A population study of prolonged grief in refugees.

AIMS: Despite the frequency that refugees suffer bereavement, there is a dearth of research into the prevalence and predictors of problematic grief reactions in refugees. To address this gap, this study reports a nationally representative population-based study of refugees to determine the prevalence of probable prolonged grief disorder (PGD) and its associated problems. METHODS: This study recruited participants from the Building a New Life in Australia (BNLA) prospective cohort study of refugees admitted to Australia between October 2013 and February 2014. The current data were collected in 2015-2016, and comprised 1767 adults, as well as 411 children of the adult respondents. Adult refugees were assessed for trauma history, post-migration difficulties, probable PGD, post-traumatic stress disorder (PTSD) and mental illness. Children were administered the Strengths and Difficulties Questionnaire. RESULTS: In this cohort, 38.1% of refugees reported bereavement, of whom 15.8% reported probable PGD; this represents 6.0% of the entire cohort. Probable PGD was associated with a greater likelihood of mental illness, probable PTSD, severe mental illness, currently unemployed and reported disability. Children of refugees with probable PGD reported more psychological difficulties than those whose parents did not have probable PGD. Probable PGD was also associated with the history of imprisonment, torture and separation from family. Only 56.3% of refugees with probable PGD had received psychological assistance. CONCLUSIONS: Bereavement and probable PGD appear highly prevalent in refugees, and PGD seems to be associated with disability in the refugees and psychological problems in their children. The low rate of access to mental health assistance for these refugees highlights that there is a need to address this issue in refugee populations.

Separation from parents during childhood trauma predicts adult attachment security and post-traumatic stress disorder.

BACKGROUND: Prolonged separation from parental support is a risk factor for psychopathology. This study assessed the impact of brief separation from parents during childhood trauma on adult attachment tendencies and post-traumatic stress. METHOD: Children (n = 806) exposed to a major Australian bushfire disaster in 1983 and matched controls (n = 725) were assessed in the aftermath of the fires (mean age 7-8 years) via parent reports of trauma exposure and separation from parents during the fires. Participants (n = 500) were subsequently assessed 28 years after initial assessment on the Experiences in Close Relationships scale to assess attachment security, and post-traumatic stress disorder (PTSD) was assessed using the PTSD checklist. RESULTS: Being separated from parents was significantly related to having an avoidant attachment style as an adult (B = -3.69, s.e. = 1.48, ß = -0.23, p = 0.013). Avoidant attachment was associated with re-experiencing (B = 0.03, s.e. = 0.01, ß = 0.31, p = 0.045), avoidance (B = 0.03, s.e. = 0.01, ß = 0.30, p = 0.001) and numbing (B = 0.03, s.e. = 0.01, ß = 0.30, p < 0.001) symptoms. Anxious attachment was associated with re-experiencing (B = 0.03, s.e. = 0.01, ß = 0.18, p = 0.001), numbing (B = 0.03, ß = 0.30, s.e. = 0.01, p < 0.001) and arousal (B = 0.04, s.e. = 0.01, ß = 0.43, p < 0.001) symptoms. CONCLUSIONS: These findings demonstrate that brief separation from attachments during childhood trauma can have long-lasting effects on one's attachment security, and that this can be associated with adult post-traumatic psychopathology.

The longitudinal relationship between post-traumatic stress disorder and perceived social support in survivors of traumatic injury.

BACKGROUND: Although perceived social support is thought to be a strong predictor of psychological outcomes following trauma exposure, the temporal relationship between perceived positive and negative social support and post-traumatic stress disorder (PTSD) symptoms has not been empirically established. This study investigated the temporal sequencing of perceived positive social support, perceived negative social support, and PTSD symptoms in the 6 years following trauma exposure among survivors of traumatic injury. METHOD: Participants were 1132 trauma survivors initially assessed upon admission to one of four Level 1 trauma hospitals in Australia after experiencing a traumatic injury. Participants were followed up at 3 months, 12 months, 24 months, and 6 years after the traumatic event. RESULTS: Latent difference score analyses revealed that greater severity of PTSD symptoms predicted subsequent increases in perceived negative social support at each time-point. Greater severity of PTSD symptoms predicted subsequent decreases in perceived positive social support between 3 and 12 months. High levels of perceived positive or negative social support did not predict subsequent changes in PTSD symptoms at any time-point. CONCLUSIONS: Results highlight the impact of PTSD symptoms on subsequent perceived social support, regardless of the type of support provided. The finding that perceived social support does not influence subsequent PTSD symptoms is novel, and indicates that the relationship between PTSD and perceived social support may be unidirectional.

