Risk of depressive disorder following disasters and military deployment: systematic review with meta-analysis

Underreporting in the military: perceived sensitivity of trauma-related and comorbid disorders among soldiers and civilian employees of the Austrian Armed Forces

Background: Underreporting is a potential source of bias. In the context of the military, the underreporting of mental health symptoms may be linked to inconsistent performance of mental health measures and heterogenous prevalence estimates. However, few studies systematically investigated the potential underreporting of mental health symptoms among military personnel.Objective: The present study systematically examined indications of underreporting symptoms of trauma-related and comorbid mental health disorders among three comparative samples of the Austrian Armed Forces.Methods: In a cross-sectional survey, 576 active duty soldiers, 764 conscripts, and 164 civilian employees rated the perceived sensitivity of items of the International Trauma Questionnaire (ITQ), several other commonly used self-report mental health measures, and the Effort-Reward Imbalance Questionnaire/short version as a control measure. Applying multilevel modelling, we tested whether mental health measures/ITQ symptom clusters would be perceived as more sensitive than the control measure across the three samples and investigated associations of demographic variables, trust in data protection and item order with sensitivity ratings.Results: All mental health measures, particularly items on alcohol use disorder and the negative self-concept symptom cluster of complex posttraumatic stress disorder (CPTSD), distrust in data protection and item order predicted perceived sensitivity. Active duty soldiers gave similar ratings as civilian employees while recruits rated the sensitivity of mental health measures lower than civilian employees in relation to the control measure.Conclusions: Although it remains unclear whether this is a specific characteristic of military populations, we conclude that military personnel may underreport mental health disorders, particularly symptoms of alcohol use disorder and CPTSD. In order to avoid biased results, strategies to reduce underreporting may be of particular importance in the field of military mental health. Further research is needed on predictors and effects of sensitivity perceptions as well as corresponding differences between civilian and military populations.Trial registration: German Clinical Trials Register identifier: DRKS00026627.

Delayed onset of depressive symptoms in deployed Dutch military personnel: Identifying distinct psychological, biochemical, and genetic pre-deployment profiles

BACKGROUND

Depression is common in the military, with research highlighting variability in depressive symptom development after deployment. This report builds on previous findings to explore differences in pre-deployment psychological, biochemical, and genetic variables across distinct depressive symptom trajectories, with a particular focus on the delayed-onset-increasing trajectory.

METHODS

A sample of 846 military personnel deployed to Afghanistan (2005-2008) was categorized into resilient (66 %, n = 558), intermediate-stable (20 %, n = 173), symptomatic-chronic (9 %, n = 74), and delayed-onset-increasing (5 %, n = 41) trajectories from pre- to 10 years post-deployment. Differences in pre-deployment characteristics (e.g., psychological, biochemical, and genetic) among the depression trajectories were examined using a non-parametric multivariate analysis.

RESULTS

Individuals in the delayed-onset-increasing trajectory had higher general mental health symptom scores than those in the resilient trajectory, but lower scores on fatigue, burnout, and personality factors than the symptomatic-chronic trajectory. No differences were found between the delayed-onset-increasing and the intermediate-stable trajectory. The symptomatic-chronic and resilient trajectories showed significant different scores across most pre-deployment psychological characteristics compared to the other trajectories. For the biochemical and genetic variables no significant differences were found.

CONCLUSIONS

Our study found that pre-deployment characteristics do not distinguish the delayed-onset-increasing trajectory from the intermediate-stable trajectory, with differences emerging post-deployment likely due to negative life events. Individuals vulnerable in one aspect of mental health may be at risk across multiple psychological domains, highlighting the need to focus on a broader range of symptoms to support vulnerable military personnel and enhance resilience.

Single-dose psilocybin for U.S. military Veterans with severe treatment-resistant depression - A first-in-kind open-label pilot study

BACKGROUND

The enduring and severe depression often suffered by Veterans causes immense suffering and is associated with high rates of suicide and disability. This is the first study to evaluate the efficacy and safety of psilocybin in Veterans with severe treatment-resistant depression (TRD).

METHODS

15 Veterans with severe TRD (major depressive episode failing to respond to ≥5 treatments, or lasting >2 years) received 25 mg of psilocybin. Primary outcome was change in Montgomery-Åsberg Depression Rating scale (MADRS) at 3 weeks posttreatment. Response was defined s ≥ 50 % reduction in MADRS, and remission as ≤10 MADRS score. Psychedelic experience was assessed using the Five-Dimensional Altered States of Consciousness scale (5D-ASC). Safety measures included assessment of suicidality and adverse events. Participants on antidepressants were tapered to avoid drug interactions.

RESULTS

Of 15 participants, 60 % met response and 53 % met remission criteria at Week 3. At 12 weeks, 47 % maintained response, and 40 % remission. Co-morbid PTSD did not significantly influence study outcomes. The psychedelic experience reported in 5D-ASC did not correlate with response. Participants judged to need antidepressants were restarted and considered non-responders from that timepoint (n = 4). No unexpected adverse events occurred.

LIMITATIONS

Limitations include the small sample size, and the uncontrolled and unblinded nature of the study.

CONCLUSIONS

In this first study on psilocybin for Veterans with severe TRD, a surprising response and remission was seen. Many Veterans had PTSD though no moderating impact of response was observed. The degree of psychedelic experience did not correlate with depression changes. Further study is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04433858.

The impact of moral injury on trajectories of depression: a five-year longitudinal study among recently discharged Israeli veterans

BACKGROUND

Perpetrating or witnessing acts that violate one's moral code are frequent among military personnel and active combatants. These events, termed potentially morally injurious events (PMIEs), were found to be associated with an increased risk of depression, in cross-sectional studies. However, the longitudinal contribution of PMIEs to depression among combatants remains unclear.

METHOD

Participants were 374 active-duty combatants who participated in a longitudinal study with four measurement points: T1-one year before enlistment, T2-at discharge from army service, and then again 6- and 12-months following discharge (T3 and T4, respectively). At T1, personal characteristics assessed through semi-structured interviews. At T2-T4, PMIEs and depressive symptoms were assessed.

RESULTS

At discharge (T2), a total of 48.7% of combatants reported experiencing PMIEs incident, compared with 42.4% at T3 and 30.7% at T4. We found a significant interaction effect in which combatants endorsing PMIEs at discharge reported higher severity of depression symptoms at discharge (T2) than combatants who reported no PMIEs. This effect decreased over time as depression levels were lower at T3 and T4.

CONCLUSIONS

PMIE experiences, and especially PMIE-Betrayal experiences, were found to be valid predictors of higher severity of depression symptoms after the first year following discharge.

Examining the clinical validity of the global psychotrauma screen in refugees

Introduction

The Global Psychotrauma Screen (GPS) is a brief transdiagnostic screener that covers a broad range of trauma-related disorders as well as risk factors known to influence the course of symptoms.

Methods

We analyzed data from African war refugees in Australia (n = 70), including the GPS, the Structured Clinical Interview for DSM-5 Disorders (SCID-5), the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), and the Brief Resilience Scale (BRS).

Results

Using the Youden's J Index to examine the clinical validity of the GPS subscales measuring PTSD, dissociation, depression, and generalized anxiety disorder (GAD), we found that a PTSD subscale score of 3 or higher, and a depression and dissociation subscale score of 1 or higher, was optimally efficient for detecting a probable diagnosis (Youden's J = 0.76, J = 0.72, and J = 0.90, respectively) with high sensitivity and specificity. We were unable to test the GPS clinical validity for GAD due to the low GAD occurrence. The GPS resilience item was not related to the total score (r = 0.02), indicating low convergent validity for resilience. Risk factors, including current stressors and childhood trauma history, were related to more severe GPS symptom scores, while lack of resilience, social support, and history of mental illness were not.

Conclusion

We conclude that the GPS may be a useful screening tool for PTSD, depression, and the dissociative subtype in refugees.

Patterns of comorbid PTSD, depression, alcohol use disorder, and insomnia symptoms in firefighters: A latent profile analysis

BACKGROUND

Firefighters are an at-risk population for multiple psychiatric conditions, including posttraumatic stress disorder (PTSD), depression, alcohol use disorders (AUDs), and insomnia. These disorders are likely to co-occur; however, patterns of comorbidity have scarcely been investigated in firefighters. We aimed to identify subgroups of comorbidity of PTSD, depression, AUDs, and insomnia in a nationwide population of firefighters in South Korea.

METHODS

A total of 54,054 firefighters responded to an online survey. Latent classes of comorbidity were categorized using latent profile analysis (LPA) based on the symptom scores of PTSD, depression, AUDs, and insomnia. Analysis of variance was performed to compare the characteristics of the identified classes, and multinomial logistic regression was conducted to examine whether anger reactions, resilience, and number of traumatic events predicted class membership.

RESULTS

The LPA identified four subgroups: minimal symptoms (n = 42,948, 79.5 %), predominant PTSD (n = 2858, 5.3 %), subthreshold symptoms and comorbidity (n = 7003, 13.0 %), and high symptoms and comorbidity (n = 1245, 2.3 %). Three comorbidity classes were defined based on severity and one class showed predominant PTSD symptoms. Number of traumatic exposures predicted predominant PTSD, while resilience and anger reactions predicted severity of comorbidities.

LIMITATIONS

The cross-sectional design and usage of self-reported questionnaires are limitations of this study.

CONCLUSIONS

The severity of PTSD, depression, AUDs and insomnia tend to correlate and co-occur in firefighters. Our findings highlight the need to assess comorbid symptoms in firefighters and need to reduce anger reactions and enhance resilience in those with multiple comorbidities.

