Diagnosis of PTSD by Army Behavioral Health Clinicians: Are Diagnoses Recorded in Electronic Health Records?

OBJECTIVE: The study sought to identify the extent to which posttraumatic stress disorder (PTSD) diagnoses are recorded in the electronic health record (EHR) in Army behavioral health clinics and to assess clinicians' reasons for not recording them and treatment factors associated with recording or not recording the diagnosis. METHODS: A total of 543 Army mental health providers completed the anonymous, Web-based survey. Clinicians reported clinical data for 399 service member patients, of whom 110 (28%) had a reported PTSD diagnosis. Data were weighted to account for sampling design and nonresponses. RESULTS: Of those given a diagnosis of PTSD by their clinician, 59% were reported to have the diagnosis recorded in the EHR, and 41% did not. The most common reason for not recording was reducing stigma or protecting the service member's career prospects. Psychiatrists were more likely than psychologists or social workers to record the diagnosis. CONCLUSIONS: Findings indicate that for many patients presenting with PTSD in Army behavioral health clinics at the time of the survey (2010), clinicians did not record a PTSD diagnosis in the EHR, often in an effort to reduce stigma. This pattern may exist for other diagnoses. Recent Army policy has provided guidance to clinicians on diagnostic recording practice. An important implication concerns the reliance on coded diagnoses in PTSD surveillance efforts by the U.S. Department of Defense (DoD). The problem of underestimated prevalence rates may be further compounded by overly narrow DoD surveillance definitions of PTSD.

Prevalence of Professional Burnout Among Military Mental Health Service Providers.

OBJECTIVE: Professional burnout is a well-documented occupational phenomenon, characterized by the gradual "wearing away" of an individual's physical and mental well-being, resulting in a variety of adverse job-related outcomes. It has been suggested that burnout is more common in occupations that require close interpersonal relationships, such as mental health services. METHODS: This study surveyed 488 mental health clinicians working with military populations about work-related outcomes, including level of professional burnout, job satisfaction, and other work-related domains. RESULTS: Approximately 21% (weighted) of the sample reported elevated levels of burnout; several domains were found to be significantly associated with burnout. CONCLUSIONS: Education about professional burnout symptoms and early intervention are essential to ensure that providers continue to provide optimal care for service members and veterans.

Assessing functional impairment in a working military population: the Walter Reed functional impairment scale.

Measurement of functional impairment is a priority for the military and other professional work groups routinely exposed to stressful traumatic events as part of their occupation. Standard measures of impairment used in general or chronically ill populations contain many items not suitable for these populations, and include mental health symptoms items that are not true measures of functioning. We created a new, 14-item scale-the Walter Reed Functional Impairment Scale-to assess functioning in 4 domains (physical, occupational, social, and personal). We asked 3,380 soldiers how much difficulty they currently have in each of the 4 domains on a 5-point scale. Behaviorally based psychosocial and occupational performance measures and general health questions were used to validate the scale. The utility of the scale was assessed against clinical measures of psychopathology and physical health (depression, posttraumatic stress disorder [PTSD], general health, generalized physical symptoms). We utilized Cronbach's alpha, item response theory, and the score test for trend to establish consistency of items and the validity of the scale. The scale exhibited excellent reliability (Cronbach's α= 0.92) and validity. The individual items and quartiles of sum scores were strongly correlated with negative occupational and social performance, and the utility of the scale was demonstrated by strong correlations with depression, PTSD, and high levels of generalized physical symptoms. This scale exhibits excellent psychometric properties in this sample of U.S. soldiers and, pending future research, is likely to have utility for other healthy occupational groups.

Mental health outcomes in US and UK military personnel returning from Iraq.

