Hispanic ethnicity and risk for combat-related posttraumatic stress disorder.

Hispanic veterans are said to exhibit higher risk of developing posttraumatic stress disorder (PTSD) than veterans of other racial/ethnic backgrounds. This prediction is based largely on findings from the National Vietnam Veterans Readjustment Study (NVVRS; R. A. Kulka et al., 1990a, 1990b). This article first summarizes the findings of the NVVRS with regard to race/ethnicity and PTSD, and then it makes a careful assessment of both the external and the internal validity of these findings. Conceptual issues are addressed and, where possible, further analyses of the NVVRS data set are conducted to identify factors that account for ethnic differences in rates of the disorder. Possible mediators of the effects of Hispanic ethnicity on vulnerability to PTSD are identified, including psychosocial factors (racial/ethnic discrimination and alienation) and sociocultural influences (stoicism and normalization of stress, alexithymia, and fatalism). Areas in which future research is needed are indicated.

Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans.

OBJECTIVE: Although posttraumatic stress disorder (PTSD) is a highly prevalent and often chronic condition, the relationship between PTSD and functioning and quality of life remains incompletely understood. METHOD: The authors undertook an archival analysis of data from the National Vietnam Veterans Readjustment Study. The study subjects consisted of the nationally representative sample of male Vietnam veterans who participated in the National Vietnam Veterans Readjustment Study. The authors estimated PTSD at the time of the interview with the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder. They examined the following outcomes: diminished well-being, physical limitations, bed day in the past 2 weeks, compromised physical health status, currently not working, and perpetration of violence. Logistic models were used to determine the association between PTSD and outcome; adjustment was made for demographic characteristics and comorbid psychiatric and other medical conditions. RESULTS: The risks of poorer outcome were significantly higher in subjects with PTSD than in subjects without PTSD in five of the six domains. For the outcome domains of physical limitations, not working, compromised physical health, and diminished well-being, these significantly higher risks persisted even in the most conservative logistic models that removed the shared effects of comorbid psychiatric and other medical disorders. CONCLUSIONS: The suffering associated with combat related-PTSD extends beyond the signs and symptoms of the disorder to broader areas of functional and social morbidity. The significantly higher risk of impaired functioning and diminished quality of life uniquely attributable to PTSD suggests that PTSD may well be the core problem in this group of difficult to treat and multiply afflicted patients.

Predictors of emotional numbing in posttraumatic stress disorder.

Little is known about the mechanisms underlying emotional numbing (EN). The functional relationship between other classes of posttraumatic stress disorder (PTSD) symptoms and EN is also not well understood. In the present study, we examined the statistical predictors of EN. We hypothesized that the severity of EN would be most strongly associated with the hyperarousal symptoms rather than the avoidance symptoms of PTSD, or comorbid depression or substance abuse. This prediction was derived from psychological and biological models that posit EN to be a product of the depletion of emotional resources subsequent to chronic hyperarousal. Using hierarchical multiple regression in two separate samples of Vietnam combat veterans, we found hyperarousal symptoms to be the most robust predictor of EN. These data suggest that there is a substantive relationship between hyperarousal symptoms and EN in PTSD.

Post-traumatic stress disorder and functioning and quality of life outcomes in female Vietnam veterans.

OBJECTIVE: This investigation assessed whether current post-traumatic stress disorder (PTSD) was associated with impaired functioning in a nationally representative sample of female Vietnam veterans. METHODS: Logistic models were used to determine the association between PTSD and outcome while adjusting for demographic characteristics and medical and psychiatric co-morbidities. RESULTS: PTSD was associated with significantly elevated odds of poorer functioning in five of the six outcome domains; only the association between perpetration of violence in the past year and PTSD did not achieve statistical significance. After adjusting for demographics and medical and psychiatric co-morbidities, PTSD remained associated with significantly elevated odds of bed days, poorer physical health, and currently not working. CONCLUSIONS: Among female Vietnam veterans PTSD is associated with a broad profile of functional impairment. The significantly increased odds of impaired functioning and diminished quality of life suggest that PTSD may be the core problem of the set of problems afflicting female Vietnam veterans.

Prevalence of psychiatric disorders among incarcerated women. II. Convicted felons entering prison.

