Reduced pre-attentive threat versus nonthreat signal discrimination in clinically healthy military personnel with recurrent combat exposure history: A preliminary event-related potential (ERP) study

Evidence now suggests that traumatic-stress impacts brain functions even in the absence of acute-onset post-traumatic stress disorder (PTSD) symptoms. These neurophysiological changes have also been suggested to account for increased risks of PTSD symptoms later developing in the aftermath of subsequent trauma. However, surprisingly few studies have explicitly examined brain function dynamics in high-risk populations, such as combat exposed military personnel without diagnosable PTSD. To extend available research, facial expression sensitive N170 event-related potential (ERP) amplitudes were examined in a clinically healthy sample of active service military personnel with recurrent combat exposure history. Consistent with several established theories of delayed-onset PTSD vulnerability, higher N170 amplitudes to backward-masked fearful and neutral facial expressions correlated with higher levels of past combat exposure. Significantly elevated amplitudes to nonthreatening neutral facial expressions also resulted in an absence of normal threat-versus-nonthreat signal processing specificity. While a modest sample size and cross-sectional design are key limitations here, ongoing prospective-longitudinal follow-ups may shed further light on the precise aetiology and prognostic utility of these preliminary findings in the near future.

Interactive relationship between alexithymia, psychological distress and posttraumatic stress disorder symptomology across time

Alexithymia, psychological distress, and posttraumatic stress disorder (PTSD) are highly related constructs. The ongoing debate about the nature and relationship between these constructs is perpetuated by an overreliance on cross-sectional research. We examined the longitudinal interactive relationship between alexithymia, psychological distress, and PTSD. We hypothesised that there is an interactive relationship between the three constructs. Military personnel (N = 1871) completed the Toronto Alexithymia Scale, the Kessler 10 and a PTSD Checklist (PCL-C) at pre-deployment, post-deployment, and at 3-4 years following the post-deployment assessment. We initially tested whether psychological distress is either a moderator or mediator in the relationship between alexithymia and PTSD across the time points. General psychological distress was a partial mediator of total PTSD severity and hyperarousal symptomology at all three time points. Psychological distress fully mediated re-experiencing and avoidance symptomology at all three time points. Our results suggest that those with alexithymia are at longitudinal risk of developing more severe PTSD symptomology and experiencing hyperarousal irrespective of temporal proximity to traumatic exposure. Further, vulnerability to the emergence of re-experiencing and avoidance symptomology for those with alexithymia is increased when one experiences greater distress. Our results show that alexithymia is a persistent risk factor for PTSD symptomology.

Three-Item Dimensions of Anger Reactions Scale

Importance

Problematic anger is prevalent and associated with adjustment difficulties in military populations. To facilitate measurement of problematic anger, a very brief valid measure is needed.

Objective

To reduce the Dimensions of Anger Reactions 5-item (DAR-5) scale to a very brief measure.

Design, Setting, and Participants

This cross-sectional study used survey data collected between 2014 and 2016 in the Australian Transition and Well-Being Research Programme and US Millennium Cohort Study. Participants were service members who were actively serving or had transitioned out of the military (separated). Statistical analyses were performed from September 2021 to June 2023.

Main Outcomes and Measures

The DAR-5 was reduced to the 3 experiential items: frequency, intensity, and duration (the DAR-3). Psychometrics for the DAR-3 and DAR-5 were compared in terms of standardized Cronbach α, positive screening result, mean, and SD. Analyses were stratified by Australian and US military service status cohorts (active duty and separated).

Results

A total of 71 010 participants were included from Australia and the US. Of 10 900 Australian participants (8145 active duty participants [74.7%]; 2755 separated participants [25.3%]), 5893 (55.2%) were aged 40 years or older and 8774 (80.5%) were male; of 60 110 US participants (24 706 active duty participants [41.1%]; 35 404 separated participants [58.9%]), 28 804 (47.9%) were aged 30 to 39 years and 43 475 (72.3%) were male. The DAR-3 demonstrated good internal consistency in the active duty (Australia: mean [SD] score, 4.97 [2.5]; α = 0.90; US: mean [SD] score, 5.04 [2.6]; α = 0.87) and separated (Australia: mean [SD] score, 6.53 [3.4]; α = 0.92; US: mean [SD] score, 6.05 [3.2]; α = 0.91) samples. The cutoff score of 8 or greater on the DAR-3 had optimal sensitivity and specificity across all samples. DAR-3 and DAR-5 were associated with posttraumatic stress disorder (PTSD), depression, aggression, and relationship conflict. While the scales did not significantly differ in their associations with PTSD, depression, and relationship conflict, the magnitude of association for aggression was significantly lower in US samples using the DAR-3 (eg, US active duty sample: DAR-5 OR, 9.96; 95% CI, 9.01-11.00; DAR-3 OR, 8.36; 95% CI, 7.58-9.22).

