Posttraumatic sleep disturbances in veterans: A pilot randomized controlled trial of cognitive behavioral therapy for insomnia and imagery rehearsal therapy

OBJECTIVES

Posttraumatic stress disorder (PTSD) is associated with sleep disturbances including insomnia and nightmares. This study compared cognitive behavioral therapy for insomnia (CBT-I) with CBT-I combined with imagery rehearsal therapy (IRT) for nightmares to evaluate if the combined treatment led to greater reductions in trauma-related sleep disturbances in Australian veterans.

METHODS

Veterans with diagnosed PTSD, high insomnia symptom severity, and nightmares (N = 31) were randomized to eight group CBT-I sessions or eight group CBT-I + IRT sessions. Self-reported sleep, nightmare, and psychological measures (primary outcome: Pittsburgh Sleep Quality Index), and objective actigraphy data were collected; the effect of obstructive sleep apnea (OSA) risk on treatment outcomes was also examined.

RESULTS

No treatment condition effects were detected for the combined treatment compared to CBT-I alone, and no moderating effect of OSA risk was detected. On average, participants from both groups improved on various self-report measures over time (baseline to 3 months posttreatment). Despite the improvements, mean scores for sleep-specific measures remained indicative of poor sleep quality. There were also no significant differences between the groups on the actigraphy indices.

CONCLUSIONS

The findings indicate that there is potential to optimize both treatments for veterans with trauma-related sleep disturbances.

Development and psychometric evaluation of the mental readiness for military transition scale (MT-Ready)

BACKGROUND

The transition to civilian life following separation from military service is associated with increased risk of mental health disorders, suicide, and poor adjustment. No measure currently enables pre-separation screening to assess mental readiness for transition and identify personnel most at risk of poor outcomes. The Mental Readiness for Military Transition Scale (MT-Ready) was developed to identify psychosocial factors predictive of post-separation psychological adjustment and mental health.

METHODS

Phase I was a qualitative study including transitioned veterans (n = 60), partners of transitioned veterans (n = 20) and mental health clinicians (n = 20) which enabled development of candidate items that were subsequently piloted with a current serving Australian Defence Force (ADF) sample (n = 19). Phase II included evaluation of the factor structure, psychometric properties, and scale refinement of the initial pool of 50 items with a convenience sample of transitioning ADF personnel (n = 345). Analyses included exploratory factor analysis, evaluation of test-retest reliability, internal consistency, convergent, divergent, discriminant and predictive validity. Receiver Operating Characteristic Curve Analysis was also conducted to determine an optimal cut-off score.

RESULTS

Exploratory factor analysis resulted in a 15-item, three-factor solution that explained 62.2% of the variance: Future focus and optimism; Anger and perceived failure; Civilian connections and social support. Reliability and convergent, divergent, and discriminant validity was established. Receiver Operating Characteristic Curve Analysis determined a cut-off score of 55. MT-Ready scores significantly differentiated those reporting adjusting versus not adjusting to civilian life 3.7 months post-separation, and predicted post-separation outcomes including symptoms of Posttraumatic Stress Disorder, depression, anxiety, psychological adjustment and quality of life.

CONCLUSIONS

This evaluation provides promising evidence the MT-Ready is a valid, reliable measure of mental readiness for transition, with predictive capability and considerable potential to assist prevention of poor post-separation outcomes among military personnel.

Compassionate mind training for ex-service personnel with PTSD and their partners

Posttraumatic stress disorder (PTSD) is a significant issue for a substantial proportion of Australian ex-service personnel. In addition to the functional impact on individuals, PTSD can have a significant impact on intimate partner relationships. Research has demonstrated that practicing compassion and self-compassion may be an important component of psychological therapy for survivors of trauma, while also demonstrating benefits to intimate relationships. This pilot study aimed to investigate the utility of a Compassionate Mind Training intervention for ex-service personnel with PTSD and their partners. An uncontrolled, within-subjects, longitudinal design was utilized with assessment at pre-intervention, post-intervention and 3-month follow-up. Twenty-four participants attended 12 biweekly group sessions. Self-report measures of compassion, quality of life and psychological symptoms were administered at each time point. Findings demonstrated a significant reduction in fears of compassion and PTSD symptoms for ex-service personnel at 3-month follow-up and a reduction in depressive symptoms and increase in quality-of-life and social safeness at post-intervention. Additionally, significant reductions in anxiety, stress, external shame and self-criticism at 3-month follow-up were found, and couples reported significant increases in relationship satisfaction. Findings from this pilot study demonstrate promising outcomes, warranting further investigation in a larger randomized controlled trial of Compassionate Mind Training for ex-service personnel and their partners.

