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Ragsdale KA, Nichols AA, Mehta M, Maples-Keller JL, Yasinski CW, Hyatt CS, Watkins LE, Loucks LA, Carbone E, Rauch SAM, Rothbaum BO. Comorbid treatment of traumatic brain injury and mental health disorders. NeuroRehabilitation 2024:NRE230235. [PMID: 38277308 DOI: 10.3233/nre-230235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
BACKGROUND The Emory Healthcare Veterans Program (EHVP) is a multidisciplinary intensive outpatient treatment program for post-9/11 veterans and service members with invisible wounds, including posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), substance use disorders (SUD), and other anxiety- and depression-related disorders. OBJECTIVE This article reviews the EHVP. METHODS The different treatment tracks that provide integrated and comprehensive treatment are highlighted along with a review of the standard, adjunctive, and auxiliary services that complement individualized treatment plans. RESULTS This review particularly emphasizes the adjunctive neurorehabilitation service offered to veterans and service members with a TBI history and the EVHP data that indicate large reductions in PTSD and depression symptoms across treatment tracks that are maintained across 12 months follow up. Finally, there is a discussion of possible suboptimal treatment response and the pilot programs related to different treatment augmentation strategies being deploying to ensure optimal treatment response for all. CONCLUSION Published data indicate that the two-week intensive outpatient program is an effective treatment program for a variety of complex presentations of PTSD, TBI, SUD, and other anxiety- and depression-related disorders in veterans and active duty service members.
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Affiliation(s)
- Katie A Ragsdale
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Anastacia A Nichols
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Mansi Mehta
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Jessica L Maples-Keller
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Carly W Yasinski
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtland S Hyatt
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Laura E Watkins
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Laura A Loucks
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Elizabeth Carbone
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
- Joseph Maxwell Cleland Atlanta VA Medical Center, Decatur, GA, USA
| | - Barbara O Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Abstract
BACKGROUND In February 2022, Russia began its invasion of Ukraine. War increases the demand for mental healthcare among affected populations, but with devastating losses across the nation, it is unclear if Ukrainian mental health services are able to meet the needs of the people. AIMS We aimed to evaluate the state of Ukrainian in-patient mental health services, which remains the backbone of the nation's psychiatric services, early in the 2022 Russian invasion. METHOD We conducted a nationwide cross-sectional study on Ukrainian in-patient mental health facilities during the 2022 Russian invasion. Using an online questionnaire, we obtained responses from the heads of 32 in-patient mental health facilities across Ukraine, representing 52.5% of all in-patient mental health facilities in the nation. We gathered information on hospital admissions, staff, humanitarian aid received and the additional needs of each facility. RESULTS Hospital admissions were reduced by 23.5% during the war (April 2022) compared with before the war (January 2022). Across facilities, 9.6% of hospital admissions in April 2022 were related to war trauma, with facilities reporting percentages as high as 30.0%. Facilities reported reductions in staff, with 9.1% of total medical workers displaced and 0.5% injured across facilities. One facility reported that 45.6% of their total medical workers were injured. Although facilities across Ukraine have received humanitarian aid (such as medical supplies, food, volunteers), they reported additionally needing equipment as well as more staff. CONCLUSIONS The mental health service structure in Ukraine has been severely damaged during the 2022 invasion, with staff shortages despite a significant number of hospital admissions related to war trauma.
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Affiliation(s)
- Ryunosuke Goto
- Department of Pediatrics, The University of Tokyo Hospital, Japan
| | - Irina Pinchuk
- Institute of Psychiatry, Taras Shevchenko National University of Kyiv, Ukraine
| | - Oleksiy Kolodezhny
- Institute of Psychiatry, Taras Shevchenko National University of Kyiv, Ukraine
| | - Nataliia Pimenova
- Institute of Psychiatry, Taras Shevchenko National University of Kyiv, Ukraine
| | - Norbert Skokauskas
- Regional Centre for Children and Youth Mental Health and Child Welfare - Central Norway, IPH, Norwegian University of Science and Technology, Norway; and Chair, Child and Adolescent Psychiatry Section, World Psychiatric Association
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3
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Dyball D, Taylor-Beirne S, Greenberg N, Stevelink SAM, Fear NT. Post-traumatic growth among UK military personnel deployed to Iraq or Afghanistan: data from phase 3 of a military cohort study. BJPsych Open 2022; 8:e170. [PMID: 36148897 PMCID: PMC9534878 DOI: 10.1192/bjo.2022.570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Post-traumatic growth (PTG) refers to beneficial psychological change following trauma. AIMS This study explores the sociodemographic, health and deployment-related factors associated with PTG in serving/ex-serving UK armed forces personnel deployed to military operations in Iraq or Afghanistan. METHOD Multinomial logistic regression analyses were applied to retrospective questionnaire data collected 2014-2016, stratified by gender. PTG scores were split into tertiles of no/very low PTG, low PTG and moderate/large PTG. RESULTS A total of 1447/4610 male personnel (30.8%) and 198/570 female personnel (34.8%) reported moderate/large PTG. Male personnel were more likely to report moderate/large PTG compared with no/very low PTG if they reported a greater belief of being in serious danger (relative risk ratio (RRR) 2.47, 95% CI 1.68-3.64), were a reservist (RRR 2.37, 95% CI 1.80-3.11), reported good/excellent general health (fair/poor general health: RRR 0.33, 95% CI 0.24-0.46), a greater number of combat experiences, less alcohol use, better mental health, were of lower rank or were younger. Female personnel were more likely to report moderate/large PTG if they were single (in a relationship: RRR 0.40, 95% CI 0.22-0.74), had left military service (RRR 2.34, 95% CI 1.31-4.17), reported better mental health (common mental disorder: RRR 0.37, 95% CI 0.17-0.84), were a reservist, reported a greater number of combat experiences or were younger. Post-traumatic stress disorder had a curvilinear relationship with PTG. CONCLUSIONS A moderate/large degree of PTG among the UK armed forces is associated with mostly positive health experiences, except for post-traumatic stress disorder.
