PTSD

Sexual assault in the military is more likely to cause lasting sexual pain in female veterans than a history of childhood sexual abuse, according to an observational study involving interviews with more than 1,000 military women.

asiseeit/Getty Images

Female veterans with histories of both childhood sexual abuse and sexual assault in the military were 4.33 times more likely to report sexual pain than female veterans with no history of sexual assault; women whose history of sexual assault occurred in the military only were 2.37 times more likely to report sexual pain. Those with histories of childhood sexual abuse but no military assaults were 1.75 times more likely to report sexual pain than those who had no history of sexual assault.

The findings suggest that sexual assault in the military is more detrimental to sexual function than childhood sexual abuse alone, which “is distinct from the pattern long observed in civilian women that childhood sexual abuse confers a greater risk for sexual pain than adulthood sexual assault,” Carey S. Pulverman, PhD, then of the Department of Veterans Affairs Center of Excellence for Research on Returning War Veterans in Waco, Tex., and coinvestigators wrote in Obstetrics & Gynecology.

The findings come from a secondary analysis of data collected for a larger project titled Sexual Violence and Women Veterans’ Gynecologic Health . The research team conducted telephone interviews with 1,004 female veterans younger than 52 years of age (mean, 38 years) who were enrolled at two large Midwestern VA medical centers and associated clinics. Sexual pain was assessed by one question: “Does it hurt you to have sexual intercourse or penetration?”

The study also identified high comorbidity between sexual pain and mental health concerns. As with sexual pain, rates of depression and PTSD were highest among female veterans with histories of both sexual abuse in childhood and sexual assault in the military, followed by women with histories of sexual assaults in the military alone, and then women with histories of childhood sexual abuse alone. Women with both histories were 6.35 times more likely to report PTSD, and 3.91 times more likely to report depression, compared with female veterans with no history of sexual assault.

Women who experienced sexual assault during their childhood and/or while serving in the military also may have been exposed to sexual assault during their pre- or postmilitary adulthood as well, but this was a small number and its effects were not evaluated, the authors noted.

Especially given the “growing numbers of women serving in the military and prevalence of sexual assault in this population,” there’s a need for more research on the sexual function of female veterans and development of “targeted treatments,” the investigators wrote.

For now, providers should be “more comprehensive in their assessment of sexual assault history” and should consider developing relationships with community providers who specialize in sexual health, they added.

The study was funded by the VA. The authors did not report any relevant financial disclosures.

SOURCE: Pulverman CS et al. Obstet Gynecol. 2019;134:63-71.

Sexual assault in the military is more likely to cause lasting sexual pain in female veterans than a history of childhood sexual abuse, according to an observational study involving interviews with more than 1,000 military women.

asiseeit/Getty Images

Female veterans with histories of both childhood sexual abuse and sexual assault in the military were 4.33 times more likely to report sexual pain than female veterans with no history of sexual assault; women whose history of sexual assault occurred in the military only were 2.37 times more likely to report sexual pain. Those with histories of childhood sexual abuse but no military assaults were 1.75 times more likely to report sexual pain than those who had no history of sexual assault.

The findings suggest that sexual assault in the military is more detrimental to sexual function than childhood sexual abuse alone, which “is distinct from the pattern long observed in civilian women that childhood sexual abuse confers a greater risk for sexual pain than adulthood sexual assault,” Carey S. Pulverman, PhD, then of the Department of Veterans Affairs Center of Excellence for Research on Returning War Veterans in Waco, Tex., and coinvestigators wrote in Obstetrics & Gynecology.

The findings come from a secondary analysis of data collected for a larger project titled Sexual Violence and Women Veterans’ Gynecologic Health . The research team conducted telephone interviews with 1,004 female veterans younger than 52 years of age (mean, 38 years) who were enrolled at two large Midwestern VA medical centers and associated clinics. Sexual pain was assessed by one question: “Does it hurt you to have sexual intercourse or penetration?”

The study also identified high comorbidity between sexual pain and mental health concerns. As with sexual pain, rates of depression and PTSD were highest among female veterans with histories of both sexual abuse in childhood and sexual assault in the military, followed by women with histories of sexual assaults in the military alone, and then women with histories of childhood sexual abuse alone. Women with both histories were 6.35 times more likely to report PTSD, and 3.91 times more likely to report depression, compared with female veterans with no history of sexual assault.

Women who experienced sexual assault during their childhood and/or while serving in the military also may have been exposed to sexual assault during their pre- or postmilitary adulthood as well, but this was a small number and its effects were not evaluated, the authors noted.

Especially given the “growing numbers of women serving in the military and prevalence of sexual assault in this population,” there’s a need for more research on the sexual function of female veterans and development of “targeted treatments,” the investigators wrote.

For now, providers should be “more comprehensive in their assessment of sexual assault history” and should consider developing relationships with community providers who specialize in sexual health, they added.

The study was funded by the VA. The authors did not report any relevant financial disclosures.

SOURCE: Pulverman CS et al. Obstet Gynecol. 2019;134:63-71.

Sexual assault in the military is more likely to cause lasting sexual pain in female veterans than a history of childhood sexual abuse, according to an observational study involving interviews with more than 1,000 military women.

asiseeit/Getty Images

Female veterans with histories of both childhood sexual abuse and sexual assault in the military were 4.33 times more likely to report sexual pain than female veterans with no history of sexual assault; women whose history of sexual assault occurred in the military only were 2.37 times more likely to report sexual pain. Those with histories of childhood sexual abuse but no military assaults were 1.75 times more likely to report sexual pain than those who had no history of sexual assault.

The findings suggest that sexual assault in the military is more detrimental to sexual function than childhood sexual abuse alone, which “is distinct from the pattern long observed in civilian women that childhood sexual abuse confers a greater risk for sexual pain than adulthood sexual assault,” Carey S. Pulverman, PhD, then of the Department of Veterans Affairs Center of Excellence for Research on Returning War Veterans in Waco, Tex., and coinvestigators wrote in Obstetrics & Gynecology.

The findings come from a secondary analysis of data collected for a larger project titled Sexual Violence and Women Veterans’ Gynecologic Health . The research team conducted telephone interviews with 1,004 female veterans younger than 52 years of age (mean, 38 years) who were enrolled at two large Midwestern VA medical centers and associated clinics. Sexual pain was assessed by one question: “Does it hurt you to have sexual intercourse or penetration?”

The study also identified high comorbidity between sexual pain and mental health concerns. As with sexual pain, rates of depression and PTSD were highest among female veterans with histories of both sexual abuse in childhood and sexual assault in the military, followed by women with histories of sexual assaults in the military alone, and then women with histories of childhood sexual abuse alone. Women with both histories were 6.35 times more likely to report PTSD, and 3.91 times more likely to report depression, compared with female veterans with no history of sexual assault.

Women who experienced sexual assault during their childhood and/or while serving in the military also may have been exposed to sexual assault during their pre- or postmilitary adulthood as well, but this was a small number and its effects were not evaluated, the authors noted.

Especially given the “growing numbers of women serving in the military and prevalence of sexual assault in this population,” there’s a need for more research on the sexual function of female veterans and development of “targeted treatments,” the investigators wrote.

For now, providers should be “more comprehensive in their assessment of sexual assault history” and should consider developing relationships with community providers who specialize in sexual health, they added.

The study was funded by the VA. The authors did not report any relevant financial disclosures.

SOURCE: Pulverman CS et al. Obstet Gynecol. 2019;134:63-71.

Psychotherapeutic treatments appear to be superior to pharmacologic treatments for adults with PTSD, recent research from a meta-analysis shows.

“Our results confirm the recommendations of many treatment guidelines, that psychotherapeutic treatments should be preferred as first-line treatments, and we found limited evidence to recommend pharmacological treatments as monotherapies, when sustained and long-term symptom improvement is intended,” Jasmin Merz, of the division of clinical psychology and psychotherapy and the department of psychology at the University of Basel (Switzerland), and colleagues wrote. The study was published in JAMA Psychiatry.

The researchers noted, however, that no intervention was found to be superior at the end of treatment and emphasized that more research for long-term outcomes are needed, as few studies directly compared the interventions long term or were underpowered.

Ms. Merz and colleagues identified 12 randomized clinical trials with 922 participants out of a total of 11,417 records in the MEDLINE, Embase, PsycINFO, PSYNDEX, and Cochrane Controlled Trials Register between January 1980 and February 2018. Overall, there were 23 direct comparisons between psychotherapeutic and pharmacologic treatments for PTSD, as well as for combination treatment, and researchers evaluated the comparative benefit across studies with random effects network and pairwise meta-analyses.

In short-term findings, no single treatment approach proved superior. However, in long-term findings, psychotherapeutic treatments were deemed superior to pharmacologic treatments in the network meta-analysis (standard mean difference, –0.83; 95% confidence interval, –1.59 to –0.07) and in the pairwise meta-analysis (95% CI, –1.18 to –0.09) in three randomized, controlled trials with the longest follow-up data available.

Combined treatment was not significantly superior to psychotherapeutic treatment in long-term results but were found to have better outcomes in the network meta-analysis (95% CI, −1.87 to −0.04). In addition, data from two randomized clinical trials showed a “large but nonsignificant benefit” to combined treatments in the pairwise meta-analysis (95% CI, –2.77 to –0.72).

“The differences in findings at the end of treatment and at long-term follow-up highlight the necessity to include long-term follow-up data when evaluating the comparative benefit of treatments, because the treatment outcomes at the end of treatment may differ fundamentally from long-term findings,” the researchers wrote. “Thus, focusing on results at the end of treatment and founding treatment recommendations on short-term data only, as done for instance in previous meta-analyses, may lead to false conclusions.”

One of the authors reported receiving personal fees from JAMA Psychiatry for performing statistical reviews. The other authors reported no relevant conflicts of interest.

SOURCE: Merz J et al. JAMA Psychiatry. 2019 Jun 12. doi: 10.1001/jamapsychiatry.2019.0951.

Psychotherapeutic treatments appear to be superior to pharmacologic treatments for adults with PTSD, recent research from a meta-analysis shows.

