pharmaceuticals, which was the sponsor of the AtEase study.

koakes@frontlinemedcom.com

On Twitter @karioakes

SCOTTSDALE, ARIZ. – A sublingual formulation of cyclobenzaprine taken at bedtime was significantly better than placebo at reducing symptoms of military-related posttraumatic stress disorder, and study participants taking cyclobenzaprine also reported better sleep, a study showed.

After 12 weeks of nightly use at bedtime, 5.6 mg of sublingual cyclobenzaprine (CBP) resulted in a significant reduction on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), compared with placebo. Under several different analytic and data imputation methods, CAPS-5 values improved by 20.2 to 22.6 points from baseline for the 5.6-mg group, compared with reductions of 17.4 to 20.6 for the placebo group (P value range, 0.038-0.016). Improvement in the CAPS-5 was the study’s primary efficacy outcome measure.

Patients also saw significantly improved global symptoms, as assessed by the Clinician Global Impression – Improvement scale (CGI-I; 63.3% responders cyclobenzaprine versus 44.6% placebo, P = 0.041).

Significant reductions in hyperarousal (P less than 0.05) and exaggerated startle (P =0.015) symptoms also were seen in the 5.6-mg cyclobenzaprine group, and those participants also had significantly less symptom-related disruption in work/school, and in social/leisure activities, as measured by those domains on the Sheehan Disability Scale (for both, P less than 0.050).

Gregory M. Sullivan, MD, chief medical officer of Tonix Pharmaceuticals, presented these findings from AtEase, a randomized, placebo-controlled, double-blind study of sublingual cyclobenzaprine for military PTSD, at a meeting of the American Society of Clinical Psychopharmacology, formerly known as the New Drug Clinical Evaluation Unit meeting.

The phase II safety, efficacy, and dose-ranging study of 245 patients (231 in the modified intent-to-treat population, and 237 in the safety population) also compared 2.8- and 5.6-mg sublingual doses. At the end of the 12-week study period, those on the lower dose did not experience significantly improved sleep or PTSD symptoms.

The AtEase participants were current or former servicemembers with PTSD. Ninety-three percent of the patients were male and had been deployed an average of 2.3 times. The index trauma occurred a mean of 7 years ago. Demographic distribution was representative of the U.S. military, according to Dr. Sullivan. The mean CAPS-5 and Montgomery-Åsberg Depression Rating Scale (MADRS) scores were similar across treatment arms. The mean CAPS-5 score for participants in the study was 39.5 representing “severe” PTSD. “These people are quite ill,” said Seth Lederman, MD, Tonix CEO, in an interview.

Oral symptoms were the most frequent side effects reported in the safety analysis. Of those taking the 2.8-mg cyclobenzaprine dose, 38.7% (36/93) experienced oral hypoesthesia, as did 36% (18/50) of the 5.6-mg dosing group. This compared with 2.1% (2/94) of the placebo group. Somnolence was noted by 11.8% (11/93) of the lower dose group, by 16% (8/50) of the higher dose group, and by 6.4% (6/94) of the placebo group. No participants discontinued the study because of adverse events.

Military traumatic brain injury may be different from most civilian TBI, said Dr. Lederman, because of both the intensity and duration of the events that precipitated the condition. Most military-related trauma stems from combat, and most patients with military-related trauma are men; in the civilian population, PTSD patients are predominantly women. “Especially in today’s military, servicemembers are deploying multiple times,” he noted. “Everyone has their breaking point.”

Effective medical treatments for military PTSD are lacking, said Dr. Sullivan. One multicenter trial found that sertraline not effective for PTSD in military veterans (J Clin Psychiatry. 2007 May;68[5]:711-20), and selective serotonin reuptake inhibitors are associated with sexual dysfunction and insomnia for some patients.

Cyclobenzaprine is thought to interact with several receptors thought to be important for sleep, including 5-HT2A, alpha-1 adrenergic, and H1 histamine receptors.