The relationship between chronic PTSD, cortical volumetry and white matter microstructure among Australian combat veterans

BACKGROUND

Posttraumatic stress disorder (PTSD) has been associated with volumetric and white matter microstructural changes among general and veteran populations. However, regions implicated have greatly varied and often conflict between studies, potentially due to confounding comorbidities within samples. This study compared grey matter volume and white matter microstructure among Australian combat veterans with and without a lifetime diagnosis of PTSD, in a homogenous sample assessed for known confounding comorbidities.

METHODS

Sixty-eight male trauma-exposed veterans (16 PTSD-diagnosed; mean age 69 years) completed a battery of psychometric assessments and underwent magnetic resonance and diffusion tensor imaging. Analyses included tract-based spatial statistics, voxel-wise analyses, diffusion connectome-based group-wise analysis, and volumetric analysis.

RESULTS

Significantly smaller grey matter volumes were observed in the left prefrontal cortex (P = 0.026), bilateral middle frontal gyrus (P = 0.021), and left anterior insula (P = 0.048) in the PTSD group compared to controls. Significant negative correlations were found between PTSD symptom severity and fractional anisotropy values in the left corticospinal tract (R² = 0.34, P = 0.024) and left inferior cerebellar peduncle (R² = 0.62, P = 0.016). No connectome-based differences in white matter properties were observed.

CONCLUSIONS

Findings from this study reinforce reports of white matter alterations, as indicated by reduced fractional anisotropy values, in relation to PTSD symptom severity, as well as patterns of reduced volume in the prefrontal cortex. These results contribute to the developing profile of neuroanatomical differences uniquely attributable to veterans who suffer from chronic PTSD.

Veteran families with complex needs: a qualitative study of the veterans' support system

Background

Families with complex needs face significant challenges accessing and navigating health and social services. For veteran families, these challenges are exacerbated by interactions between military and civilian systems of care, and the density of the veterans’ non-profit sector. This qualitative study was designed to gather rich, detailed information on complex needs in veteran families; and explore service providers’ and families’ experiences of accessing and navigating the veterans’ support system.

Methods

The study comprised participant background questionnaires (n = 34), focus groups with frontline service providers (n = 18), and one-on-one interviews with veteran families (n = 16) in Australia. The semi-structured focus groups and interviews were designed to gather rich, detailed information on four study topics: (i) health and wellbeing needs in veteran families; (ii) service-access barriers and facilitators; (iii) unmet needs and gaps in service provision; and (iv) practical solutions for improving service delivery. The study recruited participants who could best address the focus on veteran families with complex needs. The questionnaire data was used to describe relevant characteristics of the participant sample. The focus groups and interviews were audio-recorded, transcribed, and a reflexive thematic analysis was conducted to identify patterns of shared meaning in the qualitative data.

Results

Both service providers and families found the veterans’ support system difficult to access and navigate. System fragmentation was perceived to impede care coordination, and delay access to holistic care for veteran families with complex needs. The medico-legal aspects of compensation and rehabilitation processes were perceived to harm veteran identity, and undermine health and wellbeing outcomes. Recovery-oriented practice was viewed as a way to promote veteran independence and self-management. Participants expressed a strong preference for family-centred care that was informed by an understanding of military lifestyle and culture.

Conclusion

The health and wellbeing needs of veteran families intensify during the transition from full-time military service to civilian environments, and service- or reintegration-related difficulties may emerge (or persist) for a significant period of time thereafter. Veteran families with complex needs are unduly burdened by care coordination demands. There is a pressing need for high-quality implementation studies that evaluate initiatives for integrating fragmented systems of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07368-2.

Evaluation of mental health first aid training for family members of military veterans with a mental health condition

BACKGROUND

A concerning proportion of former Australian Defence Force (ADF) members meet criteria for a mental health condition. Mental health difficulties not only affect the individual veteran. They have been found to negatively impact the mental health of family, with an increased likelihood for family members of veterans developing a mental health condition. The aim of this study was to evaluate whether participating in a Mental Health First Aid (MHFA) program improved family members of veterans mental health knowledge, reduced personal and perceived mental health stigma, reduced social distancing attitudes and increased confidence and willingness to engage in MHFA helping behaviours. Additionally, the study measured participant's general mental health and levels of burnout.