“Our results confirm the recommendations of many treatment guidelines, that psychotherapeutic treatments should be preferred as first-line treatments, and we found limited evidence to recommend pharmacological treatments as monotherapies, when sustained and long-term symptom improvement is intended,” Jasmin Merz, of the division of clinical psychology and psychotherapy and the department of psychology at the University of Basel (Switzerland), and colleagues wrote. The study was published in JAMA Psychiatry.

The researchers noted, however, that no intervention was found to be superior at the end of treatment and emphasized that more research for long-term outcomes are needed, as few studies directly compared the interventions long term or were underpowered.

Ms. Merz and colleagues identified 12 randomized clinical trials with 922 participants out of a total of 11,417 records in the MEDLINE, Embase, PsycINFO, PSYNDEX, and Cochrane Controlled Trials Register between January 1980 and February 2018. Overall, there were 23 direct comparisons between psychotherapeutic and pharmacologic treatments for PTSD, as well as for combination treatment, and researchers evaluated the comparative benefit across studies with random effects network and pairwise meta-analyses.

In short-term findings, no single treatment approach proved superior. However, in long-term findings, psychotherapeutic treatments were deemed superior to pharmacologic treatments in the network meta-analysis (standard mean difference, –0.83; 95% confidence interval, –1.59 to –0.07) and in the pairwise meta-analysis (95% CI, –1.18 to –0.09) in three randomized, controlled trials with the longest follow-up data available.

Combined treatment was not significantly superior to psychotherapeutic treatment in long-term results but were found to have better outcomes in the network meta-analysis (95% CI, −1.87 to −0.04). In addition, data from two randomized clinical trials showed a “large but nonsignificant benefit” to combined treatments in the pairwise meta-analysis (95% CI, –2.77 to –0.72).

“The differences in findings at the end of treatment and at long-term follow-up highlight the necessity to include long-term follow-up data when evaluating the comparative benefit of treatments, because the treatment outcomes at the end of treatment may differ fundamentally from long-term findings,” the researchers wrote. “Thus, focusing on results at the end of treatment and founding treatment recommendations on short-term data only, as done for instance in previous meta-analyses, may lead to false conclusions.”

One of the authors reported receiving personal fees from JAMA Psychiatry for performing statistical reviews. The other authors reported no relevant conflicts of interest.

SOURCE: Merz J et al. JAMA Psychiatry. 2019 Jun 12. doi: 10.1001/jamapsychiatry.2019.0951.

Psychotherapeutic treatments appear to be superior to pharmacologic treatments for adults with PTSD, recent research from a meta-analysis shows.

“Our results confirm the recommendations of many treatment guidelines, that psychotherapeutic treatments should be preferred as first-line treatments, and we found limited evidence to recommend pharmacological treatments as monotherapies, when sustained and long-term symptom improvement is intended,” Jasmin Merz, of the division of clinical psychology and psychotherapy and the department of psychology at the University of Basel (Switzerland), and colleagues wrote. The study was published in JAMA Psychiatry.

The researchers noted, however, that no intervention was found to be superior at the end of treatment and emphasized that more research for long-term outcomes are needed, as few studies directly compared the interventions long term or were underpowered.

Ms. Merz and colleagues identified 12 randomized clinical trials with 922 participants out of a total of 11,417 records in the MEDLINE, Embase, PsycINFO, PSYNDEX, and Cochrane Controlled Trials Register between January 1980 and February 2018. Overall, there were 23 direct comparisons between psychotherapeutic and pharmacologic treatments for PTSD, as well as for combination treatment, and researchers evaluated the comparative benefit across studies with random effects network and pairwise meta-analyses.

In short-term findings, no single treatment approach proved superior. However, in long-term findings, psychotherapeutic treatments were deemed superior to pharmacologic treatments in the network meta-analysis (standard mean difference, –0.83; 95% confidence interval, –1.59 to –0.07) and in the pairwise meta-analysis (95% CI, –1.18 to –0.09) in three randomized, controlled trials with the longest follow-up data available.

Combined treatment was not significantly superior to psychotherapeutic treatment in long-term results but were found to have better outcomes in the network meta-analysis (95% CI, −1.87 to −0.04). In addition, data from two randomized clinical trials showed a “large but nonsignificant benefit” to combined treatments in the pairwise meta-analysis (95% CI, –2.77 to –0.72).

“The differences in findings at the end of treatment and at long-term follow-up highlight the necessity to include long-term follow-up data when evaluating the comparative benefit of treatments, because the treatment outcomes at the end of treatment may differ fundamentally from long-term findings,” the researchers wrote. “Thus, focusing on results at the end of treatment and founding treatment recommendations on short-term data only, as done for instance in previous meta-analyses, may lead to false conclusions.”

One of the authors reported receiving personal fees from JAMA Psychiatry for performing statistical reviews. The other authors reported no relevant conflicts of interest.

SOURCE: Merz J et al. JAMA Psychiatry. 2019 Jun 12. doi: 10.1001/jamapsychiatry.2019.0951.

SAN FRANCISCO – Longer and more powerful storms caused by climate change will put increasing pressure on mental health care. The unusually powerful 2017 hurricane season, highlighted by damage done to Puerto Rico by Hurricane Maria and to Houston by Hurricane Harvey, may serve as a harbinger of more intense storm seasons to come, according to James M. Shultz, PhD, director of the Center for Disaster and Extreme Event Preparedness at the University of Miami.

kevron2001/Getty Images

Overall, 2017 was something of a “perfect storm” season. “We’ve had predictions about what climate change would do to extreme storms. It was quite exceptional in bringing together all of the elements we have seen predicted by climate scientists,” Dr. Shultz said during a press conference at the annual meeting of the American Psychiatric Association. Study coauthor Zelde Espinel, MD, MPH, also of the center at the university, presented the poster at the meeting.

Aside from greater intensity, climate change is causing a slowing of storms once they make landfall, which increases rainfall and the risks of floods. Nowhere was that more apparent than in Houston in the aftermath of Hurricane Harvey, where tens of thousands of spontaneous rescue efforts arose to rescue people trapped in their homes.

These storms put tremendous pressure on health care systems, as in Puerto Rico when Hurricane Maria knocked out electrical grids, some of which stayed down for 6 months or more. This kind of upheaval interrupts health care infrastructure, including psychiatric services, leaving vulnerable individuals at even greater risk.

Then there are the direct and indirect effects of storms on mental health. When air conditioning and fans are inoperative because of power outages, people get exposed to extreme and relentless heat. They may experience food and water shortages. In worst cases, they may be forced out of their homes on a temporary or even permanent basis. Dr. Shultz recounted research looking at victims of Hurricane Maria.

Researchers used standardized measures to assess both survivors who remained in Puerto Rico, and others who were forced to relocate, mostly to Florida. Sixty-six percent of those interviewed had clinically significant elevated symptoms of PTSD, major depression, or generalized anxiety. A study looking at people displaced from Puerto Rico and those who stayed also found high rates of posttraumatic stress disorder and depression in both samples, and rates were actually higher in those who were displaced to Florida, Dr. Shultz said (Disaster Med Public Health Prep. 2019 Feb;13[13]:24-7).

These effects will only worsen as climate change brings more and more powerful storms, and psychiatrists must be ready to help. The year 2017 “is just a snapshot. It may in fact be just a garden variety year when we look back later in this century. We need to integrate climate science into population health preparedness,” Dr. Shultz said.

Many countries most affected by climate change are poor in resources and may have few psychiatrists available in the first place. After a storm, infrastructure and the number of trained mental health professionals may further decline. That calls for outside assistance: “We’ve been talking about the possibility of bringing interpersonal psychotherapy (to affected areas) and to have lay personnel supervised by psychiatrists be able to deliver these sorts of interventions,” he said.

Dr. Shultz has no relevant financial disclosures.

SAN FRANCISCO – Longer and more powerful storms caused by climate change will put increasing pressure on mental health care. The unusually powerful 2017 hurricane season, highlighted by damage done to Puerto Rico by Hurricane Maria and to Houston by Hurricane Harvey, may serve as a harbinger of more intense storm seasons to come, according to James M. Shultz, PhD, director of the Center for Disaster and Extreme Event Preparedness at the University of Miami.

kevron2001/Getty Images

Overall, 2017 was something of a “perfect storm” season. “We’ve had predictions about what climate change would do to extreme storms. It was quite exceptional in bringing together all of the elements we have seen predicted by climate scientists,” Dr. Shultz said during a press conference at the annual meeting of the American Psychiatric Association. Study coauthor Zelde Espinel, MD, MPH, also of the center at the university, presented the poster at the meeting.

Aside from greater intensity, climate change is causing a slowing of storms once they make landfall, which increases rainfall and the risks of floods. Nowhere was that more apparent than in Houston in the aftermath of Hurricane Harvey, where tens of thousands of spontaneous rescue efforts arose to rescue people trapped in their homes.

These storms put tremendous pressure on health care systems, as in Puerto Rico when Hurricane Maria knocked out electrical grids, some of which stayed down for 6 months or more. This kind of upheaval interrupts health care infrastructure, including psychiatric services, leaving vulnerable individuals at even greater risk.

Then there are the direct and indirect effects of storms on mental health. When air conditioning and fans are inoperative because of power outages, people get exposed to extreme and relentless heat. They may experience food and water shortages. In worst cases, they may be forced out of their homes on a temporary or even permanent basis. Dr. Shultz recounted research looking at victims of Hurricane Maria.

Researchers used standardized measures to assess both survivors who remained in Puerto Rico, and others who were forced to relocate, mostly to Florida. Sixty-six percent of those interviewed had clinically significant elevated symptoms of PTSD, major depression, or generalized anxiety. A study looking at people displaced from Puerto Rico and those who stayed also found high rates of posttraumatic stress disorder and depression in both samples, and rates were actually higher in those who were displaced to Florida, Dr. Shultz said (Disaster Med Public Health Prep. 2019 Feb;13[13]:24-7).

These effects will only worsen as climate change brings more and more powerful storms, and psychiatrists must be ready to help. The year 2017 “is just a snapshot. It may in fact be just a garden variety year when we look back later in this century. We need to integrate climate science into population health preparedness,” Dr. Shultz said.