Conclusions and Relevance

In this cross-sectional study of a very brief measure of anger, each item contributed to the overall strength of the measure without losing psychometric strength compared with the DAR-5. The consistency of these findings across military and veteran samples in Australian and US populations demonstrated the psychometric robustness of the DAR-3.

Cumulative trauma load and timing of trauma prior to military deployment differentially influences inhibitory control processing across deployment

Military personnel experience high trauma load that can change brain circuitry leading to impaired inhibitory control and posttraumatic stress disorder (PTSD). Inhibitory control processing may be particularly vulnerable to developmental and interpersonal trauma. This study examines the differential role of cumulative pre-deployment trauma and timing of trauma on inhibitory control using the Go/NoGo paradigm in a military population. The Go/NoGo paradigm was administered to 166 predominately male army combat personnel at pre- and post-deployment. Linear mixed models analyze cumulative trauma, trauma onset, and post-deployment PTSD symptoms on NoGo-N2 and NoGo-P3 amplitude and latency across deployment. Here we report, NoGo-N2 amplitude increases and NoGo-P3 amplitude and latency decreases in those with high prior interpersonal trauma across deployment. Increases in NoGo-P3 amplitude following adolescent-onset trauma and NoGo-P3 latency following childhood-onset and adolescent-onset trauma are seen across deployment. Arousal symptoms positively correlated with conflict monitoring. Our findings support the cumulative trauma load and sensitive period of trauma exposure models for inhibitory control processing in a military population. High cumulative interpersonal trauma impacts conflict monitoring and response suppression and increases PTSD symptoms whereas developmental trauma differentially impacts response suppression. This research highlights the need for tailored strategies for strengthening inhibitory control, and that consider timing and type of trauma in military personnel.

Gambling problems predict suicidality in recently transitioned military veterans

OBJECTIVE

This study investigated associations between gambling problems and suicidality in Australian veterans.

METHODS

Data drawn from n = 3,511 Australian Defence Force veterans who had recently transitioned to civilian life. Gambling problems were assessed using the Problem Gambling Severity Index (PGSI) and suicidal ideation and behaviour were assessed using items adapted from the National Survey of Mental Health and Wellbeing.

RESULTS

At-risk gambling and problem gambling were associated with increased odds of suicidal ideation [at-risk gambling: odds ratio (OR), 1.93; 95% confidence interval (CI), 1.47‒2.53; problem gambling: OR, 2.75; 95% CI 1.86‒4.06] and suicide planning or attempts (at-risk gambling: OR, 2.07; 95% CI, 1.39‒3.06; problem gambling: OR 4.22, 95% CI, 2.61‒6.81). The association with total scores on the PGSI and any suicidality was substantially reduced and became non-significant when controlling for the effects of depressive symptoms, but not financial hardship or social support.

CONCLUSIONS

Gambling problems and harms are important risk factors for suicide in veterans, and should be recognised in veteran-specific suicide prevention policies and programs, along with co-occurring mental health problems.

IMPLICATIONS FOR PUBLIC HEALTH

A comprehensive public health approach to reducing gambling harm should feature in suicide prevention efforts in veteran and military populations.

Potential peripheral biomarkers associated with the emergence and presence of posttraumatic stress disorder symptomatology: A systematic review

BACKGROUND

Evidence suggests posttraumatic stress disorder (PTSD) involves an interplay between psychological manifestations and biological systems. Biological markers of PTSD could assist in identifying individuals with underlying dysregulation and increased risk; however, accurate and reliable biomarkers are yet to be identified.

METHODS

A systematic review following the PRISMA guidelines was conducted. Databases included EMBASE, MEDLINE, and Cochrane Central. Studies from a comprehensive 2015 review (Schmidt et al., 2015) and English language papers published subsequently (between 2014 and May 2022) were included. Forty-eight studies were eligible.

RESULTS

Alterations in neuroendocrine and immune markers were most commonly associated with PTSD symptoms. Evidence indicates PTSD symptoms are associated with hypothalamic-pituitary-adrenal axis dysfunction as represented by low basal cortisol, a dysregulated immune system, characterized by an elevated pro-inflammatory state, and metabolic dysfunction. However, a considerable number of studies neglected to measure sex or prior trauma, which have the potential to affect the biological outcomes of posttraumatic stress symptoms. Mixed findings are indicative of the complexity and heterogeneity of PTSD and suggest the relationship between allostatic load, biological markers, and PTSD remain largely undefined.

CONCLUSIONS

In addition to prospective research design and long-term follow up, it is imperative future research includes covariates sex, prior trauma, and adverse childhood experiences. Future research should include exploration of biological correlates specific to PTSD symptom domains to determine whether underlying processes differ with symptom expression, in addition to subclinical presentation of posttraumatic stress symptoms, which would allow for greater understanding of biomarkers associated with disorder risk and assist in untangling directionality.

