A brief screening tool for assessing psychological trauma in clinical practice: development and validation of the New York PTSD Risk Score

Mental health status in veterans residing in rural versus non-rural areas: results from the veterans' health study

BACKGROUND

The majority of Veterans Affair (VA) hospitals are in urban areas. We examined whether veterans residing in rural areas have lower mental health service use and poorer mental health status.

METHODS

Veterans with at least 1 warzone deployment in central and northeastern Pennsylvania were randomly selected for an interview. Mental health status, including PTSD, major depression, alcohol abuse and mental health global severity, were assessed using structured interviews. Psychiatric service use was based on self-reported utilization in the past 12 months. Results were compared between veterans residing in rural and non-rural areas. Data were also analyzed using multivariate logistic regression to minimize the influence by confounding factors.

RESULTS

A total of 1730 subjects (55% of the eligible veterans) responded to the survey and 1692 of them had complete geocode information. Those that did not have this information (n = 38), were excluded from some analyses. Veterans residing in rural areas were older, more often of the white race, married, and experienced fewer stressful events. In comparison to those residing in non-rural areas, veterans residing in rural areas had lower global mental health severity scores; they also had fewer mental health visits. In multivariate logistic regression, rural residence was associated with lower service use, but not with PTSD, major depression, alcohol abuse, and global mental health severity score after adjusting confounding factors (e.g., age, gender, marital status and education).

CONCLUSIONS

Rural residence is associated with lower mental health service use, but not with poor mental health in veterans with former warzone deployment, suggesting rural residence is possibly protective.

Pilot of a screening, brief intervention and referral to treatment process for symptoms of trauma among primary care patients

BACKGROUND

For populations with high rates of trauma exposure yet low behavioural health service use, identifying and addressing trauma in the primary care setting could improve health outcomes, reduce disability and increase the efficiency of health system resources.

OBJECTIVE

To assess the acceptability and feasibility of a screening, brief intervention and referral to treatment (SBIRT) process for trauma and symptoms of posttraumatic stress disorder (PTSD) among American Indian and Alaska Native people. We also examine the short-term effects on service utilization and the screening accuracy of the Primary Care Posttraumatic Stress Disorder Screen.

METHODS

Cross-sectional pilot in two tribal primary care settings. Surveys and interviews measured acceptability among patients and providers. Health service utilization was used to examine impact. Structured clinical interview and a functional disability measure were used to assess screening accuracy.

RESULTS

Over 90% of patient participants (N = 99) reported the screening time was acceptable, the questions were easily understood, the right staff were involved and the process satisfactory. Ninety-nine percent would recommend the process. Participants screening positive had higher behavioural health utilization in the 3 months after the process than those screening negative. The Primary Care Posttraumatic Stress Disorder Screen was 100% sensitive to detect current PTSD with 51% specificity. Providers and administrators reported satisfaction with the process.

CONCLUSIONS

The SBIRT process shows promise for identifying and addressing trauma in primary care settings. Future research should explore site specific factors, cost analyses and utility compared to other behavioural health screenings.

Pilot Results from the First HIV/AIDS Intervention Among Transgender Women in the Middle East: Gender Affirmation and Social Support from Within Trans Communities in Beirut, Lebanon

Transgender women are 49 times more likely to become HIV positive than all adults worldwide. Data were unavailable for trans women's sexual and mental health in the Middle East and North Africa until 2015-2016, when HIV prevalence (10%) and suicide attempt (46%) rates were established in Lebanon. Because of the lack of evidence-based interventions for this marginalized group, the purpose of this study was to pilot test an adapted intervention, "Baynetna," to assess preliminary impact on mental and sexual health. Using the gender affirmative model and community connectedness and social cohesion constructs, we pilot tested Baynetna among sixteen trans women, who attended 6 weekly 3-h trans-facilitated group-delivered sessions in Beirut with post-test assessments at 1, 3, and 6 months. Each participant acted as her own control; we used paired t-tests to assess changes at follow-up to evaluate potential differences in outcomes. Positive directionality in intervention impact on gender affirmation satisfaction, community connectedness, and social cohesion was demonstrated. An increase in HIV testing proportion between 6 months before and after enrollment was achieved. Higher social cohesion was associated with less suicidal thoughts (p = .05). There was a significant (p = .019) relationship between more community connectedness and lower depression scores. War event exposure was associated with higher anxiety (p = .02; p = .004). Those who reported never having had a sexually transmitted infection had higher gender affirmation satisfaction scores (7.5, 95% confidence interval: 1.4-13.6) (p = .019). Increases in community connectedness, social cohesion, and gender affirmation satisfaction scores confirm Baynetna's proposed mechanisms of impact. Proportional HIV testing increases demonstrate prevention objectives' progress. The significant results contribute to confidence in Baynetna's mechanisms of action and support the hypothesis that the Gender Affirmation model is applicable to the Lebanese context. We have shown for the first time that the adapted intervention, and its constructs, are applicable in this context outside the United States.

