Faculty Bibliography

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

Aviation, military, police, and health care personnel have been particularly interested in the operational impact of sleep restriction and work schedules given the potential severe consequences of making fatigue-related errors. Most studies examining the impact of sleep loss or circadian manipulations have been conducted in controlled laboratory settings using small sample sizes. This study examined whether the relationship between prior night sleep duration and performance on the psychomotor vigilance task could be reliably detected in a field study of healthy police academy recruits. Subjects (N = 189) were medically and psychiatrically healthy. Sleep-wake activity was assessed with wrist actigraphy for 7 days. Subjects performed the psychomotor vigilance task (PVT) for 5 min on a personal digital assistant (PDA) device before and after their police academy workday and on comparable times during their days off. Mixed-effects logistic regression was used to estimate the probability of having > or =1 lapse on the PVT as a function of the previous night sleep duration during the 7 days of field testing. Valid estimates of sleep duration were obtained for 1082 nights of sleep. The probability of a lapse decreased by 3.5%/h sleep the night prior to testing. The overall probability of having a lapse decreased by 0.9%/h since awakening, holding hours of sleep constant. Perceived stress was not associated with sleep duration or probability of performance lapse. These findings demonstrate the feasibility of detecting sleep and circadian effects on cognitive performance in large field studies. These findings have implications regarding the daytime functioning of police officers

CONTEXT: Posttraumatic stress disorder (PTSD) is highly prevalent among US veterans because of combat and may impair cognition. OBJECTIVE: To determine whether PTSD is associated with the risk of developing dementia among older US veterans receiving treatment in the Department of Veterans Affairs medical centers. DESIGN: A stratified, retrospective cohort study conducted using the Department of Veterans Affairs National Patient Care Database. SETTING: Department of Veterans Affairs medical centers in the United States. PARTICIPANTS: A total of 181 093 veterans 55 years or older without dementia from fiscal years 1997 through 2000 (53 155 veterans with and 127 938 veterans without PTSD). MAIN OUTCOME MEASURES: During the follow-up period between October 1, 2000, and December 31, 2007, 31 107 (17.2%) veterans were ascertained to have newly diagnosed dementia according to International Classification of Diseases, Ninth Revision, Clinical Modification codes. RESULTS: The mean baseline age of the veterans was 68.8 years, and 174 806 (96.5%) were men. Veterans with PTSD had a 7-year cumulative incident dementia rate of 10.6%, whereas those without had a rate of 6.6% (P < .001). With age as the time scale, Cox proportional hazards models indicated that patients with PTSD were more than twice as likely to develop incident dementia compared with those without PTSD (hazard ratio, 2.31; 95% confidence interval, 2.24-2.39). After multivariable adjustment, patients with PTSD were still more likely to develop dementia (hazard ratio, 1.77; 95% confidence interval, 1.70-1.85). Results were similar when we excluded those with a history of head injury, substance abuse, or clinical depression. CONCLUSIONS: In a predominantly male veteran cohort, those diagnosed as having PTSD were at a nearly 2-fold-higher risk of developing dementia compared with those without PTSD. Mechanisms linking these important disorders need to be identified with the hope of finding ways to reduce the increased risk of dementia associated with PTSD.

Thousands of Sudanese refugees have fled to Cairo, Egypt in the wake of Sudanese civil conflicts. Sudanese refugees were evaluated with respect to symptoms of depression, post-traumatic stress disorder (PTSD) and social stress. Four respondents (22%) indicated that their interactions with the United Nations High Commissioner for Refugees (UNHCR) in Cairo, Egypt were the worst experiences since war-related atrocities. Fourteen participants (63.6%) felt 'extremely' betrayed by the UNHCR on a four point scale. Greater feelings of betrayal by the UNHCR were associated with greater avoidance and arousal symptoms of PTSD, symptoms of depression and trait anger. This is the first study of which we are aware that examines the relationship between sense of betrayal by the UNHCR and symptoms of PTSD, depression and anger among asylum seekers

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

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

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

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