2021 PUBLICATIONS

Bisson, J., Wright, K., Jones, K. A., Lewis, C., Phelps, A., Sijbrandij, M., Varker, T., & Roberts, N. P. (2021). Preventing the onset of post traumatic stress disorder. Clinical Psychology Review, 86 (102004). https://www.doi.org/10.1016/j.cpr.2021.102004

Post-traumatic stress disorder (PTSD) is a common mental health condition that requires exposure to a traumatic event. This provides unique opportunities for prevention that are not available for other disorders. The aim of this review was to undertake a systematic review and evaluation of randomized controlled trials (RCTs) of interventions designed to prevent PTSD in adults. Searches involving Cochrane, Embase, Medline, PsycINFO, PILOTS and Pubmed databases were undertaken to identify RCTs of pre-incident preparedness and post-incident interventions until May 2019. Six pre-incident and 69 post-incident trials were identified that could be included in meta-analyses. The overall quality of the evidence was low. There was emerging evidence that some interventions may be helpful but an absence of evidence for any intervention that can be strongly recommended for universal, selected or indicated prevention before or within the first three months of a traumatic event. The strongest results were found for cognitive-behavioural therapy with a trauma focus (CBT-T) in individuals with a diagnosis of acute stress disorder which supports calls to detect and treat individuals with significant symptoms rather than providing blanket preventative interventions. Further research is required to optimally configure existing interventions with some evidence of effect and to develop novel interventions to address this major public health issue.

Cowlishaw, S., Metcalf, O., Varker, T., Stone, C., Molyneaux, R., Gibbs, L., Block, K., Harms, L., MacDougall, C., Gallagher, C., Bryant, R., Lawrence-Wood, E., Kellett, C., O'Donnell, M., & Forbes, D. (2021). Anger Dimensions and Mental Health Following a Disaster: Distribution and Implications After a Major Bushfire. Journal of Traumatic Stress, 34, 46-55. https://www.doi.org/10.1002/jts.22616
Anger is an important dimension of affect and a prominent feature of posttraumatic mental health, but it is commonly overlooked in postdisaster settings. We aimed to examine the distribution and implications of significant anger problems in the aftermath of a natural disaster, via analyses of Beyond Bushfires survey data from 736 residents of rural communities 5 years after the 2009 Black Saturday bushfires in Victoria, Australia. Assessments included the five-item Dimensions of Anger Reaction (DAR-5) scale along with measures of PTSD, depression, and significant mental illness, and indicators of life satisfaction, suicidality, hostile aggressive behavior, and violence exposure. The results indicated that approximately 10% of respondents from areas highly affected by the bushfires scored above the provisional cutoff criteria for significant anger problems on the DAR-5, which was a more than 3-fold increase, OR = 3.26, relative to respondents from areas of low-to-moderate bushfire impact. The rates were higher among women, younger participants, and those who were unemployed, and co-occurred commonly, although not exclusively, with other postdisaster mental health problems. Anger problems were also associated with lower life satisfaction, β =−.31, an 8-fold increase in suicidal ideation, OR = 8.68, and a nearly 13-fold increase in hostile aggressive behavior, OR = 12.98. There were associations with anger problems and violence exposure, which were reduced when controlling for covariates, including probable PTSD. The findings provide evidence indicating that anger is a significant issue for postdisaster mental health and should be considered routinely alongside other posttraumatic mental health issues.
Dell, L., Sbisa, A., O'Donnell, M., Tuerk, P., Bryant, R., Hodson, S., Morton, D., Battersby, M., Forbes, A., & Forbes, D. (2021). Massed versus standard prolonged exposure for posttraumatic stress disorder in Australian military and veteran populations (RESTORE trial): Study protocol for a non-inferiority randomized controlled trial. Contemporary Clinical Trials, 107, 106478. https://www.doi.org/10.1016/j.cct.2021.106478

Posttraumatic stress disorder (PTSD) can be a severe problem, affecting veterans and military personnel at higher rates than the general community. First-line treatment for PTSD, prolonged exposure (PE), is typically delivered weekly for 10–12 weeks, however this duration can pose a barrier to accessing and completing the treatment, particularly for current serving military. This paper presents the RESTORE trial protocol, the first randomized controlled trial of massed PE therapy outside of the United States and by an independent research group. One hundred and thirty-five Australian Defence Force members and veterans (18–80 years) who meet criteria for PTSD related to a military trauma will be randomly allocated to one of two conditions: standard PE (SPE; 10 weekly 90-min sessions) or massed PE (MPE; 10 daily 90-min sessions). Across eight sites, patients will be assessed at pre-treatment, and at 4 weeks, 12 weeks, and 12 months post-treatment commencement. The primary outcome is clinician-measured and self-reported PTSD symptom severity at the 12 week assessment. We hypothesize that MPE will be as effective as SPE in reducing PTSD severity at 12 weeks post-treatment commencement. The adaptation and testing of evidence-based interventions is critical to reduce barriers to treatment uptake among veterans and military personnel. Outcomes of this study have the potential to result in international, cross-service uptake and delivery of this rapid treatment for veterans and military members, as well as civilians, thereby improving clinical outcomes for patients and their families.

Howard, A., Agathos, J., Phelps, A., Cowlishaw, S., Terhaag, S., Arjmand, H.-A., Armstrong, R., Berle, D., Steel, Z., Brewer, D., Human, B., Herwig, A., Wigg, C., Kemp, P., Wellauer, R., & O'Donnell, M. (2021). Prevalence and treatment implications of ICD-11 complex PTSD in Australian treatment-seeking current and ex-serving military members. European Journal of Psychotraumatology, 12 (1844441). https://www.doi.org/10.1080/20008198.2020.1844441

Despite growing support for the distinction between posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as separate diagnoses within the ICD-11 psychiatric taxonomy, the prevalence and treatment implications of CPTSD among current and ex-serving military members have not been established. The study aims were to a) establish the prevalence of provisional ICD-11 CPTSD diagnosis relative to PTSD in an Australian sample of treatment-seeking current and ex-serving military members, and b) examine the implications of CPTSD diagnosis for intake profile and treatment response. The study analysed data collected routinely from Australian-accredited treatment programmes for military-related PTSD. Participants were 480 current and ex-serving military members in this programmes who received a provisional ICD-11 diagnosis of PTSD or CPTSD at intake using proxy measures. Measures of PTSD symptoms, disturbances in self-organisation, psychological distress, mental health and social relationships were considered at treatment intake, discharge, and 3-month follow-up. Among participants with a provisional ICD-11 diagnosis, 78.2% were classified as having CPTSD, while 21.8% were classified as having PTSD. When compared to ICD-11 PTSD, participants with CPTSD reported greater symptom severity and psychological distress at intake, and lower scores on relationship and mental health dimensions of the quality of life measure. These relative differences persisted at each post-treatment assessment. Decreases in PTSD symptoms between intake and discharge were similar across PTSD (dRM = −0.81) and CPTSD (dRM = −0.76) groups, and there were no significant post-treatment differences between groups when controlling for initial scores. CPTSD is common among treatment-seeking current and ex-serving military members, and is associated with initially higher levels of psychiatric severity, which persist over time. Participants with CPTSD were equally responsive to PTSD treatment; however, the tendency for those with CPTSD to remain highly symptomatic post-treatment suggests additional treatment components should be considered.

Kakaje, A., Alsamara, K., & Forbes, D. (2021). Assessment of problematic anger using an Arabic adaptation of the Dimensions of Anger Reactions Scale-5 (DAR-5). Journal of Affective Disorders Reports, 4 (100128). https://www.doi.org/10.1016/j.jadr.2021.100128

Anger is a normal human emotion that is a common response to potentially traumatic events. Anger is also a risk factor for aggression and violence. With millions of Syrians having to flee and being refugees in other countries, anger was rarely assessed as there was no brief robust tool for anger in Arabic. The objective was to develop and test an Arabic version of the Dimensions of Anger Reactions 5 (DAR-5) scale, a five-question scale to screen for anger distress and problematic anger in adults and adolescents. DAR-5 was translated into Arabic, then back translated into English, and finally rechecked for accuracy. Participants were 1641 Syrian adults, (621 males and 1020 females) and 784 Syrian adolescents (355 males and 429 females) aged between 14 and 16 years old. Only Arabic speaking participants were included. Measures included the DAR-5 Arabic version (DAR-5-A) for both samples, the Depression Anxiety Stress Scale-21 (DASS-21) for the adults, and the Children Revised Impact of Events Scale-8 for the adolescents. High levels of internal reliability were reported and factor analysis found that DAR-5-A scores fit as a single-factor model. This cut off score also differentiated between high and low scores on anxiety, depression and stress. This study reinforces the importance of assessing for anger in these populations. The DAR-5-A is written in formal Arabic and a critical measure that can be used as a brief measure to assess for problematic anger in Arabic-speaking communities, either online or in paper questionnaires in adults and adolescents.

Liddell, B. J., O’Donnell, M., Bryant, R. A., Murphy, S., Byrow, Y., Mau, V., McMahon, T., Benson, G., & Nickerson, A. (2021). The association between COVID-19 related stressors and mental health in refugees living in Australia. European Journal of Psychotraumatology, 12 (1), 1947564. https://doi.org/10.1080/20008198.2021.1947564
Refugees may be particularly vulnerable to the adverse effects of the COVID-19 pandemic on mental health due to their traumatic pasts and the challenges of the postmigration environment. To evaluate the prevalence of COVID-19 related stressors and their relationship to key mental health and functioning outcomes in a resettled refugee sample. N = 656 refugees and asylum seekers living in Australia completed a survey in June 2020 to index their mental health (posttraumatic stress disorder (PTSD), depression, health anxiety and disability) and COVID-19 experiences. The relationship between COVID-19 stressors and mental health was examined using a series of hierarchical linear regression models while controlling for other key demographic factors. Refugees’ most prevalent stressors related to worries of being infected by COVID-19 or the risk COVID-19 posed to others, which predicted health anxiety and PTSD. Social-related difficulties predicted depression and disability symptoms. Accessing and trusting information from authorities were the least prevalent stressors and were not significantly associated with mental health outcomes; neither was accessing basic supplies and financial support. Fears relating to the future such as concerns about visa application processes predicted health anxiety and disability. Crucially, the strongest predictor of all mental health outcomes was COVID-19 serving as a reminder of difficult past events. Refugees may be uniquely affected by COVID-19 because the pandemic serves as a reminder of their past conflict and persecution trauma. It is critical that mental health strategies accommodate the specific needs of refugees during the COVID-19 pandemic.
Nickerson, A., Byrow, Y., Rasmussen, A., O'Donnell, M., Bryant, R., Murphy, S., Mau, V., McMahon, T., Benson, G., & Liddell, B. (2021). Profiles of exposure to potentially traumatic events in refugees living in Australia. Epidemiology and Psychiatric Sciences, 30. https://www.doi.org/10.1017/S2045796021000068
Refugees and asylum-seekers are typically exposed to multiple potentially traumatic events (PTEs) in the context of war, persecution and displacement, which confer elevated risk for psychopathology. There are significant limitations, however, in extant approaches to measuring these experiences in refugees. The current study aimed to identify profiles of PTE exposure, and the associations between these profiles and key demographics, contextual factors (including ongoing stressors, method of travel to Australia and separation from family), mental health and social outcomes, in a large sample of refugees resettled in Australia. Participants were 1085 from Arabic, Farsi, Tamil and English-speaking refugee backgrounds who completed an online or pen-and-paper survey in their own language. Constructs measured included PTE exposure, demographics, pre-displacement factors, ongoing stressors, post-traumatic stress disorder symptoms, depression symptoms, anger reactions, plans of suicide and social engagement. Latent class analysis identified four profiles of PTE exposure, including the torture and pervasive trauma class, the violence exposure class, the deprivation exposure class and the low exposure class. Compared to the low exposure class, participants in the trauma-exposed classes were more likely to be male, highly educated, from Farsi and Tamil-speaking backgrounds, have travelled to Australia by boat, experience more ongoing stressors and report both greater psychological symptoms and social engagement. This study found evidence for four distinct profiles of PTE exposure in a large sample of resettled refugees, and that these were associated with different demographic, psychological and social characteristics. These findings suggest that person-centred approaches represent an important potential avenue for investigation of PTE exposure in refugees, particularly with respect to identifying subgroups of refugees who may benefit from different types or levels of intervention according to their pre-migration PTE experiences.
O'Donnell, M. L., Lau, W., Chisholm, K., Agathos, J., Little, J., Terhaag, S., Brand, R., Putica, A., Holmes, A. C. N., Katona, L., Felmingham, K., Murray, K., Hosseiny, F., & Gallagher, M. W. (2021). A Pilot Study of the Efficacy of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Treating Posttraumatic Psychopathology: A Randomized Controlled Trial. Journal of Traumatic Stress, 34, 563-574. https://www.doi.org/10.1002/jts.22650

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is an intervention that targets common mechanisms that maintain symptoms across multiple disorders. The UP has been shown to be effective across many disorders, including generalized anxiety disorder, major depressive episode (MDE), and panic disorder, that commonly codevelop following trauma exposure. The present study represented the first randomized controlled trial of the UP in the treatment of trauma-related psychopathology, including posttraumatic stress disorder (PTSD), depression, and anxiety symptoms. Adults (N = 43) who developed posttraumatic psychopathology that included PTSD, MDE, or an anxiety disorder after sustaining a severe injury were randomly assigned to receive 10–14 weekly, 60-min sessions of UP (n = 22) or usual care (n = 21). The primary treatment outcome was PTSD symptom severity, with secondary outcomes of depression and anxiety symptom severity and loss of diagnosis for any trauma-related psychiatric disorder. Assessments were conducted at intake, posttreatment, and 6-month follow-up. Posttreatment, participants who received the UP showed significantly larger reductions in PTSD, Hedges’ g = 1.27; anxiety, Hedges’ g = 1.20; and depression symptom severity, Hedges’ g = 1.40, compared to those receiving usual care. These treatment effects were maintained at 6-month follow-up for PTSD, anxiety, and depressive symptom severity. Statistically significant posttreatment loss of PTSD, MDE, and agoraphobia diagnoses was observed for participants who received the UP but not usual care. This study provides preliminary evidence that the UP may be an effective non–trauma-focused treatment for PTSD and other trauma-related psychopathology.

Perkins, D., Sarris, J., Rossell, S., Bonomo, Y., Forbes, D., Davey, C., Hoyer, D., Loo, C., Murray, G., Hood, S., Schubert, V., Galvão-Coelho, N., O’Donnell, M., Carter, O., Liknaitzky, P., Williams, M., Siskind, D., Penington, D., Berk, M., & Castle, D. (2021). Medicinal psychedelics for mental health and addiction: Advancing research of an emerging paradigm. Australian and New Zealand Journal of Psychiatry. https://www.doi.org/10.1177/0004867421998785

The medical use of psychedelic substances (e.g. psilocybin, ayahuasca, lysergic acid diethylamide and 3,4-methylenedioxymethamphetamine) is attracting renewed interest, driven by a pressing need for research and development of novel therapies for psychiatric disorders, as well as promising results of contemporary studies. In this Viewpoint, we reflect upon the ‘Clinical Memorandum on Psychedelics’ recently released by the Royal Australian and New Zealand College of Psychiatrists and note subsequent developments including the application for down-scheduling of psilocybin and 3,4-methylenedioxymethamphetamine presently being considered by the Therapeutic Goods Administration and approvals for access via the Special Access Scheme. We suggest that this field is worthy of rigorous research to assess potential benefits, address safety parameters and clarify therapeutic mechanisms. To this end, we outline recent research findings, provide an overview of current knowledge relating to mechanisms of action and discuss salient aspects of the psychedelic-assisted psychotherapy treatment model. The sum of this research points towards medicinal psychedelics as a potential new class of psychiatric treatments when used within a medically supervised framework with integrated psychotherapeutic support. However, before widespread translation into clinical use can occur, appropriately designed and sufficiently powered trials are required to detect both potential positive and negative outcomes. Unique safety and regulatory challenges also need to be addressed. As for any new medical therapy, psychedelic research needs to be conducted in a rigorous manner, through the dispassionate lens of scientific enquiry. Carte blanche availability to practitioners, without specific protocols and appropriate training, would be potentially harmful to individuals and detrimental to the field.

Roberts, A., Rogers, J., Sharman, S., Melendez-Torres, G., & Cowlishaw, S. (2021). Gambling problems in primary care: A systematic review and synthesis. Addiction Research & Theory. https://doi.org/10.1080/16066359.2021.1876848
The objective was to synthesize evidence regarding gambling problems in primary care contexts as evidence suggests that problem gambling may be overrepresented. Objectives were to review all the available evidence regarding the frequency and implications of gambling problems in primary care. The latter were operationalized by covariates relating to physical and mental health that suggest clinical implications, as well as co-occurring addictive behaviors. Methods were peer-reviewed articles published in MEDLINE, Embase, PsycINFO, CINAHL, and sociological abstracts reporting data relating to gambling and associated problems were screened. Where possible, random-effects meta-analysis was used to combine study estimates. The search identified 14 articles (based on 11 individual studies) from 1708 deduplicated records. Meta-analyses of data from 10 studies indicated around 3.0% of patients reported significant levels of problem gambling, although there was substantial heterogeneity and rates ranged from around 1 to 15% across studies. In contrast, there were few studies reporting findings relating to gambling problems across a broader continuum of severity, and there is little known about subclinical problems (i.e. at-risk gambling) in primary care. There was generally consistent evidence of links between problem gambling and poor mental health and co-occurring substance use problems. In contrast, there was less evidence regarding the physical health implications of problem gambling in primary care. Primary care may provide an important environment for the detection of gambling problems and should identify patients reporting gambling problems across a continuum, consistent with principles of case finding; thereby targeting investigation on those suspected to be ‘at risk’.
Sadler, N., Van Hooff, M., Bryant, R., Lawrence-Wood, E., Baur, J., & McFarlane, A. (2021). Suicide and suicidality in contemporary serving and ex-serving Australian Defence Force personnel. Australian & New Zealand Journal of Psychiatry, 55 (5), 463-475. https://www.doi.org/10.1177/0004867421998751
The risk of suicide in contemporary serving and ex-serving Australian Defence Force personnel is an area of significant concern, driving government-directed inquiries, community campaigns and most recently, the establishment of a permanent National Commissioner for Defence and Veteran Suicide Prevention. This concern is mirrored in international militaries and despite investment in prevention programmes, suicide is a leading cause of death in military populations. This review seeks to summarise recent findings from Australian research regarding the magnitude and factors associated with suicide and suicidality in contemporary serving and ex-serving Australian Defence Force populations and discusses research findings, implications and future opportunities. Initial review of the prevalence of suicide and suicidality in the general community and military populations is presented, followed by review of recent research findings pertaining to suicides and suicidal thoughts, plans and attempts in contemporary serving and ex-serving Australian Defence Force personnel. Key findings are presented from the 2010 Australian Defence Force Mental Health and Wellbeing Prevalence Study and the 2015 Transition and Wellbeing Research Programme. Differences between serving and ex-serving Australian Defence Force cohorts were observed, with rates of completed suicide in ex-serving Australian Defence Force males more than double that of serving Australian Defence Force males, and increased risk for suicidality observed among those who had recently transitioned out of full-time Australian Defence Force service. Risk for increased suicidality and completed suicide is particularly evident for younger males of lower ranks, and those who have been medically discharged. The findings provide insight into career phases and groups that should be followed-up and targeted for prevention and early intervention programmes, including prior to and several years following transition out of full-time military service. Further research to better understand the factors that influence those who develop suicidal ideation, and those who progress to plans and attempts, will inform a more sophisticated approach to suicide prevention programmes.
Terhaag, S., Cowlishaw, S., Howard, A., O'Donnell, M., & Phelps, A. (2021). A longitudinal exploration of hearing loss, tinnitus and PTSD treatment outcomes in Australian veterans. Psychosomatic Medicine. https://www.doi.org/10.1097/psy.0000000000000978

Tinnitus, hearing loss, and posttraumatic stress disorder (PTSD) are common conditions among veterans. Shared underlying symptoms, such as hypervigilance and heightened sense of threat, may interfere with talk-based psychological treatments. The aim was to investigate the prevalence and risk factors for self-reported tinnitus and hearing loss among Australian treatment-seeking veterans, as well as links with PTSD symptoms and quality of life (QOL) after treatment. Methods were Australian veterans participating in hospital-based PTSD treatment (n = 523) completed self-report measures of subjective hearing impairment, service-related factors, PTSD symptoms, and QOL at treatment intake and discharge, as well as 3- and 9-month follow-ups. Univariate analyses of covariance modeled symptom change over time. More than half of veterans on PTSD treatment self-reported doctor-diagnosed hearing loss or tinnitus, whereas 43% reported both. However, 75% reported subjective mild to moderate hearing impairment, and only 1% reported severe impairment. Service-related factors, such as longer length of service and exposure to explosions, were risk factors for having any hearing condition. After controlling for intake scores, there were no significant differences on PTSD or QOL outcomes over time between those with and without hearing conditions. Although self-reported tinnitus and hearing loss are prevalent among veterans, those with severe hearing impairments are unlikely to be represented in this context. There is a need for psychological treatments that are accessible to patients with severe hearing impairments, which should be examined routinely among military members accessing psychological treatments.

Varker, T., Jones, K. A., Arjmand, H.-A., Hinton, M., Hiles, S. A., Freijah, I., Forbes, D., Kartal, D., Phelps, A., Bryant, R. A., McFarlane, A. C., Hopwood, M., & O'Donnell, M. (2021). Dropout from guideline-recommended psychological interventions for posttraumatic stress disorder: A systematic review and meta-analysis. Journal of Affective Disorders Reports, 4, 100093. https://www.doi.org/10.1016/j.jadr.2021.100093

Many patients drop out of guideline-recommended treatments for posttraumatic stress disorder (PTSD), yet there has been little systematic investigation of this issue. We aimed to examine dropout proportions from randomized controlled trials (RCTs) of guideline-recommended treatments for PTSD and whether proportions differed by type of treatment or trauma, PTSD severity or chronicity, or medication being permitted. Methods were systematic review and meta-analysis of RCTs of guideline-recommended treatments for PTSD. Eighty-five trials, with data for 6804 participants were included in the meta-analyses. The mean dropout proportion for guideline-recommended treatment was 20.9% (95%CI 17.2, 24.9) with evidence of high heterogeneity across studies. Military trauma was associated with higher dropout than civilian trauma. The civilian trauma group had similar dropout rates from guideline-recommended treatments, and active, waitlist or treatment as usual controls. In the military trauma group, dropout was higher from guideline-recommended treatments compared to active, waitlist or treatment as usual controls. Within this group, dropout from trauma-focused treatment was significantly higher than from non-trauma focused treatments overall, with the greatest difference in dropout rates occurring between randomization and treatment initiation. Most RCTs exclude participants who have comorbid substance use disorder, suicidal behaviour, or history of psychosis, which limits the generalizability of findings. Dropout from guideline-recommended treatment for PTSD is higher in populations who have experienced military trauma and this population dropout from treatment in higher proportions when it is trauma-focused. The reasons for disparate rates of dropouts from recommended PTSD treatments require further investigation.

Williamson, V., Murphy, D., Phelps, A., Forbes, D., & Greenberg, N. (2021). Moral Injury: The impact on mental health and implications for treatment. The Lancet. 8 (6) 453-455. https://www.doi.org/10.1016/S2215-0366(21)00113-9

Moral injury is understood to be the strong cognitive and emotional response that can occur following events that violate a person's moral or ethical code. Potentially morally injurious events include a person's own or other people's acts of omission or commission, or betrayal by a trusted person in a high-stakes situation. For example, health-care staff working during the COVID-19 pandemic might experience moral injury because they perceive that they received inadequate protective equipment, or when their workload is such that they deliver care of a standard that falls well below what they would usually consider to be good enough.

2020 PUBLICATIONS

Adler, A. B., LeardMann, C. A., Roenfeldt, K. A., Jacobson, I. G., & Forbes, D. (2020). Magnitude of problematic anger and its predictors in the Millennium Cohort. BMC Public Health, 20 (1168). https://www.doi.org/10.1186/s12889-020-09206-2

Problematic anger is intense anger associated with elevated generalized distress and that interferes with functioning. It also confers a heightened risk for the development of mental health problems. In military personnel and veterans, previous studies examining problematic anger have been constrained by sample size, cross-sectional data, and measurement limitations. The current study used Millennium Cohort survey data (N = 90,266) from two time points (2013 and 2016 surveys) to assess the association of baseline demographics, military factors, mental health, positive perspective, and self-mastery, with subsequent problematic anger. Overall, 17.3% of respondents reported problematic anger. In the fully adjusted logistic regression model, greater risk of problematic anger was predicted by certain demographic characteristics as well as childhood trauma and financial problems. Service members who were in the Army or Marines, active duty (vs. reserves/national guard), and previously deployed with high levels of combat had increased risk for problematic anger. Veterans were also more likely to report problematic anger than currently serving personnel. Mental health predictors included posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and comorbid PTSD/MDD. Higher levels of positive perspective and self-mastery were associated with decreased risk of problematic anger. Not only did 1 in 6 respondents report problematic anger, but risk factors were significant even after adjusting for PTSD and MDD, suggesting that problematic anger is more than an expression of these mental health problems. Results identify potential targets of early intervention and clinical treatment for addressing problematic anger in the military and veteran context.

Armstrong, R. M., Phillips, L., Alkemade, N., & O'Donnell, M. L. (2020). Support for ICD-11 Complex PTSD diagnosis in a homeless sample using latent class analysis. Journal of Traumatic Stress. https://www.doi.org/10.1002/jts.22554

The 11th revision of the International Classification of Diseases (ICD-11), ratified at the World Health Assembly in May 2019, introduced revised diagnostic guidelines for posttraumatic stress disorder (PTSD) as well as a separate diagnosis of complex PTSD (CPTSD). We aimed to test the new ICD-11 symptom structure for PTSD and CPTSD in a sample of individuals who have experienced homelessness. Experiences of trauma exposure and the associated mental health outcomes have been underresearched in this population. A sample of adults experiencing homelessness (N = 206) completed structured and semi-structured interviews that collected information about trauma exposure and symptoms of PTSD and CPTSD. We conducted a latent class analysis (LCA) using six symptom clusters (three PTSD symptom clusters that are components of CPTSD and three CPTSD symptom clusters). All participants reported trauma exposure, with 88.6% having experienced at least one event before 16 years of age. Four distinct classes of participants emerged in relation to the potential to meet the diagnosis: LCA CPTSD (n = 122, 59.8%), LCA no diagnosis (n = 27: 13.2%), LCA PTSD (n = 33; 16.2%), and LCA disturbance in self-organization (DSO; n = 22; 10.8%). Of note, participants with an ICD-11 CPTSD as well as those with an ICD-11 PTSD diagnosis fell into the LCA CPTSD class. Our findings provide some support for the distinction between CPTSD and PTSD within this population specifically but potentially have broader implications. Clear diagnoses will allow targeted PTSD and CPTSD treatment development.

