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Exercise and Post-Traumatic Stress Disorder in Military Veterans: A Systematic Review
Whitworth, J. W., & Ciccolo, J. T.
Military Medicine, 2016. 181(9), 953-960. doi:10.7205/MILMED-D-15-00488

Post-traumatic stress disorder (PTSD) is a prominent mental health issue for many military veterans. Recent evidence from nonveteran populations with PTSD suggests that exercise may be a potential treatment option. As such, the purpose of this review was to (1) provide the rationale for the use of exercise in the treatment of veterans with PTSD and (2) systematically review studies examining the relationship between exercise and PTSD inmilitary veterans.

A search of electronic databases (PubMed, PsycINFO, and Web of Science) for relevant studies published in print or online from January 1980 to September 2015 produced 204 unique articles and 13 relevant studies (9 observational studies, 2 experimental, and 2 qualitative).

Results of these initial studies are promising and suggest that regular exercise is inversely correlated with PTSD and its symptoms in militaryveterans. However, the longitudinal effect of exercise on PTSD in militaryveterans remains unclear because the current research lacks a common focus and suffers from several methodological limitations. Recommendations for the development of future trials are included.
Prospective associations between changes in mental health symptoms and health-related quality of life in veterans seeking posttraumatic stress disorder residential treatment
Sofko, C. A., Currier, J. M., & Drescher, K. D.
Anxiety, Stress, And Coping, 2016. 29(6), 630-643. doi:10.1080/10615806.2016.1157171

Background and Objectives: This study examined prospective associations between changes in mental health symptoms (posttraumatic stress disorder [PTSD], depression) and health-related quality of life (physical health, psychological well-being) for veterans with PTSD. Read more . . .
Sleep Quality Affects Cognitive Functioning in Returning Combat Veterans Beyond Combat Exposure, PTSD, and Mild TBI History
Martindale, S. L., Morissette, S. B., Rowland, J. A., & Dolan, S. L.
Neuropsychology, 2016. doi:10.1037/neu0000312

Abstract The article reports on the lobby by the American Legion for U.S. Congress removal of marijuana from the list of drugs without potential medical use classification. Topics include the veterans organization's Ohio convention resolution promoting potentials for post-traumatic stress disorder (PTSD)treatment, traumatic brain injury (TBI) as well as a study from the Drug Enforcement Administration. Also mentioned are Iraq war veteransdiagnosed with PTSD, Zika funding and traditional medications.
Patterns of change in response to prolonged exposure: Implications for treatment outcome.
Clapp JD, Kemp JJ, Cox KS, & Tuerk PW.
Depress Anxiety. 2016 Jun 20. PMID: 27321062

Abstract: BACKGROUND: Assessment of response to Prolonged Exposure (PE) suggests some patients may experience discontinuous change involving sudden symptom reductions and/or temporary exacerbations. The current study looked to (1) isolate profiles of PE response among treatment-seeking veterans and (2) identify factors associated with unique patterns of change. Read more . . .
Residual sleep disturbances following PTSD treatment in active duty military personnel.
Pruiksma KE, Taylor DJ, Wachen JS, Mintz J, Young-McCaughan S, Peterson AL, Yarvis JS, Borah EV, Dondanville KA, Litz BT, Hembree EA, & Resick PA; (For the STRONG STAR Consortium).
Psychol Trauma. 2016 May 30. [Epub ahead of print] PMID: 27243567

Abstract: OBJECTIVE: Sleep disturbances, including nightmares and insomnia, are frequently reported symptoms of posttraumatic stress disorder (PTSD). Insomnia is one of the most common symptoms to persist after evidence-based PTSD treatment. The purpose of this study was to examine the prevalence of sleep disturbances in a sample of active duty military personnel before and after receiving therapy for PTSD in a clinical trial and to explore the associations of insomnia and nightmares with PTSD diagnosis after treatment. Read more . . .
Cognitive-behavioral group treatment for veterans diagnosed with PTSD: Design of a hybrid efficacy-effectiveness clinical trial.
Sloan DM, Unger W, & Gayle Beck J.
Contemp Clin Trials. 2016 Mar;47:123-30. PMID: 26718094

Abstract: Despite significant advances in individual treatment approaches for PTSD, knowledge of group approaches has lagged behind. Much of the reason knowledge about group treatment for PTSD has been limited is due to the complexity of conducting randomized controlled trials in the group treatment context. This limited empirical knowledge is unfortunate given the frequency with which group treatmentfor PTSD is used in clinical settings, including the Department of Veteran Affairs.
The goal of this study is to examine the efficacy of a group cognitive-behavioral treatment (GCBT) for PTSD relative to group supportive counseling approach (i.e. group present centered treatment; GPCT).
The sample consists of 196 veterans diagnosed with PTSD who are randomly assigned to either GCBT (n=98) or GPCT (n=98). Both treatments are administered by two therapists over the course of 14 sessions. Assessments take place at baseline, mid-treatment, post-treatment and 3-, 6-, and 12-month follow-up. The primary outcome measure is the PTSD symptom severity assessed with a semi-structured diagnostic instrument.
Given the substantial rise of veterans presenting for PTSD treatment services, identifying an efficacious group treatment approach is invaluable.
Case Reports: STAIR for strengthening social support and relationships among veterans with military sexual trauma and PTSD.
Cloitre M, Jackson C, & Schmidt JA.  
Military Medicine, 2016. 181(2), e183-e187. doi:10.7205/MILMED-D-15-00209

Military sexual trauma (MST) is associated with high rates of post-traumatic stress disorder (PTSD) and multiple comorbid symptoms. In addition, women Veterans with MST report negative perceptions of social support, poor relationships, and difficulties in social and role functioning.