Deconvolution of Transcriptional Networks in Post-Traumatic Stress Disorder Uncovers Master Regulators Driving Innate Immune System Function

Post-Traumatic Stress Disorder (PTSD) is a psychiatric disorder that develops in individuals experiencing a shocking incident, but the underlying disease susceptibility gene networks remain poorly understood. Breen et al. conducted a Weighted Gene Co-expression Network Analysis on PTSD, and identified a dysregulated innate immune module associated with PTSD development. To further identify the Master Regulators (MRs) driving the network function, here we deconvoluted the transcriptional networks on the same datasets using ARACNe (Algorithm for Reconstruction of Accurate Cellular Networks) followed by protein activity analysis. We successfully identified several MRs including SOX3, TNFAIP3, TRAFD1, POU3F3, STAT2, and PML that govern the expression of a large collection of genes. Transcription factor binding site enrichment analysis verified the binding of these MRs to their predicted targets. Notably, the sub-networks regulated by TNFAIP3, TRAFD1 and PML are involved in innate immune response, suggesting that these MRs may correlate with the innate immune module identified by Breen et al. These findings were replicated in an independent dataset generated on expression microarrays. In conclusion, our analysis corroborated previous findings that innate immunity may be involved in the progression of PTSD, yet also identified candidate MRs driving the disease progression in the innate immunity pathways.

Development and preliminary performance of a risk factor screen to predict posttraumatic psychological disorder after trauma exposure

OBJECTIVE

We examined data from a prospective study of risk factors that increase vulnerability or resilience, exacerbate distress, or foster recovery to determine whether risk factors accurately predict which individuals will later have high posttraumatic (PT) symptom levels and whether brief measures of risk factors also accurately predict later symptom elevations.

METHOD

Using data from 129 adults exposed to traumatic injury of self or a loved one, we conducted receiver operating characteristic (ROC) analyses of 14 risk factors assessed by full-length measures, determined optimal cutoff scores, and calculated predictive performance for the nine that were most predictive. For five risk factors, we identified sets of items that accounted for 90% of variance in total scores and calculated predictive performance for sets of brief risk measures.

RESULTS

A set of nine risk factors assessed by full measures identified 89% of those who later had elevated PT symptoms (sensitivity) and 78% of those who did not (specificity). A set of four brief risk factor measures assessed soon after injury identified 86% of those who later had elevated PT symptoms and 72% of those who did not.

CONCLUSIONS

Use of sets of brief risk factor measures shows promise of accurate prediction of PT psychological disorder and probable PTSD or depression. Replication of predictive accuracy is needed in a new and larger sample.

Development of a Screening and Brief Intervention Process for Symptoms of Psychological Trauma Among Primary Care Patients of Two American Indian and Alaska Native Health Systems

American Indian and Alaska Native (AI/AN) people experience high rates of acute, chronic, and intergenerational trauma. Traumatic experiences often increase the risk of both medical and behavioral health problems making primary care settings opportune places to screen for trauma exposure or symptomology. The objective of this study was to determine considerations and recommendations provided by patients, health care providers, health care administrators, and tribal leaders in the development of an adult trauma screening, brief intervention, and referral for treatment process to pilot at two large AI/AN primary care systems. A qualitative and iterative data collection and analysis process was undertaken using a community-based participatory research approach guided by a cross-site steering committee. Twenty-four leaders and providers participated in individual interviews, and 13 patients participated in four focus groups. Data were thematically analyzed to select a trauma screening instrument, develop a screening process, and develop brief intervention materials. The nature of traumas experienced in the AI/AN community, the need to develop trusting patient-provider relationships, and the human resources available at each site drove the screening, brief intervention, and referral process decisions for a future trauma screening pilot in these health systems.

