Posttraumatic stress disorder, suicide, and unintended overdose death in later life: A national cohort study of veterans aged 50 and older

Comorbidities, healthcare use, and contact with healthcare transition services in older veterans after incarceration

BACKGROUND

The Health Care for Reentry Veterans (HCRV) program was established to support community reintegration for veterans after incarceration. Yet, it is unclear how those with and without HCRV contact differ. We sought to evaluate differences in medical and psychiatric conditions and healthcare utilization among mid-to late-life reentry veterans who did and did not receive HCRV outreach.

METHODS

Study participants were veterans aged ≥50 years who qualified for Medicare fee-for-service, had experienced incarceration for ≥1 year, and were released from incarceration between October 1, 2006, and September 30, 2018 (N = 9733). Using VA and Medicare claims data, we compared prevalence of medical and psychiatric diagnoses, and use of emergency, inpatient, and outpatient medical and mental health services up to 12 months after release between those with and without HCRV contact.

RESULTS

Veterans with HCRV contact (35.5%) had significantly higher rates of psychiatric conditions and medical conditions related to substance use (e.g., liver disease) compared to veterans without HCRV contact. Average time between release and first healthcare service use was significantly lower for HCRV veterans (36.5 ± SD 59.5 days) versus non-HCRV veterans (58.9 ± SD 77.5 days) and HCRV veterans were more likely to utilize the emergency department, inpatient and outpatient mental health services, and inpatient medical services.

CONCLUSION

HCRV reaches older reentry veterans with a large burden of mental health and substance use disorders. However, levels of multimorbidity were high among all older reentry veterans, pointing to a need to develop specialized geriatric models of care for this reentry population.

Efficacy and acceptability of music therapy for post-traumatic stress disorder: a systematic review and meta-analysis of randomized controlled trials

Background: Music therapy is increasingly examined in randomized controlled trials (RCTs) and shows potential in treating post-traumatic stress disorder (PTSD).Objective: This systematic review and meta-analysis critically evaluates the current clinical evidence supporting the efficacy and acceptability of music therapy for PTSD.Method: RCTs comparing music therapy in addition to care as usual (CAU) versus either CAU alone or CAU combined with standard psychotherapy/pharmacotherapy for PTSD were retrieved from major English - and Chinese-language databases. Standardized mean differences (SMDs) for post-treatment PTSD symptom scores and risk differences (RDs) for retention rates upon treatment completion were calculated to assess the efficacy and acceptability of music therapy, respectively. The Cochrane risk of bias (RoB) tool 2.0 and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) were used to assess the RoB of included studies and certainty of the evidence, respectively.Results: Nine studies, incorporating 527 PTSD patients, were included, all with high RoB. The post-treatment PTSD symptom scores were significantly lower in the music therapy group than the inactive control group (SMD = -1.64, P < .001), but comparable between the music therapy group and the active control group (SMD = -0.28, P = .330). The retention rates did not differ significantly between the music therapy group and both control groups (RD = 0.03, P = .769; RD = 0.16, P = .829). The GRADE rated certainty level of evidence as low.Conclusions: Although meta-analytic findings suggest that music therapy is effective in reducing post-traumatic symptoms in individuals with PTSD, with its therapeutic effect comparable to that of standard psychotherapy, the low level of certainty limits its generalizability. More methodologically stringent studies are warranted to strengthen the clinical evidence for the efficacy and acceptability of music therapy for PTSD.

Concurrent Alcohol and Opioid Intoxication in Emergency Department Patients Leads to Greater Resource Utilization

