Faculty Bibliography

BACKGROUND: Family history of psychiatric and substance use disorders has been associated with posttraumatic stress disorder (PTSD) in cross-sectional studies. METHOD: Using a prospective design, we examined the relationships of family history of psychiatric and substance use disorders to posttraumatic stress symptoms in 278 healthy police recruits. During academy training, recruits were interviewed on family and personal psychopathology, prior cumulative civilian trauma exposure, and completed self-report questionnaires on nonspecific symptoms of distress and alcohol use. Twelve months after commencement of active duty, participants completed questionnaires on critical incident exposure over the previous year, peritraumatic distress to the worst critical incident during this time, and posttraumatic stress symptoms. RESULTS: A path model indicated: (1) family loading for mood and anxiety disorders had an indirect effect on posttraumatic stress symptoms at 12 months that was mediated through peritraumatic distress to the officer's self-identified worst critical incident, (2) family loading for substance use disorders also predicted posttraumatic stress symptoms at 12 months and this relationship was mediated through peritraumatic distress. CONCLUSION: These findings support a model in which family histories of psychopathology and substance abuse are pre-existing vulnerability factors for experiencing greater peritraumatic distress to critical incident exposure which, in turn, increases the risk for development of symptoms of posttraumatic stress disorder. Replication in other first responders, military and civilians will be important to determine generalizability of these findings

BACKGROUND: Over 35% of returned Iraq and Afghanistan veterans in VA care have received mental health diagnoses; the most prevalent is post-traumatic stress disorder (PTSD). Little is known about these patients' use of non-mental health medical services and the impact of mental disorders on utilization. OBJECTIVE: To compare utilization across three groups of Iraq and Afghanistan veterans: those without mental disorders, those with mental disorders other than PTSD, and those with PTSD. DESIGN AND PARTICIPANTS: National, descriptive study of 249,440 veterans newly utilizing VA healthcare between October 7, 2001 and March 31, 2007, followed until March 31, 2008. MEASUREMENTS: We used ICD9-CM diagnostic codes to classify mental health status. We compared utilization of outpatient non-mental health services, primary care, medical subspecialty, ancillary services, laboratory tests/diagnostic procedures, emergency services, and hospitalizations during veterans' first year in VA care. Results were adjusted for demographics and military service and VA facility characteristics. MAIN RESULTS: Veterans with mental disorders had 42-146% greater utilization than those without mental disorders, depending on the service category (all P < 0.001). Those with PTSD had the highest utilization in all categories: 71-170% greater utilization than those without mental disorders (all P < 0.001). In adjusted analyses, compared with veterans without mental disorders, those with mental disorders other than PTSD had 55% higher utilization of all non-mental health outpatient services; those with PTSD had 91% higher utilization. Female sex and lower rank were also independently associated with greater utilization. CONCLUSIONS: Veterans with mental health diagnoses, particularly PTSD, utilize significantly more VA non-mental health medical services. As more veterans return home, we must ensure resources are allocated to meet their outpatient, inpatient, and emergency needs

Police work is one of the most stressful occupations. Previous research has indicated that work stress and trauma exposure may place individuals at heightened risk for the development of depression symptomatology. This prospective longitudinal study was designed to examine predictors of depression symptoms in police service. Participants comprised 119 healthy police recruits from an ongoing prospective study. They completed baseline measures of depression symptoms, childhood trauma exposure, neuroticism, and self-worth during academy training. Follow-up measures of depression symptoms, PTSD symptoms, critical incident exposure, negative life events, and routine work environment stress were assessed after 12 months of police service. Hierarchical linear regression analysis was conducted to examine predictors of current levels of depression symptoms, controlling for baseline depression symptoms and current PTSD symptoms. Greater childhood trauma exposure, lower self-worth during training, and greater perceived work stress in the first year of police service predicted greater depression symptoms at 12 months. Depression symptoms at 1 year of police service were partly independent from PTSD symptoms at 12 months. Greater childhood trauma exposure and lower self-worth during training may be important variables to screen as risk factors for duty-related depression. Strategies to reduce routine work environment stress have the potential to decrease duty-related depression in law enforcement

