Intergenerational transmission of post-traumatic stress disorder in Australian Vietnam veterans' families.

OBJECTIVE: To assess the association between parental post-traumatic stress disorder (PTSD) and offspring PTSD and its specificity for other disorders in a non-clinical epidemiological cohort of Australian Vietnam veterans, their partners and their sons and daughters. METHOD: Veterans were interviewed twice, in 1992-1994 and 2005-2006; partners were interviewed in 2006-2007, and their offspring in 2012-2014. A total of 125 sons and 168 daughters were interviewed from 197 families, 137 of which also included partners who were the mothers of the children. Statistical analysis used multi-level modelling to compute odds ratios and 95% confidence intervals while controlling for clustering effects within families. Parent PTSD diagnoses were examined for associations with offspring trauma exposure, PTSD and other psychiatric diagnoses. RESULTS: Veteran PTSD increased the risk of PTSD and no other disorder in both sons and daughters; partner PTSD did not. Veteran depression was also a risk factor for sons' PTSD, and alcohol disorder was linked to alcohol dependence in sons and PTSD in daughters, but not when controlling for veteran PTSD. CONCLUSION: We conclude that PTSD in a Vietnam veteran father increases the risk specifically for PTSD in his sons and daughters.

Cancer incidence in patients with schizophrenia and their first-degree relatives - a meta-analysis.

OBJECTIVE: Controversy concerning cancer incidence in schizophrenia exists because of heterogeneous study findings. METHOD: A meta-analysis was performed on standardized incidence ratios (SIR) of cancer in patients with schizophrenia and first-degree relatives and compared with general population samples. RESULTS: The pooled overall cancer incidence in patients was not significantly increased (SIR = 1.05, CI 0.95-1.15). Lung cancer incidence was slightly increased (SIR = 1.31, CI 1.01-1.71), but was reduced after adjusting for smoking prevalence. The incidence of several cancers unrelated to smoking was reduced in patients. Breast cancer rates were significantly increased in female patients. The pooled overall cancer incidence in siblings (SIR = 0.89, CI 0.84-0.94) and parents (SIR = 0.90, CI 0.88-0.93) was significantly reduced. A meta-regression detected a significant relationship between cancer risk in the general population and relative risk in patients. CONCLUSION: The meta-analysis aided exploration of inconsistent study findings. There is a discrepancy between cancer risk exposure and cancer incidence in schizophrenia consistent with a protective effect.

Communication across the divide. A trial of structured communication between general practice and emergency departments.

AIM: To evaluate the impact of structured form letters for general practitioner to emergency department (ED) communication. STUDY POPULATION: one hundred and fifty-five GPs with practices in the Liverpool local government area in metropolitan Sydney and patients referred by them to ED at Liverpool over five months from June to October 1998. DESIGN: randomised control trial of GPs as unit of randomisation; intervention GPs were encouraged to follow a structured proforma for their written communication with the ED. Control GPs were left to usual referral procedures. The ED was encouraged to fax a brief report back to GPs using the form. Impact measures: the quality of the referral letters was evaluated using a checklist that included: reason for referral; examination finding; medical history; investigations; psychosocial history; allergies; drugs given in the surgery and present medication. Surveys were sent every month to GPs to assess communication from the ED and adverse events observed by GPs. RESULTS: Most letters from GPs to the ED contained information on reasons for referral, medical history and examination findings. Reasons for referral were present in 95% of the intervention group GPs' letters compared with 99% of those of the control group. Investigations were included with 27% and present medications in 37%. Letters from GPs in the intervention group were more likely to contain a psychosocial history than those in the control group (13% compared with 1%). Most GPs reported receiving a letter from the ED although this was rarely by fax; most were brought to them by the patient. Phone calls were received by about one in five GPs each month. Most GPs found both of these to be useful. There were no differences between communication received by GPs in the intervention and control groups. CONCLUSION: This study demonstrates that improvements to communication between GPs and EDs are difficult and may require a systemic change within general practice and the hospital. Electronic systems may allow the sort of reciprocal communication required to establish and sustain improvement.

Medical-care costs associated with posttraumatic stress disorder in Vietnam veterans.

