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LATEST VA RESEARCH ON PTSD AND HEALTH RISK

BEHAVIOR -- PTSD patients are more likely to struggle

with smoking, substance abuse and obesity.

 

 

First we have a short news story about the study.

Below that will be the study without references, abstracts and citations.

Story here... http://www.estripes.com/
article.asp?section=104&article=43753

Story below:

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Health issues plague many PTSD patients

By Leo Shane III, Stars and Stripes

WASHINGTON — Patients with post-traumatic stress disorders are more likely to struggle with smoking, alcoholism and obesity, according to a new analysis of post-traumatic stress studies.

Researchers say the findings shows that counselors need to deal not just with the mental aspects of PTSD, but also the physical challenges that patients face.

“Relieving the PTSD will help with some of the burden, but these risk behaviors will still be a problem,” said Dr. Miles McFall, Director of Psychology Service at VA Puget Sound Health Care System and an author of the analysis. “They need to be treated specifically.”

The report, published in the latest issue of the Department of Veterans Affairs PTSD Research Quarterly, reviews various research performed over the last few years which shows PTSD patients are twice as likely to smoke, twice as likely to develop a drinking problem and nearly three times more likely to use drugs than the general population.

Another study showed that nearly 83 percent of those suffering from PTSD are overweight or obese, compared to just under 65 percent of the adult population in the United States.

McFall said those symptoms aren’t necessarily indicators that someone might have PTSD — for example, many veterans who don’t have stress disorders also smoke — but health professionals dealing with PTSD patients should be on the lookout for that type of destructive behavior as well.

Ideally, counselors should treat both the PTSD and the secondary problems at the same time, he said.

“We’ve seen that mental health professionals who treat both get a better result,” McFall said.

The report pointed to the high-risk health behavior as a possible reason for the shorter life space among PTSD patients.

“It cannot be assumed that these behaviors will resolve on their own without direct, targeted intervention,” the report states.

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Complete study here... http://www.ncptsd.va.gov/
ncmain/nc_archives/rsch_qtly/V17N4.pdf

Study below:

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The National Center for Post-Traumatic Stress Disorder

PTSD Research Quarterly

Published by:
National Center for PTSD
VA Medical Center (116D)
215 North Main Street
White River Junction
Vermont 05009-0001 USA

 

PTSD AND HEALTH RISK BEHAVIOR

Miles McFall, PhD
and Jessica Cook, PhD
Mental Illness Research, Education,
and Clinical Center,
VA Puget Sound Health Care System

 

PTSD is associated with increased morbidity,
utilization of medical care services, and premature
death. The proclivity of individuals with PTSD to
engage in behaviors with adverse health consequences
likely contributes to these associations,
along with dysregulated neuroendocrine and immune
system pathways, genetic vulnerabilities,
maladaptive psychological states, and learned illness
behavior (Boscarino, 2004, 2006; Schnurr &
Jankowski, 1999). This review summarizes key papers
linking PTSD with the three leading causes
of morbidity and mortality in United States.

Smoking

The National Comorbidity Survey (NCS)
showed that the prevalence of smoking in PTSD
is over 45% nationwide, compared to 23% for
the adult population at large (Lasser et al., 2000).
Although half of all ever-smokers have stopped
using tobacco, this study found that only 23% of
ever-smokers with PTSD had quit, placing them
third from the bottom in a ranking of quit rates for
13 mental disorders. Extraordinarily high rates of
smoking have been reported in several investigations
involving clinical samples with PTSD. For
example, Beckham, Kirby, and colleagues (1997)
found that 53% of VA patients with combat-related
PTSD smoked and that 48% of these veterans
smoked heavily (> 25 cigarettes/day), compared
to 28% of combat veterans without PTSD.

High concurrence of PTSD and smoking is similarly
evident among recently traumatized individuals.
Vlahov and colleagues (2002; Nandi et al.,
2005) assessed PTSD and tobacco use in a large,
representative sample of New York City residents
following the September 11th terrorist attacks. Four
months after the attacks, participants with probable
nicotine dependence were more likely to report
PTSD symptoms (18.1%) than were participants
without nicotine dependence (5.7%). Also, PTSD
was more prevalent among participants who had
increased their rate of smoking 5 to 8 weeks after
the attacks than in those who did not increase their
rate of smoking (24.2% vs. 5.6%).

