Title: Neuropsychological Profiles of Deployment-Related Mild Traumatic Brain Injury: A LIMBIC-CENC Study

Abstract:

Background and objectives: Traumatic brain injury (TBI) is a concern for US service members and veterans, leading to heterogeneous psychological and cognitive outcomes. We sought to identify neuropsychological profiles of mild TBI and posttraumatic stress disorder among the largest SMV sample to date.

Methods: We analyzed cross-sectional baseline data from SMV with prior combat deployments enrolled in the ongoing Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium prospective longitudinal study. Latent profile analysis identified symptom profiles using 35 indicators, including physical symptoms, depression, quality of life, sleep quality, postconcussive symptoms, and cognitive performance. It is important to note that the profiles were determined independently of mTBI and probable PTSD status. After profile identification, we examined associations between demographic variables, mTBI characteristics, and PTSD symptoms with symptom profile membership.

Results: The analytic sample included 1,659 SMV (mean age 41.1 ± 10.0 years; 87% male); among them 29% (n = 480) had a history of non-deployment-related mTBI only, 14% (n = 239) had deployment-related mTBI only, 36% (n = 602) had both non-deployment and deployment-related mTBI, and 30% (n = 497) met criteria for probable PTSD. A 6-profile model had the best fit, with separation on all indicators (p < 0.001). The model revealed distinct neuropsychological profiles, representing a combination of 3 self-reported functioning patterns: high (HS), moderate (MS), and low (LS), and 2 cognitive performance patterns: high (HC) and low (LC). The profiles were (1) HS/HC: n=301, 18.1%; (2) HS/LC: n=294, 17.7%; (3) MS/HC: n=359, 21.6%; (4) MS/LC: n=316, 19.0%; (5) LS/HC: n=228, 13.7%; and (6) LS/LC: n=161, 9.7%. SMV with deployment-related mTBI tended to be grouped into lower functioning profiles and were more likely to meet criteria for probable PTSD. Conversely, SMV with no mTBI exposure or non-deployment-related mTBI were clustered in higher functioning profiles and had a lower likelihood of meeting criteria for probable PTSD.

Discussion: Findings suggest varied symptom and functional profiles in SMV, influenced by injury context and probable PTSD comorbidity. Despite diagnostic challenges, comprehensive assessment of functioning and cognition can detect subtle differences related to mTBI and PTSD, revealing distinct neuropsychological profiles. Prioritizing early treatment based on these profiles may improve prognostication and support efficient recovery.

Citation: de Souza, N. L., Lindsey, H. M., Dorman, K., Dennis, E. L., Kennedy, E., Menefee, D. S., ... & Esopenko, C. (2024). Neuropsychological Profiles of Deployment-Related Mild Traumatic Brain Injury: A LIMBIC-CENC Study. Neurology, 102(12), e209417. https://doi.org/10.1212/WNL.0000000000209417

Links:

• PMID: 38833650
• https://doi.org/10.1212/WNL.0000000000209417

Publication date: June 25, 2024

Title: The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline.

Summary: The U.S. Department of Veterans Affairs and Department of Defense worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against.

Abstract: The U.S. Department of Veterans Affairs and Department of Defense worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against. Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed. The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.

Citation: Schnurr, P. P., Hamblen, J. L., Wolf, J., Coller, R., Collie, C., Fuller, M. A., ... & Kelber, M. S. (2024). The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline. Annals of Internal Medicine, 177(3), 363-374. https://doi.org/10.7326/M23-275

Links:

• PMID: 38408360
• https://doi.org/10.1177/1357633X231224491
• https://www.ptsd.va.gov/professional/articles/article-pdf/id1631252.pdf
• Report: https://www.healthquality.va.gov/guidelines/MH/ptsd/VA-DOD-CPG-PTSD-Full-CPGAug242023.pdf

Publication date: March 2024

Title: Evidence-based telehealth interventions for posttraumatic stress disorder, depression, and anxiety: A systematic review and meta-analysis.

Summary: The goal of this systematic review was to examine the efficacy of behavioral health care treatments for posttraumatic stress disorder, depression, and anxiety delivered via telehealth.