Many countries most affected by climate change are poor in resources and may have few psychiatrists available in the first place. After a storm, infrastructure and the number of trained mental health professionals may further decline. That calls for outside assistance: “We’ve been talking about the possibility of bringing interpersonal psychotherapy (to affected areas) and to have lay personnel supervised by psychiatrists be able to deliver these sorts of interventions,” he said.

Dr. Shultz has no relevant financial disclosures.

SAN FRANCISCO – Longer and more powerful storms caused by climate change will put increasing pressure on mental health care. The unusually powerful 2017 hurricane season, highlighted by damage done to Puerto Rico by Hurricane Maria and to Houston by Hurricane Harvey, may serve as a harbinger of more intense storm seasons to come, according to James M. Shultz, PhD, director of the Center for Disaster and Extreme Event Preparedness at the University of Miami.

kevron2001/Getty Images

Overall, 2017 was something of a “perfect storm” season. “We’ve had predictions about what climate change would do to extreme storms. It was quite exceptional in bringing together all of the elements we have seen predicted by climate scientists,” Dr. Shultz said during a press conference at the annual meeting of the American Psychiatric Association. Study coauthor Zelde Espinel, MD, MPH, also of the center at the university, presented the poster at the meeting.

Aside from greater intensity, climate change is causing a slowing of storms once they make landfall, which increases rainfall and the risks of floods. Nowhere was that more apparent than in Houston in the aftermath of Hurricane Harvey, where tens of thousands of spontaneous rescue efforts arose to rescue people trapped in their homes.

These storms put tremendous pressure on health care systems, as in Puerto Rico when Hurricane Maria knocked out electrical grids, some of which stayed down for 6 months or more. This kind of upheaval interrupts health care infrastructure, including psychiatric services, leaving vulnerable individuals at even greater risk.

Then there are the direct and indirect effects of storms on mental health. When air conditioning and fans are inoperative because of power outages, people get exposed to extreme and relentless heat. They may experience food and water shortages. In worst cases, they may be forced out of their homes on a temporary or even permanent basis. Dr. Shultz recounted research looking at victims of Hurricane Maria.

Researchers used standardized measures to assess both survivors who remained in Puerto Rico, and others who were forced to relocate, mostly to Florida. Sixty-six percent of those interviewed had clinically significant elevated symptoms of PTSD, major depression, or generalized anxiety. A study looking at people displaced from Puerto Rico and those who stayed also found high rates of posttraumatic stress disorder and depression in both samples, and rates were actually higher in those who were displaced to Florida, Dr. Shultz said (Disaster Med Public Health Prep. 2019 Feb;13[13]:24-7).

These effects will only worsen as climate change brings more and more powerful storms, and psychiatrists must be ready to help. The year 2017 “is just a snapshot. It may in fact be just a garden variety year when we look back later in this century. We need to integrate climate science into population health preparedness,” Dr. Shultz said.

Many countries most affected by climate change are poor in resources and may have few psychiatrists available in the first place. After a storm, infrastructure and the number of trained mental health professionals may further decline. That calls for outside assistance: “We’ve been talking about the possibility of bringing interpersonal psychotherapy (to affected areas) and to have lay personnel supervised by psychiatrists be able to deliver these sorts of interventions,” he said.

Dr. Shultz has no relevant financial disclosures.

SAN FRANCISCO – Children who witnessed the 9/11 attacks on the World Trade Center are almost fivefold as likely to suffer comorbid physical and psychiatric problems as adults, according to a case-control study presented at the American Psychiatric Association annual meeting.

The investigation included 942 people who, as children under 18 years old, were in school below Canal Street in lower Manhattan when the World Trade Center was attacked. They saw the towers collapse and were evacuated from the area, but did not lose a parent. Now 18-36 years old, they were interviewed in their homes and asked to filled out questionnaires about psychiatric and physical problems. The outcomes were compared with 563 age- and gender-matched controls who were in school in Queens at the time.

In turns out that “it made a huge difference whether you were there or not. Being there had much more impact than hearing about it or watching it on TV,” said lead investigator Lawrence Amsel, MD, an assistant professor of clinical psychiatry at Columbia University in New York.

Adults who witnessed the attacks as children were more than twice as likely to have panic disorder, marijuana use disorder, and separation anxiety, which is uncommon in adults; anxiety disorders were more prevalent, as well.

They also were almost half as likely to be living with a spouse or partner, and half as likely to be living independently. “That kind of goes along with the separation anxiety; these kids were more likely to be afraid of moving away from their family and breaking out into their own lives,” Dr. Amsel said.

Overall, 36% had a psychiatric disorder, and 27% had a physical problem, such as diabetes, asthma, or eczema; 14% had both. Among adults who were in Queens during the attacks, 28% had a psychiatric disorder, and 11% a physical problem; 4% were comorbid.

The increased odds of physical-psychiatric comorbidity among witnesses (adjusted odds ratio, 4.60; 95% confidence interval, 2.75- 7.71; P less than .0001) “was not due simply to an increase in physical conditions,” according to the study team.

“This was a single event,” Dr. Amsel said, but for children who witnessed it, “it’s had effects for decades. There were huge amounts of money sent in, and lots of health care for kids who were down there, but despite that, we have this. We think the PTSD morphed into” long-term issues, Dr. Amsel said.

“We know that one of the reasons people get psychiatric disorders” after trauma “is that they generalize the fear; the message to your brain is that everything is dangerous. You’ve got to intervene there and break the association between the fear system and everything else, so that life is still safe,” he said.

There’s an added element with human violence. “Life may be unsafe” after a natural disaster, “but you know that human beings are good and helpful. With a terrorist attack, you stop trusting people,” he said.

Cognitive behavioral therapy could help, among other approaches. It also might be helpful to teach resilience to schoolchildren, just like biology and algebra, he said.

Cases and controls were evenly split between the sexes. Just over 40% of subjects in both groups were white, followed by Hispanics, Asians, and blacks. The majority of households were middle income.

The next step is to break the results down by age, ethnicity, socioeconomic factors, and support systems. The team will run blood work and heart and lung tests on the subjects to nail down the physical problems reported by witnesses. There are concerns about the lingering effects of the dust plume.

The work is funded by the federal government. Dr. Amsel didn’t have any relevant financial disclosures.

aotto@mdedge.com

SAN FRANCISCO – Children who witnessed the 9/11 attacks on the World Trade Center are almost fivefold as likely to suffer comorbid physical and psychiatric problems as adults, according to a case-control study presented at the American Psychiatric Association annual meeting.

The investigation included 942 people who, as children under 18 years old, were in school below Canal Street in lower Manhattan when the World Trade Center was attacked. They saw the towers collapse and were evacuated from the area, but did not lose a parent. Now 18-36 years old, they were interviewed in their homes and asked to filled out questionnaires about psychiatric and physical problems. The outcomes were compared with 563 age- and gender-matched controls who were in school in Queens at the time.

In turns out that “it made a huge difference whether you were there or not. Being there had much more impact than hearing about it or watching it on TV,” said lead investigator Lawrence Amsel, MD, an assistant professor of clinical psychiatry at Columbia University in New York.

Adults who witnessed the attacks as children were more than twice as likely to have panic disorder, marijuana use disorder, and separation anxiety, which is uncommon in adults; anxiety disorders were more prevalent, as well.

They also were almost half as likely to be living with a spouse or partner, and half as likely to be living independently. “That kind of goes along with the separation anxiety; these kids were more likely to be afraid of moving away from their family and breaking out into their own lives,” Dr. Amsel said.

Overall, 36% had a psychiatric disorder, and 27% had a physical problem, such as diabetes, asthma, or eczema; 14% had both. Among adults who were in Queens during the attacks, 28% had a psychiatric disorder, and 11% a physical problem; 4% were comorbid.

The increased odds of physical-psychiatric comorbidity among witnesses (adjusted odds ratio, 4.60; 95% confidence interval, 2.75- 7.71; P less than .0001) “was not due simply to an increase in physical conditions,” according to the study team.

“This was a single event,” Dr. Amsel said, but for children who witnessed it, “it’s had effects for decades. There were huge amounts of money sent in, and lots of health care for kids who were down there, but despite that, we have this. We think the PTSD morphed into” long-term issues, Dr. Amsel said.

“We know that one of the reasons people get psychiatric disorders” after trauma “is that they generalize the fear; the message to your brain is that everything is dangerous. You’ve got to intervene there and break the association between the fear system and everything else, so that life is still safe,” he said.

There’s an added element with human violence. “Life may be unsafe” after a natural disaster, “but you know that human beings are good and helpful. With a terrorist attack, you stop trusting people,” he said.

Cognitive behavioral therapy could help, among other approaches. It also might be helpful to teach resilience to schoolchildren, just like biology and algebra, he said.

Cases and controls were evenly split between the sexes. Just over 40% of subjects in both groups were white, followed by Hispanics, Asians, and blacks. The majority of households were middle income.

The next step is to break the results down by age, ethnicity, socioeconomic factors, and support systems. The team will run blood work and heart and lung tests on the subjects to nail down the physical problems reported by witnesses. There are concerns about the lingering effects of the dust plume.

The work is funded by the federal government. Dr. Amsel didn’t have any relevant financial disclosures.

aotto@mdedge.com

SAN FRANCISCO – Children who witnessed the 9/11 attacks on the World Trade Center are almost fivefold as likely to suffer comorbid physical and psychiatric problems as adults, according to a case-control study presented at the American Psychiatric Association annual meeting.

The investigation included 942 people who, as children under 18 years old, were in school below Canal Street in lower Manhattan when the World Trade Center was attacked. They saw the towers collapse and were evacuated from the area, but did not lose a parent. Now 18-36 years old, they were interviewed in their homes and asked to filled out questionnaires about psychiatric and physical problems. The outcomes were compared with 563 age- and gender-matched controls who were in school in Queens at the time.

In turns out that “it made a huge difference whether you were there or not. Being there had much more impact than hearing about it or watching it on TV,” said lead investigator Lawrence Amsel, MD, an assistant professor of clinical psychiatry at Columbia University in New York.

Adults who witnessed the attacks as children were more than twice as likely to have panic disorder, marijuana use disorder, and separation anxiety, which is uncommon in adults; anxiety disorders were more prevalent, as well.