Problematic Anger in the Military: Focusing on the Forgotten Emotion

PURPOSE OF REVIEW

Problematic anger is common in veteran and military populations, yet understudied relative to other mental health difficulties. However, in recent years, more clinical and research attention has been turned to problematic anger. This paper highlights important new findings in the epidemiology, course, and neurobiology of anger, the associations of anger with other mental health problems and risk, and next steps for research and practice.

RECENT FINDINGS

In longitudinal research, findings show that problematic anger changes over the life course of military members and veterans, and that deployment increases the likelihood of problematic levels of anger. Problematic anger is related to a range of mental health issues, most perniciously aggression and suicidality. Promising new assessment and treatment approaches are emerging, including innovations that leverage digital technology. Key areas of research include advancing assessment of problematic anger to identify patterns of heterogeneity, as well as advancing the evidence base for anger treatments. Recommended progress in clinical practice include conducting routine assessment of problematic anger in veteran and military populations, developing prevention and early intervention for at risk individuals, and optimizing the timing of interventions throughout the military lifecycle.

Longitudinal Relationship Between Posttraumatic Stress Symptoms and Physical Symptoms in Military Veterans

OBJECTIVE

This study aimed to assess the temporal relationship of posttraumatic stress disorder (PTSD) symptoms and physical symptoms in a non-treatment-seeking deployed military sample.

METHODS

Data were from a longitudinal study of Australian Defence Force personnel deployed to the Middle East Area of Operations between 2010 and 2012 ( n = 1871). Predeployment assessment was conducted 4 months before deployment (T1). Of these, 1324 (70.8% retention rate) participated in assessment within 4 months after deployment (T2), and 1122 (60.0%) completed the third time point at 4 years after deployment (T3). PTSD symptoms were assessed with the posttraumatic stress checklist and physical symptoms with a 67-item self-report Health Symptom Checklist. To explore directional influences between symptoms over time, longitudinal cross-lagged association between the modeled latent factors for PTSD symptoms and physical symptoms was estimated using structural equation modeling.

RESULTS

From T1 to T2, there was a significant bidirectional effect with higher physical symptom count at T1 predicting higher PTSD symptom severity at T2 ( β = 0.17, p < .001) and higher PTSD symptom severity at T1 predicting higher physical symptom count at T2 ( β = 0.13, p < .001). The effect of T2 on T3 was unidirectional. PTSD symptom severity at T2 had no effect on physical symptom count at T3, but physical symptom count at T2 predicted an increase in PTSD symptom severity at T3 ( β = 0.11, p = .013).

CONCLUSIONS

Considering early physical symptoms and their physiological underpinnings after traumatic exposures could help identify those at risk of later PTSD.

General intelligence and executive functioning are overlapping but separable at genetic and molecular pathway levels: An analytical review of existing GWAS findings

Understanding the genomic architecture and molecular mechanisms of cognitive functioning in healthy individuals is critical for developing tailored interventions to enhance cognitive functioning, as well as for identifying targets for treating impaired cognition. There has been substantial progress in uncovering the genetic composition of the general cognitive ability (g). However, there is an ongoing debate whether executive functioning (EF)–another key predictor of cognitive health and performance, is separable from general g. To provide an analytical review on existing findings on genetic influences on the relationship between g and EF, we re-analysed a subset of genome-wide association studies (GWAS) from the GWAS catalogue that used measures of g and EF as outcomes in non-clinical populations. We identified two sets of single nucleotide polymorphisms (SNPs) associated with g (1,372 SNPs across 12 studies), and EF (300 SNPs across 5 studies) at p<5x10^-6. A comparative analysis of GWAS-identified g and EF SNPs in high linkage disequilibrium (LD), followed by pathway enrichment analyses suggest that g and EF are overlapping but separable at genetic variant and molecular pathway levels, however more evidence is required to characterize the genetic overlap/distinction between the two constructs. While not without limitations, these findings may have implications for navigating further research towards translatable genetic findings for cognitive remediation, enhancement, and augmentation.

Mental Health Reform: Design and Implementation of a System to Optimize Outcomes for Veterans and Their Families

The social, health, and economic burden of mental health problems in the veteran community is heavy. Internationally, the array of services and support available to veterans and their families are extensive but vary in quality, are often disconnected, complex to navigate, and lack clear coordination. This paper describes a conceptual framework to guide the design and implementation of a system of services and supports to optimize the mental health and wellbeing of all veterans and their families. The framework recognizes the diversity of veterans across intersecting identities that uniquely shape experiences of posttraumatic mental health and wellbeing. It brings together several strands of research: the values and principles that should underpin the system; the needs of diverse veterans and their families; challenges in the current services and supports; evidence-based interventions; and principles of effective implementation. Central to the future system design is a next generation stepped model of care that organizes best and next practice interventions in a coherent system, matches service provision to level of need and addresses access and navigation. Practical guidance on implementation provides an aspirational and flexible structure for system evolution, and a template for all stakeholders-individuals, groups, agencies and organizations-to effect system change.