Flavored e-cigarette use: Characterizing youth, young adult, and adult users.

The purpose of this study is to investigate how the use of flavored e-cigarettes varies between youth (12-17 years old), young adults (18-29 years old), and older adults (30 + years old). Cross-sectional surveys of school-going youth (n = 3907) and young adult college students (n = 5482) in Texas, and young adults and older adults (n = 6051) nationwide were administered in 2014-2015. Proportions and 95% confidence intervals were used to describe the percentage of e-cigarette use at initiation and in the past 30 days that was flavored, among current e-cigarette users. Chi-square tests were applied to examine differences by combustible tobacco product use and demographic factors. Most e-cigarette users said their first and "usual" e-cigarettes were flavored. At initiation, the majority of Texas school-going youth (98%), Texas young adult college students (95%), and young adults (71.2%) nationwide said their first e-cigarettes were flavored to taste like something other than tobacco, compared to 44.1% of older adults nationwide. Fruit and candy flavors predominated for all groups; and, for youth, flavors were an especially salient reason to use e-cigarettes. Among adults, the use of tobacco flavor at initiation was common among dual users (e-cigarettes + combustible tobacco), while other flavors were more common among former cigarette smokers (P = 0.03). Restricting the range of e-cigarette flavors (e.g., eliminating sweet flavors, like fruit and candy) may benefit youth and young adult prevention efforts. However, it is unclear what impact this change would have on adult smoking cessation.

Major depression and depressive symptoms in Australian Gulf War veterans 20 years after the Gulf War.

BACKGROUND: Risk of major depression (depression) was elevated in Australia's Gulf War veterans in a 2000-2002 (baseline) study. A follow up study has measured the Gulf War-related risk factors for depression, also the current prevalence and severity of depression, use of anti-depressant medication, and persistence, remittance or incidence of depression since baseline in Gulf War veterans and a military comparison group. METHODS: Participants completed the Composite International Diagnostic Interview v.2.1, the 9-item Patient Health Questionnaire and the Military Service Experience Questionnaire, and consented to Repatriation Pharmaceutical Benefits Scheme (RPBS) and PBS linkage. RESULTS: Prevalence of depression (9.7% Gulf War veterans and 7.7% comparison group; adj RR=1.2, 95% CI 0.8-1.7), and pattern of persistence, remittance and incidence of depression since baseline, were similar in the two groups, however veterans reported slightly more severe symptoms (adj median difference 1, 95% CI 0.26-1.74) and were more likely to have been dispensed anti-depressant medication (adj RR=1.56, 95% CI 1.05-2.32). Depression amongst veterans was associated with self-reported Gulf War-related stressors in a dose-response relationship (adj RR 1.06, 95% CI 1.02-1.09). LIMITATIONS: Lower participation rates at follow up resulted in reduced statistical power compared with baseline, Gulf War related stressor data collected at baseline was at risk of recall bias, and RPBS and PBS databases do not capture all dispensed Nervous System medications. CONCLUSIONS: More than 20 years after the Gulf War, veterans are experiencing slightly more severe depressive symptoms than a military comparison group, and depression continues to be associated with Gulf War-related stressors.

Depression in Gulf War veterans: a systematic review and meta-analysis.

BACKGROUND: Although post-traumatic stress disorder (PTSD) has been a focus of attention in 1990/1991 Gulf War veterans, the excess risk of depression has not been clearly identified. We investigated this through a systematic review and meta-analysis of studies comparing depression in Gulf War veterans to depression in a comparison group of non-deployed military personnel. METHOD: Multiple electronic databases and grey literature were searched from 1990 to 2012. Studies were assessed for eligibility and risk of bias according to established criteria. RESULTS: Of 14 098 titles and abstracts assessed, 14 studies met the inclusion criteria. Gulf War veterans had over twice the odds of experiencing depression [odds ratio (OR) 2.28, 95% confidence interval (CI) 1.88-2.76] and dysthymia or chronic dysphoria (OR 2.39, 95% CI 2.0-2.86) compared to non-deployed military personnel. This finding was robust in sensitivity analyses, and to differences in overall risk of bias and psychological measures used. CONCLUSIONS: Despite divergent methodologies between studies, depression and dysthymia were twice as common in Gulf War veterans and are important medical conditions for clinicians and policymakers to be aware of in managing Gulf War veterans' health.