Treatments for PTSD do not provide interventions to improve social or relationship functioning and do not consistently produce positive benefits regarding these outcomes.

This article presents a series of case studies in which an intervention focused on building social support and relationship skills is delivered to Veterans with PTSD and MST. The intervention, Skills Training in Affective and Interpersonal Regulation (STAIR) promotes social engagement and skills that support greater role functioning. It can be used as a stand-alone treatment, as an adjunctive intervention to PTSDtherapies or as part of a combination therapy in which skills precede trauma-focused work (STAIR Narrative Therapy).

Further investigation is suggested to determine the added benefits of incorporating skills building to PTSD or other diagnosis-specific interventions.
Cognitive Behavioral Social Rhythm Group Therapy for Veterans with posttraumatic stress disorder, depression, and sleep disturbance: Results from an open trial. 
Haynes PL, Kelly M, Warner L, Quan SF, Krakow B, & Bootzin RR.
Journal Of Affective Disorders, 2016.192234-243. doi:10.1016/j.jad.2015.12.012

Introduction: Cognitive Behavioral Social Rhythm Therapy (CBSRT) is a group psychotherapy tailored for Veterans with Posttraumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD), and sleep disturbances. The aims of this study were to introduce and present initial outcomes of Cognitive Behavioral Social Rhythm Therapy (CBSRT), a 12-week skills group therapy designed to improve sleep and mood by reducing chaotic or isolated lifestyles in Veterans withPTSD.

Methods: Twenty-four male Veterans with at least moderate PTSD and MDD participated in this open trial. Main outcomes were the daily sleep diary for sleep disturbances, the Clinician-Administered PTSD Scale (CAPS) for PTSD, and the Hamilton Depression Rating scale for MDD.

Results: Veterans improved on all measures (a) with large within subject effects on PTSDsymptoms, MDD symptoms, and sleep quality, and (b) with 46-58% of the sample receiving clinically significant benefits on MDD and PTSD symptoms respectively. The consistency of social rhythms was associated with the average reduction in global CAPS scores over time. Only 13% of participants dropped-out of the group therapy prematurely suggesting that this new group therapy is relatively well-tolerated by Veterans.

Limitations: Future research that employs a control condition is necessary to establish efficacy of CBSRT.

Conclusions: Data from this initial pilot study demonstrate that CBSRT may be an effective grouptreatment option for Veterans presenting with all three symptom complaints. These data also suggest that daily routine may be an important mechanism to consider in the treatment of PTSDsymptoms comorbid with depression.
Course of posttraumatic stress disorder 40 years after the Vietnam War: Findings from the national Vietnam veterans longitudinal study.
Marmar, CR, Schlenger W, Henn-Haase C, Qian M, Purchia E, Li M, & Kulka RA.
JAMA Psychiatry, 2015. 72(9), 875-881. doi:10.1001/jamapsychiatry.2015.0803

Importance The long-term course of readjustment problems in military personnel has not been evaluated in a nationally representative sample. The National Vietnam Veterans Longitudinal Study (NVVLS) is a congressionally mandated assessment of Vietnam veterans who underwent previous assessment in the National Vietnam Veterans Readjustment Study (NVVRS).

Objective To determine the prevalence, course, and comorbidities of war-zone posttraumatic stress disorder (PTSD) across a 25-year interval.

. Design, Setting, and Participants The NVVLS survey consisted of a self-report health questionnaire (n = 1409), a computer-assisted telephone survey health interview (n = 1279), and a telephone clinical interview (n = 400) in a representative national sample of veterans who served in the Vietnam theater of operations (theater veterans) from July 3, 2012, through May 17, 2013. Of 2348 NVVRS participants, 1920 were alive at the outset of the NVVLS, and 81 died during recruitment; 1450 of the remaining 1839 (78.8%) participated in at least 1 NVVLS study phase. Data analysis was performed from May 18, 2013, through January 9, 2015, with further analyses continued through April 13, 2015.

Main Outcomes and Measures  Study instruments included the Mississippi Scale for Combat-Related PTSD, PTSD Checklist for DSM-IV supplemented with PTSD Checklist for DSM-5 items (PCL-5+), Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), and Structured Clinical Interview forDSM-IV, Nonpatient Version.

Results  Among male theater veterans, we estimated a prevalence (95% CI) of 4.5% (1.7%-7.3%) based on CAPS-5 criteria for a current PTSD diagnosis; 10.8% (6.5%-15.1%) based on CAPS-5 full plus subthreshold PTSD; and 11.2% (8.3%-14.2%) based on PCL-5+ criteria for current war-zone PTSD. Among female veterans, estimates were 6.1% (1.8%-10.3%), 8.7% (3.8%-13.6%), and 6.6% (3.5%-9.6%), respectively. The PCL-5+ prevalence (95% CI) of current non–war-zone PTSD was 4.6% (2.6%-6.6%) in male and 5.1% (2.3%-8.0%) in female theater veterans. Comorbid major depression occurred in 36.7% (95% CI, 6.2%-67.2%) of veterans with current war-zone PTSD. With regard to the course of PTSD, 16.0% of theater veterans reported an increase and 7.6% reported a decrease of greater than 20 points in Mississippi Scale for Combat-Related PTSD symptoms. The prevalence (95% CI) of current PCL-5+–derived PTSD in study respondents was 1.2% (0.0%-3.0%) for male and 3.9% (0.0%-8.1%) for female Vietnam veterans.

