“You can’t un-ring the bell”: a mixed methods approach to understanding veteran and family perspectives of recovery from military-related posttraumatic stress disorder

Background Military-related posttraumatic stress disorder (PTSD) is a complex diagnosis with non-linear trajectories of coping and recovery. Current approaches to the evaluation of PTSD and treatment discontinuation often rely on biomedical models that dichotomize recovery based on symptom thresholds. This approach may not sufficiently capture the complex lived experiences of Veterans and their families. To explore conceptualizations of recovery, we sought perspectives from Veterans and their partners in a pilot study to understand: 1) how Veterans nearing completion of treatment for military-related PTSD and their partners view recovery; and 2) the experience of progressing through treatment towards recovery. Methods We employed a concurrent mixed methods design. Nine Veterans nearing the end of their treatment at a specialized outpatient mental health clinic completed quantitative self-report tools assessing PTSD and depressive symptom severity, and an individual, semi-structured interview assessing views on their treatment and recovery processes. Veterans’ partners participated in a separate interview to capture views of their partners’ treatment and recovery processes. Descriptive analyses of self-report symptom severity data were interpreted alongside emergent themes arising from inductive content analysis of qualitative interviews. Results While over half of Veterans were considered “recovered” based on quantitative assessments of symptoms, individual reflections of “recovery” were not always aligned with these quantitative assessments. A persistent narrative highlighted by participants was that recovery from military-related PTSD was not viewed as a binary outcome (i.e., recovered vs. not recovered); rather, recovery was seen as a dynamic, non-linear process. Key components of the recovery process identified by participants included a positive therapeutic relationship, social support networks, and a toolkit of adaptive strategies to address PTSD symptoms. Conclusions For participants in our study, recovery was seen as the ability to navigate ongoing issues of symptom management, re-engagement with meaningful roles and social networks, and a readiness for discontinuing intensive, specialized mental health treatment. The findings of this study highlight important considerations in balancing the practical utility of symptom severity assessments with a better understanding of the treatment discontinuation-related needs of Veterans with military-related PTSD and their families, which align with a contemporary biopsychosocial approach to recovery.

Association between social phobia and the risk of arrhythmia using the Korean National Sample Cohort: a retrospective cohort study

Background Social phobia shares symptoms with arrhythmias, such as palpitations and chest discomfort. However, it is unclear how social phobia is associated with the actual risk of arrhythmia. This study aimed to investigate whether social phobia is associated with the risk of arrhythmia using a nationally representative sample cohort. Methods This retrospective cohort study assessed data from the 2002–2013 Korean National Health Insurance Service National Sample Cohort. Using 1:3 propensity score matching for sex, age, income, and insurance status, 1514 patients with social phobia and 4542 control group patients were included in the study. Social phobia and arrhythmia were defined per the International Classification of Diseases, 10th revision. Using cox proportional hazard regression, hazard ratios (HRs) were calculated to estimate the risk of arrhythmia in patients with social phobia. Results There were statistically significant associations between social phobia history and elevated risks of arrhythmia. Patients with social phobia had a higher risk of arrhythmia after adjusting with covariates (HR = 1.78, 95%CI = 1.25–2.55). Among different types of arrhythmias, atrial fibrillation and flutter presented the highest risk (HR = 2.20, CI = 1.06–4.57) compared to paroxysmal tachycardia (HR = 1.07, CI = 0.39–2.91) and other cardiac arrhythmias (HR = 1.83, CI = 1.16–2.89). Conclusion This study identified the association between social phobia and the risk of arrhythmia in a South Korean representative cohort. These results suggest that social phobia should be treated properly to reduce arrhythmia risks.

Measuring personal recovery in a low-intensity community mental healthcare setting: validation of the Dutch version of the individual recovery outcomes counter (I.ROC)

Background Measuring progress in treatment is essential for systematic evaluation by service users and their care providers. In low-intensity community mental healthcare, a questionnaire to measure progress in treatment should be aimed at personal recovery and should require little effort to complete. Methods The Individual Recovery Outcome Counter (I.ROC) was translated from English into Dutch, and psychometric evaluations were performed. Data were collected on personal recovery (Recovery Assessment Scale), quality of life (Manchester Short Assessment of Quality of Life), and symptoms of mental illness and social functioning (Outcome Questionnaire, OQ-45) for assessing the validity of the I.ROC. Test–retest reliability was evaluated by calculating the Intraclass Correlation Coefficient and internal consistency was evaluated by calculating Cronbach’s alpha. Exploratory factor analysis was performed to determine construct validity. To assess convergent validity, the I.ROC was compared to relevant questionnaires by calculating Pearson correlation coefficients. To evaluate discriminant validity, I.ROC scores of certain subgroups were compared using either a t-test or analysis of variance. Results There were 764 participants in this study who mostly completed more than one I.ROC (total n = 2,863). The I.ROC aimed to measure the concept of personal recovery as a whole, which was confirmed by a factor analysis. The test–retest reliability was satisfactory (Intraclass Correlation Coefficient is 0.856), as were the internal consistency (Cronbachs Alpha is 0.921) and the convergent validity. Sensitivity to change was small, but comparable to that of the OQ-45. Conclusions The Dutch version of the I.ROC appears to have satisfactory psychometric properties to warrant its use in daily practice. Discriminant validity and sensitivity to change need further research.