Abstract: The goal of this systematic review was to examine the efficacy of behavioral health care treatments for posttraumatic stress disorder, depression, and anxiety delivered via telehealth. We searched a combination of keywords related to telehealth, relevant mental health disorders, and evidence-based psychotherapies in three databases (PubMed, PsycInfo, and Embase) from database inception to April 2022. We included randomized controlled trials published in English wherein at least one arm received an evidence-based psychotherapy via telehealth. To be included, studies also had to enroll an adult population with symptoms or diagnosis of PTSD, depressive disorder, or anxiety disorder. Moderate quality of evidence was consistent with only small differences, if any, in efficacy between video teleconferencing and in-person delivery for patients with PTSD (d = 0.06, 95% CI −0.17, 0.28). However, for those with depression, in-person delivery was associated with better outcomes compared to VTC (d = 0.28, 95% CI 0.03, 0.54; low quality of evidence). We also found that evidence-based treatments delivered over telephone were more efficacious for depression compared to treatment as usual (d = -0.47, 95% CI −0.66, −0.28; very low quality of evidence). Very low quality of evidence supported the use of telehealth versus waitlist for anxiety (d = -0.48, 95% CI −0.89, −0.09). A synthesis across 29 studies indicates that the efficacy of telehealth for delivery of evidence-based behavioral health interventions varies by target diagnosis and telehealth modality. More research is needed on the efficacy of telehealth treatments for depression and anxiety.

Citation: Kelber, M. S., Smolenski, D. J., Boyd, C., Shank, L. M., Bellanti, D. M., Milligan, T., ... & Evatt, D. P. (2024). Evidence-based telehealth interventions for posttraumatic stress disorder, depression, and anxiety: A systematic review and meta-analysis. Journal of Telemedicine and Telecare, 1357633X231224491. https://doi.org/10.1177/1357633X231224491

Links:

• PMID: 38254285
• https://doi.org/10.1177/1357633X231224491

Publication date: January 22, 2024

Title: Evidence-based telehealth interventions for posttraumatic stress disorder, depression, and anxiety: A systematic review and meta-analysis.

Summary: The goal of this systematic review was to examine the efficacy of behavioral health care treatments for posttraumatic stress disorder, depression, and anxiety delivered via telehealth.

Abstract: The goal of this systematic review was to examine the efficacy of behavioral health care treatments for posttraumatic stress disorder, depression, and anxiety delivered via telehealth. We searched a combination of keywords related to telehealth, relevant mental health disorders, and evidence-based psychotherapies in three databases (PubMed, PsycInfo, and Embase) from database inception to April 2022. We included randomized controlled trials published in English wherein at least one arm received an evidence-based psychotherapy via telehealth. To be included, studies also had to enroll an adult population with symptoms or diagnosis of PTSD, depressive disorder, or anxiety disorder. Moderate quality of evidence was consistent with only small differences, if any, in efficacy between video teleconferencing and in-person delivery for patients with PTSD (d = 0.06, 95% CI −0.17, 0.28). However, for those with depression, in-person delivery was associated with better outcomes compared to VTC (d = 0.28, 95% CI 0.03, 0.54; low quality of evidence). We also found that evidence-based treatments delivered over telephone were more efficacious for depression compared to treatment as usual (d = -0.47, 95% CI −0.66, −0.28; very low quality of evidence). Very low quality of evidence supported the use of telehealth versus waitlist for anxiety (d = -0.48, 95% CI −0.89, −0.09). A synthesis across 29 studies indicates that the efficacy of telehealth for delivery of evidence-based behavioral health interventions varies by target diagnosis and telehealth modality. More research is needed on the efficacy of telehealth treatments for depression and anxiety.

Citation: Kelber, M. S., Smolenski, D. J., Boyd, C., Shank, L. M., Bellanti, D. M., Milligan, T., ... & Evatt, D. P. (2024). Evidence-based telehealth interventions for posttraumatic stress disorder, depression, and anxiety: A systematic review and meta-analysis. Journal of Telemedicine and Telecare, 1357633X231224491. https://doi.org/10.1177/1357633X231224491

Links:

• PMID: 38254285
• https://doi.org/10.1177/1357633X231224491

Publication date: January 22, 2024

Title: In-Theater Mental Health Disorders Among US Soldiers Deployed Between 2008 and 2013.

Summary: Deployed service members regularly undergo demanding and stressful experiences that can contribute to mental health difficulties; however, there is a scarcity of studies examining rates of mental health disorders in-theater. The current study examined case rates of mental health disorders among deployed U.S. Army Soldiers using diagnostic encounter data from the Theater Medical Data Store.

Abstract: Deployed service members regularly undergo demanding and stressful experiences that can contribute to mental health difficulties; however, there is a scarcity of studies examining rates of mental health disorders in-theater. The current study examined case rates of mental health disorders among deployed U.S. Army Soldiers using diagnostic encounter data from the Theater Medical Data Store. Case rates were calculated across 12 categories of mental health disorders. While in theater, soldiers' highest rates were for stress reactions and adjustment disorders, depression, anxiety, and sleep disorders. The lowest rates in theater were for psychosis, bipolar, somatic, and eating disorders. Notably, female soldiers had higher rates than their male counterparts for disorders in each of the 12 diagnostic categories. Results provide crucial information to aid in decision making about necessary interventions and provider competencies in deployed settings. Knowledge gained from these data may improve force readiness, help lessen disease burden, and inform military policy and prevention efforts.