Conclusions and Relevance  Approximately 271 000 Vietnam theater veterans have current full PTSD plus subthreshold war-zone PTSD, one-third of whom have current major depressive disorder, 40 or more years after the war. These findings underscore the need for mental health services for many decades for veterans with PTSD symptoms.
The use of biomarkers in the military: From theory to practice.
Yehuda R, Neylan T, Flory J, & McFarlane A.
Psychoneuroendocrinology [serial online]. September 2013;38(9):1912-1922. PMID: 23927936, Database: PsycINFO.

This paper provides a summary of relevant issues covered in the conference, "The Use of Biomarkers in the Military: Theory to Practice" held at the New York Academy of Science on September 14, 2012. The conference covered the state of the science in identification of PTSD biomarkers, including, the definition of different classes of biomarkers pertaining to PTSD. The aim of the satellite conference was to bring together researchers who have been supported by the Department of Defense, Veterans Administration, National Institutes of Health, and other agencies around the world, who are interested in the identification of biomarkers for PTSD risk, diagnosis, symptom severity and treatment response, for a discussion of salient issues regarding biomarker development for PTSD, as well as special considerations for theuse of biomarkers in the military.
The long-term impact of combat exposure on health, interpersonal, and economic domains of functioning.
Sheffler J, Rushing N, Stanley I, & Sachs-Ericsson N.
Aging & Mental Health [serial online]. August 4, 2015;:1-11. PMID: 26241200, Database: MEDLINE with Full Text.

Purpose: Wartime combat exposure is linked to a broad array of negative outcomes. The current study identified potential differences between middle-to-older aged men exposed to combat and those not exposed for physical health, interpersonal, and economic functioning over 10 years. Post-traumatic stress disorder (PTSD) and social support were examined as moderators between combat exposure and outcomes.

Methods: Data from the National Comorbidity Survey, baseline and 10-year follow-up, were utilized. Only men aged 50-65 at follow-up (N = 727) were included. Group differences between combat and non-combat men were examined. Regression analyses were performed to examine relationships between earlier combat and health, interpersonal, and economic outcomes over time, while controlling for important covariates.

Results: Combat-exposed men were at increased risk for asthma, arthritis/rheumatism, lung diseases, headaches, and pain; they also had greater marital instability. However, combat-exposed men reported economic advantages, including higher personal earnings at follow-up. For combat-exposed men, PTSD did not increase risk for headaches; however, PTSD in non-combat men was associated with increased risk for headaches at follow-up. Whereas combat-exposed men with higher levels of social support were less likely to report chronic pain at follow-up, there were no group differences in pain at lower levels of social support.

Implications: Individuals who experience combat may be susceptible to later health and marital problems; however, as combat-exposed men age, they demonstrate some resilience, including in economic domains of life. Given that consequences of combat may manifest years after initial exposure, knowledge of combat exposure is necessary to inform treatments and the delivery of disability benefits.
Discrepancies between clinical needs and helpseeking behaviors in co-occurring posttraumatic stress and alcohol use disorders.
Müller M, Rodgers S, Vandeleur C, et al.
Comprehensive Psychiatry [serial online]. October 2015;62:209-217. PMID: 26343486, Database: MEDLINE with Full Text.

Objective: The aim of the study was to compare subjects dually diagnosed with posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) to those with only one or none of these conditions regarding helpseeking needs and behaviors.

Method: Data from a large community sample (N=3694) were used to assess the associations among lifetime PTSD and AUD, other psychiatric disorders, clinical characteristics and lifetime helpseeking behaviors derived from a semi-structured interview.

Results: Comorbid individuals had more severe clinical profiles and were more impaired than individuals with either PTSD or AUD alone or those with no/other psychiatric conditions. However, they did not differ in overall helpseeking behavior from any other group. Those with comorbid PTSD/AUD were even less likely than the other groups to seek help for depression and anxiety disorders through specific treatment facilities or the use of prescribed psychotropic drugs.

Conclusions: Despite a greater need for treatment the comorbid group did not seek more help than the others. Their lower use of prescribed drugs supports the self-medication hypothesis, suggesting that those individuals relieve their symptoms through higher alcohol use instead. Our findings underline the need for health care facilities to encourage helpseeking behavior in the aftermath of stressful life events.
Couple treatment for alcohol use disorder andposttraumatic stress disorder: Pilot results from U.S. military veterans and their partners
Schumm JA, Monson CM, O'Farrell TJ, Gustin NG & Chard KM.
J Trauma Stress, Vol 28(3) 2015 Jun pp. 247-252. PMID: 25965768 [PubMed - in process]