Exploration of potential indicators of burnout, psychological distress and post-traumatic stress disorder, among Australian female first responders

There is limited research on the psychological wellbeing of female first responders (FRs) and therefore we explore potential indicators of burnout, psychological distress and post-traumatic stress disorder among Australian female FRs. We conducted an online health survey among Australian female FRs (fire, police, paramedical, aeromedical, remote area and other e.g., State Emergency Service). Of the 422 eligible participants who submitted the online survey, 286 completed at least 80% of all survey questions and were used in the final analyses. The main outcomes of interest were moderate burnout (compared to low burnout) and high scores for combined PCL-5/K10 (compared to low scores). Using logistical regression stepwise regression models, we analysed associations between the outcomes of interest and various work-psychosocial factors. Results showed the strongest indicators of moderate burnout to be, 1) returning to work with <12-hour break, 2) exposure to gossip and slander, 3) not enough time to do things, 4) and having experienced rape/sexual assault. The strongest indicators of higher PCL-5/K10 scores were, 1) exposure to unpleasant teasing, 2) pressure at work and home, 3) having experienced physical violence (e.g., beaten/mugged), and 4) someone close to them died unexpectedly. These findings show workforce stressors have more impact on female FRs psychological wellbeing, compared to lifetime traumatic exposures.

Problem anger in veterans and military personnel: Prevalence, predictors, and associated harms of suicide and violence

BACKGROUND

Problem anger is increasingly identified as an important issue, and may be associated with suicidality and violence. This study investigates the relationship between problem anger, suicidality, and violence amongst veterans and military personnel.

METHODS

Cross-sectional survey data from n = 12,806 military personnel and veterans were subject to analyses. These considered the weighted prevalence of problem anger, while further analyses of veterans (n = 4326) considered risk factors and co-occurrence with other psychiatric conditions. Path analyses examined inter-relationships involving anger, violence and suicidality.

RESULTS

There were 30.7% of veterans and 16.4% of military personnel that reported past month problem anger, while 14.9% of veterans and 7.4% of military personnel reported physical violence. There were higher levels of suicidality among veterans (30.3%), than military personnel (14.3%). Logistic regression models indicated that PTSD was the strongest risk factor for problem anger (PCL-5, OR = 21.68), while there were small but substantial increases in anger rates associated with depression (OR = 15.62) and alcohol dependence (OR = 6.55). Path models indicated that problem anger had an influence on suicide attempts, occurring primarily through suicidal ideation, and an influence on violence. Influences of problem anger on suicidal ideation and violence remained significant when controlling for co-occurring mental health problems.

CONCLUSIONS

Problem anger, violence, and suicidality are common and inter-related issues among military personnel and veterans. Problem anger is a unique correlate of suicidality, supporting the need for anger to be included as part of violence and suicide risk assessment, and clinician training.

The role of inhibitory processes in the relationship between subsyndromal PTSD symptoms and aggressive behaviour

The issue of aggressive behaviours among military populations is important for a number of reasons, including the potential associated occupational, social and functional impacts. Controlled aggressive behaviour is an adaptive requirement of some military roles, however, this aggression can become maladaptive when uncontrolled, or contextually inappropriate. Elevated aggression among deployed veterans has been identified in a number of studies, although the reasons for it are not well understood. Deployed populations have elevated levels of stress and trauma exposure, have higher rates of childhood and other lifetime trauma exposures and have a heightened risk for subsyndromal or full PTSD. Both trauma exposure and PTSD have been found to be associated with executive function deficits, and increased anger and aggressive behaviours. The purpose of this paper was to explore the contribution of both early PTSD symptoms and cognitive disinhibition in predicting increased aggressive behaviour following deployment in a healthy active serving cohort. After controlling for pre-deployment PTSD symptoms and cognitive function, there were significant main effects of both PTSD symptoms and cognitive function on increased aggression at post-deployment. Furthermore, the positive association between PTSD symptoms and post-deployment aggression was moderated by response inhibition deficits in the domains of false positive errors as well as faster reaction times. Subsidiary analyses showed that the effects of increased reaction time in particular increased the likelihood of PTSD symptoms being coupled with increased aggression. These findings highlight the potential effects of repeated occupational stress exposure and point to possible cognitive adaptations and long-term risk for disorder.

