Long-term responses to treatment in UK veterans with military-related PTSD: an observational study

OBJECTIVES

Military-related trauma can be difficult to treat. Evaluating longer term responses to treatment and identifying which individuals may need additional support could inform clinical practice. We assessed 1-year outcomes in UK veterans treated for post-traumatic stress disorder (PTSD).

DESIGN

Within-participant design.

SETTING

The intervention was offered by Combat Stress, a mental health charity for veterans in the UK.

PARTICIPANTS

The sample included 401 veterans who completed a standardised 6-week residential treatment. Of these, 268 (67%) were successfully followed up a year after the end of treatment.

METHODS

A range of health outcomes were collected pretreatment and repeated at standard intervals post-treatment. The primary outcome was severity of PTSD symptoms, and secondary outcomes included measures of other mental health difficulties (depression, anxiety and anger), problems with alcohol, and social and occupational functioning.

RESULTS

Significant reductions in PTSD severity were observed a year after treatment (PSS-I: -11.9, 95% CI -13.1 to -10.7). Reductions in the secondary outcomes were also reported. Higher levels of post-treatment functional impairment (0.24, 95% CI 0.08 to 0.41) and alcohol problems (0.18, 95% CI 0.03 to 0.32) were associated with poorer PTSD treatment response at 12 months.

CONCLUSIONS

This uncontrolled study suggests the longer term benefits of a structured programme to treat UK veterans with PTSD. Our findings point to the importance of continued support targeted for particular individuals post-treatment to improve longer term outcomes.

Rehabilitation of Combat-Related Injuries in the Veterans Administration: A Web of Support

The Department of Veterans Affairs provides acute, subacute, and continuing rehabilitation for veterans using a hub-and-spoke system of hospitals and outpatient facilities. Using traumatic brain injury as an example, this commentary illustrates how this system provides interdisciplinary rehabilitative care to veterans throughout North Carolina.

[Rehabilitation and reintegration of soldiers injured on deployment]

The participation of the French army in the Afghan conflict has highlighted the need for discussion and action regarding the pathway, rehabilitation and reintegration of soldiers who have been physically or psychologically injured. Clinical experience demonstrates that difficulties are less likely to appear during the initial treatment phase than later on, when there is less group support and there are fewer visible effects of the recognition on the part of the institution. It is important to strengthen the links between healthcare personnel and institutional players, in order to optimise the medical and social care of these war casualties.

[The "Écoute Défense" helpline, a new care tool within the military health service]

The "Écoute Défense" helpline was launched on 23rd January 2013. This freephone number, available 24/7, is aimed at soldiers, former soldiers and their families. The main objective of the service is to listen, provide information and guide those suffering from psychological traumas which have arisen during service. Carried out by clinical psychologists from the military health service, the mission raises discussion around the challenges of this new channel for accessing care for soldiers.

Narrative transformation among military personnel on an adventurous training and sport course

In the wake of recent wars, some military personnel face considerable physical and mental health problems. In this article I explore the effects of an adapted sport and inclusive adventurous training course for military personnel who have experienced physical injury and/or psychological trauma. Using a dialogical narrative approach, I analyzed stories shared by six soldiers during the course to explore the effects of involvement. Participation in the course seemed to facilitate a narrative transformation or opening corresponding to a broadening identity and sense of self. Story plots progressed from a failing monological narrative, through a chaos narrative, toward a dialogical quest narrative prioritizing immersion in an intense present, a developing self, and a relational orientation. On the basis of narrative theory, I suggest this transformation holds positive consequences for the health and well-being of military personnel who have experienced injury and/or trauma.

Nonprofit Charity Impacts Wounded Combat Veterans And Children Facing Adversity

Mental and physical health challenges, especially for returning war veterans and their families, is a growing national concern. A grassroots program featuring equine therapy for these patients and their families shows promise in increasing self-esteem and self-confidence, reducing isolation and depression, and improving speaking and writing skills.