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Affiliation(s)
- Daniel Dyball
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, UK
| | - Sean Taylor-Beirne
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, UK.,Academic Department of Military Mental Health, King's College London, UK
| | - Neil Greenberg
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, UK
| | - Sharon A M Stevelink
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, UK
| | - Nicola T Fear
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, UK.,Academic Department of Military Mental Health, King's College London, UK
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4
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Forehand JA, Dufort V, Gradus JL, Maguen S, Watts BV, Jiang T, Holder N, Shiner B. Association between post-traumatic stress disorder severity and death by suicide in US military veterans: retrospective cohort study. Br J Psychiatry 2022; 221:1-7. [PMID: 35997207 PMCID: PMC9947187 DOI: 10.1192/bjp.2022.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is mixed evidence regarding the direction of a potential association between post-traumatic stress disorder (PTSD) and suicide mortality. AIMS This is the first population-based study to account for both PTSD diagnosis and PTSD symptom severity simultaneously in the examination of suicide mortality. METHOD Retrospective study that included all US Department of Veterans Affairs (VA) patients with a PTSD diagnosis and at least one symptom severity assessment using the PTSD Checklist (PCL) between 1 October 1999 and 31 December 2018 (n = 754 197). We performed multivariable proportional hazards regression models using exposure groups defined by level of PTSD symptom severity to estimate suicide mortality rates. For patients with multiple PCL scores, we performed additional models using exposure groups defined by level of change in PTSD symptom severity. We assessed suicide mortality using the VA/Department of Defense Mortality Data Repository. RESULTS Any level of PTSD symptoms above the minimum threshold for symptomatic remission (i.e. PCL score >18) was associated with double the suicide mortality rate at 1 month after assessment. This relationship decreased over time but patients with moderate to high symptoms continued to have elevated suicide rates. Worsening PTSD symptoms were associated with a 25% higher long-term suicide mortality rate. Among patients with improved PTSD symptoms, those with symptomatic remission had a substantial and sustained reduction in the suicide rate compared with those without symptomatic remission (HR = 0.56; 95% CI 0.37-0.88). CONCLUSIONS Ameliorating PTSD can reduce risk of suicide mortality, but patients must achieve symptomatic remission to attain this benefit.
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Affiliation(s)
| | - Vincent Dufort
- Veterans Affairs Medical Center, White River Junction, Vermont
| | - Jaimie L. Gradus
- Boston University School of Public Health, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Shira Maguen
- Veterans Affairs Medical Center, San Francisco, California
- University of California, San Francisco
| | - Bradley V. Watts
- Veterans Affairs Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Tammy Jiang
- Boston University School of Public Health, Boston, Massachusetts
| | - Nicholas Holder
- Veterans Affairs Medical Center, San Francisco, California
- University of California, San Francisco
| | - Brian Shiner
- Veterans Affairs Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- National Center for Posttraumatic Stress Disorder, White River Junction, Vermont
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5
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Aggarwal NK. Psychiatric Disorders, Military Misconduct, and Discharge Status for U.S. Veterans. J Am Acad Psychiatry Law 2022; 50:117-123. [PMID: 35012997 DOI: 10.29158/jaapl.210048-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
For three years, the U.S. District Court for the District of Connecticut has issued rulings in Manker v. Spencer and Kennedy v. Esper to certify veterans as a legal class to sue the United States Navy and Army, respectively. Each dispute centers on whether the military denied discharge upgrades to personnel who developed mental health disorders during their service. This article analyzes the facts, reasoning, and dispositions of each case, which address medicolegal standards for evaluating the relationships among psychiatric disorders, alleged misconduct during military service, and military discharge status. Implications for psychiatrists are considered in the military and civilian health sectors.
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Affiliation(s)
- Neil Krishan Aggarwal
- Dr. Aggarwal is Research Psychiatrist and Assistant Professor of Clinical Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, New York, NY.