Factors influencing the recruitment and retention of female first responders: a mixed methods systematic review protocol

OBJECTIVE

The objective of this review is to produce a set of integrated findings of quantitative and qualitative evidence regarding workplace recruitment and retention factors (including departure) of female first responders to inform recommendations for policy and practice.

INTRODUCTION

Historically, first responder workforces such as police officers, firefighters, search and rescue personnel, medical technicians, and paramedics have been largely male dominated. Over the past few decades, however, there has been a steady increase in the number of women entering this field. However, there is minimal research examining factors that influence the recruitment/retention of female first responders. The intention of this review is to identify barriers and facilitators to recruitment and retention of female first responders and to identify any differences between sexes/genders.

INCLUSION CRITERIA

This review will summarize qualitative and quantitative research examining factors influencing the recruitment/retention of female first responders. Such factors may include job satisfaction, quality of work life, burnout, compassion fatigue, and intent to remain in the workforce.

METHODS

MEDLINE (PubMed), CINAHL (EBSCO), PsycINFO (APA), PTSDpubs (formerly PILOTS; ProQuest), Embase (Elsevier), and Scopus (Elsevier) will be searched for studies published in English from 2009 to the present. Unpublished studies will be searched in Google Scholar, and ProQuest Dissertations and Theses Global. Both quantitative and qualitative studies will be screened for inclusion and critically appraised for methodological quality by two independent reviewers. Both types of data will be extracted using JBI tools for mixed methods systematic reviews. A convergent integrated approach to synthesis and integration will be used.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020156524.

Suicide and suicidality in contemporary serving and ex-serving Australian Defence Force personnel

OBJECTIVE

The risk of suicide in contemporary serving and ex-serving Australian Defence Force personnel is an area of significant concern, driving government-directed inquiries, community campaigns and most recently, the establishment of a permanent National Commissioner for Defence and Veteran Suicide Prevention. This concern is mirrored in international militaries and despite investment in prevention programmes, suicide is a leading cause of death in military populations. This review seeks to summarise recent findings from Australian research regarding the magnitude and factors associated with suicide and suicidality in contemporary serving and ex-serving Australian Defence Force populations and discusses research findings, implications and future opportunities.

METHODS

Initial review of the prevalence of suicide and suicidality in the general community and military populations is presented, followed by review of recent research findings pertaining to suicides and suicidal thoughts, plans and attempts in contemporary serving and ex-serving Australian Defence Force personnel. Key findings are presented from the 2010 Australian Defence Force Mental Health and Wellbeing Prevalence Study and the 2015 Transition and Wellbeing Research Programme.

RESULTS

Differences between serving and ex-serving Australian Defence Force cohorts were observed, with rates of completed suicide in ex-serving Australian Defence Force males more than double that of serving Australian Defence Force males, and increased risk for suicidality observed among those who had recently transitioned out of full-time Australian Defence Force service. Risk for increased suicidality and completed suicide is particularly evident for younger males of lower ranks, and those who have been medically discharged.

CONCLUSIONS

The findings provide insight into career phases and groups that should be followed-up and targeted for prevention and early intervention programmes, including prior to and several years following transition out of full-time military service. Further research to better understand the factors that influence those who develop suicidal ideation, and those who progress to plans and attempts, will inform a more sophisticated approach to suicide prevention programmes.

Anger Dimensions and Mental Health Following a Disaster: Distribution and Implications After a Major Bushfire

Anger is an important dimension of affect and a prominent feature of posttraumatic mental health, but it is commonly overlooked in postdisaster settings. We aimed to examine the distribution and implications of significant anger problems in the aftermath of a natural disaster, via analyses of Beyond Bushfires survey data from 736 residents of rural communities 5 years after the 2009 Black Saturday bushfires in Victoria, Australia. Assessments included the five-item Dimensions of Anger Reaction (DAR-5) scale along with measures of PTSD, depression, and significant mental illness, and indicators of life satisfaction, suicidality, hostile aggressive behavior, and violence exposure. The results indicated that approximately 10% of respondents from areas highly affected by the bushfires scored above the provisional cutoff criteria for significant anger problems on the DAR-5, which was a more than 3-fold increase, OR = 3.26, relative to respondents from areas of low-to-moderate bushfire impact. The rates were higher among women, younger participants, and those who were unemployed, and co-occurred commonly, although not exclusively, with other postdisaster mental health problems. Anger problems were also associated with lower life satisfaction, β = -.31, an 8-fold increase in suicidal ideation, OR = 8.68, and a nearly 13-fold increase in hostile aggressive behavior, OR = 12.98. There were associations with anger problems and violence exposure, which were reduced when controlling for covariates, including probable PTSD. The findings provide evidence indicating that anger is a significant issue for postdisaster mental health and should be considered routinely alongside other posttraumatic mental health issues.