The causal relationship between PTSD and smoking
has been examined in retrospective, longitudnal,
and twin-study research designs. Breslau et al.
(2003) analyzed prospective data from a sample of
1,200 enrollees in a health maintenance organization
as well as retrospective, lifetime data in order
to determine risk of onset of nicotine dependence
in traumatized persons with and without PTSD.
The 10-year cumulative incidence of smoking in
individuals with PTSD was 31.7%, compared to
19.9% in persons with a history of trauma exposure
without PTSD and 10.5% in those with no history of
trauma. Koenen et al. (2005) analyzed the temporal
order of onset of PTSD and daily smoking in 3,065
members of the Vietnam Era Twin Registry and
tested whether the PTSD-smoking relationship was
moderated by hereditary risk for smoking. PTSD
increased risk of subsequent daily smoking over
two-fold. Active PTSD predicted daily smoking for
veterans with high as well as low genetic vulnerability
for smoking. However, the effect for PTSD
was strongest for those with low genetic liability,
suggesting that PTSD is a non-genetic pathway
for smoking among individuals at otherwise low
risk to smoke. Smoking also may be functionally
related to PTSD as a form of “self-medication” that
temporarily relieves PTSD symptoms and negative
mood states. Support for this hypothesis was
found in a prospective observational study of cues
associated with smoking behavior in smokers with
and without PTSD (Beckham et al., 2005). Negative
affect, positive affect, and PTSD symptoms were
antecedents of naturalistic smoking in smokers
with PTSD but not in smokers without PTSD.

Three preliminary studies show that nicotine
dependence can be successfully treated in veterans
with PTSD. In a controlled trial of bupropion,
Hertzberg et al. (2001) found that 4 of 10 smokers
with PTSD randomized to bupropion stopped
smoking at 6-month follow-up compared to only
1 of 5 smokers who received placebo. McFall et
al. (2005) tested the effectiveness of having mental
healthcare providers integrate tobacco dependence
treatment into psychiatric care of veterans
with PTSD. Integrated Care (IC) for smoking was
compared to usual care (UC), consisting of referral
to a specialized tobacco cessation clinic, in a randomized
controlled trial involving 66 VA PTSD patients.
IC patients were more likely to stop smoking
than UC patients across follow-up intervals at
months 2, 4, 6, and 9 (OR = 5.2). A subsequent test
of practice-based IC for smoking in PTSD was conducted
in an open clinical trial involving 107 veterans
with PTSD (McFall et al., 2006). Seven-day
biologically verified point prevalence rates of abstinence
were similar to those in the randomized controlled trial
at 2, 4, 6, and 9 months follow-up (28% to 18%). These
treatment-related quit rates are comparable to quit rates
in individuals without mental disorders.

Alcohol and Drug Use

Several epidemiological studies document the high
prevalence of substance use disorders (excluding tobacco
use) among persons with PTSD (see review by Chilcoat
& Menard, 2003). The NCS reported that 51.9% of persons
with lifetime PTSD also had a lifetime diagnosis of
alcohol abuse/dependence and 34.5% had a lifetime diagnosis
of drug abuse/dependence (Kessler et al., 1995).
PTSD increased the odds of having an alcohol use disorder
two-fold and the odds of a drug use disorder nearly
three-fold. The National Vietnam Veterans Readjustment
Study (Kulka et al., 1990) found that 75% of male Vietnam
veterans with PTSD had a lifetime alcohol abuse/dependence
disorder, and 22% had these disorders currently.
Veterans with PTSD were almost six times more likely
than Vietnam veterans without PTSD to have a current
drug use disorder.

The functional relationships between PTSD and substance
use disorders have been studied both retrospectively
and longitudinally. In a retrospective analysis of the
order of onset of PTSD and substance use disorders, Kessler
et al. (1995) concluded that PTSD was more often than
not the primary disorder. Bremner and colleagues (1996)
studied the longitudinal course of PTSD and substance
abuse in 61 Vietnam combat veterans. The onset of PTSD
and drug and alcohol abuse occurred shortly after combat
exposure and followed a parallel course. Breslau et
al. (2003) found that PTSD predicted subsequent onset of
drug abuse/dependence, but not alcohol abuse/dependence,
in their 10-year prospective and retrospective analysis
of 1,200 community residents. Chilcoat and Breslau
(1998) followed 1,007 midwestern community residents
for 3-5 years after baseline assessment. PTSD increased
risk for subsequent drug abuse/dependence four-fold,
and this risk was greatest for prescribed drug abuse/dependence.

Conclusions about the causal pathways linking PTSD
and substance use disorders are summarized in three excellent
reviews (see Jacobsen et al., 2001; Stewart, 1996;
Stewart & Conrod, 2003). There is consensus that PTSD,
more than trauma exposure alone, accounts for subsequent
onset of substance use problems, notwithstanding the Breslau
et al. (2003) negative findings with respect to alcohol
use. There is also agreement that the “self-medication”
hypothesis is valid, based on evidence that PTSD typically
precedes onset of substance use and patients’ perceptions
that sedating substances ameliorate arousal-related
symptoms and numb distressing emotions. Also supported
is the “mutual maintenance” hypothesis whereby
substance-related toxicity and withdrawal intensify PTSD
symptoms and hence promote further substance use. Less
compelling evidence has been found for the hypothesis
that substance use increases risk for trauma exposure and
hence liability for PTSD, and the hypothesis that substances
enhance susceptibility for PTSD after trauma exposure.
Type of substances abused appear functionally tied to the
predominance of different PTSD symptom clusters (e.g.,
high physiological arousal symptoms predict alcohol use,
while re-experiencing and avoidance/numbing symptom
clusters are more strongly associated with drug abuse).
Complex neurobiological mechanisms that underlie the
pathophysiology of comorbid PTSD and addiction are detailed
in Jacobsen et al. (2001).