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6
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Abstract
Interest in the concept of moral injury among researchers, clinicians and policy makers can have undesirable consequences that are rarely considered. It can lead to misunderstanding of post-traumatic stress disorder, risks of primary and secondary gains for affected individuals and tertiary gains for third parties. This editorial calls for critical assessment of this sensitive matter.
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Affiliation(s)
- Tine Molendijk
- Department of Military Management Studies, Faculty of Military Sciences, Netherlands Defence Academy, Breda; and Centre for International Conflict Analysis and Management, Radboud University Nijmegen, The Netherlands
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7
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Abstract
BACKGROUND There are limited studies examining mortality associated with electroconvulsive therapy (ECT), and many studies do not include a control group or method to identify all patient deaths. AIMS We aimed to evaluate the risk of death associated with ECT treatments over 30 days and 1 year. METHOD We conducted a study analysing electronic medical record data from the Department of Veterans Affairs healthcare system between 2000 and 2017. We compared mortality among patients who received ECT with a matched group of patients created through propensity score matching. RESULTS Our sample included 123 479 individual ECT treatments provided to 8720 patients (including 5157 initial index courses of ECT). Mortality associated with individual ECT treatments was 3.08 per 10 000 treatments over the first 7 days after treatment. When comparing patients who received ECT with a matched group of mental health patients, those receiving ECT had a relative odds of all-cause mortality in the year after their index course of 0.87 (95% CI 0.79-1.11; P = 0.10), and a relative risk of death from causes other than suicide of 0.79 (95% CI 0.66-0.95; P < 0.01). The similar relative odds of all-cause mortality in the first 30 days after ECT was 1.06 (95% CI 0.65-1.73) for all-cause mortality, and 1.02 (95% CI 0.58-1.8) for all-cause mortality excluding suicide deaths. CONCLUSIONS There was no evidence of elevated or excess mortality after ECT. There was some indication that mortality may be reduced in patients receiving ECT compared with similar patients who do not receive ECT.
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Affiliation(s)
- Bradley V Watts
- Department of Mental Health Services, White River Junction VA Medical Center, Vermont, USA; Department of Psychiatry, Geisel School of Medicine at Dartmouth College, New Hampshire, USA; and VA Office of Systems Redesign and Improvement, Department of Veterans Affairs, Washington, DC, USA
| | - Talya Peltzman
- Department of Mental Health Services, White River Junction VA Medical Center, Vermont, USA
| | - Brian Shiner
- Department of Mental Health Services, White River Junction VA Medical Center, Vermont, USA; and Department of Psychiatry, Geisel School of Medicine at Dartmouth College, New Hampshire, USA
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8
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Pietrzak RH, Javier FG, Krystal JH, Southwick SM. Subthreshold post-traumatic stress disorder as a risk factor for post-traumatic stress disorder: results from a sample of USA veterans. Br J Psychiatry 2021; 219:456-459. [PMID: 35048836 DOI: 10.1192/bjp.2021.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Subthreshold post-traumatic stress disorder (PTSD) is more prevalent than PTSD, yet its role as a potential risk factor for PTSD is unknown. To address this gap, we analysed data from a 7-year, prospective national cohort of USA veterans. Of veterans with subthreshold PTSD at wave 1, 34.3% developed PTSD compared with 7.6% of trauma-exposed veterans without subthreshold PTSD (relative risk ratio 6.4). Among veterans with subthreshold PTSD, specific PTSD symptoms, greater age, cognitive difficulties, lower dispositional optimism and new-onset traumas predicted incident PTSD. Results suggest that preventive interventions targeting subthreshold PTSD and associated factors may help mitigate risk for PTSD in USA veterans.
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Affiliation(s)
- Robert H Pietrzak
- US Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, Connecticut, USA; and Department of Psychiatry, Yale School of Medicine, Connecticut, USA
| | - Frances G Javier
- US Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, Connecticut, USA; and Department of Psychiatry, Yale School of Medicine, Connecticut, USA
| | - John H Krystal
- US Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, Connecticut, USA; and Department of Psychiatry, Yale School of Medicine, Connecticut, USA
| | - Steven M Southwick
- US Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, Connecticut, USA; and Department of Psychiatry, Yale School of Medicine, Connecticut, USA
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Abstract
BACKGROUND Prior research has identified behavioural health outcomes as key sequelae to combat deployment. However, relatively little is known about differential patterns of change in depression or generalised anxiety linked to deployment to a combat zone. In this paper, we add to the existing trajectory literature and examine key predictive factors of behavioural health risk. AIMS The primary aim is to leverage growth mixture modelling to ascertain trajectories of psychological distress, operationalised as a coherent construct combining depression and generalised anxiety, and to identify factors that differentiate adaptive and maladaptive patterns of change. METHOD Data were collected from a brigade combat team prior to a combat deployment to Afghanistan, during deployment, at immediate re-integration and approximately 2-3 months thereafter. The main outcome was measured using the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS). RESULTS Three latent trajectories were identified: a low-stable trajectory, a declining trajectory and a rising trajectory. Most individuals aligned with the low-stable trajectory. A conditional model using covariates measured during deployment showed that the low-stable trajectory differed consistently from the remaining trajectories on self-reported loneliness and non-combat deployment stressors. CONCLUSIONS The examination of differential patterns of adaptation, to identify individuals at higher risk, is critical for the efficient targeting of resources. Our findings further indicate that loneliness may be a useful leverage point for clinical and organisational intervention.