Gambling problems among military personnel after deployment

Military and veteran populations may exhibit heightened vulnerability to gambling problems; however, there is scant relevant evidence outside the US, and few studies of transition periods, including return from operational deployment. The aim of this study was thus to highlight the extent, risk-factors, and implications of gambling problems among current members of the Australian Defence Force (ADF) following deployment to the Middle East Area of Operations (MEAO). It involved analyses of data from n = 1324 ADF personnel who deployed between 2010 and 2012, and completed surveys within four months of returning to Australia. The Problem Gambling Severity Index (PGSI) identified Problem Gambling (PG: PGSI ≥5) and At-Risk Gambling (ARG: PGSI 1-4), alongside measures of Depression (PHQ-9), Posttraumatic Stress Disorder (PCL-C), alcohol use problems (AUDIT), distress (K10), and post-deployment stressors. Analyses indicated that 7.7% of personnel reported at least some gambling problems post-deployment, including 2.0% that were distinguished by PG, and 5.7% indicating ARG. These figures were comparable to conditions including probable depression and alcohol dependence, while levels of any gambling problems were high relative to harmful drinking. Higher levels were observed among personnel who were aged 18-24, reported 0-4 years of military service, served in the Army, and comprised Non-Commissioned Officers/Other Ranks. There were strong associations with gambling problems and various indicators of mental health and wellbeing, and self-reported post-deployment difficulties. The findings indicate that gambling problems are salient concerns for some Australian military personnel post-deployment, and highlight the need for increased recognition and responses to these problems.

Prevalence and implications of gambling problems among firefighters

Firefighting is a high-risk occupation that accounts for vulnerability to a range of mental health problems and addictive behaviours. However, no research has addressed whether this vulnerability extends to gambling problems, and the aim of this study was thus to provide new data on frequency and implications of such problems in this occupational context. The sample consisted of n = 566 career and retained firefighters who participated in a cross-sectional survey of an Australian metropolitan fire service. The Problem Gambling Severity Index (PGSI) was used to operationalise both clinically significant levels of problem gambling (PGSI ≥ 5), and 'at-risk' gambling (PGSI 1-4); alongside measures of major depression (PHQ-9), anxiety (GAD-7), Posttraumatic Stress Disorder (PCL-5) and alcohol problems (AUDIT), as well as other addictive behaviours, wellbeing and psychosocial issues. Results indicated 12.3% of firefighters that reported any gambling problems across a continuum of severity (PGSI ≥ 1), including 2.3% that were problems gamblers, and 10.0% reporting at-risk gambling. The weighted prevalence of problem gambling was comparable to other significant mental health conditions including depression and PTSD, while the rate of any gambling problems was high relative to other addictive behaviours. Gambling problems were associated with poor mental health and wellbeing, but not psychosocial indicators (e.g., financial difficulties). The findings suggest that gambling problems across a spectrum of severity may be significant yet hidden issues among emergency service workers, and thus require increased recognition and responses at the organisational level.

Psychosocial factors associated with psychological distress and functional difficulties in recently transitioned and current serving regular Australian Defence Force members

The transition period from military-to-civilian life can be one of the most significant and stressful periods in the military life cycle. We explore the psychosocial factors associated with psychological distress and functional impairment among those who recently transitioned from the Australian Defence Force (ADF) and those currently serving in 2015. Using data from the Transition and Wellbeing Research Programme, multinomial logistic regression models were used to analyze the associations between a combined measure of psychological distress and functional impairment (K10/SDS) with various psychosocial, lifestyle, and physical health factors. There were 10,210 in the final analytic cohort (Transitioned=3,254; Regular 2015 ADF=6,956). Overall, the odds of belonging to the highly distressed/impaired group were greatest among those with insomnia (Odds Ratio 18.53), low resilience (OR 7.67), physical health symptoms (OR 7.16), and alcohol risk (OR 4.67). Other factors included pain (OR 3.36), financial issues (OR 2.38), and social strain (OR 1.98). The associations with insomnia and physical health symptoms were stronger among the Transitioned compared to the Regular 2015 ADF. Results of this research highlights the importance of taking a multi-dimensional perspective of symptoms in military populations, particularly in those recently transitioned from permanent service, as predictors of future risk of disorder.