Comorbidity in the prediction of Cognitive Processing Therapy treatment outcomes for combat-related posttraumatic stress disorder.

This paper examines clinical predictors of posttraumatic stress disorder (PTSD) treatment outcomes following Cognitive Processing Therapy (CPT) in Australian military veterans. Fifty nine treatment seeking veterans were enrolled in a randomized controlled trial comparing 12 sessions of CPT (n = 30) with usual treatment (n = 29) at three community-based veterans counseling centers. PTSD and key co-morbidities (depression, anxiety, anger and alcohol use) were measured. Growth curve modeling was used to examine factors which influenced PTSD severity post-treatment. For the CPT condition, baseline anger was the only co-morbidity predictive of change in PTSD severity over time. Participants with higher anger scores showed less of a decrease in PTSD severity over time. Higher anxiety in participants in treatment as usual was significantly associated with better treatment gains. This research suggests that veterans experiencing high levels of anger might benefit from targeted anger reduction strategies to increase the effectiveness of CPT treatment for PTSD.

A multisite randomized controlled effectiveness trial of cognitive processing therapy for military-related posttraumatic stress disorder.

Cognitive processing therapy (CPT) is currently applied in military veteran mental health services in many countries. This study tests the effectiveness of community-administered CPT for military-related PTSD under randomized controlled conditions. Fifty-nine treatment-seeking veterans with military-related PTSD were randomly allocated to receive 12 twice-weekly 60 min sessions of CPT or an equivalent period of usual treatment at veterans' community based counseling services. Intent to treat analyses found significantly greater improvement for participants receiving CPT over usual treatment at post-treatment and 3 month follow-up. CPT also produced greater improvements in anxiety, depression, social and dyadic relationships than usual treatment. No CPT related adverse events occurred during the trial. This trial reports the first randomized controlled trial evidence that CPT is an effective treatment for military PTSD and co-morbid conditions when compared to usual treatment and delivered in community settings by clinicians from diverse disciplines, preferred treatment orientation and levels of experience.

Remission from post-traumatic stress disorder in the general population.

BACKGROUND: Few studies have focused on post-traumatic stress disorder (PTSD) remission in the population, none have modelled remission beyond age 54 years and none have explored in detail the correlates of remission from PTSD. This study examined trauma experience, symptom severity, co-morbidity, service use and time to PTSD remission in a large population sample. METHOD: Data came from respondents (n=8841) of the 2007 Australian National Survey of Mental Health and Wellbeing (NSMHWB). A modified version of the World Health Organization's World Mental Health Composite International Diagnostic Interview (WMH-CIDI) was used to determine the presence and age of onset of DSM-IV PTSD and other mental and substance use disorders, type, age, and number of lifetime traumas, severity of re-experiencing, avoidance and hypervigilance symptoms and presence and timing of service use. RESULTS: Projected lifetime remission rate was 92% and median time to remission was 14 years. Those who experienced childhood trauma, interpersonal violence, severe symptoms or a secondary anxiety or affective disorder were less likely to remit from PTSD and reported longer median times to remission compared to those with other trauma experiences, less severe symptoms or no co-morbidity. CONCLUSIONS: Although most people in the population with PTSD eventually remit, a significant minority report symptoms decades after onset. Those who experience childhood trauma or interpersonal violence should be a high priority for intervention.

Heart rate after trauma and the specificity of fear circuitry disorders.