Delivering collaborative mental health care within supportive housing: implementation evaluation of a community-hospital partnership

Background Approaches to address unmet mental health care needs in supportive housing settings are needed. Collaborative approaches to delivering psychiatric care have robust evidence in multiple settings, however such approaches have not been adequately studied in housing settings. This study evaluates the implementation of a shifted outpatient collaborative care initiative in which a psychiatrist was added to existing housing, community mental health, and primary care supports in a women-centered supportive housing complex in Toronto, Canada. Methods The initiative was designed and implemented by stakeholders from an academic hospital and from community housing and mental health agencies. Program activities comprised multidisciplinary support for tenants (e.g. multidisciplinary care teams, case conferences), tenant engagement (psychoeducation sessions), and staff capacity-building (e.g. formal trainings, informal ad hoc questions). This mixed methods implementation evaluation sought to understand (1) program activity delivery including satisfaction with these activities, (2) consistency with team-based tenant-centered care and with pre-specified shared lenses (trauma-informed, culturally safe, harm reduction), and (3) facilitators and barriers to implementation over a one-year period. Quantitative data included reporting of program activity delivery (weekly and monthly), staff surveys, and tenant surveys (post-group surveys following tenant psychoeducation groups and an all-tenant survey). Qualitative data included focus groups with staff and stakeholders, program documents, and free-text survey responses. Results All three program activity domains (multidisciplinary supports, tenant engagement, staff capacity-building) were successfully implemented. Main program activities were multidisciplinary case conferences, direct psychiatric consultation, tenant psychoeducation sessions, formal staff training, and informal staff support. Psychoeducation for tenants and informal/formal staff support were particularly valued. Most activities were team-based. Of the shared lenses, trauma-informed care was the most consistently implemented. Facilitators to implementation were shared lenses, psychiatrist characteristics, shared time/space, balance between structure and flexibility, building trust, logistical support, and the embedded evaluation. Barriers were that the initial model was driven by leadership, confusion in initial processes, different workflows across organizations, and staff turnover; where possible, iterative changes were implemented to address barriers. Conclusions This evaluation highlights the process of successfully implementing a shifted outpatient collaborative mental health care initiative in supportive housing. Further work is warranted to evaluate whether collaborative care adaptations in supportive housing settings lead to improvements in tenant- and program-level outcomes.

Memantine augmentation of sertraline in the treatment of symptoms and executive function among patients with obsessive-compulsive disorder: A double-blind placebo-controlled, randomized clinical trial

Background Medications currently recommended for the treatment of Obsessive-Compulsive Disorder (OCD) usually decrease the severity of the symptoms by 20–30%; however, 40–60% of OCD patients do not achieve a satisfactory response. Our main objective was to investigate the effectiveness of memantine, a non-competitive N-Methyl-D-aspartate (NMDA) receptor antagonist, as an adjunct therapy to sertraline, a selective serotonin reuptake inhibitor (SSRI), to improve severity of symptoms and executive function among patients with obsessive-compulsive disorder. Methods Seventy patients with OCD according to the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) criteria, and a Yale-Brown obsessive compulsive scale (Y-BOCS) score of more than 21 were recruited to the study. They received sertraline (100 mg daily initially followed by 200 mg daily after week 4) and either memantine (10 mg twice daily) or placebo in a placebo controlled, double-blinded, parallel-group, clinical trial of 12 weeks. The primary outcome was OCD symptoms measured by the Y-BOCS. Moreover, executive function of participants was measured by the Wisconsin Card Sorting Test (WCST). Results The total score, and obsession and compulsion subscales of Y-BOCS significantly dropped in both groups with no significant difference between the two groups. However, memantine group showed a greater response in the number of completed categories subscale of the WCST (p value<0.001). We did not observe any major adverse effects in any of the groups. Conclusion Memantine has an acceptable safety and tolerability in patients with OCD and might have a positive effect on their executive function. Nevertheless, the current results don`t support the efficacy of memantine as an adjunctive agent to sertraline for symptoms in patients with OCD. Trial registration The trial was registered at the Iranian Registry of Clinical Trials on 04/10/2019 (www.irct.ir; IRCT ID: IRCT20170123032145N4).