Bowd, C., Pedder, D., Parker, P., Thompson, G., Nursey, J., & Howard, A. (2020). PTSD in contemporary veterans. Australian Doctor.
Bryant, R. A., Erlinger, M., Felmingham K., Klimova, A., Williams, L. M., Malhi, G., Forbes, D., & Korgaonkar, M. S. (2020). Reappraisal-related neural predictors of treatment response to cognitive behavior therapy for posttraumatic stress disorder. Psychological Medicine. https://www.doi.org/10.1017/S0033291720001129
Although trauma-focused cognitive behavior therapy (TF-CBT) is the frontline treatment for post-traumatic stress disorder (PTSD), one-third of patients are treatment non-responders. To identify neural markers of treatment response to TF-CBT when participants are reappraising aversive material. This study assessed PTSD patients (n = 37) prior to TF-CBT during functional magnetic brain resonance imaging (fMRI) when they reappraised or watched traumatic images. Patients then underwent nine sessions of TF-CBT, and were then assessed for symptom severity on the Clinician-Administered PTSD Scale. FMRI responses for cognitive reappraisal and emotional reactivity contrasts of traumatic images were correlated with the reduction of PTSD severity from pretreatment to post-treatment. Symptom improvement was associated with decreased activation of the left amygdala during reappraisal, but increased activation of bilateral amygdala and hippocampus during emotional reactivity prior to treatment. Lower connectivity of the left amygdala to the subgenual anterior cingulate cortex, pregenual anterior cingulate cortex, and right insula, and that between the left hippocampus and right amygdala were also associated with symptom improvement. These findings provide evidence that optimal treatment response to TF-CBT involves the capacity to engage emotional networks during emotional processing, and also to reduce the engagement of these networks when down-regulating emotions. Functional magnetic resonance imaging; post-traumatic stress disorder; prediction; reappraisal; trauma-focused cognitive behavior therapy.
Bryant, R. A., Erlinger, M., Felmingham, K., Malhi, G. S., O'Donnell, M. L., Williams, L. M., & Korgaonkar, M. S. (2020). Differential neural predictors of treatment response for fear and dysphoric features of posttraumatic stress disorder. Depression and Anxiety. https://www.doi.org/10.1002/da.23061
Although trauma-focused cognitive behavioral therapy (TF-CBT) is the frontline treatment for posttraumatic stress disorder (PTSD), at least one-third of patients are treatment nonresponders. This study aimed to identify neural markers of treatment response, specifically the prediction of remission of specific PTSD symptoms. This study assessed PTSD treatment-seeking patients (n = 40) before TF-CBT during functional magnetic brain resonance imaging (fMRI) when they processed fearful, sad, happy, and neutral faces. Patients underwent nine sessions of TF-CBT and were independently assessed on the Clinician-Administered PTSD Scale (CAPS) following treatment. Treatment responders and nonresponders were compared with healthy controls (n = 40). The severity of PTSD was assessed with the CAPS. fMRI responses were calculated for each emotion face compared to neutral contrast, which were correlated with reduction in PTSD severity from pretreatment to posttreatment. Treatment response was categorized by at least 50% reduction in the severity of PTSD. The activation of left insula during the processing of both sad and fearful faces was associated with a greater reduction of fear but not with dysphoric symptoms after treatment. Connectivity of the left insula to the pregenual anterior cingulate cortex was associated with poorer response to treatment. Responders and controllers had similar levels of activation and connectivity and were different from nonresponders. Positive response to TF-CBT is predicted during emotion processing by normal levels of recruitment of neural networks implicated in emotional information. These findings suggest that distinct neural networks are predictive of PTSD fear and dysphoric symptom reduction following TF-CBT.
Bryant, R., Edwards, B., Creamer, M., O'Donnell, M., Forbes, D., Felmingham, K. L., Silove, D., Steel, Z., McFarlane, A. C., Van Hooff, M., Nickerson, A., & Hadzi-Pavlovic, D. (2020). Prolonged grief in refugees, parenting behavior, and children’s mental health. Australian & New Zealand Journal of Psychiatry. https://www.doi.org/10.1177/0004867420967420
Many refugees experience bereavement, and as a result they suffer elevated rates of prolonged grief disorder. Evidence also indicates that elevated rates of psychological disturbance in refugee children can be associated with parental mental health. This study examined the extent to which prolonged grief disorder in refugees is associated with their parenting behaviour and in turn with their children’s mental health. This study recruited participants from the Building a New Life in Australia prospective cohort study of refugees admitted to Australia between October 2013 and February 2014. The current data were collected in 2015–2016 and comprised 1799 adults, as well as 411 children of the adult respondents. Adult refugees were assessed for trauma history, post-migration difficulties, harsh and warm parenting, probable prolonged grief disorder and posttraumatic stress disorder. Children were administered the Strengths and Difficulties Questionnaire. The current analyses on bereaved refugees comprise 110 caregivers and 178 children. In this cohort, 37% of bereaved refugees reported probable prolonged grief disorder. Path analysis indicated that caregivers’ grief was directly associated with children’s emotional difficulties. Caregiver warmth was associated with reduced emotional problems in children of refugees with minimal grief but associated with more emotional problems in caregivers with more severe grief. More harsh parenting was associated with children’s conduct problems, and this was more evident in those with less severe grief. Severity of prolonged grief disorder is directly linked to refugee children’s mental health. The association between parenting style, grief severity and children’s mental health highlights that managing grief reactions in refugees can benefit both refugees and their children.
Bryant, R., Gibbs, L., Gallagher, H. C., Pattison, P., Lusher, D., MacDougall, C., Harms, L., Block, K., Ireton, G., Richardson, J., Forbes, D., Molyneaux, R., & O'Donnell, M. (2020). The dynamic course of psychological outcomes following the Victorian Black Saturday bushfires. Australian & New Zealand Journal of Psychiatry, 55 (7), 666-677. https://www.doi.org/10.1177/0004867420969815
The objective was to profile the long-term mental health outcomes of those affected by the 2009 Black Saturday bushfires and to document the course of mental health since the disaster. The longitudinal Beyond Bushfires study included 1017 respondents (Wave 1; 3–4 years after the fires), 736 (76.1%) at Wave 2 (5 years after the fires) and 525 (51.6%) at Wave 3 (10 years after the fires). The survey indexed fire-related and subsequent stressful events, probable posttraumatic stress disorder, major depressive disorder, alcohol use, severe distress and receipt of health services for mental health problems. Relative to their status 3–4 years after the fires, there were reduced rates of fire-related posttraumatic stress disorder (6.2% vs 12.2%), general posttraumatic stress disorder (14.9% vs 18.7%) and severe distress (4.4% vs 7.5%) at 10 years. There were comparable rates between Wave 1 and Wave 3 for depression (10.9% vs 8.3%) and alcohol abuse (21.8% vs 18.5%). Of people in high-affected regions, 22.1% had posttraumatic stress disorder, depression or severe distress at Wave 3. One-third to one-half of participants who reported probable posttraumatic stress disorder or depression at any assessment did not display the disorder at the next assessment. Worsening of mental health at Wave 3 was associated with the extent of property loss, exposure to recent traumatic events or recent stressful life events. Only 24.6% of those with a probable disorder had sought professional help for this in the previous 6 months. Approximately one-fifth of people from high-affected areas have a probable psychological disorder a decade after the fires. Mental health appears to fluctuate for those who are not consistently resilient, apparently as a result of ongoing stressors. The observation that most people with probable disorder are not receiving care highlights the need for further planning about managing long-term mental health needs of disaster-affected communities.
Ceschi, G., Selosse, G., Nixon, R. D. V., Metcalf, O., & Forbes, D. (2020). Posttraumatic anger: A confirmatory factor analysis of the Dimensions of Anger Reactions Scale-5 (DAR-5) – French adaptation. European Journal of Psychotraumatology, 11(1). https://www.doi.org/10.1080/20008198.2020.1731127  

Research has shown that posttraumatic anger is common after a traumatic experience, represents a risk factor for post-trauma psychopathology, and can be screened for using the Dimensions of Anger Reactions Scale-5 (DAR-5), a concise five-item measure. However, a French version of the DAR-5 is not yet available. We aimed to provide a French adaptation (DAR-5-F) and to replicate, in a French community sample, the psychometric properties of the original DAR-5. After translation using transcultural psychometric principles, the DAR-5-F was presented to 822 fluent French speakers alongside validated scales of anger (State-Trait Anger Expression Inventory-2), anxiety and depression (Hospital Anxiety and Depression Scale), alcohol misuse (Alcohol Use Disorders Identification Test-Consumption), and trauma exposure (Life Events Checklist-5). Confirmatory factor analyses confirmed that DAR-5-F scores fit a single-factor model as described with the English version of the scale. The scale showed noteworthy internal consistency and robust convergent validity with trait anger. The screening DAR-5-F cut-off of ≥12 successfully differentiated high from low scores of STAXI-2, anxiety, depression, and traumatic exposure. The DAR-5 is a robust, psychometrically strong brief scale of anger useful for post-trauma screening, with the DAR-5-F now available for use in French-speaking populations. Future research that examines relationships between the DAR-5-F and variables such as trauma severity and posttraumatic stress symptoms will further improve our understanding of these phenomena.

Cheng, H.-Y., McGuinness, L. A., Elbers, R. G., MacArthur, G. J., Taylor, A., McAleenan, A., Dawson, S., López-López, J. A., Higgins, J. P. T., Cowlishaw, S., Lingford-Hughes, A., Hickman, M., & Kessler, D. (2020). Treatment interventions to maintain abstinence from alcohol in primary care: Systematic review and network meta-analysis. BMJ, 371 (m3934). https://www.doi.org/10.1136/bmj.m3934

The objective was to determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care. Systematic review and network meta-analysis. Medline, Embase, PsycINFO, Cochrane CENTRAL, ClinicalTrials.gov, and the World Health Organization’s International Clinical Trials Registry Platform were the data sources. Study selections were randomised controlled trials comparing two or more interventions that could be used in primary care. The population was patients with alcohol dependency diagnosed by standardised clinical tools and who became detoxified within four weeks. Outcomes of interest were continuous abstinence from alcohol (effectiveness) and all cause dropouts (as a proxy for acceptability) at least 12 weeks after start of intervention. 64 trials (43 interventions) were included. The median probability of abstinence across placebo arms was 25%. Compared with placebo, the only intervention associated with increased probability of abstinence and moderate certainty evidence was acamprosate (odds ratio 1.86, 95% confidence interval 1.49 to 2.33, corresponding to an absolute probability of 38%). Of the 62 included trials that reported all cause dropouts, interventions associated with a reduced number of dropouts compared with placebo (probability 50%) and moderate certainty of evidence were acamprosate (0.73, 0.62 to 0.86; 42%), naltrexone (0.70, 0.50 to 0.98; 41%), and acamprosate-naltrexone (0.30, 0.13 to 0.67; 17%). Acamprosate was the only intervention associated with moderate confidence in the evidence of effectiveness and acceptability up to 12 months. It is uncertain whether other interventions can help maintain abstinence and reduce dropouts because of low confidence in the evidence. Evidence is lacking for benefit from interventions that could be implemented in primary care settings for alcohol abstinence, other than for acamprosate. More evidence from high quality randomised controlled trials is needed, as are strategies using combined interventions (combinations of drug interventions or drug and psychosocial interventions) to improve treatment of alcohol dependency in primary care.

Cooper, J., Phelps, A. J., Ng, C. H., & Forbes, D. (2020). Diagnosis and treatment of post-traumatic stress disorder during the COVID-19 pandemic. Australian Journal of General Practice, 49 (12) 785-789. https://www.doi.org/10.31128/AJGP-07-20-5557

The COVID-19 pandemic has caused unprecedented stress globally, and the associated medical and health-related traumatic experiences pose significant risks for the development of post-traumatic stress disorder (PTSD), and the exacerbation of pre-existing PTSD, among patients, general practitioners (GPs) and healthcare staff. The aim of this article is to provide guidance to GPs and healthcare staff working in Australia about the diagnosis and treatment of both newly developed and pre-existing PTSD in the COVID-19 context. Case studies are presented; the authors discuss whether pandemic-related PTSD is different to PTSD caused by different types of traumatic exposure, and the associated implications for treatment. The role of GPs in the management of PTSD during the COVID-19 pandemic remains central, involving early detection, assessment and referral. Moreover, health professionals are not immune to the mental health effects of the pandemic and are encouraged to maintain their wellbeing and to seek professional treatment if needed.

Cowlishaw, S., Little, J., Sbisa, A., McFarlane, A. C., Van Hooff, M., Lawrence-Wood, E., O'Donnell, M., Hinton, M., Sadler, N., Savic, A., Forbes, D., & Metcalf, O. (2020). Prevalence and implications of gambling problems among firefighters. Addictive Behaviors, 105(106326). https://www.doi.org/10.1016/j.addbeh.2020.106326

Firefighting is a high-risk occupation that accounts for vulnerability to a range of mental health problems and addictive behaviours. However, no research has addressed whether this vulnerability extends to gambling problems, and the aim of this study was thus to provide new data on frequency and implications of such problems in this occupational context. The sample consisted of n = 566 career and retained firefighters who participated in a cross-sectional survey of an Australian metropolitan fire service. The Problem Gambling Severity Index (PGSI) was used to operationalise both clinically significant levels of problem gambling (PGSI ≥ 5), and ‘at-risk’ gambling (PGSI 1–4); alongside measures of major depression (PHQ-9), anxiety (GAD-7), Posttraumatic Stress Disorder (PCL-5) and alcohol problems (AUDIT), as well as other addictive behaviours, wellbeing and psychosocial issues. Results indicated 12.3% of firefighters that reported any gambling problems across a continuum of severity (PGSI ≥ 1), including 2.3% that were problems gamblers, and 10.0% reporting at-risk gambling. The weighted prevalence of problem gambling was comparable to other significant mental health conditions including depression and PTSD, while the rate of any gambling problems was high relative to other addictive behaviours. Gambling problems were associated with poor mental health and wellbeing, but not psychosocial indicators (e.g., financial difficulties). The findings suggest that gambling problems across a spectrum of severity may be significant yet hidden issues among emergency service workers, and thus require increased recognition and responses at the organisational level.

Cowlishaw, S., Metcalf, O., Little, J., Sbisa, A., Deans, C., O'Donnell, M., Sadler, N., Van Hoof, M., Lawrence-Wood, E., Crozier, M., Battersby, M., Forbes, D., & McFarlane, A. C. (2020). Gambling problems among military personnel after deployment. Journal of Psychiatric Research, 131, 47-53. https://www.doi.org/10.1016/j.jpsychires.2020.07.035

Military and veteran populations may exhibit heightened vulnerability to gambling problems; however, there is scant relevant evidence outside the US, and few studies of transition periods, including return from operational deployment. The aim of this study was thus to highlight the extent, risk-factors, and implications of gambling problems among current members of the Australian Defence Force (ADF) following deployment to the Middle East Area of Operations (MEAO). It involved analyses of data from n = 1324 ADF personnel who deployed between 2010 and 2012, and completed surveys within four months of returning to Australia. The Problem Gambling Severity Index (PGSI) identified Problem Gambling (PG: PGSI ≥5) and At-Risk Gambling (ARG: PGSI 1–4), alongside measures of Depression (PHQ-9), Posttraumatic Stress Disorder (PCL-C), alcohol use problems (AUDIT), distress (K10), and post-deployment stressors. Analyses indicated that 7.7% of personnel reported at least some gambling problems post-deployment, including 2.0% that were distinguished by PG, and 5.7% indicating ARG. These figures were comparable to conditions including probable depression and alcohol dependence, while levels of any gambling problems were high relative to harmful drinking. Higher levels were observed among personnel who were aged 18–24, reported 0–4 years of military service, served in the Army, and comprised Non-Commissioned Officers/Other Ranks. There were strong associations with gambling problems and various indicators of mental health and wellbeing, and self-reported post-deployment difficulties. The findings indicate that gambling problems are salient concerns for some Australian military personnel post-deployment, and highlight the need for increased recognition and responses to these problems.

Cowlishaw, S., Metcalf, O., Stone, C., O'Donnell, M. L., Lotzin, A., Forbes, D., Hegarty, K., & Kessler, D. (2020). Posttraumatic stress symptoms in primary care: A study of general practices in England. Journal of Clinical Psychology in Medical Settings. https://www.doi.org/10.1007/s10880-020-09732-6
Posttraumatic Stress Disorder (PTSD) may be a common issue in primary care in the UK, but there have been no studies of all-cause PTSD in general samples of attenders in this country. The current paper thus explores the extent and distribution of probable PTSD among patients attending general practices in England. Cross-sectional survey data from adult patients (n = 1058) attending 11 general practices in southwest England were analysed. Patients were recruited from waiting rooms and completed anonymous questionnaires, including measures of depression, anxiety and risky alcohol use. Current probable PTSD was measured using the 4-item Primary Care PTSD Scale (PC-PTSD). Results indicated 15.1% of patients that exhibited probable PTSD (PC-PTSD ≥ 3), with higher levels observed in practices from deprived areas. There were 53.8% of patients with probable PTSD that expressed the desire for help with these issues. The analyses suggested that rates were lowest among older adults, and highest among patients who were not in cohabitating relationships or were unemployed. Measures of anxiety and depression were associated with 10-fold and 16-fold increases in risk of probable PTSD, respectively, although there were no discernible associations with risky drinking. Such preliminary findings highlight the need for vigilance for PTSD in routine general practice in the UK, and signal a strong need for additional research and attention in this context. Posttraumatic Stress Disorder (PTSD) is a psychiatric condition that is linked with high levels of functional impairment and poor quality of life (Schnurr & Lunney, 2016), as well as physical health problems (Pacella, Hruska, & Delahanty, 2013). The disorder may develop following exposure to potentially traumatic events including serious accidents or disasters, exposure to war and conflict, sexual or physical assault (including intimate partner violence; IPV), and life threatening illnesses (Darves-Bornoz et al., 2008). Negative psychological reactions are common sequelae to such events and are often transitory. However, for a significant minority of survivors these symptoms may progress into a disorder characterised by intrusive re-experiencing of the event (through intrusive thoughts, visual or auditory memories and dreams), avoidance of reminders (e.g. places, people and thoughts), alterations in cognitions or mood (e.g. shame, guilt, negative cognitions), and hyperarousal (e.g. hypervigilance, exaggerated startle response; American Psychiatric Association, 2013). Population-based studies indicate around one third of adults in England report at least one major traumatic event in their lifetime, and 4.4% suffer from probable PTSD in the past month (McManus, Bebbington, Jenkins, Brugha, & NHS Digital, & UK Statistics Authority, 2016). Treatment guidelines from the UK’s National Institute for Health and Care Excellence (NICE, 2018) recommend trauma-focussed therapies (which target traumatic experiences and memories) as first-line treatments for PTSD, while also recognising benefits from some pharmacotherapies when patients are unwilling or unable to engage with psychological therapies. However, studies suggest around half of PTSD sufferers fail to receive mental health treatment (McManus et al., 2016), which can be delayed for many years due to stigma and low recognition of the disorder (Iversen et al., 2011; Kantor, Knefel, & Lueger-Schuster, 2017). Conversely, PTSD is associated with high use of generalist healthcare services (Kartha et al., 2008), including primary care, and may be encountered commonly in these environments. Effective treatments for PTSD can only be delivered if relevant conditions are recognised (NICE, 2018), and as such, there may be an important role for primary care in improving the uptake and delivery of evidence-based therapies. Guidelines from NICE recommend inquiring about PTSD when people are involved in major disasters, and also among high risk populations including refugees and asylum seekers (NICE, 2018). However, international evidence suggests that rates of PTSD in generalist medical settings, such as routine primary care, may also be significant and indicate an important context for identification and intervention strategies. Much of this research has been situated in military contexts in the U.S., where there is an expansive system of specific care for current and ex-service personnel and family members, while smaller numbers of studies have addressed civilian services. Systematic reviews of this literature have indicated prevalence estimates which vary widely across studies and settings (from 2 to 39%; Greene, Neria, & Gross, 2016), with a quantitative synthesis (based on k = 15 studies of screening tools from the U.S.) indicating a mean prevalence of 13.5% for PTSD in primary care (Spoont et al., 2015). The small number of studies from outside the U.S. estimate around 8% of men (11% of women) attending primary care exhibit PTSD in Israel (Taubman-Ben-Ari, Rabinowitz, Feldman, & Vaturi, 2001), and comparable figures of 9% among men (17% among women) in Spain (Gómez-Beneyto, Salazar-Fraile, Martí-Sanjuan, & Gonzalez-Luján, 2006). In contrast, we know of only one relevant study in UK primary care that has investigated rates of PTSD, and this identified 32% of general practice patients with a history of myocardial infarction (n = 111) who also exhibited probable PTSD (Jones, Chung, Berger, & Campbell, 2007). There is a strong need for additional studies of PTSD in primary care settings which are situated across international jurisdictions. In large part, this is because evidence from cross-national studies indicates that traumatic events are distributed unequally across countries (including high income countries), while there is also international variation in overall levels of PTSD and particularly high rates observed in high income countries (Koenen et al., 2017). Furthermore, there are important differences in the nature and organisation of health services across countries which means that existing U.S. evidence has limited generalisability to other jurisdictions. In the UK, for example, there is a publicly funded system of universal health care, called the National Health Service (NHS), which incorporates primary care services that are characterised by near universal registration of patients with a single practice, and services which are free at the point of delivery in most cases (Roland, Guthrie, & Thomé, 2012). While economic and health inequalities would seem to have widened in the U.S. (Dickman, Himmelstein, & Woolhandler, 2017), there is evidence that such universal health systems contribute towards reduced social and socio-economic disparities in access to medical services (Asaria et al., 2016; Cookson et al., 2017), thereby increasing utilisation by disadvantaged populations that may be particularly vulnerable to major types and frequencies of traumatic events (e.g. violence victimisation) and PTSD (Frissa et al., 2013; Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). Furthermore, the availability of universal health care in the UK, in particular, has limited the need for a system of specific care for ex-service personnel, such that most military veterans who report combat trauma and related mental health problems will also obtain care in the public system (versus veteran-specific services that are the main provider of care for veteran populations in the U.S.; Macmanus & Wessely, 2013). In the context of scant evidence that relates to the UK, as well as increased emphasis on responses to trauma-related mental health in the context of COVID-19 (Horesh & Brown, 2020), the aims of the current paper were to:
  1. (1)Provide new data on the extent of probable PTSD among patients attending general practices in one region of England; and
  2. (2)Explore the distribution of probable PTSD and variability according to socio-demographic and mental health characteristics which may indicate vulnerable groups.
Dalvie, S., Maihofer, A., Coleman, J., Bardley, B., Breen, B., Brick, L., Chen, C.-Y., Choi, K., Duncan, L., Guffanti, G., Haas, M., Harnal, S., Liberzon, I., Nugent, N., Provost, A., Ressler, K., Torres, K., Amstadter, A., Austin, S. B., Baker, D., Bolger, E., Bryant, R., Calabrese, J., Delahanty, D., Farrer, L., Feeny, N., Flory, J., Forbes, D., Galea, S., Gautam, A., Gelernter, J., Hammamieh, R., Jett, M., Junglen, A., Kaufman, M., Kessler, R., Khan, A., Kranzler, H. R., Lebois, L., Marmar, C., Mavissakalian, M., McFarlane, A., O'Donnell, M., Orcutt, H., Pietrzak, R., Risbrough, V., Roberts, A., Rothbaum, A., Roy-Byrne, P., Ruggiero, K., Seligowski, A., Sheerin, C., Silove, D., Smoller, J., Stein, M., Teicher, M., Usano, R., Van Hooff, M., Winternitz, S., Wolff, J., Yehuda, R., Zhao, H., Zoellner, L. A., Stein, D., Koenen, K., & Nievergelt, C. (2020). Genomic influences on self-reported childhood maltreatment. Translational Psychiatry, 10(38). https://www.doi.org/10.1038/s41398-020-0706-0

Childhood maltreatment is highly prevalent and serves as a risk factor for mental and physical disorders. Self-reported childhood maltreatment appears heritable, but the specific genetic influences on this phenotype are largely unknown. The aims of this study were to (1) identify genetic variation associated with self-reported childhood maltreatment, (2) estimate SNP-based heritability (h2snp), (3) assess predictive value of polygenic risk scores (PRS) for childhood maltreatment, and (4) quantify genetic overlap of childhood maltreatment with mental and physical health-related phenotypes, and condition the top hits from our analyses when such overlap is present. Genome-wide association analysis for childhood maltreatment was undertaken, using a discovery sample from the UK Biobank (UKBB) (n = 124,000) and a replication sample from the Psychiatric Genomics Consortium-posttraumatic stress disorder group (PGC-PTSD) (n = 26,290). h2snp for childhood maltreatment and genetic correlations with mental/physical health traits were calculated using linkage disequilibrium score regression. PRS was calculated using PRSice and mtCOJO was used to perform conditional analysis. Two genome-wide significant loci associated with childhood maltreatment (rs142346759, p = 4.35 × 10−8FOXP1; rs10262462, p = 3.24 × 10−8FOXP2) were identified in the discovery dataset but were not replicated in PGC-PTSD. h2snp for childhood maltreatment was ~6% and the PRS derived from the UKBB was significantly predictive of childhood maltreatment in PGC-PTSD (r2 = 0.0025; p = 1.8 × 10−15). The most significant genetic correlation of childhood maltreatment was with depressive symptoms (rg = 0.70, p = 4.65 × 10−40), although we show evidence that our top hits may be specific to childhood maltreatment. This is the first large-scale genetic study to identify specific variants associated with self-reported childhood maltreatment. Speculatively, FOXP genes might influence externalizing traits and so be relevant to childhood maltreatment. Alternatively, these variants may be associated with a greater likelihood of reporting maltreatment. A clearer understanding of the genetic relationships of childhood maltreatment, including particular abuse subtypes, with a range of phenotypes, may ultimately be useful in in developing targeted treatment and prevention strategies.

Davidson, S., Fletcher, S., Wadley, G., Reavley, N., Gunn, J., & Wade, D. (2020). A mobile phone app to improve the mental health of taxi drivers: Single-arm feasibility trial. JMIR mHealth and uHealth, 8(1), e13133. https://www.doi.org/10.2196/13133

Psychological distress among taxi drivers is 5 times higher than that in the general population, and more than half of all drivers have experienced 3 or more potentially traumatic events in their lifetime. Nevertheless, help-seeking for mental health problems in this male-dominated, predominately immigrant workforce is low. Mobile technologies have the potential to increase mental health awareness, teach self-help skills, and encourage help-seeking in this hard-to-reach population. This study aimed to assess the feasibility, acceptability, and potential efficacy of Driving to Health, a mobile phone–friendly mental health website app designed for people working as taxi drivers. Drivers (n=46) were recruited from the Melbourne Airport Taxi Holding Yard to participate in a single-arm trial. Self-reported, paper-based assessments were completed at baseline and at 1 month. Feasibility was measured by completion rates, representativeness of study participants, and levels of use. Acceptability was assessed by measuring users’ perception of the quality of the app and anticipated levels of future use. The efficacy of Driving to Health to increase awareness, self-help behaviors, and intentions to seek help was assessed using the user version of the Mobile App Rating Scale (uMARS) and the General Help-Seeking Questionnaire (GHSQ). Psychological symptoms were measured using the short form of the Depression, Anxiety, and Stress Scale (DASS-21). Data were analyzed using complete case analysis. In total, 42 participants comprising drivers from 10 different countries of origin, and 14 different languages, completed pre- and poststudy measures (42/46, 91% completion rate). Just under half (45%) of all users used the app more than once with an average visit of 4 min 8 seconds. Responding to the uMARS, 62% (26/42) of the participants said that they would recommend the app to many people. Nearly all (40/42, 95%) participants said that Driving to Health increased awareness of their own mental health; 86% (36/42) said that it increased their mental health knowledge; and 76% (32/42) said that it increased their self-help behaviors. Increases in help-seeking intentions on the GHSQ were not significant, and increases on all 3 scales of DASS-21 were not reliable or meaningful. This study suggests that Driving to Health is an acceptable and feasible electronic health intervention for a hard-to-reach population. Our findings also suggest that Driving to Health results in increases in mental health awareness, behaviors, and willingness to seek help.

Frewen, P., O'Donnell, M., & D'Andrea, W. (2020). Introduction to the Special Issue: Network Analysis of Traumatic Stress. Journal of Traumatic Stress, 33(1), 5-9. https://www.doi.org/10.1002/jts.22486

Network analysis has emerged as a promising new statistical methodology for traumatic stress studies. The present special issue of the Journal of Traumatic Stress amalgamates the reports of 10 studies that employed network analysis to further the field's understanding of traumatic stress. The current issue includes reports of network analyses that sought to better understand the impact of different kinds of traumatic events, including childhood and gender-based trauma exposure, on PTSD symptomatology as defined under the DSM-5 and ICD-11, and examined the relation between PTSD symptoms and trauma-related dissociative experiences as well as the impact of psychological treatment on trauma recovery. A variety of research designs from a diverse group of international samples were employed, including concurrent, longitudinal, experience-sampling, and treatment outcome studies. Finally, a commentary on the articles included in this special issue was provided by Dr. Carl Weems.

Hinton, M., M., O. D., Little, J., Cowlishaw, S., Kartal, D., Metcalf, O., Varker, T., McFarlane, A. H., M, Bryant, R., Forbes, D., Howard, A., Lau, W., Cooper, J., & Phelps, A. (2020). Defining post-traumatic stress disorder recovery in veterans: Benchmarking symptom change against functioning indicators. Stress and Health, 37, 547-556. https://www.doi.org/10.1002/smi.3019

Improved metrics of Post-traumatic stress disorder (PTSD) treatment response that extend beyond a focus on symptom reduction to incorporate meaningful, patient-centred indicators of functioning are needed in veteran populations. The aim of this study was to extend previous research by investigating whether indicators of functioning can successfully distinguish against symptom response categories derived from the Post-Traumatic Stress Disorder Checklist (PCL-5) pre- and post- PTSD treatment. Participants were 472 veterans receiving hospital-based treatment for PTSD. In addition to the PCL-5, measures included quality of life, social relationships, physical health and psychological distress. Four mutually exclusive, progressive response categories were used to define treatment response including: No Response, Response, Response and Below Threshold, and Remission. PTSD symptom reductions were associated with corresponding improvements in broader indicators of functioning. However, it was only when the magnitude of symptom reduction placed the individual in the ‘Response and Below Threshold’ category that improvement on functioning measures achieved levels indicative of a good end state. Traditional metrics of treatment ‘response’ in PTSD treatment do not necessarily indicate recovery on important functioning indicators. Only when an individual both responds to treatment and drops below threshold for probable disorder are they likely to report having meaningful levels of functioning.

Krishnadas, N., Doré, V., Lamb, F., Groot, C., McCrory, P., Guzman, R., Mulligan, R., Huang, K., O'Donnell, M., & Ponsford, J. (2020). Case Report: 18F-MK6240 Tau Positron Emission Tomography Pattern Resembling Chronic Traumatic Encephalopathy in a Retired Australian Rules Football Player. Frontiers in Neurology, 11. https://doi.org/10.3389/fneur.2020.598980

It remains unclear if tau imaging may assist diagnosis of chronic traumatic encephalopathy (CTE). Flortaucipir PET has shown superior frontal with medial temporal tau binding consistent with the provisional neuropathological criteria for mid-stage CTE in group-level analyses of retired symptomatic NFL players and in one individual with pathologically confirmed CTE. 18F-MK6240 is a new PET ligand that has high affinity for tau. We present the case of a 63-year-old cognitively impaired, former Australian rules football player with distinct superior frontal and medial temporal 18F-MK6240 binding and show it to be significantly different to the pattern seen in prodromal Alzheimer's disease (AD). The participant was recruited for a study of amyloid-β and tau several decades after traumatic brain injury. He had multiple concussions during his football career but no cognitive complaints at retirement. A thalamic stroke in his mid 50s left stable mild cognitive deficits but family members reported further short-term memory, behavioral, and personality decline preceding the study. Imaging showed extensive small vessel disease on MRI, a moderate burden of amyloid-β plaques, and 18F-MK6240 binding in bilateral superior frontal and medial temporal cortices. Voxel-wise analysis demonstrated that the frontally predominant pattern of the participant was significantly different to the posterior temporo-parietal predominant pattern of prodromal AD. Although lacking neuropathological examination to distinguish CTE from a variant of AD, the clear demonstration of a CTE-like tau pattern in a single at-risk individual suggests further research on the potential of 18F-MK6240 PET for identifying CTE is warranted.

Li, G., Wang, L., Cao, C., Fang, R., Chen, C., Qiao, Q., Yang, H., Forbes, D., & Elhai, J. D. (2020). Test of the dynamic interplay between DSM-5 PTSD symptom clusters in children and adolescents. Journal of Anxiety Disorders, 76 (102319). https://www.doi.org/10.1016/j.janxdis.2020.102319

Revealing the dynamic interplay between posttraumatic stress disorder (PTSD) symptom clusters has always been an important topic in traumatic stress studies. Based on longitudinal studies, different hypotheses have been proposed to explain PTSD symptom dynamics. But currently, no study have been conducted to test these hypotheses in children and adolescents. Data were derived from a longitudinal study of child and adolescent traumatic event survivors of an explosion accident (N = 659). DSM-5 PTSD symptoms was measured by the PTSD Checklist-5 (PCL-5) at 4, 8, and 13 months after the disaster. Latent difference score (LDS) modeling was used to evaluate the dynamic interplay between clusters. The results of LDS model indicated that intrusion level positively predicted subsequent rate of increase for hyperarousal (p = .008) and negative changes in cognitions and mood symptoms (p = .036). Also, intrusion level trended to positively predict subsequent increase rate of avoidance symptoms (p = .059). This study expands previous knowledge of dynamic relations between symptom clusters during the maintenance and fluctuation of child and adolescent PTSD symptoms. By using new methodology, this study provided novel evidence for the hypothesis that intrusion symptom plays an important role in maintaining other PTSD symptoms.