Problems with sleep for individuals with PTSD may include nightmares, as well as sleep disturbances associated with the hyperarousal that characterizes the disorder. Sleep disruption may contribute to “attenuated extinction consolidation, or a delay in the processing of emotionally charged memories,” Dr. Sullivan said. Sleep disturbances in those with PTSD also are associated with depression, substance use disorders, and suicidal behavior.

“Processing memories is an essential part of learning and extinction,” Dr. Lederman said. “We saw startle improve” in the clinical trial of sublingual cyclobenzaprine, an indication of diminished hyperarousal, he said.

The sublingual formulation, said Dr. Lederman, avoids first-pass metabolism of cyclobenzaprine, which converts large amounts of the dose to norcyclobenzaprine. This metabolite has a much longer half-life than cyclobenzaprine and is responsible, in large part, for the persistent grogginess many patients report when taking the oral formulation of the medication. Previous work showed that the exposure ratio for cyclobenzaprine/norcyclobenzaprine for oral immediate-release cyclobenzaprine was 1.2, compared with 1.9 for sublingual cyclobenzaprine

“With the sublingual formulation, we hope to achieve a true ‘on-off’ effect, really helping sleep quality and improving sleep architecture,” Dr. Lederman said.

“Early effects on sleep and hyperarousal are consistent with the mechanistic hypothesis that TNX-102 SL’s primary actions on sleep architecture and autonomic balance underlie the observed PTSD treatment effect,” wrote Dr. Sullivan. The later reduction in exaggerated startle is consistent with the memory consolidation hypothesis, he said.

Sublingual cyclobenzaprine also is being trialed for fibromyalgia, another condition where significant sleep disruption can be a prominent symptom. Next steps for military PTSD include a larger clinical trial that plans to enroll 450 patients, said Dr. Lederman.

Dr. Lederman and Dr. Sullivan are both employed by Tonix Pharmaceuticals, which was the sponsor of the AtEase study.

koakes@frontlinemedcom.com

On Twitter @karioakes

A pathway from posttraumatic stress disorder to eating disorders might be through the maladaptive coping mechanism of expressive suppression, a study of 860 older veterans shows.

“Expressive suppression reflects attempts to reduce outward expression of emotion and may be adaptive in the short term; however, this strategy becomes less effective over the long term,” wrote Karen S. Mitchell, PhD, and Erika J. Wolf, PhD., both of the National Center for PTSD, VA Boston Healthcare System. “This finding aligns with previous ... work suggesting that in some individuals, [eating disorder] symptoms may be used to cope with negative affect.”

“We weren’t surprised by the findings,” Dr. Mitchell said in an interview. “They were consistent with our hypothesis that for some people, disordered eating may be used to cope with PTSD symptoms.”

She said the clinical implications of the study are direct. “It is important to assess eating habits and other potentially harmful coping strategies among patients with trauma histories and PTSD. On the other hand, it would be helpful to assess trauma histories in patients with eating disorders to determine if trauma reminders or other PTSD symptoms serve as a maintaining factor for the eating disorder.”

Dr. Mitchell and Dr. Wolf randomly selected 1,126 veterans who had reported trauma exposure in the GfK Knowledge Networks study (Depress Anxiety. 2013 May;30[5]:432-4), which looked at psychological resilience in a sample of U.S. veterans aged 60 and older. The veterans in the randomly selected group were asked to participate in a survey about PTSD, dissociation, and disordered eating, and 860 responded, 787 of whom were men (Psychiatry Res. 2016;243:23-9).

The participants’ age range was 22-96 years; mean age was 63. Most were white (85%) and married (77%), and had attended some college (87%).

Participants were asked to complete several surveys, including the Eating Disorder Diagnostic Scale (EDDS), the Yale Food Addiction Scale, the Emotion Regulation Questionnaire, and the National Stressful Events Survey (NSES).

The investigators said the sudden, unexpected death of a loved one (17.5%), and the aftermath of combat (13.6%) were cited as the worst traumatic experiences most cited by the participants. They also cited the violent death of a loved one (7.3%), the witnessing of dead bodies or body parts (6.3%), and physical or sexual assault (5.5%) as traumatic experiences.