Neuroimmunological investigations of cerebrospinal fluid in patients with recent onset depression – a study protocol

Background A proinflammatory response has been suggested to be involved in the pathophysiology of depression in a subgroup of patients. However, comprehensive largescale studies on neuroimmunological investigations of the cerebrospinal fluid (CSF) are lacking and no largescale longitudinal CSF studies comparing patients with depression to healthy controls currently exist. Methods A longitudinal case-control study including at least 100 patients with first time depression (ICD-10: F32) within the past year with ongoing symptoms and at least 100 sex and age matched healthy controls with collection of CSF, blood, and fecal samples. All individuals will be evaluated by neurological examination including neurological soft signs, interviewed for psychopathology assessment and have symptomatology evaluated by relevant rating scales. Level of functioning and quality of life will be evaluated by a panel of interview questions and rating scales, and cognitive function assessed by a relevant test battery. In addition, a large number of potential confounders will be registered (BMI, smoking status, current medication etc.). Primary outcomes: CSF white cell count, CSF/serum albumin ratio, CSF total protein levels, IgG index, CSF levels of IL-6 and IL-8, and the prevalence of any CNS-reactive autoantibody in CSF and/or blood. Secondary outcomes: exploratory analyses of a wide range of neuroimmunological markers and specific autoantibodies. Power calculations are computed for all primary outcomes based on previous CSF studies including patients with depression and healthy controls. Discussion This study will represent the hitherto largest investigation of CSF in patients with recent onset depression compared to healthy controls. We expect to elucidate neuroimmunological alterations in individuals with depression and characterize an immunological profile paving the way for the development of effective treatments based on biomarkers. Trial registration The study is approved by The Regional Committee on Health Research Ethics (Capital Region, j.no: H-16030985) and The Danish Data Protection Agency (j.no: RHP-2016-020, I-Suite no.: 04945).

Mental health status among prison officers in the process of enforcing the law during COVID-19epidemic: a cross-sectional survey from China

Background A global public health emergency triggered by the Coronavirus Disease 2019 (COVID-19) epidemic may have are markable psychological impact on the population. There is still limited psychological research on police officers, especially prison officers in the process of enforcing the law. The present study aims to identify prevalence and influencing factors on mental health status among frontline prison officers in China during the prevention and control of the COVID-19 epidemic. Methods A cross-sectional survey with a sample of 981 frontline prison officers was conducted using snowball sampling approach. The self-administered questionnaire consisted of 4 parts: (i) informed consent form; (ii) socio-demographic section; (iii) work and life situations during the prevention and control of the COVID-19 epidemic; (iv) the Chinese version of the 12-item General Health Questionnaire (GHQ-12). Univariate analysis and multivariable logistic regression were performed to identify factors influencing mental health status. Results The prevalence of being prone to mental health problems (GHQ-12 score ≥ 4) was 33.43% among frontline prison officers. The results of GHQ-12 factors analysis indicated that the prison officers suffered from psychological issues was related to anxiety and depression, which main symptoms were unhappy and depressed, lost sleep over worry and constantly under strain. Multivariate logistic regression analysis revealed that male (OR = 1.573, 95% CI:1.385–1.853), lockdown shift inside the prison(OR = 2.203, 95% CI:2.139–2.297), more night shifts (OR = 2.163, 95% CI:2.031–2.317; OR = 2.749, 95% CI:2.194–2.901), more smoking (OR = 1.100, 95% CI:1.037–2.168), poor self-reported physical condition (OR = 1.947, 95% CI:1.478–2.250), chronic or serious illness history(OR = 1.870, 95% CI:1.314–2.660; OR = 2.214, 95% CI:1.460–2.812) were risk factors for mental health among frontline prison officers, while regular diet (OR = 0.779, 95% CI:0.539–0.928), more physical exercise (OR = 0.702, 95% CI:0.548–0.899; OR = 0.641, 95% CI:0.316–0.887), more communication with family members (OR = 0.437, 95% CI:0.295–0.616) were protective factors. Conclusion Chinese frontline prison officers experienced different psychological stress coming from the prevention and control of this epidemic. Therefore, continued surveillance of psychological problems and targeted mental health care for frontline prison officers were urgent.

