PTSD

The stresses of civilian life—job problems, divorce, money—can add to the burden when a service member is already under strain from deployment-related traumatic events, such as being wounded or sexually harassed. Those extramilitary stressors may make it more likely for reserve soldiers to abuse alcohol, say researchers from Columbia University in New York City; University of Michigan in Ann Arbor; Case Western Reserve University in Cleveland, and University of Toledo, both in Ohio.

The researchers surveyed 1,095 members of the Ohio Army National Guard who served mostly in Afghanistan and Iraq from June 2008 to February 2009. They wanted to find out the relative influence of both deployment-related trauma and civilian stress, including the influence of both or either on alcohol abuse.

Almost 60% of soldiers surveyed reported experiencing combat-related traumatic events; 13% of that group was abusing alcohol. Of the 17% who reported being sexually harassed, about 5% were abusing alcohol. Of the nearly 36% of respondents who also experienced civilian stressors, 7.1% were abusing alcohol. In a final model, only civilian stressors were associated with subsequent alcohol use disorder (AUD), independent of deployment-related traumatic events.

Of the respondents, 106 had experienced mental illness personally or in someone close to them, 156 had been through a divorce or breakup, and 105 had been unemployed for ≥ 3 months. While serving, 364 had encountered land mines, water mines, or booby traps; 573 had received hostile incoming fire; and 471 had been attacked by terrorists, insurgents, or civilians.

The civilian stressors found to be most closely associated with AUD were having a family member with a serious drug or alcohol problem (adjusted odds ratio [OR] 1.36; 95% CI, 0.96-1.94), being robbed or having the house broken into (adjusted OR, 1.48; 95% CI, 1.02-2.21), and having problems in getting access to adequate health care (adjusted OR, 1.97; 95% CI, 1.07-3.63). Having experienced sexual harassment was the most closely associated combat trauma.

It was clear to the researchers that the combination of deployment-related trauma and civilian stressors were associated with new onset of AUD. That could mean that adult-onset AUD constitutes a different phenotype from recurrent AUDs, the researchers say. They cite previous research that identified 2 “types” of people who abuse alcohol. One type has a later onset, has “greater malleability to the social environment,” uses alcohol to soothe anxiety, and has less severe alcohol dependence symptoms. The other type turns to alcohol earlier, may be genetically predisposed to alcohol abuse, uses alcohol for its euphoric effect, and has a chronic treatment history.

A consideration when evaluating the findings, the researchers say, is that the soldiers who were interviewed shortly after their deployment may have been misclassified because psychiatric symptoms tend to appear 3 to 4 months after deployment.

Source
Cerdá M, Richards C, Cohen GH, et al. Am J Prev Med. 2014;47(4):461-466.
doi: 10.1016/j.amepre.2014.06.015.

The stresses of civilian life—job problems, divorce, money—can add to the burden when a service member is already under strain from deployment-related traumatic events, such as being wounded or sexually harassed. Those extramilitary stressors may make it more likely for reserve soldiers to abuse alcohol, say researchers from Columbia University in New York City; University of Michigan in Ann Arbor; Case Western Reserve University in Cleveland, and University of Toledo, both in Ohio.

The researchers surveyed 1,095 members of the Ohio Army National Guard who served mostly in Afghanistan and Iraq from June 2008 to February 2009. They wanted to find out the relative influence of both deployment-related trauma and civilian stress, including the influence of both or either on alcohol abuse.

Almost 60% of soldiers surveyed reported experiencing combat-related traumatic events; 13% of that group was abusing alcohol. Of the 17% who reported being sexually harassed, about 5% were abusing alcohol. Of the nearly 36% of respondents who also experienced civilian stressors, 7.1% were abusing alcohol. In a final model, only civilian stressors were associated with subsequent alcohol use disorder (AUD), independent of deployment-related traumatic events.

Of the respondents, 106 had experienced mental illness personally or in someone close to them, 156 had been through a divorce or breakup, and 105 had been unemployed for ≥ 3 months. While serving, 364 had encountered land mines, water mines, or booby traps; 573 had received hostile incoming fire; and 471 had been attacked by terrorists, insurgents, or civilians.

The civilian stressors found to be most closely associated with AUD were having a family member with a serious drug or alcohol problem (adjusted odds ratio [OR] 1.36; 95% CI, 0.96-1.94), being robbed or having the house broken into (adjusted OR, 1.48; 95% CI, 1.02-2.21), and having problems in getting access to adequate health care (adjusted OR, 1.97; 95% CI, 1.07-3.63). Having experienced sexual harassment was the most closely associated combat trauma.

It was clear to the researchers that the combination of deployment-related trauma and civilian stressors were associated with new onset of AUD. That could mean that adult-onset AUD constitutes a different phenotype from recurrent AUDs, the researchers say. They cite previous research that identified 2 “types” of people who abuse alcohol. One type has a later onset, has “greater malleability to the social environment,” uses alcohol to soothe anxiety, and has less severe alcohol dependence symptoms. The other type turns to alcohol earlier, may be genetically predisposed to alcohol abuse, uses alcohol for its euphoric effect, and has a chronic treatment history.

A consideration when evaluating the findings, the researchers say, is that the soldiers who were interviewed shortly after their deployment may have been misclassified because psychiatric symptoms tend to appear 3 to 4 months after deployment.

Source
Cerdá M, Richards C, Cohen GH, et al. Am J Prev Med. 2014;47(4):461-466.
doi: 10.1016/j.amepre.2014.06.015.

The stresses of civilian life—job problems, divorce, money—can add to the burden when a service member is already under strain from deployment-related traumatic events, such as being wounded or sexually harassed. Those extramilitary stressors may make it more likely for reserve soldiers to abuse alcohol, say researchers from Columbia University in New York City; University of Michigan in Ann Arbor; Case Western Reserve University in Cleveland, and University of Toledo, both in Ohio.

The researchers surveyed 1,095 members of the Ohio Army National Guard who served mostly in Afghanistan and Iraq from June 2008 to February 2009. They wanted to find out the relative influence of both deployment-related trauma and civilian stress, including the influence of both or either on alcohol abuse.

Almost 60% of soldiers surveyed reported experiencing combat-related traumatic events; 13% of that group was abusing alcohol. Of the 17% who reported being sexually harassed, about 5% were abusing alcohol. Of the nearly 36% of respondents who also experienced civilian stressors, 7.1% were abusing alcohol. In a final model, only civilian stressors were associated with subsequent alcohol use disorder (AUD), independent of deployment-related traumatic events.

Of the respondents, 106 had experienced mental illness personally or in someone close to them, 156 had been through a divorce or breakup, and 105 had been unemployed for ≥ 3 months. While serving, 364 had encountered land mines, water mines, or booby traps; 573 had received hostile incoming fire; and 471 had been attacked by terrorists, insurgents, or civilians.

The civilian stressors found to be most closely associated with AUD were having a family member with a serious drug or alcohol problem (adjusted odds ratio [OR] 1.36; 95% CI, 0.96-1.94), being robbed or having the house broken into (adjusted OR, 1.48; 95% CI, 1.02-2.21), and having problems in getting access to adequate health care (adjusted OR, 1.97; 95% CI, 1.07-3.63). Having experienced sexual harassment was the most closely associated combat trauma.

It was clear to the researchers that the combination of deployment-related trauma and civilian stressors were associated with new onset of AUD. That could mean that adult-onset AUD constitutes a different phenotype from recurrent AUDs, the researchers say. They cite previous research that identified 2 “types” of people who abuse alcohol. One type has a later onset, has “greater malleability to the social environment,” uses alcohol to soothe anxiety, and has less severe alcohol dependence symptoms. The other type turns to alcohol earlier, may be genetically predisposed to alcohol abuse, uses alcohol for its euphoric effect, and has a chronic treatment history.

A consideration when evaluating the findings, the researchers say, is that the soldiers who were interviewed shortly after their deployment may have been misclassified because psychiatric symptoms tend to appear 3 to 4 months after deployment.

Source
Cerdá M, Richards C, Cohen GH, et al. Am J Prev Med. 2014;47(4):461-466.
doi: 10.1016/j.amepre.2014.06.015.

U.S. military veterans living in rural areas who engage in evidence-based psychotherapy and telemedicine-based collaborative care can significantly increase their chances of improving outcomes related to posttraumatic stress disorder, according to a new study.

“Although psychotherapy and pharmacotherapy treatments for PTSD have proven to be efficacious in randomized clinical trials and have been disseminated widely by the [Veterans Health Administration], stigma and geographic barriers often prevent rural veterans from engaging in these evidence-based treatments,” says the study, published in JAMA (2014 Nov. 19 [doi.101001/jamapsychiatry.2014.1575]) and led by John C. Fortney, Ph.D., of the University of Washington’s department of psychiatry and behavioral sciences in Seattle, and his associates.

In a pragmatic, randomized effectiveness trial, Dr. Fortney and his associates recruited outpatients from 11 Department of Veterans Affairs (VA) community-based outpatient clinics (CBOCs) in predominantly rural areas of the United States over the course of 22 months. A total of 265 patients completed baseline interviews and randomization after meeting eligibility criteria, which consisted of meeting diagnostic standards for PTSD; having no medical history of schizophrenia, bipolar disorder, substance dependence, or hearing impairment; having a telephone; not having a life-threatening illness; and lacking capacity to consent.

© Dron - Fotolia.com

The 265 subjects were randomized into one of two groups: those receiving usual care (UC), or those receiving the Telemedicine Outreach for PTSD (TOP) treatment developed by the investigators. Patients were mostly unemployed, middle-aged men with severe PTSD symptoms and “other mental health coexisting illnesses,” according to a press release.

Subjects in the UC group received certain health care services, such as psychotropic medications for PTSD prescribed by psychiatrists, evidence-based psychotherapy for PTSD delivered by psychologists or social workers, supportive PTSD-focused therapy delivered by psychologists or social workers (individual and group), and supportive therapy delivered by social workers (individual and group), among others. Subjects in the TOP group, however, received the attention of telephone nurse care managers, including PTSD symptom monitoring and medication regimen adherence monitoring and promotion. In addition, those in the TOP group received access to a telephone pharmacist and telepsychologist.

Subjects were enrolled in a series of 12 cognitive processing therapy sessions for the duration of the study, from Nov. 23, 2009, through Sept. 28, 2011, and attendance was taken at each session. After the sessions concluded, subjects were then followed up on for 12 months.

During that follow-up period after treatments ended, patients who received TOP had significantly larger decreases in Posttraumatic Diagnostic Scale (PDS) scores (from 35.0 to 29.1), compared with those from the UC group (from 33.5 to 32.1) at 6 months (beta = −3.81; P = .002) and 12 months (beta = −2.49; P = .04). At 12 months, TOP subjects also had significantly larger decreases in PDS scores (from 35.0 to 30.1), compared with those who received UC (from 33.5 to 29.1) .

Subjects who attended at least eight cognitive processing therapy sessions were more likely to improve their PDS scores (beta = −3.86 [95% confidence interval, −7.19 to −0.54]; P = .02). However, the authors noted that there were “no significant group differences in the number of PTSD medications prescribed and adherence to medication regimens” was not significant.

“This trial introduces a promising model for managing PTSD in a treatment-resistant population,” Dr. Fortney and his associates wrote. “Findings suggest that telemedicine-based collaborative care can successfully engage this population in evidence-based psychotherapy for PTSD, thereby improving clinical outcomes.”

Among the study limitations cited by the investigators is that the PDS was administered to assess PTSD, rather than the Clinician-Administered PTSD Scale, which is the reference standard.

The authors reported no relevant financial conflicts of interest.

dchitnis@frontlinemedcom.com

U.S. military veterans living in rural areas who engage in evidence-based psychotherapy and telemedicine-based collaborative care can significantly increase their chances of improving outcomes related to posttraumatic stress disorder, according to a new study.

“Although psychotherapy and pharmacotherapy treatments for PTSD have proven to be efficacious in randomized clinical trials and have been disseminated widely by the [Veterans Health Administration], stigma and geographic barriers often prevent rural veterans from engaging in these evidence-based treatments,” says the study, published in JAMA (2014 Nov. 19 [doi.101001/jamapsychiatry.2014.1575]) and led by John C. Fortney, Ph.D., of the University of Washington’s department of psychiatry and behavioral sciences in Seattle, and his associates.