We studied 13 U.S. male military veterans and their female partners who consented to participate in an uncontrolled trial of couple treatment for alcohol use disorder and posttraumatic stress disorder (CTAP). CTAP is a 15‐session, manualized therapy, integrating behavioral couples therapy for alcohol use disorder (AUD) with cognitive–behavioral conjoint therapy for posttraumatic stress disorder (PTSD). Due to ineligibility (n = 1) and attrition (n = 3), 9 couples completed the study, and 7 completed 12 or more sessions.
There were 8 veterans who showed clinically reliable pre‐ to posttreatment reduction of PTSD outcomes. There were also significant group‐level reductions in clinician‐, veteran‐, and partner‐rated PTSD symptoms (d = 0.94 to 1.71). Most veterans showed clinically reliable reductions in percentage days of heavy drinking. Group‐level reduction in veterans’ percentage days of heavy drinking was significant (d = 1.01). There were 4 veterans and 3 partners with clinically reliable reductions in depression, and group‐level change was significant for veterans (d = 0.93) and partners (d = 1.06). On relationship satisfaction, 3 veterans and 4 partners had reliable improvements, and 2 veterans and 1 partner had reliable deterioration. Group‐level findings were nonsignificant for veteran relationship satisfaction (d = 0.26) and for partners (d = 0.52).
These findings indicate that CTAP may be a promising intervention for individuals with comorbid PTSD and AUD who have relationship partners.
Effectiveness of cognitive processing therapy for male and female U.S. veterans with and without military sexual trauma
Voelkel E, Pukay‐Martin ND, Walter KH, Chard KM.
J Trauma Stress, Vol 28(3) Jun 2015 pp. 174-182. PMID: 25976767 [PubMed - in process]

Military sexual trauma (MST) affects approximately 2% and 36% of male and female veterans, respectively, (e.g., Allard, Gregory, Klest, & Platt). Although the deleterious consequences of MST have been clearly established, few studies have explored treatment effectiveness for this population. Using archival data from a residential treatment program, the current study explored the effectiveness of cognitive processing therapy (CPT) in treating full or subthreshold posttraumatic stress disorder (PTSD) to compare U.S. veterans reporting an MST index trauma (MST‐IT) to those without MST‐IT.
Of the 481 participants, 40.7% endorsed MST‐IT. Multiway frequency analyses were utilized to compare men and women with and without MST on baseline demographic variables. Hierarchical linear models were constructed to investigate treatment outcome by MST status and sex.
Results showed that 44.8%, 23.8%, and 19.6% of the variation in clinician‐ and self‐reported PTSD and depression symptoms were explained by three models. Scores on all outcome measures significantly decreased over time for both groups. Additionally, women demonstrated a sharper decrease in PTSD symptoms over time than men. Lastly, men who reported MST‐IT had higher PTSD symptoms than men without MST‐IT on average. With no control group or random assignment, preliminary findings suggest residential treatment including CPT may be effective for MST‐IT regardless of sex.
Do scores on the Beck Depression Inventory-II predict outcome in cognitive processing therapy?
Hemmy Asamsama O, Dickstein BD & Chard KM.
Psychol Trauma. 2015 May 25. Advance online publication. PMID: 26010112 [PubMed - as supplied by publisher]

Current treatment guidelines for posttraumatic stress disorder (PTSD) recognize that severe depression may limit the effectiveness of trauma-focused interventions, making it necessary to address depression symptomatology first. However, there is a paucity of research providing specific treatment recommendations using a common depression measure like the BeckDepression Inventory-II (BDI-II).
Accordingly, we examined the utility of using BDI-II cutoff scores for predicting response to cognitive processing therapy (CPT). Our sample was 757 military veterans receiving outpatient therapy at a Department of Veterans Affairs specialty clinic. At baseline, the majority of participants (58.9%) reported BDI-II scores suggestive of severe depression, and 459 (60.7%) met DSM–IV diagnostic criteria for major depressive disorder (MDD).
Despite this high level of depression severity, most participants who completed therapy experienced a clinically significant reduction in symptoms (75.1%). No differences were observed across BDI-II groups on rates of clinically significant change in PTSD symptoms or on rates of treatment completion. Taken together, results suggest that CPT is an effective treatment, even in cases of severe co-occurring depression. Limitations and implications for treatment guidelines are discussed.
A randomized clinical trial of group cognitive processing therapy compared with group present-centered therapy for PTSD among active duty military Personnel
Resick P, Wachen JS, Mintz J, Young-McCaughan S, Roache JD, Borah AM, Borah EV, Dondanville KA, Hembree EA, Litz BT, Peterson AL.
J Consult Clin Psychol. 2015 May 4; PMID: 25939018 [PubMed - as supplied by publisher]

Objective: To determine whether group therapy improves symptoms of posttraumatic stress disorder (PTSD), this randomized clinical trial compared efficacy of group cognitive processing therapy (cognitive only version; CPT-C) with group present-centered therapy (PCT) for active duty military personnel.
Method: Patients attended 90-min groups twice weekly for 6 weeks at Fort Hood, Texas. Independent assessments were administered at baseline, weekly before sessions, and 2 weeks, 6 months, and 12 months post treatment. A total of 108 service members (100 men, 8 women) were randomized. Inclusion criteria included PTSD following military deployment and medication stability.
Exclusion criteria included suicidal/homicidal intent or other severe mental disorders requiring immediate treatment. Follow-up assessments were administered regardless of treatment completion.
Primary outcome measures were the PTSD Checklist (Stressor Specific Version; PCL-S) and Beck Depression Inventory-II. The Posttraumatic Stress Symptom Interview (PSS-1) was a secondary measure.
Results: Both treatments resulted in large reductions in PTSD severity, but improvement was greater in CPT-C. CPT-C also reduced depression, with gains remaining during follow-up. In PCT, depression only improved between baseline and before Session 1. There were few adverse events associated with either treatment.
Conclusions: Both CPT-C and PCT were tolerated well and reduced PTSD symptoms in group format, but only CPT-C improved depression. This study has public policy implications because of the number of active military needing PTSD treatment, and demonstrates that group format of treatment of PTSD results in significant improvement and is well tolerated. Group therapy may an important format in settings in which therapists are limited.
PTSD symptoms and pain in Canadian military veterans: The mediating roles of anxiety, depression, and alcohol use. 
Irwin, K. C., Konnert, C., Wong, M., & O'Neill, T. A. (2014).
Journal Of Traumatic Stress, 27(2), 175-181. doi:10.1002/jts.21897