Development of a Screening and Brief Intervention Process for Symptoms of Psychological Trauma Among Primary Care Patients of Two American Indian and Alaska Native Health Systems

American Indian and Alaska Native (AI/AN) people experience high rates of acute, chronic, and intergenerational trauma. Traumatic experiences often increase the risk of both medical and behavioral health problems making primary care settings opportune places to screen for trauma exposure or symptomology. The objective of this study was to determine considerations and recommendations provided by patients, health care providers, health care administrators, and tribal leaders in the development of an adult trauma screening, brief intervention, and referral for treatment process to pilot at two large AI/AN primary care systems. A qualitative and iterative data collection and analysis process was undertaken using a community-based participatory research approach guided by a cross-site steering committee. Twenty-four leaders and providers participated in individual interviews, and 13 patients participated in four focus groups. Data were thematically analyzed to select a trauma screening instrument, develop a screening process, and develop brief intervention materials. The nature of traumas experienced in the AI/AN community, the need to develop trusting patient-provider relationships, and the human resources available at each site drove the screening, brief intervention, and referral process decisions for a future trauma screening pilot in these health systems.

Cumulative exposure to work-related traumatic events and current post-traumatic stress disorder in New York City's first responders

BACKGROUND AND OBJECTIVES

Cumulative exposure to work-related traumatic events (CE) is a foreseeable risk for psychiatric disorders in first responders (FRs). Our objective was to examine the impact of work-related CE that could serve as predictor of posttraumatic stress disorder (PTSD) and/or depression in FRs.

DESIGN

Cross-sectional examination of previous CE and past-month PTSD outcomes and depression in 209 FRs.

METHODS

Logistic (probable PTSD; probable depression) and Poisson regressions (PTSD score) of the outcomes on work-related CE indexes, adjusting for demographic variables. Differences across occupational groups were also examined. Receiver operating characteristic analysis determined the sensitivity and specificity of CE indexes.

RESULTS

All indexes were significantly and differently associated with PTSD; associations with depression were non-significant. The index capturing the sheer number of different incidents experienced regardless of frequency ('Variety') showed conceptual, practical and statistical advantages compared to other indexes. In general, the indexes showed poor to fair discrimination accuracy.

CONCLUSIONS

Work-related CE is specifically associated with PTSD. Focusing on the variety of exposures may be a simple and effective strategy to predict PTSD in FRs. Further research on sensitivity and specificity of exposure indexes, preferably examined prospectively, is needed and could lead to early identification of individuals at risk.

The Impact of Discrimination on the Mental Health of Trans*Female Youth and the Protective Effect of Parental Support

Significant health disparities exist for transgender female (trans*female) youth. We assessed differences in mental health outcomes based on exposure to discrimination among transgender female youth in the San Francisco Bay Area aged 16-24 years. Youth were recruited using a combination of respondent driven sampling with online and social media methods. Logistic regression models were used to estimate odds ratios for the mental health outcomes, comparing levels of discrimination and levels of resiliency promoting protective factors among sexually active youth in the sample (N = 216). High transgender-based discrimination was significantly associated with greater odds of PTSD (AOR, 2.6; 95 % CI 1.4-5.0), depression (AOR, 2.6; 95 % CI 1.2-5.9), and stress related to suicidal thoughts (AOR 7.7, 95 % CI 2.3-35.2). High racial discrimination was significantly associated with greater odds of psychological stress (AOR 3.6; 95 % CI 1.2-10.8), PTSD (AOR 2.1; 95 % CI 1.1-4.2) and stress related to suicidal thoughts (AOR 4.3, 95 % CI 1.5-13.3). Parental closeness was related to significantly lower odds of all four mental health outcomes measured, and intrinsic resiliency positively reduced risk for psychological stress, PTSD, and stress related to suicidal thoughts. Transgender and racial discrimination may have deleterious effects on the mental health of trans*female youth. Interventions that address individual and intersectional discrimination and build resources for resiliency and parental closeness may have success in preventing mental health disorders in this underserved population.

Differential HIV risk for racial/ethnic minority trans*female youths and socioeconomic disparities in housing, residential stability, and education

OBJECTIVES

We examined HIV prevalence and risk behaviors of 282 trans*female youths aged 16 to 24 years participating in the San Francisco Bay Area, California, SHINE study from 2012 to 2013 to determine differences between racial/ethnic minority and White youths.

METHODS

We conducted the χ(2) test to determine distributional differences between racial/ethnic minority and White participants in sociodemographic factors, HIV-related risk behaviors, and syndemic factors.