In a pragmatic, randomized effectiveness trial, Dr. Fortney and his associates recruited outpatients from 11 Department of Veterans Affairs (VA) community-based outpatient clinics (CBOCs) in predominantly rural areas of the United States over the course of 22 months. A total of 265 patients completed baseline interviews and randomization after meeting eligibility criteria, which consisted of meeting diagnostic standards for PTSD; having no medical history of schizophrenia, bipolar disorder, substance dependence, or hearing impairment; having a telephone; not having a life-threatening illness; and lacking capacity to consent.

© Dron - Fotolia.com

The 265 subjects were randomized into one of two groups: those receiving usual care (UC), or those receiving the Telemedicine Outreach for PTSD (TOP) treatment developed by the investigators. Patients were mostly unemployed, middle-aged men with severe PTSD symptoms and “other mental health coexisting illnesses,” according to a press release.

Subjects in the UC group received certain health care services, such as psychotropic medications for PTSD prescribed by psychiatrists, evidence-based psychotherapy for PTSD delivered by psychologists or social workers, supportive PTSD-focused therapy delivered by psychologists or social workers (individual and group), and supportive therapy delivered by social workers (individual and group), among others. Subjects in the TOP group, however, received the attention of telephone nurse care managers, including PTSD symptom monitoring and medication regimen adherence monitoring and promotion. In addition, those in the TOP group received access to a telephone pharmacist and telepsychologist.

Subjects were enrolled in a series of 12 cognitive processing therapy sessions for the duration of the study, from Nov. 23, 2009, through Sept. 28, 2011, and attendance was taken at each session. After the sessions concluded, subjects were then followed up on for 12 months.

During that follow-up period after treatments ended, patients who received TOP had significantly larger decreases in Posttraumatic Diagnostic Scale (PDS) scores (from 35.0 to 29.1), compared with those from the UC group (from 33.5 to 32.1) at 6 months (beta = −3.81; P = .002) and 12 months (beta = −2.49; P = .04). At 12 months, TOP subjects also had significantly larger decreases in PDS scores (from 35.0 to 30.1), compared with those who received UC (from 33.5 to 29.1) .

Subjects who attended at least eight cognitive processing therapy sessions were more likely to improve their PDS scores (beta = −3.86 [95% confidence interval, −7.19 to −0.54]; P = .02). However, the authors noted that there were “no significant group differences in the number of PTSD medications prescribed and adherence to medication regimens” was not significant.

“This trial introduces a promising model for managing PTSD in a treatment-resistant population,” Dr. Fortney and his associates wrote. “Findings suggest that telemedicine-based collaborative care can successfully engage this population in evidence-based psychotherapy for PTSD, thereby improving clinical outcomes.”

Among the study limitations cited by the investigators is that the PDS was administered to assess PTSD, rather than the Clinician-Administered PTSD Scale, which is the reference standard.

The authors reported no relevant financial conflicts of interest.

dchitnis@frontlinemedcom.com

U.S. military veterans living in rural areas who engage in evidence-based psychotherapy and telemedicine-based collaborative care can significantly increase their chances of improving outcomes related to posttraumatic stress disorder, according to a new study.

“Although psychotherapy and pharmacotherapy treatments for PTSD have proven to be efficacious in randomized clinical trials and have been disseminated widely by the [Veterans Health Administration], stigma and geographic barriers often prevent rural veterans from engaging in these evidence-based treatments,” says the study, published in JAMA (2014 Nov. 19 [doi.101001/jamapsychiatry.2014.1575]) and led by John C. Fortney, Ph.D., of the University of Washington’s department of psychiatry and behavioral sciences in Seattle, and his associates.

In a pragmatic, randomized effectiveness trial, Dr. Fortney and his associates recruited outpatients from 11 Department of Veterans Affairs (VA) community-based outpatient clinics (CBOCs) in predominantly rural areas of the United States over the course of 22 months. A total of 265 patients completed baseline interviews and randomization after meeting eligibility criteria, which consisted of meeting diagnostic standards for PTSD; having no medical history of schizophrenia, bipolar disorder, substance dependence, or hearing impairment; having a telephone; not having a life-threatening illness; and lacking capacity to consent.

© Dron - Fotolia.com

The 265 subjects were randomized into one of two groups: those receiving usual care (UC), or those receiving the Telemedicine Outreach for PTSD (TOP) treatment developed by the investigators. Patients were mostly unemployed, middle-aged men with severe PTSD symptoms and “other mental health coexisting illnesses,” according to a press release.

Subjects in the UC group received certain health care services, such as psychotropic medications for PTSD prescribed by psychiatrists, evidence-based psychotherapy for PTSD delivered by psychologists or social workers, supportive PTSD-focused therapy delivered by psychologists or social workers (individual and group), and supportive therapy delivered by social workers (individual and group), among others. Subjects in the TOP group, however, received the attention of telephone nurse care managers, including PTSD symptom monitoring and medication regimen adherence monitoring and promotion. In addition, those in the TOP group received access to a telephone pharmacist and telepsychologist.

Subjects were enrolled in a series of 12 cognitive processing therapy sessions for the duration of the study, from Nov. 23, 2009, through Sept. 28, 2011, and attendance was taken at each session. After the sessions concluded, subjects were then followed up on for 12 months.

During that follow-up period after treatments ended, patients who received TOP had significantly larger decreases in Posttraumatic Diagnostic Scale (PDS) scores (from 35.0 to 29.1), compared with those from the UC group (from 33.5 to 32.1) at 6 months (beta = −3.81; P = .002) and 12 months (beta = −2.49; P = .04). At 12 months, TOP subjects also had significantly larger decreases in PDS scores (from 35.0 to 30.1), compared with those who received UC (from 33.5 to 29.1) .

Subjects who attended at least eight cognitive processing therapy sessions were more likely to improve their PDS scores (beta = −3.86 [95% confidence interval, −7.19 to −0.54]; P = .02). However, the authors noted that there were “no significant group differences in the number of PTSD medications prescribed and adherence to medication regimens” was not significant.

“This trial introduces a promising model for managing PTSD in a treatment-resistant population,” Dr. Fortney and his associates wrote. “Findings suggest that telemedicine-based collaborative care can successfully engage this population in evidence-based psychotherapy for PTSD, thereby improving clinical outcomes.”

Among the study limitations cited by the investigators is that the PDS was administered to assess PTSD, rather than the Clinician-Administered PTSD Scale, which is the reference standard.

The authors reported no relevant financial conflicts of interest.

dchitnis@frontlinemedcom.com

Military sexual trauma (MST) refers to experiences of sexual assault or repeated, threatening sexual harassment experienced while on federal active duty or active duty for training. About 1 in 4 women and 1 in 100 men have reported MST to their VA doctors. However, these numbers do not account for those who have not sought health care for their MST experience or who have sought care for MST outside the VA.

Military sexual trauma is:

Military sexual trauma is the term VA uses to refer to sexual assault or sexual harassment that occurred while the veteran was in the military. A victim of MST may have been:

• Involved in sexual activity against his or her will, by physical force or nonphysical pressure. Nonphysical pressure includes threats of negative consequences for refusing to be sexually cooperative, or indirect promises of faster promotions or better treatment in exchange for sex.
• Unable to consent to sexual activities. This includes intoxication by alcohol or other substances.

Other experiences include sexual touching or grabbing, threatening or offensive remarks about a person’s body or sexual activities, as well as threatening and unwelcome sexual advances.

How do I know if I’m at risk?

Military sexual trauma can occur on or off base and while a service member—man or woman—is on or off duty. Those who commit sexual assault or sexual harassment can be men or women, military personnel or civilians, commanding officers or subordinates, strangers, friends, spouses, or intimate partners. 

When do I need medical attention?

The VA reports sexual assault is more likely to result in symptoms of PTSD (posttraumatic stress disorder) than are most other types of trauma, including combat. You should seek medical attention from your primary care doctor, a mental health professional, or your VA facility’s MST Coordinator following a MST experience, especially if you experience any of the following symptoms:

• Depression
• Suicidal thoughts
• Feeling angry or irritable most of the time
• Strong emotional reactions
• Feeling emotionally numb
• Trouble falling or staying asleep
• Nightmares
• Trouble focusing
• Difficulty remembering things
• Substance abuse
• Trouble feeling safe or trusting others
• Feeling isolated or disconnected from others
• Headaches
• Gastrointestinal difficulties
• Sexual dysfunction
• Chronic pain
• Chronic fatigue
• Weight or eating problems

Survivors who are not formally diagnosed may still struggle in certain situations with emotional reactions, memories related to their experiences of MST, or other interpersonal issues.

How is MST treated?

Because MST is an experience, not a diagnosis, treatment needs may vary from patient to patient. However, VA provides free, confidential counseling and treatment to male and female veterans for mental and physical health conditions related to experiences of MST. It is important to note that treatment is available even if the MST incident was not reported at the time it happened.

Your doctor may recommend individual therapy, group therapy, or medication, depending on your symptoms. Therapies that may be used to treat MST include:

• Cognitive behavioral therapy. The main goal of this therapy is to help you change your thought patterns, which will help you change the emotions and behavior connected with the MST experience. A counselor might encourage you to reimagine your trauma repeatedly under controlled conditions—an approach called exposure therapy—as a way of learning to cope.
• Stress inoculation (in-ock-you-lay-shun) training. This therapy involves combining stress management strategies with stress-relieving techniques, such as muscle relaxation, breathing retraining, self-dialogue, and thought stopping.
• Group therapy. This therapy enables you to discuss your trauma with others who have had similar experiences.
• Inpatient therapy. Nationwide, there are programs that offer specialized sexual trauma treatment for veterans who need more intense treatment and support, including that for severe depression or substance abuse.
• Medication. If your MST experience resulted in PTSD, your doctor may prescribe medication to help control symptoms of anxiety or to help you sleep. Your doctor will monitor you closely for any possible adverse effects of these medications. It is also possible that an STD (sexually transmitted disease) was passed during the trauma, so your doctor may choose to screen you for an STD. If the test comes back positive, your doctor will prescribe the appropriate drug for treatment.

Services are designed to help veterans at all stages of their recovery, whether that is focusing on strategies for coping with emotions and memories or, for veterans who are ready, talking about their MST experiences in depth.

What can I do to cope?

When trauma survivors take direct action to cope with their stress reactions, they put themselves in a position of power. This is called active coping, which involves accepting the impact the trauma had on your life and taking direct action to make improvements.

It is important to remember that recovery is a process and takes time. Healing from trauma, including MST, does not happen all at once, and healing does not mean that you must forget the experience. Instead, it means you have less pain and fewer bad feelings when you think about the experience, and any associated symptoms will over time bother you less.

Discussing your trauma with other survivors in a controlled setting can help you learn that you are not alone or weak. In addition, surrounding yourself with people you can talk to about your MST experience may help you feel more understood. You may even choose to distract yourself with positive recreational or work activities.

When you experience unwanted or distressing memories, remind yourself that they are just memories, and talk about them with someone you trust. If you feel that the trauma is happening again, which is known as a flashback, keep your eyes open and remind yourself where you presently are and that the trauma happened in the past.

Although VA and DoD are working to put an end to MST, it is an ongoing problem that affects a large percentage of women and men who proudly serve in the armed forces. For information on how to access free VA services and to determine your eligibility in MST benefits, visit http://www.mentalhealth.va.gov/msthome.asp.

Military sexual trauma (MST) refers to experiences of sexual assault or repeated, threatening sexual harassment experienced while on federal active duty or active duty for training. About 1 in 4 women and 1 in 100 men have reported MST to their VA doctors. However, these numbers do not account for those who have not sought health care for their MST experience or who have sought care for MST outside the VA.

Military sexual trauma is:

Military sexual trauma is the term VA uses to refer to sexual assault or sexual harassment that occurred while the veteran was in the military. A victim of MST may have been:

• Involved in sexual activity against his or her will, by physical force or nonphysical pressure. Nonphysical pressure includes threats of negative consequences for refusing to be sexually cooperative, or indirect promises of faster promotions or better treatment in exchange for sex.
• Unable to consent to sexual activities. This includes intoxication by alcohol or other substances.

Other experiences include sexual touching or grabbing, threatening or offensive remarks about a person’s body or sexual activities, as well as threatening and unwelcome sexual advances.

How do I know if I’m at risk?

Military sexual trauma can occur on or off base and while a service member—man or woman—is on or off duty. Those who commit sexual assault or sexual harassment can be men or women, military personnel or civilians, commanding officers or subordinates, strangers, friends, spouses, or intimate partners. 