Meanwhile, 23 participants (18 men [2.8%] and 5 women [9.1%]) met the criteria for bulimia nervosa; 20 met the criteria for binge eating disorder (16 men [2.5%] and 4 women [7.3%]); and 16 people (12 men [1.9%] and 4 women [7.3%]) met the proposed criteria for food addiction, reported Dr. Mitchell and Dr. Wolf, who also both are affiliated with the department of psychiatry at Boston University.

After analyzing the data, the researchers found that “the indirect path from PTSD to expressive suppression to [eating disorder] symptoms was significant in the full sample (P = .002; 95% confidence interval, 0.069-0.314) and in the male subsample (P = .029; 95% CI, 0.014-0.255).”

The researchers cited several limitations. For example, the participants’ diagnoses were not confirmed by interviews. In addition, “the validity of DSM-5 diagnoses using the EDDS and NSES has not yet been established,” they wrote.

Nevertheless, Dr. Mitchell and Dr. Wolf wrote, their findings highlight the importance of looking at eating disorders and food addiction in populations that traditionally have been underserved.

The study was funded by National Institutes of Health grant and an award from the Department of Veterans Affairs.

ghenderson@frontlinemedcom.com

A pathway from posttraumatic stress disorder to eating disorders might be through the maladaptive coping mechanism of expressive suppression, a study of 860 older veterans shows.

“Expressive suppression reflects attempts to reduce outward expression of emotion and may be adaptive in the short term; however, this strategy becomes less effective over the long term,” wrote Karen S. Mitchell, PhD, and Erika J. Wolf, PhD., both of the National Center for PTSD, VA Boston Healthcare System. “This finding aligns with previous ... work suggesting that in some individuals, [eating disorder] symptoms may be used to cope with negative affect.”

“We weren’t surprised by the findings,” Dr. Mitchell said in an interview. “They were consistent with our hypothesis that for some people, disordered eating may be used to cope with PTSD symptoms.”

She said the clinical implications of the study are direct. “It is important to assess eating habits and other potentially harmful coping strategies among patients with trauma histories and PTSD. On the other hand, it would be helpful to assess trauma histories in patients with eating disorders to determine if trauma reminders or other PTSD symptoms serve as a maintaining factor for the eating disorder.”

Dr. Mitchell and Dr. Wolf randomly selected 1,126 veterans who had reported trauma exposure in the GfK Knowledge Networks study (Depress Anxiety. 2013 May;30[5]:432-4), which looked at psychological resilience in a sample of U.S. veterans aged 60 and older. The veterans in the randomly selected group were asked to participate in a survey about PTSD, dissociation, and disordered eating, and 860 responded, 787 of whom were men (Psychiatry Res. 2016;243:23-9).

The participants’ age range was 22-96 years; mean age was 63. Most were white (85%) and married (77%), and had attended some college (87%).

Participants were asked to complete several surveys, including the Eating Disorder Diagnostic Scale (EDDS), the Yale Food Addiction Scale, the Emotion Regulation Questionnaire, and the National Stressful Events Survey (NSES).

The investigators said the sudden, unexpected death of a loved one (17.5%), and the aftermath of combat (13.6%) were cited as the worst traumatic experiences most cited by the participants. They also cited the violent death of a loved one (7.3%), the witnessing of dead bodies or body parts (6.3%), and physical or sexual assault (5.5%) as traumatic experiences.

Meanwhile, 23 participants (18 men [2.8%] and 5 women [9.1%]) met the criteria for bulimia nervosa; 20 met the criteria for binge eating disorder (16 men [2.5%] and 4 women [7.3%]); and 16 people (12 men [1.9%] and 4 women [7.3%]) met the proposed criteria for food addiction, reported Dr. Mitchell and Dr. Wolf, who also both are affiliated with the department of psychiatry at Boston University.