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Affiliation(s)
- Oscar A Cabrera
- U.S. Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, USA
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10
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Nakkas C, Annen H, Brand S. Somatization and Coping in Ethnic Minority Recruits. Mil Med 2020; 184:e680-e685. [PMID: 30793179 DOI: 10.1093/milmed/usz014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/09/2018] [Accepted: 01/16/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Military service can have beneficial social effects on minorities. However, minority groups are also often at greater risk of somatizing psychological distress and coping maladaptively. In military training this would result in lower mental health of minorities and contribute to higher drop-out rates. We thus examined if recruits with different ethnocultural backgrounds report different somatization levels and coping styles. MATERIALS AND METHODS Seven hundred and forty male recruits of the Swiss Armed Forces aged 18-26 took part in a cross-sectional study during basic training. Participants filled out self-rating questionnaires covering sociodemographics, somatization (SCL-90-R), coping styles (INCOPE-2), and social support (F-SozU). The recruits' ethnic self-identification was used to compare three groups: native Swiss (89%); Turkish or Balkan minority (5%); heterogeneous ethnic minority (6%). Group differences in somatization scores were tested with a Kruskal-Wallis test; group differences in coping styles were tested with a multivariate ANCOVA, controlling for the level of social support experienced. RESULTS Recruits from the heterogeneous ethnic minority group reported significantly greater levels of somatization than their native Swiss comrades. Coping styles did not differ between the three ethnic groups, but higher levels of social support were associated with better coping. CONCLUSION Military doctors ought to place importance on the differential diagnosis of medically unexplained physical symptoms in ethnic minority recruits. This would contribute to minimize the risk of misdiagnosis. Military mental health professionals who counsel recruits reporting somatic symptoms are advised to be sensitized to an ethnic minority status. Physical complaints could mask affective problems or be part of an adjustment disorder symptomatology.
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Affiliation(s)
- Can Nakkas
- Psychologic-Pedagogic Service of the Swiss Armed Forces (PPD A), Waffenplatz, Gebäude 338, Thun, Switzerland
| | - Hubert Annen
- Department of Military Psychology Studies, Military Academy at ETH Zurich, Birmensdorf, Switzerland
| | - Serge Brand
- University of Basel, Psychiatric Clinics (UPK), Center for Affective, Stress and Sleep Disorders (ZASS), Wilhelm Klein-Strasse 27, Basel, Switzerland
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11
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Forchuk C, Nazarov A, Hunt R, Davis B, St Cyr K, Richardson JD. The influence of depression-PTSD comorbidity on health-related quality of life in treatment-seeking veterans. Eur J Psychotraumatol 2020; 11:1748460. [PMID: 32922680 PMCID: PMC7448842 DOI: 10.1080/20008198.2020.1748460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) and depression substantially impair health-related quality of life (HRQOL) for many Canadian Armed Forces (CAF) veterans. Although PTSD and depression are highly comorbid, little is known about whether the disorders may interact in their association with HRQOL. We sought to investigate whether depressive symptoms modify the relation between PTSD and HRQOL in treatment-seeking veterans. METHOD We accessed the clinical data of 545 CAF veterans aged 18 to 65 years who were seeking treatment at a specialized clinic in London, Ontario. We used hierarchical linear regression to assess the additive and multiplicative relations between depression and PTSD symptoms on HRQOL, controlling for age and alcohol/substance abuse. Simple slopes were examined to probe significant interactions. RESULTS Probable PTSD and major depression were present in 77.4% and 85.3% of the sample, respectively, and 73.0% of the sample presented with probable PTSD-depression comorbidity. Depression symptoms significantly modified the relation between PTSD symptoms and overall mental HRQOL (β = 0.12, p <0.001, ∆R2 = 0.014), and role impairment due to emotional difficulties (β = 0.20, p <0.001, ∆R2 = 0.035). Simple slope analyses revealed the impact of PTSD was greater among those with lower depression symptoms and became weaker with greater depression symptom severity. In adjusted models, only depression was significantly associated with all mental and physical HRQOL domains; PTSD was not associated with physical HRQOL, role emotional impairment, or vitality. CONCLUSIONS For those with severe comorbid depression, PTSD symptoms were no longer associated with mental HRQOL, particularly in areas related to emotional functioning. Findings suggest the importance of targeting depression in patients presenting with PTSD-depression comorbidity.