Compelling Evidence that Exposure Therapy for PTSD Normalizes Brain Function

Functional magnetic resonance imaging (fMRI) is helping us better understand the neurologic pathways involved in posttraumatic stress disorder (PTSD). We previously reported that military service members with PTSD after deployment to Iraq or Afghanistan demonstrated significant improvement, or normalization, in the fMRI-measured activation of the amygdala, prefrontal cortex and anterior cingulate gyrus following exposure therapy for PTSD. However, our original study design did not include repeat scans of control participants, rendering it difficult to discern how much of the observed normalization in brain activity is attributable to treatment, rather than merely a practice effect. Using the same Affective Stroop task paradigm, we now report on a larger sample of PTSD-positive combat veterans that we treated with exposure therapy, as well as a combat-exposed control group of service members who completed repeat scans at 3-4 month intervals. Findings from the treatment group are similar to our prior report. Combat controls showed no significant change on repeat scanning, indicating that the observed differences in the intervention group were in fact due to treatment. We continue to scan additional study participants, in order to determine whether virtual reality exposure therapy has a different impact on regional brain activation than other therapies for PTSD.

[Neuropsychological rehabilitation in wartime]

INTRODUCTION

The decrease in the rate of mortality due to brain damage during the First World War resulted in a large number of veterans with neurological or neuropsychological sequelae. This situation, which was unknown up until then, called for the development of new therapeutic approaches to help them reach acceptable levels of autonomy.

DEVELOPMENT

This article reviews the relationship between neuropsychological rehabilitation and warfare, and describes the contributions made by different professionals in this field in the two great conflicts of the 20th century. The First World War was to mark the beginning of neuropsychological rehabilitation as we know it today. Some of the most outstanding contributions in that period were those made by Goldstein and Popplereuter in Germany or Franz in the United States. The Second World War was to consolidate this healthcare discipline, the leading figures at that time being Zangwill in England and Luria in the Soviet Union. Despite being of less importance, geopolitically speaking, the study also includes the Yom Kippur War, which exemplifies how warfare can stimulate the development of neuropsychological intervention programmes.

CONCLUSIONS

Today's neuropsychological rehabilitation programmes are closely linked to the interventions used in wartime by Goldstein, Zangwill or Luria. The means employed may have changed, but the aims are still the same, i.e. to help people with brain damage manage to adapt to their new lives.

Nature adventure rehabilitation for combat-related posttraumatic chronic stress disorder: a randomized control trial

Chronic combat-related posttraumatic stress disorder (CR-PTSD) is a condition with many treatment barriers. Nature Adventure Rehabilitation (NAR) as a second line or as a supplemental intervention has the potential to overcome some of these barriers and incorporate aspects of successful treatment modalities for PTSD within an experiential learning paradigm. In a pre-post controlled trial, CR-PTSD veterans (n=22) underwent a 1-year NAR intervention compared to a waiting list (WL) control group (n=20). Posttraumatic symptoms (PTS), depression, functional problems, quality of life, perceived control over illness (PCI) and hope were measured by self report measures. PTS, emotional and social quality of life, PCI, hope and functioning improved significantly. Change in PTS was contingent upon change in PCI. The current study is the first to present NAR as a promising supplemental intervention for chronic CR-PTSD. NAR seems to work through a process of behavioral activation, desensitization, gradual exposure to anxiety evoking situations and gaining control over symptomatology.

With Doug: an Eastern Orthodox--Gestalt framework for pastoral psychotherapy in the armed forces

In military behavioral healthcare, a short-term, solutions-focused system often privileges cognitive techniques over existential, affective, or psychodynamic approaches to care. Pastoral psychotherapy, which often privileges existential and person-centered care, has the potential to prove a pivotal complement in treating the whole person. This article offers an existential approach to pastoral psychotherapy in the military using integrated concepts and applications from Gestalt Therapy and Eastern Orthodox pastoral care.

When a parent is injured or killed in combat

When a service member is injured or dies in a combat zone, the consequences for his or her family can be profound and long-lasting. Visible, physical battlefield injuries often require families to adapt to long and stressful rounds of treatment and rehabilitation, and they can leave the service member with permanent disabilities that mean new roles for everyone in the family. Invisible injuries, both physical and psychological, including traumatic brain injury and combat-related stress disorders, are often not diagnosed until many months after a service member returns from war (if they are diagnosed at all-many sufferers never seek treatment). They can alter a service member's behavior and personality in ways that make parenting difficult and reverberate throughout the family. And a parent's death in combat not only brings immediate grief but can also mean that survivors lose their very identity as a military family when they must move away from their supportive military community. Sifting through the evidence on both military and civilian families, Allison Holmes, Paula Rauch, and Stephen Cozza analyze, in turn, how visible injuries, traumatic brain injuries, stress disorders, and death affect parents' mental health, parenting capacity, and family organization; they also discuss the community resources that can help families in each situation. They note that most current services focus on the needs of injured service members rather than those of their families. Through seven concrete recommendations, they call for a greater emphasis on family-focused care that supports resilience and positive adaptation for all members of military families who are struggling with a service member's injury or death.