Impact of air pollution and climate change on mental health outcomes: an umbrella review of global evidence

The impact of air pollution and climate change on mental health has recently raised strong concerns. However, a comprehensive overview analyzing the existing evidence while addressing relevant biases is lacking. This umbrella review systematically searched the PubMed/Medline, Scopus and PsycINFO databases (up to June 26, 2023) for any systematic review with meta-analysis investigating the association of air pollution or climate change with mental health outcomes. We used the R metaumbrella package to calculate and stratify the credibility of the evidence according to criteria (i.e., convincing, highly suggestive, suggestive, or weak) that address several biases, complemented by sensitivity analyses. We included 32 systematic reviews with meta-analysis that examined 284 individual studies and 237 associations of exposures to air pollution or climate change hazards and mental health outcomes. Most associations (n=195, 82.3%) involved air pollution, while the rest (n=42, 17.7%) regarded climate change hazards (mostly focusing on temperature: n=35, 14.8%). Mental health outcomes in most associations (n=185, 78.1%) involved mental disorders, followed by suicidal behavior (n=29, 12.4%), access to mental health care services (n=9, 3.7%), mental disorders-related symptomatology (n=8, 3.3%), and multiple categories together (n=6, 2.5%). Twelve associations (5.0%) achieved convincing (class I) or highly suggestive (class II) evidence. Regarding exposures to air pollution, there was convincing (class I) evidence for the association between long-term exposure to solvents and a higher incidence of dementia or cognitive impairment (odds ratio, OR=1.139), and highly suggestive (class II) evidence for the association between long-term exposure to some pollutants and higher risk for cognitive disorders (higher incidence of dementia with high vs. low levels of carbon monoxide, CO: OR=1.587; higher incidence of vascular dementia per 1 μg/m3 increase of nitrogen oxides, NOx: hazard ratio, HR=1.004). There was also highly suggestive (class II) evidence for the association between exposure to airborne particulate matter with diameter ≤10 μm (PM10) during the second trimester of pregnancy and the incidence of post-partum depression (OR=1.023 per 1 μg/m3 increase); and for the association between short-term exposure to sulfur dioxide (SO2) and schizophrenia relapse (risk ratio, RR=1.005 and 1.004 per 1 μg/m3 increase, respectively 5 and 7 days after exposure). Regarding climate change hazards, there was highly suggestive (class II) evidence for the association between short-term exposure to increased temperature and suicide- or mental disorders-related mortality (RR=1.024), suicidal behavior (RR=1.012), and hospital access (i.e., hospitalization or emergency department visits) due to suicidal behavior or mental disorders (RR=1.011) or mental disorders only (RR=1.009) (RR values per 1°C increase). There was also highly suggestive (class II) evidence for the association between short-term exposure to increased apparent temperature (i.e., the temperature equivalent perceived by humans) and suicidal behavior (RR=1.01 per 1°C increase). Finally, there was highly suggestive (class II) evidence for the association between the temporal proximity of cyclone exposure and severity of symptoms of post-traumatic stress disorder (r=0.275). Although most of the above associations were small in magnitude, they extend to the entire world population, and are therefore likely to have a substantial impact. This umbrella review classifies and quantifies for the first time the global negative impacts that air pollution and climate change can exert on mental health, identifying evidence-based targets that can inform future research and population health actions.

Long-term trajectories of depressive symptoms in deployed military personnel: A 10-year prospective study

BACKGROUND

Military missions, especially those involving combat exposure, are associated with an increased risk of depression. Understanding the long-term course of depressive symptoms post-deployment is important to improve decision-making regarding deployment and mental health policies in the military. This study investigates trajectories of depressive symptoms in the Dutch army, exploring the influence of factors such as demographics, early-life trauma, posttraumatic stress disorder (PTSD) symptoms, and deployment stressors.

METHODS

A cohort of 1032 military men and women deployed to Afghanistan (2005-2008) was studied from pre- to 10 years post-deployment. Depressive and PTSD symptoms were assessed using the Symptom CheckList-90 and the Self-Rating Inventory for PTSD. Demographics, early trauma, and deployment experiences were collected at baseline and after deployment, respectively. Latent Class Growth Analysis was used to explore heterogeneity in trajectories of depressive symptoms over time.

RESULTS

Four trajectories were found: resilient (65%), intermediate-stable (20%), symptomatic-chronic (9%), and late-onset-increasing (6%). The resilient group experienced fewer deployment stressors, while the symptomatic-chronic group reported more early life traumas. Trajectories with elevated depressive symptoms consistently demonstrated higher PTSD symptoms.

LIMITATIONS

Potential nonresponse bias and missing information due to the longitudinal design and extensive follow-up times.

CONCLUSIONS

This study identified multiple trajectories of depressive symptoms in military personnel up to 10 years post-deployment, associated with early trauma, deployment stressors, adverse life events and PTSD symptoms. The prevalence of the resilient trajectory suggests a substantial level of resilience among deployed military personnel. These findings provide valuable insights and a foundation for further research.

Social determinants of mental health in major depressive disorder: Umbrella review of 26 meta-analyses and systematic reviews

There is a growing recognition of the impact of social determinants of mental health (SDoMHs) on people with, or at risk of, developing serious mental illnesses. Yet it is not known how associations of individual SDoMHs with risk for major depressive disorder (MDD) vary and roughly compare with one another. Following PRISMA guidelines, this umbrella review included 26 meta-analyses and systematic reviews that reported odds ratios, effect sizes, and/or pooled prevalence rates of MDD in samples with versus without specified SDoMHs. Childhood emotional, physical, or sexual abuse and neglect; intimate partner violence in females; and food insecurity were significantly associated with increased risk of MDD, with medium effect sizes. Natural disasters, terrorist acts, and military combat during deployment had small-size adverse effects, and homelessness, incarceration, and migration were associated with significantly elevated prevalence of MDD. Conversely, higher levels of parental care were significantly associated with reduced risk of MDD with medium effect sizes. Evidence supports the use of certain interventions at the individual and community level that can reduce the impact of these factors and promote health, although much more research is warranted in this area along with meaningful healthcare and societal policies to accomplish this goal.

An exploratory domain analysis of deployment risks and protective features and their association to mental health, cognitive functioning and job performance in military personnel

BACKGROUND

Meta-analyses of military deployment involve the exploration of focused associations between predictors and peri and post-deployment outcomes.

OBJECTIVE

We aimed to provide a large-scale and high-level perspective of deployment-related predictors across eight peri and post-deployment outcomes.

DESIGN

Articles reporting effect sizes for associations between deployment-related features and indices of peri and post-deployment outcomes were selected. Three-hundred and fourteen studies (N = 2,045,067) and 1,893 relevant effects were retained. Deployment features were categorized into themes, mapped across outcomes, and integrated into a big-data visualization.

METHODS

Studies of military personnel with deployment experience were included. Extracted studies investigated eight possible outcomes reflecting functioning (e.g., post-traumatic stress, burnout). To allow comparability, effects were transformed into a Fisher's Z. Moderation analyses investigating methodological features were performed.

RESULTS

The strongest correlates across outcomes were emotional (e.g., guilt/shame: Z = 0.59 to 1.21) and cognitive processes (e.g., negative appraisals: Z = -0.54 to 0.26), adequate sleep on deployment (Z = -0.28 to - 0.61), motivation (Z = -0.33 to - 0.71), and use of various coping strategies/recovery strategies (Z = -0.25 to - 0.59).

CONCLUSIONS

Findings pointed to interventions that target coping and recovery strategies, and the monitoring of emotional states and cognitive processes post-deployment that may indicate early risk.

The long-term effects of war exposure on psychological health: An experimental study with Turkish conscript veterans

The study of the effects of war exposure on the psychological health of combatants has so far been constrained by possible selection biases which limits the establishment of causality, the clear identification of dynamics, and the generalizability of findings. In this study, we make use of a population-level natural experiment enabled by the strict military conscription system in Turkey which uses a draft lottery to randomly allocate conscripts to bases across the country, including those south-eastern areas experiencing a long running civil conflict. We build on this setting with a representative field survey of 5024 adult males. Our results indicate that those exposed to high intensity armed conflict environments during their service are more likely to experience depressive symptoms even long after their discharge. Further detailing conflict exposure, we find war traumas to be the primary drivers of the effects we observe.

Associations between media exposure and mental health among children and parents after the Great East Japan Earthquake

Background: Exposure to natural disaster media coverage is associated with mental health problems, but its long-term impacts are still unclear. Also, no study has analysed the psychological impact of exposure to natural disaster media coverage among children who are generally sensitive to threatening events.Objective: We aimed to examine how television images of victims after the 2011 Great East Japan Earthquake were associated with mental health among children and their parents.Methods: In 2012, questionnaires for sociodemographic factors were distributed to 2053 families. Parents who provided written consent were contacted in 2013 and invited to provide information on mental health problems (outcome) and retrospectively provide information on television watching at the time of the earthquake (exposure). We used data from 159 parents who completed the survey as the final sample. We used a dichotomous variable to evaluate exposure to media coverage. Multivariable regression was used to examine the association between exposure to television images of victims and mental health, adjusting for potential confounders. Bias-corrected and accelerated bootstrap confidence intervals (CIs) were used.Results: Exposure to television images of victims was significantly associated with worse psychopathology among children (β, 1.51; 95% CI, 0.07-2.96) and greater psychological distress among their parents (β, 1.49; 95% CI, 0.28-2.70). Child psychopathology and parental psychological distress were significantly correlated (r = 0.36, p < .001).Conclusions: Exposure to television images of disaster victims may produce long-term impacts on mental health among children and their parents. To reduce the likelihood of mental health problems associated with disasters, clinicians may recommend reducing exposure to television images of victims.