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Affiliation(s)
- Callista Forchuk
- The MacDonald Franklin OSI Research Centre, Parkwood Institute, St. Joseph's Health Care, London, Ontario, Canada
| | - Anthony Nazarov
- The MacDonald Franklin OSI Research Centre, Parkwood Institute, St. Joseph's Health Care, London, Ontario, Canada.,Department of Psychiatry, Western University, London, Ontario, Canada.,Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Renee Hunt
- The MacDonald Franklin OSI Research Centre, Parkwood Institute, St. Joseph's Health Care, London, Ontario, Canada.,Department of Psychiatry, Western University, London, Ontario, Canada
| | - Brent Davis
- The MacDonald Franklin OSI Research Centre, Parkwood Institute, St. Joseph's Health Care, London, Ontario, Canada.,Computer Science Department, Western University, London, Ontario, Canada
| | - Kate St Cyr
- The MacDonald Franklin OSI Research Centre, Parkwood Institute, St. Joseph's Health Care, London, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - J Don Richardson
- The MacDonald Franklin OSI Research Centre, Parkwood Institute, St. Joseph's Health Care, London, Ontario, Canada.,Department of Psychiatry, Western University, London, Ontario, Canada.,Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada.,OSI Clinic, Parkwood Institute, St. Joseph's Health Care, London, Ontario, Canada
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12
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Murphy D, Shevlin M, Pearson E, Greenberg N, Wessely S, Busuttil W, Karatzias T. A validation study of the International Trauma Questionnaire to assess post-traumatic stress disorder in treatment-seeking veterans. Br J Psychiatry 2020; 216:132-137. [PMID: 32345413 DOI: 10.1192/bjp.2020.9] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Veterans with post-traumatic stress disorder (PTSD) typically report a poorer treatment response than those who have not served in the Armed Forces. A possible explanation is that veterans often present with complex symptoms of PTSD. ICD-11 PTSD and complex PTSD (CPTSD) have not previously been explored in a military sample. AIMS This study aimed to validate the only measure of ICD-11 PTSD and CPTSD, the International Trauma Questionnaire, and assess the rates of the disorder in a sample of treatment-seeking UK veterans. METHOD A sample of help-seeking veterans (N = 177) was recruited from a national charity in the UK that provides clinical services to veterans. Participants completed measures of ICD-11 PTSD and CPTSD as well as childhood and adult traumatic life events. Confirmatory factor analysis was used to assess the latent structure of PTSD and CPTSD symptoms, and rates of the disorders were estimated. RESULTS The majority of the participants (70.7%) reported symptoms consistent with a diagnosis of either PTSD or CPTSD. Results indicated the presence of two separate disorders, with CPTSD being more frequently endorsed (56.7%) than PTSD (14.0%). CPTSD was more strongly associated with childhood trauma than PTSD. CONCLUSIONS The International Trauma Questionnaire can adequately distinguish between PTSD and CPTSD within clinical samples of veterans. There is a need to explore the effectiveness of existing and new treatments for CPTSD in military personnel.
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Affiliation(s)
- Dominic Murphy
- Research Department, Combat Stress; and King's Centre for Military Health Research, King's College London, UK
| | - Mark Shevlin
- School of Psychology, Ulster University, Northern Ireland
| | | | - Neil Greenberg
- King's Centre for Military Health Research, King's College London, UK
| | - Simon Wessely
- King's Centre for Military Health Research, King's College London, UK
| | | | - Thanos Karatzias
- School of Health & Social Care, Edinburgh Napier University; and NHS Lothian Rivers Centre for Traumatic Stress, UK
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13
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Rafferty LA, Wessely S, Stevelink SAM, Greenberg N. The journey to professional mental health support: a qualitative exploration of the barriers and facilitators impacting military veterans' engagement with mental health treatment. Eur J Psychotraumatol 2020; 10:1700613. [PMID: 33488992 PMCID: PMC7803083 DOI: 10.1080/20008198.2019.1700613] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: It is often claimed that military veterans are reticent to seek help for mental disorders, even though delayed treatment may impair recovery and impact the wellbeing of those close to the veteran. Objective: This paper aims to explore the barriers and facilitators to accessing professional mental health support for three groups of veterans who met criteria for a probable mental health disorder and: (1) do not recognize a probable mental disorder; (2) recognize they are affected by a mental disorder but are not seeking professional support; or (3) are currently seeking professional mental health support. Method: Qualitative telephone interviews were conducted with 62 UK military veterans. Thematic analysis identified core themes along an illustrative journey towards professional mental health support. Results: Distinct barriers and facilitators to care were discussed by each group of veterans depicting changes as veterans moved towards accessing professional mental health support. In contrast to much of the literature, stigma was not a commonly reported barrier to care; instead care-seeking decisions centred on a perceived need for treatment, waiting until a crisis event occurred. Whilst the recognition of treatment need represented a pivotal moment, our data identified numerous key steps which had to be surmounted prior to care-seeking. Conclusion: As care-seeking decisions within this sample appeared to centre on a perceived need for treatment future efforts designed to encourage help-seeking in UK military veterans may be best spent targeting the early identification and management of mental health disorders to encourage veterans to seek support before reaching a crisis event.