The reliability and validity of a screening scale for online gaming disorder among Chinese adolescents and young adults

Background In recent years, there have been frequent reports of gaming disorder in China, with more focus on young people. We developed and psychometrically tested a Gaming Disorder screening scale (i.e., Gaming Disorder Screening Scale - GDSS) for Chinese adolescents and young adults, based on the existing scales and diagnostic criteria, but also considering the development status of China. Methods For testing content and criterion validity, 1747 participants competed the GDSS and the Internet Addiction Test (IAT). After 15 days, 400 participants were retested with the scales for to assess test-retest reliability. Besides, 200 game players were interviewed for a diagnosis of gaming disorder. Results The Cronbach’s alpha coefficient on the GDSS was 0.93. The test-retest coefficient of 0.79. Principal components analysis identified three factors accounting for 62.4% of the variance; behavior, functioning, cognition and emotion. Confirmatory factor analysis showed a good model fit to the data (χ2 /df = 5.581; RMSEA =0.074; TLI = 0.916, CFI = 0.928). The overall model fit was significantly good in the measurement invariance tested across genders and different age groups. Based on the clinical interview, the screening cut-off point was determined to be ≥47 (sensitivity 41.4%, specificity 82.3%). Conclusions The GDSS demonstrated good reliability and validity aspects for screening online gaming disorder among Chinese adolescents and young adults.

The effect of sexual abuse and dissociation on suicide attempt

Background Suicide attempt is the most predictive risk factor of suicide. Trauma – especially sexual abuse – is a risk factor for suicide attempt and suicide. A common reaction to sexual abuse is dissociation. Higher levels of dissociation are linked to self-harm, suicide ideation, and suicide attempt, but the role of dissociation in suicidal behavior is unclear. Methods In this naturalistic study, ninety-seven acute psychiatric patients with suicidal ideation, of whom 32 had experienced sexual abuse, were included. Suicidal behaviour was assessed with The Columbia suicide history form (CSHF). The Brief trauma questionnaire (BTQ) was used to identify sexual abuse. Dissociative symptoms were assessed with Dissociative experiences scale (DES). Results Patients who had experienced sexual abuse reported higher levels of dissociation and were younger at onset of suicidal thoughts, more likely to self-harm, and more likely to have attempted suicide; and they had made more suicide attempts. Mediation analysis found dissociative experiences to significantly mediate a substantive proportion of the relationship between sexual abuse and number of suicide attempts (indirect effects = 0.17, 95% CI = 0.05, 0.28, proportion mediated = 68%). Dissociative experiences significantly mediated the role of sexual abuse as a predictor of being in the patient group with more than four suicide attempts (indirect effects = 0.11, 95% CI = 0.02, 0.19, proportion mediated = 34%). Conclusion The results illustrate the importance of assessment and treatment of sexual abuse and trauma-related symptoms such as dissociation in suicide prevention. Dissociation can be a contributing factor to why some people act on their suicidal thoughts.

Time trends in mental health indicators during the initial 16 months of the COVID-19 pandemic in Denmark

Background The COVID-19 pandemic and its associated national lockdowns have been linked to deteriorations in mental health worldwide. A number of studies analysed changes in mental health indicators during the pandemic; however, these studies generally had a small number of timepoints, and focused on the initial months of the pandemic. Furthermore, most studies followed-up the same individuals, resulting in significant loss to follow-up and biased estimates of mental health and its change. Here we report on time trends in key mental health indicators amongst Danish adults over the course of the pandemic (March 2020 - July 2021) focusing on subgroups defined by gender, age, and self-reported previously diagnosed chronic and/or mental illness. Methods We used time-series data collected by Epinion (N=8,261) with 43 timepoints between 20 March 2020 and 22 July 2021. Using a repeated cross-sectional study design, independent sets of individuals were asked to respond to the Copenhagen Corona-Related Mental Health questionnaire at each timepoint, and data was weighted to population proportions. The six mental health indicators examined were loneliness, anxiety, social isolation, quality of life, COVID-19-related worries, and the mental health scale. Gender, age, and the presence of previously diagnosed mental and/or chronic illness were used to stratify the population into subgroups for comparisons. Results Poorer mental health were observed during the strictest phases of the lockdowns, whereas better outcomes occurred during reopening phases. Women, young individuals (<34 yrs), and those with a mental- and/or chronic illness demonstrated poorer mean time-series than others. Those with a pre-existing mental illness further had a less reactive mental health time-series. The greatest differences between women/men and younger/older age groups were observed during the second lockdown. Conclusions People with mental illness have reported disadvantageous but stable levels of mental health indicators during the pandemic thus far, and they seem to be less affected by the factors that result in fluctuating time-series in other subgroups.