Background: Concurrent alcohol intoxication can complicate emergency department (ED) presentations for opioid-related adverse events. We sought to determine if there was a difference in resource utilization among patients who presented to the ED with concurrent opioid and alcohol intoxication compared to opioid intoxication alone. Methods: Using linked state-wide databases from the Maryland Healthcare Cost and Utilization Project (HCUP), we identified patients with a diagnosis of opioid intoxication treated in the ED from 2016 to 2018. We measured healthcare utilization for each patient in the ED settings for one year after the initial ED visit and estimated direct costs. We performed logistic regression comparing patients presented with co-intoxication to those without. Results: Of 12,295 patients who presented to the ED for opioid intoxication during the study period, 703 (5.7%) had concurrent alcohol intoxication. Patients with co-intoxication had more recurrent ED visits (340 vs 247.4 per 1000 patients, p < 0.05), higher index ED visit admission rates (26.9% vs 19.4%, p < 0.001), but similar overall costs ($3736 vs $2861, p < 0.05) at one year. Co-intoxication was associated with suicidal ideation (OR = 1.58, 95% CI 1.51-1.65), high zip code income (OR = 1.16, 95% CI 1.12-1.21), and higher rates of intoxication with all classes of drugs analyzed (p < 0.001). Conclusion: Our study demonstrated that mental health disorders, socioeconomic status, and increased ED utilization are associated with co-intoxication of opioids and alcohol presenting to the ED. Further research is needed to elucidate factors responsible for the increased resource use in this population.

Types of Traumatic Experiences in Drug Overdose-Related Deaths: An Exploratory Latent Class Analysis

Aim

Drug overdose related-deaths in the US are increasing, with over 100,000 deaths occurring in 2020, an increase of 30% from the previous year and the highest number recorded in a single year. It is widely known that experiences of trauma and substance use very often co-occur, but little is known about the role of trauma in the context of drug overdose-related deaths. Latent class analysis (LCA) was used to classify drug overdose-related deaths based on type of traumatic experiences and individual, social, and substance use characteristics.

Methods

Psychological autopsy data were obtained from the University of Texas Health Science Center at Houston (UTHealth) Brain Collection. A total of 31 drug overdose-related deaths collected from January 2016 through March 2022 were included in this study. LCA was used to identify latent factors via experience of four trauma categories (illness/accidents, sexual/interpersonal violence, death/trauma to another, other situations where life was in danger). Generalized linear modeling (GLM) was used to explore differences on demographic, social, substance use, and psychiatric variables between the latent classes in separate models.

Results

LCA identified 2 classes: C1 ( n =12; 39%) was characterized by higher incidence of overall trauma exposure as well as variation in trauma type; C2 ( n =19; 61%) had lower levels of overall trauma exposure with sexual/interpersonal violence as the most frequent. GLMs indicated that C1 membership was associated with higher incidence of polysubstance use, being married, and having suicidal ideation compared to C2 membership ( p s<0.05).

Conclusion

Among individuals who died by drug overdose, the exploratory LCA identified two distinct subgroups that differed in type of trauma experienced and substance use pattern, the first group having more "typical" characteristics of drug overdoses cases, the other group less typical. This suggests that those at risk of drug overdose may not always exhibit high-risk characteristics.

Lifetime posttraumatic stress disorder as a predictor of mortality: a systematic review and meta-analysis

BACKGROUND

Posttraumatic Stress Disorder (PTSD) could potentially increase the risk of mortality, and there is a need for a meta-analysis to quantify this association. This study aims to determine the extent to which PTSD is a predictor of mortality.

METHODS

EMBASE, MEDLINE, and PsycINFO were searched systematically on 12th February 2020, with updated searches conducted in July 2021, and December 2022 (PROSPERO CRD42019142971). Studies involving community-dwelling participants with a diagnosis of PTSD or PTSD symptoms, and a comparator group of individuals without PTSD, and which assessed mortality risk, were included. A random-effects meta-analysis was conducted on studies reporting Odds Ratio (OR), Hazard Ratio (HR), and Risk Ratio (RR), and subgroup analysis was also performed by age, sex, type of trauma experienced, PTSD diagnosis, and cause of death.

RESULTS

A total of 30 eligible studies of mostly good methodological quality were identified, with a total of more than 2.1 million participants with PTSD. The majority of studies involved male-dominated, veteran populations. PTSD was associated with a 47% (95% CI: 1.06-2.04) greater risk of mortality across six studies that reported OR/RR, and a 32% increased risk across 18 studies which reported time to death (HR: 1.32, 95% CI: 1.10-1.59). There was very high study heterogeneity (I2 > 94%) and this was not explained by the prespecified subgroup analysis.

CONCLUSION

PTSD is associated with increased mortality risk, however further research is required amongst civilians, involving women, and in individuals from underdeveloped countries.