BACKGROUND: Fear circuitry disorders purportedly include post-traumatic stress disorder (PTSD), panic disorder, agoraphobia, social phobia and specific phobia. It is proposed that these disorders represent a cluster of anxiety disorders triggered by stressful events and lead to fear conditioning. Elevated heart rate (HR) at the time of an aversive event may reflect strength of the unconditioned response, which may contribute to fear circuitry disorders. METHOD: This prospective cohort study assessed HR within 48 h of hospital admission in 602 traumatically injured patients, who were assessed during hospital admission and within 1 month of trauma exposure for lifetime psychiatric diagnosis. At 3 months after the initial assessment, 526 patients (87%) were reassessed for PTSD, major depressive disorder, panic disorder, agoraphobia, social phobia, obsessive compulsive disorder and generalized anxiety disorder. RESULTS: At the 3-month assessment there were 77 (15%) new cases of fear circuitry disorder and 87 new cases of non-fear circuitry disorder (17%). After controlling for gender, age, type of injury and injury severity, patients with elevated HR (defined as ≥96 beats per min) at the time of injury were more likely to develop PTSD [odds ratio (OR) 5.78, 95% confidence interval (CI) 2.32-14.43], panic disorder (OR 3.46, 95% CI 1.16-10.34), agoraphobia (OR 3.90, 95% CI 1.76-8.61) and social phobia (OR 3.98, 95% CI 1.42-11.14). Elevated HR also predicted new fear circuitry disorders that were not co-morbid with a non-fear circuitry disorder (OR 7.28, 95% CI 2.14-24.79). CONCLUSIONS: These data provide tentative evidence of a common mechanism underpinning the onset of fear circuitry disorders.

Support for the mutual maintenance of pain and post-traumatic stress disorder symptoms.

BACKGROUND: Pain and post-traumatic stress disorder (PTSD) are frequently co-morbid in the aftermath of a traumatic event. Although several models attempt to explain the relationship between these two disorders, the mechanisms underlying the relationship remain unclear. The aim of this study was to investigate the relationship between each PTSD symptom cluster and pain over the course of post-traumatic adjustment. METHOD: In a longitudinal study, injury patients (n=824) were assessed within 1 week post-injury, and then at 3 and 12 months. Pain was measured using a 100-mm Visual Analogue Scale (VAS). PTSD symptoms were assessed using the Clinician-Administered PTSD Scale (CAPS). Structural equation modelling (SEM) was used to identify causal relationships between pain and PTSD. RESULTS: In a saturated model we found that the relationship between acute pain and 12-month pain was mediated by arousal symptoms at 3 months. We also found that the relationship between baseline arousal and re-experiencing symptoms, and later 12-month arousal and re-experiencing symptoms, was mediated by 3-month pain levels. The final model showed a good fit [chi2=16.97, df=12, p>0.05, Comparative Fit Index (CFI)=0.999, root mean square error of approximation (RMSEA)=0.022]. CONCLUSIONS: These findings provide evidence of mutual maintenance between pain and PTSD.

A longitudinal analysis of alcohol consumption and the risk of posttraumatic symptoms.

BACKGROUND: Previous studies investigating the impact of alcohol ingestion on the emergence of posttraumatic psychological symptoms have generated contradictory findings. METHODS: One thousand forty-five patients, admitted to hospital following traumatic injury were assessed during hospitalisation for patterns of alcohol consumption prior to the injury and also during the month prior to reassessment at 3 months. Anxiety, depression and posttraumatic stress disorder (PTSD) were assessed post accident and at 3 months. In a sub sample (n=167), blood alcohol levels were measured at the time of admission to emergency departments. RESULTS: Moderate alcohol consumption prior to and following the accident predicted lower levels of psychological distress at 1 week and 3 months. No significant relationship was found between the blood alcohol level and psychiatric outcomes. PTSD predicted the emergence of alcohol abuse following the accident, suggesting self-medication in a subgroup of survivors. LIMITATIONS: The impact of alcohol consumption upon injury severity and the nature of injury was not controlled for and some non-participation may have been related to patterns of alcohol consumption. We relied on retrospective reports of alcohol use obtained shortly after the traumatic injury to index prior alcohol use and these reports may have been influenced by mood states at the time of recall. Our follow-up was limited to 3 months and there is a need for longer-term assessment of the relationship between prior alcohol use and subsequent posttraumatic adjustment. CONCLUSION: Given the potential impact of alcohol use on traumatic injury and post-injury recovery, we advocate active screening and early intervention strategies that focus on moderate alcohol usage.