The effect of military motion-assisted memory desensitization and reprocessing treatment on the symptoms of combat-related post traumatic stress disorder: first preliminary results

Although the symptoms of Post-Traumatic Stress Disorder (PTSD) in the general and military population seem very similar, combat-related PTSD (cr-PTSD) is typically thought to be more severe due to the repeated and prolonged exposure of traumatic events. Therapeutic adherence is reported a problem in military populations compromising treatment efficacy. Therefore, a new potential supplementary treatment is specially designed for patients with cr-PTSD. This intervention is called Military Motion Memory Desensitization and Reprocessing (3MDR). The treatment incorporates key elements of successful treatments as Virtual Reality Exposure (VRE) and Eye Movement Desensitization Reprocessing (EMDR) and adds motion to the condition. We aimed at designing a treatment procedure that preserved dual task processing principle, yet introduced new engagement by performing the desensitization during motion by to walking on a treadmill. Moreover, we aimed at exposure to real high-affect pictures of deployment setting. Subjects walk a repetitive cycle while walking and viewing high affect pictures of deployment scenes. Dual task processing was maintained by an oscillating ball. Aspects of presence are adhered to, to maximize possible positive outcome.

METHOD

Two veterans with chronic PTSD, received four weekly sessions of 3MDR therapy. The indicator of effectiveness was difference in CAPS (Clinical Administrated PTSD Scale)-score. The treatment was designed on the Computer Assisted Rehabilitation Environment (CAREN) facility.

RESULTS

The 3MDR treatment did further decrease PTSD symptoms. Patients were highly satisfied about the treatment and had no attention to drop out.

CONCLUSION

The results of the two cases suggest that the 3MDR treatment is a successful, more additional treatment that goes further into the patients affect where other treatment may stagnate. The presence was highly appreciated. Further research with more patients needs to be performed to obtain more reliable results.

Critical concerns in Iraq/Afghanistan war veteran-forensic interface: veterans treatment court as diversion in rural communities

The veteran-forensic interface is an emerging area of relevance to forensic clinicians assessing or treating returning Iraq and Afghanistan war veterans facing criminal sanctions. Veterans' Treatment Court (VTC) represents a recent diversion mechanism for low-level offenses that is based on a collaborative justice model. Thirty-nine percent of veterans who served in Iraq or Afghanistan and receiving VA services reside in rural areas. Rural veterans facing criminal justice charges may be at a disadvantage due to limited access to forensic psychiatrists with relevant expertise in providing veterans services for diversion. Therefore, widening the pool of forensic clinicians who have such expertise, as well as knowledge of the signature wounds of the wars as related to aggression and reckless behavior is necessary. This article presents an overview of VTCs and discusses the role of forensic clinicians as stakeholders in this process.

Sexuality among wounded veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND): Implications for rehabilitation psychologists

OBJECTIVE

The sexual lives of returning Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans have only been discussed minimally in the psychological literature. Given the nature of military social and cultural contexts, the potential for exposure to combat-related stressors that may lead to posttraumatic stress disorder (PTSD), and the risk of traumatic brain injury secondary to physical injury, the potential for significant psychological and relational ramifications exists. This article focuses on the intimate relationships and sexuality of returning OIF/OEF/OND veterans within the context of their personal cultural variables and the diverse experience of being a part of military life.

CONCLUSIONS

Culturally competent assessment and evidenced-based treatment approaches are highlighted to offer clinicians initial strategies to begin treatment of sexuality issues within the returning Veteran population. These clinical tools are discussed within a positive psychology approach that emphasizes healthy sexuality as a part of overall satisfactory quality of life.

Posttraumatic growth in combat veterans

Combat veterans and their families face significant challenges not only to their abilities to cope, but often to their fundamental belief systems. Traumatic events represent assaults on core beliefs, yet at times, produce cognitive processing that can ultimately result in personal transformations called posttraumatic growth (PTG). Clinicians can utilize a systematic therapeutic approach to facilitate PTG as they carry out a relationship of expert companionship. PTG in service members is described in this article, as well as the approach to facilitation of PTG.

Posttraumatic growth in combat veterans

Combat veterans and their families face significant challenges not only to their abilities to cope, but often to their fundamental belief systems. Traumatic events represent assaults on core beliefs, yet at times, produce cognitive processing that can ultimately result in personal transformations called posttraumatic growth (PTG). Clinicians can utilize a systematic therapeutic approach to facilitate PTG as they carry out a relationship of expert companionship. PTG in service members is described in this article, as well as the approach to facilitation of PTG.