When do I need medical attention?

The VA reports sexual assault is more likely to result in symptoms of PTSD (posttraumatic stress disorder) than are most other types of trauma, including combat. You should seek medical attention from your primary care doctor, a mental health professional, or your VA facility’s MST Coordinator following a MST experience, especially if you experience any of the following symptoms:

• Depression
• Suicidal thoughts
• Feeling angry or irritable most of the time
• Strong emotional reactions
• Feeling emotionally numb
• Trouble falling or staying asleep
• Nightmares
• Trouble focusing
• Difficulty remembering things
• Substance abuse
• Trouble feeling safe or trusting others
• Feeling isolated or disconnected from others
• Headaches
• Gastrointestinal difficulties
• Sexual dysfunction
• Chronic pain
• Chronic fatigue
• Weight or eating problems

Survivors who are not formally diagnosed may still struggle in certain situations with emotional reactions, memories related to their experiences of MST, or other interpersonal issues.

How is MST treated?

Because MST is an experience, not a diagnosis, treatment needs may vary from patient to patient. However, VA provides free, confidential counseling and treatment to male and female veterans for mental and physical health conditions related to experiences of MST. It is important to note that treatment is available even if the MST incident was not reported at the time it happened.

Your doctor may recommend individual therapy, group therapy, or medication, depending on your symptoms. Therapies that may be used to treat MST include:

• Cognitive behavioral therapy. The main goal of this therapy is to help you change your thought patterns, which will help you change the emotions and behavior connected with the MST experience. A counselor might encourage you to reimagine your trauma repeatedly under controlled conditions—an approach called exposure therapy—as a way of learning to cope.
• Stress inoculation (in-ock-you-lay-shun) training. This therapy involves combining stress management strategies with stress-relieving techniques, such as muscle relaxation, breathing retraining, self-dialogue, and thought stopping.
• Group therapy. This therapy enables you to discuss your trauma with others who have had similar experiences.
• Inpatient therapy. Nationwide, there are programs that offer specialized sexual trauma treatment for veterans who need more intense treatment and support, including that for severe depression or substance abuse.
• Medication. If your MST experience resulted in PTSD, your doctor may prescribe medication to help control symptoms of anxiety or to help you sleep. Your doctor will monitor you closely for any possible adverse effects of these medications. It is also possible that an STD (sexually transmitted disease) was passed during the trauma, so your doctor may choose to screen you for an STD. If the test comes back positive, your doctor will prescribe the appropriate drug for treatment.

Services are designed to help veterans at all stages of their recovery, whether that is focusing on strategies for coping with emotions and memories or, for veterans who are ready, talking about their MST experiences in depth.

What can I do to cope?

When trauma survivors take direct action to cope with their stress reactions, they put themselves in a position of power. This is called active coping, which involves accepting the impact the trauma had on your life and taking direct action to make improvements.

It is important to remember that recovery is a process and takes time. Healing from trauma, including MST, does not happen all at once, and healing does not mean that you must forget the experience. Instead, it means you have less pain and fewer bad feelings when you think about the experience, and any associated symptoms will over time bother you less.

Discussing your trauma with other survivors in a controlled setting can help you learn that you are not alone or weak. In addition, surrounding yourself with people you can talk to about your MST experience may help you feel more understood. You may even choose to distract yourself with positive recreational or work activities.

When you experience unwanted or distressing memories, remind yourself that they are just memories, and talk about them with someone you trust. If you feel that the trauma is happening again, which is known as a flashback, keep your eyes open and remind yourself where you presently are and that the trauma happened in the past.

Although VA and DoD are working to put an end to MST, it is an ongoing problem that affects a large percentage of women and men who proudly serve in the armed forces. For information on how to access free VA services and to determine your eligibility in MST benefits, visit http://www.mentalhealth.va.gov/msthome.asp.

Military sexual trauma (MST) refers to experiences of sexual assault or repeated, threatening sexual harassment experienced while on federal active duty or active duty for training. About 1 in 4 women and 1 in 100 men have reported MST to their VA doctors. However, these numbers do not account for those who have not sought health care for their MST experience or who have sought care for MST outside the VA.

Military sexual trauma is:

Military sexual trauma is the term VA uses to refer to sexual assault or sexual harassment that occurred while the veteran was in the military. A victim of MST may have been:

• Involved in sexual activity against his or her will, by physical force or nonphysical pressure. Nonphysical pressure includes threats of negative consequences for refusing to be sexually cooperative, or indirect promises of faster promotions or better treatment in exchange for sex.
• Unable to consent to sexual activities. This includes intoxication by alcohol or other substances.

Other experiences include sexual touching or grabbing, threatening or offensive remarks about a person’s body or sexual activities, as well as threatening and unwelcome sexual advances.

How do I know if I’m at risk?

Military sexual trauma can occur on or off base and while a service member—man or woman—is on or off duty. Those who commit sexual assault or sexual harassment can be men or women, military personnel or civilians, commanding officers or subordinates, strangers, friends, spouses, or intimate partners. 

When do I need medical attention?

The VA reports sexual assault is more likely to result in symptoms of PTSD (posttraumatic stress disorder) than are most other types of trauma, including combat. You should seek medical attention from your primary care doctor, a mental health professional, or your VA facility’s MST Coordinator following a MST experience, especially if you experience any of the following symptoms:

• Depression
• Suicidal thoughts
• Feeling angry or irritable most of the time
• Strong emotional reactions
• Feeling emotionally numb
• Trouble falling or staying asleep
• Nightmares
• Trouble focusing
• Difficulty remembering things
• Substance abuse
• Trouble feeling safe or trusting others
• Feeling isolated or disconnected from others
• Headaches
• Gastrointestinal difficulties
• Sexual dysfunction
• Chronic pain
• Chronic fatigue
• Weight or eating problems

Survivors who are not formally diagnosed may still struggle in certain situations with emotional reactions, memories related to their experiences of MST, or other interpersonal issues.

How is MST treated?

Because MST is an experience, not a diagnosis, treatment needs may vary from patient to patient. However, VA provides free, confidential counseling and treatment to male and female veterans for mental and physical health conditions related to experiences of MST. It is important to note that treatment is available even if the MST incident was not reported at the time it happened.

Your doctor may recommend individual therapy, group therapy, or medication, depending on your symptoms. Therapies that may be used to treat MST include:

• Cognitive behavioral therapy. The main goal of this therapy is to help you change your thought patterns, which will help you change the emotions and behavior connected with the MST experience. A counselor might encourage you to reimagine your trauma repeatedly under controlled conditions—an approach called exposure therapy—as a way of learning to cope.
• Stress inoculation (in-ock-you-lay-shun) training. This therapy involves combining stress management strategies with stress-relieving techniques, such as muscle relaxation, breathing retraining, self-dialogue, and thought stopping.
• Group therapy. This therapy enables you to discuss your trauma with others who have had similar experiences.
• Inpatient therapy. Nationwide, there are programs that offer specialized sexual trauma treatment for veterans who need more intense treatment and support, including that for severe depression or substance abuse.
• Medication. If your MST experience resulted in PTSD, your doctor may prescribe medication to help control symptoms of anxiety or to help you sleep. Your doctor will monitor you closely for any possible adverse effects of these medications. It is also possible that an STD (sexually transmitted disease) was passed during the trauma, so your doctor may choose to screen you for an STD. If the test comes back positive, your doctor will prescribe the appropriate drug for treatment.

Services are designed to help veterans at all stages of their recovery, whether that is focusing on strategies for coping with emotions and memories or, for veterans who are ready, talking about their MST experiences in depth.

What can I do to cope?

When trauma survivors take direct action to cope with their stress reactions, they put themselves in a position of power. This is called active coping, which involves accepting the impact the trauma had on your life and taking direct action to make improvements.

It is important to remember that recovery is a process and takes time. Healing from trauma, including MST, does not happen all at once, and healing does not mean that you must forget the experience. Instead, it means you have less pain and fewer bad feelings when you think about the experience, and any associated symptoms will over time bother you less.

Discussing your trauma with other survivors in a controlled setting can help you learn that you are not alone or weak. In addition, surrounding yourself with people you can talk to about your MST experience may help you feel more understood. You may even choose to distract yourself with positive recreational or work activities.

When you experience unwanted or distressing memories, remind yourself that they are just memories, and talk about them with someone you trust. If you feel that the trauma is happening again, which is known as a flashback, keep your eyes open and remind yourself where you presently are and that the trauma happened in the past.

Although VA and DoD are working to put an end to MST, it is an ongoing problem that affects a large percentage of women and men who proudly serve in the armed forces. For information on how to access free VA services and to determine your eligibility in MST benefits, visit http://www.mentalhealth.va.gov/msthome.asp.

Anxiety is a necessary and natural reaction to trauma, but, sometimes, anxiety symptoms become excessive and problematic, as experienced with posttraumatic stress disorder (PTSD). Some patients who struggle with PTSD endure a relentless apprehension so intense that it keeps them from participating in everyday activities, such as attending work and partaking in social activities. Associated anxiety symptoms severely impair everyday function and include increased heart rate, sweating, intrusive images, poor attention, fear, or insomnia. Posttraumatic stress disorder symptoms often lead to occupational dysfunction, relationship difficulty, and numerous other functional impairments.

Approximately 300,000 veterans meet the criteria for PTSD related to ongoing or recent wars.¹ The veteran does not bear the personal and functional burden alone; however, the financial load is felt throughout society. One recent study suggests that for veterans diagnosed with PTSD, the first 2 years after deployment cost society an estimated $7,000 per individial.² Current research suggests that this potentially debilitating disorder occurs in about 14% of Operation Iraqi Freedom/Operation Enduring Freedom combat troops, whereas the similar U.S. demographic population experiences PTSD at a rate of about 7%.^1,3 The ongoing military trauma exposures are compelling the mental health community to establish efficient and effective treatment options.^4,5

Several treatment strategies exist to reduce PTSD symptoms, but health care professionals must seek a balance between therapeutic benefit and cost. The treatment of PTSD is diverse and variable; however, in the most recent Clinical Practice Guideline (CPG) for PTSD, the VA and DoD specifically endorse some psychotherapeutic interventions while dissuading the use of others.⁶ Of note, the VA and DoD CPG strongly encourages Stress Inoculation Training (SIT) and similar cognitive therapies aimed at guiding patients through the process of consciously understanding the relationship between thoughts and feelings and then modifying thoughts to appropriately manage stressors.⁶ Meanwhile, group psychotherapy has been determined to be “somewhat helpful.”⁶ Even though cognitive- and group-based therapies have long been established as efficacious for numerous psychological disorders (depression, obsessive compulsive disorder, eating disorders, etc), neither the American Group Psychotherapy Association nor the VA and DoD CPG directly endorse the use of group cognitive behavioral therapy (GCBT) for the treatment of PTSD.^6,7 However, both VA and DoD mental health providers commonly practice CBT and various group psychotherapies for the treatment of PTSD.

Despite the widespread use of CBT, there is a gap in the clinical understanding of the evidence supporting GCBT for PTSD. The goal of this synthesis was to understand the efficacy of treating PTSD symptoms with group psychotherapy. To begin this investigation, the following PICO (population, intervention, comparison, outcome) question was asked: In adults diagnosed with PTSD, how effective is group cognitive behavioral therapy in reducing PTSD-related symptoms?

Methods

Research articles addressing the use of GCBT in PTSD were obtained via database searches that took place during October 2012 (Table). Searched databases included the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews Randomized Controlled Trials, Psychological Information (PsycINFO), and Public Medicine (PubMed).

The PubMed database was searched using the following MeSH (medical subject heading) terms: “psychotherapy, group” and “stress disorders, post-traumatic” and “cognitive therapy.” Limitations were set to include only patients aged ≥ 18 years, results in English, those involving human subjects, and articles published within the past 5 years. A manual search of references was also conducted, and relevant articles were retained.

Articles that addressed primary substance abuse, other DSM Axis I disorders, intimate partner violence, or family issues were excluded from the evidence sample due to concerns of an alternate treatment focus. Articles with a focus on telehealth or alternative medicine were considered confounding to the scope of this review were also excluded. It was also noted that the term CBT is used collectively for an umbrella of treatments; however, treatments that focused on elements other than the components of CBT being delivered in a group were not included. To prevent duplication of the results, research from an inclusive review was not considered individually.