They also were almost half as likely to be living with a spouse or partner, and half as likely to be living independently. “That kind of goes along with the separation anxiety; these kids were more likely to be afraid of moving away from their family and breaking out into their own lives,” Dr. Amsel said.

Overall, 36% had a psychiatric disorder, and 27% had a physical problem, such as diabetes, asthma, or eczema; 14% had both. Among adults who were in Queens during the attacks, 28% had a psychiatric disorder, and 11% a physical problem; 4% were comorbid.

The increased odds of physical-psychiatric comorbidity among witnesses (adjusted odds ratio, 4.60; 95% confidence interval, 2.75- 7.71; P less than .0001) “was not due simply to an increase in physical conditions,” according to the study team.

“This was a single event,” Dr. Amsel said, but for children who witnessed it, “it’s had effects for decades. There were huge amounts of money sent in, and lots of health care for kids who were down there, but despite that, we have this. We think the PTSD morphed into” long-term issues, Dr. Amsel said.

“We know that one of the reasons people get psychiatric disorders” after trauma “is that they generalize the fear; the message to your brain is that everything is dangerous. You’ve got to intervene there and break the association between the fear system and everything else, so that life is still safe,” he said.

There’s an added element with human violence. “Life may be unsafe” after a natural disaster, “but you know that human beings are good and helpful. With a terrorist attack, you stop trusting people,” he said.

Cognitive behavioral therapy could help, among other approaches. It also might be helpful to teach resilience to schoolchildren, just like biology and algebra, he said.

Cases and controls were evenly split between the sexes. Just over 40% of subjects in both groups were white, followed by Hispanics, Asians, and blacks. The majority of households were middle income.

The next step is to break the results down by age, ethnicity, socioeconomic factors, and support systems. The team will run blood work and heart and lung tests on the subjects to nail down the physical problems reported by witnesses. There are concerns about the lingering effects of the dust plume.

The work is funded by the federal government. Dr. Amsel didn’t have any relevant financial disclosures.

aotto@mdedge.com

SAN FRANCISCO – Veterans who are survivors of military sexual trauma during their service face unique challenges in their treatment and recovery. They are often reluctant to report their experiences – and understandably so.

“Military sexual assault represents a huge violation of that trust and safety. That’s what makes it so toxic and hard for participants to [come] forward, because they’re accused of breaking cohesion of their unit and breaking morale, and yet they have been mistreated,” Niranjan Karnik, MD, PhD, associate dean for community behavioral health at Rush Medical College, Chicago, said in an interview.

Dr. Karnik moderated a session on the prevalence and treatment of military sexual assault at the annual meeting of the American Psychiatric Association. Although the Department of Veterans Affairs treats many survivors of sexual assault, not all of them feel comfortable in that environment. “A VA hospital has a quasi-military feel to it, and that’s a reflection of what it is and the people who are there. That can be an inhibition – and can even be a trigger for [PTSD] symptoms,” Dr. Karnik said.

Survivors may also worry about being labeled, or about adverse entries going into their official record and how that could affect them in the future. “I don’t think there are [VA] policies that put them at risk, but they can perceive that,” Dr. Karnik said. The issue is a stark contrast to veterans who are suffering from combat-related trauma.

“When a combat trauma survivor goes to the VA, they feel protected because their colleagues are there. With military sexual trauma, because of that violation of trust from their peers, it can really exacerbate things,” Dr. Karnik said.

Fortunately, there are alternatives, such as the Road Home* Program at Rush Hospital, which has a few military accoutrements but more closely resembles a civilian center. “It can be an easier access point. The VA is taking care of a large majority of patients. We are a boutique program for the vets who can’t or feel unable to go through the VA program,” Dr. Karnik said.

Overall, 52.5% of women and 8.9% of men in the military report sexual harassment, and 23.6% of women and 1.9% of men report being sexually assaulted. That amounts to 14,900 service members, 8,600 women, and 6,300 men who were assaulted in 2016, according to Neeral K. Sheth, DO, assistant professor of psychiatry at Rush Medical College, who also presented at the session. The frequency of assault is higher among LGBTQ individuals, and African American men and women are more likely to experience sexual harassment.

There are options for treatment of military sexual trauma (MST). The 3-week Road Home intensive outpatient treatment program at Rush Hospital combines group and individual cognitive-processing therapy, which is a cognitive-behavioral therapy that has been shown to improve PTSD resulting from MST. The program places combat trauma and MST trauma patients into separate cohorts, each containing individual and group components. Individual sessions closely follow a manualized protocol, while group sessions offer an opportunity to practice cognitive-processing therapy skills.

The team adapted the program to MST treatment by incorporating dialectical-behavioral therapy skills modules in the first week of the program, and implemented one-on-one skills consultation by request throughout the program.

An analysis of 191 subjects participating in 19 cohorts (12 combat, 9 MST cohorts) showed a 92% completion rate, which was similar, regardless of gender or cohort type. Both cohorts had significant reductions in PTSD severity as measured by the PTSD Checklist for DSM-5, and depression symptoms as measured by the Patient Health Questionnaire–9.

Another program, Families OverComing Under Stress, can also be adapted to MST. It is designed to build resiliency and wellness within families dealing with trauma or loss. It incorporates family assessment, psychoeducation tailored to the needs of the entire family, family-level resilience skills, and a narrative component.

An important element is the identification and management of stress reminders – triggers that remind the individual of a trauma and may cause a sudden shift in mood or behavior. A family member’s knowledge that the survivor is experiencing a stress reminder can reduce misunderstandings or unhelpful interpretations of behavior.

In fact, family considerations are often what bring veterans in for help in the first place, according to Dr. Karnik. He or she may be concerned about behavioral problems in a child, which the VA cannot address because its federal funding dictates a sole focus on the veteran. “We will take care of the whole family,” Dr. Karnik said. “Often that’s the entry point, and that allows us to do some engagement with the veteran, and things start to get uncovered.”

Dr. Karnik has no relevant financial disclosures.

*CORRECTION,  5/21/2019

SAN FRANCISCO – Veterans who are survivors of military sexual trauma during their service face unique challenges in their treatment and recovery. They are often reluctant to report their experiences – and understandably so.

“Military sexual assault represents a huge violation of that trust and safety. That’s what makes it so toxic and hard for participants to [come] forward, because they’re accused of breaking cohesion of their unit and breaking morale, and yet they have been mistreated,” Niranjan Karnik, MD, PhD, associate dean for community behavioral health at Rush Medical College, Chicago, said in an interview.

Dr. Karnik moderated a session on the prevalence and treatment of military sexual assault at the annual meeting of the American Psychiatric Association. Although the Department of Veterans Affairs treats many survivors of sexual assault, not all of them feel comfortable in that environment. “A VA hospital has a quasi-military feel to it, and that’s a reflection of what it is and the people who are there. That can be an inhibition – and can even be a trigger for [PTSD] symptoms,” Dr. Karnik said.

Survivors may also worry about being labeled, or about adverse entries going into their official record and how that could affect them in the future. “I don’t think there are [VA] policies that put them at risk, but they can perceive that,” Dr. Karnik said. The issue is a stark contrast to veterans who are suffering from combat-related trauma.

“When a combat trauma survivor goes to the VA, they feel protected because their colleagues are there. With military sexual trauma, because of that violation of trust from their peers, it can really exacerbate things,” Dr. Karnik said.

Fortunately, there are alternatives, such as the Road Home* Program at Rush Hospital, which has a few military accoutrements but more closely resembles a civilian center. “It can be an easier access point. The VA is taking care of a large majority of patients. We are a boutique program for the vets who can’t or feel unable to go through the VA program,” Dr. Karnik said.

Overall, 52.5% of women and 8.9% of men in the military report sexual harassment, and 23.6% of women and 1.9% of men report being sexually assaulted. That amounts to 14,900 service members, 8,600 women, and 6,300 men who were assaulted in 2016, according to Neeral K. Sheth, DO, assistant professor of psychiatry at Rush Medical College, who also presented at the session. The frequency of assault is higher among LGBTQ individuals, and African American men and women are more likely to experience sexual harassment.

There are options for treatment of military sexual trauma (MST). The 3-week Road Home intensive outpatient treatment program at Rush Hospital combines group and individual cognitive-processing therapy, which is a cognitive-behavioral therapy that has been shown to improve PTSD resulting from MST. The program places combat trauma and MST trauma patients into separate cohorts, each containing individual and group components. Individual sessions closely follow a manualized protocol, while group sessions offer an opportunity to practice cognitive-processing therapy skills.

The team adapted the program to MST treatment by incorporating dialectical-behavioral therapy skills modules in the first week of the program, and implemented one-on-one skills consultation by request throughout the program.

An analysis of 191 subjects participating in 19 cohorts (12 combat, 9 MST cohorts) showed a 92% completion rate, which was similar, regardless of gender or cohort type. Both cohorts had significant reductions in PTSD severity as measured by the PTSD Checklist for DSM-5, and depression symptoms as measured by the Patient Health Questionnaire–9.

Another program, Families OverComing Under Stress, can also be adapted to MST. It is designed to build resiliency and wellness within families dealing with trauma or loss. It incorporates family assessment, psychoeducation tailored to the needs of the entire family, family-level resilience skills, and a narrative component.

An important element is the identification and management of stress reminders – triggers that remind the individual of a trauma and may cause a sudden shift in mood or behavior. A family member’s knowledge that the survivor is experiencing a stress reminder can reduce misunderstandings or unhelpful interpretations of behavior.

In fact, family considerations are often what bring veterans in for help in the first place, according to Dr. Karnik. He or she may be concerned about behavioral problems in a child, which the VA cannot address because its federal funding dictates a sole focus on the veteran. “We will take care of the whole family,” Dr. Karnik said. “Often that’s the entry point, and that allows us to do some engagement with the veteran, and things start to get uncovered.”

Dr. Karnik has no relevant financial disclosures.

*CORRECTION,  5/21/2019

SAN FRANCISCO – Veterans who are survivors of military sexual trauma during their service face unique challenges in their treatment and recovery. They are often reluctant to report their experiences – and understandably so.