VA integrated post-combat care: a systemic approach to caring for returning combat veterans

The Department of Veterans Affairs (VA's) mission is to care for those who have borne the battle. As medical technology has advanced, more and more of our returning combat Veterans survive what would have been fatal wounds in previous conflicts ( Gawande, 2004 ). But survival is only the immediate goal-our job is to restore Veterans to the greatest level of health, independence, and quality of life that is medically possible. The VA is achieving this goal through close collaboration with the Department of Defense (DoD) to facilitate a smooth transition and continuum of care that ensures Veterans and Service Members receive the care they deserve. This article describes VA's system of Veteran-centered, post-combat care programs that rely on significant involvement of social workers to support Service Members, Veterans and their families through recovery, rehabilitation, and re-integration into their home communities.

Cardiac coherence and posttraumatic stress disorder in combat veterans

BACKGROUND

The need for treatment of posttraumatic stress disorder (PTSD) among combat veterans returning from Afghanistan and Iraq is a growing concern. PTSD has been associated with reduced cardiac coherence (an indicator of heart rate variability [HRV]) and deficits in early stage information processing (attention and immediate memory) in different studies. However, the co-occurrence of reduced coherence and cognition in combat veterans with PTSD has not been studied before.

PRIMARY STUDY OBJECTIVE

A pilot study was undertaken to assess the covariance of coherence and information processing in combat veterans. An additional study goal was assessment of effects of HRV biofeedback (HRVB) on coherence and information processing in these veterans.

METHODS/DESIGN

A two-group (combat veterans with and without PTSD), pre-post study of coherence and information processing was employed with baseline psychometric covariates.

SETTING

The study was conducted at a VA Medical Center outpatient mental health clinic.

PARTICIPANTS

Five combat veterans from Iraq or Afghanistan with PTSD and five active-duty soldiers with comparable combat exposure who were without PTSD.

INTERVENTION

Participants met with an HRVB professional once weekly for 4 weeks and received visual feedback in HRV patterns while receiving training in resonance frequency breathing and positive emotion induction.

PRIMARY OUTCOME MEASURES

Cardiac coherence, word list learning, commissions (false alarms) in go-no go reaction time, digits backward.

RESULTS

Cardiac coherence was achieved in all participants, and the increase in coherence ratio was significant post-HRVB training. Significant improvements in the information processing indicators were achieved. Degree of increase in coherence was the likely mediator of cognitive improvement.

CONCLUSION

Cardiac coherence is an index of strength of control of parasympathetic cardiac deceleration in an individual that has cardinal importance for the individual's attention and affect regulation.

Combat exposure, posttraumatic stress symptoms and risk-taking behavior in veterans of the Second Lebanon War

Prior research has revealed heightened risk-taking behavior among veterans with posttraumatic stress disorder (PTSD). This study examined whether the risktaking behavior is a direct outcome of the traumatic exposure or whether this relationship is mediated by posttraumatic stress symptoms. The sample was comprised of 180 traumatized Israeli reserve soldiers, who sought treatment in the wake of the Second Lebanon War. Combat exposure was indirectly associated with risk-taking behavior primarily through its relationship with posttraumatic stress symptoms. Results of the multivariate analyses depict the implication of posttraumatic stress symptoms in risk taking behavior, and the role of self-medication and of aggression in traumatized veterans.

A VA medical center's PTSD residential recovery program

With the influx of military veterans with Post Traumatic Stress Disorder (PTSD) increasingly affecting all healthcare facilities, including acute care and long term, learning from the experience of VA hospitals in treating those with PTSD may prove valuable. In this article, Tripler/VA Provost Marshal Donald E. Delaney describes a program that has been in operation since 1994. He may be contacted for further in formation at (808) 433-4465 or Donald.devaney@amedd.army .mil

British prisoners-of-war: from resilience to psychological vulnerability: reality or perception

