Prevalence and implications of gambling problems among firefighters.

Firefighting is a high-risk occupation that accounts for vulnerability to a range of mental health problems and addictive behaviours. However, no research has addressed whether this vulnerability extends to gambling problems, and the aim of this study was thus to provide new data on frequency and implications of such problems in this occupational context. The sample consisted of n = 566 career and retained firefighters who participated in a cross-sectional survey of an Australian metropolitan fire service. The Problem Gambling Severity Index (PGSI) was used to operationalise both clinically significant levels of problem gambling (PGSI ≥ 5), and 'at-risk' gambling (PGSI 1-4); alongside measures of major depression (PHQ-9), anxiety (GAD-7), Posttraumatic Stress Disorder (PCL-5) and alcohol problems (AUDIT), as well as other addictive behaviours, wellbeing and psychosocial issues. Results indicated 12.3% of firefighters that reported any gambling problems across a continuum of severity (PGSI ≥ 1), including 2.3% that were problems gamblers, and 10.0% reporting at-risk gambling. The weighted prevalence of problem gambling was comparable to other significant mental health conditions including depression and PTSD, while the rate of any gambling problems was high relative to other addictive behaviours. Gambling problems were associated with poor mental health and wellbeing, but not psychosocial indicators (e.g., financial difficulties). The findings suggest that gambling problems across a spectrum of severity may be significant yet hidden issues among emergency service workers, and thus require increased recognition and responses at the organisational level.

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.

Stability of symptom patterns in Australian Gulf War veterans: 10-year longitudinal study.

OBJECTIVES: Previously we established that symptoms reported by 1990-1991 Gulf War veterans were correlated and exhibited a pattern with 3 factors (psychophysiological distress, somatic distress and arthroneuromuscular distress), and this pattern was similar to that observed in a military comparison group. In this follow-up study, we examined whether the patterns of symptomatology have changed over time. METHODS: Using data on 56 symptoms that was collected in 2000-2003 (wave 1) and 2011-2012 (wave 2) from an Australian cohort of Gulf War veterans (veterans) and a military comparison group, exploratory factor analysis was conducted and Tucker's Congruence Coefficient (TCC) was used to determine factor structure similarity across study groups and waves. RESULTS: The results showed that the 3 factors observed at wave 1 were still present at wave 2, and factor structures across study groups and study waves were fairly similar, with TCC ranging 0.86-0.92. Veterans consistently reported more symptoms across all 3 factors. Veterans' symptomatology specific to psychophysiological distress increased between waves 1 and 2 (ratio of means 1.15; 95% CI 1.07 to 1.25) but psychophysiological distress symptomatology was constant in the comparison group (ratio of means 0.97; 95% CI 0.89 to 1.06). Somatic and arthroneuromuscular distress symptomatology significantly increased over time for both study groups, although at a similar rate. CONCLUSIONS: While the symptom groupings (measured by the 3 factors) remained unchanged at 10 years of follow-up, and remained comparable between Gulf War and comparison group, symptomatology continued to be elevated in Gulf War veterans than in the comparison group, and was most evident for psychophysiological distress.

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.

Mental health services required after disasters: learning from the lasting effects of disasters.

Disasters test civil administrations' and health services' capacity to act in a flexible but well-coordinated manner because each disaster is unique and poses unusual challenges. The health services required differ markedly according to the nature of the disaster and the geographical spread of those affected. Epidemiology has shown that services need to be equipped to deal with major depressive disorder and grief, not just posttraumatic stress disorder, and not only for victims of the disaster itself but also the emergency service workers. The challenge is for specialist advisers to respect and understand the existing health care and support networks of those affected while also recognizing their limitations. In the initial aftermath of these events, a great deal of effort goes into the development of early support systems but the longer term needs of these populations are often underestimated. These services need to be structured, taking into account the pre-existing psychiatric morbidity within the community. Disasters are an opportunity for improving services for patients with posttraumatic psychopathology in general but can later be utilized for improving services for victims of more common traumas in modern society, such as accidents and interpersonal violence.

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.

A psychopharmacological treatment algorithm for generalised anxiety disorder (GAD).

Generalised anxiety disorder (GAD) is defined as excessive and uncontrollable worry and anxiety about everyday life situations. It is a chronic disorder, and is associated with substantial somatisation, high rates of comorbid depression and other anxiety disorders, and significant disability. The evidence base for pharmacotherapy and psychotherapy has continued to grow, and a wide range of drug choices for GAD now exists. Current guidelines for GAD generally restrict themselves to presentation of the evidence for various treatments, which, as a result, generally do not offer detailed discussion or recommendation of strategies beyond the first level of treatment, or take into account the individual circumstances of the patient. Thus, there is a lack of algorithm-based treatment guidelines for GAD. Our aim is, therefore, to present an algorithm for the psychopharmacologic management of GAD, intended for all clinicians who treat patients with GAD, where issues of pharmacotherapy are under consideration. We also hope that these GAD algorithms and other guidelines can help to identify high-priority areas that need further study. In this algorithm, we provide a sequenced approach to the pharmacotherapy of GAD, taking into account salient symptomatology and comorbidity, levels of evidence and extent of response. Special issues, including comorbidity, insomnia, suicidality, substance abuse, treatment adherence, pregnancy and lactation, cross-cultural issues, use of medication in the elderly, psychosocial treatment and dosing issues are also addressed.