Mental health and resilience in the Irish defense forces during the COVID-19 global pandemic

The Irish Defense Forces (DF) responded to the COVID-19 pandemic and national public health crisis by deploying personnel to aid domestic civil authorities in medical and care settings, contact tracing, logistics, and operations. Current research on COVID-19 reveals increased psychological distress among frontline workers and the general public. Resilience has previously been associated with lower levels of psychological distress. This study sets out to test these associations, and to examine mental health differences between DF personnel deployed in Ireland on pandemic-related duties (DIPD) and non-DIPD. Participants were 231 DF members who completed the: Connor-Davidson Resilience Scale-10, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Perceived Coronavirus Threat Questionnaire, Brief Trauma Questionnaire, Post-traumatic Stress Disorder Checklist-5, and Alcohol Use Disorder Identification Test. Independent t-tests revealed no differences between DIPD and non-DIPD on measures of psychological distress or on self-rated mental health prior to COVID-19 (PC19) and during COVID-19 (DC19). Results of multiple hierarchical regression analyses revealed that depression predicted lower levels of resilience, while multiple traumatic events predicted higher levels of resilience. The total adjusted variance explained by the model was 25%. Clinical and policy implications for improving access to psychological support within the DF and military populations are discussed.

Variability in the psychological impact of four waves of COVID-19: a time-series study of 60 000 text-based counseling sessions

BACKGROUND

Continuous exposure to stressors can lead to vulnerability and, in some cases, resilience. This study examined the variation in its psychological impact across the first four waves of COVID-19 in Hong Kong.

METHODS

Transcripts from Open Up, an online text-based counseling service, between January 2019 and January 2021 were analyzed (N = 60 775). We identified COVID-19 mentioned sessions using keywords and further categorized them into those that also mentioned symptoms of common mental disorders (CMDs) and those that did not. Autoregressive integrated moving average models were used to analyze the associations between the severity of the outbreak and the mention of COVID-19 and CMDs.

RESULTS

Results revealed that the pandemic led to increased psychological distress. Compared to prior to its advent, more people sought help in the initial months of the outbreak. Furthermore, associations were found between the severity of the outbreak and the number of help-seeker mentioning the pandemic, as well as between the outbreak severity and the number of help-seekers disclosing psychological distress. However, these relationships were not uniform across the four waves of outbreaks; a dissociation between outbreak severity and help-seekers' concern was found in the fourth wave.

CONCLUSION

As the pandemic waxes and wanes, people may become habituated to its psychological toll. This may be interpreted as a form of resilience. Instead of worsening with time, the psychological impact of COVID-19 may reduce with repeated exposure.

Ketamine's rapid antidepressant effects are mediated by Ca2+-permeable AMPA receptors

Ketamine is shown to enhance excitatory synaptic drive in multiple brain areas, which is presumed to underlie its rapid antidepressant effects. Moreover, ketamine's therapeutic actions are likely mediated by enhancing neuronal Ca2+ signaling. However, ketamine is a noncompetitive NMDA receptor (NMDAR) antagonist that reduces excitatory synaptic transmission and postsynaptic Ca2+ signaling. Thus, it is a puzzling question how ketamine enhances glutamatergic and Ca2+ activity in neurons to induce rapid antidepressant effects while blocking NMDARs in the hippocampus. Here, we find that ketamine treatment in cultured mouse hippocampal neurons significantly reduces Ca2+ and calcineurin activity to elevate AMPA receptor (AMPAR) subunit GluA1 phosphorylation. This phosphorylation ultimately leads to the expression of Ca2+-Permeable, GluA2-lacking, and GluA1-containing AMPARs (CP-AMPARs). The ketamine-induced expression of CP-AMPARs enhances glutamatergic activity and glutamate receptor plasticity in cultured hippocampal neurons. Moreover, when a sub-anesthetic dose of ketamine is given to mice, it increases synaptic GluA1 levels, but not GluA2, and GluA1 phosphorylation in the hippocampus within 1 hr after treatment. These changes are likely mediated by ketamine-induced reduction of calcineurin activity in the hippocampus. Using the open field and tail suspension tests, we demonstrate that a low dose of ketamine rapidly reduces anxiety-like and depression-like behaviors in both male and female mice. However, when in vivo treatment of a CP-AMPAR antagonist abolishes the ketamine's effects on animals' behaviors. We thus discover that ketamine at the low dose promotes the expression of CP-AMPARs via reduction of calcineurin activity, which in turn enhances synaptic strength to induce rapid antidepressant actions.

Disaster Mental Health Risk Reduction: Appraising Disaster Mental Health Research as If Risk Mattered

The globally increasing frequency, intensity, and complexity of extreme climatic events and disasters poses significant challenges for the future health and wellbeing of affected populations around the world [...].

Longitudinal assessment and determinants of short-term and longer-term psychological distress in a sample of healthcare workers during the COVID-19 pandemic in Quebec, Canada

Introduction

Previous research has demonstrated the negative impact of the COVID-19 pandemic emergency on the wellbeing of healthcare workers. However, few research contributions reported a longitudinal evaluation of psychological distress and examined determinants of its duration and course over time. The present study aims to explore the impact of the pandemic emergency on HCWs mental health by adopting a longitudinal design and assessing mental health as combination of overlapping clinical symptoms (post-traumatic stress disorder, depression and anxiety).

Methods

Data were collected weekly through a mobile application during and after the first wave of COVID-19 in the province of Quebec, Canada, in 2020. Analysis was conducted on a final sample of 382 participants. Participants were grouped into "resilient" (RES) if they did not manifest clinical-level psychological distress during monitoring, "short-term distress" (STD) if distress exceeded the clinical threshold for 1-3 weeks, and longer-term distress (LTD) if it occurred for four or more weeks, even if not consecutively. Descriptive statistics for all variables were computed for each subgroup (RES, STD and LTD), and pairwise comparisons between each group for every descriptive variable were made using chi square statistics for categorical variables and t-test for continuous variables. Predictors of distress groups (STD and LTD vs RES) were assessed running multinomial hierarchical logistic regression models.

Results

In our sample, almost two third (59.4%) HCWs did not manifest moderate or severe distress during the monitoring time. Short-term distress, mostly post-traumatic symptoms that lasted for less than 4 weeks, were the most common distress response, affecting almost one third of participants. Longer psychological distress occurred only in a smaller percentage (12.6%) of cases, as a combination of severe posttraumatic, depressive and anxiety symptoms. Perceived occupational stress was the most significant risk factor; moreover individual, peritraumatic work and family risk and protective factors, were likely to significantly affect the stress response.

Discussion

Results tend to provide a more complex and resiliency-oriented representation of psychological distress compared to previous cross-sectional studies, but are in line with stress response studies. Findings allow us to better describe the profiles of distress response in STD and LTD groups. Participants that manifest short term distress experience acute stress reaction in which the interplay between personal, family and professional life events is associated with the stress response. Conversely, longer term distress response in HCWs presents a more complex mental health condition with an higher level of impairment and support needs compared to participants with short-term distress.

Deployment-related PTSD symptomatology and social functioning: Probing the mediating roles of emotion regulation and mentalization in an outpatient veteran sample

Deployment-related posttraumatic stress disorder (PTSD) impacts social functioning in families. Therefore, it is important to examine the factors that contribute to social functioning in families that are confronted with deployment-related PTSD. The goal of this study was to assess the association between PTSD symptom severity and social functioning using self-report questionnaires in an outpatient veteran sample and to test the mediating roles of emotion regulation (Study 1, N = 100) and mentalization (Study 2, N = 38). Study 1 demonstrated that emotion regulation problems fully mediated PTSD associated family dysfunctioning. Study 2 did not demonstrate a mediation role of mentalization, but also did not demonstrate an association between PTSD and social dysfunctioning. Maladaptive mentalization was associated with poor child adjustment. Critically, a between-study comparison revealed that PTSD symptom severity was significantly higher in Study 1 than in Study 2. Overall, our findings suggest that social dysfunctioning may only appear when a given severity threshold of PTSD is reached, in which emotion regulation might be a key clinical factor. Maladaptive mentalization may be critical for post-deployment child adjustment. Future research should further examine social functioning in samples with different PTSD severity profiles and include the role of mentalization. Longitudinal data are needed to gain further insight into the causal relationships among the factors considered and the etiological pathways that lead to developing social dysfunction over time.

The long-term impacts of the Canterbury earthquakes on the mental health of the Christchurch Health and Development Study cohort

OBJECTIVE

Long-term studies following disasters are rare. It is important to quantify long-term effects of disasters to determine impacts on populations over time. We therefore aim to report the long-term associations between exposure to the Canterbury earthquakes and common mental disorders, taking into account potential confounding factors.

METHODS

The Christchurch Health and Development Study is a 40-year longitudinal study of a birth cohort of New Zealand children (635 males and 630 females). The Christchurch Health and Development Study includes 884 participants with data on earthquake exposure and mental health outcomes at ages 34 and 40 years. Rates of Diagnostic and Statistical Manual of Mental Disorders (4th ed.) disorders were measured categorically and using an expanded definition that included sub-syndromal symptoms. The current impact of the earthquakes is reported using 12-month prevalence data 7 years after the earthquakes. The cumulative impact of the earthquakes over the 7 years since onset is also reported.