Citation: Willing, M. M. P., Tate, L. L., O'Gallagher, K. G., Evatt, D. P., & Riggs, D. S. (2022). In-Theater Mental Health Disorders Among US Soldiers Deployed Between 2008 and 2013. MSMR, 29(11), 11-17. PMID: 36790903

Links: PMID: 36790903

Publication date: November 1, 2022

Title: Diagnostic and functional outcomes of adjustment disorder in U.S. active duty service members.

Summary: The purpose of this study was to provide an overview of the course of Adjustment Disorder in active duty service members without a prior mental health history.

Abstract: Adjustment Disorder is a commonly diagnosed psychiatric disorder. However, little is known about its course, predictors of its diagnostic outcomes, or its association with functional impairment. Our primary aim was to examine diagnostic transitions of service members with an incident AD diagnosis (IADx) to one of three states: 1) another psychiatric diagnosis, 2) chronic AD, or 3) no psychiatric diagnosis. Secondary outcomes included predictors of diagnostic course and functional outcomes associated with follow-up diagnoses. Health records of a random sample of 10,720 service members with an IADx were analyzed using multinomial logit regression and hazard rate model with competing risks.  IADx transitions were 24.3 % to another psychiatric diagnosis, 8.9 % with chronic AD, and 43.7 % without a diagnosis. Nearly a quarter (23.1 %) separated from service. Deployment was the strongest predictor of transitioning to another diagnosis. Those who transitioned to another diagnosis separated at an increased rate and with more adverse outcomes. Diagnostic findings are based on data in the electronic health record, and we could not specifically identify the stressor that precipitated an AD diagnosis. These findings describe the course of AD in military personnel and may not generalize to civilians. AD, as initially diagnosed, represents a heterogeneous disorder with an enduring impact across the military career for a considerable proportion of service members. As an early indicator of more severe psychiatric outcomes, an IADx may signal an opportunity for early intervention and screening, particularly in service members with a history of deployment.

Citation: Morgan, M. A., O'Gallagher, K., Kelber, M. S., Wilson, A. L. G., & Evatt, D. P. (2023). Diagnostic and functional outcomes of adjustment disorder in US active duty service members. Journal of Affective Disorders, 323, 185-192. https://doi.org/10.1016/j.jad.2022.11.079

Links:

• PMID: 36455712
• https://doi.org/10.1016/j.jad.2022.11.079

Publication date: February 15, 2023

Title: Pilot outcomes of cognitive processing therapy implementation in military health system outpatient behavioral health clinics.

Summary: Enterprise data indicates that U.S. service members with posttraumatic stress disorder (PTSD) may not receive an evidence-based treatment (EBT) or may receive an EBT with low fidelity to the core components. This study presents the evaluation of a pilot implementation of evidence-based psychotherapy for the treatment of PTSD in the Military Health System.

Abstract: Enterprise data indicates that U.S. service members with posttraumatic stress disorder may not receive an evidence-based treatment or may receive an EBT with low fidelity to the core components. Successful delivery of EBTs requires provider training and ongoing supervision/consultation, adjustment of clinic processes and structure, and leadership support. The Department of Defense Practice-Based Implementation Network is a dedicated team of implementation science specialists that support the integration of EBTs into clinical practice in the Military Health System. The PBI Network conducted a Cognitive Processing Therapy pilot to investigate the acceptability and feasibility of a novel trauma specialist implementation approach proposed by South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR). This approach, CPT Trauma Specialist, called for training designated behavioral health therapists as the primary CPT providers in their clinics. In collaboration with the Uniformed Services University Center for Deployment Psychology, the PBI Network provided training and consultation to 26 providers across 13 MHS BH clinics and supported ongoing facilitation. Despite provider interest and clinic leadership support, less than half of the pilot provider participants were able to meet the consultation and CPT delivery requirements for designation as a CPT trauma trained specialist. Prevalent implementation barriers included lack of adequate clinic resources, provider challenges balancing clinical and military-related duties, the need to focus on high-risk patients, and other military system-related constraints. These findings highlight the need for implementation scientists to examine alternatives to traditional training models and identify fidelity-consistent adaptations that allow for delivery of evidence-based care within highly constrained systems of care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Citation: Skopp, N. A., Kaplan, D. A., Todd, B. L., Drell, M. B., & Pratt, K. M. (2023). Pilot outcomes of cognitive processing therapy implementation in military health system outpatient behavioral health clinics. Psychological Services, 20(3), 496. PMID: 35099229 http://dx.doi.org/10.1037/ser0000611

Links:

• PMID: 35099229
• http://dx.doi.org/10.1037/ser0000611

Publication date: August 2023