OBJECTIVE: This study examined the relationship between medical-care costs of Vietnam veterans and predictor factors, including posttraumatic stress disorder (PTSD). METHOD: We merged medical-care cost data from the Department of Veterans' Affairs and the Health Insurance Commission with data from an epidemiological study of 641 Australian Vietnam veterans. Posttraumatic stress disorder and other factors were examined as predictors of medical-care cost using regression analysis. RESULTS: We found that a diagnosis of PTSD was associated with medical costs 60% higher than average. Those costs appeared to be partly associated with higher treatment costs for physical conditions in those with PTSD and also related mental health comorbidities. Major predictors of medical-care cost were age ($137 per year for each 5-year increase in age) and number of diagnoses reported ($81 to $112 per year for each diagnosis). Mental health factors such as depression ($14 per year for each symptom reported) and anxiety ($27 per year for each symptom reported) were also important predictors. CONCLUSIONS: The findings indicate that, however they are incurred, high healthcare and, presumably, also economic and personal costs are associated with PTSD. There is an important social obligation as well as substantial economic reasons to deal with these problems. From both perspectives, continued efforts to identify and implement effective prevention and treatment programs are warranted.

Screening for low prevalence disorders.

OBJECTIVE: To examine the epidemiologic theory of screening as it applies to low prevalence disorders, such as schizophrenia, in order to identify the tasks required for primary and secondary prevention. METHOD: Review of principles of screening, computation of prevented fraction for varying sensitivities, specificities and prevalences of disease, and review of prevalence of schizophrenia in Australian general practice. RESULTS: There is no currently available efficient method of screening for schizophrenia or for prodromal symptoms. From the genesis of disease to eventual outcome, the milestones that are passed in the case of schizophrenia are uncertain in their nature and the intervening time periods are of uncertain and possibly varying duration. The extent of false positives and negatives in low prevalence disorders is high unless the specificity is very high. CONCLUSION: It may be feasible to screen for behaviours that are precursors to schizophrenia; however, screening depends upon the existence of a reliable screening instrument that can be shown to discriminate accurately between diseased and disease-free individuals. Development of a method for screening requires comparison against formal clinical assessment of both screen positives and screen negatives. For low prevalence disorders the predictive values may be low unless specificity is high.

Distress experienced by participants during an epidemiological survey of posttraumatic stress disorder.

We examined the potential for epidemiological studies of mental disorders, specifically of posttraumatic stress disorder (PTSD), to cause further harm to participants involved. Of 1,000 randomly selected Australian Vietnam veterans, 641 agreed to participate in an epidemiological survey. Participants were asked about distress experienced during the interview when traumatic events were raised. Significant distress attributed to the interview was reported by 75.3% of those with current PTSD, 56.5% of those with past PTSD, and 20.6% of those with no PTSD diagnosis. Distress did not affect participants' use of medical services following the interview nor did it affect their willingness to continue participating in the study. We concluded that research interviews about PTSD may cause short-term distress, but found no evidence of long-term harm.

Acute effects of low levels of ambient ozone on peak expiratory flow rate in a cohort of Australian children.

BACKGROUND: We enrolled a cohort of primary schoolchildren with a history of wheeze (n = 148) in an 11-month longitudinal study to examine the relationship between ambient ozone concentrations and peak expiratory flow rate. METHODS: Enrolled children recorded peak expiratory flow rates (PEFR) twice daily. We obtained air pollution, meteorological and pollen data. In all, 125 children remained in the final analysis. RESULTS: We found a significant negative association between daily mean deviation in PEFR and same-day mean daytime ozone concentration (beta-coefficient = 0.88; P = 0.04) after adjusting for co-pollutants, time trend, meteorological variables, pollen count and ALTERNARIA: count. The association was stronger in a subgroup of children with bronchial hyperreactivity and a doctor diagnosis of asthma (beta-coefficient = -2.61; P = 0.001). There was no significant association between PEFR and same-day daily daytime maximum ozone concentration. We also demonstrated a dose-response relationship with mean daytime ozone concentration. CONCLUSIONS: Moderate levels of ambient ozone have an adverse health effect on children with a history of wheezing, and this effect is larger in children with bronchial hyperreactivity and a doctor diagnosis of asthma.

Where's the common ground? A survey of hospitals, community health centres and divisions of general practice in Australia.