SUMMARY OF EVIDENCE

Six works fulfilled the PICO criteria and were of sufficient quality to be synthesized. Of the 6 articles retained for synthesis, 2 were high-level reviews. Both reviews supported the use of GCBT for PTSD treatment. Barrera and colleagues reported an overall large effect size regardless of the presence of exposure in-group among the 12 treatment conditions and 651 study participants.⁸ These researchers also reported that in-group exposure did not further traumatize other group members.

Similarly, although a notably older and smaller review, Bisson and Andrew reported a significant standard mean deviation between 4 GCBT treatment and wait list controls. These reviewers did not find a significant difference between trauma- and nontrauma-focused treatment groups. The reviews also noted that individual psychotherapy and/or pharmacotherapy was most often continued throughout the reviewed studies.^8,9

The 4 other studies contribute substantively to this synthesis but arguably represent lower evidence quality. A large longitudinal study of 496 Australian veterans reported a large effect size that was sustained 9 months after treatment began.¹⁰ These researchers used an intensive outpatient program that included medication and other treatment modalities as the basis for GCBT delivery. They reported that the majority of the patients revealed improvement in PTSD symptoms.

Another study sampled a similar group of 10 combat veterans but focused particular attention on sleep-related PTSD symptoms of insomnia, nightmares, and sleep quality.¹¹ Although these researchers were unable to report a significant difference in overall PTSD symptoms for the 8 subjects who completed the protocol, they did find a large effect size on insomnia severity and a medium effect size on sleep quality. Regular treatment, including medication, continued throughout this study.

Other researchers reported a medium effect size on PTSD symptoms while using GCBT in a heterogeneous group with various anxiety disorders, including obsessive compulsive disorder, generalized anxiety disorder, social phobia, panic disorders, and PTSD.¹² Although reporting similar results as all other included studies, this study has some significant limitations, including a 26% dropout rate among the 152 participants. The final study included for synthesis reported a remarkable 67% elimination of the PTSD diagnosis among 6 motor vehicle accident survivors in the small, uncontrolled study.¹³ Concomitant treatments, including medications, were not reported in detail for these 4 studies except as mentioned.

As a whole, the 6 studies revealed some appreciable commonalities. Time since diagnosis did not seem to influence the results. Attrition was consistently found to be similar to other PTSD treatments. The reported session topics were loosely based on common CBT tenets (ie, education, challenging cognitions, and relaxation techniques) and were typically similar among treatment groups, including the use of homework.

DISCUSSION

As the diagnosis of PTSD increases to unfamiliar levels, GCBT has the potential to be helpful to clinicians and patients seeking alternatives to their current treatments.^1,4,14 The reported results imply that GCBT can be useful in PTSD symptom reduction. This could be particularly useful to VA and military providers or rural providers operating with limited resources.

Treatment protocols are not well established and should be approached with care prior to the establishment of CBT treatment groups for those diagnosed with PTSD. Session overviews and descriptions, such as those mentioned in Thompson and colleagues, could provide a reference point for future use.¹³

Also worth considering, CBT can be an ambiguous term requiring deliberate definition within treatment protocols. As noted in the VA and DoD CPG, exposure- and trauma-focused treatment designs can be efficacious, but these elements do not seem to be required within the GCBT treatment setting.

The current research also suggests GCBT efficacy regardless of the index trauma. This does not suggest that heterogeneous groups were frequently studied nor can conclusions be drawn regarding heterogeneous treatment groups. Elements such as group size and session length are inconsistently reported and require specific consideration as well. There is a distinct lack of research directly comparing individual CBT with GCBT directly, which prohibits meaningful conclusions regarding PTSD symptom reduction. This research gap may well have influenced the recommendations within the VA and DoD CPG. Although some higher quality studies exist, many of the published reports on GCBT have noteworthy design flaw, such as inadequate controls and statistical analysis.

LIMITATIONS

There are some limitations to this literature synthesis. Although the search was limited to the past 5 years, the inclusion of reviews accounts for older evidence. As alluded to earlier, the lack of a standardized GCBT treatment protocol challenges results comparisons as well. The consequent treatment variations make direct interstudy comparison and synthesis difficult. Similarly, outcome measures varied between studies. Also, group psychotherapy is well established and accepted. Therefore, much of the supporting research was accomplished outside the parameters of this literature search. This empirical view of group psychotherapy among mental health providers may also contribute to the lack of available research.

It is also worth noting that studies finding neutral or negative results are often unpublished. This publication bias could account for the lack of available evidence. The research reports do not consistently report therapist qualifications; however, board certificates in group psychotherapy and CBT are undeniably variables available for debate. The inclusion of uncontrolled trials limits these findings as well. Although the above limitations are not exhaustive, they do provide necessary caveats to future generalizations.

FUTURE IMPLICATIONS

Perhaps the most important information to gain from future research is that of treatment outcomes. Studies that include a detailed outcome evaluation could reveal patient satisfaction, efficacy, and financial considerations. In the presence of adequate supportive data, GCBT could contribute outcome data regarding trauma survivor symptom normalization, peer support formation, access to care, treatment efficiency, and health care resources utilization. As noted in Barrera and colleagues, future analysis will require a greater volume of trials with an overall increase in methodological rigor.⁸

Current research has demonstrated a solid base from which to spawn specific treatment protocols. The available research is investigational in terms of treatment procedures. Replication of these studies could dictate treatment protocol and contribute substantively to future VA and DoD CPG updates. Future researchers should consider the use of a standard PTSD symptom assessment tool to make interstudy comparisons more meaningful. The length of treatment and exposure elements should be targeted specifically in future research as these components currently vary the most.

The military represents an obvious avenue for future research due to increased PTSD diagnosis in recent years. Although the etiology of the increase in PTSD is unclear and most likely multifactorial (decreased resilience, increased awareness, increased pursuit of secondary gains, etc), the need for treatment options is apparent.¹ Group cohesion has been shown to be a core component of successful group psychotherapy, so military members who are accustomed to unit cohesion might represent a uniquely suitable population for this modality.¹⁵ Interestingly and for reasons not currently understood, veterans do not see effects of therapy as large as their civilian counterparts.⁸ This underscores the need for further evaluation of military-specific outcomes.

CONCLUSIONS

Although the available evidence is not robust, results do support the careful use of GCBT as an effective treatment for PTSD symptom reduction.⁸ Group psychotherapy has been generally regarded as an efficacious and cost-effective method to achieve similar outcomes to individual therapy. Increasing PTSD prevalence compels mental health care providers to explore all available treatment options. The potential for GCBT as an option is exciting, especially for mental health providers and those with limited resources. Rising health care standards and the current national fiscal situation is dictating a reevaluation of treatment options; so perhaps all health care providers will soon consider the use of GCBT.

As with any group assignment, the clinician should carefully consider the individual’s suitability and desire for group participation.¹⁶ With GCBT, providers could facilitate the relief of relentless apprehension and functional impairment for several patients simultaneously. Although there are many details left to explore regarding the use of GCBT for PTSD, the therapy’s foundation for use as a PTSD treatment is apparent.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Anxiety is a necessary and natural reaction to trauma, but, sometimes, anxiety symptoms become excessive and problematic, as experienced with posttraumatic stress disorder (PTSD). Some patients who struggle with PTSD endure a relentless apprehension so intense that it keeps them from participating in everyday activities, such as attending work and partaking in social activities. Associated anxiety symptoms severely impair everyday function and include increased heart rate, sweating, intrusive images, poor attention, fear, or insomnia. Posttraumatic stress disorder symptoms often lead to occupational dysfunction, relationship difficulty, and numerous other functional impairments.

Approximately 300,000 veterans meet the criteria for PTSD related to ongoing or recent wars.¹ The veteran does not bear the personal and functional burden alone; however, the financial load is felt throughout society. One recent study suggests that for veterans diagnosed with PTSD, the first 2 years after deployment cost society an estimated $7,000 per individial.² Current research suggests that this potentially debilitating disorder occurs in about 14% of Operation Iraqi Freedom/Operation Enduring Freedom combat troops, whereas the similar U.S. demographic population experiences PTSD at a rate of about 7%.^1,3 The ongoing military trauma exposures are compelling the mental health community to establish efficient and effective treatment options.^4,5

Several treatment strategies exist to reduce PTSD symptoms, but health care professionals must seek a balance between therapeutic benefit and cost. The treatment of PTSD is diverse and variable; however, in the most recent Clinical Practice Guideline (CPG) for PTSD, the VA and DoD specifically endorse some psychotherapeutic interventions while dissuading the use of others.⁶ Of note, the VA and DoD CPG strongly encourages Stress Inoculation Training (SIT) and similar cognitive therapies aimed at guiding patients through the process of consciously understanding the relationship between thoughts and feelings and then modifying thoughts to appropriately manage stressors.⁶ Meanwhile, group psychotherapy has been determined to be “somewhat helpful.”⁶ Even though cognitive- and group-based therapies have long been established as efficacious for numerous psychological disorders (depression, obsessive compulsive disorder, eating disorders, etc), neither the American Group Psychotherapy Association nor the VA and DoD CPG directly endorse the use of group cognitive behavioral therapy (GCBT) for the treatment of PTSD.^6,7 However, both VA and DoD mental health providers commonly practice CBT and various group psychotherapies for the treatment of PTSD.

Despite the widespread use of CBT, there is a gap in the clinical understanding of the evidence supporting GCBT for PTSD. The goal of this synthesis was to understand the efficacy of treating PTSD symptoms with group psychotherapy. To begin this investigation, the following PICO (population, intervention, comparison, outcome) question was asked: In adults diagnosed with PTSD, how effective is group cognitive behavioral therapy in reducing PTSD-related symptoms?

Methods

Research articles addressing the use of GCBT in PTSD were obtained via database searches that took place during October 2012 (Table). Searched databases included the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews Randomized Controlled Trials, Psychological Information (PsycINFO), and Public Medicine (PubMed).

The PubMed database was searched using the following MeSH (medical subject heading) terms: “psychotherapy, group” and “stress disorders, post-traumatic” and “cognitive therapy.” Limitations were set to include only patients aged ≥ 18 years, results in English, those involving human subjects, and articles published within the past 5 years. A manual search of references was also conducted, and relevant articles were retained.

Articles that addressed primary substance abuse, other DSM Axis I disorders, intimate partner violence, or family issues were excluded from the evidence sample due to concerns of an alternate treatment focus. Articles with a focus on telehealth or alternative medicine were considered confounding to the scope of this review were also excluded. It was also noted that the term CBT is used collectively for an umbrella of treatments; however, treatments that focused on elements other than the components of CBT being delivered in a group were not included. To prevent duplication of the results, research from an inclusive review was not considered individually.

SUMMARY OF EVIDENCE

Six works fulfilled the PICO criteria and were of sufficient quality to be synthesized. Of the 6 articles retained for synthesis, 2 were high-level reviews. Both reviews supported the use of GCBT for PTSD treatment. Barrera and colleagues reported an overall large effect size regardless of the presence of exposure in-group among the 12 treatment conditions and 651 study participants.⁸ These researchers also reported that in-group exposure did not further traumatize other group members.

Similarly, although a notably older and smaller review, Bisson and Andrew reported a significant standard mean deviation between 4 GCBT treatment and wait list controls. These reviewers did not find a significant difference between trauma- and nontrauma-focused treatment groups. The reviews also noted that individual psychotherapy and/or pharmacotherapy was most often continued throughout the reviewed studies.^8,9

The 4 other studies contribute substantively to this synthesis but arguably represent lower evidence quality. A large longitudinal study of 496 Australian veterans reported a large effect size that was sustained 9 months after treatment began.¹⁰ These researchers used an intensive outpatient program that included medication and other treatment modalities as the basis for GCBT delivery. They reported that the majority of the patients revealed improvement in PTSD symptoms.

Another study sampled a similar group of 10 combat veterans but focused particular attention on sleep-related PTSD symptoms of insomnia, nightmares, and sleep quality.¹¹ Although these researchers were unable to report a significant difference in overall PTSD symptoms for the 8 subjects who completed the protocol, they did find a large effect size on insomnia severity and a medium effect size on sleep quality. Regular treatment, including medication, continued throughout this study.

Other researchers reported a medium effect size on PTSD symptoms while using GCBT in a heterogeneous group with various anxiety disorders, including obsessive compulsive disorder, generalized anxiety disorder, social phobia, panic disorders, and PTSD.¹² Although reporting similar results as all other included studies, this study has some significant limitations, including a 26% dropout rate among the 152 participants. The final study included for synthesis reported a remarkable 67% elimination of the PTSD diagnosis among 6 motor vehicle accident survivors in the small, uncontrolled study.¹³ Concomitant treatments, including medications, were not reported in detail for these 4 studies except as mentioned.