Lowe, S. R., Ratanatharathorn, A., Lai, B. S., van der Mei, W., Barbano, A. C., Bryant, R. A., Delahanty, D. L., Matsuoka, Y. J., Olff, M., Schnyder, U., Laska, E., Koenen, K. C., Shalev, A. Y., Kessler, R. C., Seedat, S., deRoon-Cassini, T. A., Freedman, S., Mouthaan, J., Sijbrandij, M., an Zuiden, M., Nishi, D., McFarlane, A., Silove, D., O'Donnell, M., Wei Qi, W., & Gevonden, M. (2020). Posttraumatic stress disorder symptom trajectories within the first year following emergency department admissions: Pooled results from the International Consortium to Predict PTSD. Psychological Medicine. https://www.doi.org/10.1017/S0033291719004008
Research exploring the longitudinal course of posttraumatic stress disorder (PTSD) symptoms has documented four modal trajectories (low, remitting, high, and delayed), with proportions varying across studies. Heterogeneity could be due to differences in trauma types and patient demographic characteristics. This analysis pooled data from six longitudinal studies of adult survivors of civilian-related injuries admitted to general hospital emergency departments (EDs) in six countries (pooled N = 3083). Each study included at least three assessments of the clinician-administered PTSD scale in the first post-trauma year. Latent class growth analysis determined the proportion of participants exhibiting various PTSD symptom trajectories within and across the datasets. Multinomial logistic regression analyses examined demographic characteristics, type of event leading to the injury, and trauma history as predictors of trajectories differentiated by their initial severity and course. Five trajectories were found across the datasets: Low (64.5%), Remitting (16.9%), Moderate (6.7%), High (6.5%), and Delayed (5.5%). Female gender, non-white race, prior interpersonal trauma, and assaultive injuries were associated with increased risk for initial PTSD reactions. Female gender and assaultive injuries were associated with risk for membership in the Delayed (v. Low) trajectory, and lower education, prior interpersonal trauma, and assaultive injuries with risk for membership in the High (v. Remitting) trajectory. The results suggest that over 30% of civilian-related injury survivors admitted to EDs experience moderate-to-high levels of PTSD symptoms within the first post-trauma year, with those reporting assaultive violence at increased risk of both immediate and longer-term symptoms.
Molyneaux, R., Gibbs, L., Bryant, R. A., Humphreys, C., Hegarty, K., Kellett, C., Gallagher, H. C., Block, K., Harms, L., Richardson, J. F., Alkemade, N., & Forbes, D. (2020). Interpersonal violence and mental health outcomes following disaster. British Journal of Psychiatry, 6(1), E1. https://www.doi.org/10.1192/bjo.2019.82
Disasters pose a documented risk to mental health, with a range of peri- and post-disaster factors (both pre-existing and disaster-precipitated) linked to adverse outcomes. Among these, increasing empirical attention is being paid to the relation between disasters and violence. This study examined self-reported experiences of assault or violence victimisation among communities affected by high, medium, and low disaster severity following the 2009 bushfires in Victoria, Australia. The association between violence, mental health outcomes and alcohol misuse was also investigated. Participants were 1016 adults from high-, medium- and low-affected communities, 3–4 years after an Australian bushfire disaster. Rates of reported violence were compared by areas of bushfire-affectedness. Logistic regression models were applied separately to men and women to assess the experience of violence in predicting general and fire-related post-traumatic stress disorder, depression and alcohol misuse. Reports of experiencing violence were significantly higher among high bushfire-affected compared with low bushfire-affected regions. Analyses indicated the significant relationship between disaster-affectedness and violence was observed for women only, with rates of 1.0, 0 and 7.4% in low, medium and high bushfire-affected areas, respectively. Among women living in high bushfire-affected areas, negative change to income was associated with an increased likelihood of experiencing violence (odds ratio, 4.68). For women, post-disaster violence was associated with more severe post-traumatic stress disorder and depression symptoms. Women residing within high bushfire-affected communities experienced the highest levels of violence. These post-disaster experiences of violence are associated with post-disaster changes to income and with post-traumatic stress disorder and depression symptoms among women. These findings have critical implications for the assessment of, and interventions for, women experiencing or at risk of violence post-disaster.
Murphy, D., Howard, A., Forbes, D., Busuttil, W., & Phelps, A. (2019). Comparing the profiles of UK and Australian military veterans supported by national treatment programmes for post-traumatic stress disorder (PTSD). Journal of the Royal Army Medical Corps. https://www.doi.org/10.1136/jramc-2019-001268 

The aim of this study was to compare and contrast the profiles of military veterans seeking formal support for post-traumatic stress disorder (PTSD) in national treatment programmes in Australia and the UK to better understand the needs of this vulnerable population. Data were extracted from 1926 participants in these treatment programmes. This consisted of 1230 from the UK who had accessed support between 2014 and early 2019, and 696 from Australia who had accessed support between 2014 and 2018. Comparison was made between a number of sociodemographic characteristics (age, sex and educational achievements), military factors (branch of military, time since leaving the military and whether participants were early service leavers or not) and health outcomes (PTSD, anger, alcohol misuse, anxiety and depression). Small differences were observed, with those in the UK cohort appearing to be younger, having lower educational achievement, being more likely to be ex-Army, having longer periods of enlistment in the military and taking longer to seek help. Further, minor differences were reported in health outcomes, with those in the UK cohort reporting more severe symptoms of PTSD, anger, anxiety and depression. Overall, the observed differences between the cohorts were modest, suggesting that treatment-seeking veterans from the Australian and UK cohorts reported similar presentations. This provides evidence to support the establishment of international cohorts of treatment-seeking veterans to improve knowledge within this field.

Nickerson, A., Byrow, Y., Hoffman, J., O'Donnell, M., Bryant, R. A., Mastrogiovanni, N., McMahon, T., Benson, G., Mau, V., & Liddell, B. J. (2020). The longitudinal association between moral injury appraisals and psychological outcomes in refugees. Psychological Medicine, 1-13. https://www.doi.org/10.1017/S0033291720004262
Refugees report a diverse array of psychological responses following persecution and displacement. Little is known, however, regarding the mechanisms that underlie differential psychological reactions in refugees. This study investigated the longitudinal impact of negative moral appraisals about one's own actions [i.e. moral injury-self (MI-self) appraisals] and others' actions [i.e. moral injury-other (MI-others) appraisals] on a variety of psychological symptoms over a period of 6 months. Participants were 1085 Arabic, Farsi, Tamil, or English-speaking refugees who completed a survey at baseline and 6 months later either on-line or via pen-and-paper. The survey indexed demographic factors, exposure to potentially traumatic events (PTEs), exposure to ongoing stressors, MI-other appraisals, MI-self appraisals, re-experiencing and arousal symptoms, and feelings of sadness, anger and shame. Findings indicated that, after controlling for demographics, PTE exposure and ongoing stressors, MI-other appraisals predicted increased re-experiencing and hyperarousal symptoms, and feelings of sadness and shame. MI-self appraisals predicted decreased feelings of shame, and decreased re-experiencing symptoms. In contrast, psychological symptoms at baseline did not as strongly influence MI appraisals 6 months later. These findings highlight the important role that cognitive appraisals of adverse events play in the longitudinal course of psychological symptoms. These results thus have important implications for the development of tailored psychological interventions to alleviate the mental health burden held by refugees.
Nursey, J., Sbisa, A., Knight, H., Ralph, N., Cowlishaw, S., Forbes, D., O'Donnell, M. L., Hinton, M., Cooper, J. A., Hopwood, M., McFarlane, A. C., Herring, S., & Fitzgerald, P. (2020). Exploring Theta Burst Stimulation for Posttraumatic Stress Disorder in Australian Veterans – A Pilot Study. Military Medicine, usaa149. https://www.doi.org/10.1093/milmed/usaa149

Post-traumatic stress disorder (PTSD) is a severe and debilitating condition affecting a significant proportion of the veteran community. A substantial number of veterans with PTSD fail to benefit from trauma-focused psychological therapies or pharmacotherapy or are left with residual symptoms, and therefore, investigation of new and innovative treatment is required. Theta Burst Stimulation (TBS) is a novel form of Repetitive Transcranial Magnetic Stimulation, which has been shown to improve depression symptoms and associated cognitive deficits. The current pilot study aimed to explore the acceptability, safety, and tolerability of intermittent TBS (iTBS) as a treatment for PTSD in Australian veterans. This study employed a case series, repeated-measures design. Eight Australian Defence Force veterans with PTSD received 20 bilateral iTBS treatments (1 session per day, 5 days per week over a 4-week period) and were assessed on a range of mental health and neuropsychological measures, including the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and Hamilton Depression Rating Scale (HAM-D), at pretreatment, post-treatment, and a 3-month follow-up. Treatment was generally welltolerated, with reported side-effects including mild to moderate site-specific cranial pain and headaches during stimulation, which were relieved with the use of low dose analgesics. No serious side effects or adverse events were reported. Participants exhibited reductions in both PTSD and depression symptom severity (the repeated-measures effect size [dRM] for the CAPS-5 was −1.78, and the HAM-D was −1.16 post-treatment), as well as improvements in working memory and processing speed. Although significance cannot be inferred, these preliminary estimates of effect size indicate change over time. Bilateral iTBS appears to be welltolerated by Australian veterans. Within this repeated-measures case series, iTBS treatment shows promise in reducing both PTSD and mood symptoms, as well as improving cognitive difficulties associated with these disorders. Large-scale randomized controlled trials of this promising treatment are warranted.

O'Donnell M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International Journal of Environmental Research and Public Health, 14(16), 2537. https://www.doi.org/10.3390/ijerph16142537

Despite its high prevalence in clinical and consultant liaison psychiatry populations, adjustment disorder research has traditionally been hindered by its lack of clear diagnostic criteria. However, with the greater diagnostic clarity provided in the Diagnostic and Statistical Manual of Mental Disorders – fifth edition (DSM-5) and the International Statistical Classification of Diseases and Related Health Problems, 11th edition (ICD-11), adjustment disorder has been increasingly recognised as an area of research interest. This paper evaluates the commonalities and differences between the ICD-11 and DSM-5 concepts of adjustment disorder and reviews the current state of knowledge regarding its symptom profile, course, assessment, and treatment. In doing so, it identifies the gaps in our understanding of adjustment disorder and discusses future directions for research.

O'Donnell, M., Lau, W., Fredrickson, J., Gibson, K., Bryant, R. A., Bisson, J., Burke, S., Busuttil, W., Coghlan, A., Creamer, M., Gray, D., Greenberg, N., McDermott, B., McFarlane, A. C., Monson, C., Phelps, A., Ruzek, J. I., Schnurr, P. P., Ugsang, J., Watson, P., Whitton, S., Williams, R., Cowlishaw, S., & Forbes, D. (2020). An open label pilot study of a brief psychosocial intervention for disaster and trauma survivors. Frontiers in Psychiatry, 11, 483. https://www.doi.org/10.3389/fpsyt.2020.00483

In the aftermath of disaster, a large proportion of people will develop psychosocial difficulties that impair recovery, but for which presentations do not meet threshold criteria for disorder. Although these adjustment problems can cause high distress and impairment, and often have a trajectory towards mental health disorder, few evidence-based interventions are available to facilitate recovery. This paper describes the development and pilot testing of an internationally developed, brief, and scalable psychosocial intervention that targets distress and poor adjustment following disaster and trauma. The Skills fOr Life Adjustment and Resilience (SOLAR) program was developed by an international collaboration of trauma and disaster mental health experts through an iterative expert consensus process. The resulting five session, skills-based intervention, deliverable by community-based or frontline health or disaster workers with little or no formal mental health training (known as coaches), was piloted with 15 Australian bushfire survivors using a pre-post with follow up, mixed-methods design study. Findings from this pilot demonstrated that the SOLAR program was safe and feasible for non-mental health frontline workers (coaches) to deliver locally after two days of training. Participants' attendance rates and feedback about the program indicated that the program was acceptable. Pre-post quantitative analysis demonstrated reductions in psychological distress, posttraumatic stress symptoms, and impairment. This study provides preliminary evidence that the delivery of the SOLAR program after disaster by trained, frontline workers with little or no mental health experience is feasible, acceptable, safe, and beneficial in reducing psychological symptoms and impairment among disaster survivors. Randomized controlled trials of the SOLAR program are required to advance evidence of its efficacy.

Palinkas, L. A., O'Donnell, M. L., Lau, W., & Wong, M. (2020). Strategies for delivering mental health services in response to global climate change: A narrative review. International Journal of Environmental Research and Public Health, 17 (22), Article 8562. https://www.doi.org/10.3390/ijerph17228562

This narrative review examined strategies for preparedness and response to mental health impacts of three forms of climate change from a services perspective: (1) acute and extreme weather events such as hurricanes, floods, and wildfires, (2) sub-acute or long-term events such as droughts and heatwaves; and (3) the prospect of long-term and permanent changes, including higher temperatures, rising sea levels, and an uninhabitable physical environment. Strategies for acute events included development and implementation of programs and practices for monitoring and treating mental health problems and strengthening individual and community resilience, training of community health workers to deliver services, and conducting inventories of available resources and assessments of at-risk populations. Additional strategies for sub-acute changes included advocacy for mitigation policies and programs and adaptation of guidelines and interventions to address the secondary impacts of sub-acute events, such as threats to livelihood, health and well-being, population displacement, environmental degradation, and civil conflict. Strategies for long-lasting changes included the implementation of evidence-based risk communication interventions that address the existing and potential threat of climate change, promoting the mental health benefits of environmental conservation, and promoting psychological growth and resilience.

Pirkis, J., Phelps, A., & Jessop, M. (2020). Psychology and the big picture. InPsych, 42 (5). https://psychology.org.au/for-members/publications/inpsych/2020/oct-nov-vol-42-issue-5/psychology-and-the-big-picture 

The Macquarie Dictionary defines psychology as ‘the systematic study of the mind, or of mental states and processes’, suggesting that training in the discipline will teach keen young students about how individuals reason, perceive and react to things, express emotions and behave. This implies that a psychology degree prepares new graduates for jobs in which much of the work is done on a one-to-one basis, in a range of different settings. Psychology is certainly about individuals, and there are many, many psychologists around Australia who are making a massive difference to individuals’ lives. However, we would argue that psychology is about more than this. Training in psychology equips graduates with myriad skills that enable them to influence policy and practice in a way that improves the mental health and wellbeing of whole populations, if they choose to take up this challenge.

Ponsford, J., Lee, N. K., Wong, D., McKay, A., Haines, K., Downing, M., Alway, Y., Furtado, C., & O'Donnell, M. L. (2019). Factors associated with response to cognitive behavioral therapy for anxiety and depression following traumatic brain injury. Journal of Head Trauma Rehabilitation, 35(2), 117-126. https://www.doi.org/10.1097/HTR.0000000000000510

Given the high frequency and significance of anxiety and depression following traumatic brain injury (TBI), there is a need to evaluate the efficacy of psychological interventions and to understand factors influencing response to such interventions. The present study investigated factors associated with positive response to cognitive behavioral therapy adapted for cognitive impairments (CBT-ABI) for individuals with anxiety and depression following TBI, including demographic and injury-related factors, pretreatment levels of anxiety and depression, working alliance, and change expectancy as predictors. Participants were 45 individuals enrolled in an active treatment condition within a randomized controlled trial, examining the efficacy of a 9-session CBT-ABI program for anxiety and depression following TBI. These participants completed all CBT sessions. Mixed-effects regressions controlling for baseline anxiety and depression indicated that for anxiety, older age at injury, as well as higher level of baseline anxiety, was associated with greater symptom reduction. For depression, longer time since injury and higher expectancy for change, as well as higher baseline level of depression, were significantly associated with a greater reduction in depression symptoms. This study paves the way for more detailed studies of the therapeutic processes involved in alleviating anxiety and depression following TBI.

Putica, A., Van Dam, N. T., Steward, T., Agathos, J., Felmingham, K., & O'Donnell, M. (2020). Alexithymia in post-traumatic stress disorder is not just emotion numbing: Systematic review of neural evidence and clinical implications. Journal of Affective Disorders, 278, 519-527. https://www.doi.org/10.1016/j.jad.2020.09.100

Alexithymia is very common among those with Post-traumatic stress disorder with estimates suggesting that as many as 42% of individuals with PTSD exhibit clinically-relevant alexithymia. One proposed explanation for this comorbidity is that alexithymia symptoms exhibit structural overlap with PTSD-related emotion numbing. Given the need to identify via objective measurement whether alexithymia and emotional numbing are overlapping or different experiences, a review of neural circuitry involved in these conditions is warranted. In this paper, we briefly discuss emotion processing in Alexithymia and PTSD, presenting a PRISMA systematic review of the relevant functional neuroimaging studies. Our results suggest that alexithymia is linked to alterations in the Default Mode Network (DMN) while PTSD-related emotion numbing appears to be primarily linked to alterations in the salience network. Our results suggest that emotion numbing may be linked to neural networks associated with disorder-level negative affect while alexithymia is linked to alterations in neural networks associated with emotional meta-cognition and attentional control, providing evidence that these constructs are at least partially distinct in the brain. This has important clinical implications and may inform the selection of appropriate treatments. The impact of the review may be limited due to cross-study variations in control groups, different trauma histories, individual differences and emotion processing paradigms utilised.

Roberts, A., Sharman, S., Landon, J., Cowlishaw, S., Murphy, R., Meleck, S., & Bowden-Jones, H. (2020). Intimate partner violence in treatment seeking problem gamblers. Journal of Family Violence, 35(65-72). https://www.doi.org/10.1007/s10896-019-00045-3

The co-occurrence of Intimate Partner Violence (IPV) and gambling disorder is an emerging area of research but no studies, as yet, have examined these within a gambling treatment-seeking population from the UK. In a sample of 204 patients, the study utilised routine clinical data and the Jellinek–Inventory for assessing Partner Violence (J-IPV) to determine the prevalence of IPV perpetration and victimisation. 20.1% of participants reported any IPV in the past year; 12.3% reported perpetration and 14.1% reported victimisation in the past year. Clinical scores were greater among patients disclosing IPV; higher anxiety and depression scores coupled with victimisation, alongside greater problem gambling severity; age, anxiety, depression and debt scores among those reporting IPV perpetration. There is need for enhanced vigilance and first-line responses to IPV in problem gambling treatment services. There is also a need for professional support for the clinicians working with these clients.

Sadler, N., Forbes, D., & O'Donnell, M. L. (2020). Mental health, wellbeing and suicidality following separation from the military: Advancing research and practice. Psychiatry: Interpersonal and Biological Processes, 83 (2), 176-178. https://www.doi.org/10.1080/00332747.2020.1767991

The article by Wang et al. (in press) investigating the mental health and suicidality of separating U.S. Reserve and National Guard Personnel provides a useful point to reflect on the similarities of emergent findings across surveys examining transition from military service. While there has been much research examining the mental health impact of military service on active duty or currently serving members, and also on veterans long discharged from military service, it has been relatively recently that research has examined the impact of transition from military service. While we all acknowledge that transitions are, by their very nature, challenging, growing evidence is pointing to transition from military service as a point of significance and potential vulnerability. Despite the risks and challenges associated with military service, including exposures to potentially traumatic events, there are aspects of military service that appear to be protective for mental health, with Wang et al. (in press) and others (Van Hooff et al., 2018) finding that transitioned members report more mental health problems and suicidal thoughts and behavior than those currently serving. This may be because, in part, transitioning personnel include those transitioning for medical reasons, so the currently or active serving group represents the working well. However, this is not the complete picture.

Schlichthorst, M., King, K., Reifels, L., Phelps, A., & Pirkis, J. (2019). Using social media networks to engage men in conversations on masculinity and suicide: Content analysis of Man Up Facebook campaign data. Social Media + Society, 5(4), 1-13. https://www.doi.org/10.1177/2056305119880019

We analyzed comments published on the Man Up Facebook page (manuptvseries) during the roll-out of the Man Up digital campaign. The aim was to gain insight into how the public perceived the Man Up campaign and the conversation topics that the campaign instigated. We downloaded Facebook threads (posts and comments) from the manuptvseries page using NCapture and performed conventional content analysis on a random set of comments (n = 2,236) to identify how the campaign was perceived and what were the popular conversations. Overall, the campaign was perceived extremely positively by the Facebook audience showing many comments endorsing the content of the campaign by sharing among their Facebook community. The strongest themes were expressing emotions, help and support, and masculinity/gender roles which related to the higher level theme of expressions of masculinity. Another strong theme was suicide and topics related to suicide. Comments acknowledged the importance of discussing the issues of male suicide and masculinity publicly. Men were less engaged with topics on masculinity and expressing emotions compared with women and recognized stigma around help-seeking for mental health issues. The Man Up Facebook campaign did foster a public discussion on masculinity and suicide. A gendered approach in mental health promotion is needed with stigma still present for men when seeking help for mental health problems. Social media holds considerable potential for the use of health promotion campaigns aiming to increase interpersonal communication on challenging health topics. Yet, these campaigns need to carefully manage the risk of reinforcing stereotypes.

Schnabel, A., Hallford, D. J., Stewart, M., McGillivray, J., Forbes, D., & Austin, D. W. (2020). An initial examination of post-traumatic stress disorder in mothers of children with autism spectrum disorder: Challenging child behaviors as Criterion A traumatic stressors. Autism Research. https://www.doi.org/10.1002/aur.2301

Parenting a child with autism spectrum disorder (ASD) is associated with high levels of stress. Several studies have conceptualized this as a traumatic stress response to challenging child behaviors such as self-harm, suicidal ideation, and physical aggression toward caregivers. In the present study, we explored the relevance of a trauma-based diagnostic framework to a sample of 30 mothers (M age = 42.97, SD = 5.82) of children with ASD (M age = 12.43, SD = 3.15). Participants were interviewed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) for post-traumatic stress disorder (PTSD) and an abbreviated Mini International Neuropsychiatric Interview to assess for comorbidity. Three participants were excluded as they met criteria for PTSD from a traumatic event unrelated to their parenting experience. Of the remaining 27 participants, 6 (22.2%) met criteria for PTSD in the context of traumatic parenting experiences. Descriptions of traumatic events experienced are summarized. Results suggest that, for some parents, challenging child behaviors such as physical violence toward the caregiver from the child, self-injurious behaviors, and suicidal behaviors function as traumatic stressors as per Criterion A of PTSD (American Psychiatric Association [2013]. Diagnostic and statistical manual of mental disorders [DSM-5]. Arlington, VA). This has implications for health professionals engaged with parents of children with ASD, who should consider the possibility of PTSD when challenging behaviors of a potentially traumatic nature are present.

Schnabel, A., Youssef, G. J., Hallford, D. J., Hartley, E. J., McGillivray, J. A., Stewart, M., Forbes, D., & Austin, D. W. (2020). Psychopathology in parents of children with autism spectrum disorder: A systematic review and meta-analysis of prevalence. Autism, 24(1), 26-40. https://www.doi.org/10.1177/1362361319844636

Parents of children with autism spectrum disorder appear to experience high levels of psychological distress, yet little is known about the prevalence of psychological disorders in this population. The aim of this systematic review and meta-analysis was to estimate the proportion of these parents who experience clinically significant psychopathology. Articles reporting proportions of psychological disorders in a sample of parents of children with autism spectrum disorder were located. The initial search returned 25,988 articles. Thirty-one studies with a total sample of 9208 parents were included in the final review. The median meta-analytic proportions were 31% (95% confidence interval = [24%, 38%]) for depressive disorders, 33% (95% confidence interval = [20%, 48%]) for anxiety disorders, 10% (95% confidence interval = [1%, 41%]) for obsessive-compulsive disorder, 4% (95% confidence interval = [0%, 22%]) for personality disorders, 2% (95% confidence interval = [1%, 4%]) for alcohol and substance use disorders and 1% (95% confidence interval = [0%, 5%]) for schizophrenia spectrum disorders. Significant heterogeneity was detected in these categories. Further research is needed to gain more insight into variables that may moderate parental psychopathology. This review and meta-analysis is the first to provide prevalence estimates of psychological disorders in parents of children with autism spectrum disorder.

Shang, F., Kaniasty, K., Cowlishaw, S., Wade, D., Ma, H., & Forbes, D. (2020). The impact of received social support on posttraumatic growth after disaster: Addressing both social support quantity and quality. Psychological Trauma: Theory, Research, Practice and Policy. https://www.doi.org/10.1037/tra0000541

Few studies have investigated the relationship between received social support (actual help received) and posttraumatic growth (PTG), and these studies focused only on the quantity of support received. This study examined the joint implications of both the quantity and quality of postdisaster received social support for PTG. Method: Data were collected from Lushan earthquake (China, in 2013) survivors at 7 (n = 199) and 31 (n = 161) months after the earthquake. The main effects of quantity and quality of received support, and the interaction between support quantity and support quality, were examined using hierarchical multiple regression analyses controlling for the extent of disaster exposure, postdisaster negative life events, and sociodemographic factors. Results: Neither quantity nor quality of received social support exerted significant main effects on PTG. However, the influence of the amount of received social support on PTG was moderated by the quality of received social support. Among survivors who appraised the postdisaster social support they received as higher in quality, greater amounts of received support were associated with more subsequent PTG. Among those survivors who appraised the postdisaster social support they received as lower in quality, greater quantity of received support was associated with lower levels of reported PTG. Conclusion: This study calls attention to the importance of enhancing the quality of help provided to disaster survivors because simply “more” support is not necessarily better.

Stewart, M., Schnabel, A., Hallford, D. J., McGillivray, J., Forbes, D., Foster, M., Shandley, K., Gardam, M., & Austin, D. (2020). Challenging child behaviours positively predict symptoms of posttraumatic stress disorder in parents of children with autism spectrum disorder and rare diseases. Research in Autism Spectrum Disorders, 69, 101467. https://www.doi.org/10.1016/j.rasd.2019.101467

This study investigated the validity of conceptualising elevated stress in parents of children who exhibit challenging behaviour within the framework of posttraumatic stress disorder (PTSD). It was hypothesised that parents of children with autism spectrum disorder (ASD), and parents of children with a rare disease would endorse greater PTSD symptomatology than parents of typically developing (TD) children, and that challenging child behaviours would positively predict PTSD symptomatology. The Life Events Checklist for DSM-5, Developmental Behaviour Checklist (Parent) and PTSD Checklist for DSM-5 were administered to 395 parents. Significantly more PTSD symptomatology was reported by parents of children with ASD and parents of children with a rare disease than parents of TD children, and challenging child behaviours positively predicted PTSD symptomatology in both groups. A PTSD framework may validly explain elevated stress among some parents of children with ASD and parents of children with a rare disease, and has important implications for support delivered to parents by healthcare providers.

Terhaag, S., Cowlishaw, S., Steel, Z., Brewer, D., Howard, A., Armstrong, R., Human, B., Forbes, D., & Phelps, A. (2019). Psychiatric comorbidity for veterans with posttraumatic stress disorder (PTSD): A latent profile analysis and implications for treatment. Psychological Trauma: Theory, Research, Practice and Policy. https://www.doi.org/10.1037/tra0000520

Background and Objective: Psychiatric comorbidity is common among veterans with posttraumatic stress disorder (PTSD), but there is little known about the patterns of co-occurring mental health problems and implications for treatment. The aim of this study was to identify comorbidity profiles among veterans at treatment intake and assess associations with PTSD and quality of life (QOL) outcomes. Method: The study included 2,522 veterans accessing outpatient treatment for PTSD in Australia who self-completed measures of comorbid issues including depression, anger, alcohol use problems, guilt, and dissociation. Latent Profile Analysis (LPA) was used to identify subgroups based on comorbidity profiles, and their association with outcomes. Results: LPA suggested 5 comorbidity profiles: (a) low comorbidity severity, (b) moderate comorbidity severity with low alcohol, (c) moderate comorbidity severity with high alcohol, (d) high comorbidity severity with low alcohol, and (e) high comorbidity severity with high alcohol. The absence of alcohol problems was associated with improved treatment outcomes when overall comorbidity severity was high but not moderate. While all profiles evidenced symptom improvement from intake to discharge and follow-up, this did not correspond to quality of life improvements equally across classes. The highest severity comorbidity class experienced no improvement on psychological quality of life. Conclusions: The comorbidity profiles of veterans in treatment for PTSD can be distinguished by levels of severity and the specific presence or absence of alcohol use problems. Alcohol use problems have discernible implications for treatment in the context of comorbidity. Group treatments for PTSD should consider tailoring interventions to comorbidity profiles.

Varker, T., Kartal, D., Watson, L., Freijah, I., O'Donnell, M., Forbes, D., Phelps, A., Hopwood, M., McFarlane, A. C., Cooper, J., Wade, D., Bryant, R., & Hinton, M. (2020). Defining response and non-response to PTSD treatments: A systematic review. Clinical Psychology: Science and Practice, 27, e12355. https://www.doi.org/10.1111/cpsp.12355

There is currently no uniform definition of treatment response for posttraumatic stress disorder (PTSD) to guide researchers and clinicians in the area of posttraumatic mental health. The aim of this systematic review was to explore the operationalization of PTSD treatment response, by reviewing and synthesizing the key criteria used to define treatment response and treatment nonresponse in published trials. Randomized controlled trials (RCTs) assessing the effectiveness of first‐line interventions for PTSD were identified for inclusion. Of those, 143 trials provided 226 definitions of treatment response, grouped under five main categories: treatment response (n = 181), remission (n = 23), recovery (n = 5), treatment nonresponse (n = 5), and worsening (n = 12). Overall, the results showed the PTSD field utilizes diverse and interchangeable operational definitions of treatment response and nonresponse, indicating a need for more precise conceptual definitions and operational criteria. A set of operational research definitions are presented in order to advance the PTSD treatment field.

Varker, T., Watson, L., Gibson, K., Forbes, D., & O'Donnell, M. (2020). Efficacy of psychoactive drugs for the treatment of posttraumatic stress disorder: A systematic review of MDMA, ketamine, LSD, and psilocybin. Journal of Psychoactive Drugs, 53 (1), 85-95. https://www.doi.org/10.1080/02791072.2020.1817639

The aim of this systematic review was to examine the efficacy of MDMA, ketamine, LSD, and psilocybin for the treatment of posttraumatic stress disorder (PTSD). A search of four databases for English language, peer-reviewed literature published from inception to 18th October 2019 yielded 2,959 records, 34 of which were screened on full-text. Observational studies and RCTs which tested the efficacy of MDMA, ketamine, LSD, or psilocybin for reducing PTSD symptoms in adults, and reported changes to PTSD diagnosis or symptomatology, were included. Nine trials (five ketamine and four MDMA) met inclusion criteria. Trials were rated on a quality and bias checklist and GRADE was used to rank the evidence. The evidence for ketamine as a stand-alone treatment for comorbid PTSD and depression was ranked “very low”, and the evidence for ketamine in combination with psychotherapy as a PTSD treatment was ranked “low”. The evidence for MDMA in combination with psychotherapy as a PTSD treatment was ranked “moderate”.