The Associations Between Physical and Psychological Symptoms and Traumatic Military Deployment Exposures

Current paradigms regarding the effects of traumatic exposures on military personnel do not consider physical symptoms unrelated to injury or illness as independent outcomes of trauma exposure, characteristically dealing with these symptoms as comorbidities of psychological disorders. Our objective was to ascertain the proportions of deployed military personnel who experienced predominantly physical symptoms, predominantly psychological symptoms, and comorbidity of the two and to examine the association between traumatic deployment exposures (TDEs) and these symptomatic profiles. Data were taken from a cross-sectional study of Australian Defence Force personnel who were deployed to the Middle East during 2001-2009 (N = 14,032). Four groups were created based on distributional splits of physical and psychological symptom scales: low-symptom, psychological, physical, and comorbid. Multinomial logistic regression models assessed the probability of symptom group membership, compared with low-symptom, as predicted by self-reported TDEs. Group proportions were: low-symptom, 78.3%; physical, 5.0%; psychological, 9.3%; and comorbid, 7.5%. TDEs were significant predictors of all symptom profiles. For subjective, objective, and human death and degradation exposures, respectively, the largest relative risk ratios (RRRs) were for the comorbid profile, RRRs = 1.47, 1.19, 1.48; followed by the physical profile, RRRs = 1.27, 1.15, 1.40; and the psychological profile, RRRs = 1.22, 1.07, 1.22. Almost half of participants with physical symptoms did not have comorbid psychological symptoms, suggesting that physical symptoms can occur as a discrete outcome trauma exposure. The similar dose-response association between TDEs and the physical and psychological profiles suggests trauma is similarly associated with both outcomes.

Identifying clusters of health symptoms in deployed military personnel and their relationship with probable PTSD

OBJECTIVE

Among military personnel posttraumatic stress disorder is strongly associated with non-specific health symptoms and can have poor treatment outcomes. This study aimed to use machine learning to identify and describe clusters of self-report health symptoms and examine their association with probable PTSD, other psychopathology, traumatic deployment exposures, and demographic factors.

METHOD

Data were from a large sample of military personnel who deployed to the Middle East (n = 12,566) between 2001 and 2009. Participants completed self-report measures including health symptoms and deployment trauma checklists, and several mental health symptom scales. The data driven machine learning technique of self-organised maps identified health symptom clusters and logistic regression examined their correlates.

RESULTS

Two clusters differentiated by number and severity of health symptoms were identified: a small 'high health symptom cluster' (HHSC; n = 366) and a large 'low health symptom cluster' (LHSC; n = 12,200). The HHSC had significantly higher proportions of (Gates et al., 2012 [1]) scaled scores indicative of PTSD (69% compared with 2% of LHSC members), Unwin et al. (1999a) [2] scores on other psychological scales that were indicative of psychopathology, and (Graham et al., n.d. [3]) deployment trauma. HHSC members with probable PTSD had a stronger relationship with subjective (OR 1.25; 95% CI 1.12, 1.40) and environmental (OR 1.08; 95% CI 1.03, 1.13) traumatic deployment exposures than LHSC members with probable PTSD.

CONCLUSION

These findings highlights that health symptoms are not rare in military veterans, and that PTSD is strongly associated with health symptoms. Results suggest that there may be subtypes of PTSD, differentiated by health symptoms.

The Value of Physical Symptoms in Screening For Posttraumatic Stress Disorder in the Military

Physical symptoms are highly comorbid with posttraumatic stress disorder (PTSD). As PTSD is underdiagnosed, this study explored the value of self-reported physical symptoms in screening for 30-day PTSD in military personnel. Two physical symptom scales were constructed using items from a 67-item health symptom checklist, clinical interviews were used as the diagnostic reference standard, and diagnostic utility of physical symptoms was compared with the current gold standard screen, the PTSD checklist (PCL). Receiver operating characteristic analyses showed that both a 9-item and a 10-item physical symptom scale were of value in predicting PTSD (areas under the curve 0.81 and 0.85). Importantly, two thirds of PTSD positive personnel missed by the PCL were captured with physical symptoms scales, and when physical symptoms were added to the PCL, prediction was improved (areas under the curve 0.90 to 0.92). Our findings highlight the value of including assessing physical symptoms in PTSD screening.

Treatment of military-related post-traumatic stress disorder: challenges, innovations, and the way forward

Post-traumatic stress disorder (PTSD) is one of the common mental disorders in military and veteran populations. Considerable research and clinical opinion has been focused on understanding the relationship between PTSD and military service and the implications for prevention, treatment, and management. This paper examines factors associated with the development of PTSD in this population, considers issues relating to engagement in treatment, and discusses the empirical support for best practice evidence-based treatment. The paper goes on to explore the challenges in those areas, with particular reference to treatment engagement and barriers to care, as well as treatment non-response. The final section addresses innovative solutions to these challenges through improvements in agreed terminology and definitions, strategies to increase engagement, early identification approaches, understanding predictors of treatment outcome, and innovations in treatment. Treatment innovations include enhancing existing treatments, emerging non-trauma-focused interventions, novel pharmacotherapy, personalized medicine approaches, advancing functional outcomes, family intervention and support, and attention to physical health.