As a whole, the 6 studies revealed some appreciable commonalities. Time since diagnosis did not seem to influence the results. Attrition was consistently found to be similar to other PTSD treatments. The reported session topics were loosely based on common CBT tenets (ie, education, challenging cognitions, and relaxation techniques) and were typically similar among treatment groups, including the use of homework.

DISCUSSION

As the diagnosis of PTSD increases to unfamiliar levels, GCBT has the potential to be helpful to clinicians and patients seeking alternatives to their current treatments.^1,4,14 The reported results imply that GCBT can be useful in PTSD symptom reduction. This could be particularly useful to VA and military providers or rural providers operating with limited resources.

Treatment protocols are not well established and should be approached with care prior to the establishment of CBT treatment groups for those diagnosed with PTSD. Session overviews and descriptions, such as those mentioned in Thompson and colleagues, could provide a reference point for future use.¹³

Also worth considering, CBT can be an ambiguous term requiring deliberate definition within treatment protocols. As noted in the VA and DoD CPG, exposure- and trauma-focused treatment designs can be efficacious, but these elements do not seem to be required within the GCBT treatment setting.

The current research also suggests GCBT efficacy regardless of the index trauma. This does not suggest that heterogeneous groups were frequently studied nor can conclusions be drawn regarding heterogeneous treatment groups. Elements such as group size and session length are inconsistently reported and require specific consideration as well. There is a distinct lack of research directly comparing individual CBT with GCBT directly, which prohibits meaningful conclusions regarding PTSD symptom reduction. This research gap may well have influenced the recommendations within the VA and DoD CPG. Although some higher quality studies exist, many of the published reports on GCBT have noteworthy design flaw, such as inadequate controls and statistical analysis.

LIMITATIONS

There are some limitations to this literature synthesis. Although the search was limited to the past 5 years, the inclusion of reviews accounts for older evidence. As alluded to earlier, the lack of a standardized GCBT treatment protocol challenges results comparisons as well. The consequent treatment variations make direct interstudy comparison and synthesis difficult. Similarly, outcome measures varied between studies. Also, group psychotherapy is well established and accepted. Therefore, much of the supporting research was accomplished outside the parameters of this literature search. This empirical view of group psychotherapy among mental health providers may also contribute to the lack of available research.

It is also worth noting that studies finding neutral or negative results are often unpublished. This publication bias could account for the lack of available evidence. The research reports do not consistently report therapist qualifications; however, board certificates in group psychotherapy and CBT are undeniably variables available for debate. The inclusion of uncontrolled trials limits these findings as well. Although the above limitations are not exhaustive, they do provide necessary caveats to future generalizations.

FUTURE IMPLICATIONS

Perhaps the most important information to gain from future research is that of treatment outcomes. Studies that include a detailed outcome evaluation could reveal patient satisfaction, efficacy, and financial considerations. In the presence of adequate supportive data, GCBT could contribute outcome data regarding trauma survivor symptom normalization, peer support formation, access to care, treatment efficiency, and health care resources utilization. As noted in Barrera and colleagues, future analysis will require a greater volume of trials with an overall increase in methodological rigor.⁸

Current research has demonstrated a solid base from which to spawn specific treatment protocols. The available research is investigational in terms of treatment procedures. Replication of these studies could dictate treatment protocol and contribute substantively to future VA and DoD CPG updates. Future researchers should consider the use of a standard PTSD symptom assessment tool to make interstudy comparisons more meaningful. The length of treatment and exposure elements should be targeted specifically in future research as these components currently vary the most.

The military represents an obvious avenue for future research due to increased PTSD diagnosis in recent years. Although the etiology of the increase in PTSD is unclear and most likely multifactorial (decreased resilience, increased awareness, increased pursuit of secondary gains, etc), the need for treatment options is apparent.¹ Group cohesion has been shown to be a core component of successful group psychotherapy, so military members who are accustomed to unit cohesion might represent a uniquely suitable population for this modality.¹⁵ Interestingly and for reasons not currently understood, veterans do not see effects of therapy as large as their civilian counterparts.⁸ This underscores the need for further evaluation of military-specific outcomes.

CONCLUSIONS

Although the available evidence is not robust, results do support the careful use of GCBT as an effective treatment for PTSD symptom reduction.⁸ Group psychotherapy has been generally regarded as an efficacious and cost-effective method to achieve similar outcomes to individual therapy. Increasing PTSD prevalence compels mental health care providers to explore all available treatment options. The potential for GCBT as an option is exciting, especially for mental health providers and those with limited resources. Rising health care standards and the current national fiscal situation is dictating a reevaluation of treatment options; so perhaps all health care providers will soon consider the use of GCBT.

As with any group assignment, the clinician should carefully consider the individual’s suitability and desire for group participation.¹⁶ With GCBT, providers could facilitate the relief of relentless apprehension and functional impairment for several patients simultaneously. Although there are many details left to explore regarding the use of GCBT for PTSD, the therapy’s foundation for use as a PTSD treatment is apparent.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Anxiety is a necessary and natural reaction to trauma, but, sometimes, anxiety symptoms become excessive and problematic, as experienced with posttraumatic stress disorder (PTSD). Some patients who struggle with PTSD endure a relentless apprehension so intense that it keeps them from participating in everyday activities, such as attending work and partaking in social activities. Associated anxiety symptoms severely impair everyday function and include increased heart rate, sweating, intrusive images, poor attention, fear, or insomnia. Posttraumatic stress disorder symptoms often lead to occupational dysfunction, relationship difficulty, and numerous other functional impairments.

Approximately 300,000 veterans meet the criteria for PTSD related to ongoing or recent wars.¹ The veteran does not bear the personal and functional burden alone; however, the financial load is felt throughout society. One recent study suggests that for veterans diagnosed with PTSD, the first 2 years after deployment cost society an estimated $7,000 per individial.² Current research suggests that this potentially debilitating disorder occurs in about 14% of Operation Iraqi Freedom/Operation Enduring Freedom combat troops, whereas the similar U.S. demographic population experiences PTSD at a rate of about 7%.^1,3 The ongoing military trauma exposures are compelling the mental health community to establish efficient and effective treatment options.^4,5

Several treatment strategies exist to reduce PTSD symptoms, but health care professionals must seek a balance between therapeutic benefit and cost. The treatment of PTSD is diverse and variable; however, in the most recent Clinical Practice Guideline (CPG) for PTSD, the VA and DoD specifically endorse some psychotherapeutic interventions while dissuading the use of others.⁶ Of note, the VA and DoD CPG strongly encourages Stress Inoculation Training (SIT) and similar cognitive therapies aimed at guiding patients through the process of consciously understanding the relationship between thoughts and feelings and then modifying thoughts to appropriately manage stressors.⁶ Meanwhile, group psychotherapy has been determined to be “somewhat helpful.”⁶ Even though cognitive- and group-based therapies have long been established as efficacious for numerous psychological disorders (depression, obsessive compulsive disorder, eating disorders, etc), neither the American Group Psychotherapy Association nor the VA and DoD CPG directly endorse the use of group cognitive behavioral therapy (GCBT) for the treatment of PTSD.^6,7 However, both VA and DoD mental health providers commonly practice CBT and various group psychotherapies for the treatment of PTSD.

Despite the widespread use of CBT, there is a gap in the clinical understanding of the evidence supporting GCBT for PTSD. The goal of this synthesis was to understand the efficacy of treating PTSD symptoms with group psychotherapy. To begin this investigation, the following PICO (population, intervention, comparison, outcome) question was asked: In adults diagnosed with PTSD, how effective is group cognitive behavioral therapy in reducing PTSD-related symptoms?

Methods

Research articles addressing the use of GCBT in PTSD were obtained via database searches that took place during October 2012 (Table). Searched databases included the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews Randomized Controlled Trials, Psychological Information (PsycINFO), and Public Medicine (PubMed).

The PubMed database was searched using the following MeSH (medical subject heading) terms: “psychotherapy, group” and “stress disorders, post-traumatic” and “cognitive therapy.” Limitations were set to include only patients aged ≥ 18 years, results in English, those involving human subjects, and articles published within the past 5 years. A manual search of references was also conducted, and relevant articles were retained.

Articles that addressed primary substance abuse, other DSM Axis I disorders, intimate partner violence, or family issues were excluded from the evidence sample due to concerns of an alternate treatment focus. Articles with a focus on telehealth or alternative medicine were considered confounding to the scope of this review were also excluded. It was also noted that the term CBT is used collectively for an umbrella of treatments; however, treatments that focused on elements other than the components of CBT being delivered in a group were not included. To prevent duplication of the results, research from an inclusive review was not considered individually.

SUMMARY OF EVIDENCE

Six works fulfilled the PICO criteria and were of sufficient quality to be synthesized. Of the 6 articles retained for synthesis, 2 were high-level reviews. Both reviews supported the use of GCBT for PTSD treatment. Barrera and colleagues reported an overall large effect size regardless of the presence of exposure in-group among the 12 treatment conditions and 651 study participants.⁸ These researchers also reported that in-group exposure did not further traumatize other group members.

Similarly, although a notably older and smaller review, Bisson and Andrew reported a significant standard mean deviation between 4 GCBT treatment and wait list controls. These reviewers did not find a significant difference between trauma- and nontrauma-focused treatment groups. The reviews also noted that individual psychotherapy and/or pharmacotherapy was most often continued throughout the reviewed studies.^8,9

The 4 other studies contribute substantively to this synthesis but arguably represent lower evidence quality. A large longitudinal study of 496 Australian veterans reported a large effect size that was sustained 9 months after treatment began.¹⁰ These researchers used an intensive outpatient program that included medication and other treatment modalities as the basis for GCBT delivery. They reported that the majority of the patients revealed improvement in PTSD symptoms.

Another study sampled a similar group of 10 combat veterans but focused particular attention on sleep-related PTSD symptoms of insomnia, nightmares, and sleep quality.¹¹ Although these researchers were unable to report a significant difference in overall PTSD symptoms for the 8 subjects who completed the protocol, they did find a large effect size on insomnia severity and a medium effect size on sleep quality. Regular treatment, including medication, continued throughout this study.

Other researchers reported a medium effect size on PTSD symptoms while using GCBT in a heterogeneous group with various anxiety disorders, including obsessive compulsive disorder, generalized anxiety disorder, social phobia, panic disorders, and PTSD.¹² Although reporting similar results as all other included studies, this study has some significant limitations, including a 26% dropout rate among the 152 participants. The final study included for synthesis reported a remarkable 67% elimination of the PTSD diagnosis among 6 motor vehicle accident survivors in the small, uncontrolled study.¹³ Concomitant treatments, including medications, were not reported in detail for these 4 studies except as mentioned.

As a whole, the 6 studies revealed some appreciable commonalities. Time since diagnosis did not seem to influence the results. Attrition was consistently found to be similar to other PTSD treatments. The reported session topics were loosely based on common CBT tenets (ie, education, challenging cognitions, and relaxation techniques) and were typically similar among treatment groups, including the use of homework.

DISCUSSION

As the diagnosis of PTSD increases to unfamiliar levels, GCBT has the potential to be helpful to clinicians and patients seeking alternatives to their current treatments.^1,4,14 The reported results imply that GCBT can be useful in PTSD symptom reduction. This could be particularly useful to VA and military providers or rural providers operating with limited resources.

Treatment protocols are not well established and should be approached with care prior to the establishment of CBT treatment groups for those diagnosed with PTSD. Session overviews and descriptions, such as those mentioned in Thompson and colleagues, could provide a reference point for future use.¹³

Also worth considering, CBT can be an ambiguous term requiring deliberate definition within treatment protocols. As noted in the VA and DoD CPG, exposure- and trauma-focused treatment designs can be efficacious, but these elements do not seem to be required within the GCBT treatment setting.

The current research also suggests GCBT efficacy regardless of the index trauma. This does not suggest that heterogeneous groups were frequently studied nor can conclusions be drawn regarding heterogeneous treatment groups. Elements such as group size and session length are inconsistently reported and require specific consideration as well. There is a distinct lack of research directly comparing individual CBT with GCBT directly, which prohibits meaningful conclusions regarding PTSD symptom reduction. This research gap may well have influenced the recommendations within the VA and DoD CPG. Although some higher quality studies exist, many of the published reports on GCBT have noteworthy design flaw, such as inadequate controls and statistical analysis.