RESULTS

There was a linear trend towards increasing rates of disorder with increasing exposure to the earthquakes. After adjusting for covariates, the 12-month prevalence of anxiety disorder symptoms was significantly increased (p = 0.003). The earthquakes were also associated with cumulative increases in symptoms of post-traumatic stress disorder (p < 0.001), anxiety disorder (p = 0.016), nicotine dependence (p = 0.012), and the total number of disorders (p = 0.039).

CONCLUSION

The Canterbury earthquakes were associated with persistent increases in Anxiety Disorder symptoms 7 years after their onset. The earthquakes were also associated with cumulative increases in symptoms of common psychiatric disorders. The magnitude of these effects is small, may no longer be clinically significant and has decreased over time.

Prevalence of psychiatric symptoms and associated factors in the adult population from the area affected by the tailings dam rupture - Brumadinho Health Project

OBJECTIVE

To examine the prevalence of psychiatric symptoms and associated factors in the adult population of Brumadinho (MG), after the dam collapse.

METHODS

We included 2,740 participants with information about symptoms of post-traumatic stress disorder (PTSD), depression, anxiety, thoughts of death/self-harm, and poor sleep quality collected in 2021. Prevalence values of all conditions were estimated to compare the prevalence of psychiatric symptoms with the participants' sociodemographic characteristics and place of residence. Pearson's c2 test was used, with Rao Scott's correction. Crude and adjusted logistic regressions estimated odds ratios and 95% confidence intervals to assess the association between psychiatric symptoms and participants' characteristics.

RESULTS

The most common condition was depressive symptoms (29.3%), followed by post-traumatic stress symptoms (22.9%) and anxious symptoms (18.9%). Regarding the association between participants' characteristics in the adjusted analysis, being a female and living in a mining area was positively associated with symptoms of PTSD, depression, anxiety, thoughts of death/self-harm, and poor sleep quality. A positive association was also found between high school education and post-traumatic stress symptoms. In contrast a negative association was found between being aged ≥60 years and symptoms of PTSD, depression, and anxiety.

CONCLUSION

High prevalence values were found for all psychiatric symptoms after the dam failure in Brumadinho. Being a female, living in the mining area, being ≥60 years old, and having an educational level were all associated with the psychiatric symptoms investigated.

Long term mental health trajectories after disasters and pandemics: A multilingual systematic review of prevalence, risk and protective factors

The patterns of long-term psychological response after disasters and pandemics remain unclear. We aimed to determine the trajectories for post-traumatic stress symptoms (PTSS), depression and anxiety prevalence following disasters and pandemic exposure; and identify associated risk and protective factors. A systematic review of the English, Chinese, and Japanese longitudinal mental health literature was conducted. We searched Cochrane, MEDLINE, ProQuest, PsycINFO, PubMed, Web of Science, and CINAHL (English), CNKI and SINOMED (Chinese) and CiNii (Japanese) for studies published between January 2000 and May 2022. Following a pre-specified protocol (PROSPERO: CRD42020206424), conditional linear growth curve models and ANOVA analyses were conducted. The search identified 77,891 papers, with a final sample of 234: 206 English, 24 Chinese, and 4 Japanese-language papers. PTSS rates improved for all ages (p = .018, eta² = 0.035). In contrast, depression and anxiety prevalence remained elevated for years following exposure (p = .424, eta² = 0.019 and p = .051, eta² = 0.064, respectively), with significantly higher rates for children and adolescents (p < .005, eta² > 0.056). Earthquakes and pandemics were associated with higher prevalence of PTSS (p < .019, eta² > 0.019). Multi-level risk and protective factors were identified. The chronicity of mental health outcomes highlights a critical need for tailored, sustainable mental health services, particularly for children and adolescents, in disaster- and pandemic-affected settings.

Appraising Evidence-Based Mental Health and Psychosocial Support (MHPSS) Guidelines-PART II: A Content Analysis with Implications for Disaster Risk Reduction

High quality mental health and psychosocial support (MHPSS) guidelines are indispensable for policy and practice to address the mental health consequences of disasters. This contribution complements a review that assessed the methodological quality of 13 MHPSS guidelines. We analyzed the content of the four highest-ranking guidelines and explored implications for disaster risk reduction (DRR). A qualitative explorative thematic analysis was conducted. The four guidelines proved largely similar, overlapping or at least complementary in their MHPSS definitions, stated purpose of the guidelines, user and target groups, terminology, and models used. Many recommended MHPSS measures and interventions were found in all of the guidelines and could be assigned to five categories: basic relief, information provision, emotional and social support, practical support, and health care. The guidelines stress the importance of monitoring needs and problems, evaluating the effect of service delivery, deliberate implementation and preparation, and investments in proper conditions and effective coordination across professions, agencies, and sectors. The MHPSS knowledge base embedded in the guidelines is comprehensive, coherent, and sufficiently universal to serve as the "overarching framework" considered missing yet vital for the integration of MHPSS approaches in DRR. Although application contexts differ geographically, this common ground should allow policymakers and practitioners globally to plan, implement, and evaluate MHPSS actions contributing to DRR, ideally together with target groups.

Community disaster exposure and first onset of depression: A panel analysis of nationally representative South African data, 2008-2017

Sub-Saharan Africa faces unprecedented disasters, with climate change expected to exacerbate the frequency and severity of unpredictable and stressful catastrophic events. Unlike developed nations, reconstruction in developing nations is hindered by resource constraints, with certain communities potentially experiencing multiple and enduring effects of disasters. Despite the potential danger of such cumulative community disaster exposure on mental health (e.g. depression), large-scale population-level evidence for the region is limited. We investigated the association between exposure to cumulative disaster and the first onset of depression in a nationally representative survey in South Africa. We used panel data from the South African National Income Dynamics Study (SA-NIDS) from 2008-2017, consisting of 17,255 adult study participants who were depression free at baseline. Risk of first depression onset between individuals exposed and unexposed to community disaster was measured, accounting for multiple disaster exposure over time by fitting generalized estimating equation (GEE) regression models. Data on the geographic location of disasters were obtained from the South African government gazette, and mapped with the government delineated SA-NIDS households' locations. Of the sampled individuals, 2,986 were exposed to disaster during the study duration (17.3%). Increased cumulative community disaster was significantly associated with the likelihood of depression onset (adjusted relative risk [aRR] = 1.20, p<0.01, 95% CI: 1.09-1.33), even after controlling for socio-demographic factors. In sub-group analyses, greater likelihood of depression onset was found among females [but not in men] (aRR = 1.23, p<0.01, 95% CI: 1.09-1.38), Black African [but not in other population group] (aRR = 1.21, p<0.01, 95% CI: 1.09-1.36), lower education attainment group [but not in tertiary and above educational attainment group] (aRR = 1.20, p<0.01, 95% CI: 1.08-1.33), and lower income attainment group [but not in the top income quartile group] (aRR = 1.24, p<0.01, 95% CI: 1.11-1.38), due to cumulative community disaster. Although cumulative community disaster exposure was significantly associated with the first onset of depression, its negative impact may be more pronounced among individuals considered chronically socially vulnerable (i.e. the groups above) in South Africa. Given that many individuals in South Africa rely on social, food parcel relief, and health services from government/public sector, timely access to community-based supportive intervention is needed for disaster survivors, prioritizing socially vulnerable groups to help mitigate problems associated with mental health challenges.

Appraising Evidence-Based Mental Health and Psychosocial Support (MHPSS) Guidelines-PART I: A Systematic Review on Methodological Quality Using AGREE-HS

In 2007, the Inter-Agency Standing Committee (IASC) published its guidelines for mental health and psychosocial support (MHPSS) in emergency situations. This was one of the first sets of MHPSS guidelines, developed during the last decades, to aid policymakers and practitioners in the planning and implementation of disaster mental health risk reduction activities. However, the potential merit of MHPSS guidelines for this purpose is poorly understood. The objective of this study is to review available MHPSS guidelines in disaster settings and assess their methodological quality. MHPSS guidelines, frameworks, manuals and toolkits were selected via a systematic literature review as well as a search in the grey literature. A total of 13 MHPSS guidelines were assessed independently by 3-5 raters using the Appraisal of Guidelines for Research and Evaluation-Health Systems (AGREE-HS) instrument. Guideline quality scores varied substantially, ranging between 21.3 and 67.6 (range 0-100, M = 45.4), with four guidelines scoring above midpoint (50). Overall, guidelines scored highest (on a 1-7 scale) on topic (M = 5.3) and recommendations (M = 4.2), while implementability (M = 2.7) is arguably the area where most of the progress is to be made. Ideally, knowledge derived from scientific research aligns with the receptive contexts of policy and practice where risks are identified and mitigated.

The interplay between acute post-traumatic stress, depressive and anxiety symptoms on healthcare workers functioning during the COVID-19 emergency: A multicenter study comparing regions with increasing pandemic incidence

BACKGROUND

Healthcare workers (HCWs) deployed to the frontline during the COVID-19 pandemic are at risk for developing mental disorders, with a possible impact on their wellbeing and functioning. The present study aimed at investigating post-traumatic stress symptoms (PTSS), anxiety and depressive symptoms and their relationships with impairment in the functioning impairment among frontline HCWs from three Italian regions differently exposed to the first wave of the COVID-19 emergency: Tuscany (low), Emilia-Romagna (medium) and Lombardy (high).