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Affiliation(s)
- Laura A Rafferty
- Kings' Centre for Military Health Research, King's College London, London, UK
| | - Simon Wessely
- Kings' Centre for Military Health Research, King's College London, London, UK
| | - Sharon A M Stevelink
- Kings' Centre for Military Health Research and Department of Psychological Medicine, King's College London, London, UK
| | - Neil Greenberg
- Kings' Centre for Military Health Research, King's College London, London, UK
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14
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Nazarov A, Fikretoglu D, Liu A, Richardson JD, Thompson M. Help-seeking for mental health issues in deployed Canadian Armed Forces personnel at risk for moral injury. Eur J Psychotraumatol 2020; 11:1729032. [PMID: 32194921 PMCID: PMC7067158 DOI: 10.1080/20008198.2020.1729032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 02/01/2020] [Accepted: 02/04/2020] [Indexed: 10/31/2022] Open
Abstract
Objective: Potentially morally injurious experiences (PMIE) (events that transgress an individual's subjective moral standards) have been associated with psychologically distressing moral emotions such as shame and guilt. Military leaders and clinicians have feared that those with PMIEs may be less likely to seek help due to the withdrawing nature of shame/guilt; however, to date, help-seeking patterns of military personnel with PMIEs has not been explored. Our objective is to address this research gap. Method: Data from a nationally-representative mental health survey of active Canadian military personnel were analysed. To assess the association between exposure to three PMIEs and past-year help-seeking across different provider categories (i.e. professionals, para-professionals (those delegated with mental health advisory tasks but are not licenced to practice as medical professionals), non-professionals), a series of logistic regressions were conducted, controlling for exposure to other deployment and non-deployment-related psychological trauma, psychiatric variables, military factors, and sociodemographic variables. Analytical data frame included only personnel with a history of Afghanistan deployment (N = 4854). Results: Deployed members exposed to PMIEs were more likely to seek help from their family doctor/general practitioner (OR = 1.72; 95%CI = 1.25-2.36), paraprofessionals (OR = 1.72; 95%CI = 1.25-2.36), and non-professionals (OR = 1.44; 95%CI = 1.06-1.95) in comparison to members not exposed to PMIEs. Those exposed to PMIEs were also more likely to seek professional care from the civilian health care system (OR = 1.94; 95%CI = 1.27-2.96). Conclusion: Contrary to long-held, but untested, assumptions regarding the impact of PMIEs on help-seeking, we found those with PMIEs are more likely to seek help from gatekeeper professionals (i.e. general practitioners), para-professionals, and non-professionals rather than specialized mental health professionals (e.g. psychologists). Increased utilization of civilian professionals raises concerns that active military members may be avoiding military health services. Clinically, this highlights the need to increase awareness of moral injury to ensure that actively serving military members are provided with appropriate advice and treatment.
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Affiliation(s)
- Anthony Nazarov
- The MacDonald Franklin OSI Research Centre, Lawson Health ResearchInstitute, London, Ontario, Canada.,Department of Psychiatry, Western University, London, Ontario, Canada.,Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Deniz Fikretoglu
- Department of National Defence, Defence Research and Development Canada, Toronto, Ontario, Canada.,Douglas Mental Health University Institute, McGill University, Montreal, Quebec, Canada
| | - Aihua Liu
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - J Don Richardson
- The MacDonald Franklin OSI Research Centre, Lawson Health ResearchInstitute, London, Ontario, Canada.,Department of Psychiatry, Western University, London, Ontario, Canada.,Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada.,Operational Stress Injury Clinic, St. Joseph's Health Care, London, Ontario, Canada
| | - Megan Thompson
- Department of National Defence, Defence Research and Development Canada, Toronto, Ontario, Canada
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Loscalzo Y, Giannini M, Gori A, Fabio AD. The Wellbeing of Italian Peacekeeper Military: Psychological Resources, Quality of Life and Internalizing Symptoms. Front Psychol 2018; 9:103. [PMID: 29487552 PMCID: PMC5816820 DOI: 10.3389/fpsyg.2018.00103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 01/22/2018] [Indexed: 11/30/2022] Open
Abstract
Working as a peacekeeper is associated with the exposure to acute and/or catastrophic events and chronic stressors. Hence, the meager literature about peacekeepers' wellbeing has mainly analyzed Post-Traumatic Stress Disorder (PTSD). This study aims to deep the analysis of the wellbeing of peacekeepers military. Based on the few studies on this population, we hypothesized that Italian peacekeeper military officers and enlisted men (n = 167; 103 males, 6 females, 58 missing) exhibit lower levels of internalizing symptoms (i.e., PTSD, depression, general anxiety, obsessions, and somatization) as compared to a control group (n = 60; 32 males, 28 females). Moreover, we hypothesized that peacekeepers have higher levels of psychological resources (i.e., self-efficacy, self-esteem, social support) and quality of life (i.e., higher life satisfaction and lower general stress). We compared the groups by means of MANOVAs on the subscales of the Psychological Treatment Inventory (PTI; Gori et al., 2015). We found that Italian peacekeepers have lower internalizing symptoms and higher levels of self-efficacy and self-esteem than the control group; however, no statistically significant differences were observed on perceived social support. Finally, peacekeepers have a higher quality of life: scores reflect higher life satisfaction and lower distress than the control group. This study is in line with previous literature supporting the claim that Italian peacekeeper military officers have sufficient psychological resources for coping with the stressful situations implied in peacekeeping missions. Future studies should deepen the analysis of the military's psychological characteristics by comparing war veterans and peacekeeper military.