“Military sexual assault represents a huge violation of that trust and safety. That’s what makes it so toxic and hard for participants to [come] forward, because they’re accused of breaking cohesion of their unit and breaking morale, and yet they have been mistreated,” Niranjan Karnik, MD, PhD, associate dean for community behavioral health at Rush Medical College, Chicago, said in an interview.

Dr. Karnik moderated a session on the prevalence and treatment of military sexual assault at the annual meeting of the American Psychiatric Association. Although the Department of Veterans Affairs treats many survivors of sexual assault, not all of them feel comfortable in that environment. “A VA hospital has a quasi-military feel to it, and that’s a reflection of what it is and the people who are there. That can be an inhibition – and can even be a trigger for [PTSD] symptoms,” Dr. Karnik said.

Survivors may also worry about being labeled, or about adverse entries going into their official record and how that could affect them in the future. “I don’t think there are [VA] policies that put them at risk, but they can perceive that,” Dr. Karnik said. The issue is a stark contrast to veterans who are suffering from combat-related trauma.

“When a combat trauma survivor goes to the VA, they feel protected because their colleagues are there. With military sexual trauma, because of that violation of trust from their peers, it can really exacerbate things,” Dr. Karnik said.

Fortunately, there are alternatives, such as the Road Home* Program at Rush Hospital, which has a few military accoutrements but more closely resembles a civilian center. “It can be an easier access point. The VA is taking care of a large majority of patients. We are a boutique program for the vets who can’t or feel unable to go through the VA program,” Dr. Karnik said.

Overall, 52.5% of women and 8.9% of men in the military report sexual harassment, and 23.6% of women and 1.9% of men report being sexually assaulted. That amounts to 14,900 service members, 8,600 women, and 6,300 men who were assaulted in 2016, according to Neeral K. Sheth, DO, assistant professor of psychiatry at Rush Medical College, who also presented at the session. The frequency of assault is higher among LGBTQ individuals, and African American men and women are more likely to experience sexual harassment.

There are options for treatment of military sexual trauma (MST). The 3-week Road Home intensive outpatient treatment program at Rush Hospital combines group and individual cognitive-processing therapy, which is a cognitive-behavioral therapy that has been shown to improve PTSD resulting from MST. The program places combat trauma and MST trauma patients into separate cohorts, each containing individual and group components. Individual sessions closely follow a manualized protocol, while group sessions offer an opportunity to practice cognitive-processing therapy skills.

The team adapted the program to MST treatment by incorporating dialectical-behavioral therapy skills modules in the first week of the program, and implemented one-on-one skills consultation by request throughout the program.

An analysis of 191 subjects participating in 19 cohorts (12 combat, 9 MST cohorts) showed a 92% completion rate, which was similar, regardless of gender or cohort type. Both cohorts had significant reductions in PTSD severity as measured by the PTSD Checklist for DSM-5, and depression symptoms as measured by the Patient Health Questionnaire–9.

Another program, Families OverComing Under Stress, can also be adapted to MST. It is designed to build resiliency and wellness within families dealing with trauma or loss. It incorporates family assessment, psychoeducation tailored to the needs of the entire family, family-level resilience skills, and a narrative component.

An important element is the identification and management of stress reminders – triggers that remind the individual of a trauma and may cause a sudden shift in mood or behavior. A family member’s knowledge that the survivor is experiencing a stress reminder can reduce misunderstandings or unhelpful interpretations of behavior.

In fact, family considerations are often what bring veterans in for help in the first place, according to Dr. Karnik. He or she may be concerned about behavioral problems in a child, which the VA cannot address because its federal funding dictates a sole focus on the veteran. “We will take care of the whole family,” Dr. Karnik said. “Often that’s the entry point, and that allows us to do some engagement with the veteran, and things start to get uncovered.”

Dr. Karnik has no relevant financial disclosures.

*CORRECTION,  5/21/2019

Stress disorders triggered by life events or trauma have a marked deleterious impact on the cardiovascular system, especially in the short term, suggests a Swedish population-based cohort study of more than 1.6 million people.

Previous studies have had limited power to detect associations and have seldom explored conditions other than PTSD, noted the investigators, led by Huan Song, PhD. In addition, little is known about how genetic predisposition to cardiovascular disease may influence the association.

Results of the new study, reported online in the BMJ, showed that with a median follow-up of about 6.5 years, relative to unaffected siblings, patients who had PTSD, acute stress reaction, adjustment disorder, or another stress reaction had a 64% higher risk of developing a cardiovascular disease during the first year post diagnosis, and a 29% higher risk thereafter.

In the first year, risk was most elevated for heart failure – nearly seven times higher for the patients than for their siblings. In addition, overall risk was increased to a significantly greater extent for cardiovascular diseases with early onset, starting before age 50 years, than for those with later onset, according to Dr. Song of the Center of Public Health Sciences at the University of Iceland, Reykjavík, and the Karolinska Institutet in Stockholm. Findings were essentially the same when patients were instead compared with age- and sex-matched individuals from the general population.

“Stress-related disorders are robustly associated with multiple types of cardiovascular disease, independently of familial background, history of somatic/psychiatric diseases, and psychiatric comorbidity,” Dr. Song and her coinvestigators wrote. “These findings call for enhanced clinical awareness and, if verified, monitoring or early intervention among patients with recently diagnosed stress related disorders.”

Study details

In their population-based cohort study of the Swedish National Patient Register, the investigators identified 136,637 patients with new-onset, stress-related disorders diagnosed between 1987 and 2013. They compared these patients with 171,314 unaffected full siblings and with 1,366,370 unaffected matched people from the general population. Median follow-up was 6.2 years, 6.9 years, and 6.5 years, respectively.

Results showed that the crude incidence rate of any cardiovascular disease was 10.5 per 1,000 person years among the patients with stress-related disorders, 8.4 per 1,000 person years among their unaffected siblings, and 6.9 per 1,000 person years among the matched unaffected individuals from the general population.

Compared with unaffected siblings, patients with stress-related disorders had a 60% elevated risk for developing any cardiovascular disease during the first year after diagnosis. Risk in this window was most elevated for heart failure (hazard ratio, 6.95); cerebrovascular disease other than ischemic and hemorrhagic stroke and arachnoidal bleeding (HR, 5.64), conduction disorders (HR, 5.00), and cardiac arrest (HR, 3.37).

Risk of any cardiovascular disease associated with stress-related disorders was still elevated but to a lesser extent after the first year post diagnosis (HR, 1.29). During this period, risk was most elevated for arterial thrombosis/embolus (HR, 2.02), hemorrhagic stroke (HR, 1.56), and fatal cerebrovascular events (HR, 1.56).

In analyses looking at age of onset of the cardiovascular disease, stress-related disorders showed stronger association with early-onset disease (occurring before age 50 years) than with later-onset disease (HR, 1.40 vs. 1.24; P = .002).

Fatal cardiovascular disease was the only category for which the associations were modified by presence of psychiatric comorbidity. Here, presence of such comorbidity amplified the risk conferred by the stress-related disorder.

Findings were much the same when patients were compared with matched individuals from the general population. Risk for any cardiovascular disease was again elevated substantially in the first year post diagnosis by 71%, and to 36% thereafter.

The authors reported that they had no relevant conflicts of interest. The study was supported by the Icelandic Research Fund, an ERC Consolidator Grant, the Karolinska Institutet, and the Swedish Research Council.

SOURCE: Song H et al. BMJ. 2019 Apr 10. doi: 10.1136/bmj.l1255.

Stress disorders triggered by life events or trauma have a marked deleterious impact on the cardiovascular system, especially in the short term, suggests a Swedish population-based cohort study of more than 1.6 million people.

Previous studies have had limited power to detect associations and have seldom explored conditions other than PTSD, noted the investigators, led by Huan Song, PhD. In addition, little is known about how genetic predisposition to cardiovascular disease may influence the association.

Results of the new study, reported online in the BMJ, showed that with a median follow-up of about 6.5 years, relative to unaffected siblings, patients who had PTSD, acute stress reaction, adjustment disorder, or another stress reaction had a 64% higher risk of developing a cardiovascular disease during the first year post diagnosis, and a 29% higher risk thereafter.

In the first year, risk was most elevated for heart failure – nearly seven times higher for the patients than for their siblings. In addition, overall risk was increased to a significantly greater extent for cardiovascular diseases with early onset, starting before age 50 years, than for those with later onset, according to Dr. Song of the Center of Public Health Sciences at the University of Iceland, Reykjavík, and the Karolinska Institutet in Stockholm. Findings were essentially the same when patients were instead compared with age- and sex-matched individuals from the general population.

“Stress-related disorders are robustly associated with multiple types of cardiovascular disease, independently of familial background, history of somatic/psychiatric diseases, and psychiatric comorbidity,” Dr. Song and her coinvestigators wrote. “These findings call for enhanced clinical awareness and, if verified, monitoring or early intervention among patients with recently diagnosed stress related disorders.”

Study details

In their population-based cohort study of the Swedish National Patient Register, the investigators identified 136,637 patients with new-onset, stress-related disorders diagnosed between 1987 and 2013. They compared these patients with 171,314 unaffected full siblings and with 1,366,370 unaffected matched people from the general population. Median follow-up was 6.2 years, 6.9 years, and 6.5 years, respectively.

Results showed that the crude incidence rate of any cardiovascular disease was 10.5 per 1,000 person years among the patients with stress-related disorders, 8.4 per 1,000 person years among their unaffected siblings, and 6.9 per 1,000 person years among the matched unaffected individuals from the general population.

Compared with unaffected siblings, patients with stress-related disorders had a 60% elevated risk for developing any cardiovascular disease during the first year after diagnosis. Risk in this window was most elevated for heart failure (hazard ratio, 6.95); cerebrovascular disease other than ischemic and hemorrhagic stroke and arachnoidal bleeding (HR, 5.64), conduction disorders (HR, 5.00), and cardiac arrest (HR, 3.37).

Risk of any cardiovascular disease associated with stress-related disorders was still elevated but to a lesser extent after the first year post diagnosis (HR, 1.29). During this period, risk was most elevated for arterial thrombosis/embolus (HR, 2.02), hemorrhagic stroke (HR, 1.56), and fatal cerebrovascular events (HR, 1.56).