After analyzing the data, the researchers found that “the indirect path from PTSD to expressive suppression to [eating disorder] symptoms was significant in the full sample (P = .002; 95% confidence interval, 0.069-0.314) and in the male subsample (P = .029; 95% CI, 0.014-0.255).”

The researchers cited several limitations. For example, the participants’ diagnoses were not confirmed by interviews. In addition, “the validity of DSM-5 diagnoses using the EDDS and NSES has not yet been established,” they wrote.

Nevertheless, Dr. Mitchell and Dr. Wolf wrote, their findings highlight the importance of looking at eating disorders and food addiction in populations that traditionally have been underserved.

The study was funded by National Institutes of Health grant and an award from the Department of Veterans Affairs.

ghenderson@frontlinemedcom.com

A pathway from posttraumatic stress disorder to eating disorders might be through the maladaptive coping mechanism of expressive suppression, a study of 860 older veterans shows.

“Expressive suppression reflects attempts to reduce outward expression of emotion and may be adaptive in the short term; however, this strategy becomes less effective over the long term,” wrote Karen S. Mitchell, PhD, and Erika J. Wolf, PhD., both of the National Center for PTSD, VA Boston Healthcare System. “This finding aligns with previous ... work suggesting that in some individuals, [eating disorder] symptoms may be used to cope with negative affect.”

“We weren’t surprised by the findings,” Dr. Mitchell said in an interview. “They were consistent with our hypothesis that for some people, disordered eating may be used to cope with PTSD symptoms.”

She said the clinical implications of the study are direct. “It is important to assess eating habits and other potentially harmful coping strategies among patients with trauma histories and PTSD. On the other hand, it would be helpful to assess trauma histories in patients with eating disorders to determine if trauma reminders or other PTSD symptoms serve as a maintaining factor for the eating disorder.”

Dr. Mitchell and Dr. Wolf randomly selected 1,126 veterans who had reported trauma exposure in the GfK Knowledge Networks study (Depress Anxiety. 2013 May;30[5]:432-4), which looked at psychological resilience in a sample of U.S. veterans aged 60 and older. The veterans in the randomly selected group were asked to participate in a survey about PTSD, dissociation, and disordered eating, and 860 responded, 787 of whom were men (Psychiatry Res. 2016;243:23-9).

The participants’ age range was 22-96 years; mean age was 63. Most were white (85%) and married (77%), and had attended some college (87%).

Participants were asked to complete several surveys, including the Eating Disorder Diagnostic Scale (EDDS), the Yale Food Addiction Scale, the Emotion Regulation Questionnaire, and the National Stressful Events Survey (NSES).

The investigators said the sudden, unexpected death of a loved one (17.5%), and the aftermath of combat (13.6%) were cited as the worst traumatic experiences most cited by the participants. They also cited the violent death of a loved one (7.3%), the witnessing of dead bodies or body parts (6.3%), and physical or sexual assault (5.5%) as traumatic experiences.

Meanwhile, 23 participants (18 men [2.8%] and 5 women [9.1%]) met the criteria for bulimia nervosa; 20 met the criteria for binge eating disorder (16 men [2.5%] and 4 women [7.3%]); and 16 people (12 men [1.9%] and 4 women [7.3%]) met the proposed criteria for food addiction, reported Dr. Mitchell and Dr. Wolf, who also both are affiliated with the department of psychiatry at Boston University.

After analyzing the data, the researchers found that “the indirect path from PTSD to expressive suppression to [eating disorder] symptoms was significant in the full sample (P = .002; 95% confidence interval, 0.069-0.314) and in the male subsample (P = .029; 95% CI, 0.014-0.255).”

The researchers cited several limitations. For example, the participants’ diagnoses were not confirmed by interviews. In addition, “the validity of DSM-5 diagnoses using the EDDS and NSES has not yet been established,” they wrote.

Nevertheless, Dr. Mitchell and Dr. Wolf wrote, their findings highlight the importance of looking at eating disorders and food addiction in populations that traditionally have been underserved.

The study was funded by National Institutes of Health grant and an award from the Department of Veterans Affairs.

ghenderson@frontlinemedcom.com