LIMITATIONS

There are some limitations to this literature synthesis. Although the search was limited to the past 5 years, the inclusion of reviews accounts for older evidence. As alluded to earlier, the lack of a standardized GCBT treatment protocol challenges results comparisons as well. The consequent treatment variations make direct interstudy comparison and synthesis difficult. Similarly, outcome measures varied between studies. Also, group psychotherapy is well established and accepted. Therefore, much of the supporting research was accomplished outside the parameters of this literature search. This empirical view of group psychotherapy among mental health providers may also contribute to the lack of available research.

It is also worth noting that studies finding neutral or negative results are often unpublished. This publication bias could account for the lack of available evidence. The research reports do not consistently report therapist qualifications; however, board certificates in group psychotherapy and CBT are undeniably variables available for debate. The inclusion of uncontrolled trials limits these findings as well. Although the above limitations are not exhaustive, they do provide necessary caveats to future generalizations.

FUTURE IMPLICATIONS

Perhaps the most important information to gain from future research is that of treatment outcomes. Studies that include a detailed outcome evaluation could reveal patient satisfaction, efficacy, and financial considerations. In the presence of adequate supportive data, GCBT could contribute outcome data regarding trauma survivor symptom normalization, peer support formation, access to care, treatment efficiency, and health care resources utilization. As noted in Barrera and colleagues, future analysis will require a greater volume of trials with an overall increase in methodological rigor.⁸

Current research has demonstrated a solid base from which to spawn specific treatment protocols. The available research is investigational in terms of treatment procedures. Replication of these studies could dictate treatment protocol and contribute substantively to future VA and DoD CPG updates. Future researchers should consider the use of a standard PTSD symptom assessment tool to make interstudy comparisons more meaningful. The length of treatment and exposure elements should be targeted specifically in future research as these components currently vary the most.

The military represents an obvious avenue for future research due to increased PTSD diagnosis in recent years. Although the etiology of the increase in PTSD is unclear and most likely multifactorial (decreased resilience, increased awareness, increased pursuit of secondary gains, etc), the need for treatment options is apparent.¹ Group cohesion has been shown to be a core component of successful group psychotherapy, so military members who are accustomed to unit cohesion might represent a uniquely suitable population for this modality.¹⁵ Interestingly and for reasons not currently understood, veterans do not see effects of therapy as large as their civilian counterparts.⁸ This underscores the need for further evaluation of military-specific outcomes.

CONCLUSIONS

Although the available evidence is not robust, results do support the careful use of GCBT as an effective treatment for PTSD symptom reduction.⁸ Group psychotherapy has been generally regarded as an efficacious and cost-effective method to achieve similar outcomes to individual therapy. Increasing PTSD prevalence compels mental health care providers to explore all available treatment options. The potential for GCBT as an option is exciting, especially for mental health providers and those with limited resources. Rising health care standards and the current national fiscal situation is dictating a reevaluation of treatment options; so perhaps all health care providers will soon consider the use of GCBT.

As with any group assignment, the clinician should carefully consider the individual’s suitability and desire for group participation.¹⁶ With GCBT, providers could facilitate the relief of relentless apprehension and functional impairment for several patients simultaneously. Although there are many details left to explore regarding the use of GCBT for PTSD, the therapy’s foundation for use as a PTSD treatment is apparent.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Individuals suffering from psychogenic nonepileptic seizures with posttraumatic stress disorder have significant verbal and visual memory impairments, and a greater likelihood of a history of substance abuse than individuals without PTSD, even if those individuals have a history of trauma, investigators have found in a case-control study.

“Up to 90% of patients with PNESs [psychogenic nonepileptic seizures] have been reported to have histories of significant traumatic experiences, with particularly high instances of childhood sexual and physical abuse, compared with control groups and the general population,” wrote Lorna Myers, Ph.D., of the Northeast Regional Epilepsy Group, New York, and her associates.

Those with psychogenic nonepileptic seizures and PTSD had the highest rates of psychiatric medication use, substance abuse, history of rape, and history of physical abuse, compared with individuals who had psychogenic nonepileptic seizures without a diagnosis of PTSD but with a history of trauma, and individuals with psychogenic nonepileptic seizures and no history of trauma, according to the study (Epilepsy & Behavior 2014;37:82-6).

Investigators for the study – which enrolled 17 people with psychogenic nonepileptic seizures and PTSD, 29 people with psychogenic nonepileptic seizures and a history of trauma but no PTSD, and 17 individuals with psychogenic nonepileptic seizures but no PTSD or trauma history – also found that those with psychogenic nonepileptic seizures and PTSD scored lowest in delayed narrative memory, and showed the highest scores for self-perceived verbal memory, visuospatial memory, and overall Memory Complaints Inventory.

Dr. Myers and her associates cited several limitations. For example, they did not collect data on the patients’ ethnic or racial backgrounds, which suggests that information on “PNES pathology and neuropsychological functions” might have been missed.

The authors declared no conflicts of interest.

Individuals suffering from psychogenic nonepileptic seizures with posttraumatic stress disorder have significant verbal and visual memory impairments, and a greater likelihood of a history of substance abuse than individuals without PTSD, even if those individuals have a history of trauma, investigators have found in a case-control study.

“Up to 90% of patients with PNESs [psychogenic nonepileptic seizures] have been reported to have histories of significant traumatic experiences, with particularly high instances of childhood sexual and physical abuse, compared with control groups and the general population,” wrote Lorna Myers, Ph.D., of the Northeast Regional Epilepsy Group, New York, and her associates.

Those with psychogenic nonepileptic seizures and PTSD had the highest rates of psychiatric medication use, substance abuse, history of rape, and history of physical abuse, compared with individuals who had psychogenic nonepileptic seizures without a diagnosis of PTSD but with a history of trauma, and individuals with psychogenic nonepileptic seizures and no history of trauma, according to the study (Epilepsy & Behavior 2014;37:82-6).

Investigators for the study – which enrolled 17 people with psychogenic nonepileptic seizures and PTSD, 29 people with psychogenic nonepileptic seizures and a history of trauma but no PTSD, and 17 individuals with psychogenic nonepileptic seizures but no PTSD or trauma history – also found that those with psychogenic nonepileptic seizures and PTSD scored lowest in delayed narrative memory, and showed the highest scores for self-perceived verbal memory, visuospatial memory, and overall Memory Complaints Inventory.

Dr. Myers and her associates cited several limitations. For example, they did not collect data on the patients’ ethnic or racial backgrounds, which suggests that information on “PNES pathology and neuropsychological functions” might have been missed.

The authors declared no conflicts of interest.

Individuals suffering from psychogenic nonepileptic seizures with posttraumatic stress disorder have significant verbal and visual memory impairments, and a greater likelihood of a history of substance abuse than individuals without PTSD, even if those individuals have a history of trauma, investigators have found in a case-control study.

“Up to 90% of patients with PNESs [psychogenic nonepileptic seizures] have been reported to have histories of significant traumatic experiences, with particularly high instances of childhood sexual and physical abuse, compared with control groups and the general population,” wrote Lorna Myers, Ph.D., of the Northeast Regional Epilepsy Group, New York, and her associates.

Those with psychogenic nonepileptic seizures and PTSD had the highest rates of psychiatric medication use, substance abuse, history of rape, and history of physical abuse, compared with individuals who had psychogenic nonepileptic seizures without a diagnosis of PTSD but with a history of trauma, and individuals with psychogenic nonepileptic seizures and no history of trauma, according to the study (Epilepsy & Behavior 2014;37:82-6).

Investigators for the study – which enrolled 17 people with psychogenic nonepileptic seizures and PTSD, 29 people with psychogenic nonepileptic seizures and a history of trauma but no PTSD, and 17 individuals with psychogenic nonepileptic seizures but no PTSD or trauma history – also found that those with psychogenic nonepileptic seizures and PTSD scored lowest in delayed narrative memory, and showed the highest scores for self-perceived verbal memory, visuospatial memory, and overall Memory Complaints Inventory.

Dr. Myers and her associates cited several limitations. For example, they did not collect data on the patients’ ethnic or racial backgrounds, which suggests that information on “PNES pathology and neuropsychological functions” might have been missed.

The authors declared no conflicts of interest.

With the understanding that healing after war is a long-term process, Welcome Back Veterans (http://www.welcomebackveterans.org), founded by Major League Baseball Charities, the nonprofit McCormick Foundation, and the charitable Entertainment Industry Foundation, was created to “inspire Americans to reach out and help our returning veterans and their families.”

Welcome Back Veterans offers resources on PTSD, including an overview and related statistics, a detailed symptoms list, treatment information, support group names and phone numbers, and a reading list of books on PTSD, all vetted by the organization.

Highlighted veteran stories are posted in the Latest News, which are also accessible via e-mail sign-ups and RSS feeds. A robust list of family resources is available, as well as many inspiring active-duty military personnel and veteran videos.

In addition to the online resources provided for free on the website, Welcome Back Veterans is funding programs at various institutions throughout the U.S. The McCormick Foundation donation page may be accessed directly through
the homepage of Welcome Back Veterans.

With the understanding that healing after war is a long-term process, Welcome Back Veterans (http://www.welcomebackveterans.org), founded by Major League Baseball Charities, the nonprofit McCormick Foundation, and the charitable Entertainment Industry Foundation, was created to “inspire Americans to reach out and help our returning veterans and their families.”

Welcome Back Veterans offers resources on PTSD, including an overview and related statistics, a detailed symptoms list, treatment information, support group names and phone numbers, and a reading list of books on PTSD, all vetted by the organization.

Highlighted veteran stories are posted in the Latest News, which are also accessible via e-mail sign-ups and RSS feeds. A robust list of family resources is available, as well as many inspiring active-duty military personnel and veteran videos.

In addition to the online resources provided for free on the website, Welcome Back Veterans is funding programs at various institutions throughout the U.S. The McCormick Foundation donation page may be accessed directly through
the homepage of Welcome Back Veterans.

With the understanding that healing after war is a long-term process, Welcome Back Veterans (http://www.welcomebackveterans.org), founded by Major League Baseball Charities, the nonprofit McCormick Foundation, and the charitable Entertainment Industry Foundation, was created to “inspire Americans to reach out and help our returning veterans and their families.”

Welcome Back Veterans offers resources on PTSD, including an overview and related statistics, a detailed symptoms list, treatment information, support group names and phone numbers, and a reading list of books on PTSD, all vetted by the organization.

Highlighted veteran stories are posted in the Latest News, which are also accessible via e-mail sign-ups and RSS feeds. A robust list of family resources is available, as well as many inspiring active-duty military personnel and veteran videos.

In addition to the online resources provided for free on the website, Welcome Back Veterans is funding programs at various institutions throughout the U.S. The McCormick Foundation donation page may be accessed directly through
the homepage of Welcome Back Veterans.

WASHINGTON – The use of D-cycloserine has promise as a way to augment the beneficial effects of virtual reality therapy of posttraumatic stress disorder, results of two recently published studies show. The results were discussed during a symposium at the annual convention of the American Psychological Association.

In one study of Iraq and Afghanistan veterans, the use of D-cycloserine (DCS) did not provide an advantage overall, compared with alprazolam or placebo. However, DCS was associated with favorable effects on cortisol and startle reactivity, compared with the other two groups, said one of the authors, Tanja Jovanovic, Ph.D. In another trial, a small proof-of concept study, the PTSD remission rate 6 months after treatment was almost 70% among those treated with a combination of virtual reality (VR) therapy and DCS, compared with 17% among those treated with VR therapy and placebo.

DCS, an NMDA (N-methyl-D-aspartate)-receptor partial agonist approved as an antibacterial by the Food and Drug Administration, has been found to enhance exposure therapy for conditions that include social anxiety and acrophobia in previous studies. NMDA also has been found to facilitate extinction learning in animal studies, said Dr. Jovanovic director of the neurophysiology laboratory at the Grady Trauma Project at Emory University, Atlanta.

In the study, 156 veterans of the Iraq and Afghanistan wars were randomized to treatment with DCS (50 mg), alprazolam (0.25 mg), or placebo plus five sessions of virtual reality exposure therapy (after an introductory VR session). Assessments of patients – which included evaluation of PTSD symptoms, psychophysiologic responses, and cortisol reactivity – were performed before treatment and 3, 6, and 12 months after treatment. Monitoring included placing electrodes under the eye to measure the contraction of the eye blink muscle and skin conductance testing during exposure to the VR scenes (two convoy explosion scenes and a city scene), said Dr. Jovanovic, one of the authors of the study, which was published in June (Am. J. Psychiatry 2014;171:640-8).