BACKGROUND: Research of military personnel who deployed to the conflicts in Iraq or Afghanistan has suggested that there are differences in mental health outcomes between UK and US military personnel. AIMS: To compare the prevalence of post-traumatic stress disorder (PTSD), hazardous alcohol consumption, aggressive behaviour and multiple physical symptoms in US and UK military personnel deployed to Iraq. METHOD: Data were from one US (n = 1560) and one UK (n = 313) study of post-deployment military health of army personnel who had deployed to Iraq during 2007-2008. Analyses were stratified by high- and low-combat exposure. RESULTS: Significant differences in combat exposure and sociodemographics were observed between US and UK personnel; controlling for these variables accounted for the difference in prevalence of PTSD, but not in the total symptom level scores. Levels of hazardous alcohol consumption (low-combat exposure: odds ratio (OR) = 0.13, 95% CI 0.07-0.21; high-combat exposure: OR = 0.23, 95% CI 0.14-0.39) and aggression (low-combat exposure: OR = 0.36, 95% CI 0.19-0.68) were significantly lower in US compared with UK personnel. There was no difference in multiple physical symptoms. CONCLUSIONS: Differences in self-reported combat exposures explain most of the differences in reported prevalence of PTSD. Adjusting for self-reported combat exposures and sociodemographics did not explain differences in hazardous alcohol consumption or aggression.

The prevalence of post-traumatic stress disorder (PTSD) in US combat soldiers: a head-to-head comparison of DSM-5 versus DSM-IV-TR symptom criteria with the PTSD checklist.

BACKGROUND: The definition of post-traumatic stress disorder (PTSD) underwent substantial changes in the 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). How this will affect estimates of prevalence, whether clinical utility has been improved, and how many individuals who meet symptom criteria according to the previous definition will not meet new criteria is unknown. Updated screening instruments, including the PTSD checklist (PCL), have not been compared with previously validated methods through head-to-head comparisons. METHODS: We compared the new 20-item PCL, mapped to DSM-5 (PCL-5), with the original validated 17-item specific stressor version (PCL-S) in 1822 US infantry soldiers, including 946 soldiers who had been deployed to Iraq or Afghanistan. Surveys were administered in November, 2013. Soldiers alternately received either of two surveys that were identical except for the order of the two PCL versions (911 per group). Standardised scales measured major depression, generalised anxiety, alcohol misuse, and functional impairment. RESULTS: In analysis of all soldiers, 224 (13%) screened positive for PTSD by DSM-IV-TR criteria and 216 (12%) screened positive by DSM-5 criteria (κ 0·67). In soldiers exposed to combat, 177 (19%) screened positive by DSM-IV-TR and 165 (18%) screened positive by DSM-5 criteria (0·66). However, of 221 soldiers with complete data who met DSM-IV-TR criteria, 67 (30%) did not meet DSM-5 criteria, and 59 additional soldiers met only DSM-5 criteria. PCL-5 scores from 15-38 performed similarly to PCL-S scores of 30-50; a PCL-5 score of 38 gave optimum agreement with a PCL-S of 50. The two definitions showed nearly identical association with other psychiatric disorders and functional impairment. CONCLUSIONS: Our findings showed the PCL-5 to be equivalent to the validated PCL-S. However, the new PTSD symptom criteria do not seem to have greater clinical utility, and a high percentage of soldiers who met criteria by one definition did not meet the other criteria. Clinicians need to consider how to manage discordant outcomes, particularly for service members and veterans with PTSD who no longer meet criteria under DSM-5. FUNDING: US Army Military Operational Medicine Research Program (MOMRP), Fort Detrick, MD.

Use of evidence-based treatment for posttraumatic stress disorder in Army behavioral healthcare.

OBJECTIVE: To identify the extent to which evidence-based psychotherapy (EBP) and psychopharmacologic treatments for posttraumatic stress disorder (PTSD) are provided to U.S. service members in routine practice, and the degree to which they are consistent with evidence-based treatment guidelines. METHOD: We surveyed the majority of Army behavioral health providers (n = 2,310); surveys were obtained from 543 (26%). These clinicians reported clinical data on a total sample of 399 service member patients. Of these patients, 110 (28%) had a reported PTSD diagnosis. Data were weighted to account for sampling design and nonresponses. RESULTS: Army providers reported 86% of patients with PTSD received evidence-based psychotherapy (EBP) for PTSD. As formal training hours in EBPs increased, reported use of EBPs significantly increased. Although EBPs for PTSD were reported to be widely used, clinicians who deliver EBP frequently reported not adhering to all core procedures recommended in treatment manuals; less than half reported using all the manualized core EBP techniques. CONCLUSIONS: Further research is necessary to understand why clinicians modify EBP treatments, and what impact this has on treatment outcomes. More data regarding the implications for treatment effectiveness and the role of clinical context, patient preferences, and clinical decision-making in adapting EBPs could help inform training efforts and the ways that these treatments may be better adapted for the military.