Olfactory identification dysfunction, aggression and impulsivity in war veterans with post-traumatic stress disorder.

BACKGROUND: Due to neuropsychological conceptualizations of orbitoprefrontal cortex (OFC) dysfunction underpinning impulsive aggression and the incidence of such behaviour in post-traumatic stress disorder (PTSD), this study aimed to explore olfactory identification (OI) ability in war veterans with PTSD as a probe of putative OFC dysfunction; and to explore the utility of OI ability in predicting aggressive and impulsive behavior in this clinical population. METHOD: Participants comprised 31 out-patient male war veterans with PTSD (mean=58.23 years, s.d.=2.56) recruited from a Melbourne Veterans Psychiatry Unit, and 31 healthy age- and gender-matched controls (mean=56.84 years, s.d.=7.24). All participants were assessed on clinical measures of PTSD, depression, anxiety, and alcohol misuse; olfactory identification; neurocognitive measures of dorsolateral prefrontal, lateral prefrontal and mesial temporal functioning; and self-report measures of aggression and impulsivity. RESULTS: War veterans with PTSD exhibited significant OI deficits (OIDs) compared to controls, despite uncompromised performance on cognitive measures. OIDs remained after covaring for IQ, anxiety, depression and alcohol misuse, and were significant predictors of aggression and impulsivity. CONCLUSIONS: This research contributes to emerging evidence of orbitoprefrontal dysfunction in the pathophysiology underlying PTSD. This is the first study to report OIDs as a predictor of aggression and impulsivity in this clinical population. It prompts further exploration of the potential diagnostic utility of OIDs in the assessment of PTSD. Such measures may help delineate the clinical complexity of PTSD, and support more targeted interventions for individuals with a greater susceptibility to aggressive and impulsive behaviors.

Demands for vascular access in a renal dialysis unit: implications for a regional vascular unit.

BACKGROUND: The development of regional dialysis units and the expanding indications for dialysis has led to increased demand for vascular access surgery. Consequently, the provision and maintenance of access, and the management of related complications has created a considerable burden on vascular surgical units in hospitals providing renal replacement therapy (RRT). AIMS: The objectives of our study were to review our experience with a variety of vascular access modalities for haemodialysis and to quantify the associated surgical workload. METHODS: We reviewed our experience in a consecutive group of dialysis patients who had access surgery for RRT in a regional hospital setting. RESULTS: Between January 1995 and January 2000, 69 patients entered the long-term dialysis programme in the Mid-Western region (population = 320,000). Of the 158 procedures performed, 138 (87%) were for access creation, and 20 (13%) related to access revision procedures. Twenty patients (29%) developed a total of 30 access related complications. Vascular access procedures accounted for 10% of the vascular surgical workload (1598 procedures) in the five-year period. CONCLUSION: Vascular access is an important part of the haemodialysis services and surgical expertise should be available at local level to cope with likely demand.

Psychological health of Australian veterans of the 1991 Gulf War: an assessment using the SF-12, GHQ-12 and PCL-S.

BACKGROUND: Elevated rates of psychological morbidity and symptomatology have been widely reported in 1991 Gulf War veterans. The present study used brief self-report instruments to compare the psychological health of Australian Gulf War veterans with that of a randomly sampled military comparison group. METHOD: The 12-item Short Form Health Survey (SF-12), 12-item General Health Questionnaire (GHQ-12), Posttraumatic Stress Disorder Checklist--Specific (PCL-S) and Military Service Experience (MSE) questionnaire were administered to 1424 male Australian Gulf War veterans and 1548 male Australian Defence Force members who were operational at the time of the Gulf War conflict, but were not deployed there. RESULTS: The Gulf War veterans exhibited poorer psychological health, as measured by the above three instruments, than the comparison group members. For Gulf War veterans, the number of stressful experiences, as measured by the MSE questionnaire, was correlated with scores on the three instruments. SF-12 mental health component summary scores and PCL-S caseness, but not GHQ-12 caseness, differed significantly between Gulf War veterans and comparison group members who had been on at least one active deployment. CONCLUSIONS: More than a decade after the 1991 Gulf War, Australian Gulf War veterans are exhibiting higher levels of current (past month) psychological ill-health, as measured using the GHQ-12 and PCL-S, as well as lower mental health status, as measured by the SF-12, than the comparison group. Although not a replacement for formal psychiatric diagnosis, instruments such as those above may aid in the assessment of veterans' psychological health.