Symptoms of posttraumatic stress disorder (PTSD) and pain are often comorbid among veterans. The purpose of this study was to investigate to what extent symptoms of anxiety, depression, and alcohol use mediated the relationship between PTSDsymptoms and pain among 113 treated male Canadian veterans.

Measures of PTSD, pain, anxiety symptoms, depression symptoms, and alcohol use were collected as part of the initial assessment. The bootstrapped resampling analyses were consistent with the hypothesis of mediation for anxiety and depression, but not alcohol use. The confidence intervals did not include zero and the indirect effect of PTSD on pain through anxiety was .04, CI [.03, .07]. The indirect effect of PTSD on pain through depression was .04, CI [.02, .07].

These findings suggest that PTSD and pain symptoms among veterans may be related through the underlying symptoms of anxiety and depression, thus emphasizing the importance of targeting anxiety and depression symptoms when treating comorbid PTSD and pain patients. 
Somatic symptoms and health-related quality of life among treatment-seeking Canadian Forces personnel with PTSD.
St. Cyr, K., McIntyre-Smith, A., Contractor, A. A., Elhai, J. D., & Richardson, J. D.
Psychiatry Research,218(1-2), 148-152. doi:10.1016/j.psychres.2014.03.038

This study examined the association between somatic complaints and health-related quality of life (HR-QoL) in treatment-seeking Canadian military personnel with military-related Posttraumatic Stress Disorder (PTSD).

Current and formerCanadian Forces (CF) members attending the Parkwood Hospital Operational Stress Injury Clinic in London, Ontario (N = 291) were administered self-report questionnaires assessing number and severity of somatic complaints, PTSD and depressive symptom severity, and mental and physical health-related quality of life (HR-QoL) prior to commencing treatment. Regression analyses were used to identify the role of somatic complaints on physical and mental HR-QoL, after controlling for PTSD symptom cluster and depressive symptom severity.

Somatic symptom severity accounted for only a small amount of the variance in mental HR-QoL after accounting for PTSD symptom cluster and depressive symptom severity, but accounted for a larger proportion of the variance in physical HR-QoL after accounting for PTSD cluster and depressive symptom severity.

Understanding the role of somatization in the symptom-presentation of military personnel with PTSD may provide additional avenues for treatment with this population. 
The efficacy of nabilone, a synthetic cannabinoid, in the treatment of PTSD-associated nightmares: A preliminary randomized, double-blind, placebo-controlled cross-over design study.
Jetly, R., Heber, A., Fraser, G., & Boisvert, D.  
Psychoneuroendocrinology, 51585-588. doi:10.1016/j.psyneuen.2014.11.002

Objective: Investigate the efficacy of nabilone capsules (NAB) in reducing the frequency and intensity of nightmares in subjects with PTSD.

Patients and methods: Canadian male military personnel with PTSD, who despite standard treatment continued to experience trauma-related nightmares, received double-blind treatment with 0.5mg NAB or placebo (PBO), and then titrated to the effective dose (nightmare suppression) or reaching a maximum of 3.0mg. Subjects were followed for 7 weeks and then, following a 2-week washout period, were titrated with the other study treatment and followed for an additional 7 weeks. The modified intent-to-treat (mITT) population, which included all treated subjects that met inclusion/exclusion criteria, was analyzed.

Results: Ten subjects were included in the mITT population. The mean reduction in nightmares as measured by the CAPS Recurring and Distressing Dream scores were −3.6 ± 2.4 and −1.0 ± 2.1 in the NAB and PBO groups, respectively (p =0.03). Mean global improvement as measured by the Clinical Global Impression of Change (CGI-C) was 1.9 ± 1.1 (i.e. much improved) and 3.2 ± 1.2 (i.e. minimally improved) in the NAB and PBO groups, respectively (p =0.05) Five out of 10 (50%) were much improved on NAB versus 1 out of 9 (11%) on PBO. Results for the General Well Being Questionnaire (WBQ) were 20.8 ± 22 and −0.4 ± 20.6 in the NAB and PBO groups, respectively (p = 0.04). The proportion of subjects who experienced a treatment-related occurrence of adverse events was 50% in the NBO group and 60% in the PBO group. No event was severe nor resulted in a drop-out. This study is registered with Health Canada.

Conclusion: In this small sample NAB provided significant relief for military personnel with PTSD, indicating that it shows promise as a clinically-relevant treatment for patients with nightmares and a history of non-response to traditional therapies. These findings need to be replicated in a larger cohort. There is a need for further exploration of the effect of nabilone on other symptoms of PTSD such as re-experiencing, hyper vigilance and insomnia.
Prevalence of mental health symptoms in Dutch military personnel returning from deployment to Afghanistan: A 2-year longitudinal analysis.
Reijnen, A., Rademaker, A. R., Vermetten, E., & Geuze, E.
European Psychiatry: The Journal Of The Association Of European Psychiatrists, 30(2), 341-346. doi:10.1016/j.eurpsy.2014.05.003

Objective: Recent studies in troops deployed to Iraq and Afghanistan have shown that combat exposure and exposure to deployment-related stressors increase the risk for the development of mental health symptoms. The aim of this study is to assess the prevalence of mental health symptoms in a cohort of Dutch military personnel prior to and at multiple time-points after deployment.