METHOD

The study utilised an uncontrolled design with assessment at three time points (baseline, post-program and three-month follow-up). Participants (N = 57) were immediate and extended family members of former ADF members with a mental health condition, who took part in a two-day standard adult MHFA program. At each time point, participants completed self-report measures assessing mental health knowledge, personal and perceived mental health stigma, social distancing attitudes, confidence and willingness to engage in MHFA helping behaviours, general mental health and burnout. Cochranes Q and repeated measures ANOVA was computed to measure the impact of time on the outcome variables.

RESULTS

Results indicated significant improvements in MHFA knowledge and confidence in providing MHFA assistance. Significant reductions in personal mental health stigma (i.e. an individual's attitude towards mental health) for schizophrenia were observed and maintained at follow up. High levels of perceived mental health stigma (i.e. the belief an individual holds about others attitudes towards mental health) were reported with no significant changes observed following the MHFA program. Results did not indicate any significant benefit in improving general psychological distress or burnout at follow up. The participant sample had high levels of mental health difficulties with over half reporting a lifetime mental health diagnosis.

CONCLUSION

The study is an important contribution to the international literature on MHFA. The provision of a MHFA program to family members of military veterans has not previously been evaluated. Implications of the findings are discussed with regards to future directions of MHFA research and implementing MHFA programs in this population.

Assessing psychological adjustment and cultural reintegration after military service: development and psychometric evaluation of the post-separation Military-Civilian Adjustment and Reintegration Measure (M-CARM)

BACKGROUND

The transition out of military service and subsequent reintegration to civilian life has been established as a period associated with an increased risk of psychological adjustment difficulties, psychiatric disorders and suicide risk, yet no tool exists to measure cultural and psychological adjustment following permanent separation from the military. This study describes the two-phase mixed-methods development and validation of the self-report Military-Civilian Adjustment and Reintegration Measure (M-CARM).

METHODS

In Phase I, four focus groups (n = 20) and semi-structured one-on-one interviews (n = 80) enabled thematic analysis and generation of 53 initial items that were reviewed by an expert multidisciplinary panel (n = 12) and piloted for clarity and relevance in an Australian service-veteran sample (n = 11). In Phase II, psychometric properties of the 47 items resulting from Phase I were evaluated with online assessment of a convenience sample of transitioned Australian Defence Force veterans (n = 725). Analyses included exploratory and confirmatory factor analyses, as well as evaluation of test-retest reliability, internal consistency, and convergent, divergent and discriminant validity.

RESULTS

Exploratory factor analysis on a randomized split-half sample (n = 357), resulted in a 21-item, five-factor solution of Purpose and Connection, Help seeking, Beliefs about civilians, Resentment and regret, and Regimentation, explaining 53.22% of the variance. Confirmatory factor analysis (n = 368) verified this factor structure without modification (χ2 = 304.96, df = 160; CFI = .96, TLI = .94, NFI = .91, RMSEA = .05). Strong convergent, divergent and discriminant validity was demonstrated as M-CARM scores significantly correlated with related constructs assessed by standardised clinical measures as well as differentiated groups based on three binary reintegration items, with large effect sizes (d = > 1). Strong test-retest reliability for the total score (n = 186, r = .93) and excellent internal consistency (n = 725, a = .90) were also found.

CONCLUSIONS

Results provide promising evidence the M-CARM is a valid, reliable measure of psychological and cultural reintegration to civilian life, with potential for considerable clinical and research application.

Assessing physical activity in people with mental illness: 23-country reliability and validity of the simple physical activity questionnaire (SIMPAQ)

BACKGROUND

Physical inactivity is a key contributor to the global burden of disease and disproportionately impacts the wellbeing of people experiencing mental illness. Increases in physical activity are associated with improvements in symptoms of mental illness and reduction in cardiometabolic risk. Reliable and valid clinical tools that assess physical activity would improve evaluation of intervention studies that aim to increase physical activity and reduce sedentary behaviour in people living with mental illness.

METHODS

The five-item Simple Physical Activity Questionnaire (SIMPAQ) was developed by a multidisciplinary, international working group as a clinical tool to assess physical activity and sedentary behaviour in people living with mental illness. Patients with a DSM or ICD mental illness diagnoses were recruited and completed the SIMPAQ on two occasions, one week apart. Participants wore an Actigraph accelerometer and completed brief cognitive and clinical assessments.

RESULTS

Evidence of SIMPAQ validity was assessed against accelerometer-derived measures of physical activity. Data were obtained from 1010 participants. The SIMPAQ had good test-retest reliability. Correlations for moderate-vigorous physical activity was comparable to studies conducted in general population samples. Evidence of validity for the sedentary behaviour item was poor. An alternative method to calculate sedentary behaviour had stronger evidence of validity. This alternative method is recommended for use in future studies employing the SIMPAQ.