RESULTS

Of the trans*female youths, 4.8% were HIV positive. Racial/ethnic minority and White trans*female youths differed significantly in gender identity and sexual orientation. Racial/ethnic minority youths also had significantly lower educational attainment, were less likely to have lived with their parents of origin as a child, and were significantly more likely to engage in recent condomless anal intercourse than were Whites.

CONCLUSIONS

Efforts to assess the impact of multiple-minority stress on racial/minority trans*female youths are needed imminently, and prevention efforts must address macrolevel disparities for trans*female youths, especially those from racial/ethnic minority groups, to reduce these disparities and prevent incident cases of HIV.

Prevalence and correlates of substance use among trans female youth ages 16-24 years in the San Francisco Bay Area

BACKGROUND

Substance use is highly prevalent among transgender (trans*) females and has been associated with negative health outcomes, including HIV infection. Little is known about psychosocial risk factors that may influence the onset of substance use among trans*female youth, which can contribute to health disparities during adulthood.

METHODS

We conducted a secondary data analysis of a study on HIV risk and resilience among trans*female youth (N=292). Prevalence of substance use was assessed and multivariable logistic regression models were used to examine the relationship between posttraumatic stress disorder (PTSD), psychological distress, gender-related discrimination, parental drug or alcohol problems (PDAP) and multiple substance use outcomes.

RESULTS

Most (69%) of the trans*female youth reported recent drug use. In multivariable analyses, those with PTSD had increased odds of drug use [AOR=1.94 (95% CI=1.09-3.44)]. Those who experienced gender-related discrimination had increased odds of drug use [AOR=2.28 (95% CI=1.17-4.44)], drug use concurrent with sex [AOR=2.35 (95% CI=1.11-4.98)] and use of multiple drugs [AOR=3.24 (95% CI=1.52-6.88)]. Those with psychological distress had increased odds of using multiple heavy drugs [AOR=2.27 (95% CI=1.01-5.12)]. Those with PDAP had increased odds of drugs use [AOR=2.62 (95% CI=1.43-4.82)], drug use concurrent with sex [AOR=2.01 (95% CI, 1.15-3.51)] and use of multiple drugs [AOR=2.10 (95% CI=1.22-3.62)].

CONCLUSIONS

Substance use is highly prevalent among trans*female youth and was significantly associated with psychosocial risk factors. In order to effectively address substance use among trans*female youth, efforts must address coping related to gender-based discrimination and trauma. Furthermore, structural level interventions aiming to reduce stigma and gender-identity discrimination might also be effective.

Characteristics and trends in peer-reviewed publications in the field of psychosomatic medicine

BACKGROUND

The field of psychosomatic medicine/consultation-liaison psychiatry, now a subspecialty in psychiatry, has focused its efforts on clinical care, education, and research at the interface of psychiatry, medicine, and neurology.

OBJECTIVE

We sought to categorize characteristics and trends (over the past decade) in several journals intended primarily for practitioners of psychosomatic medicine.

METHODS

We reviewed all articles published in 3 peer-reviewed journals (i.e., Psychosomatics, General Hospital Psychiatry, and the Journal of Psychosomatic Research) in 2002 and 2012.

RESULTS

Each of the 3 journals has a different approach to publication of original research, clinical reviews, and case reports.

CONCLUSIONS

The 3 journals demonstrate differing levels of international involvement, publish a different number of articles of different types (e.g., case reports, reviews, and original research), and focus on different types of medical-psychiatric problems.

Validation of the Chinese version of the Modified Caregivers Strain Index among Hong Kong caregivers: an initiative of medical social workers

Family caregivers may often experience caregiving stress and burden. To systematically assess this issue, medical social workers may need to use a brief and valid measurement in their practice. In the Hong Kong Chinese context, one additional challenge is to examine whether a measurement developed in the West is valid for Hong Kong Chinese caregivers. Thus, medical social workers in Hong Kong initiated this research study to validate the Chinese version of the Modified Caregiver Strain Index (C-M-CSI). A total of 223 Chinese caregivers of patients with various chronic illnesses were recruited for this validation study. C-M-CSI demonstrated good reliability (Cronbach's alpha coefficient = .91), concurrent validity with the Chinese version of the Caregiver Burden Inventory, and discriminant validity with the Chinese version of the Meaning in Life Questionnaire. Factor analysis yielded a single factor as the original M-CSI, which explained 49 percent of variance. Construct validity was shown by differentiating spousal and nonspousal caregivers, as well as caregivers of patients with and without behavioral problems. C-M-CSI is recommended as a brief and valid measurement that can be used by medical social workers in assessing the caregiving strain of Chinese caregivers of patients in Hong Kong.