Posttraumatic stress disorder associated with combat service in Iraq or Afghanistan: reconciling prevalence differences between studies.

Studies of posttraumatic stress disorder (PTSD) prevalence associated with deployment to Iraq or Afghanistan report wide variability, making interpretation and projection for research and public health purposes difficult. This article placed this literature within a military context. Studies were categorized according to deployment time-frame, screening case definition, and study group (operational infantry units exposed to direct combat versus population samples with a high proportion of support personnel). Precision weighted averages were calculated using a fixed-effects meta-analysis. Using a specific case definition, the weighted postdeployment PTSD prevalence was 5.5% (95% CI, 5.4-5.6) in population samples and 13.2% (12.8-13.7) in operational infantry units. Both population-level and unit-specific studies provided valuable and unique information for public health purposes; understanding the military context is essential for interpreting prevalence studies.

Mild traumatic brain injury (concussion), posttraumatic stress disorder, and depression in U.S. soldiers involved in combat deployments: association with postdeployment symptoms.

OBJECTIVES: Several studies have examined the relationship between concussion/mild traumatic brain injury (mTBI), posttraumatic stress disorder (PTSD), depression, and postdeployment symptoms. These studies indicate that the multiple factors involved in postdeployment symptoms are not accounted for in the screening processes of the Department of Defense/Veteran's Affairs months after concussion injuries. This study examined the associations of single and multiple deployment-related mTBIs on postdeployment health. METHODS: A total of 1502 U.S. Army soldiers were administered anonymous surveys 4 to 6 months after returning from deployment to Iraq or Afghanistan assessing history of deployment-related concussions, current PTSD, depression, and presence of postdeployment physical and neurocognitive symptoms. RESULTS: Of these soldiers, 17% reported an mTBI during their previous deployment. Of these, 59% reported having more than one. After adjustment for PTSD, depression, and other factors, loss of consciousness was significantly associated with three postconcussive symptoms, including headaches (odds ratio [OR] = 1.5, 95% confidence interval [CI] = 1.1-2.3). However, these symptoms were more strongly associated with PTSD and depression than with a history of mTBI. Multiple mTBIs with loss of consciousness increased the risk of headache (OR = 4.0, 95% CI = 2.4-6.8) compared with a single occurrence, although depression (OR = 4.2, 95% CI = 2.6-6.8) remained as strong a predictor. CONCLUSIONS: These data indicate that current screening tools for mTBI being used by the Department of Defense/Veteran's Affairs do not optimally distinguish persistent postdeployment symptoms attributed to mTBI from other causes such as PTSD and depression. Accumulating evidence strongly supports the need for multidisciplinary collaborative care models of treatment in primary care to collectively address the full spectrum of postwar physical and neurocognitive health concerns.

Factors associated with interest in receiving help for mental health problems in combat veterans returning from deployment to Iraq.

Mental health problems in service members often go untreated. This study focused on factors related to interest in receiving help in a survey sample of 577 combat veterans who were screened positive for posttraumatic stress disorder, depression, or generalized anxiety disorder 3 months after returning from Iraq. Over three quarters of respondents recognized that they had a current problem, but only 40% were interested in receiving help. Interest in receiving help was associated with recognizing a problem and receiving mental health services in the past year. More negative attitudes toward mental health care were associated with lower interest in receiving help; paradoxically, more negative perceptions of unit stigma were associated with increased interest in receiving help. Further studies are needed to better define the relationship between stigma perceptions, interest in receiving care, and actual care utilization and to determine whether attitudes toward mental health care can be modified through changes in how care is delivered. Attitudes toward mental health care should be considered in treatment interventions.