Wu, Y., Levis, B., Sun, Y., Krishnan, A., He, C., Riehm, K. E., Rice, D. B., Azar, M., Yan, X. W., Neupane, D., Bhandari, P. M., Imran, M., Chiovitti, M. J., Saadat, N., Boruff, J. T., Cuijpers, P., Gilbody, S., McMillan, D., Ioannidis, J. P. A., Kloda, L. A., Patten, S. B., Shrier, I., Ziegelstein, R. C., Henry, M., Ismail, Z., Loiselle, C. G., Mitchell, N. D., Tonelli, M., Al-Adawi, S., Beraldi, A., Braeken, A. P. B. M., Büel-Drabe, N., Bunevicius, A., Carter, G., Chen, C.-K., Cheung, G., Clover, K., Conroy, R. M., Cukor, D., da Rocha e Silva, C. E., Dabscheck, E., Daray, F. M., Douven, E., Downing, M. G., Feinstein, A., Ferentinos, P. P., Fischer, F. H., Flint, A. J., Fujimori, M., Gallagher, P., Gandy, M., Goebel, S., Grassi, L., Härter, M., Jenewein, J., Jetté, N., Julião, M., Kim, J.-M., Kim, S.-W., Kjærgaard, M., Köhler, S., Loosman, W. L., Löwe, B., Martin-Santos, R., Massardo, L., Matsuoka, Y., Mehnert, A., Michopoulos, I., Misery, L., Navines, R., O’Donnell, M. L., Öztürk, A., Peceliuniene, J., Pintor, L., Ponsford, J. L., Quinn, T. J., Reme, S. E., Reuter, K., Rooney, A. G., Sánchez-González, R., Schwarzbold, M. L., Cankorur, V. S., Shaaban, J., Sharpe, L., Sharpe, M., Simard, S., Singer, S., Stafford, L., Stone, J., Sultan, S., Teixeira, A. L., Tiringer, I., Turner, A., Walker, J., Walterfang, M., Wang, L.-J., White, J., Wong, D. K., Benedetti, A., & Thombs, B. D. (2020). Probability of major depression diagnostic classification based on the SCID, CIDI and MINI diagnostic interviews controlling for hospital anxiety and depression scale – depression subscale scores: An individual participant data meta-analysis of 73 primary studies. Journal of Psychosomatic Research, 129, 109892. https://www.doi.org/10.1016/j.jpsychores.2019.109892

Two previous individual participant data meta-analyses (IPDMAs) found that different diagnostic interviews classify different proportions of people as having major depression overall or by symptom levels. We compared the odds of major depression classification across diagnostic interviews among studies that administered the Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D). Data accrued for an IPDMA on HADS-D diagnostic accuracy were analysed. We fit binomial generalized linear mixed models to compare odds of major depression classification for the Structured Clinical Interview for DSM (SCID), Composite International Diagnostic Interview (CIDI), and Mini International Neuropsychiatric Interview (MINI), controlling for HADS-D scores and participant characteristics with and without an interaction term between interview and HADS-D scores. There were 15,856 participants (1942 [12%] with major depression) from 73 studies, including 15,335 (97%) non-psychiatric medical patients, 164 (1%) partners of medical patients, and 357 (2%) healthy adults. The MINI (27 studies, 7345 participants, 1066 major depression cases) classified participants as having major depression more often than the CIDI (10 studies, 3023 participants, 269 cases) (adjusted odds ratio [aOR] = 1.70 (0.84, 3.43)) and the semi-structured SCID (36 studies, 5488 participants, 607 cases) (aOR = 1.52 (1.01, 2.30)). The odds ratio for major depression classification with the CIDI was less likely to increase as HADS-D scores increased than for the SCID (interaction aOR = 0.92 (0.88, 0.96)). Compared to the SCID, the MINI may diagnose more participants as having major depression, and the CIDI may be less responsive to symptom severity.

2019 PUBLICATIONS

Barbano, A. C., Van der Mei, W. F., deRoon-Cassini, T. A., Grauer, E., Lowe, S. R., Matsuoka, Y. J., O'Donnell, M. L., Olff, M., Qi, W., Ratanatharathorn, A., Schnyder, U., Seedat, S., Kessler, R. C., Koenen, K. C., & Shalev, A. Y. (2019). Differentiating PTSD from anxiety and depression: Lessons from the ICD-11 PTSD diagnostic criteria. Depression and Anxiety, 36(6), 490-498. https://doi.org/10.1177/0004867419846403

Objective: The number of refugees worldwide is unprecedented in recent history. Little is known, however, about profiles of psychological symptoms following persecution and displacement.   Methods: This study reports on a latent class analysis that identified profiles of posttraumatic stress disorder (PTSD), depression and anxiety symptoms in a nationally representative sample of 1625 refugees in Australia. The association between specific symptom profiles, exposure to potentially traumatic events and post-migration stressors, and overall health and help-seeking was examined.   Results: Latent class analysis yielded an optimal five-class solution. These classes comprised the Pervasive Symptom class (19.2%), the High PTSD Symptom class (17.1%), the High Depression/Anxiety Symptom class (16.4%), the Moderate PTSD Symptom class (16.2%) and the Low Symptom class (31.1%). Participants in the symptomatic classes were more likely to be female, older and report greater post-migration stressors than those in the Low Symptom class. In addition, individuals in classes characterized by PTSD symptoms had been exposed to more types of potentially traumatic events. Membership in symptomatic classes was associated with poorer overall heath and greater help-seeking.   Conclusion: Qualitatively distinct symptom profiles were observed in a nationally representative sample of refugees. In addition to a group of people who reported high symptoms across psychological disorders and may warrant clinical intervention, we identified two subclinical classes who may be missed by existing diagnostic classification systems. Post-migration stressors play an important role in influencing refugee symptom profiles over and above exposure to potentially traumatic events. Clinicians should consider specific symptom profiles and contextual factors when planning interventions with refugees.

Bisson, J. I., Berliner, L., Cloitre, M., Forbes, D., Jensen, T. K., Lewis, C., Monson, C. M., Olff, M., Pilling, S., Riggs, D., Roberts, N. P., & Shapiro, F. (2019). The International Society for Traumatic Stress Studise New Guidelines for the Prevention and Treatment of Posttraumatic Stress Disorder: Methodology and Development Process. Journal of Traumatic Stress, 32(4), 475-483. https://doi.org/10.1002/jts.22421

Over the last two decades, treatment guidelines have become major aids in the delivery of evidence‐based care and improvement of clinical outcomes. The International Society for Traumatic Stress Studies (ISTSS) produced the first guidelines for the prevention and treatment of posttraumatic stress disorder (PTSD) in 2000 and published its latest recommendations, along with position papers on complex PTSD (CPTSD), in November 2018. A rigorous methodology was developed and followed; scoping questions were posed, systematic reviews were undertaken, and 361 randomized controlled trials were included according to the a priori agreed inclusion criteria. In total, 208 meta‐analyses were conducted and used to generate 125 recommendations (101 for adults and 24 for children and adolescents) for specific prevention and treatment interventions, using an agreed definition of clinical importance and recommendation setting algorithm. There were eight strong, eight standard, five low effect, 26 emerging evidence, and 78 insufficient evidence to recommend recommendations. The inclusion of separate scoping questions on treatments for complex presentations of PTSD was considered but decided against due to definitional issues and the virtual absence of studies specifically designed to clearly answer possible scoping questions in this area. Narrative reviews were undertaken and position papers prepared (one for adults and one for children and adolescents) to consider the current issues around CPTSD and make recommendations to facilitate further research. This paper describes the methodology and results of the ISTSS Guideline process and considers the interpretation and implementation of the recommendations.

Block, K., Robyn, M., Gibbs, L., Alkemade, N., Baker, E., MacDougall, C., Ireton, G., & Forbes, D. (2019). The role of the natural environment in disaster recovery: “We live here because we love the bush”. Health and Place, 57, 61-69. https://doi.org/10.1016/j.healthplace.2019.03.007

This mixed-methods study explored the role of connection to the natural environment in recovery from the ‘Black Saturday’ bushfires that blazed across Victoria, Australia, in February 2009. Qualitative findings demonstrated that many participants had a strong connection to the natural environment, experienced considerable grief as a result of its devastation in the fires and drew solace from seeing it regenerate over the following months and years. Quantitative analyses indicated that a strong attachment to the environment was associated with reduced psychological distress, fewer symptoms of major depression and fire-related PTSD, and higher levels of resilience, post-traumatic growth and life satisfaction. While social connections are increasingly recognized as supportive of disaster recovery, the influence of landscapes also needs to be recognized in terms of the impact of their destruction as well as their therapeutic potential.

Bryant, R. A., Edwards, B., Creamer, M., O'Donnell, M. L., Forbes, D., Felmingham, K. L., Silove, D., Steel, Z., McFarlane, A. C., van Hooff, M., Nickerson, A., & Hadzi-Pavlovic, D. (2019). A population study of prolonged grief in refugees. Epidemiology and Psychiatric Sciences, 29, e44. https://doi.org/10.1017/S2045796019000386

Aims: Despite the frequency that refugees suffer bereavement, there is a dearth of research into the prevalence and predictors of problematic grief reactions in refugees. To address this gap, this study reports a nationally representative population-based study of refugees to determine the prevalence of probable prolonged grief disorder (PGD) and its associated problems.   Methods: This study recruited participants from the Building a New Life in Australia (BNLA) prospective cohort study of refugees admitted to Australia between October 2013 and February 2014. The current data were collected in 2015–2016, and comprised 1767 adults, as well as 411 children of the adult respondents. Adult refugees were assessed for trauma history, post-migration difficulties, probable PGD, post-traumatic stress disorder (PTSD) and mental illness. Children were administered the Strengths and Difficulties Questionnaire.   Results: In this cohort, 38.1% of refugees reported bereavement, of whom 15.8% reported probable PGD; this represents 6.0% of the entire cohort. Probable PGD was associated with a greater likelihood of mental illness, probable PTSD, severe mental illness, currently unemployed and reported disability. Children of refugees with probable PGD reported more psychological difficulties than those whose parents did not have probable PGD. Probable PGD was also associated with the history of imprisonment, torture and separation from family. Only 56.3% of refugees with probable PGD had received psychological assistance.   Conclusions: Bereavement and probable PGD appear highly prevalent in refugees, and PGD seems to be associated with disability in the refugees and psychological problems in their children. The low rate of access to mental health assistance for these refugees highlights that there is a need to address this issue in refugee populations.

Forbes, D., Pedlar, D., Adler, A. B., Bennett, C., Bryant, R. A., Busuttil, W., Cooper, J., Creamer, M. C., Fear, N. T., Greenberg, N., Heber, A., Hinton, M., Hopwood, M., Jetly, R., Lawrence-Wood, E., McFarlane, A. C., Metcalf, O., O’Donnell, M. L., Phelps, A., Richardson, J. D., Sadler, N., Schnurr, P. P., Sharp, M. L., Thompson, J. M., Ursano, R. J., Van Hooff, M., Wade, D., & Wessely, S. (2019). Treatment of military-related posttraumatic stress disorder: Challenges, innovations, and the way forward. International Review of Psychiatry, 31(1), 95-110. https://doi.org/10.1080/09540261.2019.1595545

Post-traumatic stress disorder (PTSD) is one of the common mental disorders in military and veteran populations. Considerable research and clinical opinion has been focused on understanding the relationship between PTSD and military service and the implications for prevention, treatment, and management. This paper examines factors associated with the development of PTSD in this population, considers issues relating to engagement in treatment, and discusses the empirical support for best practice evidence-based treatment. The paper goes on to explore the challenges in those areas, with particular reference to treatment engagement and barriers to care, as well as treatment non-response. The final section addresses innovative solutions to these challenges through improvements in agreed terminology and definitions, strategies to increase engagement, early identification approaches, understanding predictors of treatment outcome, and innovations in treatment. Treatment innovations include enhancing existing treatments, emerging non-trauma-focused interventions, novel pharmacotherapy, personalized medicine approaches, advancing functional outcomes, family intervention and support, and attention to physical health.

Gallagher, C. H., Block, K., Gibbs, L., Forbes, D., Lusher, D., Molyneaux, R., Richardson, J., Pattison, P., MacDougall, C., & Bryant, R. B. (2019). The effect of group involvement on post-disaster mental health: a Longitudinal multilevel analysis. Social Science and Medicine, 220, 167-175. https://doi.org/10.1016/j.socscimed.2018.11.006

Involvement in voluntary associations is a key form of social capital and plays an especially important role following disaster as a venue for coordination and decision-making for the wider community. Yet, relatively little attention has been paid to how group involvement affects mental health, at either the individual or community level. The aim of this study was to assess the impact of involvement in voluntary associations on mental health among residents of bushfire-affected communities. A longitudinal sample of 642 individuals affected by the 2009 Victorian bushfires in south-eastern Australia were surveyed in 2012 and 2014 (3- and 5-years post-disaster). A further subsample (n = 552) of residents residing continuously within 22 bushfire-affected communities were examined for community-level effects using multilevel regression methods. After adjusting for demographics, disaster exposure, and network variables, group involvement at time 1 bore a curvilinear relationship with PTSD at both time points: moderate involvement was most beneficial, with no participation, or high amounts, yielding poorer outcomes. High amounts of group involvement was likewise linked to a greater risk of major depression. Furthermore, communities with higher median levels of group involvement reported lower levels of PTSD symptoms and major depression two years later. With respect to group involvement, more is not always better. For individuals, moderation – if possible – is key. Meanwhile, community-level health benefits come when most people participate to some extent, suggesting that the distribution of involvement across the community is important.

Gibbs L, Nursey J, Cook J, Ireton G, Alkemade N, Roberts M, Gallagher C, Bryant R, Block K, Molyneaux R, Forbes D.(2019) Delayed disaster impacts on academic performance of primary school children. Child Development. 00 (0) 1-11. https://www.doi.org/10.1111/cdev.13200 

Social disruption caused by natural disasters often interrupts educational opportunities for children. However, little is known about children's learning in the following years. This study examined change in academic scores for children variably exposed to a major bushfire in Australia. Comparisons were made between children attending high, medium, and low disaster-affected primary schools 2-4 years after the disaster (n = 24,642; 9-12 years). The results showed that in reading and numeracy expected gains from Year 3 to Year 5 scores were reduced in schools with higher levels of bushfire impact. The findings highlight the extended period of academic impact and identify important opportunities for intervention in the education system to enable children to achieve their academic potential.

Gibson, K., Haslam, N., & Kaplan, I. (2019). Distressing encounters in the context of climate change: Idioms of distress, determinants, and response to distress in Tuvalu. Transcultural Psychiatry, 56(4), 667-696. https://doi.org/10.1177/1363461519847057

Across the globe there is a critical need for culturally informed and locally valid approaches to mental health assessment and intervention, particularly among disadvantaged and marginalized populations. To be optimally effective, such approaches must be informed by a sound understanding of locally relevant idioms of distress and its determinants, including those caused or exacerbated by global power disparities and structural inequities. Climate change, arising due to anthropogenic sources located predominantly in industrialized nations, is one potential determinant of distress having disproportionate adverse impacts on already marginalized populations. The present study formed part of a broader project examining the intersections of culture, climate change, and distress in the Polynesian nation of Tuvalu – a focal point of global concern over the human costs of climate change. The study explored determinants and idioms of distress and culturally prescribed responses to coping with distress. Results are based on fieldwork conducted in 2015 entailing semi-structured interviews with 16 key informants and 23 lay residents of Funafuti atoll, recruited using maximal variation purposive sampling. Findings are examined in consideration of the unfolding impacts of climate change and the threat it portends for the future, both of which were identified as salient determinants of distress, in keeping with theorized relationships between climate change and mental health. The study underscores the necessity of attending to the relationships between global forces, local cultures, and individual experiences of distress, as efforts to provide access to culturally informed social and mental health services expand globally.

Hamblen, J. L., Norman, S. B., Sonis, J., Phelps, A. J., Bisson, J. I., Delgado Nunes, V., Megnin-Viggars, O., Forbes, D., Riggs, D., & Schnurr, P. (2019). A Guide to Guidelines for the Treatment of Posttraumatic Stress Disorder in Adults: An Update. Psychotherapy and Practice Innovations, 56(3), 359-373. https://doi.org/10.1037/pst0000231

Clinical practice guidelines (CPGs) are used to support clinicians and patients in diagnostic and treatment decision-making. Along with patients’ preferences and values, and clinicians’ experience and judgment, practice guidelines are a critical component to ensure patients are getting the best care based on the most updated research findings. Most CPGs are based on systematic reviews of the treatment literature. Although most reviews are now restricted to randomized controlled trials, others may consider nonrandomized effectiveness trials. Despite a reliance on similar procedures and data, methodological decisions and the interpretation of the evidence by the guideline development panel can result in different recommendations. In this article, we will describe key methodological points for 5 recently released CPGs on the treatment of posttraumatic stress disorder in adults and highlight some of the differences in both the process and the subsequent recommendations.

Harb, G., Cook, J. M., Phelps, A., Gehrman, P. R., Forbes, D., Localio, R., Harpaz-Rotem, I., Gur, R. C., & Ross, R. J. (2019). Randomized Controlled Trial of Imaginary Rehearsal for Posttraumatic Nightmares in Combat Veterans. Journal of Clinical Sleep Medicine, 15(5), 757-767. https://doi.org/10.5664/jcsm.7770

Study objectives: To examine the efficacy of imagery rehearsal (IR) combined with cognitive behavioral therapy for insomnia (CBT-I) compared to CBT-I alone for treating recurrent nightmares in military veterans with posttraumatic stress disorder (PTSD). Methods: In this randomized controlled study, 108 male and female United States veterans of the Iraq and Afghanistan conflicts with current, severe PTSD and recurrent, deployment-related nightmares were randomized to six sessions of IR + CBT-I (n = 55) or CBT-I (n = 53). Primary outcomes were measured with the Nightmare Frequency Questionnaire (NFQ) and Nightmare Distress Questionnaire (NDQ). Results: Improvement with treatment was significant (29% with reduction in nightmare frequency and 22% with remission). Overall, IR + CBT-I was not superior to CBT-I (NFQ: −0.12; 95% confidence interval = −0.87 to 0.63; likelihood ratio chi square = 4.7(3), P = .2); NDQ: 1.5, 95% confidence interval = −1.4 to 4.4; likelihood ratio chi square = 7.3, P = .06). Conclusions: Combining IR with CBT-I conferred no advantage overall. Further research is essential to examine the possibly greater benefit of adding IR to CBT-I for some subgroups of veterans with PTSD.

Kartal, D., Alkemade, N., & Kiropoulos, L. (2019). Trauma and Mental Health in Resettled Refugees: Mediating Effect of Host Language Acquisition on Posttraumatic Stress Disorder, Depressive and Anxiety Symptoms. Transcultural Psychiatry, 56(1), 3-23. https://doi.org/10.1177/1363461518789538

This study examined the relationship between traumatic exposure, host language acquisition and mental health (posttraumatic stress, depressive and anxiety symptoms) in long-term resettled refugees. Participants included a community sample of Bosnian refugees (N = 138, 55% male, mean age of 40 years old) that had resettled in Australia and Austria on average 18 years prior. Two mediation models were tested based on two competing theories. Model A examined whether language acquisition mediates the relationship between traumatic exposure and mental health problems experienced by refugees. Model B examined whether mental health symptoms mediate the relationship between exposure to traumatic events and the acquisition of host language. Model A fit the data well (CFI = 1.00, SRMR = .017, RMSEA < .001, χ2p = .526), while Model B was rejected as an acceptable model for the data (CFI = .556, SRMR = .136, RMSEA = .352). In Model A, the indirect pathway from trauma to mental health via language acquisition was significant for PTSD (β = .067, p = .028) and anxiety symptoms (β = .063, p = .026) but not depression symptoms (β = .048, p = .071). Intervention strategies aimed at improving host language acquisition may be important not only in successful adaptation to daily living in the host country, but also to improve the mental health of traumatized refugees.

King, K., Schlichthorst, M., Turnure, J., Phelps, A., Spitall, M. J., & Pirkis, J. (2019). Evaluating the effectiveness of a website about masculinity and suicide to prompt help-seeking. Health Promotion Journal of Australia, 30(3), 381-389. https://doi.org/10.1002/hpja.237

Issue addressed: A website was designed to form the core of a multimedia strategy surrounding the Man Up documentary – a three‐part documentary that aimed to address the problem of male suicide in Australia. Together these formed a media‐based, public health intervention that explored the link between masculinity and suicide and promoted help‐seeking. This is of great importance given the demonstrated link between masculine norms, men's reduced help‐seeking and suicidal thinking. This study assesses the website's effectiveness in facilitating help‐seeking and fostering conversations about suicide, mental health and help‐seeking. Help‐seeking indicators included website clicks to helping organisations, downloads of health information from the website and request for help received via emails.   Methods: Google Analytics data, emails to the Man Up team received through the website and open‐ended responses to an online survey were analysed.   Results: The website reached 43 140 users. Indictors of help‐seeking activity on the website included 307 outbound clicks to helping organisations and 802 downloads of health information. Qualitative analysis of emails received and responses to the survey demonstrated that Man Up's messages resonated with viewers and provided further evidence of help‐seeking.   Conclusion: The findings demonstrate that the website provided an important opportunity for people to engage with Man Up and seek help.   So what? - Media‐based public health interventions offer enormous potential to provide suicide prevention interventions and promote help‐seeking. The website evaluation findings provide insight into the ways in which websites can be used as part of a multimedia strategy to address the problem of male suicide.

Lotzin, A., Buth, S., Sehner, S., Hiller, P., Martens, M., Read, J., Harter, M., Cowlishaw, S., & Schaefer, I. (2019). Learning How to Ask – Does a one-day training increase trauma inquiry in routine substance use disorder practices? Results of a cluster-randomized controlled trial. Journal of Substance Abuse Treatment, 107, 8-16. https://doi.org/10.1016/j.jsat.2019.08.005

Aims: To examine the effectiveness of a one-day skills training program for increasing trauma inquiry in routine substance use disorder treatment.   Design: Cluster-randomized two-armed controlled trial, with 12 substance use disorder (SUD) organizations operating 25 counseling centers, randomly assigned to training in trauma inquiry (13 counseling centers of 8 SUD organizations) or no training (12 counseling centers of 4 SUD organizations).   Setting: SUD counseling centers in Northern Germany.   Cases: N = 5204 SUD counseling services.   Intervention: The professionals assigned to the intervention group received a one-day training in trauma inquiry plus a 1.5-hour refresher session 3 months later. Professionals in the control group received no training.   Measures: Over a 12-month period, professionals documented for each counseling service whether they asked the client about four traumatic events: physical abuse, emotional abuse, sexual abuse and neglect.   Analysis: Primary outcomes were rates of asking about physical abuse, sexual abuse, emotional abuse and neglect in the 6 months after training. These were compared across conditions, while adjusting for baseline probabilities in the 6 months before the intervention, using mixed-effects logistic regression.   Findings: In the 6 months after training, the rate of asking about physical abuse was 18% higher in the SUD counseling services of trained professionals, relative to services of untrained professionals (OR = 1.18, 95% CI = [1.01–1.37, p = .035]). No effect was found for asking about sexual abuse, emotional abuse and neglect.   Conclusion: A one-day training program in trauma inquiry, combined with a brief refresher session, was effective in increasing inquiries about physical abuse in routine counseling practice. The training was ineffective in increasing inquiries about sexual abuse, emotional abuse and neglect. The effectiveness of a one-day training of trauma inquiry might be increased by a longer training, or by combining it with additional elements, such as ongoing supervision.

Metcalf, O., Stone, C., Hinton, M., O'Donnell, M., Hopwood, M., McFarlane, A. C., Forbes, D., Kartal, D., Watson, L., Freijah, I., & Varker, T. (2019). Treatment augmentation for posttraumatic stress disorder: A systematic review. Clinical Psychology: Science and Practice, e12310. https://doi.org/10.1111/cpsp.12310

This systematic review examined the efficacy of all augmentation approaches for first‐line posttraumatic stress disorder (PTSD) interventions. From 9,890 records, 34 trials were eligible for inclusion, covering 28 different augmentation approaches. Overall, augmentation approaches were ineffective if they targeted a mechanism similar to the first‐line treatment. Augmentation approaches combining two guideline‐recommended treatments were largely ineffective, reflecting ceiling effects. Pharmacological augmentation approaches targeting fear extinction mechanisms were largely ineffective, or worsened outcomes relative to prolonged exposure alone, as these approaches may inadvertently strengthen fear memories. Augmentation approaches targeting general cognitive enhancement showed promise and provided support for augmentation interventions that require little cognitive or emotional work and target mechanisms different than the first‐line treatment.

Murphy, D., Howard, A., Forbes, D., Busuttil, W., & Phelps, A. (2019). Comparing the profiles of UK and Australian military veterans supported by national treatment programmes for post-traumatic stress disorder (PTSD). Journal of the Royal Army Medical Corps. https://doi.org/10.1136/jramc-2019-001268

Introduction: The aim of this study was to compare and contrast the profiles of military veterans seeking formal support for post-traumatic stress disorder (PTSD) in national treatment programmes in Australia and the UK to better understand the needs of this vulnerable population.   Methods: Data were extracted from 1926 participants in these treatment programmes. This consisted of 1230 from the UK who had accessed support between 2014 and early 2019, and 696 from Australia who had accessed support between 2014 and 2018. Comparison was made between a number of sociodemographic characteristics (age, sex and educational achievements), military factors (branch of military, time since leaving the military and whether participants were early service leavers or not) and health outcomes (PTSD, anger, alcohol misuse, anxiety and depression).   Results: Small differences were observed, with those in the UK cohort appearing to be younger, having lower educational achievement, being more likely to be ex-Army, having longer periods of enlistment in the military and taking longer to seek help. Further, minor differences were reported in health outcomes, with those in the UK cohort reporting more severe symptoms of PTSD, anger, anxiety and depression.   Conclusions: Overall, the observed differences between the cohorts were modest, suggesting that treatment-seeking veterans from the Australian and UK cohorts reported similar presentations. This provides evidence to support the establishment of international cohorts of treatment-seeking veterans to improve knowledge within this field.

Nickerson, A., Byrow, B., O'Donnell, M., Mau, V., McMahon, T., Pajak, R., Li, S., Hamilton, A., Minihan, S., Liu, C., Bryant, R. A., Berle, D., & Liddell, B. (2019). The association between visa insecurity and mental health, disability and social engagement in refugees living in Australia. European Journal of Psychotraumatology, 10(1). https://doi.org/10.1080/20008198.2019.1688129

Background: The vast majority of the world’s refugees and people seeking asylum live in a state of sustained displacement. Little is known, however, about the mental health impact of prolonged insecurity.   Objective: This study aimed to investigate the association between insecure visa status and mental health, suicidality, disability and social engagement in a sample of refugees and asylum-seekers living in Australia   Method: Participants were 1,085 refugees with secure (i.e. permanent residency or Australian citizenship, n = 826, 76.1%) and insecure (i.e. asylum-seeker claim, bridging visa, temporary visa, n = 259, 23.9%) visa status who had arrived in Australia since January 2011, and were from Arabic, Farsi, Tamil or English-speaking backgrounds. Participants completed an online survey assessing pre- and post-migration experiences, mental health, disability and social engagement.   Results: Results indicated that, after controlling for background factors, refugees with insecure visas had significantly greater PTSD symptoms, depression symptoms, thoughts of being better off dead and suicidal intent compared to those with secure visas. There were no group differences in disability. Refugees with insecure visas received support from significantly more groups in the Australian community than those with secure visas. Further, refugees with insecure visa status who had low group membership showed greater depression symptoms and suicidal intent than those with secure visa status who had low group membership.   Conclusion: Findings highlight the negative mental health consequences of living in a state of protracted uncertainty for refugees and people seeking asylum, and the key role of social engagement in influencing mental health amongst insecure visa holders. Results also underscore the importance of designing and implementing policies and services that facilitate improved mental health for those with visa insecurity.

Nickerson, A., Hadzi-Pavlovic, D., Edwards, B., O'Donnell, M. L., Creamer, M., Felmingham K. L., Forbes, D., McFarlane, A. C., Silove, D., Steel, Z., van Hoof, M., & Bryant, R. A. (2019). Identifying distinctive psychological symptom profiles among a nationally representative sample of refugees resettled in Australia. Australian & New Zealand Journal of Psychiatry, 53(9), 908-919. https://doi.org/10.1177/0004867419846403

Objective: The number of refugees worldwide is unprecedented in recent history. Little is known, however, about profiles of psychological symptoms following persecution and displacement.   Methods: This study reports on a latent class analysis that identified profiles of posttraumatic stress disorder (PTSD), depression and anxiety symptoms in a nationally representative sample of 1625 refugees in Australia. The association between specific symptom profiles, exposure to potentially traumatic events and post-migration stressors, and overall health and help-seeking was examined.   Results: Latent class analysis yielded an optimal five-class solution. These classes comprised the Pervasive Symptom class (19.2%), the High PTSD Symptom class (17.1%), the High Depression/Anxiety Symptom class (16.4%), the Moderate PTSD Symptom class (16.2%) and the Low Symptom class (31.1%). Participants in the symptomatic classes were more likely to be female, older and report greater post-migration stressors than those in the Low Symptom class. In addition, individuals in classes characterized by PTSD symptoms had been exposed to more types of potentially traumatic events. Membership in symptomatic classes was associated with poorer overall heath and greater help-seeking.   Conclusion: Qualitatively distinct symptom profiles were observed in a nationally representative sample of refugees. In addition to a group of people who reported high symptoms across psychological disorders and may warrant clinical intervention, we identified two subclinical classes who may be missed by existing diagnostic classification systems. Post-migration stressors play an important role in influencing refugee symptom profiles over and above exposure to potentially traumatic events. Clinicians should consider specific symptom profiles and contextual factors when planning interventions with refugees.