In analyses looking at age of onset of the cardiovascular disease, stress-related disorders showed stronger association with early-onset disease (occurring before age 50 years) than with later-onset disease (HR, 1.40 vs. 1.24; P = .002).

Fatal cardiovascular disease was the only category for which the associations were modified by presence of psychiatric comorbidity. Here, presence of such comorbidity amplified the risk conferred by the stress-related disorder.

Findings were much the same when patients were compared with matched individuals from the general population. Risk for any cardiovascular disease was again elevated substantially in the first year post diagnosis by 71%, and to 36% thereafter.

The authors reported that they had no relevant conflicts of interest. The study was supported by the Icelandic Research Fund, an ERC Consolidator Grant, the Karolinska Institutet, and the Swedish Research Council.

SOURCE: Song H et al. BMJ. 2019 Apr 10. doi: 10.1136/bmj.l1255.

Stress disorders triggered by life events or trauma have a marked deleterious impact on the cardiovascular system, especially in the short term, suggests a Swedish population-based cohort study of more than 1.6 million people.

Previous studies have had limited power to detect associations and have seldom explored conditions other than PTSD, noted the investigators, led by Huan Song, PhD. In addition, little is known about how genetic predisposition to cardiovascular disease may influence the association.

Results of the new study, reported online in the BMJ, showed that with a median follow-up of about 6.5 years, relative to unaffected siblings, patients who had PTSD, acute stress reaction, adjustment disorder, or another stress reaction had a 64% higher risk of developing a cardiovascular disease during the first year post diagnosis, and a 29% higher risk thereafter.

In the first year, risk was most elevated for heart failure – nearly seven times higher for the patients than for their siblings. In addition, overall risk was increased to a significantly greater extent for cardiovascular diseases with early onset, starting before age 50 years, than for those with later onset, according to Dr. Song of the Center of Public Health Sciences at the University of Iceland, Reykjavík, and the Karolinska Institutet in Stockholm. Findings were essentially the same when patients were instead compared with age- and sex-matched individuals from the general population.

“Stress-related disorders are robustly associated with multiple types of cardiovascular disease, independently of familial background, history of somatic/psychiatric diseases, and psychiatric comorbidity,” Dr. Song and her coinvestigators wrote. “These findings call for enhanced clinical awareness and, if verified, monitoring or early intervention among patients with recently diagnosed stress related disorders.”

Study details

In their population-based cohort study of the Swedish National Patient Register, the investigators identified 136,637 patients with new-onset, stress-related disorders diagnosed between 1987 and 2013. They compared these patients with 171,314 unaffected full siblings and with 1,366,370 unaffected matched people from the general population. Median follow-up was 6.2 years, 6.9 years, and 6.5 years, respectively.

Results showed that the crude incidence rate of any cardiovascular disease was 10.5 per 1,000 person years among the patients with stress-related disorders, 8.4 per 1,000 person years among their unaffected siblings, and 6.9 per 1,000 person years among the matched unaffected individuals from the general population.

Compared with unaffected siblings, patients with stress-related disorders had a 60% elevated risk for developing any cardiovascular disease during the first year after diagnosis. Risk in this window was most elevated for heart failure (hazard ratio, 6.95); cerebrovascular disease other than ischemic and hemorrhagic stroke and arachnoidal bleeding (HR, 5.64), conduction disorders (HR, 5.00), and cardiac arrest (HR, 3.37).

Risk of any cardiovascular disease associated with stress-related disorders was still elevated but to a lesser extent after the first year post diagnosis (HR, 1.29). During this period, risk was most elevated for arterial thrombosis/embolus (HR, 2.02), hemorrhagic stroke (HR, 1.56), and fatal cerebrovascular events (HR, 1.56).

In analyses looking at age of onset of the cardiovascular disease, stress-related disorders showed stronger association with early-onset disease (occurring before age 50 years) than with later-onset disease (HR, 1.40 vs. 1.24; P = .002).

Fatal cardiovascular disease was the only category for which the associations were modified by presence of psychiatric comorbidity. Here, presence of such comorbidity amplified the risk conferred by the stress-related disorder.

Findings were much the same when patients were compared with matched individuals from the general population. Risk for any cardiovascular disease was again elevated substantially in the first year post diagnosis by 71%, and to 36% thereafter.

The authors reported that they had no relevant conflicts of interest. The study was supported by the Icelandic Research Fund, an ERC Consolidator Grant, the Karolinska Institutet, and the Swedish Research Council.

SOURCE: Song H et al. BMJ. 2019 Apr 10. doi: 10.1136/bmj.l1255.

LAS VEGAS – Despite recent advances in the diagnosis and treatment of posttraumatic stress disorder, researchers have yet to fully understand its pathophysiology.

“We don’t know whether there is just one type of pathophysiology or if there are different mechanisms and different etiologies that contribute to the symptomatic heterogeneity that we see,” Murray B. Stein, MD, MPH, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

“Many theories currently being studied are inflammatory theories, looking at autonomic dysregulation, glucocorticoid sensitivity, hippocampal volume/dysfunction, and cortical-amygdala circuit dysregulation.”

Dr. Stein expects clinicians to gain an improved understanding of PTSD and a myriad of other conditions in the coming years as the Million Veteran Program (MVP) gets underway. MVP researchers are building one of the world’s largest medical databases by asking 1 million veteran volunteers to provide a blood sample and complete surveys about their health, military experience, lifestyle, and other topics that might contribute to health and disease. They will study how genes influence diseases such as diabetes and cancer, and military-related illnesses, such as PTSD. “It’s an amazing study, where over the next decade, you’re going to hear research findings not just on PTSD but in other areas of mental health and physical health,” said Dr. Stein, distinguished professor of psychiatry and family medicine and public health at the University of California, San Diego. So far, he said, 700,000 veterans are enrolled.


Dr. Stein shared preliminary findings from one component of the MVP study, in which participants complete the PTSD Checklist (PCL-17), a widely used 17-item self-report measure of PTSD symptoms in the past month. Using Manhattan plot analysis, Dr. Stein and his colleagues conducted a PTSD genomewide association study based on PCL-17 total scores. They found several genes significantly associated with PTSD, including LRRIQ3, TRAIP, KCNIP4, PCDHA1, MAD1L1, TSNARE1, EXD3, MGC57346-CRHR1, and TCF4. “This is the first study in the world to find this many genes [associated with PTSD],” said Dr. Stein, a staff psychiatrist with the VA San Diego Healthcare System. “The MAD1L1 gene is also one that’s come up in schizophrenia and in major depression. In fact, if we look at genetic correlations of how PTSD is genetically associated to other disorders that have been studied in this way, like major depression and schizophrenia, we find that there is shared variation. However, there are also unique features, so we are learning what we think is true about mental disorders overall, that in some ways comorbidity is explained by genetic risk, but there are also individual specific risk factors that go with specific disorders.

“We’re exploring each of those genes.”

dbrunk@mdedge.com

LAS VEGAS – Despite recent advances in the diagnosis and treatment of posttraumatic stress disorder, researchers have yet to fully understand its pathophysiology.

“We don’t know whether there is just one type of pathophysiology or if there are different mechanisms and different etiologies that contribute to the symptomatic heterogeneity that we see,” Murray B. Stein, MD, MPH, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

“Many theories currently being studied are inflammatory theories, looking at autonomic dysregulation, glucocorticoid sensitivity, hippocampal volume/dysfunction, and cortical-amygdala circuit dysregulation.”

Dr. Stein expects clinicians to gain an improved understanding of PTSD and a myriad of other conditions in the coming years as the Million Veteran Program (MVP) gets underway. MVP researchers are building one of the world’s largest medical databases by asking 1 million veteran volunteers to provide a blood sample and complete surveys about their health, military experience, lifestyle, and other topics that might contribute to health and disease. They will study how genes influence diseases such as diabetes and cancer, and military-related illnesses, such as PTSD. “It’s an amazing study, where over the next decade, you’re going to hear research findings not just on PTSD but in other areas of mental health and physical health,” said Dr. Stein, distinguished professor of psychiatry and family medicine and public health at the University of California, San Diego. So far, he said, 700,000 veterans are enrolled.


Dr. Stein shared preliminary findings from one component of the MVP study, in which participants complete the PTSD Checklist (PCL-17), a widely used 17-item self-report measure of PTSD symptoms in the past month. Using Manhattan plot analysis, Dr. Stein and his colleagues conducted a PTSD genomewide association study based on PCL-17 total scores. They found several genes significantly associated with PTSD, including LRRIQ3, TRAIP, KCNIP4, PCDHA1, MAD1L1, TSNARE1, EXD3, MGC57346-CRHR1, and TCF4. “This is the first study in the world to find this many genes [associated with PTSD],” said Dr. Stein, a staff psychiatrist with the VA San Diego Healthcare System. “The MAD1L1 gene is also one that’s come up in schizophrenia and in major depression. In fact, if we look at genetic correlations of how PTSD is genetically associated to other disorders that have been studied in this way, like major depression and schizophrenia, we find that there is shared variation. However, there are also unique features, so we are learning what we think is true about mental disorders overall, that in some ways comorbidity is explained by genetic risk, but there are also individual specific risk factors that go with specific disorders.

“We’re exploring each of those genes.”

dbrunk@mdedge.com

LAS VEGAS – Despite recent advances in the diagnosis and treatment of posttraumatic stress disorder, researchers have yet to fully understand its pathophysiology.

“We don’t know whether there is just one type of pathophysiology or if there are different mechanisms and different etiologies that contribute to the symptomatic heterogeneity that we see,” Murray B. Stein, MD, MPH, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

“Many theories currently being studied are inflammatory theories, looking at autonomic dysregulation, glucocorticoid sensitivity, hippocampal volume/dysfunction, and cortical-amygdala circuit dysregulation.”

Dr. Stein expects clinicians to gain an improved understanding of PTSD and a myriad of other conditions in the coming years as the Million Veteran Program (MVP) gets underway. MVP researchers are building one of the world’s largest medical databases by asking 1 million veteran volunteers to provide a blood sample and complete surveys about their health, military experience, lifestyle, and other topics that might contribute to health and disease. They will study how genes influence diseases such as diabetes and cancer, and military-related illnesses, such as PTSD. “It’s an amazing study, where over the next decade, you’re going to hear research findings not just on PTSD but in other areas of mental health and physical health,” said Dr. Stein, distinguished professor of psychiatry and family medicine and public health at the University of California, San Diego. So far, he said, 700,000 veterans are enrolled.