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.

The health of Australian veterans of the 1991 Gulf War: factor analysis of self-reported symptoms.

BACKGROUND: A recent report showed that Australian veterans of the 1991 Gulf War displayed a greater prevalence of a multitude of self-reported symptoms than a randomly sampled comparison group of military personnel who were eligible for deployment but were not deployed to the Gulf. AIMS: To investigate whether the pattern, rather than frequency, of symptom reporting in these Australian Gulf War veterans differed from that of the comparison group personnel. METHODS: Factor analysis was used to determine whether the co-occurrence of 62 symptoms in 1322 male Gulf War veterans can be explained by a number of underlying dimensions, called factors. The methodology was also applied to 1459 male comparison group subjects and the factor solutions of the two groups were compared. RESULTS: For the Gulf War veterans, a three factor solution displayed replicability and construct validity. The three factors were labelled as psycho-physiological distress, somatic distress, and arthro-neuromuscular distress, and were broadly similar to those described in previous studies of Gulf War veterans. A concordant three factor solution was also found for the comparison group subjects, with strong convergence of the factor loadings and factor scores across the two groups being displayed. CONCLUSION: Results did not display evidence of a unique pattern of self-reported symptoms among Gulf War veterans. Results also indicated that the differences between the groups lie in the degrees of expression of the three underlying factors, consistent with the well documented evidence of increased self-reported symptom prevalence in Gulf War veterans.

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.

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.

Working memory in posttraumatic stress disorder--an event-related potential study.

This study examined ERP topography during the updating and the utilization of working memory in subjects with PTSD. Event-related potentials of 18 participants with PTSD and 18 controls were recorded from 32 scalp electrodes during an auditory target detection task requiring the constant updating of target identity. Midline N2 and P3 abnormalities previously noted in PTSD during target detection were replicated. Scalp topographic data revealed sustained reduction in activity over the right hemisphere during working memory updating. Executive processes were associated with brief but widespread right hemisphere reductions during the P3, followed by sustained, bilateral reduction frontally. This study identifies an abnormal pattern of cortical network function during both the updating and use of working memory in PTSD.

Posttraumatic stress disorder in a general psychiatric inpatient population.

This study examined the incidence of traumatic experiences and prevalence of lifetime posttraumatic stress disorder (PTSD) in a sample of 141 general hospital psychiatric inpatients. Sixty-one percent of the patients reported at least one traumatic event during their lifetime and 28% met the formal DSM-III-R criteria for a lifetime diagnosis of PTSD. A high degree of comorbidity between PTSD and other psychiatric disorders was found, but PTSD was the incident disorder in at least 50% of cases. The experience of trauma and its associated complex patterns of symptomatology suggest that PTSD complicates the process of recovery from another disorder.

Traumatic stress in the 21st century.

OBJECTIVE: The introduction to a series of articles on traumatic stress aims to examine the ambivalent relationship between traumatic stress and psychiatry. It provides an outline to the very significant contribution that this field made before the conceptualisation of posttraumatic stress disorder (PTSD) and how the research and theoretical thinking in this field can provide many insights into the relationship between environmental factors and psychological health. It focuses on the relevance of this field to general psychiatry. RESULT: Posttraumatic stress disorder has emerged as the most common anxiety disorder in women. As well, there are high rates discovered in a range of chronically ill psychiatric patient populations. In particular, strategies for dealing with the issues of childhood abuse and neglect are not often considered by adult psychiatric services for the chronically and severely mentally ill, despite there being important predictors of suicidal behaviour, hospitalisation and prolonged disability. An effective consideration of the available evidence is often complicated by concerns about the impact of financial compensation on the presentation of psychopathology. This is a complex social dialectic whose impact is important to the practise of psychiatry. Equally, this field in itself must avoid becoming excessively rigid in its clinical definitions and the particular interventions which are espoused. CONCLUSIONS: The impact of traumatic events on long-term psychological adjustment and physical health have been under estimated. Identification of those at risk is an important issue given that effective treatments are now available. This is an area in which further conceptual thinking is required. It also provides particular opportunities to explore the biological processes of, and interaction between, the environment and the underlying genetic and neurobiological processes which are critical to the modulation of psychopathology.