Ouimette, Moos, Brown, and colleagues (2003) published
six informative papers about the modifiability of
substance use symptoms among veterans with PTSD (see
Ouimette, Moos, & Brown, 2003 for review). These studies
document 1, 2, and 5-year outcomes from longitudinal
naturalistic assessment of inpatient substance abuse treatment
for veterans with PTSD (n = 140) and those without
PTSD (n = 1,116). Nearly half of substance users with
PTSD were abstinent from alcohol and drugs at follow-up
year 1 or 2. However, veterans with PTSD showed less
improvement on substance use outcomes than patients
without PTSD. Two years post-discharge, substance use
remission for veterans with PTSD was associated with receiving
more outpatient treatment sessions for substance
abuse and mental health problems, as well as attendance
and active participation in self-help groups (Ouimette et
al., 2000). The odds of substance use remission at the 5-
year mark were 3.7 times greater for veterans who received
PTSD treatment during the first year after discharge and
4.6 times greater for veterans receiving PTSD treatment
in the fifth year (Ouimette, Moos, & Finney, 2003). This
research supports recommendations for proximate if not
concurrent treatment of both conditions.

Poor Diet and Physical Inactivity

Obesity and physical inactivity may partially explain
the elevated prevalence of diabetes and cardiovascular
disease among individuals with PTSD (Boscarino, 2006).
In a study of 221 help-seeking male veterans with PTSD,
Vieweg et al. (2006a) reported that 82.8% were overweight
or obese, having an average Body Mass Index (BMI) of
30.2. This rate exceeds estimates for these conditions in
the U.S. adult population at large (64.5%; Flegal et al.,
2002) and in veterans specifically. Dobie et al. (2004) surveyed
1,259 female veterans enrolled in VA healthcare and
similarly found that those with PTSD were 1.8 times more
likely to be obese (BMI > 30) than those without PTSD.
David et al. (2004) compared the BMI of two populations
of help-seeking veterans at risk for poor health practices,
namely, those with PTSD and those with alcohol dependence.
The average BMI was 30.1 for veterans with PTSD
versus 25.1 for veterans with alcohol dependence.

Vieweg et al. (2006b) showed that psychotropic medication
use did not account for the overweight and obesity
problems of veterans with PTSD. A more likely explanation
is the pronounced physical inactivity among these
veterans. Buckley (2004) performed an archival analysis
of clinic records to assess preventative and health-riskrelated
behaviors in 826 treatment-seeking male veterans
with PTSD. Fifty-nine percent of the sample reported exercising
fewer than two times per week (> 20 min. duration),
which is less than half the minimal standards
for exercise recommended by the U.S. Surgeon General
(USDHHS, 1996). McFall et al. (2005) similarly reported
that among veterans with diabetes, those with PTSD (n
= 11,775) were more physically inactive than those without
any mental disorder (70% vs. 59%). Chronic pain explained
nearly all of the association between PTSD and
physical inactivity in this study.

Conclusions and Treatment Implications

A reliable association exists between PTSD and leading
causes of morbidity and mortality. Health-risk behaviors
constitute only one of several factors responsible for the
poor health of individuals with PTSD, as the association
between PTSD and adverse health outcomes holds
even after they are statistically controlled (see review by
Schnurr & Jankowski, 1999). Future research challenges
include identifying: (1) the specific contribution of PTSD
to increased health-risk behaviors compared with other
disorders, such as depression, and (2) cognitive, affective,
and neuroendocrine pathways that mediate poor healthhabit
choices in persons with PTSD. Further research
should also replicate and expand preliminary investigations
linking PTSD with other health-risk behaviors, such
as aggression, weapons possession, and sensation-seeking
behavior (Beckham, Feldman et al., 2005; Freeman &
Roca, 2001; McFall et al., 1999).

Routine screening of health-risk behaviors in individuals
seeking help for PTSD is clearly indicated, and interventions
for these behaviors should be incorporated into
treatment plans. Conversely, early detection and sustained
intervention for PTSD should be a standard of care
for persons primarily seeking help for substance use disorder.
Although alleviation of PTSD symptoms favorably
impacts some health-risk behaviors, it cannot be assumed
that these behaviors will resolve on their own without direct,
targeted intervention.

Many questions remain unanswered about how to best
provide health-habit interventions for individuals with
PTSD. These include questions about the timing and sequencing
of interventions and whether (and how) standard
health-promotion interventions should be tailored
to accommodate special needs of individuals with PTSD.
In the meantime, research supports the general principle
of delivering concurrent (or closely proximate) treatment
for PTSD and associated risk behaviors. Ideally, care of
both conditions should be integrated into the clinical activities
of a single provider team, in order to minimize
barriers associated with referral to outside consultants
that undermine treatment adherence. Remission of addictive
disorders in veterans with PTSD is associated with
providing treatment sessions of greater numbers and
duration. The effectiveness of interventions for obesity,
physical inactivity, and other health-risk behaviors common
in PTSD remains undetermined.

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Larry Scott  --