Dr. Stein shared preliminary findings from one component of the MVP study, in which participants complete the PTSD Checklist (PCL-17), a widely used 17-item self-report measure of PTSD symptoms in the past month. Using Manhattan plot analysis, Dr. Stein and his colleagues conducted a PTSD genomewide association study based on PCL-17 total scores. They found several genes significantly associated with PTSD, including LRRIQ3, TRAIP, KCNIP4, PCDHA1, MAD1L1, TSNARE1, EXD3, MGC57346-CRHR1, and TCF4. “This is the first study in the world to find this many genes [associated with PTSD],” said Dr. Stein, a staff psychiatrist with the VA San Diego Healthcare System. “The MAD1L1 gene is also one that’s come up in schizophrenia and in major depression. In fact, if we look at genetic correlations of how PTSD is genetically associated to other disorders that have been studied in this way, like major depression and schizophrenia, we find that there is shared variation. However, there are also unique features, so we are learning what we think is true about mental disorders overall, that in some ways comorbidity is explained by genetic risk, but there are also individual specific risk factors that go with specific disorders.

“We’re exploring each of those genes.”

dbrunk@mdedge.com

A current theory holds that during a traumatic event, a person may learn to associate the people, locations, and objects in the situation with the trauma, and long after the event even the “safe” stimuli can trigger fearful and defensive responses. Experts believe it is an “overlearned response” to a threatening experience. But the way in which that learning happens is not well understood, say researchers from Yale University in New Haven, Connecticut, and the Icahn School of Medicine at Mount Sinai in New York City. Their study, though, may shed new light on how people with PTSD symptoms learn and unlearn fear.

In the study, funded in part by the National Institute of Mental Health, the researchers examined how the mental adjustments performed during learning and the way the brain tracks these adjustments relate to symptom severity.

They gave combat veterans with varying levels of PTSD symptom severity a reversal learning task. Participants were shown 2 mildly angry human faces and mildly shocked after viewing 1 face, but not the other. Then the task was reversed, with the aim of having the participants “unlearn” their original fear conditioning and testing their ability to relearn how to respond to negative surprises in the environment.

Although all participants were able to perform the reversal learning, the researchers found “pronounced differences in the ‘learning rates.’” Highly symptomatic veterans tended to overreact when what they expected to happen and what actually happened did not match up.

The researchers say they found biomarkers that could explain the different reactions. In the highly symptomatic veterans, 2 areas of the brain—the amygdala and striatum—were less able to track changes in threat level.

“One’s inability to adequately adjust expectations for potentially aversive outcomes has potential clinical relevance,” said Ilan Harpaz-Rotem, PhD, co-leader of the study, “as this deficit may lead to avoidance and depressive behavior.”

The researchers say their findings could give a “more fine-grained understanding of how learning processes may go awry in the aftermath of combat trauma.”

A current theory holds that during a traumatic event, a person may learn to associate the people, locations, and objects in the situation with the trauma, and long after the event even the “safe” stimuli can trigger fearful and defensive responses. Experts believe it is an “overlearned response” to a threatening experience. But the way in which that learning happens is not well understood, say researchers from Yale University in New Haven, Connecticut, and the Icahn School of Medicine at Mount Sinai in New York City. Their study, though, may shed new light on how people with PTSD symptoms learn and unlearn fear.

In the study, funded in part by the National Institute of Mental Health, the researchers examined how the mental adjustments performed during learning and the way the brain tracks these adjustments relate to symptom severity.

They gave combat veterans with varying levels of PTSD symptom severity a reversal learning task. Participants were shown 2 mildly angry human faces and mildly shocked after viewing 1 face, but not the other. Then the task was reversed, with the aim of having the participants “unlearn” their original fear conditioning and testing their ability to relearn how to respond to negative surprises in the environment.

Although all participants were able to perform the reversal learning, the researchers found “pronounced differences in the ‘learning rates.’” Highly symptomatic veterans tended to overreact when what they expected to happen and what actually happened did not match up.

The researchers say they found biomarkers that could explain the different reactions. In the highly symptomatic veterans, 2 areas of the brain—the amygdala and striatum—were less able to track changes in threat level.

“One’s inability to adequately adjust expectations for potentially aversive outcomes has potential clinical relevance,” said Ilan Harpaz-Rotem, PhD, co-leader of the study, “as this deficit may lead to avoidance and depressive behavior.”

The researchers say their findings could give a “more fine-grained understanding of how learning processes may go awry in the aftermath of combat trauma.”

A current theory holds that during a traumatic event, a person may learn to associate the people, locations, and objects in the situation with the trauma, and long after the event even the “safe” stimuli can trigger fearful and defensive responses. Experts believe it is an “overlearned response” to a threatening experience. But the way in which that learning happens is not well understood, say researchers from Yale University in New Haven, Connecticut, and the Icahn School of Medicine at Mount Sinai in New York City. Their study, though, may shed new light on how people with PTSD symptoms learn and unlearn fear.

In the study, funded in part by the National Institute of Mental Health, the researchers examined how the mental adjustments performed during learning and the way the brain tracks these adjustments relate to symptom severity.

They gave combat veterans with varying levels of PTSD symptom severity a reversal learning task. Participants were shown 2 mildly angry human faces and mildly shocked after viewing 1 face, but not the other. Then the task was reversed, with the aim of having the participants “unlearn” their original fear conditioning and testing their ability to relearn how to respond to negative surprises in the environment.

Although all participants were able to perform the reversal learning, the researchers found “pronounced differences in the ‘learning rates.’” Highly symptomatic veterans tended to overreact when what they expected to happen and what actually happened did not match up.

The researchers say they found biomarkers that could explain the different reactions. In the highly symptomatic veterans, 2 areas of the brain—the amygdala and striatum—were less able to track changes in threat level.

“One’s inability to adequately adjust expectations for potentially aversive outcomes has potential clinical relevance,” said Ilan Harpaz-Rotem, PhD, co-leader of the study, “as this deficit may lead to avoidance and depressive behavior.”

The researchers say their findings could give a “more fine-grained understanding of how learning processes may go awry in the aftermath of combat trauma.”

Nearly 80% of veterans are overweight or obese. According to researchers from Walter Reed National Military Medical Center in Maryland and Yale School of Medicine in Connecticut, obesity is more common among veterans with posttraumatic stress disorder (PTSD) compared with that in other veterans in the VHA (47% vs 41%). Moreover, they say, veterans with PTSD lose less weight during weight-loss treatment than do those without comorbid mental health conditions. PTSD also has been associated with night eating, food addiction, binge eating, and eating as a coping strategy. In a national survey, veterans who self-reported a diagnosis of PTSD were more likely to endorse eating because of emotions or stress.

The researchers conducted a study of 126 veterans referred to the MOVE! Weight Management Program at VA Connecticut Healthcare System. Although it replicates and extends findings from other studies, they believe theirs is the first study examining emotional eating among veterans seeking obesity treatment.

The veterans were given the Yale Emotional Overeating Questionnaire (YEOQ), which assesses how often the respondent has eaten an unusually large amount of food in response to anxiety, sadness, loneliness, tiredness, anger, happiness, boredom, guilt, and physical pain. The researchers also used the Primary Care PTSD Screen to test for PTSD.

A positive PTSD screen was associated with significantly higher scores on the YEOQ overall as well as higher scores on each individual item. Higher scores on the PTSD screen also were associated with more frequent emotional eating for all emotions.

The researchers note that findings about the predictive validity of emotional eating questionnaires have been mixed. Although emotions may influence eating patterns, other mechanisms could be at work, such as general concern about, or lack of control over, eating.

However, the researchers suggest that veterans with PTSD may need specific attention given to alternative coping strategies when facing difficult emotions as part of weight loss treatment.

Nearly 80% of veterans are overweight or obese. According to researchers from Walter Reed National Military Medical Center in Maryland and Yale School of Medicine in Connecticut, obesity is more common among veterans with posttraumatic stress disorder (PTSD) compared with that in other veterans in the VHA (47% vs 41%). Moreover, they say, veterans with PTSD lose less weight during weight-loss treatment than do those without comorbid mental health conditions. PTSD also has been associated with night eating, food addiction, binge eating, and eating as a coping strategy. In a national survey, veterans who self-reported a diagnosis of PTSD were more likely to endorse eating because of emotions or stress.

The researchers conducted a study of 126 veterans referred to the MOVE! Weight Management Program at VA Connecticut Healthcare System. Although it replicates and extends findings from other studies, they believe theirs is the first study examining emotional eating among veterans seeking obesity treatment.

The veterans were given the Yale Emotional Overeating Questionnaire (YEOQ), which assesses how often the respondent has eaten an unusually large amount of food in response to anxiety, sadness, loneliness, tiredness, anger, happiness, boredom, guilt, and physical pain. The researchers also used the Primary Care PTSD Screen to test for PTSD.

A positive PTSD screen was associated with significantly higher scores on the YEOQ overall as well as higher scores on each individual item. Higher scores on the PTSD screen also were associated with more frequent emotional eating for all emotions.

The researchers note that findings about the predictive validity of emotional eating questionnaires have been mixed. Although emotions may influence eating patterns, other mechanisms could be at work, such as general concern about, or lack of control over, eating.

However, the researchers suggest that veterans with PTSD may need specific attention given to alternative coping strategies when facing difficult emotions as part of weight loss treatment.

Nearly 80% of veterans are overweight or obese. According to researchers from Walter Reed National Military Medical Center in Maryland and Yale School of Medicine in Connecticut, obesity is more common among veterans with posttraumatic stress disorder (PTSD) compared with that in other veterans in the VHA (47% vs 41%). Moreover, they say, veterans with PTSD lose less weight during weight-loss treatment than do those without comorbid mental health conditions. PTSD also has been associated with night eating, food addiction, binge eating, and eating as a coping strategy. In a national survey, veterans who self-reported a diagnosis of PTSD were more likely to endorse eating because of emotions or stress.