Methods: Military personnel (n=994) completed various questionnaires at 5 time-points; starting prior to deployment and following the same cohort at 1 and 6months and 1 and 2years after their return from Afghanistan.

Results: The prevalence of symptoms of fatigue, PTSD, hostility, depression and anxiety was found to significantly increase after deployment compared with pre-deployment rates. As opposed to depressive symptoms and fatigue, the prevalence ofPTSD was found to decrease after the 6-month assessment. The prevalence of sleeping problems and hostility remained relatively stable.

Conclusions: The prevalence of mental health symptoms in military personnel increases after deployment, however, symptoms progression over time appears to be specific for various mental health symptoms. Comprehensive screening and monitoring for a wide range of mental health symptoms at multiple time-points after deployment is essential for early detection and to provide opportunities for intervention.
Elevated risk for autoimmune disorders in Iraq and Afghanistan veterans with posttraumatic stress disorder.
O'Donovan, A., Cohen, B. E., Seal, K. H., Bertenthal, D., Margaretten, M., Nishimi, K., & Neylan, T. C. (2015).
Biological Psychiatry, 77(4), 365-374. doi:10.1016/j.biopsych.2014.06.015

Background: Posttraumatic stress disorder (PTSD) is associated with endocrine and immune abnormalities that could increase risk for autoimmune disorders. However, little is known about the risk for autoimmune disorders among individuals with PTSD.

Methods: We conducted a retrospective cohort study of 666,269 Iraq and Afghanistan veterans under age 55 who were enrolled in the Department of Veterans Affairs health care system between October 7, 2001, and March 31, 2011. Generalized linear models were used to examine if PTSD, other psychiatric disorders, and military sexual trauma exposure increased risk for autoimmune disorders, including thyroiditis, inflammatory bowel disease, rheumatoid arthritis, multiple sclerosis, and lupus erythematosus, adjusting for age, gender, race, and primary care visits.

Results: PTSD was diagnosed in 203,766 veterans (30.6%), and psychiatric disorders other than PTSD were diagnosed in an additional 129,704 veterans (19.5%). Veterans diagnosed with PTSD had significantly higher adjusted relative risk (ARR) for diagnosis with any of the autoimmune disorders alone or in combination compared with veterans with no psychiatric diagnoses (ARR = 2.00; 95% confidence interval, 1.91-2.09) and compared with veterans diagnosed with psychiatric disorders other than PTSD (ARR = 1.51; 95% confidence interval, 1.43-1.59; p < .001). The magnitude of the PTSD-related increase in risk for autoimmune disorders was similar in women and men, and military sexual trauma exposure was independently associated with increased risk in both women and men.

Conclusions: Trauma exposure and PTSD may increase risk for autoimmune disorders. Altered immune function, lifestyle factors, or shared etiology may underlie this association.
Being a female veteran: A grounded theory of Coping With Transitions.
Burkhart, L., & Hogan, N. (2015).  
Social Work In Mental Health, 13(2), 108-127. doi:10.1080/15332985.2013.870102

Female veterans, the fastest growing segment in the military, have unique pre-military histories and military experiences that are associated with post-military physical and mental health service needs. Successful treatment is contingent on a clearer understanding of the processes underlying these experiences.

Data from 20 female veterans who served post–Gulf War were analyzed to generate a substantive theory of the process of women who entered, served in, and transitioned out of the military. Coping with transitions emerged as the basic psychosocial process used by female veterans. The Coping with Transitions process is comprised of seven categories:Choosing the Military, Adapting to the Military, Being in the Military, Being a Female in the Military, Departing the Military, Experiencing Stressors of Being a Civilian,and Making Meaning of Being a Veteran-Civilian.

The results of this study provide a theoretical description of the process female veterans experience when transitioning from a civilian identity, through military life stressors and adaptations, toward gaining a dual identity of being a veteran-civilian. 
Mental health of UK Armed Forces medical personnel post-deployment. 
Cawkill, P., Jones, M., Fear, N. T., Jones, N., Fertout, M., Wessely, S., & Greenberg, N. (2015).
Occupational Medicine (Oxford, England), 65(2), 157-164.

Abstract: Background: The mental health effects of deployment vary widely, and personnel in both combat and combat support roles, including medical personnel, may be adversely affected.

Aims: To compare the mental health of deployed UK military medical staff in both forward and rear locations and to compare these two groups with other deployed military personnel.

Methods: Participants were medics who had deployed to Iraq or Afghanistan and provided information about their deployed role, experiences during and on return from deployment and demographic and military factors. Health outcomes included common mental health problems (using 12-item General Health Questionnaire), post-traumatic stress disorder (PTSD, using 17-item Post-Traumatic Stress Disorder Checklist-Civilian Version), multiple physical symptoms and alcohol use (using 10-item Alcohol Use Disorders Identification Test).