BACKGROUND: Divisions of general practice are key structures for integration between general practice and other health services in Australia. AIM: To compare the views of divisions of general practice toward integration of care with those of hospitals and community health services. METHOD: Representative national samples of public hospitals and community health centres (CHCs) and a census of divisions of general practice (DGP) were surveyed on their current collaborations and links as well as barriers to and factors that enhance integration between general practitioners and other health services. RESULTS: There is wide agreement on the need for greater integration. Personal links (via letter, phone and face to face) were thought to be useful. However, general practice liaison officers were seen as especially useful. All organizations rated different accountabilities and responsibilities as a highly significant barrier. Resources, structures for collaboration and high level organisational support were rated as being more useful in enabling greater integration. CONCLUSION: Formalizing collaboration will require changes to funding and accountability. However there is also a need for cultural change to support greater integration of patient care between general practice and both hospitals and community health services.

Hoping and coping in young people who have been sexually abused.

BACKGROUND: Very little research has been conducted on the relationship between sexual abuse, reduced hopefulness and impaired coping. METHOD: The sample consisted of 22 abused young people (2 males (9%) and 20 females (91%)) and 29 nonabused young people (4 males (14%) and 25 females (86%)). Hopefulness, despair, depression, self-esteem, anxiety, number of negative life events and various parent, family and demographic variables were measured. The aim was to establish significant predictors of outcome, with outcome measured at the extreme end of the spectrum by self-injury and suicidal ideation and attempts. RESULTS: Depression predicted hopefulness and despair. Depression, anxiety, number of caregiver changes, despair and global personal hopefulness were significant predictors of outcome. Child sexual abuse itself was not a significant predictor of self-injury, suicidal ideation or suicide attempts in this sample. CONCLUSIONS: Each of the significant predictors of outcome, other than caregiver changes, has been linked to the learned helplessness paradigm. Depression and anxiety may be mediated by despair and hopefulness in their prediction of self-injury and suicidal attempts and ideation. To modify young people's long-term view of their futures and thereby reduce their vulnerability to depression and anxiety and in turn their tendency toward self-injury and suicide, something more than generic casework will be necessary. If self-injury, suicidal ideation and behaviour are to be effectively addressed, it is likely that anxiety and depression will need to be treated vigorously and attention will need to be paid to the perceived future.

Combat, dissociation, and posttraumatic stress disorder in Australian Vietnam veterans.

The specificity of various wartime stressors for different posttraumatic stress disorder (PTSD) symptoms is inconsistently reported in the literature. Combat, wounding, and peritraumatic dissociation have not been assessed together in their effects on each of the various PTSD symptom clusters. This cohort study of a random sample of male Australian Army Vietnam veterans yielded psychiatric assessments of 641 subjects. PTSD measures comprised symptom criteria for reexperiencing, numbing and avoidance, hyperarousal, and PTSD diagnosis both lifetime and current within the past month. Logistic regression is used to examine the effects of combat, wounding, and peritraumatic dissociation together on PTSD. Combat experiences comprised four components derived from a principal components analysis of combat experiences: direct combat exposure, exposure to death and injury, exposure to civilian death and injury, and exposure to mutilation. Each was differentially related to reexperiencing, avoidance, hyperarousal, and PTSD diagnosis. Being wounded was not related to lifetime or current PTSD and peritraumatic dissociation was related to all diagnostic components of PTSD in the presence of other variables.

Posttraumatic stress disorder and other predictors of health care consumption by Vietnam veterans.

A total of 641 randomly selected Australian veterans of the Vietnam War were interviewed about their use of health care in the previous two weeks to determine what factors contributed to health care consumption. Seventy-three variables were examined by univariate linear regression and then grouped into seven categories relating to age, physical and mental health, predisposition to posttraumatic stress disorder (PTSD), deployment and repatriation experiences, and membership in veterans groups. PTSD was associated with an additional cost of $79 in health care for the two-week period. Each physical diagnosis was associated with an additional $28. Alcohol consumption was not related to health care costs. Other important variables contributing to costs were depression, educational status, the quality of the repatriation experience, and social support.

Prior childhood sexual abuse in mothers of sexually abused children.