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Affiliation(s)
- Yura Loscalzo
- Department of Health Sciences, School of Psychology, University of Florence, Florence, Italy
| | - Marco Giannini
- Department of Health Sciences, School of Psychology, University of Florence, Florence, Italy
| | - Alessio Gori
- Department of Human Sciences, LUMSA University, Rome, Italy
| | - Annamaria Di Fabio
- Psychology Section, Department of Education and Psychology, University of Florence, Florence, Italy
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Trautmann S, Goodwin L, Höfler M, Jacobi F, Strehle J, Zimmermann P, Wittchen HU. Prevalence and severity of mental disorders in military personnel: a standardised comparison with civilians. Epidemiol Psychiatr Sci 2017; 26:199-208. [PMID: 27086743 PMCID: PMC6998688 DOI: 10.1017/s204579601600024x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 03/22/2016] [Indexed: 11/06/2022] Open
Abstract
AIMS Provision and need for mental health services among military personnel are a major concern across nations. Two recent comparisons suggest higher rates of mental disorders in US and UK military personnel compared with civilians. However, these findings may not apply to other nations. Previous studies have focused on the overall effects of military service rather than the separate effects of military service and deployment. This study compared German military personnel with and without a history of deployment to sociodemographically matched civilians regarding prevalence and severity of 12-month DSM-IV mental disorders. METHOD 1439 deployed soldiers (DS), 779 never deployed soldiers (NS) and 1023 civilians were assessed with an adapted version of the Munich Composite International Diagnostic interview across the same timeframe. Data were weighted using propensity score methodology to assure comparability of the three samples. RESULTS Compared with adjusted civilians, the prevalence of any 12-month disorder was lower in NS (OR: 0.7, 95% CI: 0.5-0.99) and did not differ in DS. Significant differences between military personnel and civilians regarding prevalence and severity of individual diagnoses were only apparent for alcohol (DS: OR: 0.3, 95% CI: 0.1-0.6; NS: OR: 0.2, 95% CI: 0.1-0.6) and nicotine dependence (DS: OR: 0.5, 95% CI: 0.3-0.6; NS: OR: 0.5, 95% CI: 0.3-0.7) with lower values in both military samples. Elevated rates of panic/agoraphobia (OR: 2.7, 95% CI: 1.4-5.3) and posttraumatic stress disorder (OR: 3.2, 95% CI: 1.3-8.0) were observed in DS with high combat exposure compared with civilians. CONCLUSIONS Rates and severity of mental disorders in the German military are comparable with civilians for internalising and lower for substance use disorders. A higher risk of some disorders is reduced to DS with high combat exposure. This finding has implications for mental health service provision and the need for targeted interventions. Differences to previous US and UK studies that suggest an overall higher prevalence in military personnel might result from divergent study methods, deployment characteristics, military structures and occupational factors. Some of these factors might yield valuable targets to improve military mental health.
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Affiliation(s)
- S. Trautmann
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - L. Goodwin
- Department of Psychological Medicine, King's Centre for Military Health Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - M. Höfler
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - F. Jacobi
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - J. Strehle
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - P. Zimmermann
- Centre for Psychiatry and Posttraumatic Stress, Federal Armed Forces Hospital Berlin, Berlin, Germany
| | - H.-U. Wittchen
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
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Rothbaum BO, Price M, Jovanovic T, Norrholm SD, Gerardi M, Dunlop B, Davis M, Bradley B, Duncan E, Rizzo A“S, Ressler KJ. A randomized, double-blind evaluation of D-cycloserine or alprazolam combined with virtual reality exposure therapy for posttraumatic stress disorder in Iraq and Afghanistan War veterans. Am J Psychiatry 2014; 171:640-8. [PMID: 24743802 PMCID: PMC4115813 DOI: 10.1176/appi.ajp.2014.13121625] [Citation(s) in RCA: 236] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined the effectiveness of virtual reality exposure augmented with D-cycloserine or alprazolam, compared with placebo, in reducing posttraumatic stress disorder (PTSD) due to military trauma. METHOD After an introductory session, five sessions of virtual reality exposure were augmented with D-cycloserine (50 mg) or alprazolam (0.25 mg) in a double-blind, placebo-controlled randomized clinical trial for 156 Iraq and Afghanistan war veterans with PTSD. RESULTS PTSD symptoms significantly improved from pre- to posttreatment across all conditions and were maintained at 3, 6, and 12 months. There were no overall differences in symptoms between D-cycloserine and placebo at any time. Alprazolam and placebo differed significantly on the Clinician-Administered PTSD Scale score at posttreatment and PTSD diagnosis at 3 months posttreatment; the alprazolam group showed a higher rate of PTSD (82.8%) than the placebo group (47.8%). Between-session extinction learning was a treatment-specific enhancer of outcome for the D-cycloserine group only. At posttreatment, the D-cycloserine group had the lowest cortisol reactivity and smallest startle response during virtual reality scenes. CONCLUSIONS A six-session virtual reality treatment was associated with reduction in PTSD diagnoses and symptoms in Iraq and Afghanistan veterans, although there was no control condition for the virtual reality exposure. There was no advantage of D-cycloserine for PTSD symptoms in primary analyses. In secondary analyses, alprazolam impaired recovery and D-cycloserine enhanced virtual reality outcome in patients who demonstrated within-session learning. D-cycloserine augmentation reduced cortisol and startle reactivity more than did alprazolam or placebo, findings that are consistent with those in the animal literature.