Predicting PTSD using the New York Risk Score with genotype data: potential clinical and research opportunities

BACKGROUND

We previously developed a post-traumatic stress disorder (PTSD) screening instrument, ie, the New York PTSD Risk Score (NYPRS), that was effective in predicting PTSD. In the present study, we assessed a version of this risk score that also included genetic information.

METHODS

Utilizing diagnostic testing methods, we hierarchically examined different prediction variables identified in previous NYPRS research, including genetic risk-allele information, to assess lifetime and current PTSD status among a population of trauma-exposed adults.

RESULTS

We found that, in predicting lifetime PTSD, the area under the receiver operating characteristic curve (AUC) for the Primary Care PTSD Screen alone was 0.865. When we added psychosocial predictors from the original NYPRS to the model, including depression, sleep disturbance, and a measure of health care access, the AUC increased to 0.902, which was a significant improvement (P = 0.0021). When genetic information was added in the form of a count of PTSD risk alleles located within FKBP5, COMT, CHRNA5, and CRHR1 genetic loci (coded 0-6), the AUC increased to 0.920, which was also a significant improvement (P = 0.0178). The results for current PTSD were similar. In the final model for current PTSD with the psychosocial risk factors included, genotype resulted in a prediction weight of 17 for each risk allele present, indicating that a person with six risk alleles or more would receive a PTSD risk score of 17 × 6 = 102, the highest risk score for any of the predictors studied.

CONCLUSION

Genetic information added to the NYPRS helped improve the accuracy of prediction results for a screening instrument that already had high AUC test results. This improvement was achieved by increasing PTSD prediction specificity. Further research validation is advised.

The New York PTSD risk score for assessment of psychological trauma: male and female versions

We previously developed a new posttraumatic stress disorder (PTSD) screening instrument-the New York PTSD Risk Score (NYPRS). Since research suggests different PTSD risk factors and outcomes for men and women, in the current study we assessed the suitability of male and female versions of this screening instrument among 3298 adults exposed to traumatic events. Using diagnostic test methods, including receiver operating characteristic (ROC) curve and bootstrap techniques, we examined different prediction domains, including core PTSD symptoms, trauma exposures, sleep disturbances, depression symptoms, and other measures to assess PTSD prediction models for men and women. While the original NYPRS worked well in predicting PTSD, significant interaction was detected by gender, suggesting that separate models are warranted for men and women. Model comparisons suggested that while the overall results appeared robust, prediction results differed by gender. For example, for women, core PTSD symptoms contributed more to the prediction score than for men. For men, depression symptoms, sleep disturbance, and trauma exposure contributed more to the prediction score. Men also had higher cut-off scores for PTSD compared to women. There were other gender-specific differences as well. The NYPRS is a screener that appears to be effective in predicting PTSD status among at-risk populations. However, consistent with other medical research, this instrument appears to require male and female versions to be the most effective.

Predicting Future PTSD using a Modified New York Risk Score: Implications for Patient Screening and Management

AIM: We previously developed a posttraumatic stress disorder (PTSD) screening instrument - the New York PTSD Risk Score - that was effective in predicting PTSD. In the present study, we assessed a 12-month prospective version of this risk score, which is important for patient management, follow-up, and for emergency medicine. METHODS: Using data collected in a study of New York City adults after the World Trade Center Disaster (WTCD), we developed a new PTSD prediction tool. Using diagnostic test methods, including receiver operating curve (ROC) and bootstrap procedures, we examined different prediction variables to assess PTSD status 12 months after initial assessment among 1,681 trauma-exposed adults. RESULTS: While our original PTSD screener worked well in the short term, it was not specifically developed to predict long-term PTSD. In the current study, we found that the Primary Care PTSD Screener (PCPS), when combined with psychosocial predictors from the original NY Risk Score, including depression, trauma exposure, sleep disturbance, and healthcare access, increased the area under the ROC curve (AUC) from 0.707 to 0.774, a significant improvement (p<0.0001). When additional risk-factor variables were added, including negative life events, handedness, self-esteem, and pain status, the AUC increased to 0.819, also a significant improvement (p=0.001). Adding Latino and foreign status to the model further increased the AUC to 0.839 (p=0.007). CONCLUSION: A prospective version of the New York PTSD Risk Score appears to be effective in predicting PTSD status 12 months after initial assessment among trauma-exposed adults. Further research is advised to further validate and expand these findings.