Given the long distances involved and the kinds of activities planned, crewmembers participating in long-duration exploratory space missions such as an expedition to Mars will have more autonomy than in previous space missions. In order to study the impact of high versus low crew autonomy on crewmembers and the crew-mission control interaction, we conducted a series of pilot studies involving three space simulation settings: NEEMO missions, the Haughton-Mars Project, and the pilot phase of the Mars 500 Program. As in our previous on-orbit studies on the Mir and International Space Station, crew and mission control subjects working in missions involving these three settings completed a weekly study questionnaire that assessed mood and interpersonal interactions using the Profile of Mood States, the Group Environment Scale, and the Work Environment Scale. The Mars 500 pilot study also directly assessed individual and group autonomy. In these studies, high autonomy periods were those where crewmembers planned much of their work schedule, whereas low autonomy periods were those where mission control personnel developed the schedule, much as happens now during actual space flight conditions. Our results suggested that high work autonomy was well-received by the crews, mission goals were accomplished, and there were no adverse effects. During high autonomy periods, crewmember mood was generally reported as being better and creativity was higher, but mission control personnel reported some confusion about their work role. The crewmember group environment in the Mars 500 pilot study was dependent on the nationality mix. Despite scoring lower in work pressure overall, the four Russian crewmembers reported a greater rise in work pressure from low to high autonomy than the two Europeans. In contrast, the European crewmembers reported a greater rise in dysphoric mood in going from low to high autonomy, whereas the Russians' emotional state remained the same or slightly improved. It is time to study the effects of high autonomy with larger subject samples during actual space missions on-orbit in preparation for future exploratory missions, where high autonomy will be the norm. (C) 2010 Elsevier Ltd. All rights reserved

Although military personnel serving in Iraq and Afghanistan are at high risk of developing mental health problems, many report significant barriers to care and few seek help. Integrated primary care is a comprehensive model of health care that aims to improve access to care and provides a framework to assess and meet the complex psychiatric needs of newly returning veterans by embedding mental health specialists within primary care. We describe the role of psychologists in a Department of Veterans Affairs (VA) integrated primary care clinic that serves veterans of Iraq and Afghanistan. Psychologists based in primary care can assist veterans with reintegration to civilian life by providing rapid mental health assessment, normalizing re-adjustment concerns, planning for veterans' safety, implementing brief interventions within primary care, facilitating transition to additional mental health care, and informing veterans of other available psychosocial services. A case example demonstrating the psychologist's role highlights the benefits of an integrated care model. Implications of employing this model include reduction of symptoms and impairment by reducing stigma and barriers to seeking mental health care, increased motivation to engage in treatment, and implementation of early interventions. This model may also be beneficial in the civilian health care sector with groups that are at high risk for mental health problems, yet experience barriers to care, particularly stigma.

This study examined the mental health impact of reported direct and indirect killing among 2,797 U.S. soldiers returning from Operation Iraqi Freedom. Data were collected as part of a postdeployment screening program at a large Army medical facility. Overall, 40% of soldiers reported killing or being responsible for killing during their deployment. Even after controlling for combat exposure, killing was a significant predictor of posttraumatic disorder (PTSD) symptoms, alcohol abuse, anger, and relationship problems. Military personnel returning from modern deployments are at risk of adverse mental health conditions and related psychosocial functioning related to killing in war. Mental health assessment and treatment should address reactions to killing to optimize readjustment following deployment

Little is known about mental health services utilization among Iraq and Afghanistan veterans receiving care at Department of Veterans Affairs (VA) facilities. Of 49,425 veterans with newly diagnosed posttraumatic stress disorder (PTSD), only 9.5% attended 9 or more VA mental health sessions in 15 weeks or less in the first year of diagnosis. In addition, engagement in 9 or more VA treatment sessions for PTSD within 15 weeks varied by predisposing variables (age and gender), enabling variables (clinic of first mental health diagnosis and distance from VA facility), and need (type and complexity of mental health diagnoses). Thus, only a minority of Iraq and Afghanistan veterans with new PTSD diagnoses received a recommended number and intensity of VA mental health treatment sessions within the first year of diagnosis