METHODS

514 frontline HCWs were consecutively enrolled in hospital units devoted to the treatment of COVID-19 patients. They completed the IES-R, PHQ-9 and GAD-7 to assess PTSS, depressive and anxiety symptoms respectively, and the WSAS to investigate functioning impairment.

RESULTS

A total of 23.5% of HCWs reported severe PTSS, 22.4% moderate-severe anxiety symptoms, 19.3% moderate-severe depressive symptoms and 22.8% impairment in global functioning. HCWs from the higher-exposure regions reported significantly higher scores in all instruments than those from lower-exposure regions. In a multiple linear regression model, PTSS, depressive and anxiety symptoms presented a significant positive association with the functioning impairment. Both PTSS and depression resulted to be independently related to functioning impairment.

LIMITATIONS

The cross-sectional design and the use of self-report instruments.

CONCLUSIONS

Depressive and PTSS appear to be the greatest contributors to functioning impairment in HCWs exposed to a massive stressful sanitary event as the COVID-19 pandemic. A more accurate assessment of work-related mental health outcomes in such population could help planning effective prevention strategies and therapeutic interventions.

Cumulative trauma from multiple natural disasters increases mental health burden on residents of Fort McMurray

BACKGROUND

Fort McMurray, a city in northern Alberta, Canada, has experienced multiple traumatic events in the last five years, including the 2016 wildfire, the 2020 floods, and the COVID-19 pandemic. Traumatic events often lead to increased mental health burdens in affected communities.

OBJECTIVE

To assess if the number of traumatic events experienced by residents of Fort McMurray correlates with the prevalence and severity of mental health issues experienced.

METHODOLOGY

A cross-sectional study using an online survey questionnaire was used to gather demographic, trauma (wildfire, flooding, and COVID-19), and clinical information from the resident of Fort McMurray between April 24 to June 2 2021. Likely Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), Post-Traumatic Stress Disorder (PTSD) and low resilience were measured using standardised rating scales. Data were analyzed with SPSS version 26 using Chi-Square tests and multivariate regression analysis.

RESULTS

Respondents who experienced COVID-19 and either flood or wildfire traumas (N = 101) were eleven times more likely to have GAD symptoms (OR: 11.39; 95% CI: 1.43-91.04), four times more likely to have likely MDD, (OR: 3.85; 95% CI: .995-14.90), ten times more likely to have likely PTSD (OR: 10.47; 95% CI: 1.28-85.67), and low resilience (OR: 10.56; 95% CI: 1.21-92.17). Respondents who experienced COVID-19, flooding, and wildfire traumas (N = 47) were eighteen times more likely to express GAD symptoms (OR: 18.30; 95% CI: 2.20-152.45) and more than eleven times likely to have likely PTSD (OR: 11.41; 95% CI: 1.34-97.37) in comparison to the respondents who experienced COVID-19 only trauma (N = 19).

CONCLUSION

Measures to reduce climate change and associated natural disasters could reduce the impact of cumulative trauma and associated mental health burden in vulnerable populations. It is essential that more mental health resources are mobilised to support communities impacted by multiple natural disasters.

HIGHLIGHTS

The number of traumatic disasters experienced in residents of Fort McMurray five years after the 2016 wildfires, a year after the 2020 flooding, and during the COVID-19 pandemic correlates with the prevalence and severity of the mental health conditions reported in this study.

Prevalência de sintomas psiquiátricos e seus fatores associados na população adulta da área atingida pelo rompimento da barragem de rejeitos: Projeto Saúde Brumadinho

RESUMO: Objetivo: Examinar a prevalência dos sintomas psiquiátricos e seus fatores associados na população adulta de Brumadinho (MG), após o rompimento da barragem. Métodos: Foram incluídos 2.740 participantes com informações coletadas em 2021 sobre os sintomas de estresse pós-traumático (TEPT), depressão, ansiedade, ideias de morte/automutilação e pior qualidade do sono. Estimaram-se as prevalências de todas as condições. Para a comparação das prevalências dos sintomas psiquiátricos e as características sociodemográficas e local de moradia, empregou-se o teste χ2 de Pearson, com correção de Rao-Scott. Regressões logísticas brutas e ajustadas estimaram os odds ratios e intervalos de confiança de 95%, permitindo a avaliação da associação entre os sintomas psiquiátricos e as características dos participantes. Resultados: Os sintomas depressivos foram a condição mais prevalente (29,3%), seguidos pelos sintomas de TEPT (22,9%) e sintomas ansiosos (18,9%). Com relação à investigação da associação entre as características dos participantes na análise ajustada, observou-se que o sexo feminino e os moradores da área de mineração apresentaram relação positiva com os sintomas de TEPT, depressivos, ansiosos, ideia de morte e pior qualidade de sono. Também se encontraram associação positiva entre a escolaridade de nível médio e os sintomas de TEPT e associação negativa entre aqueles com ≥60 anos e os sintomas de TEPT, depressivos e ansiosos. Conclusão: Altas prevalências foram encontradas para todos os sintomas psiquiátricos após a ruptura da barragem em Brumadinho. Sexo feminino, local de moradia na área de mineração, ≥60 anos e escolaridade foram associados aos sintomas psiquiátricos investigados.

Sex- and stress-dependent effects of a single injection of ketamine on open field and forced swim behavior

Ketamine has emerged as a novel treatment for common psychiatric conditions such as Major Depressive Disorder (MDD) and anxiety disorders, many of which can be initiated and exacerbated by psychological stress. Sex differences in the frequency of both anxiety and depressive disorders are well known and could be due to sex differences in neuroendocrine responses to stress. Ketamine is known to modulate the hormonal response to stress, specifically corticosterone. It is not clear if the acute effect of ketamine on corticosterone differs by sex, or what role this could play in subsequent behavior. Here we test whether a single injection of (R,S)-ketamine (30 mg/kg, i.p.), administered either with or without unpredictable chronic stress (UCS), has different sustained effects on open field test (OFT), elevated zero maze (EZM) or forced swim test (FST) behavior in female versus male C57BL/6J mice. In the OFT (24 h post-injection), ketamine increased center square exploration in males but not females. In contrast, in the FST (72 h post-injection), females showed a trend toward a decrease in immobility after ketamine whereas males were not strongly modulated. These behavioral effects of ketamine were stronger in the presence of UCS than in unstressed animals. UCS animals also showed lower corticosterone after injection than unstressed animals, and in the presence of UCS ketamine increased corticosterone; these effects were similar in both sexes. Corticosterone post-injection did not predict subsequent behavior. These findings complement a growing preclinical literature suggesting both stress-dependency and sex differences in OFT and FST behavioral responses to ketamine.LAY SUMMARYIn humans, it is known that major depression and anxiety disorders, which can be caused or made worse by exposure to psychological stress, occur roughly twice as frequently in women than in men, but the underpinnings of these effects are not well characterized. In the current study, we explored how sex interacts with stress and ketamine (a rapidly acting antidepressant) by assessing both open field and forced swim behavior in mice after chronic mild stress. We report the novel finding that male mice exhibit greater exploration of the aversive center square in the open field after ketamine, whereas females trended toward lower immobility (often interpreted as an antidepressant-like effect) in the forced swim test after this drug, and these effects were amplified by prior stress exposure.

Are Noradrenergic Transmission Reducing Drugs Antidepressants?

Major depressive disorder (MDD) remains a significant public health problem worldwide, and revised treatment strategies are therefore urgently needed, including the creation of novel antidepressant compounds or using existing molecular entities in new ways. Etiologic theories of MDD from decades ago have suggested that synaptic deficiencies of monoaminergic neurotransmitters play a causative role in this neuropsychiatric disorder, and that boosting monoamines with drugs such as SSRIs, SNRIs, TCAs, and MAOIs has antidepressant effects and in some individuals can even induce hypomania or mania. While other factors, such as various intracellular molecular pathways and hippocampal neurogenesis, undoubtedly also play a role in MDD, monoaminergic boosting drugs nonetheless have clearly demonstrated antidepressant properties. There is also, however, a body of studies in the preclinical literature suggesting that monoaminergic transmission reducing drugs, including noradrenergic ones, also have antidepressant-like behavioral properties in rodents. Given that there is increasing evidence that the monoamines have u-shaped or Janus-faced dose-response properties, in which a mid-range value is "optimal" in a variety of behavioral and physiological processes, it is plausible that either too much or too little synaptic norepinephrine in key circuits may exacerbate MDD in some individuals. Here we briefly review rodent depression-related behavioral data, focusing on the forced swim test, from three major classes of noradrenergic transmission reducing drugs (alpha2 agonists, beta blockers, alpha1 antagonists), and find much support for the hypothesis that they have antidepressant-like properties. Whether these drugs are antidepressants in human subjects remains to be determined.

Economic burden of treatment-resistant depression among veterans in the United States

OBJECTIVE

Evidence is limited on the economic burden associated with treatment-resistant depression (TRD) among US veterans. We evaluated the economic burden among patients with major depressive disorder (MDD) with and without TRD, and those without MDD in the Veterans Health Administration (VHA).

METHODS

Three cohorts were identified using VHA claims data (01APR2014-31MAR2018). Patients with MDD (aged ≥18) who failed ≥2 antidepressant treatments of adequate dose and duration were defined as having TRD; patients with MDD not meeting this criterion constituted the non-TRD MDD cohort (index: first antidepressant claim). The non-MDD cohort included those without MDD diagnosis (index: randomly assigned). Patients with psychosis, schizophrenia, manic/bipolar disorder, or dementia in the 6-month pre-index period were excluded. Patients with non-TRD MDD and non-MDD were matched 1:1 to patients with TRD based on demographic characteristics (age, gender, race, index year). Health care resource utilization (HRU) and costs were analyzed during the post-index period using a negative binomial model and ordinary least squares regression model, respectively.

