This page features a curated list of recent PTSD clinical research articles published in peer-reviewed medical and psychological journals, with an emphasis on PTSD treatment for military veterans and their families.
Hawkins, Eric J., Simon B. Goldberg, Carol A. Malte, and Andrew J. Saxon. "New Coprescription of Opioids and Benzodiazepines and Mortality Among Veterans Affairs Patients With Posttraumatic Stress Disorder". Journal of Clinical Psychiatry 80, no. 4 (2019): 18m12689. https://doi.org/10.4088/JCP.18m12689
ERIC J HAWKINS PHD
VA PUGET SOUND HCS (S116ATC)
1660 S COLUMBIAN WAY
SEATTLE WA 98108-1532
Background: Opioids and benzodiazepines are commonly coprescribed medications. The mortality risk associated with their concurrent use is unknown.
Objective: To estimate the all-cause mortality risk for patients newly prescribed opioids and benzodiazepines concurrently relative to patients prescribed benzodiazepines only, opioids only, or neither medication.
Methods: This propensity score–matched, retrospective, cohort study included 17,476 patients receiving Veterans Affairs (VA) health care between October 1, 2009, and September 30, 2011, and diagnosed with posttraumatic stress disorder identified using ICD-9-CM code 309.81.
One-year total and cause-specific mortality was assessed by hazard ratios and subhazard ratios, adjusted for propensity score, age, baseline psychiatric and medical comorbidity, and daily medication dose.
Results: Concurrent users (n = 4,369) were propensity score matched 1:1 with benzodiazepine-only users, opioid-only users, and nonusers.
One year after medication start, the concurrent cohort had higher rates of all-cause mortality (116 deaths) relative to benzodiazepine-only (75 deaths; adjusted hazard ratio = 1.52; 95% CI, 1.14–2.03), opioid-only (67 deaths; 1.76; 95% CI, 1.32–2.35), and nonuser (60 deaths; 1.85; 95% CI, 1.30–2.64) cohorts.
Risk of overdose death was greater among patients in the concurrent cohort relative to patients in the benzodiazepine-only (adjusted subhazard ratio = 2.59; 95% CI, 1.00–6.66), opioid-only (2.58; 95% CI, 1.09–6.11), and nonuser (9.16; 95% CI, 2.27–37.02) cohorts.
For circulatory disease–related deaths, the adjusted subhazard ratio for concurrent medication users was 1.81 (95% CI, 1.01–3.24) relative to nonusers.
Conclusions: New coprescription of opioids and benzodiazepines was associated with increased all-cause mortality and overdose death compared with new prescription of benzodiazepines only, opioids only, or neither medication and increased circulatory disease–related death relative to neither medication.
* The VA fully funded this important research, and all the researchers are VA employees, which demonstrates VA's willingness to examine itself via empirical investigations.
* The researchers analyzed data from 2009–2011. Since that time, the nation and VA have recognized the dangers of long-term opioid prescriptions, and the increased dangers of combining opioid medication with a benzodiazepine such as Xanax (alprazolam), Klonopin (clonazepam), or Ativan (lorazepam).
The VA has taken steps to reduce opioid prescriptions1,2 and has embraced the multi-disciplinary, multi-modal treatment of chronic pain.3
Some problems persist, as evidenced by a May 2018 Government Accountability Office report, Progress Made Towards Improving Opioid Safety, but Further Efforts to Assess Progress and Reduce Risk Are Needed, but patient safety has improved significantly over the last 10 years.
1. Lin, Lewei A., Amy SB Bohnert, Robert D. Kerns, Michael A. Clay, Dara Ganoczy, and Mark A. Ilgen. "Impact of the Opioid Safety Initiative on Opioid-related Prescribing in Veterans." Pain 158, no. 5 (2017): 833-839.
2. Pharmacy Benefits Management (PBM) Academic Detailing Service, Veterans Health Administration, "Safe and Responsible Use of Opioids for Chronic Pain: A Patient Information Guide", ver. 2 (rev. October 2018).
3. Meyer, Laurence and Friedhelm Sandbrink, "VHA Response to the Opioid Epidemic and Comprehensive Addiction and Recovery Act of 2016 (CARA)", National Academies of Sciences, Engineering, and Medicine (NASEM) presentation (10 Jan 2019).
Stefanovics, Elina A. and Robert A. Rosenheck. "Predictors of Post-discharge Suicide Attempt Among Veterans Receiving Specialized Intensive Treatment for Posttraumatic Stress Disorder". Journal of Clinical Psychiatry 80, no. 5 (2019):19m12745. https://doi.org/10.4088/JCP.19m12745
Objective: There has been increasing concern about the high risk of suicide among US veterans, especially those with posttraumatic stress disorder (PTSD). Among those at greatest risk are veterans recently discharged from inpatient or specialized intensive treatment programs, but little is known about clinical correlates of suicide attempts among such veterans and this information that might facilitate prevention efforts.
Methods: National program evaluation data were obtained at program entry and 4 months after discharge from 30,384 veterans from 57 sites (fiscal years 1993–2011) who were discharged from specialized intensive PTSD programs nationally in the Veterans Health Administration.