BACKGROUND: No unbiased estimates of the rates of psychiatric disorder among women prison inmates are available. Nonetheless, available data suggest that some psychiatric disorders are prevalent in this population. The objective of the study was to determine the rates, risk factors, and outcomes of specific psychiatric disorders among women prison inmates. METHODS: A virtual census of women felons (N = 805) entering prison in North Carolina was assessed using in-person interviews. Assessments were conducted for 8 disorders, using the Composite International Diagnostic Interview as the primary assessment measure. For validation purposes, one quarter of the inmates were reassessed for 2 of these disorders, using structured clinical interviews. RESULTS: Inmates were found to have high rates of substance abuse and dependence and antisocial and border-line personality disorders compared with women in community epidemiologic studies. Rates among inmates were also somewhat elevated for mood disorders but not for anxiety disorders. The rate of reports of lifetime exposure to traumatic events was also high. Rates of disorder tended to be higher among white than among African American women. CONCLUSION: High rates of substance abuse, psychiatric disorder, and psychological distress associated with exposure to traumatic events suggest that women in prison have a need for treatment for substance abuse and other mental health problems.

Peritraumatic dissociation and posttraumatic stress in male Vietnam theater veterans.

OBJECTIVE: The aim of this study was to determine the reliability and validity of a proposed measure of peritraumatic dissociation and, as part of that effort, to determine the relationship between dissociative experiences during disturbing combat trauma and the subsequent development of posttraumatic stress disorder (PTSD). METHOD: A total of 251 male Vietnam theater veterans from the Clinical Examination Component of the National Vietnam Veterans Readjustment Study were examined to determine the relationship of war zone stress exposure, retrospective reports of dissociation during the most disturbing combat trauma events, and general dissociative tendencies with PTSD case determination. RESULTS: The total score on the Peritraumatic Dissociation Experiences Questionnaire--Rater Version was strongly associated with level of posttraumatic stress symptoms, level of stress exposure, and general dissociative tendencies and weakly associated with general psychopathology scales from the MMPI-2. Logistic regression analyses supported the incremental value of dissociation during trauma, over and above the contributions of level of war zone stress exposure and general dissociative tendencies, in accounting for PTSD case determination. CONCLUSIONS: These results provide support for the reliability and validity of the Peritraumatic Dissociation Experiences Questionnaire--Rater Version and for a trauma-dissociation linkage hypothesis: the greater the dissociation during traumatic stress exposure, the greater the likelihood of meeting criteria for current PTSD.

Problems in families of male Vietnam veterans with posttraumatic stress disorder.

Interviews were conducted with a nationally representative sample of 1,200 male Vietnam veterans and the spouses or co-resident partners of 376 of these veterans. The veteran interview contained questions to determine the presence of posttraumatic stress disorder (PTSD) and items tapping family and marital adjustment, parenting problems, and violence. The spouse or partner (S/P) interview assessed the S/P's view of these items, as well as her view of her own mental health, drug, and alcohol problems and behavioral problems of school-aged children living at home. Compared with families of male veterans without current PTSD, families of male veterans with current PTSD showed markedly elevated levels of severe and diffuse problems in marital and family adjustment, in parenting skills, and in violent behavior. Clinical implications of these findings are discussed.

Evaluation of state efforts to improve systems of care for children and adolescents with severe emotional disturbances: the CASSP (Child and Adolescent Service System Program) initial cohort study.

In 1984, the National Institute of Mental Health (NIMH) began funding its Child and Adolescent Service System Program (CASSP). In this paper, we present findings from a descriptive study of the experiences of the initial cohort of states to receive CASSP grants, conceived and conducted when the projects were approaching the end of their fifth and final year of NIMH funding. Detailed case studies were conducted of each of the 10 initial cohort projects, and the findings analyzed across projects. Data were collected from three major sources: (1) existing documentation about the projects, (2) site visits to each of the projects, and (3) information from relevant secondary sources. Findings suggest that the initial cohort projects utilized a variety of strategies and encountered a variety of barriers and facilitating factors. The projects generally implemented the intended CASSP program and did so by using a variety of strategies. The projects were judged by stakeholders in their states to have influenced the service systems in their states in the intended directions: toward a more comprehensive system of care that emphasizes community-based treatment; toward better integrated, more collaborative efforts among the state agencies involved; toward a more detailed understanding on the part of system stakeholders of the mental health problems of children and adolescents who have severe emotional disturbances, and of the influence of those problems on the lives of the children and their families; and toward increased involvement by parents and other family members in the care of these children and adolescents.