Results: The sample comprised 321 medical personnel. The response rate was 56%. The mental health outcomes for forward located medics (FMs) were no different than those for rear located medics (RLMs). When comparing FMs and RLMs against all other military roles, a small but significant increase in PTSD symptoms in FMs was found. FMs were more likely to rate their work while deployed as being above their skills and experience, report exposure to more combat experiences and report a more challenging homecoming experience than RLMs.

Conclusions: These results suggest that while the overall rates of self-reported mental health disorders were similar in FMs and RLMs, FMs reported more PTSD symptoms than all other roles, which may have been related to working in more hostile environments in more challenging roles while deployed and their experiences on returning home.
Prazosin for military combat-related PTSD nightmares: A critical review.
Writer BW, Meyer EG, Schillerstrom JE.
The Journal of Neuropsychiatry and Clinical Neurosciences, Vol 26(1), Win 2014. pp.24-33. Publisher: American Psychiatric Assn [Journal Article]

Abstract: Military combat is a common trauma experience associated with posttraumatic stress disorder (PTSD). Trauma-related nightmares are a hallmark symptom of PTSD. They can be resistant to label-pharmacological PTSD treatment, and they are associated with a variety of adverse health outcomes. The purpose of this article is to review and evaluate prazosin therapy for combat-related PTSD nightmares. Consistent with available literature for all-causes PTSD nightmares, prazosin is an effective off-label option for combat-related PTSD nightmares. Future trials may further instruct use in specific combat-exposure profiles.
Post-traumatic growth among veterans in the USA: Results from the National Health and Resilience in Veterans Study.
Tsai J, El-Gabalawy R, Sledge WH, Southwick SM, Pietrzak RH.
Psychological Medicine, Vol 45(1), Jan, 2015. pp.165-179. Publisher: Cambridge University Press [Journal Article]

Abstract: Background: There is increasing recognition that, in addition to negative psychological consequences of trauma such as post-traumatic stress disorder (PTSD), some individuals may develop post-traumatic growth (PTG) following such experiences. To date, however, data regarding the prevalence, correlates and functional significance of PTG in population-based samples are lacking. Read more . . .
Sleep problems may mediate associations between rumination and PTSD and depressive symptoms among OIF/OEF veterans.
Borders A, Rothman DJ, McAndrew LM.
Psychological Trauma: Theory, Research, Practice, and Policy, Vol 7(1), Jan, 2015. pp.76-84. Publisher: Educational Publishing Foundation [Journal Article]

Abstract: Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans have high rates of posttraumatic stress disorder (PTSD), depression, and sleep problems. Identifying potential contributing factors to these mental health problems is crucial for improving treatments in this population. Rumination, or repeated thoughts about negative experiences, is associated with worse PTSD, depression, and sleep problems in nonveterans. Therefore, we hypothesized that rumination would be associated with worse sleep problems, PTSD, and depressive symptoms in OIF/OEF veterans. Additionally, we proposed a novel hypothesis that sleep problems are a mechanism by which rumination contributes to depressive and PTSD symptoms.
In this cross-sectional study, 89 OIF/OEF veterans completed measures of trait rumination, sleep problems, and PTSD and depressive symptoms. Analyses confirmed that greater rumination was associated with worse functioning on all mental health measures. Moreover, greater global sleep problems statistically mediated the association between higher rumination and more PTSD and depressive symptoms. Specifically, sleep disturbance and daytime somnolence but not sleep quantity emerged as significant mediators.
Although it is impossible with the current nonexperimental data to test causal mediation, these results support the idea that rumination could contribute to impaired sleep, which in turn could contribute to psychological symptoms. We suggest that interventions targeting both rumination and sleep problems may be an effective way to treat OIF/OEF veterans with PTSD or depressive symptoms.
Association of Parental Status and Diagnosis of Posttraumatic Stress Disorder Among Veterans of Operations Iraqi and Enduring Freedom.
Janke-Stedronsky SR, Greenawalt DS, Stock EM, Tsan JY, MacCarthy AA, MacCarthy DJ, Copeland LA.
Psychological Trauma: Theory, Research, Practice, and Policy. Publisher: Educational Publishing Foundation

Abstract: Research indicates that concerns about disruption of family relationships during military service may be associated with greater posttraumatic stress symptomatology. The current study sought to extend previous findings by examining the relative odds of a posttraumatic stress disorder (PTSD) diagnosis among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans with dependent children versus veterans without dependent children. Administrative databases were queried to identify 36,334 OEF/OIF veterans with dependent children seeking care in the Veterans Health Administration (VA) during fiscal years 2006–2009. These veterans were matched 1:1 on age, gender, and demobilization date to veterans without dependent children (N = 72,668). In unconditional analyses, OEF/OIF veterans with dependent children versus those without were significantly more likely to incur a PTSD diagnosis (44% vs. 28%).
After controlling for demographic variables, mental health utilization, and other serious mental illness, OEF/OIF veterans with dependent children were about 40% more likely to carry a diagnosis of PTSD. The association was stronger for men than for women. It may be of value for clinicians to consider parental status when assessing and treating veterans with PTSD. In-depth study of OEF/OIF veterans is needed to determine whether disruption of family relationships leads to increased psychological stress or parents are more likely than nonparents to seek VA mental health services for PTSD symptoms.
Elucidating the transdiagnostic dimensional structure of trauma-related psychopathology: Findings from VA cooperative study 504—Risperidone treatment for military service related chronic post traumatic stress disorder.
Pietrzak RH, Rosenheck RA, Cramer J A, Vessichio J C, Tsai, J, Southwick SM, Krystal JH. VA CSP 504 Collaborative Group
Journal of Affective Disorders, Vol 172, Feb 1, 2015. pp.331-336. Publisher: Elsevier Science [Journal Article]