After five series of VR treatment, PTSD symptoms significantly decreased in all three groups after treatment, based on changes on the Clinician-Administered PTSD Scale (CAPS) score, but the greatest degree of reduction in symptoms at 12 months was observed in the DCS group, she said. Those treated with DCS "showed the biggest decline and actually maintained those gains at 6 months, which we did not see with the other groups."

In addition, those treated with DCS had a reduction in cortisol and startle reactivity that was greater than the changes observed in the two other groups. The magnitude of startle reactivity at baseline was related to the change in the CAPS score 6 months later, "so those gains they are maintaining at 6 months are predicted by their initial response to the virtual reality session pretreatment ... the more reactive, the better they got," Dr. Jovanovic reported.

The same also was true for skin conductance findings: The more reactive they were at baseline in this measure, the more improved the patients were at follow-up, but this association was only evident in the DCS-treated patients, Dr. Jovanovic said.

Measurements of cortisol levels before exposure to the VR scenes, immediately afterward, and 15 minutes afterward determined that cortisol reactivity was attenuated with treatment. Cortisol reactivity significantly dropped in all three groups, from before treatment to the 6-month follow-up but was the lowest in the DCS-treated patients. In the alprazolam-treated group, the higher the cortisol reactivity was before treatment, the worse the outcomes were with treatment, the reverse of what was seen with other psychophysiological measures, she added.

During the same symposium on the use of VR in the treatment of PTSD, JoAnn Difede, Ph.D., professor of psychiatry, Cornell University, New York, described the use of DCS "as a cognitive enhancer" for treatment of people with PTSD related to the World Trade Center attacks in 2001. "We see this as very promising," she said.

In one double-blind, proof-of-concept study, 25 people with PTSD were randomized to DCS (100 mg) or placebo administered 90 minutes before weekly sessions of VR therapy, timed so that plasma concentrations would peak during the session. In the placebo group, 3 dropped out, but none of the 13 patients in the DCS group dropped out (Neuropsychopharmacology 2014; 39:1052-8).

Six months after treatment, 9 of the 13 patients (69%) in the DCS group were in remission, compared with 2 of the 12 (17%) on placebo plus VR exposure. Remission was defined as a CAPS total score of 20 or less, and minimal or no impairment in social, occupational, and other important areas of function, as judged by an independent blinded assessor.

Dr. Difede, also director of the program for anxiety and traumatic stress studies at New York-Presbyterian Hospital, said the two groups began to diverge at the third session, and those who received DCS continued to improve 6 months later. A post-hoc analysis identified a "drastic improvement" in anger and sleep among those treated with DCS, a finding that she and her associates plan to look at more closely. The study presented by Dr. Jovanovic was funded by the National Institute of Mental Health. Dr. Difede received partial funding support from DeWitt-Wallace Fund of the New York Community Trust. The trust was not involved in the design, data collection, or in any other aspects of the study.

emechcatie@frontlinemedcom.com

WASHINGTON – The use of D-cycloserine has promise as a way to augment the beneficial effects of virtual reality therapy of posttraumatic stress disorder, results of two recently published studies show. The results were discussed during a symposium at the annual convention of the American Psychological Association.

In one study of Iraq and Afghanistan veterans, the use of D-cycloserine (DCS) did not provide an advantage overall, compared with alprazolam or placebo. However, DCS was associated with favorable effects on cortisol and startle reactivity, compared with the other two groups, said one of the authors, Tanja Jovanovic, Ph.D. In another trial, a small proof-of concept study, the PTSD remission rate 6 months after treatment was almost 70% among those treated with a combination of virtual reality (VR) therapy and DCS, compared with 17% among those treated with VR therapy and placebo.

DCS, an NMDA (N-methyl-D-aspartate)-receptor partial agonist approved as an antibacterial by the Food and Drug Administration, has been found to enhance exposure therapy for conditions that include social anxiety and acrophobia in previous studies. NMDA also has been found to facilitate extinction learning in animal studies, said Dr. Jovanovic director of the neurophysiology laboratory at the Grady Trauma Project at Emory University, Atlanta.

In the study, 156 veterans of the Iraq and Afghanistan wars were randomized to treatment with DCS (50 mg), alprazolam (0.25 mg), or placebo plus five sessions of virtual reality exposure therapy (after an introductory VR session). Assessments of patients – which included evaluation of PTSD symptoms, psychophysiologic responses, and cortisol reactivity – were performed before treatment and 3, 6, and 12 months after treatment. Monitoring included placing electrodes under the eye to measure the contraction of the eye blink muscle and skin conductance testing during exposure to the VR scenes (two convoy explosion scenes and a city scene), said Dr. Jovanovic, one of the authors of the study, which was published in June (Am. J. Psychiatry 2014;171:640-8).

After five series of VR treatment, PTSD symptoms significantly decreased in all three groups after treatment, based on changes on the Clinician-Administered PTSD Scale (CAPS) score, but the greatest degree of reduction in symptoms at 12 months was observed in the DCS group, she said. Those treated with DCS "showed the biggest decline and actually maintained those gains at 6 months, which we did not see with the other groups."

In addition, those treated with DCS had a reduction in cortisol and startle reactivity that was greater than the changes observed in the two other groups. The magnitude of startle reactivity at baseline was related to the change in the CAPS score 6 months later, "so those gains they are maintaining at 6 months are predicted by their initial response to the virtual reality session pretreatment ... the more reactive, the better they got," Dr. Jovanovic reported.

The same also was true for skin conductance findings: The more reactive they were at baseline in this measure, the more improved the patients were at follow-up, but this association was only evident in the DCS-treated patients, Dr. Jovanovic said.

Measurements of cortisol levels before exposure to the VR scenes, immediately afterward, and 15 minutes afterward determined that cortisol reactivity was attenuated with treatment. Cortisol reactivity significantly dropped in all three groups, from before treatment to the 6-month follow-up but was the lowest in the DCS-treated patients. In the alprazolam-treated group, the higher the cortisol reactivity was before treatment, the worse the outcomes were with treatment, the reverse of what was seen with other psychophysiological measures, she added.

During the same symposium on the use of VR in the treatment of PTSD, JoAnn Difede, Ph.D., professor of psychiatry, Cornell University, New York, described the use of DCS "as a cognitive enhancer" for treatment of people with PTSD related to the World Trade Center attacks in 2001. "We see this as very promising," she said.

In one double-blind, proof-of-concept study, 25 people with PTSD were randomized to DCS (100 mg) or placebo administered 90 minutes before weekly sessions of VR therapy, timed so that plasma concentrations would peak during the session. In the placebo group, 3 dropped out, but none of the 13 patients in the DCS group dropped out (Neuropsychopharmacology 2014; 39:1052-8).

Six months after treatment, 9 of the 13 patients (69%) in the DCS group were in remission, compared with 2 of the 12 (17%) on placebo plus VR exposure. Remission was defined as a CAPS total score of 20 or less, and minimal or no impairment in social, occupational, and other important areas of function, as judged by an independent blinded assessor.

Dr. Difede, also director of the program for anxiety and traumatic stress studies at New York-Presbyterian Hospital, said the two groups began to diverge at the third session, and those who received DCS continued to improve 6 months later. A post-hoc analysis identified a "drastic improvement" in anger and sleep among those treated with DCS, a finding that she and her associates plan to look at more closely. The study presented by Dr. Jovanovic was funded by the National Institute of Mental Health. Dr. Difede received partial funding support from DeWitt-Wallace Fund of the New York Community Trust. The trust was not involved in the design, data collection, or in any other aspects of the study.

emechcatie@frontlinemedcom.com

WASHINGTON – The use of D-cycloserine has promise as a way to augment the beneficial effects of virtual reality therapy of posttraumatic stress disorder, results of two recently published studies show. The results were discussed during a symposium at the annual convention of the American Psychological Association.

In one study of Iraq and Afghanistan veterans, the use of D-cycloserine (DCS) did not provide an advantage overall, compared with alprazolam or placebo. However, DCS was associated with favorable effects on cortisol and startle reactivity, compared with the other two groups, said one of the authors, Tanja Jovanovic, Ph.D. In another trial, a small proof-of concept study, the PTSD remission rate 6 months after treatment was almost 70% among those treated with a combination of virtual reality (VR) therapy and DCS, compared with 17% among those treated with VR therapy and placebo.

DCS, an NMDA (N-methyl-D-aspartate)-receptor partial agonist approved as an antibacterial by the Food and Drug Administration, has been found to enhance exposure therapy for conditions that include social anxiety and acrophobia in previous studies. NMDA also has been found to facilitate extinction learning in animal studies, said Dr. Jovanovic director of the neurophysiology laboratory at the Grady Trauma Project at Emory University, Atlanta.

In the study, 156 veterans of the Iraq and Afghanistan wars were randomized to treatment with DCS (50 mg), alprazolam (0.25 mg), or placebo plus five sessions of virtual reality exposure therapy (after an introductory VR session). Assessments of patients – which included evaluation of PTSD symptoms, psychophysiologic responses, and cortisol reactivity – were performed before treatment and 3, 6, and 12 months after treatment. Monitoring included placing electrodes under the eye to measure the contraction of the eye blink muscle and skin conductance testing during exposure to the VR scenes (two convoy explosion scenes and a city scene), said Dr. Jovanovic, one of the authors of the study, which was published in June (Am. J. Psychiatry 2014;171:640-8).

After five series of VR treatment, PTSD symptoms significantly decreased in all three groups after treatment, based on changes on the Clinician-Administered PTSD Scale (CAPS) score, but the greatest degree of reduction in symptoms at 12 months was observed in the DCS group, she said. Those treated with DCS "showed the biggest decline and actually maintained those gains at 6 months, which we did not see with the other groups."

In addition, those treated with DCS had a reduction in cortisol and startle reactivity that was greater than the changes observed in the two other groups. The magnitude of startle reactivity at baseline was related to the change in the CAPS score 6 months later, "so those gains they are maintaining at 6 months are predicted by their initial response to the virtual reality session pretreatment ... the more reactive, the better they got," Dr. Jovanovic reported.

The same also was true for skin conductance findings: The more reactive they were at baseline in this measure, the more improved the patients were at follow-up, but this association was only evident in the DCS-treated patients, Dr. Jovanovic said.

Measurements of cortisol levels before exposure to the VR scenes, immediately afterward, and 15 minutes afterward determined that cortisol reactivity was attenuated with treatment. Cortisol reactivity significantly dropped in all three groups, from before treatment to the 6-month follow-up but was the lowest in the DCS-treated patients. In the alprazolam-treated group, the higher the cortisol reactivity was before treatment, the worse the outcomes were with treatment, the reverse of what was seen with other psychophysiological measures, she added.

During the same symposium on the use of VR in the treatment of PTSD, JoAnn Difede, Ph.D., professor of psychiatry, Cornell University, New York, described the use of DCS "as a cognitive enhancer" for treatment of people with PTSD related to the World Trade Center attacks in 2001. "We see this as very promising," she said.

In one double-blind, proof-of-concept study, 25 people with PTSD were randomized to DCS (100 mg) or placebo administered 90 minutes before weekly sessions of VR therapy, timed so that plasma concentrations would peak during the session. In the placebo group, 3 dropped out, but none of the 13 patients in the DCS group dropped out (Neuropsychopharmacology 2014; 39:1052-8).

Six months after treatment, 9 of the 13 patients (69%) in the DCS group were in remission, compared with 2 of the 12 (17%) on placebo plus VR exposure. Remission was defined as a CAPS total score of 20 or less, and minimal or no impairment in social, occupational, and other important areas of function, as judged by an independent blinded assessor.

Dr. Difede, also director of the program for anxiety and traumatic stress studies at New York-Presbyterian Hospital, said the two groups began to diverge at the third session, and those who received DCS continued to improve 6 months later. A post-hoc analysis identified a "drastic improvement" in anger and sleep among those treated with DCS, a finding that she and her associates plan to look at more closely. The study presented by Dr. Jovanovic was funded by the National Institute of Mental Health. Dr. Difede received partial funding support from DeWitt-Wallace Fund of the New York Community Trust. The trust was not involved in the design, data collection, or in any other aspects of the study.

emechcatie@frontlinemedcom.com

As a seasoned psychiatrist, I try to take most events in stride. My main reaction to unsettling events is to flatten down and take my own pulse.