Nievergelt, C., Maihofer, A., Klengel, T., Atkinson, E., Chen, C-Y., Choi, K., … Forbes, D., …O’Donnell, M., … Koenen, K. (2019). International meta-analysis of PTSD genome-wide association studies identifies sex- and ancestry-specific genetic risk loci. Nature Communications, 10(4558). https://doi.org/10.1038/s41467-019-12576-w

The risk of posttraumatic stress disorder (PTSD) following trauma is heritable, but robust common variants have yet to be identified. In a multi-ethnic cohort including over 30,000 PTSD cases and 170,000 controls we conduct a genome-wide association study of PTSD. We demonstrate SNP-based heritability estimates of 5–20%, varying by sex. Three genome-wide significant loci are identified, 2 in European and 1 in African-ancestry analyses. Analyses stratified by sex implicate 3 additional loci in men. Along with other novel genes and non-coding RNAs, a Parkinson’s disease gene involved in dopamine regulation, PARK2, is associated with PTSD. Finally, we demonstrate that polygenic risk for PTSD is significantly predictive of re-experiencing symptoms in the Million Veteran Program dataset, although specific loci did not replicate. These results demonstrate the role of genetic variation in the biology of risk for PTSD and highlight the necessity of conducting sex-stratified analyses and expanding GWAS beyond European ancestry populations.

O'Donnell M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment Disorder: Current Developments and Future Directions. International Journal of Environmental Research and Public Health, 14(16), 2537. https://doi.org/10.3390/ijerph16142537

Despite its high prevalence in clinical and consultant liaison psychiatry populations, adjustment disorder research has traditionally been hindered by its lack of clear diagnostic criteria. However, with the greater diagnostic clarity provided in the Diagnostic and Statistical Manual of Mental Disorders - fifth edition (DSM-5) and the International Statistical Classification of Diseases and Related Health Problems, 11th edition (ICD-11), adjustment disorder has been increasingly recognised as an area of research interest. This paper evaluates the commonalities and differences between the ICD-11 and DSM-5 concepts of adjustment disorder and reviews the current state of knowledge regarding its symptom profile, course, assessment, and treatment. In doing so, it identifies the gaps in our understanding of adjustment disorder and discusses future directions for research.

Ponsford, J., Lee, N. K., Wong, D., McKay, A., Haines, K., Downing, M., Alway, Y., Furtado, C., & O'Donnell, M. L. (2019). Factors associated with response to cognitive behavioral therapy for anxiety and depression following traumatic brain injury. Journal of Head Trauma Rehabilitation. https://www.doi.org/10.1097/HTR.0000000000000510

Background: Given the high frequency and significance of anxiety and depression following traumatic brain injury (TBI), there is a need to evaluate the efficacy of psychological interventions and to understand factors influencing response to such interventions. The present study investigated factors associated with positive response to cognitive behavioral therapy adapted for cognitive impairments (CBT-ABI) for individuals with anxiety and depression following TBI, including demographic and injury-related factors, pretreatment levels of anxiety and depression, working alliance, and change expectancy as predictors.   Methods: Participants were 45 individuals enrolled in an active treatment condition within a randomized controlled trial, examining the efficacy of a 9-session CBT-ABI program for anxiety and depression following TBI. These participants completed all CBT sessions.   Results: Mixed-effects regressions controlling for baseline anxiety and depression indicated that for anxiety, older age at injury, as well as higher level of baseline anxiety, was associated with greater symptom reduction. For depression, longer time since injury and higher expectancy for change, as well as higher baseline level of depression, were significantly associated with a greater reduction in depression symptoms.   Conclusions: This study paves the way for more detailed studies of the therapeutic processes involved in alleviating anxiety and depression following TBI.

Reifels, L., Mills, K., Dückers, M., & O’Donnell, M. L. (2019). Psychiatric epidemiology and disaster exposure in Australia. Epidemiology and Psychiatric Sciences, 28(3), 310-320. https://doi.org/10.1017/S2045796017000531

Aims: To examine the lifetime prevalence and risk of psychiatric disorders associated with natural and man-made disaster exposure in Australia.   Methods: We utilised data from a nationally representative population survey (N = 8841) which were analysed through univariate and multivariate logistic regression in order to examine the full spectrum of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) affective, anxiety and substance use disorders associated with exposure to natural and man-made disaster.   Results: Man-made disaster exposure was primarily associated with an increased lifetime risk (odds ratio (95% CI)) of alcohol abuse disorder 2.29 (1.56–3.37), post-traumatic stress disorder (PTSD) 2.27 (1.36–3.79), obsessive–compulsive disorder (OCD) 1.95 (1.08–3.51) and major depressive disorder 1.69 (1.01–2.85). Multiple natural disaster exposure was associated with an increased lifetime risk of panic disorder 2.26 (1.11–4.61). Among the broader disorder spectrum examined, alcohol abuse disorder accounted for the single greatest increase in lifetime disorder prevalence associated with man-made disaster exposure, and the greatest number of natural or man-made disaster exposed individuals who had developed a lifetime psychiatric disorder. Despite the relatively greater disorder risk associated with man-made disaster, natural disaster exposure was associated with more cases of psychiatric disorder, likely due to the frequency with which these events occur in Australia.   Conclusions: Notwithstanding the inability to draw causal inferences from cross-sectional survey data, population-based analyses provide a comprehensive and consistent method to ascertain the population imprint of psychiatric disorder and disaster exposure. Mental health policy and services should be targeting a range of psychiatric disorders in disaster contexts in addition to the usual focus on PTSD and depression, including alcohol abuse, panic disorder and OCD. Despite the relatively greater disorder risk associated with man-made disaster exposure, the national burden of psychiatric disorder in natural disaster contexts is particularly high.

Schlichthorst, M., King, K., Reifels, L., Phelps, A., & Pirkis, J. (2019). Using social media networks to engage men in conversations on masculinity and suicide: Content analysis of Man Up Facebook campaign data. Social Media + Society, 5(4), 1-13. https://doi.org/10.1177/2056305119880019

We analysed comments published on the Man Up Facebook page (manuptvseries) during the roll-out of the Man Up digital campaign. The aim was to gain insight into how the public perceived the Man Up campaign and the conversation topics that the campaign instigated. We downloaded Facebook threads (posts and comments) from the manuptvseries page using NCapture and performed conventional content analysis on a random set of comments (n = 2,236) to identify how the campaign was perceived and what were the popular conversations. Overall, the campaign was perceived extremely positively by the Facebook audience showing many comments endorsing the content of the campaign by sharing among their Facebook community. The strongest themes were expressing emotions, help and support, and masculinity/gender roles which related to the higher level theme of expressions of masculinity. Another strong theme was suicide and topics related to suicide. Comments acknowledged the importance of discussing the issues of male suicide and masculinity publicly. Men were less engaged with topics on masculinity and expressing emotions compared with women and recognized stigma around help-seeking for mental health issues. The Man Up Facebook campaign did foster a public discussion on masculinity and suicide. A gendered approach in mental health promotion is needed with stigma still present for men when seeking help for mental health problems. Social media holds considerable potential for the use of health promotion campaigns aiming to increase interpersonal communication on challenging health topics. Yet, these campaigns need to carefully manage the risk of reinforcing stereotypes.

Shalev, A., Gevonden, M., Ratanatharathorn, A., Laska, E., van der Mei, W. F., Qi, W., Lowe, S., Lai, B. S., Bryant, R. A., Delahanty, D., Matsuoka, Y. J., Olff, M., Schnyder, U., Seedat, S., deRoon-Cassini, T. A., Kessler, R. C., Koenen, K. C., & International Consortium to Predict PTSD. (2019). Estimating the risk of PTSD in recent trauma survivors: results of the International Consortium to Predict PTSD (ICPP). World Psychiatry, 18(1), 77-87. https://doi.org/10.1002/wps.20608

A timely determination of the risk of post‐traumatic stress disorder (PTSD) is a prerequisite for efficient service delivery and prevention. We provide a risk estimate tool allowing a calculation of individuals’ PTSD likelihood from early predictors. Members of the International Consortium to Predict PTSD (ICPP) shared individual participants’ item‐level data from ten longitudinal studies of civilian trauma survivors admitted to acute care centers in six countries. Eligible participants (N=2,473) completed an initial clinical assessment within 60 days of trauma exposure, and at least one follow‐up assessment 4‐15 months later. The Clinician‐Administered PTSD Scale for DSM‐IV (CAPS) evaluated PTSD symptom severity and diagnostic status at each assessment. Participants’ education, prior lifetime trauma exposure, marital status and socio‐economic status were assessed and harmonized across studies. The study's main outcome was the likelihood of a follow‐up PTSD given early predictors. The prevalence of follow‐up PTSD was 11.8% (9.2% for male participants and 16.4% for females). A logistic model using early PTSD symptom severity (initial CAPS total score) as a predictor produced remarkably accurate estimates of follow‐up PTSD (predicted vs. raw probabilities: r=0.976). Adding respondents’ female gender, lower education, and exposure to prior interpersonal trauma to the model yielded higher PTSD likelihood estimates, with similar model accuracy (predicted vs. raw probabilities: r=0.941). The current model could be adjusted for other traumatic circumstances and accommodate risk factors not captured by the ICPP (e.g., biological, social). In line with their use in general medicine, risk estimate models can inform clinical choices in psychiatry. It is hoped that quantifying individuals’ PTSD risk will be a first step towards systematic prevention of the disorder.

Shang, F., Kaniasty, K., Cowlishaw, S., Wade, D., Ma, H., & Forbes, D. (2019). Social support following a natural disaster: A longitudinal study of survivors of the 2013 Lushan earthquake in China. Psychiatry Research, Elsevier, 273, 641-646. https://doi.org/10.1016/j.psychres.2019.01.085

The idea that social support post-disaster is beneficial to survivors’ mental health is widely accepted by both researchers and practitioners. However previous social support studies are mainly focused on perceived social support, and the limited received social support studies have produced mixed results. In this study we modelled the influence of both quantity and quality of received social support on long-term mental health outcomes in a longitudinal study of 2013 Lushan earthquake survivors in China. Survivors were invited to complete a questionnaire interview 7 months after the earthquake and were followed up 31 months later (n = 161). Hierarchical regression analyses that controlled for disaster exposure variables showed that greater quality of social support received 7 months after disaster predicted lower levels of posttraumatic stress symptoms and psychological distress two years later, however quantity of received social support was not significant in predicting these two outcomes. These results remained robust when controlled for gender, negative life events and family financial status. The findings of this study suggest that what appears to be critical in the process of supporting disaster survivors is the quality, not necessarily the quantity, of support provided.

Suomi, A., Evans, L., Rodgers, B., Taplin, S., & Cowlishaw, S. (2019). Couple and family therapies for post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, 12(CD011257), 57. https://www.doi.org/10.1002/14651858.CD011257.pub2
Post‐traumatic stress disorder (PTSD) refers to an anxiety or trauma‐ and stressor‐related disorder that is linked to personal or vicarious exposure to traumatic events. PTSD is associated with a range of adverse individual outcomes (e.g. poor health, suicidality) and significant interpersonal problems which include difficulties in intimate and family relationships. A range of couple‐ and family‐based treatments have been suggested as appropriate interventions for families impacted by PTSD. The objectives of this review were to: (1) assess the effects of couple and family therapies for adult PTSD, relative to 'no treatment' conditions, 'standard care', and structured or non‐specific individual or group psychological therapies; (2) examine the clinical characteristics of studies that influence the relative effects of these therapies; and (3) critically evaluate methodological characteristics of studies that may bias the research findings. We searched MEDLINE (1950‐ ), Embase (1980‐ ) and PsycINFO (1967‐ ) via the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) to 2014, then directly via Ovid after this date. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library. We conducted supplementary searches of PTSDPubs (all available years) (this database is formerly known as PILOTS (Published International Literature on Traumatic Stress)). We manually searched the early editions of key journals and screened the reference lists and bibliographies of included studies to identify other relevant research. We also contacted the authors of included trials for unpublished information. Studies have been incorporated from searches to 3 March 2018. Eligible studies were randomised controlled trials (RCTs) of couple or family therapies for PTSD in adult samples. The review considered any type of therapy that was intended to treat intact couples or families where at least one adult family member met criteria for PTSD. It was required that participants were diagnosed with PTSD according to recognised classification systems. We used the standard methodological procedures prescribed by Cochrane. Three review authors screened all titles and abstracts and two authors independently extracted data from each study deemed eligible and assessed the risk of bias for each study. We used odds ratios (OR) to summarise the effects of interventions for dichotomous outcomes, and standardised mean differences (SMD) to summarise post‐treatment between‐group differences on continuous measures. We included four trials in the review. Two studies examined the effects of cognitive behavioural conjoint/couple's therapy (CBCT) relative to a wait list control condition, although one of these studies only reported outcomes in relation to relationship satisfaction. One study examined the effects of structural approach therapy (SAT) relative to a PTSD family education (PFE) programme; and one examined the effects of adjunct behavioural family therapy (BFT) but failed to report any outcome variables in sufficient detail — we did not include it in the meta‐analysis. One trial with 40 couples (80 participants) showed that CBCT was more effective than wait list control in reducing PTSD severity (SMD −1.12, 95% CI −1.79 to −0.45; low‐quality evidence), anxiety (SMD −0.93, 95% CI −1.58 to −0.27; very low‐quality evidence) and depression (SMD −0.66, 95% CI −1.30 to −0.02; very low‐quality evidence) at post‐treatment for the primary patient with PTSD. Data from two studies indicated that treatment and control groups did not differ significantly according to relationship satisfaction (SMD 1.07, 95% CI −0.17 to 2.31; very low‐quality evidence); and one study showed no significant differences regarding depression (SMD 0.28, 95% CI −0.35 to 0.90; very low‐quality evidence) or anxiety symptoms (SMD 0.15, 95% CI −0.47 to 0.77; very low‐quality evidence) for the partner of the patient with PTSD. One trial with 57 couples (114 participants) showed that SAT was more effective than PFE in reducing PTSD severity for the primary patient (SMD −1.32, 95% CI −1.90 to −0.74; low‐quality evidence) at post‐treatment. There was no evidence of differences on the other outcomes, including relationship satisfaction (SMD 0.01, 95% CI −0.51 to 0.53; very low‐quality evidence), depression (SMD 0.21, 95% CI −0.31 to 0.73; very low‐quality evidence) and anxiety (SMD −0.16, 95% CI −0.68 to 0.36; very low‐quality evidence) for intimate partners; and depression (SMD −0.28, 95% CI −0.81 to 0.24; very low‐quality evidence) or anxiety (SMD −0.34, 95% CI −0.87 to 0.18; very low‐quality evidence) for the primary patient. Two studies reported on adverse events and dropout rates, and no significant differences between groups were observed. Two studies were classified as having a 'low' or 'unclear' risk of bias in most domains, except for performance bias that was rated ‘high’. Two studies had significant amounts of missing information resulting in 'unclear' risk of bias. There were too few studies available to conduct subgroup analyses. There are few trials of couple‐based therapies for PTSD and evidence is insufficient to determine whether these offer substantive benefits when delivered alone or in addition to psychological interventions. Preliminary RCTs suggest, however, that couple‐based therapies for PTSD may be potentially beneficial for reducing PTSD symptoms, and there is a need for additional trials of both adjunctive and stand‐alone interventions with couples or families which target reduced PTSD symptoms, mental health problems of family members and dyadic measures of relationship quality.
Terhaag, S., Cowlishaw, S., Steel, Z., Brewer, D., Howard, A., Armstrong, R., Human, B., Forbes, D., & Phelps, A. (2019). Psychiatric comorbidity for veterans with posttraumatic stress disorder (PTSD): A latent profile analysis and implications for treatment. Psychological Trauma: Theory, Research, Practice and Policy. https://www.doi.org/10.1037/tra0000520

Background and objective: Psychiatric comorbidity is common among veterans with posttraumatic stress disorder (PTSD), but there is little known about the patterns of co-occurring mental health problems and implications for treatment. The aim of this study was to identify comorbidity profiles among veterans at treatment intake and assess associations with PTSD and quality of life (QOL) outcomes.   Method: The study included 2,522 veterans accessing outpatient treatment for PTSD in Australia who self-completed measures of comorbid issues including depression, anger, alcohol use problems, guilt, and dissociation. Latent Profile Analysis (LPA) was used to identify subgroups based on comorbidity profiles, and their association with outcomes.   Results: LPA suggested 5 comorbidity profiles: (a) low comorbidity severity, (b) moderate comorbidity severity with low alcohol, (c) moderate comorbidity severity with high alcohol, (d) high comorbidity severity with low alcohol, and (e) high comorbidity severity with high alcohol. The absence of alcohol problems was associated with improved treatment outcomes when overall comorbidity severity was high but not moderate. While all profiles evidenced symptom improvement from intake to discharge and follow-up, this did not correspond to quality of life improvements equally across classes. The highest severity comorbidity class experienced no improvement on psychological quality of life.   Conclusions: The comorbidity profiles of veterans in treatment for PTSD can be distinguished by levels of severity and the specific presence or absence of alcohol use problems. Alcohol use problems have discernible implications for treatment in the context of comorbidity. Group treatments for PTSD should consider tailoring interventions to comorbidity profiles.

Varker, T., Brand, R. M., Ward, J., Terhaag, S., & Phelps, A. (2019). Efficacy of synchronous telepsychology interventions for people with anxiety, depression, posttraumatic stress disorder and adjustment disorder: A rapid evidence assessment. Psychological Services, 16(4), 621-635. https://www.doi.org/10.1037/ser0000239

Telepsychology holds promise as a treatment delivery method that may increase access to services as well as reduce barriers to treatment accessibility. The aim of this rapid evidence assessment was to assess the evidence for synchronous telepsychology interventions for 4 common mental health conditions (depression, anxiety, posttraumatic stress disorder, and adjustment disorder). Randomized controlled trials published between 2005 and 2016 that investigated synchronous telepsychology (i.e., telephone delivered, video teleconference delivered, or Internet delivered text based) were identified through literature searches. From an initial yield of 2,266 studies, 24 were included in the review. Ten studies investigated the effectiveness of telephone-delivered interventions, 11 investigated the effectiveness of video teleconference (VTC) interventions, 2 investigated Internet-delivered text-based interventions, and 2 were reviews of multiple telepsychology modalities. There was sufficient evidence to support VTC and telephone-delivered interventions for mental health conditions. The evidence for synchronous Internet-delivered text-based interventions was ranked as "unknown." Telephone-delivered and VTC-delivered psychological interventions provide a mode of treatment delivery that can potentially overcome barriers and increase access to psychological interventions.

Wade, D., Terhaag, S., Putica, A., & Metcalf, O. (2019). Training plus intensive consultation improves uptake and outcome expectations of prolonged exposure therapy among practitioners treating emergency service personnel with posttraumatic stress disorder. Australasian Psychiatry. https://www.doi.org/10.1177/1039856219881966

Objective: Prolonged exposure (PE) therapy is an evidence-based psychological treatment of post-traumatic stress disorder (PTSD), yet uptake amongst practitioners is less than desirable. The aim of this study was to evaluate the efficacy of a PE training workshop plus intensive consultation programme to improve practitioners' self-efficacy and outcome expectations as well as uptake of PE for emergency service patients with PTSD.   Method: Forty-five psychologists attended a PE training workshop in Sydney. Participants completed questionnaires at pre- and post-workshop and six-month follow-up.   Results: The findings suggest that participation in the programme was associated with improvements in practitioners' beliefs in their ability to deliver PE to patients, an increase in their use of a range of PE components and an increase in their use of in vivo exposure with a greater proportion of patients.   Conclusion: Effective training approaches for evidence-based treatments of PTSD should incorporate intensive consultation following training. Future studies should consider additional strategies to encourage practitioners to deliver PE to more patients with PTSD.

Wong, D., Hsieh, M. Y., McKay, A., Haines, K., O’Donnell, M., & Ponsford, J. (2019). Cognitive behavior Therapy for anxiety and depression – Adapted for brain injury (CBT-ABI). A treatment Manual. ASSBI Resources, Sydney, Australia.
Yeterian, J. D., Berke, D. S., Carney, J. R., McIntyre‐Smith, A., St. Cyr, K., King, L., Kline, N. K., Phelps, A., Litz, B. T., & Members of the Moral Injury Outcomes Project Consortium. (2019). Defining and Measuring Moral Injury: Rationale, Design, and Preliminary Findings From the Moral Injury Outcome Scale Consortium. Journal of Traumatic Stress, 32(3), 363-372. https://www.doi.org/10.1002/jts.22380

In the current paper, we first describe the rationale for and methodology employed by an international research consortium, the Moral Injury Outcome Scale (MIOS) Consortium, the aim of which is to develop and validate a content‐valid measure of moral injury as a multidimensional outcome. The MIOS Consortium comprises researchers and clinicians who work with active duty military service members and veterans in the United States, the United Kingdom, the Netherlands, Australia, and Canada. We describe the multiphase psychometric development process being conducted by the Consortium, which will gather phenomenological data from service members, veterans, and clinicians to operationalize subdomains of impact and to generate content for a new measure of moral injury. Second, to illustrate the methodology being employed by the Consortium in the first phase of measure development, we present a small subset of preliminary results from semistructured interviews and questionnaires conducted with care providers (N = 26) at three of the 10 study sites. The themes derived from these initial preliminary clinician interviews suggest that exposure to potentially morally injurious events is associated with broad psychological/behavioral, social, and spiritual/existential impacts. The early findings also suggest that the outcomes associated with acts of commission or omission and events involving others’ transgressions may overlap. These results will be combined with data derived from other clinicians, service members, and veterans to generate the MIOS.

2018 PUBLICATIONS

Baecher, J., Kangas, M., Taylor, A., O'Donnell, M., Bryant, R., Silove, D., McFarlane, A., & Wade, D. (2018). The role of site and severity of injury as predictors of mental health outcomes following traumatic injury. Stress and Health, 34(4), 6. https://digital.library.adelaide.edu.au/dspace/bitstream/2440/113408

The aim of this study was to investigate the influence of injury site and severity as predictors of mental health outcomes in the initial 12 months following traumatic injury. Using a multisite, longitudinal study, participants with a traumatic physical injury (N = 1,098) were assessed during hospital admission and followed up at 3 months (N = 932, 86%) and at 12 months (N = 715, 71%). Injury site was measured using the Abbreviated Injury Scale 90, and objective injury severity was measured using the Injury Severity Score. Participants also completed the Hospital Anxiety and Depression Scale and the Clinician Administered Post‐traumatic Stress Disorder (PTSD) Scale. A random intercept mixed modelling analysis was conducted to evaluate the effects of site and severity of injury in relation to anxiety, PTSD, and depressive symptoms. Injury severity, as well as head and facial injuries, was predictive of elevated PTSD symptoms, and external injuries were associated with both PTSD and depression severity. In contrast, lower extremity injuries were associated with depressive and anxiety symptoms. The findings suggest that visible injuries are predictive of reduced mental health, particularly PTSD following traumatic injury. This has clinical implications for further advancing the screening for vulnerable injured trauma survivors at risk of chronic psychopathology.

Baker, F. A., Metcalf, O., Varker, T., & O’Donnell, M. (2018). A systematic review of the efficacy of creative arts therapies in the treatment of adults with PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, Advance online publication. https://psycnet.apa.org/record/2017-53954-001

Objective: There is a growing body of literature supporting the use of creative arts therapies; however, the efficacy of creative arts therapies in the treatment of posttraumatic stress disorder (PTSD) has not been systematically evaluated. The aim of this systematic review was to examine the efficacy of creative arts therapy including music therapy, art therapy, dance/movement therapy, and drama therapy, in the treatment of PTSD.

Method: Ten databases were searched for peer-reviewed literature published from inception to December 2016. Studies were included in the review if they used a randomized controlled trial (RCT), a pseudo RCT, or a controlled study design; tested the efficacy of one of the creative arts therapies described above; and reported changes to PTSD diagnosis or symptomatology.

Results: From an initial yield of 1,918 records, 1,653 records were screened on title and abstract and 125 were screened at full-text. Seven studies met the inclusion criteria for review, with four studies investigating art therapy, two studies investigating music therapy, and a final study investigating drama therapy. Individual studies were initially rated on a standardized quality and bias checklist, and then GRADE was used to rate the overall evidence for each intervention. The evidence for music therapy, art therapy, and drama therapy was ranked as low to very low, with no studies found for dance/movement therapy. Generally, the quality of the trials was very poor. Future directions for this field of research are to improve the scientific quality of the research trials in this area.

Bryant, R., Edwards, B., Creamer, M., O’Donnell, M., Forbes, D., Felmingham, K., Silove, D., Steel, Z., Nickerson, A., McFarlane, A., van Hooff, M., & Hadzi-Pavlovic, D. (2018). The effect of post-traumatic stress disorder on refugees' parenting and their children's mental health: A cohort study. Lancet Public Health, 3(5), 10. https://reader.elsevier.com/reader/sd/pii

Background: Children and adolescents, who account for most of the world's refugees, have an increased prevalence of psychological disorders. The mental health of refugee children is often associated with the severity of post-traumatic stress disorder (PTSD) in their caregivers. Despite the potential for refugee caregivers' PTSD to affect child mental health, little evidence exists concerning the underlying mechanisms of this association. This study tested the effect of refugee caregivers' previous trauma and levels of ongoing stressors on current PTSD, and in turn how this influences parenting behaviour and consequent child psychological health.

Methods: This cohort study recruited participants from the Building a New Life in Australia study, a population-based prospective cohort study of refugees admitted to 11 sites in Australia between October, 2013, and February, 2014. Eligible participants were aged 18 years or older and the principal or secondary applicant (ie, the refugee applicant within a migrating family unit) for a humanitarian visa awarded between May, 2013, and December, 2013. Primary caregiver PTSD and postmigration difficulties were assessed at Wave 1 (in 2013), and caregiver PTSD was reassessed at Wave 2 (in 2014). At Wave 3, between October, 2015, and February, 2016, primary caregivers repeated measures of trauma history, postmigration difficulties, probable PTSD, and harsh and warm parenting style, and completed the Strengths and Difficulties Questionnaire for their child. We used path analysis to investigate temporal patterns in PTSD, trauma history, postmigration stressors, parenting style, and children's psychological difficulties.

Findings: The current data comprised 411 primary caregivers who provided responses in relation to at least one child (660 children). 394 primary caregivers with 639 children had data on independent variables and were included in the final model. Path analyses revealed that caregivers' trauma history and postmigration difficulties were associated with greater subsequent PTSD, which in turn was associated with greater harsh parenting and in turn, higher levels of child conduct problems (β=0·049, p=0·0214), hyperactivity (β=0·044, p=0·0241), emotional symptoms (β=0·041, p=0·0218), and peer problems (β=0·007, p=0·047). There was also a direct path from primary caregiver PTSD to children's emotional problems (β=0·144, p=0·0001).

Interpretation: PTSD in refugees is associated with harsh parenting styles, leading to adverse effects on their children's mental health. Programmes to enhance refugee children's mental health should account for PTSD in parents and caregivers, and the parenting behaviours that these children are exposed to.

Cash, R., Varker, T., McHugh, T., Metcalf, O., Howard, A., Lloyd, D., Costello, J., Said, D., & Forbes, D. (2018). Effectiveness of an anger intervention for military members with PTSD: A clinical case series. Military Medicine, 183(9-10), e286–e290. http://bit.ly/35KTrrd

Objective: Problematic anger is a significant clinical issue in military personnel, and is further complicated by comorbid post-traumatic stress disorder (PTSD). Despite increasing numbers of military personnel returning from deployment with anger and aggression difficulties, the treatment of problematic anger has received scant attention. There are currently no interventions that directly target problematic anger in the context of military-related PTSD. The aim of this case series is to examine the effectiveness of an intervention specifically developed for treating problematic anger in current serving military personnel with comorbid PTSD.

Methods: Eight Australian Defence Force Army personnel with problematic anger and comorbid PTSD received a manualized 12-session cognitive behaviorally based anger intervention, delivered one-to-one by Australian Defence Force mental health clinicians. Standardized measures of anger, PTSD, depression, and anxiety were administered pre- and post-treatment.

Results: The initial mean severity scores for anger indicated a high degree of pre-treatment problematic anger. Anger scores reduced significantly from pre to post-treatment (d = 1.56), with 88% of participants exhibiting meaningful reduction in anger scores. PTSD symptoms also reduced significantly (d = 0.96), with 63% of participants experiencing a clinically meaningful reduction in PTSD scores. All of those who took part in the therapy completed all therapy sessions.

Conclusions: This brief report provides preliminary evidence that an intervention for problematic anger not only significantly reduces anger levels in military personnel, but can also significantly reduce PTSD symptoms. Given that anger can interfere with PTSD treatment outcomes, prioritizing anger treatment may improve the effectiveness of PTSD interventions.

Choi, Y., Hwa-Bok Choi, H., & O’Donnell, M. (2018). Disaster Reintegration Model: A qualitative analysis on developing Korean disaster mental health support model. International Journal of Environmental Research and Public Health, 15(2), 13. https://www.mdpi.com/1660-4601/15/2/362/pdf

This study sought to describe the mental health problems experienced by Korean disaster survivors, using a qualitative research method to provide empirical resources for effective disaster mental health support in Korea. Participants were 16 adults or elderly adults who experienced one or more disasters at least 12 months ago recruited via theoretical sampling. Participants underwent in-depth individual interviews on their disaster experiences, which were recorded and transcribed for qualitative analysis, which followed Strauss and Corbin’s (1998) Grounded theory. After open coding, participants’ experiences were categorized into 130 codes, 43 sub-categories and 17 categories. The categories were further analyzed in a paradigm model, conditional model and the Disaster Reintegration Model, which proposed potentially effective mental health recovery strategies for disaster survivors, health providers and administrators. To provide effective assistance for mental health recovery of disaster survivors, both personal and public resilience should be promoted while considering both cultural and spiritual elements.

Choi, Y.J., O’Donnell, M., Choi, H.B., Jung, H.S., & Cowlishaw, S. (2018). Associations among elder abuse, depression and PTSD in South Korean older adults. International Journal of Enviromental Research and Public Health, 15(9), 8. https://www.mdpi.com/1660-4601/15/9/1948/pdf

Increasing attention is being placed on the prevalence of elder abuse and its impact on mental health. This study conducted a survey of 172 elderly people in South Korea to determine the prevalence of elder abuse and the relationships involving elder abuse, depression and posttraumatic stress disorder (PTSD). Participants completed a battery of self-report questionnaires, which included the Korean Geriatric Depression Screening Scale (KGDS) and Impact of Event Scale-Revised Korean version (IES-R-K). Descriptive analyses were conducted to examine the frequency of specific forms of abuse. Logistic regression models were estimated to identify the factors that contributed to risk of abuse exposure and the relationship between exposure and PTSD or depression. The results indicated around 22% of the participants reported abuse exposure, which most commonly included being refused physical contact, verbal threats, and/or being excluded from decision-making about personal issues. Low education and being unmarried, separated or divorced was associated with an increased risk of abuse exposure. There were strong associations between elder abuse and PTSD symptoms, while comparable relationships with depression were weaker and were not robust to the inclusion of control variables. The findings provided empirical support for the relationship between abuse experiences of the elderly and poor mental health and raise important issues for the mental health care of the elderly.