The researchers conducted a study of 126 veterans referred to the MOVE! Weight Management Program at VA Connecticut Healthcare System. Although it replicates and extends findings from other studies, they believe theirs is the first study examining emotional eating among veterans seeking obesity treatment.

The veterans were given the Yale Emotional Overeating Questionnaire (YEOQ), which assesses how often the respondent has eaten an unusually large amount of food in response to anxiety, sadness, loneliness, tiredness, anger, happiness, boredom, guilt, and physical pain. The researchers also used the Primary Care PTSD Screen to test for PTSD.

A positive PTSD screen was associated with significantly higher scores on the YEOQ overall as well as higher scores on each individual item. Higher scores on the PTSD screen also were associated with more frequent emotional eating for all emotions.

The researchers note that findings about the predictive validity of emotional eating questionnaires have been mixed. Although emotions may influence eating patterns, other mechanisms could be at work, such as general concern about, or lack of control over, eating.

However, the researchers suggest that veterans with PTSD may need specific attention given to alternative coping strategies when facing difficult emotions as part of weight loss treatment.

Civilian patients with mild traumatic brain injury (TBI) who are black, have psychiatric history or lower education, or whose injury was caused by assault might be at greater risk of developing posttraumatic stress disorder or major depression, a longitudinal study suggests.

Stockdevil/Thinkstock

“Our findings may have implications for surveillance and treatment of mental disorders after TBI,” wrote Murray B. Stein, MD, MPH, and his associates. The study was published Jan. 30 in JAMA Psychiatry.

The researchers looked at the risk factors for and prevalence of posttraumatic stress disorder (PTSD) and major depressive disorder among 1,155 patients. The patients were enrolled at 11 level 1 trauma centers across the United States after they were evaluated for mild TBI in emergency departments as part of a prospective study called Transforming Research and Clinical Knowledge in Traumatic Brain Injury, or TRACK-TBI. The comparison group was 230 patients with nonhead orthopedic trauma injuries, wrote Dr. Stein, distinguished professor of psychiatry and family medicine and public health at the University of California, San Diego, and his associates.

They found that each additional year of education was associated with a significant 11% reduction in the risk of developing PTSD after mild TBI (P = .005). Also, black patients had a greater than fivefold higher risk of PTSD (P less than.001) than that of individuals who were not black.

Among patients with a history of mental illness and those who had experienced their injury as a result of assault or violence – as opposed to a motor vehicle accident or fall, for example – both had a greater than threefold higher risk of developing PTSD (odds ratio, 3.57 and 3.43 respectively). A prior TBI was nonsignificantly associated with an increased risk of developing PTSD.

Lower education duration, being black, or a history of mental illness also were all significantly associated with an increased risk of developing major depressive disorder after mild TBI.

However, duration of lost consciousness or posttraumatic amnesia, evidence of brain injury on CT, or hospitalization did not predict an increased risk of PTSD or major depression.

“Although MDD and PTSD are prevalent after TBI, little is known about which patients are at risk for developing them,” Dr. Stein and his associates wrote.

Noting that having a prior mental health problem was an “exceptionally strong” risk factor for PTSD and MDD after TBI, the authors said this could represent continuation or exacerbation of the prior mental health issue, or the triggering of a new episode in a person with a past history who had recovered.

“However, in either case this finding underscores the importance of clinicians being aware of the mental health history of their patients with [mild TBI], as this information is central to expectations regarding both short-term and long-term outcome,” they wrote.

Dr. Stein and his associates cited as a limitation their reliance on patient or family report. In addition, they said, the elevated risk for mental disorders among black individuals after mild TBI, which was independent of socioeconomic status or cause of injury, was not understood. “Unmeasured covariates may be part of the explanation; this is a topic needing further study,” they wrote.

The study was supported by the National Institutes of Health, the U.S. Department of Defense, Abbott Laboratories, and One Mind. Four authors declared consultancies, advisory board positions, speaking fees, and shares or stock options with the pharmaceutical and private industry. Two authors declared grants from the study sponsors.

SOURCE: Stein MB et al. JAMA Psychiatry. 2019. Jan 30. doi: 10.1001/jamapsychiatry.2018.4288.

Civilian patients with mild traumatic brain injury (TBI) who are black, have psychiatric history or lower education, or whose injury was caused by assault might be at greater risk of developing posttraumatic stress disorder or major depression, a longitudinal study suggests.

Stockdevil/Thinkstock

“Our findings may have implications for surveillance and treatment of mental disorders after TBI,” wrote Murray B. Stein, MD, MPH, and his associates. The study was published Jan. 30 in JAMA Psychiatry.

The researchers looked at the risk factors for and prevalence of posttraumatic stress disorder (PTSD) and major depressive disorder among 1,155 patients. The patients were enrolled at 11 level 1 trauma centers across the United States after they were evaluated for mild TBI in emergency departments as part of a prospective study called Transforming Research and Clinical Knowledge in Traumatic Brain Injury, or TRACK-TBI. The comparison group was 230 patients with nonhead orthopedic trauma injuries, wrote Dr. Stein, distinguished professor of psychiatry and family medicine and public health at the University of California, San Diego, and his associates.

They found that each additional year of education was associated with a significant 11% reduction in the risk of developing PTSD after mild TBI (P = .005). Also, black patients had a greater than fivefold higher risk of PTSD (P less than.001) than that of individuals who were not black.

Among patients with a history of mental illness and those who had experienced their injury as a result of assault or violence – as opposed to a motor vehicle accident or fall, for example – both had a greater than threefold higher risk of developing PTSD (odds ratio, 3.57 and 3.43 respectively). A prior TBI was nonsignificantly associated with an increased risk of developing PTSD.

Lower education duration, being black, or a history of mental illness also were all significantly associated with an increased risk of developing major depressive disorder after mild TBI.

However, duration of lost consciousness or posttraumatic amnesia, evidence of brain injury on CT, or hospitalization did not predict an increased risk of PTSD or major depression.

“Although MDD and PTSD are prevalent after TBI, little is known about which patients are at risk for developing them,” Dr. Stein and his associates wrote.

Noting that having a prior mental health problem was an “exceptionally strong” risk factor for PTSD and MDD after TBI, the authors said this could represent continuation or exacerbation of the prior mental health issue, or the triggering of a new episode in a person with a past history who had recovered.

“However, in either case this finding underscores the importance of clinicians being aware of the mental health history of their patients with [mild TBI], as this information is central to expectations regarding both short-term and long-term outcome,” they wrote.

Dr. Stein and his associates cited as a limitation their reliance on patient or family report. In addition, they said, the elevated risk for mental disorders among black individuals after mild TBI, which was independent of socioeconomic status or cause of injury, was not understood. “Unmeasured covariates may be part of the explanation; this is a topic needing further study,” they wrote.

The study was supported by the National Institutes of Health, the U.S. Department of Defense, Abbott Laboratories, and One Mind. Four authors declared consultancies, advisory board positions, speaking fees, and shares or stock options with the pharmaceutical and private industry. Two authors declared grants from the study sponsors.

SOURCE: Stein MB et al. JAMA Psychiatry. 2019. Jan 30. doi: 10.1001/jamapsychiatry.2018.4288.

Civilian patients with mild traumatic brain injury (TBI) who are black, have psychiatric history or lower education, or whose injury was caused by assault might be at greater risk of developing posttraumatic stress disorder or major depression, a longitudinal study suggests.

Stockdevil/Thinkstock

“Our findings may have implications for surveillance and treatment of mental disorders after TBI,” wrote Murray B. Stein, MD, MPH, and his associates. The study was published Jan. 30 in JAMA Psychiatry.

The researchers looked at the risk factors for and prevalence of posttraumatic stress disorder (PTSD) and major depressive disorder among 1,155 patients. The patients were enrolled at 11 level 1 trauma centers across the United States after they were evaluated for mild TBI in emergency departments as part of a prospective study called Transforming Research and Clinical Knowledge in Traumatic Brain Injury, or TRACK-TBI. The comparison group was 230 patients with nonhead orthopedic trauma injuries, wrote Dr. Stein, distinguished professor of psychiatry and family medicine and public health at the University of California, San Diego, and his associates.

They found that each additional year of education was associated with a significant 11% reduction in the risk of developing PTSD after mild TBI (P = .005). Also, black patients had a greater than fivefold higher risk of PTSD (P less than.001) than that of individuals who were not black.

Among patients with a history of mental illness and those who had experienced their injury as a result of assault or violence – as opposed to a motor vehicle accident or fall, for example – both had a greater than threefold higher risk of developing PTSD (odds ratio, 3.57 and 3.43 respectively). A prior TBI was nonsignificantly associated with an increased risk of developing PTSD.

Lower education duration, being black, or a history of mental illness also were all significantly associated with an increased risk of developing major depressive disorder after mild TBI.

However, duration of lost consciousness or posttraumatic amnesia, evidence of brain injury on CT, or hospitalization did not predict an increased risk of PTSD or major depression.

“Although MDD and PTSD are prevalent after TBI, little is known about which patients are at risk for developing them,” Dr. Stein and his associates wrote.

Noting that having a prior mental health problem was an “exceptionally strong” risk factor for PTSD and MDD after TBI, the authors said this could represent continuation or exacerbation of the prior mental health issue, or the triggering of a new episode in a person with a past history who had recovered.

“However, in either case this finding underscores the importance of clinicians being aware of the mental health history of their patients with [mild TBI], as this information is central to expectations regarding both short-term and long-term outcome,” they wrote.

Dr. Stein and his associates cited as a limitation their reliance on patient or family report. In addition, they said, the elevated risk for mental disorders among black individuals after mild TBI, which was independent of socioeconomic status or cause of injury, was not understood. “Unmeasured covariates may be part of the explanation; this is a topic needing further study,” they wrote.

The study was supported by the National Institutes of Health, the U.S. Department of Defense, Abbott Laboratories, and One Mind. Four authors declared consultancies, advisory board positions, speaking fees, and shares or stock options with the pharmaceutical and private industry. Two authors declared grants from the study sponsors.

SOURCE: Stein MB et al. JAMA Psychiatry. 2019. Jan 30. doi: 10.1001/jamapsychiatry.2018.4288.