Abstract: Background: Three of the most common trauma-related mental disorders—posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD)—are highly comorbid and share common transdiagnostic symptom dimensions of threat (i.e., fear) and loss (i.e., dysphoria) symptomatology. However, empirical evaluation of the dimensional structure of component aspects of these disorders is lacking. Read more . . .
My fellow soldiers . . . reject suicide
Robert Semrau, a former Officer with the Canadian Forces, wrote an open letter to all the men and women of the Canadian Forces and coalition allies. The letter is made available by the CBC radio ("the current" with Anna Maria Tremonti):
Gender differences in the effects of deployment-related stressors and pre-deployment risk factors on the development of PTSD symptoms in National Guard Soldiers deployed to Iraq and Afghanistan.
Polusny MA, Kumpula MJ, Meis LA, Erbes CR, Arbisi PA, Murdoch M, Thuras P, Kehle-Forbes SM, & Johnson AK.
J Psychiatr Res. 2013 Oct 5

OBJECTIVE: Although women in the military are exposed to combat and its aftermath, little is known about whether combat as well as pre-deployment risk/protective factors differentially predict post-deployment PTSD symptoms among women compared to men. The current study assesses the influence of combat-related stressors and pre-deployment risk/protective factors on women's risk of developing PTSD symptoms following deployment relative to men's risk. Read more . . .
Longitudinal relationships of insomnia, nightmares, and PTSD severity in recent combat veterans.
Pigeon WR, Campbell CE, Possemato K, & Ouimette P.
J Psychosom Res. 2013 Dec;75(6):546-50 PMID: 24290044 [PubMed - in process]

OBJECTIVE: This observational, longitudinal study of veterans with recent combat exposure describes the prevalence, severity and associations of posttraumatic stress disorder (PTSD), insomnia, and nightmares over time. Read more . . .
Posttraumatic stress disorder and cardiometabolic disease.
Levine AB, Levine LM, & Levine TB.
Cardiology. 2013 Oct 24;127(1):1-19 PMID: 24157651 [PubMed - as supplied by publisher]

The need for addressing posttraumatic stress disorder (PTSD) among combat veterans returning from Afghanistan and Iraq is a growing public health concern. Current PTSD management addresses psychiatric parameters of this condition. However, PTSD is not simply a psychiatric disorder. Traumatic stress increases the risk for inflammation-related somatic diseases and early mortality.

The metabolic syndrome reflects the increased health risk associated with combat stress and PTSD. Obesity, dyslipidemia, hypertension, diabetes mellitus, and cardiovascular disease are prevalent among PTSD patients. However, there has been little appreciation for the need to address these somatic PTSD comorbidities.

Medical professionals treating this vulnerable population should screen patients for cardiometabolic risk factors and avail themselves of existing preventive diet, exercise, and pharmacologic modalities that will reduce such risk factors and improve overall long-term health outcomes and quality of life. There is the promise that cardiometabolic preventive therapy complementing psychiatric intervention may, in turn, help improve the posttraumatic stress system dysregulation and favorably impact psychiatric and neurologic function.
Posttraumatic stress disorder and risk for coronary heart disease- A meta-analytic review.
Edmondson D, Kronish IM, Shaffer JA, Falzon L, & Burg MM.
Am Heart J. 2013 Nov;166(5):806-14 PMID: 24176435 [PubMed - in process]

OBJECTIVE: The aim of this study was to estimate the association of posttraumatic stress disorder (PTSD) with risk for incident coronary heart disease (CHD).

DESIGN: A systematic review and meta-analysis were used as study designs. Read more . . .
Lifetime major depression and comorbid disorders among current-era women veterans.
Curry JF, Aubuchon-Endsley N, Brancu M, Runnals JJ, Va Mid-Atlantic Mirecc Women Veterans Research Workgroup, Va Mid-Atlantic Mirecc Registry Workgroup, & Fairbank JA.
J Affect Disord. 2013 Oct 16; PMID: 24210623 [PubMed - as supplied by publisher]

BACKGROUND: Most research on women veterans' mental health has focused on postraumatic stress disorder (PTSD) or reactions to military sexual trauma. Although depression is also a frequent diagnosis among women veterans, little is known about its characteristics, including comorbid conditions and patterns of disorder onset. We investigated lifetime diagnoses of major depressive disorder (MDD) and comorbid conditions in a primarily treatment-seeking research sample of male and female veterans to determine frequency of lifetime MDD, comorbid disorders and their temporal onset. Read more . . .
Substance use disorders and PTSD- An exploratory study of treatment preferences among military veterans.
Back SE, Killeen TK, Teer AP, Hartwell EE, Federline A, Beylotte F, & Cox E.
Addict Behav. 2013 Oct 5; PMID: 24199930 [PubMed - as supplied by publisher]

BACKGROUND: Substance use disorders (SUDs) and Post Traumatic Stress Disorder (PTSD) frequently co-occur among Veterans and are associated with poor treatment outcomes. Historically, treatments for SUDs and PTSD have been delivered sequentially and independently. More recently, however, integrated treatments have shown promise. This study investigated Veterans' perceptions of the interrelationship between SUDs and PTSD, as well as treatment preferences. Read more . . .
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