In contemporary culture, soldiers held as prisoners-of-war (POWs) or as hostages are considered at significant risk of mental illness, in particular post-traumatic stress disorder (PTSD). This assumption contrasts with the psychiatric orthodoxy of the First World War when it was concluded in both Britain and Germany that POWs were protected against 'war neurosis'. Although 'barbed wire disease' was identified during time of captivity, post-release effects were not recognized. The repatriation of 'protected' POWs in 1943 prompted a reassessment of the psychological impact of imprisonment when servicemen of previous good character began to behave aberrantly. Rehabilitation programmes were designed to enable soldiers to re-adapt to service or civilian roles. Difficulties of adjustment were cast in social and cognitive terms, and corrective measures were occupational and educational. Psychiatric disorders found in POWs were explained in terms of a pre-conflict predisposition to, or a history of, mental illness. However, retrospective studies of veteran POWs have found a high prevalence of PTSD. A change in attitudes is explored in relation to the advance of medical terminology into the territory of emotions and the attribution of pathological processes to self-recovering mental states. The reclassification of the effects of imprisonment implies that diagnoses in military psychiatry are culturally determined and can be understood only if they are placed in a context that includes changing beliefs about mental illness, the formal development of the psychiatric profession and the immediate needs of the armed forces.

Trauma-related nightmares among American Indian veterans: views from the dream catcher

Dreams hold particular relevance in mental health work with American Indians (AIs). Nightmares are a common sequelae of trauma and a frequent defining feature of post-traumatic stress disorder (PTSD). Despite mounting evidence of the prevalence of trauma and PTSD among AIs and the important cultural role of dreams, no work to date has directly examined nightmares in trauma. Drawing from epidemiological and clinical sources, data are presented about nightmares among Northern Plains AI veterans. Nightmares are common among these veterans: 97% of combat veterans with PTSD report nightmares. These rates are higher than rates among other veteran populations. The frequency of nightmares and sleep disturbances increases with trauma and PTSD severity in this population. Qualitative materials, in the form of a brief cultural overview and a case presentation, are included to illustrate clinical and cultural contexts of nightmares in the Northern Plains. Clinicians working with this population should be aw are of the high frequency and cultural context of nightmares for AI veterans. In order to improve culturally appropriate care, further research is needed to better understand the frequency, meaning, and context of nightmares in trauma and PTSD for AI populations.

[A new approach to medical rehabilitation of combatants]

The study of endocrine-metabolic and immune status of combatants with different forms of chronic diseases but free of combat wounds gave grounds for working up a new approach to correction of poststress disorders. The above correction includes staged rehabilitation with a corrective basic complex at the first stage.

Military TBI during the Iraq and Afghanistan wars

Traumatic brain injury (TBI) is an important source of morbidity in the Iraq and Afghanistan wars. Although penetrating brain injuries are more readily identified, closed brain injuries occur more commonly. Explosion or blast injury is the most common cause of war injuries. The contribution of the primary blast wave (primary blast injury) in brain injury is an area of active research. Lessons learned from the sports concussion and civilian mild TBI literature are useful. Individuals with TBI and posttraumatic stress disorder require treatment of both conditions. Families and communities need to be cognizant of the needs of these returning veterans.

Health problems of substance-dependent veterans with and those without trauma history

Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) are associated with an increased risk for health problems. We examined whether trauma history and PTSD were related to physical health in patients with an SUD. We compared health stressors, health service utilization, and self-rated health status in three groups of male veterans receiving SUD treatment: (1) no trauma exposure (SUD-only group), n = 55; (2) with PTSD (SUD-PTSD group), n = 32; and (3) trauma exposure without PTSD (SUD-trauma group), n = 34. The veterans were assessed quarterly for 1 year. Groups differed in their likelihood of experiencing chronic health stressors at all time points. The SUD-only group consistently had the lowest rates of chronic health stressors, the SUD-PTSD group had the highest rates, and the SUD-trauma group fell in between. In contrast, groups did not differ in rates of acute health problems. Chronic health stressors appear to be associated with trauma exposure and psychologic response to the trauma. Substance use disorder interventions may benefit from incorporation of primary care services.

The war-related illness and injury study centers: a resource for deployment-related health concerns

Combat veterans often return from deployment having experienced a wide range of exposures, symptoms, and medical conditions. The Department of Veterans Affairs established war-related illness and injury study centers to serve combat veterans with unexplained illnesses. We report the exposures, clinical status, and utilization of 53 combat veterans who participated in the National Referral Program (NRP) from January 2002 until March 2004. Participants were primarily male (81%) and served in the Persian Gulf War (79%). Common diagnoses were chronic fatigue syndrome (n = 23, 43%), neurotic depression (n = 21, 40%), and post-traumatic stress disorder (n = 20, 38%). Self-reported exposures related to weaponry, disease prophylaxis, environmental hazards, stress, and poor hygiene. A small increase in mean SF-36V mental component scores (2.8 points, p = 0.009) and use of rehabilitation therapies (1.6 additional visits, p = 0.018) followed the NRP referral. The small gain in mental function suggests that the NRP may benefit combat veterans with long and complex medical histories.