Cowlishaw, S., McCambridge, J., & Kessler, D. (2018). Identification of gambling problems in primary care: properties of the NODS-CLiP screening tool. Journal of Addiction Medicine, 12(6). http://bit.ly/33l8uqc

Introduction: There are several brief screening tools for gambling that possess promising psychometric properties, but have uncertain utility in generalist healthcare environments which prioritize prevention and brief interventions. This study describes an examination of the National Opinion Research Centre Diagnostic and Statistical Manual of Mental Disorders Screen for Gambling Problems (NODS-CLiP), in comparison with the Problem Gambling Severity Index (PGSI), when used to operationalize gambling problems across a spectrum of severity.

Methods: Data were obtained from 1058 primary care attendees recruited from 11 practices in England who completed various measures including the NODS-CLiP and PGSI. The performance of the former was defined by estimates of sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs), when PGSI indicators of problem gambling (5+) and any gambling problems (1+), respectively, were reference standards.

Results: The NODS-CLiP demonstrated perfect sensitivity for problem gambling, along with high specificity and a NPV, but a low PPV. There was much lower sensitivity when the indicator of any gambling problems was the reference standard, with capture rates indicating only 20% of patients exhibiting low to moderate severity gambling problems (PGSI 1–4) were identified by the NODS-CLiP.

Conclusions: The NODS-CLiP performs well when identifying severe cases of problem gambling, but lacks sensitivity for less severe problems and may be unsuitable for settings which prioritize prevention and brief interventions. There is a need for screening measures which are sensitive across the full spectrum of risk and severity, and can support initiatives for improving identification and responses to gambling problems in healthcare settings such as primary care.

Forbes, D., Nickerson, A., Bryant, R.A., Creamer, M., Silove, D., McFarlane, A.C., Van Hooff, M., Phelps, A., Felmingham, K.L., Malhi, G.S., Steel, Z., Fredrickson, J., Alkemade, N., & O’Donnell, M. (2018). The impact of post-traumatic stress disorder symptomatology on quality of life: The sentinel experience of anger, hypervigilance and restricted affect. Australian & New Zealand Journal of Psychiatry. doi: https://journals.sagepub.com/doi/abs/10.1177/0004867418772917

Background: It is unclear which specific symptoms of post-traumatic stress disorder are related to poor perceived quality of life.

Objective: To investigate the influence of post-traumatic stress disorder symptomatology on quality of life in traumatic injury survivors.

Method: Traumatic injury survivors completed questionnaires on post-traumatic stress disorder symptomatology and quality of life at 3 months (n = 987), 12 months (n = 862), 24 months (n = 830) and 6 years (n = 613) post trauma.

Results: Low quality of life was reported by 14.5% of injury survivors at 3 months and 8% at 6 years post event. The post-traumatic stress disorder symptom clusters that contributed most to poor perceived quality of life were numbing and arousal, the individual symptoms that contributed most were anger, hypervigilance and restricted affect.

Conclusions: There was variability in the quality of life of traumatic injury survivors in the 6 years following trauma and a consistent proportion reported low quality of life. Early intervention to reduce anger, hypervigilance and restricted affect symptoms may provide a means to improving the quality of life of traumatic injury survivors.

Gibbs, L., Block, K., MacDougall, C., Harms, L., Baker, E., Richardson, J., Ireton, G., Gallagher, H.C., Bryant, R., Lusher, .D, Pattison, P., Watson, J., Gillett, J., Pirrone, A., Molyneaux, R., Sexton-Bruce, S., & Forbes, D. (2018). Ethical use and impact of participatory approaches to research in post-disaster environments: An Australian bushfire case study. BioMed Research International, 2018, 12. http://downloads.hindawi.com/journals/bmri.pdf

This paper presents a case study of Beyond Bushfires, a large, multisite, mixed method study of the psychosocial impacts of major bushfires in Victoria, Australia. A participatory approach was employed throughout the study which was led by a team of academic investigators in partnership with service providers and government representatives and used on-site visits and multiple methods of communication with communities across the state to inform decision-making throughout the study. The ethics and impacts of conducting and adapting the approach within a post-disaster context will be discussed in reference to theories and models of participatory health research. The challenges of balancing local interests with state-wide implications will also be explored in the description of the methods of engagement and the study processes and outcomes. Beyond Bushfires demonstrates the feasibility of incorporating participatory methods in large, post-disaster research studies and achieving rigorous findings and multilevel impacts, while recognising the potential for some of the empowering aspects of the participatory experience to be reduced by the scaled-up approach.

Gibbs, L., Molyneaux, R., Whiteley, S., Block, K., Harms, L., Bryant, R.A., Forbes, D., Gallagher, H.C., MacDougall, C., & Ireton, G. (2018). Distress and satisfaction with research participation: Impact on retention in longitudinal disaster research. International Journal of Disaster Risk Reduction, 27,7. https://reader.elsevier.com/reader/sd/pii/S2212420917302777

Previous studies of the impact of post-trauma research participation indicate that while the research experience may be emotional, it can still be valued by participants. This paper describes participant experiences of the Australian post-bushfire research study–Beyond Bushfires. It examines the relationships between distress during research participation, probable mental health conditions, and satisfaction with the research experience over time.

A range of strategies was incorporated into the study, including a distress and risk assessment and referral protocol, to minimise any risk of harm for people who had experienced the 2009 bushfires and their aftermath. Participants included 1056 respondents (Wave 1) interviewed via telephone and web-based survey between December 2011 through January 2013, and 736 (76.1%) of the participants were re-surveyed between July and November 2014 (Wave 2). Research impact was monitored through two questions about survey experience on each occasion. Reported distress at completing the survey was generally low, while overall satisfaction was relatively high. Participants’ reported satisfaction was not associated with their reported level of distress as a result of the survey; and reported participation distress at Wave 1 did not predict whether a respondent would return to complete the survey at Wave 2. Fire-related Posttraumatic stress symptoms were associated with increased satisfaction and likelihood to return at Wave 2.

These findings suggest that for Beyond Bushfires survey respondents the perceived benefits outweighed the costs of participation over time.

King, K., Schlichthorst, M., Spittal, M.J., Phelps, A., & Pirkis, J. (2018). Can a documentary increase help-seeking intentions in men? A randomised controlled trial. Journal of Epidemiology and Community Health, 72(1), 7. https://jech.bmj.com/content/jech/72/1/92.full.pdf

Background: We investigated whether a public health intervention—a three-part documentary called Man Up which explored the relationship between masculinity and mental health, well-being and suicidality—could increase men’s intentions to seek help for personal and emotional problems.

Methods: We recruited men aged 18 years or over who were not at risk of suicide to participate in a double-blind randomised controlled trial. Participants were randomly assigned (1:1) via computer randomisation to view Man Up (the intervention) or a control documentary. We hypothesised that 4 weeks after viewing Man Up participants would report higher levels of intention to seek help than those who viewed the control documentary. Our primary outcome was assessed using the General Help Seeking Questionnaire, and was analysed for all participants. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616001169437, Universal Trial Number: U1111-1186-1459) and was funded by the Movember Foundation.

Results: Three hundred and fifty-four men were assessed for eligibility for the trial and randomised to view Man Up or the control documentary. Of these, 337 completed all stages (nine participants were lost to follow-up in the intervention group and eight in the control group). Linear regression analysis showed a significant increase in intentions to seek help in the intervention group, but not in the control group (coef.=2.06, 95% CI 0.48 to 3.63, P=0.01).

Conclusions: Our trial demonstrates the potential for men’s health outcomes to be positively impacted by novel, media-based public health interventions that focus on traditional masculinity.

Kuhn, E., van der Meer, C., Owen, J. E., Hoffman, J. E., Cash, R., Carrese, P., Olff, M., Bakker, A., Schellong, J., Lorenz, P., Schopp, M., Rau, H., Weidner, K., Arnberg, F. K., Cernvall, M., & Iversen, T. (2018). PTSD Coach around the world. mHealth, 4,15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994444/pdf

Posttraumatic stress disorder (PTSD) is a global public health problem. Unfortunately, many individuals with PTSD do not receive professional care due to a lack of available providers, stigma about mental illness, and other concerns. Technology-based interventions, including mobile phone applications (apps) may be a viable means of surmounting such barriers and reaching and helping those in need. Given this potential, in 2011 the U.S Veterans Affairs National Center for PTSD released PTSD Coach, a mobile app intended to provide psycho-education and self-management tools for trauma survivors with PTSD symptoms. Emerging research on PTSD Coach demonstrates high user satisfaction, feasibility, and improvement in PTSD symptoms and other psychosocial outcomes. A model of openly sharing the app's source code and content has resulted in versions being created by individuals in six other countries: Australia, Canada, The Netherlands, Germany, Sweden, and Denmark. These versions are described, highlighting their significant adaptations, enhancements, and expansions to the original PTSD Coach app as well as emerging research on them. It is clear that the sharing of app source code and content has benefited this emerging PTSD Coach community, as well as the populations they are targeting. Despite this success, challenges remain especially reaching trauma survivors in areas where few or no other mental health resources exist.

Lau, W., Silove, D., Edwards, B., Forbes, D., Bryant, R., McFarlane, A., & Felmingham, K. (2018). Adjustment of refugee children and adolescents in Australia: outcomes from wave three of the Building a New Life in Australia study. BMC Medicine, 16(157). https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1124-5

Background: High-income countries like Australia play a vital role in resettling refugees from around the world, half of whom are children and adolescents. Informed by an ecological framework, this study examined the post-migration adjustment of refugee children and adolescents 2–3 years after arrival to Australia. We aimed to estimate the overall rate of adjustment among young refugees and explore associations with adjustment and factors across individual, family, school, and community domains, using a large and broadly representative sample.

Methods: Data were drawn from Wave 3 of the Building a New Life in Australia (BNLA) study, a nationally representative, longitudinal study of settlement among humanitarian migrants in Australia. Caregivers of refugee children aged 5–17 (N = 694 children and adolescents) were interviewed about their children’s physical health and activity, school absenteeism and achievement, family structure and parenting style, and community and neighbourhood environment. Parent and child forms of the Strengths and Difficulties Questionnaire (SDQ) were completed by caregivers and older children to assess social and emotional adjustment.

Results: Sound adjustment according to the SDQ was observed regularly among young refugees, with 76-94% (across gender and age) falling within normative ranges. Comparison with community data for young people showed that young refugees had comparable or higher adjustment levels than generally seen in the community. However, young refugees as a group did report greater peer difficulties. Bivariate and multivariate linear regression analyses showed that better reported physical health and school achievement were associated with higher adjustment. Furthermore, higher school absenteeism and endorsement of a hostile parenting style were associated with lower adjustment.

Conclusions: This is the first study to report on child psychosocial outcomes from the large, representative longitudinal BNLA study. Our findings indicate sound adjustment for the majority of young refugees resettled in Australia. Further research should examine the nature of associations between variables identified in this study. Overall, treating mental health problems early remains a priority in resettlement. Initiatives to enhance parental capability, physical health, school achievement and participation could assist to improve settlement outcomes for young refugees.

Lau, W., Silove, D., Edwards, B., Forbes, D., Bryant, R., McFarlane, A., Hadzi-Pavlovic, D., Steel, Z., Nickerson, A., van Hooff, M., Felmingham, K., Cowlishaw, S., Alkemade, N., Kartal, D., & O’Donnell, M. (2018). An ecological approach to investigating the adjustment of refugee children and adolescents in Australia: Outcomes from wave three of the Building a New Life in Australia study. BMC Medicine, 16(157), 17. https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1124-5

Background: High-income countries like Australia play a vital role in resettling refugees from around the world, half of whom are children and adolescents. Informed by an ecological framework, this study examined the post-migration adjustment of refugee children and adolescents 2–3 years after arrival to Australia. We aimed to estimate the overall rate of adjustment among young refugees and explore associations with adjustment and factors across individual, family, school, and community domains, using a large and broadly representative sample.

Methods: Data were drawn from Wave 3 of the Building a New Life in Australia (BNLA) study, a nationally representative, longitudinal study of settlement among humanitarian migrants in Australia. Caregivers of refugee children aged 5–17 (N = 694 children and adolescents) were interviewed about their children’s physical health and activity, school absenteeism and achievement, family structure and parenting style, and community and neighbourhood environment. Parent and child forms of the Strengths and Difficulties Questionnaire (SDQ) were completed by caregivers and older children to assess social and emotional adjustment.

Results: Sound adjustment according to the SDQ was observed regularly among young refugees, with 76-94% (across gender and age) falling within normative ranges. Comparison with community data for young people showed that young refugees had comparable or higher adjustment levels than generally seen in the community. However, young refugees as a group did report greater peer difficulties. Bivariate and multivariate linear regression analyses showed that better reported physical health and school achievement were associated with higher adjustment. Furthermore, higher school absenteeism and endorsement of a hostile parenting style were associated with lower adjustment.

Conclusions: This is the first study to report on child psychosocial outcomes from the large, representative longitudinal BNLA study. Our findings indicate sound adjustment for the majority of young refugees resettled in Australia. Further research should examine the nature of associations between variables identified in this study. Overall, treating mental health problems early remains a priority in resettlement. Initiatives to enhance parental capability, physical health, school achievement and participation could assist to improve settlement outcomes for young refugees.

McCarthy, S., Thomas, S.L., Randle, M., Bestman, A., Pitt, H., Cowlishaw, S., & Daube, M. (2018). Women’s gambling behaviour, product preferences and perceptions of product harm: Differences by age and gambling status. Harm Reduction Journal, 15(22), 12. https://harmreductionjournal.biomedcentral.com/pdf

Background: Women’s participation in, and harm from gambling, is steadily increasing. There has been very limited research to investigate how gambling behaviour, product preferences, and perceptions of gambling harm may vary across subgroups of women.

Methods: This study surveyed a convenience sample of 509 women from Victoria and New South Wales, Australia. Women were asked a range of questions about their socio-demographic characteristics and gambling behaviour. Focusing on four gambling products in Australia—casino gambling, electronic gambling machines (EGMs), horse betting, and sports betting—women were asked about their frequency of participation, their product preferences, and perceptions of product harms. The sample was segmented a priori according to age and gambling risk status, and differences between groups were identified using Chi-square tests and ANOVAs. Thematic analysis was used to interpret qualitative data.

Results: Almost two thirds (n = 324, 63.7%) of women had engaged with one of the four products in the previous 12 months. Compared to other age groups, younger women aged 16–34 years exhibited a higher proportion of problem gambling, gambled more frequently, and across more products. While EGMs were the product gambled on most frequently by women overall, younger women were significantly more likely to bet on sports and gamble at casinos relative to older women. Qualitative data indicated that younger women engaged with gambling products as part of a “night out”, “with friends”, due to their “ease of access” and perceived “chance of winning big”. There were significant differences in the perceptions of the harms associated with horse and sports betting according to age and gambling risk status, with younger women and gamblers perceiving these products as less harmful.

Conclusions: This study highlights that there are clear differences in the gambling behaviour, product preferences, and perceptions of product harms between subgroups of women. A gendered approach will enable public health researchers and policymakers to ensure that the unique factors associated with women’s gambling are taken into consideration in a comprehensive public health approach to reducing and preventing gambling harm.

Murphy, M., Hollinghurst, S., & Cowlishaw, S. (2018). Primary Care Outcomes Questionnaire: A new instrument for primary care. British Journal of General Practice, 68(671), 8. https://bjgp.org/content/bjgp/68/671/e433.full.pdf

Background: Patients attend primary care for many reasons and to achieve a range of possible outcomes. There is currently no Patient Reported Outcome Measure (PROM) designed to capture these diverse outcomes, and trials of interventions in primary care may thus fail to detect beneficial effects.

Aim: This study describes the psychometric testing of the Primary Care Outcomes Questionnaire

(PCOQ), which was designed to capture a broad range of outcomes relevant to primary care.

Design and setting: Questionnaires were administered in primary care in South West England.

Method: Patients completed the PCOQ in GP waiting rooms before a consultation, and a second questionnaire, including the PCOQ and seven comparator PROMs, after 1 week. Psychometric testing included exploratory factor analysis on the PCOQ, internal consistency, correlation coefficients between domain scores and comparator measures, and repeated measures effect sizes indicating change across 1 week.

Results: In total, 602 patients completed the PCOQ at baseline, and 264 (44%) returned the followup questionnaire. Exploratory factor analysis suggested four dimensions underlying the PCOQ items: health and wellbeing, health knowledge and self-care, confidence in health provision, and confidence in health plan. Each dimension was internally consistent and correlated as expected with comparator PROMs, providing evidence of construct validity. Patients reporting an improvement in their main problem exhibited small to moderate improvements in relevant domain scores on the PCOQ.

Conclusion: The PCOQ was acceptable, feasible, showed strong psychometric properties, and was responsive to change. It is a promising new tool for assessment of outcomes of primary care interventions from a patient perspective.

Nickerson, A., Liddell, B.J., Keegan, D., Edwards, B., Felmingham, K.L., Forbes, D., Hadzi-Pavlovic, D., McFarlane, A.C., O'Donnell, M., Silove, D., Steel, Z., Van Hoof, M., & Bryant, R.A. (2018). Longitudinal association between trust, psychological symptoms and community engagement in resettled refugees. Psychological Medicine, 9. https://www.researchgate.net/profile/Angela_Nickerson

The mental health and social functioning of millions of forcibly displaced individuals worldwide represents a key public health priority for host governments. This is the first longitudinal study with a representative sample to examine the impact of interpersonal trust and psychological symptoms on community engagement in refugees.

Methods: Participants were 1894 resettled refugees, assessed within 6 months of receiving a permanent visa in Australia, and again 2-3 years later. Variables measured included post-traumatic stress disorder symptoms, depression/anxiety symptoms, interpersonal trust and engagement with refugees' own and other communities.

Results: A multilevel path analysis was conducted, with the final model evidencing good fit (Comparative Fit Index = 0.97, Tucker-Lewis Index = 0.89, Root Mean Square Error of Approximation = 0.05, Standardized Root-Mean-Square-Residual = 0.05). Findings revealed that high levels of depression symptoms were associated with lower subsequent engagement with refugees' own communities. In contrast, low levels of interpersonal trust were associated with lower engagement with the host community over the same timeframe.

Conclusions: Findings point to differential pathways to social engagement in the medium-term post-resettlement. Results indicate that depression symptoms are linked to reduced engagement with one's own community, while interpersonal trust is implicated in engagement with the broader community in the host country. These findings have potentially important implications for policy and clinical practice, suggesting that clinical and support services should target psychological symptoms and interpersonal processes when fostering positive adaptation in resettled refugees.

O’Donnell, M., Metcalf, O., Watson, L., Phelps, A., & Varker, T. (2018). A systematic review of the efficacy of psychological and pharmacological treatments for adjustment disorder in adults. Journal of Traumatic Stress, 31(3), 321. https://onlinelibrary.wiley.com/doi/abs/10.1002/jts.22295

Adjustment disorder is a common psychiatric disorder, yet knowledge of the efficacious treatments for adjustment disorder is limited. In this systematic review, we aimed to examine psychological and pharmacological interventions that target adjustment disorder in adults to determine which interventions have the best evidence for improving adjustment disorder symptoms. We performed database searches for literature published between January 1980 and September 2016 and identified studies that included both a sample majority of individuals diagnosed with adjustment disorder and findings on adjustment disorder symptom outcomes. There were 29 studies that met the inclusion criteria for qualitative synthesis; the majority of studies (59%) investigated psychological therapies rather than pharmacological treatments (35%). The range of psychological therapies tested was diverse, with the majority containing cognitive behavioral therapy (CBT) components (53%), followed by three studies that were psychodynamic‐related, three studies that were behavioral therapy–based, and two studies that involved relaxation techniques. We rated individual studies using a modified National Health and Medical Research Council quality and bias checklist and then used the Grading of Recommendations Assessment, Development and Evaluation (GRADE; Grade Working Group, 2004) system to rate the overall quality of the evidence. Despite several randomized controlled trials, the quality of the evidence for positive effects of all psychological and pharmacological treatments on symptoms of adjustment disorder was ranked as low to very low. Future high‐quality research in the treatment of adjustment disorder has the potential to make a significant difference to individuals who struggle to recover after stressful events.

Petrie, K., Milligan Saville, J., Gayed, A., Deady, M., Phelps, A., Dell, A., Forbes, D., Bryant, R.A., Calvo, R.A., Glozier, N., & Harvey, S.B. (2018). Prevalence of PTSD and common mental disorders amongst ambulance personnel: a systematic review and meta-analysis. Social Psychiatry and Psychiatric Epidemiology. http://www.astss.org.au/Article_PrevalenceOfPTSDAndCommonMenta.pdf

Purpose: There is increasing concern regarding the mental health impact of first responder work, with some reports suggesting ambulance personnel may be at particularly high risk. Through this systematic review and meta-analysis we aimed to determine the prevalence of mental health conditions among ambulance personnel worldwide.

Methods: A systematic search and screening process was conducted to identify studies for inclusion in the review. To be eligible, studies had to report original quantitative data on the prevalence of at least one of the following mental health outcome(s) of interest (PTSD, depression, anxiety, general psychological distress) for ambulance personnel samples. Quality of the studies was assessed using a validated methodological rating tool. Random effects modelling was used to estimate pooled prevalence, as well as subgroup analyses and meta-regressions for five variables implicated in heterogeneity.

Results: In total, 941 articles were identified across all sources, with 95 full-text articles screened to confirm eligibility. Of these, 27 studies were included in the systematic review, reporting on a total of 30,878 ambulance personnel. A total of 18 studies provided necessary quantitative information and were retained for entry in the meta-analysis. The results demonstrated estimated prevalence rates of 11% for PTSD, 15% for depression, 15% for anxiety, and 27% for general psychological distress amongst ambulance personnel, with date of data collection a significant influence upon observed heterogeneity.

Conclusion: Ambulance personnel worldwide have a prevalence of PTSD considerably higher than rates seen in the general population, although there is some evidence that rates of PTSD may have decreased over recent decades.

Phelps A.J., Steele, Z., Cowlishaw, S., Metcalf, O., Alkemade, N., Elliot, P., O’Donnell, M., Redston, S., Kerr, K., Howard, A., Nursey, J., Cooper, J., Armstrong, R., Fitzgerald, L., & Forbes, D. (2018). Treatment outcomes for military veterans with PTSD: Response trajectories by symptom cluster. Journal of Traumatic Stress, 31(3). https://onlinelibrary.wiley.com/doi/abs/10.1002/jts.22299

Although effective posttraumatic stress disorder (PTSD) treatments are available, outcomes for veterans with PTSD are relatively modest. Previous researchers have identified subgroups of veterans with different response trajectories but have not investigated whether PTSD symptom clusters (based on a four‐factor model) have different patterns of response to treatment. The importance of this lies in the potential to increase treatment focus on less responsive symptoms. We investigated treatment outcomes by symptom cluster for 2,685 Australian veterans with PTSD. We used Posttraumatic Stress Disorder Checklist scores obtained at treatment intake, posttreatment, and 3‐ and 9‐month follow‐ups to define change across symptom clusters. Repeated measures effect sizes indicated that arousal and numbing symptoms exhibited the largest changes between intake and posttreatment, dRM = −0.61 and dRM = −0.52, respectively, whereas avoidance and intrusion symptoms showed more modest reductions, dRM = −0.36 and dRM = −0.30, respectively. However, unlike the other symptom clusters, the intrusions cluster continued to show significant changes between posttreatment and 3‐month follow‐up, dRM = −0.21. Intrusion and arousal symptoms also showed continued changes between 3‐ and 9‐month follow‐ups although these effects were very small, dRM = −0.09. Growth curve model analyses produced consistent findings and indicated modest initial changes in intrusion symptoms that continued posttreatment. These findings may reflect the longer time required for emotional processing, relative to behavioral changes in avoidance, numbing, and arousal, during the program; they also reinforce the importance of prioritizing individual trauma‐focused therapy directly targeting intrusions as the core component of programmatic treatment.

Phelps, A.J., Steel, A., Metcalf, O., Alkemade, N., Kerr, K., O’Donnell, M., Nursey, J., Cooper, J., Howard, A., Armstrong, R., & Forbes, D. (2018). Key patterns and predictors of response to treatment for military veterans with posttraumatic stress disorder: A growth mixture modelling approach. Psychological Medicine, 48(1), 13. https://www.cambridge.org/core/journals/psychological-medicine/article

Background: To determine the patterns and predictors of treatment response trajectories for veterans with post-traumatic stress disorder (PTSD).

Methods: Conditional latent growth mixture modelling was used to identify classes and predictors of class membership. In total, 2686 veterans treated for PTSD between 2002 and 2015 across 14 hospitals in Australia completed the PTSD Checklist at intake, discharge, and 3 and 9 months follow-up. Predictor variables included co-morbid mental health problems, relationship functioning, employment and compensation status.

Results: Five distinct classes were found: those with the most severe PTSD at intake separated into a relatively large class (32.5%) with small change, and a small class (3%) with a large change. Those with slightly less severe PTSD separated into one class comprising 49.9% of the total sample with large change effects, and a second class comprising 7.9% with extremely large treatment effects. The final class (6.7%) with least severe PTSD at intake also showed a large treatment effect. Of the multiple predictor variables, depression and guilt were the only two found to predict differences in response trajectories.

Conclusions: These findings highlight the importance of assessing guilt and depression prior to treatment for PTSD, and for severe cases with co-morbid guilt and depression, considering an approach to trauma-focused therapy that specifically targets guilt and depression-related cognitions.

Roberts, A., Landon, J., Sharman, S., Hakes, J., Suomi, A., & Cowlishaw, S. (2018). Gambling and interpersonal violence: Results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The American Journal on Addictions, 27, 13. http://eprints.lincoln.ac.uk/Gambling-and-Interpersonal-Violence

Background and objectives: Links between intimate partner violence (IPV) and gambling problems are under researched in general population samples. Understanding these relationships will allow for improved identification and intervention. We investigated these relationships and sought to determine whether links were attenuated by axis I and II disorders.

Methods: This study examined data from waves 1 and 2 (N = 25,631) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC); a nationally representative survey of U.S. adults. Gambling symptoms and other psychiatric disorders were measured at wave 1 by the Alcohol Use Disorder and Associated Disability Interview Schedule-DSM-IV Version (AUDADIS-IV). Physical IPV victimization and perpetration in the last 12 months were assessed 3 years later at wave 2 using items from the Conflict Tactics Scale-R. Binary logistic regression models were used to examine associations separately for males and females.

Results: Problem gambling was associated with increased odds of both IPV perpetration for males (OR = 2.62, 95%CI = 1.22-5.60) and females (OR = 2.87, 95%CI = 1.29-6.42), and with IPV victimization for females only (OR = 2.97, 95%CI = 1.31-6.74). Results were attenuated with inclusion of axis I and axis II disorders; links between gambling and IPV were weaker than those involving other mental health conditions.

Conclusions and scientific significance: There are prospective associations with gambling problems and physical IPV which have implications for identification, spontaneous disclosure, and treatment seeking. The links between gambling problems and violence are complex and should not be considered independently of co-occurring mental health and substance use disorders.

Spittal, M., Grant, G., O'Donnell, M., McFarlane, A., & Studdert, D. (2018). Development of prediction models of stress and long-term disability among claimants to injury compensation systems: A cohort study. BMJ Open, 8(4), 10. https://bmjopen.bmj.com/content/bmjopen/8/4/e020803.full.pdf

Objectives: We sought to develop prognostic risk scores for compensation-related stress and long-term disability using markers collected within 3 months of a serious injury.

Design: Cohort study. Predictors were collected at baseline and at 3 months post-injury. Outcome data were collected at 72 months post-injury.

Setting: Hospitalised patients with serious injuries recruited from four major trauma hospitals in Australia.

Participants: 332 participants who made claims for compensation for their injuries to a transport accident scheme or a workers' compensation scheme.

Primary outcome measures: 12-item WHO Disability Assessment Schedule and 6 items from the Claims Experience Survey.

Results: Our model for long-term disability had four predictors (unemployed at the time of injury, history of a psychiatric disorder at time of injury, post-traumatic stress disorder symptom severity at 3 months and disability at 3 months). This model had good discrimination (R2=0.37) and calibration. The disability risk score had a score range of 0-180, and at a threshold of 80 had sensitivity of 56% and specificity of 86%. Our model for compensation-related stress had five predictors (intensive care unit admission, discharged to home, number of traumatic events prior to injury, depression at 3 months and not working at 3 months). This model also had good discrimination (area under the curve=0.83) and calibration. The compensation-related stress risk score had score range of 0-220 and at a threshold of 100 had sensitivity of 74% and specificity of 75%. By combining these two scoring systems, we were able to identify the subgroup of claimants at highest risk of experiencing both outcomes.

Conclusions: The ability to identify at an early stage claimants at high risk of compensation-related stress and poor recovery is potentially valuable for claimants and the compensation agencies that serve them. The scoring systems we developed could be incorporated into the claims-handling processes to guide prevention-oriented interventions.

Varker, T., Brand, R.M., Ward, J., Terhaag, S., & Phelps, A. (2018). Efficacy of synchronous telepsychology interventions for people with anxiety, depression, posttraumatic stress disorder and adjustment disorder: A rapid evidence assessment. Psychological Services. https://psycnet.apa.org/record/2018-24930-001

Telepsychology holds promise as a treatment delivery method that may increase access to services as well as reduce barriers to treatment accessibility. The aim of this rapid evidence assessment was to assess the evidence for synchronous telepsychology interventions for 4 common mental health conditions (depression, anxiety, posttraumatic stress disorder, and adjustment disorder). Randomized controlled trials published between 2005 and 2016 that investigated synchronous telepsychology (i.e., telephone delivered, video teleconference delivered, or Internet delivered text based) were identified through literature searches. From an initial yield of 2,266 studies, 24 were included in the review. Ten studies investigated the effectiveness of telephone-delivered interventions, 11 investigated the effectiveness of video teleconference (VTC) interventions, 2 investigated Internet-delivered text-based interventions, and 2 were reviews of multiple telepsychology modalities. There was sufficient evidence to support VTC and telephone-delivered interventions for mental health conditions. The evidence for synchronous Internet-delivered text-based interventions was ranked as "unknown." Telephone-delivered and VTC-delivered psychological interventions provide a mode of treatment delivery that can potentially overcome barriers and increase access to psychological interventions.