However, when I saw the article in the Lancet Psychiatry (2014 Aug. 14 [doi:10.1016/S2215-0366(14)70235-4]) by my longtime colleague, Col. (Ret.) Charles W. Hoge, M.D., and his coauthors, my pulse went way up, and "Oh, my God" was my very unscientific reaction.

As readers may recall, the new definition of posttraumatic stress disorder raises the number of symptoms from 17 to 20, and 8 of those original symptoms were substantially reworded. In addition, PTSD was moved in the new manual from an anxiety disorder to disorders related to trauma and stressors.

In their study, Dr. Hoge and his coauthors administered surveys to soldiers looking at DSM-IV-TR and DSM-5 criteria. In brief, about a third of soldiers who met DSM-IV-TR criteria for PTSD did not meet DSM-5 criteria. Almost a third were in the opposite camp, meeting DSM-5 but not the older criteria, wrote Dr. Hoge of the Center for Psychiatry and Neuroscience at the Walter Reed Army Institute of Research in Silver Spring, Md. The main issue is about criterion C and the splitting up of avoidance symptoms from depressive symptoms.

Why was my reaction so strong? I had thought that the new criteria would widen those eligible for the diagnosis. Instead, it eliminates almost a third of them, mainly because they did not meet the avoidant criteria. (Please read the article for the full complex details.)

In the disability system in the military and Veterans Affairs system, the diagnosis of PTSD carries major weight. So what will happen if the criteria exclude them?

The good news is that both Veterans Affairs and the Department of Defense have made it clear that service members and veterans who already have the diagnosis according to the DSM-IV will not have it changed as a result of DSM-5, so the new definition mostly pertains to those newly seeking care or benefits now. It remains unclear what diagnosis should be used for those veterans who clearly would have met the previous definition (which has been used for more than 25 years), but not the new one. The DSM-5 recommends the use of adjustment disorder in this case, but some experts are concerned that the use of this diagnosis for this purpose will have negative effects. A major issue is that service members can be separated without benefits for an adjustment disorder. Questions also remain about whether adjustment disorder should have even been paired with PTSD in the same chapter in the new DSM-5.

In the accompanying commentary, Dr. Alexander C. McFarlane, of the Centre for Traumatic Studies at the University of Adelaide, Australia, warns about the negative consequences of the change in definition (Lancet Psychiatry 2014 Aug. 14 [doi:10.1016/S2215-0366(14)70321-9]. He also urges caution when the new diagnosis is used in forensic or disability evaluations.

I recommend that readers review this important article and commentary, and that the military and the VA also take a cautious approach.

Dr. Ritchie is former chief of psychiatry for the U.S. Army and current chief clinical officer in the behavioral health department for the District of Columbia.

As a seasoned psychiatrist, I try to take most events in stride. My main reaction to unsettling events is to flatten down and take my own pulse.

However, when I saw the article in the Lancet Psychiatry (2014 Aug. 14 [doi:10.1016/S2215-0366(14)70235-4]) by my longtime colleague, Col. (Ret.) Charles W. Hoge, M.D., and his coauthors, my pulse went way up, and "Oh, my God" was my very unscientific reaction.

As readers may recall, the new definition of posttraumatic stress disorder raises the number of symptoms from 17 to 20, and 8 of those original symptoms were substantially reworded. In addition, PTSD was moved in the new manual from an anxiety disorder to disorders related to trauma and stressors.

In their study, Dr. Hoge and his coauthors administered surveys to soldiers looking at DSM-IV-TR and DSM-5 criteria. In brief, about a third of soldiers who met DSM-IV-TR criteria for PTSD did not meet DSM-5 criteria. Almost a third were in the opposite camp, meeting DSM-5 but not the older criteria, wrote Dr. Hoge of the Center for Psychiatry and Neuroscience at the Walter Reed Army Institute of Research in Silver Spring, Md. The main issue is about criterion C and the splitting up of avoidance symptoms from depressive symptoms.

Why was my reaction so strong? I had thought that the new criteria would widen those eligible for the diagnosis. Instead, it eliminates almost a third of them, mainly because they did not meet the avoidant criteria. (Please read the article for the full complex details.)

In the disability system in the military and Veterans Affairs system, the diagnosis of PTSD carries major weight. So what will happen if the criteria exclude them?

The good news is that both Veterans Affairs and the Department of Defense have made it clear that service members and veterans who already have the diagnosis according to the DSM-IV will not have it changed as a result of DSM-5, so the new definition mostly pertains to those newly seeking care or benefits now. It remains unclear what diagnosis should be used for those veterans who clearly would have met the previous definition (which has been used for more than 25 years), but not the new one. The DSM-5 recommends the use of adjustment disorder in this case, but some experts are concerned that the use of this diagnosis for this purpose will have negative effects. A major issue is that service members can be separated without benefits for an adjustment disorder. Questions also remain about whether adjustment disorder should have even been paired with PTSD in the same chapter in the new DSM-5.

In the accompanying commentary, Dr. Alexander C. McFarlane, of the Centre for Traumatic Studies at the University of Adelaide, Australia, warns about the negative consequences of the change in definition (Lancet Psychiatry 2014 Aug. 14 [doi:10.1016/S2215-0366(14)70321-9]. He also urges caution when the new diagnosis is used in forensic or disability evaluations.

I recommend that readers review this important article and commentary, and that the military and the VA also take a cautious approach.

Dr. Ritchie is former chief of psychiatry for the U.S. Army and current chief clinical officer in the behavioral health department for the District of Columbia.

As a seasoned psychiatrist, I try to take most events in stride. My main reaction to unsettling events is to flatten down and take my own pulse.

However, when I saw the article in the Lancet Psychiatry (2014 Aug. 14 [doi:10.1016/S2215-0366(14)70235-4]) by my longtime colleague, Col. (Ret.) Charles W. Hoge, M.D., and his coauthors, my pulse went way up, and "Oh, my God" was my very unscientific reaction.

As readers may recall, the new definition of posttraumatic stress disorder raises the number of symptoms from 17 to 20, and 8 of those original symptoms were substantially reworded. In addition, PTSD was moved in the new manual from an anxiety disorder to disorders related to trauma and stressors.

In their study, Dr. Hoge and his coauthors administered surveys to soldiers looking at DSM-IV-TR and DSM-5 criteria. In brief, about a third of soldiers who met DSM-IV-TR criteria for PTSD did not meet DSM-5 criteria. Almost a third were in the opposite camp, meeting DSM-5 but not the older criteria, wrote Dr. Hoge of the Center for Psychiatry and Neuroscience at the Walter Reed Army Institute of Research in Silver Spring, Md. The main issue is about criterion C and the splitting up of avoidance symptoms from depressive symptoms.

Why was my reaction so strong? I had thought that the new criteria would widen those eligible for the diagnosis. Instead, it eliminates almost a third of them, mainly because they did not meet the avoidant criteria. (Please read the article for the full complex details.)

In the disability system in the military and Veterans Affairs system, the diagnosis of PTSD carries major weight. So what will happen if the criteria exclude them?

The good news is that both Veterans Affairs and the Department of Defense have made it clear that service members and veterans who already have the diagnosis according to the DSM-IV will not have it changed as a result of DSM-5, so the new definition mostly pertains to those newly seeking care or benefits now. It remains unclear what diagnosis should be used for those veterans who clearly would have met the previous definition (which has been used for more than 25 years), but not the new one. The DSM-5 recommends the use of adjustment disorder in this case, but some experts are concerned that the use of this diagnosis for this purpose will have negative effects. A major issue is that service members can be separated without benefits for an adjustment disorder. Questions also remain about whether adjustment disorder should have even been paired with PTSD in the same chapter in the new DSM-5.

In the accompanying commentary, Dr. Alexander C. McFarlane, of the Centre for Traumatic Studies at the University of Adelaide, Australia, warns about the negative consequences of the change in definition (Lancet Psychiatry 2014 Aug. 14 [doi:10.1016/S2215-0366(14)70321-9]. He also urges caution when the new diagnosis is used in forensic or disability evaluations.

I recommend that readers review this important article and commentary, and that the military and the VA also take a cautious approach.

Dr. Ritchie is former chief of psychiatry for the U.S. Army and current chief clinical officer in the behavioral health department for the District of Columbia.

COPENHAGEN – Older veterans who had sleep disturbances were at a 30% greater risk of developing dementia, according to a retrospective analysis of 200,000 medical records presented at the Alzheimer’s Association International Conference 2014.

And having posttraumatic stress disorder (PTSD) in addition to sleep disturbances put veterans at an 80% greater risk.

"As veterans are turning 65 and older, it’s important for us to understand who in that population is at an increased risk of developing dementia, so when we have that therapy or lifestyle intervention, we can intervene at that point," said Heather M. Snyder, Ph.D., director of medical and scientific operations at the Alzheimer’s Association. Dr. Snyder was not involved in the study.

For the study, researchers studied the records of veterans 55 years and older for 8 years. They found that almost 11% of the veterans with sleep disturbance developed dementia, compared with 9% of those without sleep disturbance, almost a 30% risk increase. The results were similar for veterans who had sleep apnea and nonapnea insomnia.

Meanwhile, researchers found no significant interaction between sleep disturbance and traumatic brain injury or PTSD, with regard to increased risk of dementia. However, veterans who had both PTSD and sleep disturbance had an 80% increased risk of developing dementia.

In a video interview, Dr. Kristine Yaffe, professor of psychiatry and neurology at the University of California, San Francisco, explains the study’s findings, shares practice pearls, and discusses the implications for younger veterans.

nmiller@frontlinemedcom.com

On Twitter @naseemmiller

COPENHAGEN – Older veterans who had sleep disturbances were at a 30% greater risk of developing dementia, according to a retrospective analysis of 200,000 medical records presented at the Alzheimer’s Association International Conference 2014.

And having posttraumatic stress disorder (PTSD) in addition to sleep disturbances put veterans at an 80% greater risk.

"As veterans are turning 65 and older, it’s important for us to understand who in that population is at an increased risk of developing dementia, so when we have that therapy or lifestyle intervention, we can intervene at that point," said Heather M. Snyder, Ph.D., director of medical and scientific operations at the Alzheimer’s Association. Dr. Snyder was not involved in the study.

For the study, researchers studied the records of veterans 55 years and older for 8 years. They found that almost 11% of the veterans with sleep disturbance developed dementia, compared with 9% of those without sleep disturbance, almost a 30% risk increase. The results were similar for veterans who had sleep apnea and nonapnea insomnia.

Meanwhile, researchers found no significant interaction between sleep disturbance and traumatic brain injury or PTSD, with regard to increased risk of dementia. However, veterans who had both PTSD and sleep disturbance had an 80% increased risk of developing dementia.

In a video interview, Dr. Kristine Yaffe, professor of psychiatry and neurology at the University of California, San Francisco, explains the study’s findings, shares practice pearls, and discusses the implications for younger veterans.

nmiller@frontlinemedcom.com

On Twitter @naseemmiller

COPENHAGEN – Older veterans who had sleep disturbances were at a 30% greater risk of developing dementia, according to a retrospective analysis of 200,000 medical records presented at the Alzheimer’s Association International Conference 2014.

And having posttraumatic stress disorder (PTSD) in addition to sleep disturbances put veterans at an 80% greater risk.

"As veterans are turning 65 and older, it’s important for us to understand who in that population is at an increased risk of developing dementia, so when we have that therapy or lifestyle intervention, we can intervene at that point," said Heather M. Snyder, Ph.D., director of medical and scientific operations at the Alzheimer’s Association. Dr. Snyder was not involved in the study.

For the study, researchers studied the records of veterans 55 years and older for 8 years. They found that almost 11% of the veterans with sleep disturbance developed dementia, compared with 9% of those without sleep disturbance, almost a 30% risk increase. The results were similar for veterans who had sleep apnea and nonapnea insomnia.

Meanwhile, researchers found no significant interaction between sleep disturbance and traumatic brain injury or PTSD, with regard to increased risk of dementia. However, veterans who had both PTSD and sleep disturbance had an 80% increased risk of developing dementia.

In a video interview, Dr. Kristine Yaffe, professor of psychiatry and neurology at the University of California, San Francisco, explains the study’s findings, shares practice pearls, and discusses the implications for younger veterans.

nmiller@frontlinemedcom.com

On Twitter @naseemmiller