CONCLUSIONS

The SIMPAQ is a brief measure of physical activity and sedentary behaviour that can be reliably and validly administered by health professionals.

DNA methylation from germline cells in veterans with PTSD

In this study we investigated genome-wide sperm DNA methylation patterns in trauma-exposed Vietnam veterans. At the genome-wide level, we identified 3 CpG sites associated with PTSD in sperm including two intergenic and one CpG within the CCDC88C gene. Of those associated with PTSD in sperm at a nominal level, 1868 CpGs were also associated with PTSD in peripheral blood (5.6% overlap) including the RORA, CRHR1 and DOCK2 genes that have been previously implicated in PTSD. A total of 10 CpG sites were significantly associated with a reported history of a diagnosed mental health condition in children and reached genome-wide significance. CpGs associated with a history of a reported mental health condition in children were also enriched (90% of tested genes) for genes previously reported to be resistant to demethylation, making them strong candidates for transgenerational inheritance. In conclusion, our findings identify a unique sperm-specific DNA methylation pattern that is associated with PTSD.

Detailed Polysomnography in Australian Vietnam Veterans With and Without Posttraumatic Stress Disorder

STUDY OBJECTIVES

Recent results from the PTSD Initiative, a cross-sectional cohort study in Australian Vietnam veterans (VV) with and without posttraumatic stress disorder (PTSD), demonstrated an increased prevalence of self-reported sleep disturbances in those with PTSD. This study aimed to objectively assess the prevalence of sleep disorders in the same cohort using detailed polysomnography (PSG).

METHODS

Participants from the PTSD Initiative were recruited to undergo PSG. PTSD status was determined with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). Subjective sleep information was attained via structured questionnaires. Data from single night PSG were compared between trauma-exposed VV with and without PTSD.

RESULTS

A total of 74 trauma-exposed male VV (40 with PTSD) underwent PSG (prospective n = 59, retrospective n = 15). All PSG parameters were similar between groups. No difference was seen in PSG-diagnosed obstructive sleep apnea (OSA) or periodic limb movements of sleep (PLMS). VV with PTSD showed a trend toward increased duration of sleep with oxygen saturations < 90% (10% versus 1.8%; P = .07). VV with PTSD reported increased sleep onset latency (42.4 versus 13.3 minutes; P < .01); were less likely to report sleeping well (32.5% versus 67.5%; P < .01); had higher OSA risk using Berlin Questionnaire (BQ) (70% versus 38.2%; P < .01); and had higher rates of partner-reported limb movements (56.4% versus 17.6%; P < .01). No association between PSG-diagnosed OSA and PTSD severity was evident.

CONCLUSIONS

In Australian VV with and without PTSD, no difference was seen across all PSG parameters including the diagnosis and severity of OSA and PLMS. However, VV with PTSD demonstrated an increased perception of sleep disturbances.

Increased risk of attempted suicide in Australian veterans is associated with total and permanent incapacitation, unemployment and posttraumatic stress disorder severity

BACKGROUND

Military veterans have higher rates of suicidality and completed suicides compared to the general population. Previous research has demonstrated suicidal behaviour is higher in US combat veterans who are younger, suffer from posttraumatic stress disorder, depression and anxiety and score lower on measures of health. However, research on predictors of suicide for Australian veterans is limited. The aim of this study was to identify significant demographic and psychological differences between veterans with posttraumatic stress disorder who had attempted suicide and those with posttraumatic stress disorder who had not, as well as determine predictors of suicide attempts within an Australian cohort.

METHODS

A retrospective analysis was conducted on 229 ex-service personnel diagnosed with posttraumatic stress disorder who had attended a Military Service Trauma Recovery Day Program as outpatients at Toowong Private Hospital from 2007 to 2014. Patients completed a battery of mental health self-report questionnaires assessing symptoms of posttraumatic stress disorder, alcohol use, anger, depression, anxiety and quality of life. Demographic information and self-reported history of suicide attempts were also recorded.

RESULTS

Results indicated the average age was significantly lower, and the rates of posttraumatic stress disorder, anger, anxiety and depression symptoms were significantly higher in those veterans with history of a suicide attempt. Multivariate logistic regression analyses indicated posttraumatic stress disorder symptom severity, unemployment or total and permanent incapacity pension status significantly predicted suicide attempt history.