Varker, T., Metcalf, O., Forbes, D., Chisholm, K., Harvey, S., Van Hooff, M., Bryant, R., McFarlane, A.C., & Phelps, A. (2018). Research into Australian emergency service workers mental health and wellbeing: An evidence map. Australian and New Zealand Journal of Psychiatry, 52(2), 129-148. http://bit.ly/37JfOiO

Telepsychology holds promise as a treatment delivery method that may increase access to services as well as reduce barriers to treatment accessibility. The aim of this rapid evidence assessment was to assess the evidence for synchronous telepsychology interventions for 4 common mental health conditions (depression, anxiety, posttraumatic stress disorder, and adjustment disorder). Randomized controlled trials published between 2005 and 2016 that investigated synchronous telepsychology (i.e., telephone delivered, video teleconference delivered, or Internet delivered text based) were identified through literature searches. From an initial yield of 2,266 studies, 24 were included in the review. Ten studies investigated the effectiveness of telephone-delivered interventions, 11 investigated the effectiveness of video teleconference (VTC) interventions, 2 investigated Internet-delivered text-based interventions, and 2 were reviews of multiple telepsychology modalities. There was sufficient evidence to support VTC and telephone-delivered interventions for mental health conditions. The evidence for synchronous Internet-delivered text-based interventions was ranked as "unknown." Telephone-delivered and VTC-delivered psychological interventions provide a mode of treatment delivery that can potentially overcome barriers and increase access to psychological interventions.

Wade, D., Lau, W., Nixon, R. (2018). A clinician’s quick guide of evidence-based approaches: Post-traumatic stress disorder. Clinical Practice Guidelines, 22(1), 2. https://aps.onlinelibrary.wiley.com/doi/abs/10.1111/cp.12142

2017 PUBLICATIONS

Bowman, S., Alvarez-Jimenez, M., Wade, D., Howie, L., & McGorry, P. (2017). The positive and negative experiences of caregiving for siblings of young people with first episode psychosis. Frontiers in Psychology, 8(730). doi: doi.org/10.3389/fpsyg.2017.00730

Background: The impact of first episode psychosis (FEP) upon parents’ experience of caregiving has been well-documented. However, the determinants and nature of this remain poorly understood in siblings. It is hypothesized that siblings of young people with FEP are also impacted by caregiving and burden. This study aimed to characterize the experience of caregiving for siblings of young people with FEP.

Method: Survey methodology was used to explore the experience of 157 siblings in the first 18 months of their brother or sister’s treatment for FEP. Participants reported on their appraisal of the negative and positive aspects of caregiving as measured by the Experience of Caregiving Inventory (ECI). Descriptive statistics were used to establish the results for the total sample as well as for gender and birth order differences. A series of multivariate regression analyses were conducted to determine the relationships between illness characteristics and siblings’ experience of caregiving.

Results: Older brothers reported the lowest scores for negative experiences in caregiving and younger sisters reported the highest. Negative experiences in caregiving resulted in less warmth within the sibling relationship and impacted negatively upon quality of life. When the young person with FEP had attempted suicide and/or been physically violent, siblings experienced more caregiver burden. Multivariate analysis showed that female gender was a significant factor in explaining the impact of illness related variables on the experience of caregiving.

Conclusion: Suicide attempts and a history of violence resulted in higher caregiving burden for siblings regardless of whether they lived with the young person experiencing FEP or not. Female siblings are at higher risk of negative experiences from caregiving resulting in a reduced quality of life and a changed sibling relationship. Suicide attempts and violence are indicators for intensive case management to improve outcomes for the individual with FEP which may in turn reduce the burden experienced by the sibling. Clinicians can use these findings to identify siblings, assertively intervene and provide increased psychological support, psychoeducation and practical problem solving to reduce the burden. The caregiving role that they already play for their ill brother or sister should be recognized.

Bryant R., Creamer M., O'Donnell M., Forbes D., McFarlane, A., Silove, D., & Hadzi-Pavlovic, D. (2017). Acute and chronic posttraumatic stress symptoms in the emergence of posttraumatic stress disorder. JAMA: Psychiatry, 74(2), 7. doi: https://jamanetwork.com/journals/jamapsychiatry/fullarticle

Importance: Little is understood about how the symptoms of posttraumatic stress develop over time into the syndrome of posttraumatic stress disorder (PTSD).

Objective  To use a network analysis approach to identify the nature of the association between PTSD symptoms in the acute phase after trauma and the chronic phase.

Design, Setting, and Participants: A prospective cohort study enrolled 1138 patients recently admitted with traumatic injury to 1 of 4 major trauma hospitals across Australia from March 13, 2004, to February 26, 2006. Participants underwent assessment during hospital admission (n = 1388) and at 12 months after injury (n = 852). Networks of symptom associations were analyzed in the acute and chronic phases using partial correlations, relative importance estimates, and centrality measures of each symptom in terms of its association strengths, closeness to other symptoms, and importance in connecting other symptoms to each other. Data were analyzed from March 3 to September 5, 2016.

Main Outcomes and Measures: Severity of PTSD was assessed at each assessment with the Clinician-Administered PTSD Scale.

Results: Of the 1138 patients undergoing assessment at admission (837 men [73.6%] and 301 women [26.4%]; mean [SD] age, 37.90 [13.62] years), strong connections were found in the acute phase. Reexperiencing symptoms were central to other symptoms in the acute phase, with intrusions and physiological reactivity among the most central symptoms in the networks in terms of the extent to which they occur between other symptoms (mean [SD], 1.2 [0.7] and 1.0 [0.9], respectively), closeness to other symptoms (mean [SD], 0.9 [0.3] and 1.1 [0.9], respectively), and strength of the associations (mean [SD], 1.6 [0.3] and 1.5 [0.3] respectively) among flashbacks, intrusions, and avoidance of thoughts, with moderately strong connections between intrusions and nightmares, being upset by reminders, and physiological reactivity. Intrusions and physiological reactivity were central in the acute phase. Among the 852 patients (73.6%) who completed the 12-month assessment, overall network connectivity was significantly stronger at 12 months than in the acute phase (global strength values, 6.57 vs 7.60; paired difference, 1.03; P < .001). The network associations among the reexperiencing symptoms were strengthened at 12 months, and physiological reactivity was strongly associated with the startle response, which was also associated with hypervigilance. Strong connectivity among emotional numbing, detachment from others, and disinterest in activities as well as moderately strong links among irritability (anger), concentration deficits, and sleep disturbance were found.

Conclusions and Relevance: As time elapses after trauma, fear circuitry and dysphoric PTSD symptoms appear to emerge as connected networks. Intrusive memories and reactivity are centrally associated with other symptoms in the acute phase, potentially pointing to the utility of addressing these symptoms in early intervention strategies.

Bryant, R., Creamer, M., O'Donnell, M., Forbes, D., Felmingham, K., Silove, D., Malhim G., van Hooff, M., McFarlane, A., & Nickerson, A. (2017). Separation from parents during childhood trauma predicts adult attachment security and post-traumatic stress disorder. Psychological Medicine, 47(11), 8. doi: https://www.cambridge.org/core/journals/

Prolonged separation from parental support is a risk factor for psychopathology. This study assessed the impact of brief separation from parents during childhood trauma on adult attachment tendencies and post-traumatic stress.

Children (n = 806) exposed to a major Australian bushfire disaster in 1983 and matched controls (n = 725) were assessed in the aftermath of the fires (mean age 7–8 years) via parent reports of trauma exposure and separation from parents during the fires. Participants (n = 500) were subsequently assessed 28 years after initial assessment on the Experiences in Close Relationships scale to assess attachment security, and post-traumatic stress disorder (PTSD) was assessed using the PTSD checklist.

Being separated from parents was significantly related to having an avoidant attachment style as an adult (B = −3.69, s.e. = 1.48, β = −0.23, p = 0.013). Avoidant attachment was associated with re-experiencing (B = 0.03, s.e. = 0.01, β = 0.31, p = 0.045), avoidance (B = 0.03, s.e. = 0.01, β = 0.30, p = 0.001) and numbing (B = 0.03, s.e. = 0.01, β = 0.30, p < 0.001) symptoms. Anxious attachment was associated with re-experiencing (B = 0.03, s.e. = 0.01, β = 0.18, p = 0.001), numbing (B = 0.03, β = 0.30, s.e. = 0.01, p < 0.001) and arousal (B = 0.04, s.e. = 0.01, β = 0.43, p < 0.001) symptoms.

These findings demonstrate that brief separation from attachments during childhood trauma can have long-lasting effects on one's attachment security, and that this can be associated with adult post-traumatic psychopathology.

Forbes, D., O'Donnell, M., & Bryant, R. (2017). Psychosocial recovery following community disasters: An international collaboration. Australian & New Zealand Journal of Psychiatry, 51(7), 2. doi: https://journals.sagepub.com/doi/pdf

Gallagher, H. C., Lusher, D., Gibbs, L., Pattison, P., Forbes, D., Block, K., Harms L., Macdougall C., Kellett C., Ireton G., & Bryant, R. (2017). Dyadic effects of attachment on mental health: Couples in a postdisaster context. Journal of Family Psychology, 31(2), 11. doi: https://psycnet.apa.org/doi

Research on mental health following disasters has led to the identification of many individual protective and risk factors for postdisaster mental health. However, there is little understanding of the exact influence that disasters have on the functioning of intimate relationships. Especially relevant are attachment styles, which are likely to play an important role in the provision and perception of social support between partners, and subsequent mental health outcomes. Heterosexual couples (N = 127) affected by the 2009 Victorian “Black Saturday” bushfires in southeastern Australia were surveyed for disaster experiences, posttraumatic stress disorder (PTSD) symptoms, depression, and attachment style between May 2012 and January 2013, approximately 3 years after the disaster. Using actor–partner interdependence models (APIM), we examined both intrapersonal and interpersonal associations of attachment anxiety and avoidance with depression and PTSD, in combination with shared disaster exposure. Male partners’ attachment avoidance was associated with depression and PTSD in both partners. By contrast, a female partner’s attachment avoidance was associated with greater depression and PTSD in herself, but fewer PTSD symptoms in a male partner. Amid the chronic stressors of a postdisaster setting, the attachment avoidance of the male partner may play a particularly negative role, with his tendency toward isolation and denial becoming especially maladaptive for the couple as a whole. The female partner’s attachment avoidance is likewise an important factor, but its associations with negative social support and relationship breakup must be clarified to understand its impact on partnership functioning. The impact of disasters on psychological functioning has been repeatedly supported in empirical research, with depression, posttraumatic stress disorder (PTSD), anxiety, and substance use all found to occur at heightened rates in the wake of disasters (Kessler et al., 2008; Norris et al., 2002; Su, Chou, Ou-Yang, & Chou, 2006; Van Griensven et al., 2006). The routes of influence that disasters have on the individual, however, are various and complex. In particular, supportive social relationships have frequently been identified as a key contributor to better mental health outcomes (e.g., Brewin, Andrews, & Valentine, 2000). However, relatively little is understood about the many interpersonal cognitive, affective, and behavioral processes that are a part of these relationships, and how they affect well-being. One way that researchers can begin to better understand the complex interplay between disaster impact, social relationships, and mental health is to focus on specific types of relationships, and examine processes of interpersonal influence across these particularly important social ties. A prime example is intimate partnerships (e.g., marital, “de facto,” cohabiting). Marital status is a positive factor for health status in the general population, and the quality and stability of such relationships remain key mediators of their health benefits (Frech & Williams, 2007; Holt-Lunstad, Birmingham, & Jones, 2008). The health benefits of partnerships are less clear in the wake of disasters (Brooks & McKinlay, 1992; Norris et al., 2002; Monson, Gradus, Bash, Griffin, & Resick, 2009). In all, there is little understanding of the exact influence that disasters have on the functioning of intimate relationships, and the subsequent impact on individual mental health (Lowe, Rhodes, & Scoglio, 2012). A handful of studies has suggested that the heightened responsibilities for support and nurturance that come with partnerships may be particularly burdensome following a disaster, exacerbating marital stress (Norris & Uhl, 1993), and exerting a negative influence on mental health, especially for the female partner (Gleser, Green, & Winget, 1981, Solomon, Smith, Robins, & Fischbach, 1987). Nonetheless, the shortage of research in this area is conspicuous, given population-level findings that large-scale, community-based disasters (e.g., hurricanes, earthquakes) trigger widespread changes in intimate partnerships, including elevated rates of divorce, marriage, and birth (Cohan & Cole, 2002; Cohan, Cole, & Schoen, 2009). A primary lens through which to investigate the intersection of intimate relationships and mental health is that of attachment (Bowlby, 1982), which describes individuals’ basic patterns of proximity- and support-seeking, caregiving, and felt security within close social relationships, especially during times of stress and threat. In the current study, we add to previous empirical research considering the association between attachment styles, and one’s partner’s mental health. This study contributes to a limited body of research of dyadic (within-couple) processes of attachment within posttraumatic settings, and, to our knowledge, constitutes the first such investigation within the context of a community-based disaster.

Lloyd, D., Varker, T., Pham, T., O’Connor, J., & Phelps, A. (2017). Reach, accessibility and effectiveness of an online self-guided wellbeing website for the military community. Journal of Military and Veterans’ Health, 25(2), 8-15. ISSN: https://jmvh.org/wp-content/uploads/2017/07/AMMA-JMVH-April-2017_lr.pdf#page=8

Online mental healthcare resources have proliferated at a greater pace than evidence for their effectiveness. They may nevertheless be an attractive alternative for contemporary veterans and serving personnel who are reluctant to engage in traditional face to face treatment. This has created an urgent need to evaluate the effectiveness of online mental health care for the military community. This paper reports on the two-stage evaluation of the Wellbeing Toolbox, a self-guided website for ex-serving members and their families. Stage 1 evaluated the reach and acceptability of the website. Results from user experience interviews and a survey of 291 open access users indicated that the site reached a relevant audience and was accessible and acceptable for the ex-service community Stage 2 investigated the effectiveness of the Wellbeing Toolbox in achieving wellbeing goals (the primary outcome) and other mental health outcomes (secondary outcomes). All 30 participants in the effectiveness trial achieved at least some of their individual wellbeing goals, with most success in "getting active", "building support" and "keeping calm" goals. There was no corresponding improvement in overall mental health status. The value and role of self-guided online help is discussed.

Nickerson, A., Creamer, M., Forbes, D., McFarlane, A., O'Donnell, M., Silove, D., Steel, Z., Flemingham, K., Hadzi-Pavlovic, D., & Bryant, R. (2017). The longitudinal relationship between posttraumatic stress disorder and perceived social support in survivors of traumatic injury. Psychological Medicine, 47(1). doi: https://www.cambridge.org/core/journals/psychological-medicine/article/traumatic-injury/

Although perceived social support is thought to be a strong predictor of psychological outcomes following trauma exposure, the temporal relationship between perceived positive and negative social support and post-traumatic stress disorder (PTSD) symptoms has not been empirically established. This study investigated the temporal sequencing of perceived positive social support, perceived negative social support, and PTSD symptoms in the 6 years following trauma exposure among survivors of traumatic injury.

Participants were 1132 trauma survivors initially assessed upon admission to one of four Level 1 trauma hospitals in Australia after experiencing a traumatic injury. Participants were followed up at 3 months, 12 months, 24 months, and 6 years after the traumatic event.

Latent difference score analyses revealed that greater severity of PTSD symptoms predicted subsequent increases in perceived negative social support at each time-point. Greater severity of PTSD symptoms predicted subsequent decreases in perceived positive social support between 3 and 12 months. High levels of perceived positive or negative social support did not predict subsequent changes in PTSD symptoms at any time-point.

Results highlight the impact of PTSD symptoms on subsequent perceived social support, regardless of the type of support provided. The finding that perceived social support does not influence subsequent PTSD symptoms is novel, and indicates that the relationship between PTSD and perceived social support may be unidirectional.

O’Donnell, M. L., Schaefer, I., Varker, T., Kartal, D., Forbes, D., Bryant, R., Derrick, S., Creamer, M. C., McFarlane, A., Malhi, G., Felmingham, K., Van Hoof, M., Nickerson, A., & Steel, Z. (2017). A systematic review of person-centered approaches to investigating trauma exposure. Clinical Psychology Review, 57, 22. doi: https://www.researchgate.net/profile/Tracey_Varker/publication/

Recent research has found that exposure to traumatic events may occur in certain patterns, rather than randomly. Person-centered analyses, and specifically latent class analysis, is becoming increasingly popular in examining patterns, or ‘classes’ of trauma exposure. This review aimed to identify whether there are consistent homogeneous subgroups of trauma-exposed individuals, and the relationship between these trauma classes and psychiatric diagnosis. A systematic review of the literature was completed using the databases EMBASE, MEDLINE (PubMed) and PsycINFO. From an initial yield of 189, 17 studies met inclusion criteria. All studies identified a group of individuals who had a higher likelihood of exposure to a wide range of traumas types, and this group consistently exhibited worse psychiatric outcomes than other groups. Studies differed in the nature of the other groups identified although there was often a class with high levels of sexual interpersonal trauma exposure, and a class with high levels of non-sexual interpersonal trauma. There was some evidence that risk for psychiatric disorder differed across these classes. Person-centered approaches to understanding the relationship between trauma exposure and mental health may offer ways to improve our understanding of the role trauma exposure plays in increasing vulnerability to psychiatric disorder.

Phelps, A. J., Steel, A., Metcalf, O., Alkemade, N., Kerr, K., O’Donnell, M., Nursey, J., Cooper, J., Howard, A., Armstrong, R., & Forbes, D. (2017). Key patterns and predictors of response to treatment for military veterans with posttraumatic stress disorder: A growth mixture modelling approach. Psychological Medicine, 48(1), 13. https://www.cambridge.org/core/journals/psychological-medicine/article

To determine the patterns and predictors of treatment response trajectories for veterans with post-traumatic stress disorder (PTSD). Conditional latent growth mixture modelling was used to identify classes and predictors of class membership. In total, 2686 veterans treated for PTSD between 2002 and 2015 across 14 hospitals in Australia completed the PTSD Checklist at intake, discharge, and 3 and 9 months follow-up. Predictor variables included co-morbid mental health problems, relationship functioning, employment and compensation status.

Five distinct classes were found: those with the most severe PTSD at intake separated into a relatively large class (32.5%) with small change, and a small class (3%) with a large change. Those with slightly less severe PTSD separated into one class comprising 49.9% of the total sample with large change effects, and a second class comprising 7.9% with extremely large treatment effects. The final class (6.7%) with least severe PTSD at intake also showed a large treatment effect. Of the multiple predictor variables, depression and guilt were the only two found to predict differences in response trajectories.

These findings highlight the importance of assessing guilt and depression prior to treatment for PTSD, and for severe cases with co-morbid guilt and depression, considering an approach to trauma-focused therapy that specifically targets guilt and depression-related cognitions.

Phelps, A., Varker, T., Metcalf, O., & Dell, L. (2017). What are effective psychological interventions for veterans with sleep disturbances? A Rapid Evidence Assessment. Military Medicine, 182(1), 11. doi: 10.7205/MILMED-D-16-00010

Background: Insomnia and related sleep disturbances commonly occur in veterans, with prevalence rates as high as 90% reported in some studies. Military-specific factors such as sleep disturbances during military training and deployment, as well as a higher prevalence of post-traumatic stress disorder (PTSD), which is known to poorly impact sleep, may contribute to higher insomnia rates in veterans. Although evidence-based guidelines for the treatment of insomnia exist, the unique nature of veterans sleep problems means they may differ in their response to treatment. The aim of this study was to review the evidence for interventions for veterans with sleep disturbances.

Methods: This literature review used a rapid evidence assessment methodology, also known as rapid review. The rapid evidence assessment methodology involves rigorously locating, appraising, and synthesising the evidence while making concessions to the breadth or the depth of the process in order to significantly decrease the length of the process. EMBASE, MEDLINE (PubMed), PsychINFO, Cochrane, Clinical Guidelines Portal (Australia), and the National Guideline Clearinghouse (United States) were searched for peer-reviewed literature and guidelines published from 2004 to August 2015 that investigated psychological interventions for veterans with sleep disturbances. The literature was assessed in terms of strength (quality, quantity, and level of evidence), direction, and the consistency, generalizability, and applicability of the findings to the population of interest. These assessments were then collated to determine an overall ranking of level of support for each intervention: "Supported" (clear, consistent evidence of a beneficial effect), "Promising" (evidence suggestive of a beneficial effect but further research is required), "Unknown" (insufficient evidence of beneficial effect and further research is required), and "Not Supported" (clear consistent evidence of no effect or negative harmful effect).

Findings: From an initial yield of 1,131 articles, 18 studies met the inclusion criteria for review. The majority of the studies investigated the effectiveness of cognitive behavioral therapy for insomnia (CBTi; n = 10). Five studies investigated CBTi with an adjunctive psychotherapy, typically for PTSD-related sleep disturbances. One further study investigated sleep hygiene education (a component of CBTi) with pharmacotherapy. Two final studies investigated hypnotherapy and mind-body bridging, respectively. Overall, the quality of the studies was mixed, with some high and some poor quality studies.

Discussion: There was sufficient evidence to support CBTi with adjunctive psychotherapy for veterans with PTSD-related sleep disturbances, although the evidence for CBTi in the treatment of general sleep disturbance for veterans was ranked as "promising." This indicates a beneficial effect, but more research is needed to confidently establish efficacy in a veteran population. There is currently insufficient evidence to support the use of sleep hygiene education and pharmacotherapy, hypnotherapy, or mind-body bridging. Further research dismantling the components of CBTi is needed to identify which are the critical components. Such research has the potential to lead to brief, targeted, and accessible treatments that overcome the time and stigma-related barriers to care that veterans often face.

Silove, D., Baker, J., Mohsin, M., Teesson, M., Creamer, M., O'Donnell, M., Forbes, D., Carragher, N., Slade, T., Mills, K., Bryant, R., McFarlane, A., Steel, Z., Felmingham, K., & Rees, S. (2017). The contribution of gender-based violence and network trauma to gender differences in Post-Traumatic Stress Disorder. PLoS ONE, 12(2), 12. doi: https://journals.plos.org/plosone/article/file

Background: Posttraumatic stress disorder (PTSD) occurs twice as commonly amongst women as men. Two common domains of trauma, network trauma and gender based violence (GBV), may contribute to this gender difference in PTSD rates. We examined data from a nationally representative sample of the Australian population to clarify the characteristics of these two trauma domains in their contributions to PTSD rates in men and women.

Methods: We drew on data from the 2007 Australian National Survey of Mental Health and Well-being to assess gender differences across a comprehensive range of trauma domains, including (1) prevalence of lifetime exposure; (2) identification of an index trauma or DSM-IV Criterion A event; and (3) the likelihood of developing full DSM-IV PTSD symptoms once an index trauma was identified.

Results: Men reported more traumatic events (TEs) overall but women reported twice the prevalence of lifetime PTSD (women, 13.4%; men, 6.3%). Women reported a threefold higher level of exposure to GBV and were seven times more likely to nominate GBV as the index trauma as compared to men. Women were twice more likely than men to identify a network trauma as the index trauma and more likely to meet full PTSD symptoms in relation to that event (women, 20.6%; men, 14.6%).

Conclusion: Women are more likely to identify GBV and network trauma as an index trauma. Women’s far greater exposure to GBV contributes to their higher prevalence of PTSD. Women are markedly more likely to develop PTSD when network trauma is identified as the index trauma. Preventing exposure to GBV and providing timely interventions for acute psychological reactions following network trauma may assist in reducing PTSD rates amongst women.

Stewart, M., Knight, T., McGillivray, J., Forbes D., & Austin, D. (2016). Through a trauma-based lens: A qualitative analysis of the experience of parenting a child with an autism spectrum disorder. Journal of Intellectual & Developmental Disability, 42(3), 10. doi: https://www.tandfonline.com/doi/abs/10.3109/

Background: Although parents of children with autism spectrum disorder (ASD) exhibit high levels of parenting stress, minimal research has examined the type of stress they experience. Understanding parenting stress is critical as the effects are not limited to the parent. The aim of this study was to investigate the validity of conceptualising parenting stress within a traumatic stress framework.

Method: Twelve mothers participated in focus groups, which were recorded and transcribed verbatim. Interpretative phenomenological analysis was used, then researchers examined for spontaneous reporting of DSM-5-defined traumatic stressors and trauma symptomatology.

Results: Forty percent of mothers experienced traumatic stressors and trauma-related symptomatology. Sixty percent of mothers did not report traumatic stressors but reported trauma-related symptomatology regardless.

Conclusions: The use of a traumatic stress framework to conceptualise some parenting experiences was supported. This finding has important implications for the development of interventions to prevent or reduce stress.

Stewart, M., McGillivray, J., Forbes, D., & Austin, D. (2017). Parenting a child with an autism spectrum disorder: A review of parent mental health and its relationship to a trauma-based conceptualisation. Advances in Mental Health, 15(1), 10. doi: https://www.tandfonline.com/doi/abs/10.1080/18387357.2015.1133075

The impact on parental psychological functioning as a result of living with disruptive, challenging, and dangerous behaviours exhibited by some children with Autism Spectrum Disorder (ASD) is investigated. Core features of ASD along with aggression, elopement, self-injury, and suicidal ideation can cause significant parental distress. This parenting experience may be associated with depression, anxiety, somatisation, and anger-hostility. It is proposed that a traumatic stress framework may assist in conceptualising some parents' experiences and psychological symptomatology. A systematic review revealed only one study that had explored posttraumatic stress symptoms amongst parents of children with ASD. Consequently, a narrative literature review has been conducted to explore this emerging area of enquiry. The Diagnostic and Statistical Manual of Mental Health Disorders (fifth edition) recognises direct experience as well as witnessing actual or threatened serious injury as a traumatic event that can lead to trauma-related psychopathology. Despite some parents of children with ASD experiencing traumatic events (e.g. their child engaging in self-injurious behaviours), prevalence rates of Posttraumatic Stress Disorder amongst this population are unknown. Further research is required to determine the validity of adopting a traumatic stress framework when considering parent symptomatology, and if such a framework were valid, there would be significant implications for optimising support and intervention for parents.

Wade, D., Mewton, L., Varker, T., Phelps, A., &  Forbes, D. (2017). The impact of potentially traumatic events on the mental health of males who have served in the military: Findings from the Australian National Survey of Mental Health and Wellbeing. Australian & New Zealand Journal of Psychiatry, 51(7), 10. doi: https://journals.sagepub.com/doi/pdf/10.1177/0004867416671413

Objective: The study investigated the impact of potentially traumatic events on mental health outcomes among males who had ever served in the Australian Defence Force (ADF).

Method: Data from a nationally representative household survey of Australian residents, the 2007 National Survey of Mental Health and Wellbeing, were used for this study.

Results: Compared with community members, ADF males were significantly more likely to haveexperienced not only deployment and other war-like events but also accidents or other unexpected events, and trauma to someone close. For non-deployed males, ADF members were at increased risk of accidents orother unexpected events compared to community members. After controlling for the effect of potentially traumatic events that were more prevalent among all ADF members, the increased risk of mental disorders among ADF members was no longer evident. For non-deployed males, ADF and community members were at comparable risk of poor mental health outcomes. A significant minority of ADF members had onset of a mental disorder prior to their first deployment.

Conclusions: Deployment and other potentially traumatic events among ADF members can help to explain their increased vulnerability to mental disorders compared with community members. Providers should routinely enquire about a range of potentially traumatic events among serving and ex-serving military personnel.

Whittle, S., Vijayakumar, N., Simmons, J. G., Dennison, M., Schwartz, O., Pantelis, C., Sheeber, L., Byrne, M. L., & Allen, N. B. (2017). Role of positive parenting in the association between neighborhood social disadvantage and brain development across adolescence. Jama Psychiatry, 47(8). doi: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2631892

Importance: The negative effects of socioeconomic disadvantage on lifelong functioning are pronounced, with some evidence suggesting that these effects are mediated by changes in brain development. To our knowledge, no research has investigated whether parenting might buffer these negative effects.

Objective: To establish whether positive parenting behaviors moderate the effects of socioeconomic disadvantage on brain development and adaptive functioning in adolescents.

Design, Setting, and Participants: In this longitudinal study of adolescents from schools in Melbourne, Australia, data were collected at 3 assessments between 2004 and 2012. Data were analyzed between August 2016 and April 2017.

Exposures: Both family (parental income-to-needs, occupation, and education level) and neighborhood measures of socioeconomic disadvantage were assessed. Positive maternal parenting behaviors were observed during interactions in early adolescence.

Main Outcomes and Measures: Structural magnetic resonance imaging scans at 3 times (early, middle, and late adolescence) from ages 11 to 20 years. Global and academic functioning was assessed during late adolescence. We used linear mixed models to examine the effect of family and neighborhood socioeconomic disadvantage as well as the moderating effect of positive parenting on adolescent brain development. We used mediation models to examine whether brain developmental trajectories predicted functional outcomes during late adolescence.

Results: Of the included 166 adolescents, 86 (51.8%) were male. We found that neighborhood, but not family, socioeconomic disadvantage was associated with altered brain development from early (mean [SD] age, 12.79 [0.425] years) to late (mean [SD] age, 19.08 [0.460] years) adolescence, predominantly in the temporal lobes (temporal cortex: random field theory corrected; left amygdala: B, −0.237; P < .001; right amygdala: B, −0.209; P = .008). Additionally, positive parenting moderated the effects of neighborhood disadvantage on the development of dorsal frontal and lateral orbitofrontal cortices as well as the effects of family disadvantage on the development of the amygdala (occupation: B, 0.382; P = .004; income-to-needs: B, 27.741; P = .004), with some male-specific findings. The pattern of dorsal frontal cortical development in males from disadvantaged neighborhoods exposed to low maternal positivity predicted increased rates of school noncompletion (indirect effect, −0.018; SE, 0.01; 95% CI, −0.053 to −0.001).

Conclusions and Relevance: Our findings highlight the importance of neighborhood disadvantage in influencing brain developmental trajectories. Further, to our knowledge, we present the first evidence that positive maternal parenting might ameliorate the negative effects of socioeconomic disadvantage on frontal lobe development (with implications for functioning) during adolescence. Results have relevance for designing interventions for children from socioeconomically disadvantaged backgrounds.