OBJECTIVE: To see if mothers who were sexually abused in their own childhood are at increased risk of their children being sexually abused and to see if prior sexual abuse in mothers affects their parenting abilities. METHOD: Sixty-seven mothers whose children had been sexually abused by others and 65 control mothers were asked about sexual abuse in their own childhood. The sexually abused children of mothers who had been sexually abused in their own childhood were compared with the sexually abused children of mothers who had not suffered child sexual abuse as children. Comparisons were made on self-esteem, depression and behavior in the children. RESULTS: Thirty-four percent of mothers of sexually abused children gave a history of sexual abuse in their own childhoods, compared with 12% of control mothers. Assessment of the sexually abused children for self-esteem, depression and behavior at the time of diagnosis, after 18 months and after 5 years showed no difference in any of these measures at any of the three time intervals between those whose mothers had suffered child sexual abuse and those whose mothers had not been abused. CONCLUSION: In this study, sexual abuse in a mother's own childhood was related to an increased risk of sexual abuse occurring in the next generation, although prior maternal sexual abuse did not effect outcome in children who were sexually abused.

Postwar experiences and treatment-seeking behavior in a community counselling setting.

Previous research investigating the impact of postwar experiences on Vietnam veterans has focused on veteran morbidity. This emphasis has meant that the impact of these factors on treatment-seeking behavior has received little empirical attention. This study examined the association between postwar factors and treatment-seeking behavior in a sample of 692 Australian Vietnam veterans. Logistic regression analyses were used to compute the odds ratios associated with postwar experiences and self-referral to a community-based counselling service. Results suggest that veterans who reported experiencing negative feelings toward others when they first arrived home were more likely to seek treatment. Other factors, such as a veteran's perception of societal attitudes and the reception they received, were not associated with treatment-seeking behavior.

Risk factors for posttraumatic stress disorder in Australian Vietnam veterans.

OBJECTIVE: The aims of this paper are to determine the risk factors for combat-related posttraumatic stress disorder (PTSD) and to examine the relative contribution of pre-military factors, pre-trauma psychiatric diagnoses, military factors such as combat posting, and combat and casualty stress exposure. METHOD: An epidemiological cohort study using standardised psychiatric, social and health interviews was undertaken with a national random sample of male Australian Army Vietnam veterans. Multivariate logistic regression was used to examine the relative contribution of factors derived from interview and from military records in four categories: pre-enlistment circumstances including home life, education, major life stress; pre-Vietnam psychiatric diagnoses; military experiences before and during Vietnam; and combat and stress experiences. RESULTS: Of the 128 data items examined, significant associations were found for 39, in addition to combat stress. Pre-enlistment items accounted for about 3% of the deviance towards PTSD diagnosis, pre-enlistment psychiatric diagnosis about 13%, military variables about 7% and combat stress about 18%; all factors together accounted for 42%. CONCLUSIONS: The results confirm that pre-military and military variables make only a small but significant contribution to PTSD either alone or after controlling for combat stress; that psychiatric diagnoses of depression, dysthymia and agoraphobia make strong contributions to PTSD; but that combat stress makes the largest contribution even after controlling for the effects of other variables. Psychiatric diagnoses and combat stress appear to be independent in their effects on PTSD.

Posttraumatic stress disorder and comorbidity in Australian Vietnam veterans: risk factors, chronicity and combat.

OBJECTIVE: The objective of this study was to examine the relationship between combat-related posttraumatic stress disorder (PTSD) and comorbid DSM-III-R psychiatric diagnoses to determine commonalities in risk factors, relative onsets and the role of combat exposure. METHOD: An epidemiological cohort study using standardised psychiatric, social and health interviews was undertaken with a national random sample of male Australian Army Vietnam veterans. Interviews and searches of military records yielded risk factors for PTSD, which were examined for association with each psychiatric diagnosis. Relative onsets of PTSD and each Diagnostic Interview Schedule diagnosis were compared. Comorbidity odds ratios were adjusted for combat exposure effects using logistic regression, and the relation between each diagnosis and combat was assessed after controlling for PTSD. RESULTS: Commonality of risk factor profile was evident for several diagnoses, and for many their onset preceded PTSD onset. Combat was independently related to only a few diagnoses after controlling for PTSD, and PTSD remained strongly associated with several conditions after controlling for combat exposure. CONCLUSIONS: The analysis suggests that the disorders that may constitute risk factors or vulnerabilities for PTSD comprise depression and dysthymia, antisocial personality disorder, agoraphobia and simple phobia, while those that may be consequent on PTSD are panic and generalised anxiety disorder, drug use disorders and somatoform pain disorder. Alcohol and drug use disorders and social phobia may have a mixed aetiology, while obsessive-compulsive disorder may be serendipitously related to PTSD through an association with risk of combat. Gambling disorder is unrelated.

