We conducted a systematic review of the literature to explore the longitudinal course of PTSD in DSM-5-defined trauma exposed populations to identify the course of illness and recovery for ...individuals and populations experiencing PTSD.
We reviewed the published literature from January 1, 1998 to December 31, 2010 for longitudinal studies of directly exposed trauma populations in order to: (1) review rates of PTSD in the first year after a traumatic event; (2) examine potential types of proposed DSM-5 direct trauma exposure (intentional and non-intentional); and (3) identify the clinical course of PTSD (early onset, later onset, chronicity, remission, and resilience). Of the 2537 identified articles, 58 articles representing 35 unique subject populations met the proposed DSM-5 criteria for experiencing a traumatic event, and assessed PTSD at two or more time points within 12 months of the traumatic event.
The mean prevalence of PTSD across all studies decreases from 28.8% (range =3.1-87.5%) at 1 month to 17.0% (range =0.6-43.8%) at 12 months. However, when traumatic events are classified into intentional and non-intentional, the median prevalences trend down for the non-intentional trauma exposed populations, while the median prevalences in the intentional trauma category steadily increase from 11.8% to 23.3%. Across five studies with sufficient data, 37.1% of those exposed to intentional trauma develop PTSD. Among those with PTSD, about one third (34.8%) remit after 3 months. Nearly 40% of those with PTSD (39.1%) have a chronic course, and only a very small fraction (3.5%) of new PTSD cases appears after three months.
Understanding the trajectories of PTSD over time, and how it may vary by type of traumatic event (intentional vs. non-intentional) will assist public health planning and treatment.
The events of Sept. 11, 2001, highlighted the importance of understanding the effects of trauma on disaster workers. To better plan for the health care of disaster workers, this study examined acute ...stress disorder, posttraumatic stress disorder (PTSD), early dissociative symptoms, depression, and health care utilization in disaster workers.
Exposed disaster workers (N=207) and unexposed comparison subjects (N=421) were examined at 2, 7, and 13 months after an airplane crash.
Exposed disaster workers had significantly higher rates of acute stress disorder, PTSD at 13 months, depression at 7 months, and depression at 13 months than comparison subjects. Those who were younger and single were more likely to develop acute stress disorder. Exposed disaster workers with acute stress disorder were 3.93 times more likely to be depressed at 7 months. Those with high exposure and previous disaster experience or who had acute stress disorder were more likely to develop PTSD. Similarly, those who were depressed at 7 months were 9.5 times more likely to have PTSD. Those who were depressed at 13 months were 7.96 times more likely to also meet PTSD criteria. More exposed disaster workers than comparison subjects obtained medical care for emotional problems at 2, 7, and 13 months. Overall, 40.5% of exposed disaster workers versus 20.4% of comparison subjects had acute stress disorder, depression at 13 months, or PTSD.
Exposed disaster workers are at increased risk of acute stress disorder, depression, or PTSD and seek care for emotional problems at an increased rate.
The suicide rate among US Army soldiers has increased substantially in recent years.
To estimate the lifetime prevalence and sociodemographic, Army career, and psychiatric predictors of suicidal ...behaviors among nondeployed US Army soldiers.
A representative cross-sectional survey of 5428 nondeployed soldiers participating in a group self-administered survey.
Lifetime suicidal ideation, suicide plans, and suicide attempts.
The lifetime prevalence estimates of suicidal ideation, suicide plans, and suicide attempts are 13.9%, 5.3%, and 2.4%. Most reported cases (47.0%-58.2%) had pre-enlistment onsets. Pre-enlistment onset rates were lower than in a prior national civilian survey (with imputed/simulated age at enlistment), whereas post-enlistment onsets of ideation and plans were higher, and post-enlistment first attempts were equivalent to civilian rates. Most reported onsets of plans and attempts among ideators (58.3%-63.3%) occur within the year of onset of ideation. Post-enlistment attempts are positively related to being a woman (with an odds ratio OR of 3.3 95% CI, 1.5-7.5), lower rank (OR = 5.8 95% CI, 1.8-18.1), and previously deployed (OR = 2.4-3.7) and are negatively related to being unmarried (OR = 0.1-0.8) and assigned to Special Operations Command (OR = 0.0 95% CI, 0.0-0.0). Five mental disorders predict post-enlistment first suicide attempts in multivariate analysis: pre-enlistment panic disorder (OR = 0.1 95% CI, 0.0-0.8), pre-enlistment posttraumatic stress disorder (OR = 0.1 95% CI, 0.0-0.7), post-enlistment depression (OR = 3.8 95% CI, 1.2-11.6), and both pre- and post-enlistment intermittent explosive disorder (OR = 3.7-3.8). Four of these 5 ORs (posttraumatic stress disorder is the exception) predict ideation, whereas only post-enlistment intermittent explosive disorder predicts attempts among ideators. The population-attributable risk proportions of lifetime mental disorders predicting post-enlistment suicide attempts are 31.3% for pre-enlistment onset disorders, 41.2% for post-enlistment onset disorders, and 59.9% for all disorders.