RESULTS

After 1:1 exact matching, 10,449 patients were included in each cohort (mean age: 48.9 years). Patients with TRD had higher per patient per year (PPPY) HRU than non-TRD MDD (all-cause inpatient visits: incidence rate ratio [IRR]: 1.70 [95% confidence interval: 1.57-1.83]) and non-MDD (IRR: 5.04 [95% confidence interval: 4.51-5.63]), and incurred higher total all-cause health care costs PPPY than non-TRD MDD (mean difference: $5,906) and non-MDD (mean difference: $11,873; all p<.0001).

CONCLUSION

Among US veterans, TRD poses a significant incremental economic burden relative to non-TRD MDD and non-MDD.

Prevalence of Mental Ill-Health in a Cohort of First Responders Attending the Fort McMurray Fire

OBJECTIVES

The study was designed to estimate the prevalence of mental disorders in a cohort of firefighters who had been deployed to a devastating fire in Fort McMurray, Alberta, in 2016.

METHODS

A cohort of firefighters was established and followed up by online questionnaires. The contact in October 2018 to March 2019 included the PCL-5 questionnaire screening for post-traumatic stress disorder (PTSD) and the Hospital Anxiety and Depression Scale (HADS) screening for anxiety and depression. A sample was selected comprising all scoring ≥31 on the PCL-5 or ≥12 on either scale of the HADS, 30% of those scoring 8 to 11 on the HADS, and 10% of those with lower scores on all scales. This sample was assessed through a structured clinical interview to categorize disorders as defined in Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5). Interviews were carried out face-to-face or by telephone between August 2019 and February 2020. Diagnoses in the interview sample were reweighted to obtain prevalence estimates for the whole cohort. In an analysis of receiver operating characteristics (ROC), possible cut points for scores from each screening questionnaire were examined.

RESULTS

In 2018 to 2019, 1,000 of the cohort of 1,234 firefighters completed the HADS and 998 completed the PCL-5. Of these, 282 were identified for structured clinical interviews for DSM-5 (SCID) assessment. Interviews were carried out with 192. Among those assessed, 40.6% met the criteria for PTSD, 30.7% for an anxiety disorder, and 28.5% for a depressive disorder. When reweighted to allow for sampling and losses to assessment, cohort prevalence estimates were as follows: PTSD 21.4% (15.7% to 29.1%), anxiety disorders 15.8% (11.0% to 22.5%), and depressive disorders 14.3% (9.9% to 20.8%). Lower prevalence estimates were obtained when using the cut point with least misclassification in the ROC analysis.

CONCLUSION

Using the gold-standard SCID assessment, high rates of mental disorders were found in this cohort of firefighters who had experienced a devastating fire. Fewer cases would have been identified by screening questionnaire alone.

Crisis leadership: An evolutionary concept analysis

AIM

The purpose of this study was to define crisis leadership in the nursing context.

BACKGROUND

Leadership during critical situations is perhaps the most crucial element for crisis resolution.

METHODS

Rodgers' evolutionary approach was used to conduct a concept analysis on crisis leadership and find its critical attributes, antecedents, and consequences. The researchers examined articles published in English and Korean from six databases. Articles from 2000 to 2016-with the key terms of crisis leadership, crisis management, crisis intervention, crisis, and disaster-were considered for analysis. Eleven studies were included in the final review.

RESULTS

The core attributes of crisis leadership from a nursing perspective consisted of six attributes: clear, fast, frank communication; a high degree of collaboration; sharing of information; decision-making and fair prioritization; building trust; competency.

CONCLUSIONS

Based on this review, crisis leadership should be revised to focus on competency, nursing interventions, measurement tools, and training protocol development.

WWII traumatic events, subjective well-being and valuation of life in the very old

Background

Experiencing war is a major trigger for physical and mental health problems. People in the German population who are currently over 80 years of age experienced the Second World War (WWII) as children or adolescents, at a time when psychological vulnerability is high. Empirical results show that positive subjective well-being (SWB) and valuation of life (VoL) in older cohorts are widespread; however, when confronted with existential age-associated changes, many older adults experience increased burden, sometimes bringing biographical vulnerabilities to the forefront. This study investigated SWB and VoL in the very old and examined the influence of negative WWII experiences on these outcomes.

Method

Cross-sectional data from the “Survey on quality of life and subjective well-being of the very old in North Rhine-Westphalia (NRW80+)” are presented. Multiple regression models, adjusted for gender, age, physical health, and full inpatient care, were computed to assess the impact of suffering from the effects of WWII traumatic experiences on SWB and VoL.

Results

Over 13% spontaneously reported suffering from the effects of WWII events and an additional 29% reported negative experiences when explicitly asked about them. Multiple regression models showed elevated depression scores for participants suffering from the effects of WWII traumatic events. No association with positive affect was found. Suffering from the effects of WWII traumatic events did not influence VoL engagement with life or VoL optimism.

Discussion

Many very old adults still seem to struggle with the repercussions of WWII traumatic experiences. Future studies could further examine if the missing association with positive affect and VoL is a sign of resilience.

Forecasting military mental health in a complete sample of Danish military personnel deployed between 1992-2013

OBJECTIVE

Mental health problems (MHP) are a relatively common consequence of deployment to war zones. Early identification of those at risk of post-deployment MHP would improve prevention efforts. However, screening instruments based on linear models have not been successful. Machine learning (ML) has shown promise for providing the methodological frame for better prognostic models.

METHODS

The study population was all Danish military personnel deployed for the first time between January 1, 1992 and December 31, 2013. From extensive registry data, 21 pre- or at-deployment predictors comprising early adversity, social, clinical and demographic variables were used to predict psychiatric contacts (psychiatric diagnosis and/or use of psychotropic medicine) occurring within 6.5 years after homecoming. Four supervised ML methods (penalized logistic regression, random forests, support vector machines and gradient boosting machines) were compared in ability to classify those with high risk of post-deployment MHP and those without.

RESULTS

Of 27594 subjects, 2175 (8%) had a psychiatric contact. All four ML methods applied had performances well above chance (Area under the Receiver-operating Curve 0.62-0.68). Positive predictive value for the best model was 0.16. A range of pre-deployment factors were found to be predictive of post-deployment psychiatric contacts.

CONCLUSIONS

ML methods can be useful in early identification of soldiers with high risk of MPH in the years following their first deployment. However, performances were modest and positive predictive values were low, limiting the applicability of the models for pre-deployment screening. Future studies should include neurobiological data and deployment experiences to increase accuracy of the models.

Mindfulness practice for protecting mental health during the COVID-19 pandemic

Emerging evidence shows that the coronavirus disease 2019 (COVID-19) pandemic is negatively affecting mental health around the globe. Interventions to alleviate the psychological impact of the pandemic are urgently needed. Whether mindfulness practice may protect against the harmful emotional effects of a pandemic crisis remains hitherto unknown. We investigated the influence of mindfulness training on mental health during the COVID-19 outbreak in China. We hypothesized that mindfulness practitioners might manifest less pandemic-related distress, depression, anxiety, and stress than non-practitioners and that more frequent practice would be associated with an improvement in mental health during the pandemic. Therefore, we assessed pandemic-related distress and symptoms of depression, anxiety, and stress, as well as the frequency of meditation practice at the peak of new infections (Feb 4-5; N = 673) and three weeks later (Feb 29-30; N = 521) in mindfulness practitioners via online questionnaires. Self-reported symptoms were also collected from non-practitioners at peak time only (N = 1550). We found lower scores of pandemic-related distress in mindfulness practitioners compared to non-practitioners. In general, older participants showed fewer symptoms of depression and anxiety. In younger practitioners, pandemic-related distress decreased from peak to follow-up. Importantly, increased mindfulness training during the preceding two weeks was associated with lower scores of depression and anxiety at both assessments. Likewise, practice frequency predicted individual improvement in scores of depression, anxiety, and stress at follow-up. Our results indicate that mindfulness meditation might be a viable low-cost intervention to mitigate the psychological impact of the COVID-19 crisis and future pandemics.

Co-occurrence Pattern of Posttraumatic Stress Disorder and Depression in People Living With HIV: A Latent Profile Analysis

Background: The comorbidity of posttraumatic stress disorder (PTSD) and depression is common among people living with the HIV (PLWH). Given the high prevalence and serious clinical consequences of the comorbidity of these two disorders, we conducted a latent profile analysis to examine the co-occurrence pattern of PTSD and depression in PLWH.

Methods: The data for this cross-sectional study of PLWH were collected from 602 patients with HIV in China. A secondary analysis using latent profile analysis was conducted to examine HIV-related PTSD and depression symptoms.

Results: A four-class solution fits the data best, with the four classes characterized as asymptomatic (42.9%), mild symptoms (33.9%), low to moderate symptoms (19.8%), and high to moderate symptoms (3.4%). The severity of PTSD and depression symptoms was comparable in this solution, and no group was dominated by PTSD or depression.

Conclusion: The absence of a distinct subcluster of PLWH with only PTSD or depression symptoms supports that PTSD and depression in PLWH are psychopathological manifestations after traumatic exposures. Health care staff should pay more attention to the existence of comorbid symptoms of individuals, develop integrated interventions for the symptoms cluster, and evaluate their effectiveness in clinical practice.