CONTEXT: Most neuroimaging studies of posttraumatic stress disorder (PTSD) have focused on potential abnormalities in the whole hippocampus, but the subfields of this structure, which have distinctive histological characteristics and specialized functions, have not been investigated. Studies of individual subfields may clarify the role of the hippocampus in PTSD. OBJECTIVE: To determine if PTSD is associated with structural alterations in specific subfields of the hippocampus. DESIGN: Case-control study. PARTICIPANTS: A total of 17 male veterans with combat trauma and PTSD (mean [SD] age, 41 [12] years) and 19 age-matched male veterans without PTSD who were recruited from the outpatient mental health clinic of the San Francisco Veterans Affairs Medical Center and by advertising in the community. INTERVENTIONS: High-resolution magnetic resonance imaging at 4 T. MAIN OUTCOME MEASURE: Volumes of hippocampal subfields. RESULTS: Posttraumatic stress disorder was associated with 11.4% (1.5%) (P = .02) smaller mean (SD) cornu ammonis 3 (CA3)/dentate gyrus subfield volumes, irrespective of age-related alterations, whereas other subfields were spared. Age was associated with reduced volume of the CA1 subfield (P = .03). Total hippocampal volume was also reduced in PTSD by a mean (SD) of 6.5% (0.6%) but, related to both PTSD (P = .05) and age (P = .01), was consistent with the measurements in the subfields. CONCLUSIONS: The findings indicate for the first time in humans that PTSD is associated with selective volume loss of the CA3/dentate gyrus subfields, consistent with animal studies, implying that chronic stress suppresses neurogenesis and dendritic branching in these structures

The 'first night effect' (FNE) is the alteration of sleep architecture observed on the first night of polysomnographic (PSG) studies. It is unclear whether the FNE reflects adaptation to the equipment, sleeping environment, or both. Moreover, it is possible that certain patient populations, such as those with posttraumatic stress disorder (PTSD), demonstrate greater adaptation effects that are highly context dependent. We assessed FNE in participants with PTSD and healthy controls in a cross-sectional study consisting of PSG testing at home and in the hospital. Contrary to our expectations, the PTSD group showed no adaptation effects in either setting. Only the control group assigned to the 'hospital first' condition showed significant decreases in total sleep time on night 1 versus night 2 of the study. The results suggest that the FNE is related to adaptation to the combination of the hospital environment and the recording equipment

BACKGROUND: Prolonged disruption of sleep in animal studies is associated with decreased neurogenesis in the dentate gyrus. Our objective was to determine whether insomnia severity in a sample of posttraumatic stress disorder (PTSD) patients and control subjects was associated with decreased volume in the CA3/dentate hippocampal subfield. METHODS: Volumes of hippocampal subfields in 17 veteran men positive for PTSD (41 +/- 12 years) and 19 age-matched male veterans negative for PTSD were measured with 4-T magnetic resonance imaging. Subjective sleep quality was measured by the Insomnia Severity Index (ISI) and the Pittsburgh Sleep Quality Index. RESULTS: Higher scores on the ISI, indicating worse insomnia, were associated with smaller volumes of the CA3/dentate subfields (r = -.48, p < .01) in the combined sample. Adding the ISI score as a predictor for CA3/dentate volume to a hierarchical linear regression model after first controlling for age and PTSD symptoms accounted for a 13% increase in incremental variance (t = -2.47, p = .02). CONCLUSIONS: The findings indicate for the first time in humans that insomnia severity is associated with volume loss of the CA3/dentate subfields. This is consistent with animal studies showing that chronic sleep disruption is associated with decreased neurogenesis and dendritic branching in these structures