CONCLUSION

Among a cohort of Australian veterans with posttraumatic stress disorder, psychopathology severity, unemployment and total and permanent incapacity status are significantly associated with suicidality. This study highlights the importance of early identification of posttraumatic stress disorder and psychopathology, therapeutic and social engagement, and prioritisation of tangible employment options or meaningful and goal-directed activities for veterans deemed unable to work.

Adult Day Care and the Nursing Home

Adult day-care clients are compared with nursing home applicants who were reviewed and recommended for community or institution-based care. Social, health, and service-use characteristics are contrasted in order to identify factors that distinguish adult day care from nursing home care as an appropriate placement. Socioeconomic status, severity of physical disability, living arrangement, sensory impairment, use of in-home services, and days in the hospital tend to distinguish the groups. The groups are quite similar in demographic characteristics, mental status, frequency of out-patient physician visits, and number and types of diseases. The authors outline criteria that might be used to determine appropriate placement. They also point out the need for future research in order to draw comparisons among different types of adult day-care programs and to develop predictive models for service use and continuity of participation in adult day care.

University student depression inventory (USDI): confirmatory factor analysis and review of psychometric properties

BACKGROUND

The 30-item USDI is a self-report measure that assesses depressive symptoms among university students. It consists of three correlated three factors: lethargy, cognitive-emotional and academic motivation. The current research used confirmatory factor analysis to asses construct validity and determine whether the original factor structure would be replicated in a different sample. Psychometric properties were also examined.

METHOD

Participants were 1148 students (mean age 22.84 years, SD=6.85) across all faculties from a large Australian metropolitan university. Students completed a questionnaire comprising of the USDI, the depression anxiety stress scale (DASS) and Life Satisfaction Scale (LSS).

RESULTS

The three correlated factor model was shown to be an acceptable fit to the data, indicating sound construct validity. Internal consistency of the scale was also demonstrated to be sound, with high Cronbach alpha values. Temporal stability of the scale was also shown to be strong through test-retest analysis. Finally, concurrent and discriminant validity was examined with correlations between the USDI and DASS subscales as well as the LSS, with sound results further supporting the construct validity of the scale. Cut-off points were also developed to aid total score interpretation.

LIMITATIONS

Response rates are unclear. In addition, the representativeness of the sample could be improved potentially through targeted recruitment (i.e. reviewing the online sample statistics during data collection, examining the representativeness trends and addressing particular faculties within the university that were underrepresented).

CONCLUSIONS

The USDI provides a valid and reliable method of assessing depressive symptoms found among university students.

Looking back: an analysis of reminiscence function and triggers

The purpose of this study was two-fold: to determine if hypothesized functions and triggers of reminiscence are empirically supported by a Reminiscence Uses Scale and Reminiscence Triggers Scale, and to determine if functions can be predicted from triggers subject variables.Ninety-one elderly residents of retirement communities completed the paper and pencil survey instrument. A factor analysis of the Reminiscence Uses Scale yielded three factor subscales: Self-Regard/Image Enhancement, Present Problem Solving, and Existential/Self-Understanding. In contrast, five factor subscales were extracted from the Reminiscence Triggers Scale: Death Awareness/Resignation, Death Awareness-Other, Realization of Goals/Accomplishments, Changes/Threats to body, and Change in Career/Life's Direction. A multiple regression analysis indicated that Self-Regard/Image Enhancement was predicted by Realization of Goals/Accomplishments and Reminiscence Frequency; Present Problem Solving was predicted by Death Awareness/Resignation; and Existential/Self-Understanding by Changes/Threats to body and Life Review. These findings support a basic distinction between inter-and intrapersonal reminiscence, suggest a relationship between contemporaneous experiences and memories, and lend empirical support to the construct validity of earlier theoretical views on reminiscence in old age.

Reminiscence and the second half of life

The theoretical and empirical literature on reminiscence during the second half of life is reviewed. In general, the theoretical accounts suggest reminiscence to be an evaluative, private phenomenon involving large segments of one's past and serving an adaptive function. The unique set of problems and concerns of late life activates the process which involves the assessment of both positive and negative events and generally produces some adjustment-relevant insight in one's life or self. As a group, the empirical research has lagged behind theory and is in its earliest stage; procedural differences and methodological flaws render the findings unclear. However, it was tentatively concluded that reminiscence is a complex phenomenon varying along many dimensions--content, frequency, form, function, affect, outcome and eliciting stimuli. Suggestions for future investigations call for focused, rigorous examination of the dimensions of reminiscence, careful definition and measurement of key constructs and the amination of specific theoretical hypotheses. Also recommended for study was the relationship of critical life events to reminiscence and adaptation, and the likelihood of reminiscence being a life-long activity.