2016 PUBLICATIONS

Bryant, R. A., McFarlane, A. C., Silove, D., O’Donnell, M. L., Forbes, D., & Creamer, M. (2016). The lingering impact of resolved PTSD on subsequent functioning. Clinical Psychological Science, 4(3), 6. doi: https://journals.sagepub.com/doi/abs/10.1177/2167702615598756

This study investigated whether impairment persists after posttraumatic stress disorder (PTSD) has resolved. Traumatically injured patients (N = 1,035) were assessed during hospital admission and at 3 (85%) and 12 months (73%). Quality of life prior to traumatic injury was measured with the World Health Organization Quality of Life–BREF during hospitalization and at each subsequent assessment. PTSD was assessed using the Clinician-Administered PTSD Scale at 3 and 12 months. After controlling for preinjury functioning, current pain, and comorbid depression, patients whose PTSD symptoms had resolved by 12 months were more likely to have poorer quality of life in psychological (OR = 3.51), physical (OR = 10.17), social (OR = 4.54), and environmental (OR = 8.83) domains than those who never developed PTSD. These data provide initial evidence that PTSD can result in lingering effects on functional capacity even after remission of symptoms.

Bryant, R., Gallagher, C., Gibbs, L., Pattison, P., Macdougall, C., Harms, L., Block, K., Baker, E., Sinnott, B.A., Ireton, G., Richardson, J., Forbes, D., & Lusher, D. (2016). Mental health and social networks after disaster. The American Journal of Psychiatry, 174(3), 9. doi: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2016.15111403

Objective: Although disasters are a major cause of mental health problems and typically affect large numbers of people and communities, little is known about how social structures affect mental health after a disaster. The authors assessed the extent to which mental health outcomes after disaster are associated with social network structures.

Method: In a community-based cohort study of survivors of a major bushfire disaster, participants (N=558) were assessed for probable posttraumatic stress disorder (PTSD) and probable depression. Social networks were assessed by asking participants to nominate people with whom they felt personally close. These nominations were used to construct a social network map that showed each participant’s ties to other participants they nominated and also to other participants who nominated them. This map was then analyzed for prevailing patterns of mental health outcomes.

Results: Depression risk was higher for participants who reported fewer social connections, were connected to other depressed people, or were connected to people who had left their community. PTSD risk was higher if fewer people reported being connected with the participant, if those who felt close to the participant had higher levels of property loss, or if the participant was linked to others who were themselves not interconnected. Interestingly, being connected to other people who in turn were reciprocally close to each other was associated with a lower risk of PTSD.

Conclusions: These findings provide the first evidence of disorder-specific patterns in relation to one’s social connections after disaster. Depression appears to co-occur in linked individuals, whereas PTSD risk is increased with social fragmentation. These patterns underscore the need to adopt a sociocentric perspective of postdisaster mental health in order to better understand the potential for societal interventions in the wake of disaster.

Bryant, R., O'Donnell, M., Forbes, D., McFarlane, A., Silove, D., & Creamer, M. (2016). The course of suicide risk following traumatic injury. The Journal of Clinical Psychiatry, 77(5), 6. doi: 10.4088/JCP.14m09661

Objective: Although traumatic injuries affect millions of patients each year and increase risk for psychiatric disorder, no evidence currently exists regarding associated suicidal risk. This study reports a longitudinal investigation of suicidal risk in the 2 years after traumatic injury.

Methods: A prospective design cohort study was conducted in 4 major trauma hospitals across Australia. A total of 1,129 traumatically injured patients were assessed during hospital admission between April 2004 and February 2006 and were followed up at 3 months (88%), 12 months (77%), and 24 months (72%). Lifetime psychiatric disorder was assessed in hospital using the Mini-International Neuropsychiatric Interview, version 5.5, which was also used to assess the prevalence of suicidality, psychiatric disorder, and exposure to adverse life events at 3, 12, and 24 months after traumatic injury.

Results: Approximately 6% of patients reported moderate/high suicidal risk at each assessment. At each assessment, half of suicidal patients reported no suicidal risk at the previous assessment. Suicidality at 24 months was predicted by current pain levels (odds ratio [OR] = 1.16; 95% CI, 1.09-1.23), recent life events (OR = 1.30; 95% CI,1.17-1.44), and current psychiatric disorder (OR = 17.07; 95% CI, 7.03-41.42), whereas only 36.6% of suicidal patients had consulted a mental health professional in the previous month, and 66.2% had consulted a primary care physician.

Conclusions: Suicidal risk affects a significant proportion of patients who experience a traumatic injury, and the risk for suicide fluctuates markedly in the initial years following the injury. Primary care physicians need to be trained to assess for suicidal risk in the initial years after a traumatic injury.

Byllesby, B. M., Durham, T. A., Forbes, D., Armour, C., & Elhai, J. D. (2016). An investigation of PTSD's core dimensions and relations with anxiety and depression. Psychological Trauma: Theory, Research, Practice, and Policy, 8(2), 214-217. doi: https://ByllesbyDurhamForbesArmourElhai2016.pdf

Objective: Posttraumatic stress disorder (PTSD) is highly comorbid with anxiety and depressive disorders, which is suggestive of shared variance or common underlying dimensions. The purpose of the present study was to examine the relationship between the latent factors of PTSD with the constructs of anxiety and depression in order to increase understanding of the co-occurrence of these disorders.

Method: Data were collected from a nonclinical sample of 186 trauma-exposed participants using the PTSD Checklist and Hospital Anxiety and Depression Scale. Confirmatory factor analyses were conducted to determine model fit comparing 3 PTSD factor structure models, followed by Wald tests comparing the relationships between PTSD factors and the core dimensions of anxiety and depression.

Results: In model comparisons, the 5-factor dysphoric arousal model of PTSD provided the best fit for the data, compared to the emotional numbing and dysphoria models of PTSD. Compared to anxious arousal, the dysphoric arousal and numbing factors of PTSD were more related to depression severity. Numbing, anxious arousal, and dysphoric arousal were not differentially related to the latent anxiety factor.

Conclusions: The underlying factors of PTSD contain aspects of the core dimensions of both anxiety and depression. The heterogeneity of PTSD’s associations with anxiety and depressive constructs requires additional empirical exploration because clarification regarding these relationships will impact diagnostic classification as well as clinical practice.

Contractor, A., Armour, C., Forbes, D., & Elhai, J. (2016). Posttraumatic stress disorder's underlying dimensions and their relation with impulsivity facets. The Journal of Nervous and Mental Disease, 204(1), 5. doi: https://journals.lww.com/jonmd/Abstract.aspx

Research indicates a significant relationship between posttraumatic stress disorder (PTSD) and impulsivity (Kotler, Julian, Efront, and Amir, J Nerv Ment Dis 189:162–167, 2001; Ledgerwood and Petry, J Trauma Stress 19:411–416, 2006). The present study assessed relations between PTSD symptom clusters and impulsivity subscales in an effort to assess the specific impulsivity component most related to PTSD's alterations in arousal/reactivity and alterations in mood/cognitions symptoms. In the current study, the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, and the UPPS Impulsivity Scale were administered to a sample of 412 nonclinical subjects with a trauma history. Results indicated that PTSD's alterations in arousal/reactivity and mood/cognition factors were most related to impulsivity's sensation-seeking tendency compared with other impulsivity components. Results highlight the importance of assessing and addressing (1) sensation-seeking tendencies and (2) urges to act impulsively when experiencing negative affect in trauma treatment. Furthermore, it is possible that sensation-seeking tendencies are primarily driving the comorbidity between PTSD and certain impulsive behaviors.

Durham, T. A., Byllesby, B. M., Armour, C., Forbes D., & Elhai, J. (2016). Relations between anger and DSM-5 posttraumatic stress disorder symptoms. Psychiatry Research, 244, 7. doi: https://www.sciencedirect.com/science/articleS016517811630138X

The present study investigated the relationship between posttraumatic stress disorder (PTSD) and anger. Anger co-occurring with PTSD is found to have a severe effect across a wide range of traumatic experiences, making this an important relationship to examine. The present study utilized data regarding dimensions of PTSD symptoms and anger collected from a non-clinical sample of 247 trauma-exposed participants. Confirmatory factor analysis (CFA) was used to determine the underlying factor structure of both PTSD and anger by examining anger in the context of three models of PTSD. Results indicate that a five-factor representation of PTSD and one-factor representation of anger fit the data best. Additionally, anger demonstrated a strong relationship with the dysphoric arousal and negative alterations in cognitions and mood (NACM) factors; and dysphoric arousal was differentially related to anger. Clinical implications include potential need to reevaluate PTSD's diagnostic symptom structure and highlight the potential need to target and treat comorbid anger in individuals with PTSD. In regard to research, these results support the heterogeneity of PTSD.

Fletcher, S., O'Donnell, M., & Forbes, D. (2016). Personality and trajectories of posttraumatic psychopathology: A latent change modelling approach. Journal of Anxiety Disorders, 42, 9. doi: https://www.sciencedirect.com/science/article/abs/pii

Background: Survivors of traumatic events may develop a range of psychopathology, across the internalizing and externalizing dimensions of disorder and associated personality traits. However, research into personality-based internalizing and externalizing trauma responses has been limited to cross-sectional investigations of PTSD comorbidity. Personality typologies may present an opportunity to identify and selectively intervene with survivors at risk of posttraumatic disorder. Therefore this study examined whether personality prospectively influences the trajectory of disorder in a broader trauma-exposed sample.

Methods: During hospitalization for a physical injury, 323 Australian adults completed the Multidimensional Personality Questionnaire—Brief Form and Structured Clinical Interview for DSM-IV, with the latter readministered 3 and 12 months later. Latent profile analysis conducted on baseline personality scores identified subgroups of participants, while latent change modelling examined differences in disorder trajectories.

Results: Three classes (internalizing, externalizing, and normal personality) were identified. The internalizing class showed a high risk of developing all disorders. Unexpectedly, however, the normal personality class was not always at lowest risk of disorder. Rather, the externalizing class, while more likely than the normal personality class to develop substance use disorders, were less likely to develop PTSD and depression.

Conclusions: Results suggest that personality is an important mechanism in influencing the development and form of psychopathology after trauma, with internalizing and externalizing subtypes identifiable in the early aftermath of injury. These findings suggest that early intervention using a personality-based transdiagnostic approach may be an effective method of predicting and ultimately preventing much of the burden of posttraumatic disorder.

Forbes, D., Alkemade, N., Nickerson, A., Bryant, R. A., Creamer, M., Silove, D., McFarlane, A. C., Van Hoof, M., Phelps, A. J., Rees, S., Steele, Z., & O’Donnell, M. L. (2016). Prediction of late onset psychiatric disorder in survivors of severe injury: Findings of a latent transition analysis. Journal of Clinical Psychiatry, 77(6), 6. doi: https://www.psychiatrist.com/jcp/article/Pages/2016/v77n06/v77n0618.aspx

There is a growing body of evidence indicating that late or delayed onset of psychiatric disorder following traumatic injury and other psychological trauma is common. This research, however, has not examined factors that pose risks for delayed development of different types of psychopathology or at different time points. Such research has considerable implications for the development of screening, assessment, and intervention practices. This article investigates risk factors for late-onset disorders up to 72 months after a severe injury.In this 6-year longitudinal study, 1,167 hospitalized patients with severe injury recruited between April 2004 and February 2006 were analyzed with repeated measures at 3, 12, and 72 months after injury. The Mini-International Neuropsychiatric Interview (MINI) and Clinician-Administered PTSD Scale (CAPS) were employed to complete diagnoses according to DSM-IV. Latent transition analyses with continuous covariates (injury severity, social support, recent life events, and pain) and 1 dichotomous covariate (presence/absence of a psychiatric disorder before injury) were conducted to identify risk factors for transitioning out of a No Disorder class and into one of 3 previously reported psychopathology classes (PTSD [posttraumatic stress disorder]/Depression, Alcohol/Depression, and Alcohol only) between 3 and 12 months (transition 1) and between 12 and 72 months (transition 2) postinjury.Movement into the PTSD/Depression class was predicted by injury severity at transitions 1 (P = .003) and 2 (P = .017) and social support (P = .006) at transition 1. Past psychiatric history increased the likelihood of moving into the PTSD/Depression class, with anxiety or mood disorders specifically implicated in transition 1. Movement into the Alcohol/Depression class was predicted by social support at transitions 1 (P = .008) and 2 (P < .001) and also by injury severity (P < .001) and pain (P < .001) at transition 2. Movement into the Alcohol class was predicted only by pain (P = .011) at transition 2. A history of a substance use or alcohol use disorder before injury was implicated in movement into both of the alcohol-based classes.Predictors of developing a delayed-onset psychiatric disorder after severe injury differed by duration after injury and class of disorder. These findings highlight the need to offer targeted screening based on these risk factors to severe injury survivors up to 12 months postinjury, even when they present without disorder at 3 months.

Forbes, D., O’Donnell, M. L., Brand, R., M., Korn, S., Creamer, M., McFarlane, A. C., Sim, M. R., Forbes, A. B., & Hawthorne, G. (2016). The long-term mental health impact of peacekeeping: Prevalence and predictors of psychiatric disorder. British Journal of Psychiatry Open, 2(1), 32-37. doi: https://www.cambridge.org/core/services/aop-cambridge-core/content/view/pdf

Background: The mental health outcomes of military personnel deployed on peacekeeping missions have been relatively neglected in the military mental health literature.

Aims: To assess the mental health impacts of peacekeeping deployments.

Method: In total, 1025 Australian peacekeepers were assessed for current and lifetime psychiatric diagnoses, service history and exposure to potentially traumatic events (PTEs). A matched Australian community sample was used as a comparator. Univariate and regression analyses were conducted to explore predictors of psychiatric diagnosis.

Results: Peacekeepers had significantly higher 12-month prevalence of post-traumatic stress disorder (16.8%), major depressive episode (7%), generalised anxiety disorder (4.7%), alcohol misuse (12%), alcohol dependence (11.3%) and suicidal ideation (10.7%) when compared with the civilian comparator. The presence of these psychiatric disorders was most strongly and consistently associated with exposure to PTEs.

Conclusions: Veteran peacekeepers had significant levels of psychiatric morbidity. Their needs, alongside those of combat veterans, should be recognised within military mental health initiatives.

Gallagher, H. C., Richardson, J., Forbes, D., Harms, L., Gibbs, L., Alkemade, N., MacDougall, C., Waters, E., Block, K., & Bryant, R. A. (2016). Mental health following separation in a disaster: The role of attachment. Journal of Traumatic Stress, 29(1), 8. doi: https://onlinelibrary.wiley.com/doi/pdf/10.1002/jts.22071

Short-term separation from close family members during a disaster is a highly salient event for those involved. Yet, its subsequent impact on mental health has received little empirical attention. One relevant factor may be attachment style, which influences patterns of support-seeking under threatening conditions. Individuals (N = 914) affected by the 2009 Victorian bushfires in southeastern Australia were assessed for disaster experiences, depression, posttraumatic stress disorder (PTSD) symptoms, and attachment style 3–4 years after the fires. Using multigroup structural equation modelling, individuals who reported separation from close family members during the bushfires (n = 471) were compared to those who reported no separation (n = 443). Cross-sectional results indicated that separated individuals had higher levels of PTSD symptoms. Furthermore, attachment anxiety was more strongly positively associated with depression among separated (b = 0.62) versus not separated individuals (b = 0.32). Unexpectedly, among separated individuals, attachment avoidance had a statistically weaker association with depression (b = 0.17 vs. b = 0.35) and with PTSD symptoms (b = 0.06 vs. b = 0.22). These results suggest that attachment anxiety amplifies a negative reaction to separation; meanwhile, for avoidant individuals, separation in times of danger may facilitate defensive cognitive processes.

Germain, C. L., Kangas, M., Taylor, A., & Forbes, D. (2016). The role of trauma-related cognitive processes in the relationshipbetween combat-PTSD symptom severity and anger expression and control. Australian Journal of Psychology, 68(2), 8. doi: https://aps.onlinelibrary.wiley.com/doi/pdf/10.1111

Objective: Research suggests that the way anger is expressed and efforts to control anger may be particularly important in post-traumatic stress disorder (PTSD). However, factors influencing the association between PTSD symptom severity and anger expression and control, and whether these associations are influenced in part by cognitive processes, have yet to be investigated in combat veterans. The aim of the present study was to investigate the mediating effect of trauma-related cognitive variables between combat-PTSD symptom severity and anger expression in Australian veterans.

Method: A sample of 149 treatment-seeking Australian older-aged veterans with chronic combat-related PTSD completed a battery of measures that assessed combat -PTSD symptom severity, anger indices, trauma-related rumination, cognitive suppression, and trauma appraisals.

Results: Path analyses revealed that negative beliefs about self partially mediated the effect of PTSD symptom severity and anger suppression, and PTSD symptom severity and anger control, while negative beliefs about the world partially mediated the association between PTSD severity and outward expression of anger. A significant direct effect from combat-PTSD symptom severity to outward expression was also found.

Conclusions: Findings lend support to targeted assessment and treatment of negative trauma-related appraisals, particularly negative beliefs about self and the world, to concomitantly enhance anger coping and emotion regulation in middle to older-aged veterans with chronic combat-related PTSD.

Gibbs, L., Gallagher, H. C., Block, K., Snowdon, E., Bryant, R., Harms, L., Ireton, G., Kellett, C., Sinnott, V., Richardson, J., Lusher, D., Forbes, D., MacDougall, C., & Waters, E. (2016). Post-bushfire relocation decision-making and personal wellbeing: A case study from Victoria, Australia. In A. Awotona (Ed.), Planning for Community-based Disaster Resilience Worldwide: Learning from Case Studies in Six Continents. Ashgate Publishing Limited.

Metcalf, O., Varker, T., Forbes D., Phelps, A., Dell, L., Di Battista, A., Ralph, N., & O’Donnell, M. (2016). Efficacy of fifteen emerging interventions for the treatment of posttraumatic stress disorder: A systematic review. Journal of Traumatic Stress, 29(1), 5. doi: https://onlinelibrary.wiley.com/doi/pdf/10.1002

Although there is an abundance of novel interventions for the treatment of posttraumatic stress disorder (PTSD), often their efficacy remains unknown. This systematic review assessed the evidence for 15 new or novel interventions for the treatment of PTSD. Studies that investigated changes to PTSD symptoms following the delivery of any 1 of the 15 interventions of interest were identified through systematic literature searches. There were 19 studies that met the inclusion criteria for this study. Eligible studies were assessed against methodological quality criteria and data were extracted. The majority of the 19 studies were of poor quality, hampered by methodological limitations, such as small sample sizes and lack of control group. There were 4 interventions, however, stemming from a mind–body philosophy (acupuncture, emotional freedom technique, mantra-based meditation, and yoga) that had moderate quality evidence from mostly small to moderate-sized randomized controlled trials. The active components, however, of these promising emerging interventions and how they related to or were distinct from established treatments remain unclear. The majority of emerging interventions for the treatment of PTSD currently have an insufficient level of evidence supporting their efficacy, despite their increasing popularity. Further well designed controlled trials of emerging interventions for PTSD are required.

Nursey, J., & Phelps, A. (2016). Stress, Trauma and Memory in PTSD. In G. Fink (Ed.). Stress Concepts and Cognition, Emotion and Behaviour (Vol. 38, pp. 1-8). San Diego, USA: Elsevier Inc.

Nursey, J., Lau, W., & Forbes, D. (2016). Management of psychological trauma across service settings and contexts. InPsych, 38.

Natural disasters by their very nature occur suddenly and have the potential to cause great harm at an individual, family, community, and societal level. They occur frequently, and with the escalation in extreme events related to climate change, the frequency, and severity of natural disasters will only increase (Intergovernmental Panel on Climate Change (IPCC), 2014). Globally, a growing number of people are being exposed to natural disaster; however, the vulnerability to exposure is not equally shared. Those who are socially, physically, economically, culturally, politically, institutionally, or otherwise disadvantaged are especially vulnerable to experiencing natural disaster.

O'Donnell, M., Alkemade, N., Creamer, M., Mc Farlane, A., Silove, D., Bryant R., Felmingham, K., Steel, Z., & Forbes, D. (2016). A longitudinal study of Adjustment Disorder after trauma. American Journal of Psychiatry, 173(12), 8. doi: https://ajp.psychiatryonline.org/doi/pdf

Adjustment disorder has been recategorized as a trauma- and stressor-related disorder in DSM-5. The aim of this study was to determine the prevalence of adjustment disorder in the first 12 months after severe injury; to determine whether adjustment disorder was a less severe disorder compared with other disorders in terms of disability and quality of life; to investigate the trajectory of adjustment disorder; and to examine whether the subtypes described in DSM-5 are distinguishable.

Method: In a multisite, cohort study, injury patients were assessed during hospitalization and at 3 and 12 months postinjury (N=826). Structured clinical interviews were used to assess affective, anxiety, and substance use disorders, and self-report measures of disability, anxiety, depression, and quality of life were administered.

Results: The prevalence of adjustment disorder was 19% at 3 months and 16% at 12 months. Participants with adjustment disorder reported worse outcomes relative to those with no psychiatric diagnosis but better outcomes compared with those diagnosed with other psychiatric disorders. Participants with adjustment disorder at 3 months postinjury were significantly more likely to meet criteria for a psychiatric disorder at 12 months (odds ratio=2.67, 95% CI=1.59−4.49). Latent-profile analysis identified a three-class model that was based on symptom severity, not the subtypes identified by DSM-5.

Conclusions: Recategorization of adjustment disorder into the trauma- and stressor-related disorders is supported by this study. However, further description of the phenomenology of the disorder is required.

O'Donnell, M., Alkemade, N., Creamer, M., McFarlane, A., Silove, D., Bryant, R., & Forbes, D. (2016). The long-term psychiatric sequelae of severe injury. The Journal of Clinical Psychiatry, 77(4), e473-e479. doi: https://www.psychiatrist.com/jcp/article/Pages/2016/v77n04

The impact of mental health on disease burden associated with injury represents a major public health issue, yet almost no information is available on the associated long-term mental health outcomes. The primary aim of this study was to assess the psychiatric outcomes 6 years after a severe injury and their subsequent impact on long-term disability. The secondary aim was to investigate the relationship between a mild traumatic brain injury (mTBI) and long-term psychiatric disorder and its impact on disability. From April 2004 to February 2006, randomly selected injury patients admitted to 4 hospitals across Australia were assessed during hospitalization and at 72 months after trauma (N = 592). Injury characteristics, the presence of an mTBI (ICD-9 criteria), and previous psychiatric history were assessed during hospitalization. Structured clinical interviews for psychiatric disorders (DSM-IV and DSM-5) and a self-report measure of disability (WHODAS II) were administered at 72 months.At 72 months after a severe injury, 28% of patients met criteria for at least 1 psychiatric disorder, with 45% of those presenting with comorbid diagnoses. The most prevalent psychiatric disorder was a major depressive episode (11%) followed by substance use disorder (9%), agoraphobia (9%), posttraumatic stress disorder (6%), and generalized anxiety disorder (6%). The presence of any psychiatric disorder was found to increase the risk for disability (P < .001, odds ratio = 6.04). An mTBI was found to increase the risk for having some anxiety disorders but not to increase disability by itself.The long-term psychiatric consequences of severe injury are substantial and represent a significant contributor to long-term disability. This study points to an important intersection between injury and psychiatric disorder as a leading contributor to disease burden and suggests this growing burden will impose new challenges on health systems.

O’Donnell, M., & Forbes, D. (2016). Natural disaster, older adults, and mental health – a dangerous combination. International Psychogeriatrics, 28(1), 1. doi: 10.1017/S1041610215001891

Natural disasters by their very nature occur suddenly and have the potential to cause great harm at an individual, family, community, and societal level. They occur frequently, and with the escalation in extreme events related to climate change, the frequency, and severity of natural disasters will only increase (Intergovernmental Panel on Climate Change (IPCC), 2014). Globally, a growing number of people are being exposed to natural disaster; however, the vulnerability to exposure is not equally shared. Those who are socially, physically, economically, culturally, politically, institutionally, or otherwise disadvantaged are especially vulnerable to experiencing natural disaster.

Sunderland, M., Carragher, N., Chapman, C., Mills, K., Teesson, M., Lockwood, E., Forbes, D., & Slade, T. (2016). The shared and specific relationships between exposure to potentially traumatic events and transdiagnostic dimensions of psychopathology. Journal of Anxiety Disorders, 38, 8. https://www.sciencedirect.com/science/article/abs/pii/S0887618516300135

The experience of traumatic events has been linked to the development of psychopathology. Changing perspectives on psychopathology have resulted in the hypothesis that broad dimensional constructs account for the majority of variance across putatively distinct disorders. As such, traumatic events may be associated with several disorders due to their relationship with these broad dimensions rather than any direct disorder-specific relationship. The current study used data from 8871 Australians to test this hypothesis. Two broad dimensions accounted for the majority of relationships between traumatic events and mental and substance use disorders. Direct relationships remained between post-traumatic stress disorder and six categories of traumatic events in the total population and between drug dependence and accidents/disasters for males only. These results have strong implications for how psychopathology is conceptualized and offer some evidence that traumatic events are associated with an increased likelihood of experiencing psychopathology in general.

Wade, D., Fletcher, S., Carty, J., & Creamer, M. (2016). Post-traumatic stress disorder in women. In D. Castle, & K. Abel (Eds.), Comprehensive Women's Mental Health (pp. 208-219). Cambridge: Cambridge University.

Wade, D., Varker, T., Kartal, D., Hetrick, S., O'Donnel, M., & Forbes, D. (2016). Gender difference in outcomes following trauma-focused interventions for posttraumatic stress disorder: Systematic review and meta-analysis. Psychological Trauma: Theory, Research, Practice, and Policy, 8(3), 356-364. doi: https://minerva-access.unimelb.edu.au/bitstream/handle/11343/115318.pdf

Objective: Currently, there is a lack of evidence on whether women and men respond differently to trauma-focused psychological treatments for posttraumatic stress disorder (PTSD). This study was a systematic review and meta-analysis to examine whether gender is associated with response to trauma-focused psychological interventions for PTSD. Method: The Cochrane Collaboration systematic review methodology (Higgins & Green, 2011) was used as a guide for this study. Randomized controlled trials comparing trauma-focused interventions for PTSD with comparison conditions were identified in a literature review. Results: Forty-eight randomized controlled trials were included in the meta-analysis: 25 had a mixed gender sample, 18 were female only, and 5 were male only. There was evidence that women had greater reductions than men in the primary outcome measure of clinician-rated PTSD symptoms when trauma-focused psychological interventions were compared with any comparison condition at both postintervention and short-term follow-up. This finding was supported by a direct effects meta-analysis of studies that provided data on both females and males. Conclusions: The current findings support a gender difference in outcomes following trauma-focused psychological interventions for PTSD. Future research should seek to identify specific factors related to gender that facilitate or inhibit response to these interventions.

Whittle, S., Vijayakumar, N., Dennison, M., Schwartz, O., Simmons, J. G., Sheeber, L., & Allen, N. (2016). Observed measures of negative parenting predict brain development during adolescence. PLoS ONE, 11(1), 15. doi: https://journals.plos.org/plosone/article/journal.pone.0147774

Limited attention has been directed toward the influence of non-abusive parenting behaviour on brain structure in adolescents. It has been suggested that environmental influences during this period are likely to impact the way that the brain develops over time. The aim of this study was to investigate the association between aggressive and positive parenting behaviors on brain development from early to late adolescence, and in turn, psychological and academic functioning during late adolescence, using a multi-wave longitudinal design. Three hundred and sixty-seven magnetic resonance imaging (MRI) scans were obtained over three time points from 166 adolescents (11–20 years). At the first time point, observed measures of maternal aggressive and positive behaviors were obtained. At the final time point, measures of psychological and academic functioning were obtained. Results indicated that a higher frequency of maternal aggressive behavior was associated with alter- ations in the development of right superior frontal and lateral parietal cortical thickness, and of nucleus accumbens volume, in males. Development of the superior frontal cortex in males mediated the relationship between maternal aggressive behaviour and measures of late adolescent functioning. We suggest that our results support an association between negative parenting and adolescent functioning, which may be mediated by immature or delayed brain maturation.

2015 PUBLICATIONS

Armour, C., Contractor, A., Elhai, J. D., Stringer, M., Lyle, G., Forbes, D., & Richardson, J. (2015). Identifying latent profiles of posttraumatic stress and major depression symptoms in Canadian veterans: Exploring differences across profiles in health related functioning. Psychiatry Research, 228(1), 7. doi: https://www.sciencedirect.com/science/article/S0165178115001341

Posttraumatic stress disorder (PTSD) has been consistently reported as being highly comorbid with major depressive disorder (MDD) and as being associated with health related functional impairment (HRF). We used archival data from 283 previously war-zone deployed Canadian veterans. Latent profile analysis (LPA) was used to uncover patterns of PTSD and MDD comorbidity as measured via the PTSD Checklist-Military version (PCL-M) and the Patient Health Questionnaire-9 (PHQ-9). Individual membership of latent classes was used in a series of one-way ANOVAs to ascertain group differences related to HRF as measured via the Short-Form-36 Health Survey (SF-36). LPA resulted in three discrete patterns of PTSD and MDD comorbidity which were characterized by high symptoms of PTSD and MDD, moderate symptoms, and low symptoms. All ANOVAs comparing class membership on the SF-36 subscales were statistically significant demonstrating group differences across levels of HRF. The group with the highest symptoms reported the worst HRF followed by the medium and low symptom groups. These findings are clinically relevant as they demonstrate the need for continual assessment and targeted treatment of co-occurring PTSD and MDD.

Armour, C., Contractor, A., Elhai, J., Stringer, M., Lyle, G., Forbes, D., & Richardson, J.D. (2015). Identifying latent profiles of posttraumatic stress and major depression symptoms in Canadian veterans: Exploring differences across profiles in health related functioning. Psychiatry Research. doi: http://dx.doi.org/10.1016/j.psychres.2015.03.011

Posttraumatic stress disorder (PTSD) has been consistently reported as being highly comorbid with major depressive disorder (MDD) and as being associated with health related functional impairment (HRF). We used archival data from 283 previously war-zone deployed Canadian veterans. Latent profile analysis (LPA) was used to uncover patterns of PTSD and MDD comorbidity as measured via the PTSD Checklist-Military version (PCL-M) and the Patient Health Questionnaire-9 (PHQ-9). Individual membership of latent classes was used in a series of one-way ANOVAs to ascertain group differences related to HRF as measured via the Short-Form-36 Health Survey (SF-36). LPA resulted in three discrete patterns of PTSD and MDD comorbidity which were characterized by high symptoms of PTSD and MDD, moderate symptoms, and low symptoms. All ANOVAs comparing class membership on the SF-36 subscales were statistically significant demonstrating group differences across levels of HRF. The group with the highest symptoms reported the worst HRF followed by the medium and low symptom groups. These findings are clinically relevant as they demonstrate the need for continual assessment and targeted treatment of co-occurring PTSD and MDD.