Lifetime and current prevalence of specific psychiatric disorders among Vietnam veterans and controls.

To determine if Vietnam theater veterans were more likely than controls to have a specific psychiatric disorder other than posttraumatic stress disorder, the rates of specific psychiatric disorders were estimated using the Diagnostic Interview Schedule for national samples of veterans who served in Vietnam, other veterans of the Vietnam era, and matched civilian controls. Overall, there were few differences in rates of disorder between theater and other veterans; there were somewhat more differences between theater veterans and civilians. There were striking differences, however, in rates for most disorders, both lifetime and current, between male theater veterans with high levels of exposure to war zone stress and other male veterans or civilians. Female veterans exposed to high levels of war zone stress also had higher rates than other female respondents for several disorders.

Acute and chronic effects of alcohol use on violence.

While the empirical association of drinking and problem drinking to violence is well established, the etiological nature of the relationship is poorly understood. Using data collected from 1,149 convicted male felons, the acute (drinking just before the violent event) and chronic (a psychiatric diagnosis of alcohol abuse or dependence) effects of alcohol use on violence were analyzed. Logistic regression models were used to examine the relationship of acute and chronic alcohol effects to incarceration for a violent offense and arrest for a violent offense, with demographic and criminal history factors controlled. The acute effects of alcohol were found to be significantly associated with incarceration for a violent offense, but the net explanatory capacity of acute alcohol effects was not large. Chronic alcohol effects were not significantly associated with incarceration for a violent offense or arrest for a violent offense in the previous year. The findings were interpreted as being consistent with the hypothesis that alcohol effects violence directly, acting through the acute effects of use, rather than indirectly through the effects of underlying or mediating factors.

Antisocial personality and substance abuse disorders.

The relationship between antisocial personality (ASP) disorder and drug and alcohol disorders was examined using data from the Diagnostic Interview Schedule (DIS) gathered on a sample of 1,149 male prison inmates. The results of a linear canonical discriminant function analysis indicate differences among those with a DIS/ASP diagnosis that are related to the presence or absence of an accompanying substance abuse diagnosis: whites are more likely than nonwhites to receive the ASP diagnosis with a substance abuse diagnosis, and substance abuse appears to magnify ASP symptomatology. Diagnostic and clinical implications of findings are discussed.

Validity of Medicaid household respondent reporting of ambulatory visits for mental disorders.

Comparison with administrative records or "best estimate file" enables an evaluation of the accuracy of household reports of mental health use in the four-State Medicaid Household Survey conducted as part of the National Medical Care Utilization and Expenditure Survey. Underreporting of probability of ambulatory mental health use ranged from 14 to 24% compared to 5 to 7% for ambulatory health visits; household estimates of number of mental health visits seemed to be more accurate than administrative records. Household reporting of provider type seemed to be very accurate for psychiatrist visits, but there seemed to be a tendency to report psychologist visits as psychiatrist visits.

Choice of payment plan in the Medicare capitation demonstration.

This article identifies factors that influence the choice between joining an HMO and remaining with the traditional fee-for-service system among aged Medicare beneficiaries in three communities. Sources of marketing information were found to be strongly and positively related to the decision to join the HMO. Among beneficiaries who had to switch providers to join, persons who had a prior usual source of care and those who were satisfied with the amount of paperwork required to use that source of care were less likely to enroll in the HMO. Persons who did not have to switch providers to join the HMO were more likely to enroll in the prepaid program if they were satisfied with the amount of paperwork involved in using the HMO prior to the demonstration. Differences among the three communities suggest that the barrier to HMO enrollment presented by having a prior source of care who is not affiliated with the HMO may attenuate as the number of competing HMOs in the community increases, making the medical care environment more competitive. In the community with the most HMOs, persons who already had supplemental insurance were less likely to enroll than those who did not. None of the six HMOs studied experienced adverse selection, based on pre-enrollment health status.