Opioid substitution treatment reduces substance use equivalently in patients with and without posttraumatic stress disorder

OBJECTIVE

The purpose of this study was to determine whether opioid-dependent patients with diagnosed posttraumatic stress disorder (PTSD) have poorer long-term outcomes in opioid substitution treatment than do patients without PTSD.

METHOD

This prospective observational study examined outcomes of 255 opioid-dependent patients (men = 248) entering opioid substitution treatment at eight clinics in the Veterans Health Administration (VHA). Subjects were interviewed at treatment entry, 6 months, and 1 year about substance use and related problems, health status, treatment satisfaction, and non-VHA health care utilization. Medical records were reviewed to obtain toxicology results, health care utilization data, and diagnoses. Medical record review identified a diagnosis of PTSD in 71 (28%) patients. Substance-use and mental-health outcomes and health care utilization in the first year following treatment entry were compared between patients with and without a diagnosis of PTSD.

RESULTS

Patients with and without PTSD had similar treatment responses. Although patients with PTSD had longer histories of drug use at intake, at 1-year follow-up they showed reductions in heroin, cocaine, and alcohol use, comparable to patients without the disorder. PTSD patients received higher doses of opiate medication, attended more psychosocial treatment sessions for substance-use disorder, and had better treatment retention. Psychiatric symptoms for patients with PTSD were more severe at intake and showed little improvement throughout treatment.

CONCLUSIONS

Opioid substitution therapy is as effective at reducing substance use in PTSD patients as it is in patients without the disorder, but additional services are needed for treatment of psychological problems that are largely unchanged by treatment for addiction.

Employment outcomes and PTSD symptom severity

A diagnosis of chronic war-related posttraumatic stress disorder (PTSD) has been linked consistently to poor employment outcomes. This study investigates the relation further, analyzing how symptom severity correlates with work status, occupation type, and earnings. Study participants were male Vietnam veterans with severe or very severe PTSD who received treatment in the Department of Veterans Affairs system (N = 325). Veterans with more severe symptoms were more likely to work part-time or not at all. Among workers, more severe symptoms were weakly associated with having a sales or clerical position. Conditional on employment and occupation category, there was no significant relation between PTSD symptom level and earnings. Alternative PTSD symptom measures produced similar results. Our findings suggest that even modest reductions in PTSD symptoms may lead to employment gains, even if the overall symptom level remains severe.

Predicting high-risk behaviors in veterans with posttraumatic stress disorder

The present study sought to identify posttraumatic stress disorder (PTSD) patients at high risk for negative behavioral outcomes (violence, suicide attempts, and substance use). The Mississippi Scale for Combat-Related PTSD, the Beck Depression Inventory, and demographic and behavioral data from 409 male combat veterans who completed a VA residential rehabilitation program for PTSD were analyzed using signal detection methods (receiver operating characteristics). A validation sample (N = 221) was then used to test interactions identified in the signal detection analyses. The best predictors of behaviors at follow-up were those same behaviors shortly before intake, followed by depressive and PTSD symptoms. However, for each of the models other than that for hard drug use, cutoffs determined at the symptom level did not lend themselves to replication. Recent high-risk behaviors, rather than patients' history, appear to be more predictive of high-risk behaviors postdischarge.

Unresolved grief in combat veterans with PTSD

Clinicians have documented the importance of loss of comrades during combat as a significant source of distress. However, empirical studies have not focused on unresolved grief as a possible outcome of combat experiences. Consequently, unresolved grief has often been treated "after the fact" in the context of treating PTSD and depressive symptoms. In this study, we therefore, sought to demonstrate the prominence of combat-related grief-specific symptoms in a sample of Vietnam veterans being treated for PTSD. Our results indicated that indeed this sample of veterans reported high levels of grief-specific symptoms comparable to that found in bereaved individuals whose spouse had recently died, verifying its prominence as an important component of combat-related stress. Furthermore, grief severity was uniquely associated with losses of comrades during combat whereas no such relationship was shown for trauma or depressive symptoms. The latter finding suggested that in fact higher levels of grief stemmed from interpersonal losses during the war and was not simply an artifact of current general distress level.