The Mandate of the Collective: Apology Representativeness Determines Perceived Sincerity and Forgiveness in Intergroup Contexts

The sincerity of an apology is often critical for it to be viewed positively by victims. For collective apologies, we argue that sincerity takes on a particular meaning: It is a function of the apology's perceived representativeness for the offender group's will or sentiment. Consistent with this notion, when an apologetic (vs. nonapologetic) message was democratically chosen (Study 1) or explicitly endorsed by the majority of the offending outgroup (Study 2), it was considered more sincere and, through this, led to more forgiveness. Furthermore, while disagreement about an apology within the offender group reduced its perceived representativeness and sincerity, this was less so when the dissenters could be subtyped: when disagreement was correlated with an existing subgroup within the offending outgroup (Study 3) and in line with expectations for that subgroup (Study 4). This research shows that victim group members consider intragroup processes within the offending outgroup for attributions of sincerity.

Re-experiencing phenomena following a disaster: The long-term predictive role of intrusion symptoms in the development of post-trauma depression and anxiety

BACKGROUND

Contention in the literature regarding the diagnostic utility of intrusion symptoms highlights that they have high sensitivity but low specificity in predicting PTSD. They are highly prevalent following a range of traumatic events, and across a range of disorders. The prevalence of intrusion symptoms in the absence of PTSD suggests their relevance to the development of other psychopathology. Therefore, the predictive role of intrusion symptoms for other post-trauma psychopathology was examined using data from an epidemiological, longitudinal sample of adults recruited in childhood.

METHOD

From 5 phases of data collection for this sample, these analyses focused on the 20 year and 28 year follow-ups (n=583). Lifetime exposure to trauma was assessed using a modified set of 10 Criterion-A events from the Composite International Diagnostic Interview (CIDI), with PTSD assessed in reference to a self-nominated worst lifetime event, and other DSM-IV disorder also assessed using the CIDI.

RESULTS

Results showed that the presence of intrusion symptoms without PTSD at the 20 year follow-up was predictive of increased risk at 28 years for depressive but not anxiety disorders.

LIMITATIONS

There was limited psychopathology in the sample, reducing the power to examine many individual disorders. Furthermore, trauma history and psychiatric symptoms were retrospectively reported, introducing the possibility of recall bias.

CONCLUSION

Together the findings suggest that intrusion symptoms may play an aetiological role in the development and/or maintenance of disorders other than PTSD.

The Well-Being of Australian Service Mothers

In recent years servicewomen with dependent children have for the first time in history been deployed into conflict zones in support of Australian Defence Force operations. This represents a significant social change, and the implications of deployment on the health of these service mothers are not fully understood. Data from women who participated in the Middle East Area of Operations Census study were analyzed to compare the psychological and physical symptoms reported by service mothers with service women who had no dependent children at the time of deploying to Afghanistan and/or Iraq. Of the 921 women who were included in this analysis, 235 had dependent children and 686 had no dependent children (comparison group). Service mothers were significantly older and were more likely to have served in the Air Force than women in the comparison group. Findings demonstrate that serving mothers were not at any significantly higher risk of psychological distress, post-traumatic stress symptoms, alcohol misuse, or reporting of somatic symptoms, than women who had no dependent children. A number of possible explanations for these findings are discussed, including the healthy soldier/mother effect, support from partners and extended family members, and collegial networks.

Seeking treatment for symptomatic malaria in Papua New Guinea

BACKGROUND

Malaria places a significant burden on the limited resources of many low income countries. Knowing more about why and where people seek treatment will enable policy makers to better allocate the limited resources. This study aims to better understand what influences treatment-seeking behaviour for malaria in one such low-income country context, Papua New Guinea (PNG).

METHODS

Two culturally, linguistically and demographically different regions in PNG were selected as study sites. A cross sectional household survey was undertaken in both sites resulting in the collection of data on 928 individuals who reported suffering from malaria in the previous four weeks. A probit model was then used to identify the factors determining whether or not people sought treatment for presumptive malaria. Multinomial logit models also assisted in identifying the factors that determined where people sought treatments.

RESULTS

Results in this study build upon findings from other studies. For example, while distance in PNG has previously been seen as the primary factor in influencing whether any sort of treatment will be sought, in this study cultural influences and whether it was the first, second or even third treatment for a particular episode of malaria were also important. In addition, although formal health care facilities were the most popular treatment sources, it was also found that traditional healers were a common choice. In turn, the reasons why participants chose a particular type of treatment differed according to the whether they were seeking an initial or subsequent treatments.

CONCLUSIONS

Simply bringing health services closer to where people live may not always result in a greater use of formal health care facilities. Policy makers in PNG need to consider within-country variation in treatment-seeking behaviour, the important role of traditional healers and also ensure that the community fully understands the potential implications of not seeking treatment for illnesses such as malaria at a formal health care facility.