Patterns of alcohol and drug abuse in drug treatment clients from different ethnic backgrounds.

In this paper we have sought to identify differences in alcohol consumption patterns and problems among young adult males from white, black, and Hispanic ethnic groups entering drug treatment programs. In overall consumption patterns we found results similar to those obtained in general population studies. However, about one-third of the clients in all ethnic groups could be classified as heavier drinkers (drinking at least once a week and 4 or more drinks per drinking occasion) in the period immediately prior to treatment. About one-fourth of the clients in each ethnic group consumed a daily average of 2.5 ounces of absolute alcohol. Compared with the other ethnic groups, blacks were the most likely to be abstainers and reported regular alcohol use and drunkenness at later ages. Regardless of the pattern of development, similar proportions of the clients in all ethnic groups reported heavier drinking levels by age 21-30. Consistent with the current hypotheses in the literature, whites reported much higher levels of alcohol-related problems and prior treatment. Despite having similar levels of drinking, black and Hispanic ethnic groups did not appear to recognize alcohol as a problem or to report alcohol-related problems to the extent that whites did. Examination of drug-use patterns showed great variation in the nature and extent of drug use among the three ethnic groups. Whites were distributed among the seven patterns of use. Heroin use with cocaine, marijuana, and alcohol was the predominant pattern for blacks and Hispanics. Although the patterns of drug use differed greatly, these patterns were not differentially related to alcohol consumption or alcohol-related problems within ethnic groups. On the contrary, the drug-use patterns appeared to be a stronger predictor than ethnicity of use and problems. Multiple-nonnarcotic-users reported the highest levels of alcohol consumption and the greatest numbers of alcohol-related problems. This group typically reported the highest number of alcohol-related problems. Expression of a current need for treatment and a history of prior alcohol treatment were highest for black multiple-nonnarcotic-users. Our examination of the influences of family and friends was based on a limited number of questions available in the data. Heavier drinking was reported by clients who lived with friends, had family or friends who drank regularly, or had extensive involvement in the drug-use network, including drug sales. No ethnic differences were found.(ABSTRACT TRUNCATED AT 400 WORDS)

Access to health care among aged Medicare beneficiaries.

The goal of the National Medical Care Utilization and Expenditure Survey (NMCUES) is to improve the understanding of the ways in which Americans use and pay for health care. This report is one in a series of descriptive reports based on NMCUES data. Data concerning several aspects of participants' access to health care services were collected in NMCUES. These included identification of a regular source of care, several characteristics of physical access to the regular source (transportation mode, travel time, waiting room time), insurance coverage, and the existence of medically unattended conditions. The purpose of this report is to provide descriptive information about selected aspects of access to health care among noninstitutionalized elderly people who reported being covered by Medicare. The results presented are based on data collected about noninstitutionalized people in the NMCUES national household sample who: (1) were 65 years of age and over at any time during the survey year, and (2) reported being covered by Medicare Hospital Insurance, Supplementary Medical Insurance, or both during the survey year (1980). The regular source of care for three out of four (74 percent) of the elderly Medicare beneficiaries was a physician's office (including group practice or doctor's clinic), while for 9 percent the regular source was a hospital outpatient clinic, emergency room, health center, or other provider type (referred to hereafter as "clinic"). Of the elderly Medicare beneficiaries, 10 percent reported no regular source of care, and the regular source was unknown for 7 percent. Of those with no regular source of care, 80 percent identified their seldom getting sick as an important reason for having no regular source, 24 percent identified their desire to go to different places for different health care needs, 14 percent said their usual source was no longer available, and 5 percent identified their recently moving into the area as an important reason. Nearly six out of ten (59 percent) of the elderly Medicare beneficiaries who reported that their regular source was a physician's office drove themselves there, and about four out of ten (43 percent) of those who reported that their regular source was a clinic drove themselves to the clinic. On the average, people traveled nearly 10 minutes more to a clinic than to a physician's office (29 versus 20 minutes). There was little variability in reported length of travel time among the various demographic categories--e.g., men tended to travel for the same length of time as did women, black people for the same travel time as white people.(ABSTRACT TRUNCATED AT 400 WORDS)