Post-War Syndromes: Illustrating the Impact of the Social Psyche on Notions of Risk, Responsibility, Reason, and Remedy

The 20th century offered many examples of post-war syndromes such as Da Costa's syndrome, irritable heart, shell shock, effort syndrome, medical evacuation syndrome, post-traumatic stress disorder, and Gulf War syndrome. These post-war syndromes occur under conditions of substantial medical and scientific uncertainty, conditions that potentially magnify the impact of social context on clinical care for these syndromes. This article reviews the social circumstances surrounding four post-war syndromes. The case is made that social context has significantly impacted professional and lay perceptions of causal mediators, relevant risk factors, defining symptoms, and appropriate therapies for these syndromes. Furthermore, it is argued that social context influences what parties are held responsible for post-war syndromes, and what clinical disciplines are ultimately deemed appropriate to provide legitimate post-war illness care.

Long-term course of treatment-seeking Vietnam veterans with posttraumatic stress disorder: mortality, clinical condition, and life satisfaction

This study is a 6-year longitudinal study of 51 treatment-seeking male veterans with combat-related posttraumatic stress disorder. Measures of PTSD and psychiatric symptomatology, social functioning, and program impact were assessed at admission to an inpatient treatment program, at 18 months, and 6 years later. Previous studies had shown that the treatment program's impact on course of illness had been negligible. The sample showed an extremely high mortality rate of 17% over 6 years. The remaining veterans showed improvement in violence and alcohol and drug use, but an increase in hyperarousal symptoms and social isolation. Nearly three-fourths had had an inpatient hospitalization. Veterans' self-ratings, in contrast, indicated significant improvement in all areas of functioning except employment, as well as an overall positive view of the impact of the program on their lives. Results indicate that the majority of the veteran sample had experienced some improvement in their ability to cope with their chronic illness, decreasing their use of violence and substance abuse but still were experiencing high levels of symptomatology. The extremely high mortality rate, however, provides a somber reminder of the seriousness of this disorder.

[Application of natural and preformed physical factors during medical rehabilitation in participants of military conflicts]

The authors have performed individually adjusted complexes of balneophysiotherapeutic procedures in soldiers and officers who had taken part in local military conflicts. Functional and biochemical investigations show that in those military who had no wounds but had a weak posttraumatic stress reaction the above complexes are rather effective.

The MMPI-2 as a predictor of symptom change following treatment for posttraumatic stress disorder

This study sought to examine the impact of personality factors on symptom change following treatment for 141 Vietnam veterans with chronic combat-related posttraumatic stress disorder (PTSD) using the Minnesota Multiphasic Personality Inventory-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989). A series of partial correlation and linear multivariate regression analyses identified social alienation, associated with anger and substance use, as the most potent negative predictor of symptom change. Of the scales assessing personality disorder, Borderline Personality was identified as the strongest negative predictor of outcome. Regression analyses examining the most salient scales identified 5 items that contributed 14% of the variance in the prediction of change scores independently of the 21% accounted for by pretreatment PTSD severity.

Stages in the implementation of innovative clinical programs in complex organizations

Organizational processes can have an important impact on the introduction of innovative treatments into practice. Conceptual frameworks from organization theory and experiences implementing several hundred specialized mental health programs in the Department of Veterans Affairs (VA) over the past 15 years are used to illustrate stages and processes in the implementation of new treatment models. Four phases in the implementation of new treatments in complex organizational settings are described: a) the decision to implement, b) initial implementation, c) sustained implementation, and d) termination or transformation. Key strategies for moving research into practice include constructing decision-making coalitions, linking new initiatives to legitimate goals and values, quantitative monitoring of implementation and performance, and the development of self-sustaining communities of practice as well as learning organizations. Effective dissemination of new treatment methods requires different organizational strategies at different phases of implementation.

Psychiatric battle casualties: an intra- and interwar comparison

BACKGROUND

Psychiatric casualties are recognised as an important and inevitable feature of modern warfare. At the beginning of the 20th century they were scarcely acknowledged and still less treated. Today, as a result of lessons learned in the First and Second World Wars, numbers can be predicted on the basis of battle intensity and effective clinical interventions applied.

AIMS

To discover more about the factors that cause psychiatric casualties and their relationship to total battle casualties.

METHOD

A survey of historical War Office reports and the papers of Royal Army Medical Corps psychiatrists has provided both statistics and treatment strategies.

RESULTS

Reported psychiatric casualties were low in the Boer War, influenced, in part, by the misdiagnosis of psychosomatic disorders. Their incidence rose appreciably in the First World War with the identification of shell-shock and neurasthenia. The Second World War saw the collection of accurate data, and combat stress was treated efficiently, although few soldiers returned to fighting units.