Self-reported problems: a comparison between PTSD-diagnosed veterans, their spouses, and clinicians.

This study investigated self-reported problems in a sample of help-seeking Vietnam veterans, comparing the veteran's own view with clinician and spouse perspectives, with the aim of examining convergence in reports across different informants. Veterans with PTSD (N = 459) were asked to list and rate their five most serious problems. Spouses and treating clinicians completed the same questionnaire in relation to the veteran. Rates of endorsement for each problem area, and levels of agreement between raters, were calculated. Veterans, spouses, and clinicians were all likely to rate anger as a high priority, with veterans also likely to nominate anxiety and depression. Spouses were likely to nominate more observable behavioural problems such as interpersonal difficulties and avoidance, while clinicians were likely to nominate indications of psychopathology, such as anxiety, depression, and intrusive thoughts. Agreement across raters was generally high, although interpretation of agreement levels was complex.

Post-traumatic stress disorder: findings from the Australian National Survey of Mental Health and Well-being.

BACKGROUND: We report on the epidemiology of post-traumatic stress disorder (PTSD) in the Australian community, including information on lifetime exposure to trauma, 12-month prevalence of PTSD, sociodemographic correlates and co-morbidity. METHODS: Data were obtained from a stratified sample of 10,641 participants as part of the Australian National Survey of Mental Health and Well-being. A modified version of the Composite International Diagnostic Interview was used to determine the presence of PTSD, as well as other DSM-IV anxiety, affective and substance use disorders. RESULTS: The estimated 12-month prevalence of PTSD was 1-33%, which is considerably lower than that found in comparable North American studies. Although females were at greater risk than males within the subsample of those who had experienced trauma, the large gender differences noted in some recent epidemiological research were not replicated. Prevalence was elevated among the never married and previously married respondents, and was lower among those aged over 55. For both men and women, rape and sexual molestation were the traumatic events most likely to be associated with PTSD. A high level of Axis 1 co-morbidity was found among those persons with PTSD. CONCLUSIONS: PTSD is a highly prevalent disorder in the Australian community and is routinely associated with high rates of anxiety, depression and substance disorders. Future research is needed to investigate rates among other populations outside the North American continent.

Risk factors for posttrauma reactions in police officers: a longitudinal study.

This prospective, longitudinal study investigated risk factors in the development of psychological ill health and posttraumatic stress symptoms in a sample of 223 junior police officers. Participants were assessed using a self-report methodology during training and again 12 months later on a range of personality, trauma exposure, and symptom measures. Risk factors for general psychological ill health at phase 2 of the research were found to comprise mostly stable, preexisting characteristics such as personality style, gender, and trait dissociation. Conversely, specific traumatic stress symptoms were more heavily influenced by experiences in the intervening 12 months, such as severity of incident exposure and peritraumatic dissociation. The implications for differential intervention are discussed.

The validity of the PTSD checklist as a measure of symptomatic change in combat-related PTSD.

Little research to date has examined the ability of self-report measures to assess changes in symptom severity and diagnostic status as a function of treatment. This study investigated the validity of the posttraumatic stress disorder (PTSD) checklist (PCL) as a measure of symptomatic change following programmatic treatment. A sample of 97 Vietnam veterans with combat-related PTSD was assessed using the clinician-administered PTSD scale (CAPS) and the PCL prior to, and 9 months following, participation in a PTSD treatment program. Using the CAPS as the "gold standard" measure of PTSD symptomatology, the PCL demonstrated high diagnostic accuracy pre- and posttreatment. However, significant variations in accuracy were evident in the ability of the PCL to determine the presence and severity of individual symptoms at each time point. In addition, as symptoms improved from pre- to posttreatment, and approached the threshold criteria, the PCL demonstrated reductions in diagnostic accuracy. As a measure of overall symptomatic change, the PCL underrated improvement in comparison to the CAPS. The results supported the use of an overall cut-off score of 50 on the PCL for a diagnosis, and an item score of 3 for symptom criterion, in this population.