The fact that approximately one-third of post-enlistment suicide attempts are associated with pre-enlistment mental disorders suggests that pre-enlistment mental disorders might be targets for early screening and intervention. The possibility of higher fatality rates among Army suicide attempts than among civilian suicide attempts highlights the potential importance of means control (ie, restricting access to lethal means such as firearms) as a suicide prevention strategy.
The purpose of this article was to examine the accuracy of DSM-5 proposed criteria for persistent complex bereavement disorder in identifying putative cases of clinically impairing grief and in ...excluding nonclinical cases. Performance of criteria sets for prolonged grief disorder and complicated grief were similarly assessed.
Participants were family members of U.S. military service members who died of any cause since September 11, 2001 (N=1,732). Putative clinical and nonclinical samples were derived from this community sample using cutoff scores from the Inventory of Complicated Grief and the Work and Social Adjustment Scale. Items from a self-report grief measure (Complicated Grief Questionnaire) were matched to DSM-5 persistent complex bereavement disorder, prolonged grief disorder, and complicated grief criteria. Endorsed items were used to identify cases.
Criteria sets varied in their ability to identify clinical cases. DSM-5 persistent complex bereavement disorder criteria identified 53%, prolonged grief disorder criteria identified 59%, and complicated grief criteria identified more than 90% of putative clinical cases. All criteria sets accurately excluded virtually all nonclinical grief cases and accurately excluded depression in the absence of clinical grief.
The DSM-5 persistent complex bereavement disorder criteria accurately exclude nonclinical, normative grief, but also exclude nearly half of clinical cases, whereas complicated grief criteria exclude nonclinical cases while identifying more than 90% of clinical cases. The authors conclude that significant modification is needed to improve case identification by DSM-5 persistent complex bereavement disorder diagnostic criteria. Complicated grief criteria are superior in accurately identifying clinically impairing grief.
The US Army experienced a sharp increase in soldier suicides beginning in 2004. Administrative data reveal that among those at highest risk are soldiers in the 12 months after inpatient treatment of ...a psychiatric disorder.
To develop an actuarial risk algorithm predicting suicide in the 12 months after US Army soldier inpatient treatment of a psychiatric disorder to target expanded posthospitalization care.
There were 53,769 hospitalizations of active duty soldiers from January 1, 2004, through December 31, 2009, with International Classification of Diseases, Ninth Revision, Clinical Modification psychiatric admission diagnoses. Administrative data available before hospital discharge abstracted from a wide range of data systems (sociodemographic, US Army career, criminal justice, and medical or pharmacy) were used to predict suicides in the subsequent 12 months using machine learning methods (regression trees and penalized regressions) designed to evaluate cross-validated linear, nonlinear, and interactive predictive associations.
Suicides of soldiers hospitalized with psychiatric disorders in the 12 months after hospital discharge.
Sixty-eight soldiers died by suicide within 12 months of hospital discharge (12.0% of all US Army suicides), equivalent to 263.9 suicides per 100,000 person-years compared with 18.5 suicides per 100,000 person-years in the total US Army. The strongest predictors included sociodemographics (male sex odds ratio (OR), 7.9; 95% CI, 1.9-32.6 and late age of enlistment OR, 1.9; 95% CI, 1.0-3.5), criminal offenses (verbal violence OR, 2.2; 95% CI, 1.2-4.0 and weapons possession OR, 5.6; 95% CI, 1.7-18.3), prior suicidality OR, 2.9; 95% CI, 1.7-4.9, aspects of prior psychiatric inpatient and outpatient treatment (eg, number of antidepressant prescriptions filled in the past 12 months OR, 1.3; 95% CI, 1.1-1.7), and disorders diagnosed during the focal hospitalizations (eg, nonaffective psychosis OR, 2.9; 95% CI, 1.2-7.0). A total of 52.9% of posthospitalization suicides occurred after the 5% of hospitalizations with highest predicted suicide risk (3824.1 suicides per 100,000 person-years). These highest-risk hospitalizations also accounted for significantly elevated proportions of several other adverse posthospitalization outcomes (unintentional injury deaths, suicide attempts, and subsequent hospitalizations).
The high concentration of risk of suicide and other adverse outcomes might justify targeting expanded posthospitalization interventions to soldiers classified as having highest posthospitalization suicide risk, although final determination requires careful consideration of intervention costs, comparative effectiveness, and possible adverse effects.
Traumatic brain injury (TBI) is increasingly recognized as a risk factor for deleterious mental health and functional outcomes. The purpose of this study was to examine the strength and specificity ...of the association between deployment-acquired TBI and subsequent posttraumatic stress and related disorders among U.S. Army personnel.
A prospective, longitudinal survey of soldiers in three Brigade Combat Teams was conducted 1-2 months prior to an average 10-month deployment to Afghanistan (T0), upon redeployment to the United States (T1), approximately 3 months later (T2), and approximately 9 months later (T3). Outcomes of interest were 30-day prevalence postdeployment of posttraumatic stress disorder (PTSD), major depressive episode, generalized anxiety disorder, and suicidality, as well as presence and severity of postdeployment PTSD symptoms.