Effective Adoption of Tablets for Psychodiagnostic Assessments in Rural Burundi: Evidence for the Usability and Validity of Mobile Technology in the Example of Differentiating Symptom Profiles in AMISOM Soldiers 1 Year After Deployment

Research on the use of mobile technology in health sciences has identified several advantages of so-called mHealth (mobile health) applications. Tablet-supported clinical assessments are becoming more and more prominent in clinical applications, even in low-income countries. The present study used tablet computers for assessments of clinical symptom profiles in a sample of Burundian AMISOM soldiers (i.e., African Union Mission to Somalia; a mission approved by the UN). The study aimed to demonstrate the feasibility of mHealth-supported assessments in field research in Burundi. The study was conducted in a resource-poor setting, in which tablet computers are predestined to gather data in an efficient and reliable manner. The overall goal was to prove the validity of the obtained data as well as the feasibility of the chosen study setting. Four hundred sixty-three soldiers of the AMISOM forces were investigated after return from a 1-year military mission in Somalia. Symptoms of posttraumatic stress disorder (PTSD) and depression were assessed. The used data-driven approach based on a latent profile analysis revealed the following four distinct groups, which are based on the soldiers' PTSD and depression symptom profiles: Class 1: moderate PTSD, Class 2: moderate depression, Class 3: low overall symptoms, and Class 4: high overall symptoms. Overall, the four identified classes of soldiers differed significantly in their PTSD and depression scores. The study clearly demonstrates that tablet-supported assessments can provide a useful application of mobile technology in large-scale studies, especially in resource-poor settings. Based on the data collected for the study at hand, it was possible to differentiate different sub-groups of soldiers with distinct symptom profiles, proving the statistical validity of the gathered data. Finally, advantages and challenges for the application of mobile technology in a resource-poor setting are outlined and discussed.

Increased alcohol use during the COVID-19 pandemic: The effect of mental health and age in a cross-sectional sample of social media users in the U.S

The COVID-19 pandemic has triggered a public health crisis of unprecedented scale. Increased alcohol use has been extensively documented during other crises, particularly among persons with anxiety and depression. Despite COVID-19's differential impact by age, the association of age, mental health and alcohol use during the pandemic has not been explored. This study aimed to examine whether age modified the association of anxiety and depressive symptoms with alcohol use during the COVID-19 pandemic. Two online surveys were administered to U.S. adult social media users in March and April 2020. Generalized linear models were conducted in 2020 among 5850 respondents (52.9% female; 22.0% aged 18-39 years, 47.0% aged 40-59 years, and 31.0% aged ≥60 years) to examine if age modified the association of anxiety and depression symptomatology and alcohol use. Overall, 29% of respondents reported increased alcohol use. Adjusted odds ratios of reporting increased alcohol use were 1.41 (95% CI = 1.20-1.66) among respondents with anxiety symptoms and 1.64 (95% CI = 1.21-2.23) among those with depressive symptoms compared to those without such symptoms. Whereas respondents aged 18-39 years had the highest probability of reporting increased alcohol use, the probability of older persons (40-59 and ≥60 years) reporting increased drinking was much greater among those with symptoms of anxiety and depression, compared to those without symptoms. These findings warrant age-differentiated public health messaging on the risks of excessive alcohol use and scale-up of substance use services for middle-aged and older adults with symptoms of depression and anxiety.

Repurposing Cholinesterase Inhibitors as Antidepressants? Dose and Stress-Sensitivity May Be Critical to Opening Possibilities

When stress becomes chronic it can trigger lasting brain and behavioral changes including Major Depressive Disorder (MDD). There is conflicting evidence regarding whether acetylcholinesterase inhibitors (AChEIs) may have antidepressant properties. In a recent publication, we demonstrated a strong dose-dependency of the effect of AChEIs on antidepressant-related behavior in the mouse forced swim test: whereas the AChEI donepezil indeed promotes depression-like behavior at a high dose, it has antidepressant-like properties at lower doses in the same experiment. Our data therefore suggest a Janus-faced dose-response curve for donepezil in depression-related behavior. In this review, we investigate the mood-related properties of AChEIs in greater detail, focusing on both human and rodent studies. In fact, while there have been many studies showing pro-depressant activity by AChEIs and this is a major concept in the field, a variety of other studies in both humans and rodents show antidepressant effects. Our study was one of the first to systematically vary dose to include very low concentrations while measuring behavioral effects, potentially explaining the apparent disparate findings in the field. The possibility of antidepressant roles for AChEIs in rodents may provide hope for new depression treatments. Importantly, MDD is a psychosocial stress-linked disorder, and in rodents, stress is a major experimental manipulation for studying depression mechanisms, so an important future direction will be to determine the extent to which these depression-related effects are stress-sensitive. In sum, gaining a greater understanding of the potentially therapeutic mood-related effects of low dose AChEIs, both in rodent models and in human subjects, should be a prioritized topic in ongoing translational research.

The Symptom Structure of Postdisaster Major Depression: Convergence of Evidence from 11 Disaster Studies Using Consistent Methods

Agreement has not been achieved across symptom factor studies of major depressive disorder, and no studies have identified characteristic postdisaster depressive symptom structures. This study examined the symptom structure of major depression across two databases of 1181 survivors of 11 disasters studied using consistent research methods and full diagnostic assessment, addressing limitations of prior self-report symptom-scale studies. The sample included 808 directly-exposed survivors of 10 disasters assessed 1–6 months post disaster and 373 employees of 8 organizations affected by the September 11, 2001 terrorist attacks assessed nearly 3 years after the attacks. Consistent symptom patterns identifying postdisaster major depression were not found across the 2 databases, and database factor analyses suggested a cohesive grouping of depression symptoms. In conclusion, this study did not find symptom clusters identifying postdisaster major depression to guide the construction and validation of screeners for this disorder. A full diagnostic assessment for identification of postdisaster major depressive disorder remains necessary.

Repeated Dosing of Ketamine in the Forced Swim Test: Are Multiple Shots Better Than One?

The anesthetic drug ketamine has been successfully repurposed as an antidepressant in human subjects. This represents a breakthrough for clinical psychopharmacology, because unlike monoaminergic antidepressants, ketamine has rapid onset, including in Major Depressive Disorder (MDD) that is resistant to conventional pharmacotherapy. This rapid therapeutic onset suggests a unique mechanism of action, which continues to be investigated in reverse translational studies in rodents. A large fraction of rodent and human studies of ketamine have focused on the effects of only a single administration of ketamine, which presents a problem because MDD is typically a persistent illness that may require ongoing treatment with this drug to prevent relapse. Here we review behavioral studies in rodents that used repeated dosing of ketamine in the forced swim test (FST), with an eye toward eventual mechanistic studies. A subset of these studies carried out additional experiments with only a single injection of ketamine for comparison, and several studies used chronic psychosocial stress, where stress is a known causative factor in some cases of MDD. We find that repeated ketamine can in some cases paradoxically produce increases in immobility in the FST, especially at high doses such as 50 or 100 mg/kg. Several studies however provide evidence that repeated dosing is more effective than a single dose at decreasing immobility, including behavioral effects that last longer. Collectively, this growing literature suggests that repeated dosing of ketamine has prominent depression-related effects in rodents, and further investigation may help optimize the use of this drug in humans experiencing MDD.

Positive cognitive appraisal "buffers" the long-term effect of peritraumatic distress on maternal anxiety: The Queensland Flood Study

BACKGROUND

Limited research has evaluated distinct aspects of disaster experience as predictors of affective symptoms. In this study, we examined the extent to which maternal depression and anxiety over time were predicted by (1) objective hardship from a flood during pregnancy, (2) peritraumatic distress and (3) cognitive appraisal of the flood's consequences.

METHODS

Data were drawn from the 2011 Queensland Flood Study, a prospective, longitudinal study of pregnancy (n = 183). Mothers' disaster experience was measured within 1 year after the flood. Their levels of depression, anxiety and stress were measured at 16 months, 30 months, 4 years and 6 years after childbirth. Linear mixed models were employed to evaluate symptom trajectories.

RESULTS

There were no time-dependent effects of disaster-related variables. Objective hardship did not predict outcomes. Peritraumatic distress significantly predicted depression and anxiety symptoms when cognitive appraisal was negative. Conversely, when cognitive appraisal was neutral or positive, the effect of peritraumatic distress was "buffered". For anxiety, but not depression, this interaction survived Bonferroni correction. Neutral/positive cognitive appraisal similarly moderated the effect of peritraumatic dissociation.

LIMITATIONS

The generalizability of our findings is limited by overall low levels of depression and anxiety, along with a predominantly Caucasian, higher socioeconomic status sample. Potential confounders such as pre-disaster anxiety were not controlled for.

CONCLUSION

In line with previous evidence, this study supports the predictive validity of peritraumatic distress for post-disaster depression and anxiety. Our findings suggest that cognitive appraisal could be a relevant target for interventions aimed at fostering maternal resilience.