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Affiliation(s)
| | | | | | | | | | | | | | - Bekh Bradley
- Emory University School of Medicine,Atlanta VAMC
| | - Erica Duncan
- Emory University School of Medicine,Atlanta VAMC
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Abstract
This article investigates a novel type of war neurosis defined by Yugoslav psychiatrists in the aftermath of the Second World War. This uniquely Yugoslav war trauma-'partisan hysteria'-was diagnosed exclusively in Communist resistance soldiers-partisans-and did not manifest itself in the form of battle exhaustion or anxiety, as was the case in other armies. Rather, it demonstrated a heightened willingness to fight, and consisted of simulations of wartime battles. Yugoslav psychiatrists argued that 'partisan hysteria' most frequently affected uneducated and immature partisans, who were given important political responsibilities but experienced severe trauma due to their own inadequacy. I argue that 'partisan hysteria' served as an opportunity for upper-middle-class psychiatric professionals to criticise the increasing upward social mobility after the socialist revolution of 1945. Surprisingly, this touched upon an issue that had already provoked deep disquiet within the Communist Party, and resonated with the Party's own concerns regarding social mobility.
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Affiliation(s)
- Ana Antić
- Department of History, Classics and Archaeology, 27-28 Russell Square, Birkbeck College, London WC1B 5DQ, UK.
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Abstract
World War I witnessed the admission of large numbers of German soldiers with neurological symptoms for which there was no obvious organic cause. This posed a considerable challenge for the military and medical authorities and resulted in an active discussion on the etiology and treatment of these disorders. Current historiography is reliant on published physician accounts, and this represents the first study of treatment approaches based on original case notes. We analyzed patient records from two leading departments of academic psychiatry in Germany, those at Berlin and Jena, in conjunction with the contemporaneous medical literature. Treatment, which can be broadly classified into reward and punishment, suggestion, affective shock, cognitive learning, and physiological methods, was developed in the context of the emerging fields of animal learning and neurophysiology. A further innovative feature was the use of quantitative methods to assess outcomes. These measures showed good response rates, though most cured patients were not sent back to battle because of their presumed psychopathic constitution. While some treatments appear unnecessarily harsh from today's perspective and were also criticized by leading psychiatrists of the time, the concentration of effort and involvement of so many senior doctors led to the development of psychotherapeutic methods that were to influence the field of psychiatric therapy for decades to come.
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Affiliation(s)
| | - Edgar Jones
- Kings College London, King's Centre for Military Health Research, Institute of Psychiatry, London, UK.
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Azad A, McKinnon ND, Joshi KG, Faubion MD. Snapshot of air force psychiatry: wilford Hall medical center. Psychiatry (Edgmont) 2009; 6:52-53. [PMID: 19724763 PMCID: PMC2720844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
In line with Psychiatry 2009's mission to strengthen its global presence as a leading source of evidence-based information for practicing clinicians, we are pleased to launch the new column, "Psychiatric Clinics from Around the World." This series will enable readers to become familiar with facilities around the world that provide psychiatric care. We hope you find the column interesting. We start the series with a column featuring Wilford Hall Medical Center, the flagship psychiatric facility of the United States Air Force.United States Air Force psychiatry plays a vital role in Operation Iraqi Freedom and Operation Enduring Freedom (Afghanistan). Outside of the military, little is known about US Air Force psychiatry and the Wilford Hall Medical Center. Wilford Hall Medical Center is the US Air Force's flagship hospital and premiere psychiatric hospital. This article briefly discusses the history of Wilford Hall Medical Center and its psychiatric contributions to the wars in Iraq and Afghanistan.
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Affiliation(s)
- Alvi Azad
- Drs. Azad, McKinnon, and Faubion are from Wilford Hall Medical Center, Lackland AFB, San Antonio, Texas, and the University of Texas Health Science Center at San Antonio, Texas; Dr. Joshi is from Wilford Hall Medical Center, Lackland AFB, San Antonio, Texas
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