Complete information was available for 4,645 soldiers. Approximately one in five soldiers reported exposure to mild (18.0%) or more-than-mild (1.2%) TBI(s) during the index deployment. Even after adjusting for other risk factors (e.g., predeployment mental health status, severity of deployment stress, prior TBI history), deployment-acquired TBI was associated with elevated adjusted odds of PTSD and generalized anxiety disorder at T2 and T3 and of major depressive episode at T2. Suicidality risk at T2 appeared similarly elevated, but this association did not reach statistical significance.
The findings highlight the importance of surveillance efforts to identify soldiers who have sustained TBIs and are therefore at risk for an array of postdeployment adverse mental health outcomes, including but not limited to PTSD. The mechanism(s) accounting for these associations need to be elucidated to inform development of effective preventive and early intervention programs.
Although high rates of current mental disorder are known to exist in the US Army, little is known about the proportions of these disorders that had onsets prior to enlistment.
To estimate the ...proportions of 30-day DSM-IV mental disorders among nondeployed US Army personnel with first onsets prior to enlistment and the extent which role impairments associated with 30-day disorders differ depending on whether the disorders had pre- vs post-enlistment onsets.
A representative sample of 5428 soldiers participating in the Army Study to Assess Risk and Resilience in Servicemembers completed self-administered questionnaires and consented to linkage of questionnaire responses with administrative records.
Thirty-day DSM-IV internalizing (major depressive, bipolar, generalized anxiety, panic, and posttraumatic stress) and externalizing (attention-deficit/hyperactivity, intermittent explosive, alcohol/drug) disorders were assessed with validated self-report scales. Age at onset was assessed retrospectively. Role impairment was assessed with a modified Sheehan Disability Scale.
A total of 25.1% of respondents met criteria for any 30-day disorder (15.0% internalizing; 18.4% externalizing) and 11.1% for multiple disorders. A total of 76.6% of cases reported pre-enlistment age at onset of at least one 30-day disorder (49.6% internalizing; 81.7% externalizing). Also, 12.8% of respondents reported severe role impairment. Controlling for sociodemographic and Army career correlates, which were broadly consistent with other studies, 30-day disorders with pre-enlistment (χ₈² = 131.8, P < .001) and post-enlistment (χ₇² = 123.8, P < .001) ages at onset both significantly predicted severe role impairment, although pre-enlistment disorders were more consistent powerful predictors (7 of 8 disorders significant; odds ratios, 1.6-11.4) than post-enlistment disorders (5 of 7 disorders significant; odds ratios, 1.5-7.7). Population-attributable risk proportions of severe role impairment were 21.7% for pre-enlistment disorders, 24.3% for post-enlistment disorders, and 43.4% for all disorders.
Interventions to limit accession or increase resilience of new soldiers with pre-enlistment mental disorders might reduce prevalence and impairments of mental disorders in the US Army.
Abstract Background Suicide rates have risen considerably in the United States Army in the past decade. Suicide risk is highest among those with past suicidality (suicidal ideation or attempts). The ...incidence of posttraumatic stress disorder (PTSD) and depressive illnesses has risen concurrently in the U.S. Army. We examined the relationship of PTSD and depression, independently and in combination, and rates of past-year suicidality in a representative sample of U.S. Army soldiers. Methods This study used the DoD Survey of Health Related Behaviors Among Active Duty Military Personnel (DoD HRB) ( N =5927). Probable PTSD and depression were assessed with the PTSD Checklist (PCL) and the 10-item short form of the Center for Epidemiologic Studies Depression Scale (CES-D), respectively. Past-year suicidality was assessed via self-report. Results Six percent of Army service members reported suicidality within the past year. PTSD and MDD were each independently associated with past-year suicidality. Soldiers with both disorders were almost three times more likely to report suicidality within the past year than those with either diagnosis alone. Population-attributable risk proportions for PTSD, depression, and both disorders together were 24%, 29%, and 45%, respectively. Limitations The current study is subject to the limitations of a cross-sectional survey design and the self-report nature of the instruments used. Conclusions PTSD and depression are each associated with suicidality independently and in combination in the active duty component of the U.S. Army. Soldiers presenting with either but especially both disorders may require additional outreach and screening to decrease suicidal ideation and attempts.
Responding to an unprecedented increase in the suicide rate among soldiers, in 2008 the US Army and US National Institute of Mental Health funded the Army Study to Assess Risk and Resilience in ...Servicemembers (Army STARRS), a multicomponent epidemiological and neurobiological study of risk and resilience factors for suicidal thoughts and behaviors, and their psychopathological correlates among Army personnel. Using a combination of administrative records, representative surveys, computerized neurocognitive tests, and blood samples, Army STARRS and its longitudinal follow-up study (STARRS-LS) are designed to identify potentially actionable findings to inform the Army's suicide prevention efforts. The current report presents a broad overview of Army STARRS and its findings to date on suicide deaths, attempts, and ideation, as well as other important outcomes that may increase suicide risk (e.g., mental disorders, sexual assault victimization). The findings highlight the complexity of environmental and genetic risk and protective factors in different settings and contexts, and the importance of life and career history in understanding suicidal thoughts and behaviors.
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