Rates of attempted suicide were 10.6% in the 4 months prior to admission and 3.4% in the 4 months following discharge. Bivariate analyses and multivariable logistic regression were used to identify baseline characteristics, especially PTSD symptoms, associated with suicide attempts prior to admission and after discharge.
Further analyses examined the association of changes in symptoms and other outcomes with reported post-discharge suicide attempts.
Results: Suicide attempts both prior to admission and after discharge were associated with psychiatric and substance abuse comorbidity and especially suicidal ideation and violent behavior.
Clinical changes independently associated with post-discharge suicide attempts included increased suicidal thoughts (β = 0.96, P < .001), violent behavior (β = 0.49, P < .001), and alcohol use (β = 0.56, P < .001).
Conclusions: In this longitudinal study, violent behavior assessed at admission and as a change measure after discharge, along with suicidal ideation and alcohol use, were associated with suicide attempts.
Additional therapeutic attention to violent behavior and alcohol use, quite likely reflecting underlying impulsivity, may help reduce the risk of suicide attempts.
Both authors are affiliated with:
* Corresponding author:
Elina A. Stefanovics, PhD, Yale University School of Medicine, VA Connecticut Healthcare System/116A, 950 Campbell Ave, West Haven, CT 06516 (firstname.lastname@example.org).
Berke, Danielle S., Julie Yeterian, Candice Presseau, Luke Rusowicz-Orazem, Nora K. Kline, William P. Nash, and Brett T. Litz. Dynamic Changes in Marines’ Reports of PTSD Symptoms and Problem Alcohol Use Across the Deployment Cycle. Psychology of Addictive Behaviors 33, no. 2 (2019): 162-170. https://doi.org/10.1037/adb0000430
Posttraumatic stress disorder (PTSD) and alcohol misuse are commonly co-occurring problems in active-duty service members (SMs) and veterans.
Unfortunately, relatively little is known about the temporal associations between these problems in the acute period following exposure to combat stressors.
Discerning the temporal associations between these problems across the deployment cycle could inform prevention and treatment efforts.
In this study, we examined the association between PTSD symptom severity and problem alcohol use in a large cohort of United States Marines (n = 758) evaluated prior to deployment and approximately 1, 5, and 8 months postdeployment.
Results indicate that problem alcohol use was associated with a subsequent exacerbation of PTSD symptoms between the 1st and 2nd and 2nd and 3rd postdeployment assessments.
PTSD symptom severity was associated with increased problem alcohol use between the 1st and 2nd postdeployment assessments.
These findings suggest that problem drinking may lead to new onset or worsening of PTSD symptoms over time and that SMs [Service Members] with greater PTSD symptom severity upon returning from deployment may increase alcohol use in the weeks immediately following homecoming.
The relationship between PTSD and substance use disorders is an important factor in PTSD C&P exams. If a veteran's posttraumatic stress disorder is service-connected, and if the veteran also suffers from a substance use disorder, the VA mental health examiner must determine if the substance use disorder is "proximately due to or the result of" PTSD or if PTSD has aggravated a pre-existing substance use disorder.1
This research suggests, at least with this cohort of U.S. Marines, that the causal relationship goes both ways.
Moore, Bret A. and Walter E. Penk, eds. Treating PTSD in Military Personnel, Second Edition: A Clinical Handbook. New York: Guildford, 2019. [Publication date: 3 Apr 2019]
Pre-order from Guilford Press for $38.75 (List price: $45.00).
Description (from publisher):
This state-of-the-science guide to assessing and treating posttraumatic stress disorder (PTSD) in active-duty service members and veterans has now been extensively revised with 65% new material.
Leading authorities review available evidence-based treatments, including individual, group, and couple and family therapy approaches.
Knowledge about military culture, the stressors experienced by service members, and common challenges for both military and civilian practitioners is woven through the volume and reflected in the vivid case examples.
Chapters on specific clinical issues delve into co-occurring affective, anxiety, substance use, and sleep disorders; treatment of particular types of trauma; suicide prevention; and more.
New to This Edition
Chapters on additional treatments: mindfulness-based behavioral and cognitive therapies, stress inoculation training, cognitive-behavioral conjoint therapy, group therapy, and complementary and alternative therapies.
Chapters on additional clinical issues: chronic pain, moral injury, complex traumatic stress disorders, and posttraumatic growth.
Updated throughout with the latest treatment research and DSM-5 diagnostic changes.
Review by Dr. Brian Marx
“Moore and Penk have once again assembled a 'who’s who' of leading researchers to present the latest on evidence-based treatments for PTSD in military personnel. The second edition of this handbook is an absolute 'must read' for anyone who provides care to this population. The detailed insights into important considerations for working with military personnel, careful attention to clinical issues that frequently co-occur with PTSD, and clearly presented case examples that illustrate how to implement the various treatments successfully are what make this volume stand apart.”
—Brian P. Marx, PhD, National Center for PTSD, VA Boston Healthcare System; Department of Psychiatry, Boston University School of Medicine.
1. Disabilities that are proximately due to, or aggravated by, service-connected disease or injury, 38 C.F.R. § 3.310.
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