Outcomes and Correlates of Major Depression in 11 Disaster Studies Using Consistent Methods

This study investigated psychosocial functioning and employment status in association with postdisaster major depression and its course in survivors of 11 different disasters in a sample of 808 directly-exposed survivors of 10 disasters and 373 survivors of the 11 September 2001 (9/11), terrorist attacks on New York City’s World Trade Center (total n = 1181). Participants were assessed between 1987 and 2007 with structured diagnostic interviews in a prospective longitudinal design. Consistent research methods allowed merging of the disaster databases for analysis using multivariate modeling. Postdisaster major depression in the study cohort from the 9/11 disaster was more than twice as prevalent as in the other disasters, possibly reflecting the greater psychosocial/interpersonal loss and bereavement experienced by 9/11 disaster survivors. At follow up, employment was associated with remission of postdisaster major depression, non-development of PTSD, and coping via family or friends. Functioning problems were associated with disaster injuries, but not with persistent major depression. This study is unprecedented in its large sample of survivors across the full range of disaster typology studied using consistent methods and full structured interview diagnostic assessment. These findings may help guide future interventions to address postdisaster depression.

Occupational Risk for Post-Traumatic Stress Disorder and Trauma-Related Depression: A Systematic Review with Meta-Analysis

There is evidence suggesting that occupational trauma leads to post-traumatic stress disorder (PTSD) and depression. However, there is a lack of high-quality reviews studying this association. We, therefore, conducted a systematic review with a meta-analysis to summarize the evidence of occupational trauma on PTSD and depression. After a database search on studies published between 1994 and 2018, we included 31 studies, of which only four had a low risk of bias. For soldiers exposed to wartime deployment, the pooled relative risk (RR) was 2.18 (95% CI 1.83-2.60) for PTSD and 1.15 (95% CI 1.06-1.25) for depression. For employees exposed to occupational trauma, there also was an increased risk for PTSD (RR = 3.18; 95% CI 1.76-5.76) and for depression (RR = 1.73; 95% CI 1.44-2.08). The overall quality of the evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was moderate; the evidence was high only for the association between workers after exposure to trauma and development of PTSD. The study results indicate an increased risk of PTSD and depression in soldiers after participation in war and in employees after occupational trauma.

Probable PTSD, depression and anxiety in 40,299 UK police officers and staff: Prevalence, risk factors and associations with blood pressure

INTRODUCTION

Police employees undertake challenging duties which may adversely impact their health. This study explored the prevalence of and risk factors for probable mental disorders amongst a representative sample of UK police employees. The association between mental illness and alterations in blood pressure was also explored.

METHODS

Data were used from the Airwave Health Monitoring Study which was established to monitor the possible physical health impacts of a new communication system on police employees. Data included sociodemographic characteristics, lifestyle habits, depression, anxiety, and post-traumatic stress disorder (PTSD) symptoms and blood pressure. Descriptive statistics were used to explore the prevalence of probable mental disorders and associated factors. Stepwise linear regression was conducted, controlling for confounding variables, to examine associations between mental disorders and blood pressure.

RESULTS

The sample included 40,299 police staff, police constable/sergeants and inspectors or above. Probable depression was most frequently reported (9.8%), followed by anxiety (8.5%) and PTSD (3.9%). Groups at risk for probable mental disorders included police staff, and police employees who reported drinking heavily. Police employees exposed to traumatic incidents in the past six months had a doubling in rates of anxiety or depression and a six-fold increase in PTSD compared to those with no recent trauma exposure. Adjusted logistic regression models did not reveal any significant association between probable mental disorders and systolic blood pressure but significantly elevated diastolic blood pressure (≈1mmHg) was found across mental disorders.

CONCLUSIONS

These results show lower rates of probable mental disorders, especially PTSD, than reported in other studies focusing on police employees. Although mental ill health was associated with increased diastolic blood pressure, this was unlikely to be clinically significant. These findings highlight the importance of continued health monitoring of members of the UK police forces, focusing on employees recently exposed to traumatic incidents, heavy drinkers and police staff.

World Trade Center Health Program: First Decade of Research

The terrorist attacks on 11 September 2001 placed nearly a half million people at increased risk of adverse health. Health effects research began shortly after and continues today, now mostly as a coordinated effort under the federally mandated World Trade Center (WTC) Health Program (WTCHP). Established in 2011, the WTCHP provides medical monitoring and treatment of covered health conditions for responders and survivors and maintains a research program aimed to improve the care and well-being of the affected population. By 2020, funds in excess of USD 127 M had been awarded for health effects research. This review describes research findings and provides an overview of the WTCHP and its future directions. The literature was systematically searched for relevant articles published from 11 September 2001 through 30 June 2020. Synthesis was limited to broad categories of mental health, cancer, respiratory disease, vulnerable populations, and emerging conditions. In total, 944 WTC articles were published, including peer-reviewed articles funded by the WTCHP (n = 291) and other sources. Research has focused on characterizing the burden and etiology of WTC-related health conditions. As the program moves forward, translational research that directly enhances the care of individuals with chronic mental and physical health conditions is needed.

Considering Exposure Assessment in Epidemiological Studies of Chronic Health in Military Populations

Exposure assessment is an important factor in all epidemiological research seeking to identify, evaluate, and control health risks. In the military and veteran context, population health research to explore exposure-response links is complicated by the wide variety of environments and hazards encountered during active service, long latency periods, and a lack of information on exposures in potentially vulnerable subgroups. This paper summarizes some key considerations for exposure assessment in long-term health studies of military populations, including the identification of hazards related to military service, characterization of potentially exposed groups, exposure data collection, and assignment of exposures to estimate health risks. Opportunities and future directions for exposure assessment in this field are also discussed.

Making the transition: How finding a good job is a risky business for military Veterans in Northern Ireland

Veterans transitioning from the military to civilian life may encounter difficulties in different domains of functioning. Most research in this area comes from the US and Israel, with Veterans in Northern Ireland (NI) in the United Kingdom, remaining an understudied population. This qualitative study aimed to examine the nature of transition experiences of NI Veterans by analyzing responses (N = 252) to an open-ended question related to the transition process, in a self-report survey. Thematic analysis highlighted both positive and negative experiences across high-level themes. These were related to (1a) how good the military life had been, (1b) the transition had been easy for some Veterans, and (1c) the skills gained in the military have been valuable; (2) it was hard to adjust to civilian life/still adjusting; (3) negative employment experiences; (4) lack of trust; (5) transitioning is hard in NI; and (6) inadequate support, post-service. The findings highlight that NI Veterans share some of the same challenges as other Veterans; however, the challenges in NI are compounded by ongoing security concerns and political tensions, which means living under the radar is a reality for many, making finding meaningful work and community integration difficult. The findings indicate that preparation for civilian life and the acculturation process needs to start many months before discharge. Perhaps more crucially, regiments should work closely with and support civilian employers to equip them to recognize and value the skills ex-Services Veterans can offer, and find a good fit for their skills within their organizations.

Screening for psychotrauma related symptoms: Japanese translation and pilot testing of the Global Psychotrauma Screen

Background: The impact of traumatic experiences or adverse life experiences has been shown to potentially affect a wide range of mental health outcomes. However, there was no brief instrument to screen for a range of psychological problems in different domains after a potentially traumatic event, and for risk factors and protective factors. Objective: The aim of this study is to examine the internal consistency and concurrent validity of the Japanese version of the Global Psychotrauma Screen (GPS) in a traumatized sample in Japan. Method: A total sample (n = 58) with varying levels of potential posttrauma symptoms due to domestic violence or other events were recruited into this study. Self-rating measures of posttraumatic stress disorder (PTSD), depression, anxiety, and alcohol problems were conducted to investigate the concurrent validity. Results: The results show that a range of posttrauma symptoms assessed by the GPS were highly endorsed by this traumatized sample in all domains except for self-harm, derealization, and depersonalization. The GPS sum score was highly correlated (r > 0.79) with other measures of PTSD, depression, and anxiety symptoms. Also, the subdomain scores showed acceptable correlations with corresponding domain measures. Participants who had been sexually assaulted or had unwanted sexual experiences, and participants who had been physically assaulted during childhood, had higher scores on the total GPS and on subdomains of PTSD, as well as symptoms associated with Complex PTSD. Conclusions: This study provides an initial indication that the GPS may be a useful screening tool for trauma survivors and elucidates that the consequences of trauma are not limited to PTSD.

PTSD and Burnout are Related to Lifetime Mood Spectrum in Emergency Healthcare Operator

Background:

PTSD and burnout are frequent conditions among emergency healthcare personnel because exposed to repeated traumatic working experiences. Increasing evidence suggests high comorbidity between PTSD and mood symptoms, particularly depression, although the real nature of this relationship still remains unclear. The purpose of this study was to investigate the relationship between PTSD, burnout and lifetime mood spectrum, assessed by a specific scale, among health-care professionals of a major University Hospital in Italy.

Methods:

N=110 Emergency Unit workers of the Azienda Ospedaliero-Universitaria Pisana (Pisa, Italy) were assessed by the TALS-SR, MOODS-SR lifetime version and the ProQOL R-IV.

Results:

Approximately 60% of participants met at least one PTSD symptom criterion (criterion B, 63.4%; criterion C, 40.2%; criterion D 29.3%; criterion E, 26.8%), according to DSM-5 diagnosis. Almost sixteen percent of the sample reported a full symptomatic DSM-5 PTSD (work-related) diagnosis, and these showed significantly higher scores in all MOODS-SR depressive domains, as well as in the rhythmicity domain, compared with workers without PTSD. Further, mood-depressive and cognition-depressive MOODS-SR domains resulted to be predictive for PTSD. Significant correlations emerged between either PTSD diagnosis and criteria or ProQOL subscales and all the MOOD-SR domains.

Conclusion:

A significant association emerged among PTSD, burnout and lifetime MOOD Spectrum, particularly the depressive component, in emergency health care operators, suggesting this population should be considered at-risk and undergo regular screenings for depression and PTSD.