Sexually abused children 5 years after presentation: a case-control study.

OBJECTIVE: A total of 68 sexually abused children and their nonoffending parents were reassessed 5 years after presentation and were compared with a cohort of children of similar age and sex who were not known to have been abused. METHOD: Outcome measures were behavior, depression, self-esteem, anxiety, eating problems, drug use, suicide attempts, self-injury, running away, criminal activity, and attributional style. Recent life events, demographics, family functioning, and mothers' mental health were taken into account when examining outcome. RESULTS: Although the abused children had experienced more negative life events, were from lower socioeconomic groups, had more changes in parent figures, and had mothers who were more psychologically distressed, multiple regression analysis showed that after allowing for these and other demographic factors, there were still significant differences between the groups after the 5 years. The abused children displayed more disturbed behavior, had lower self-esteem, were more depressed or unhappy, and were more anxious than controls. Sexually abused children had significantly higher levels of bingeing, self-injury, and suicide attempts. CONCLUSIONS: It is clear that many children who are sexually abused have ongoing problems. Their ongoing problems may be indicative of false beliefs about themselves and the sexual abuse experience.

Five years after child sexual abuse: persisting dysfunction and problems of prediction.

OBJECTIVE: To assess change in behavior, depression, and self-esteem in sexually abused children after 5 years and to determine which factors predict later functioning. METHOD: Sixty-eight of 84 children and their nonoffending parents were reassessed after 5 years for depression, self-esteem, and behavior problems in the children; parental mental health; and family functioning. RESULTS: There were no significant changes in depression, self-esteem, or behavior over 5 years. Forty-three percent of the children were now sad or depressed, 43% had low self-esteem, and 46% had behavioral dysfunction. While some children improved, a nearly equal number deteriorated, with no clear pattern of change. The only abuse-related variables associated with 5-year functioning were further contact with the abuser, which was significantly associated with depression and self-esteem, and sexual abuse prior to intake, which was related to an increased incidence of behavior problems. Older children showed more depression and lower self-esteem but less behavioral dysfunction. Poor family functioning at 5 years was associated with low self-esteem and behavior problems. Treatment had no effect on depression, self-esteem, or behavior. Multivariate analysis showed that depression and self-esteem at intake were prognostic indicators of 5-year outcome. CONCLUSION: Many sexually abused children have continuing problems with behavior, self-esteem, and depression. Family and abuse-related variables do not appear to be good predictors of outcome, although sexually abused children who are sad or depressed and have low self-esteem at intake are likely to have continuing problems in these areas.

Domestic violence in the Emergency Department: 2. Detection by doctors and nurses.

This study was conducted in 1991 and 1992 to determine the detection rates of domestic violence victims by doctors and nurses at the Emergency Department (ED) of Royal Brisbane Hospital, a major public hospital in Australia. The objective was to determine the outcome of an education program about domestic violence conducted in 1991 for doctors and nurses in the ED. As part of two case-control studies, the self-reports of those who disclosed domestic violence on a screening questionnaire were compared with the recording of domestic violence on each individual medical record. Subjects were drawn from two screening studies carried out 1 year apart which were conducted to assess the prevalence of domestic violence among attendees at the ED. An education program about domestic violence was conducted for doctors and nurses in the ED between the two screening studies. The examination of the medical records showed that detection rates of victims of domestic violence were unchanged between the two case-control studies. Both studies found that 50.0% of those who reported the experience of domestic violence within the 24 hours prior to index presentation, on the screening questionnaire in the prevalence studies, were recorded as such in their medical records. The low detection rates indicate the requirement for doctors and nurses to receive appropriate training to identify and record the psychosocial aspects of domestic violence victims. As well as training, referral systems need to be set in place to address the psychosocial aspects of domestic violence victims.