CONCLUSIONS

A constant relationship exists between the incidence of the total killed and wounded and the number of psychiatric casualties, mediated by the nature of the fighting and quality of the troops involved.

Two-year mental health service use and course of remission in patients with substance use and posttraumatic stress disorders

OBJECTIVE

Comorbid diagnoses of substance abuse/dependence and posttraumatic stress disorder (SUD-PTSD) adversely affect substance abuse patients' treatment outcomes. Recently, several practices have been recommended for the treatment of SUD-PTSD patients based on empirical findings, including providing PTSD-specific care. Accordingly, this study examines the association between outpatient PTSD treatment and the long-term course of SUD-PTSD patients.

METHOD

Male substance abuse/dependence patients (N = 125) with a comorbid diagnosis of PTSD completed 1-and 2-year follow-ups. Based on these reports, 26 patients were stably remitted from substance abuse, 39 were partially remitted and 60 were not remitted at either follow-up. These three groups were compared on mental health service use indices gathered from patients' self-reports of inpatient treatment and nationwide Veterans Affairs (VA) databases abstracting outpatient visits.

RESULTS

SUD-PTSD patients who attended more outpatient substance abuse, psychiatric and PTSD services in the first year following treatment (and cumulatively over the 2-year follow-up) were more likely to maintain a stable course of remission from substance use in the 2 years following inpatient SUD treatment. When the three types of sessions were examined in regression analyses, PTSD sessions in the second year and the total number of PTSD sessions over the 2 years following the index treatment episode emerged as the most significant predictors of remission. Self-help group participation was also associated with a remitted course for SUD-PTSD patients.

CONCLUSIONS

These data suggest that PTSD-focused treatment services are an essential treatment component for substance abuse/dependence patients with PTSD.

[The medico-psychological rehabilitation of participants in combat actions in a general hospital]

There were investigated 453 servicemen--participants of fighting actions in Chechnya [correction of Chechenskaya] Republic in whom the incidence of psychologic stress reactions nearly twice exceeded disorders of other types of psychic dysfunction. 5 groups of combatants were selected and severity of psychic disorders depending on duration of participation in fighting actions was determined. Posttraumatic stress disorders were revealed in 14.5% of servicemen, no signs of psychologic desadaptation were detected in 16.6%, 16.9% had pathologic psychogenic reactions, 18.6% showed pathologic level of psychic disorders, and psychologic stress reactions were noted in 33.4%. The developed individual programs of medico-psychologic rehabilitation depending on type and severity of psychic disorders will allow to reduce the period of restorative treatment and significantly decrease servicemen discharge from the Armed Forces because of psychic disorders.

The collective mind: trauma and shell-shock in twentieth-century Russia

This article deals with the treatment and wider understanding of shell-shock and trauma in modern Russia. At the beginning of the twentieth century, when psychiatrists in many European countries were beginning to think about the issue of shell-shock, Russian psychiatrists took part in the general debate. After the Bolshevik revolution, however, the Russian psychiatric profession became isolated and heavily ideologized, and the treatment of all forms of trauma within the Soviet Union developed along specific lines. At the social level, trauma disappeared as an issue. The idea of a damaged ego was not a central consideration in Soviet psychological thinking. People survived by working, and by reference to the collective, rather than to individual consciousness. Trauma, in its modern form of PTSD, only re-emerged in Soviet psychological discourse as a result of contact between veterans of the Soviet Union's war in Afghanistan and American veterans of Vietnam. Despite the Soviet Union's anguished history, the concept of trauma is still largely ignored by the population as a whole.

Treatment outcome in Australian veterans with combat-related posttraumatic stress disorder: a cause for cautious optimism?

This study investigated treatment outcome in combat-related posttraumatic stress disorder (PTSD). Participants were 419 Australian Vietnam veterans who completed a 12-week hospital-based program. A comprehensive protocol assessed PTSD, comorbidity, and social functioning at admission and at 3 and 9 months posttreatment. Overall, the group showed significant improvements in core PTSD symptoms, anxiety, depression, alcohol abuse, social dysfunction, and anger. Changes occurred mostly between admission and 3 months posttreatment, with gains maintained at 9 months. Ratings by patients and their partners indicated perceived improvement and strong satisfaction with treatment. Nevertheless, treatment gains were variable and, for most veterans, considerable pathology remained following the programs. The current study provides grounds for cautious optimism in the treatment of combat-related PTSD.