Anxiety Disorders: McFall M

Fu SS, McFall M, Saxon AJ, Beckham JC, Carmody TP, Baker DG, Joseph AM. · Center for Chronic Disease Outcomes Research, Veterans Affairs Medical Center, and Department of Medicine, University of Minnesota, Minneapolis, MN, USA. · Nicotine Tob Res. · Pubmed #17978982 No free full text.

Abstract: We conducted a systematic review of what is known about the relationship between post-traumatic stress disorder (PTSD) and smoking to guide research on underlying mechanisms and to facilitate the development of evidence-based tobacco treatments for this population of smokers. We searched Medline, PsychINFO, and the Cochrane Central Register of Controlled Trials and identified 45 studies for review that presented primary data on PTSD and smoking. Smoking rates were high among clinical samples with PTSD (40%-86%) as well as nonclinical populations with PTSD (34%-61%). Most studies showed a positive relationship between PTSD and smoking and nicotine dependence, with odds ratios ranging between 2.04 and 4.52. Findings also suggest that PTSD, rather than trauma exposure itself, is more influential for increasing risk of smoking. A small but growing literature has examined psychological factors related to smoking initiation and maintenance and the overlapping neurobiology of PTSD and nicotine dependence. Observational studies indicate that smokers with PTSD have lower quit rates than do smokers without PTSD. Yet a few tobacco cessation treatment trials in smokers with PTSD have achieved quit rates comparable with controlled trials of smokers without mental disorders. In conclusion, the evidence points to a causal relationship between PTSD and smoking that may be bidirectional. Specific PTSD symptoms may contribute to smoking and disrupt cessation attempts. Intervention studies that test behavioral and pharmacological interventions designed specifically for use in patients with PTSD are needed to reduce morbidity and mortality in this population.

Radant A, Tsuang D, Peskind ER, McFall M, Raskind W. · Veterans Affairs Northwest Network Mental Illness Research, Education and Clinical Center (MIRECC), VA Puget Sound (116), 1660 S. Columbian Way, Seattle, WA 98108, USA. · Psychiatry Res. · Pubmed #11440771 No free full text.

Abstract: Family and twin studies suggest a substantial genetic contribution to the etiology of posttraumatic stress disorder (PTSD). Identification of the nature of this genetic contribution should enhance understanding of the pathophysiology of PTSD and suggest improved therapeutic strategies for its treatment. However, a broadly defined phenotype, specific requirement for an environmental exposure and high frequency of comorbid psychiatric illness all complicate genetic studies of PTSD. It is likely that genetic heterogeneity, incomplete penetrance, pleiotropy and the involvement of more than one gene all constitute formidable obstacles to the genetic analysis of PTSD. One way to circumvent these problems is to perform genetic analysis of traits associated with PTSD, rather than PTSD itself, an approach that has been fruitful for other diseases with complex modes of inheritance. Hypothalamic-pituitary-adrenal axis hypofunction, physiologic markers of increased arousal, and increased acoustic startle response are all potential PTSD-associated traits that might be susceptible to genetic analysis. However, the capacity of these traits to distinguish PTSD from non-PTSD patients and their familial pattern must be better defined before they can be employed in genetic studies.

Jakupcak M, Roberts LJ, Martell C, Mulick P, Michael S, Reed R, Balsam KF, Yoshimoto D, McFall M. · Seattle VA Puget Sound Health Care System, WA, USA. · J Trauma Stress. · Pubmed #16789005 No free full text.

Abstract: A pilot study was conducted to investigate the feasibility and effectiveness of behavioral activation (BA) therapy for veterans with posttraumatic stress disorder (PTSD). Eleven veterans seeking treatment at a Veterans Administration outpatient PTSD clinic were enrolled in the study protocol, consisting of 16-weekly individual sessions of BA. Nine veterans completed the protocol, one participant completed 15 sessions, and one dropped out after one session. Clinician-rated PTSD symptom severity showed significant pre- to posttreatment improvement and was associated with a moderate effect size. A number of participants also were improved on measures of depression and quality of life, but changes did not reach statistical significance. Findings suggest that BA is a well-tolerated, potentially beneficial intervention for veterans with chronic symptoms of PTSD.

McFall M, Saxon AJ, Thompson CE, Yoshimoto D, Malte C, Straits-Troster K, Kanter E, Zhou XH, Dougherty CM, Steele B. · PTSD Programs (S-116 MHC), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA. · Am J Psychiatry. · Pubmed #15994714 links to  free full text

Abstract: OBJECTIVE: Smoking is highly prevalent and refractory among people with posttraumatic stress disorder (PTSD). This study aimed to improve the rate of quitting smoking for veterans with PTSD by integrating treatment for nicotine dependence into mental health care. METHOD: Smokers undergoing treatment for PTSD (N=66) were randomly assigned to 1) tobacco use treatment delivered by mental health providers and integrated with psychiatric care (integrated care) versus 2) cessation treatment delivered separately from PTSD care by smoking-cessation specialists (usual standard of care). Seven-day point prevalence abstinence was the primary outcome, measured at 2, 4, 6, and 9 months after random assignment. Data were analyzed by using a generalized estimating equations approach following the intent-to-treat principle. RESULTS: Subjects assigned to integrated care were five times more likely than subjects undergoing the usual standard of care to abstain from smoking across follow-up assessment intervals (odds ratio=5.23). Subjects in the integrated care condition were significantly more likely than subjects in usual standard of care to receive transdermal nicotine and nicotine gum. They also received a greater number of smoking-cessation counseling sessions. Stopping smoking was not associated with worsening symptoms of PTSD or depression. CONCLUSIONS: Smoking-cessation interventions can be safely incorporated into routine mental health care for PTSD and are more effective than treatment delivered separately by a specialized smoking-cessation clinic. Integrating cessation treatment into psychiatric care may have the potential for improving smoking quit rates in other populations of chronically mentally ill smokers.

Conrad KJ, Wright BD, McKnight P, McFall M, Fontana A, Rosenheck R. · Midwest Center for Health Services and Policy Research, Hines VA Hospital, Hines, IL 60141, USA. · J Appl Meas. · Pubmed #14757989 No free full text.

Abstract: This study examined whether Rasch analysis could provide more information than true score theory (TST) in determining the usefulness of reverse-scored items in the Mississippi Scale for Posttraumatic Stress Disorder (M-PTSD). Subjects were 803 individuals in inpatient PTSD units at 10 VA sites. TST indicated that the M-PTSD performed well and could be improved slightly by deleting one item. Factor analysis using raw scores indicated that the reverse-scored items formed the second factor and had poor relationships with normally scored items. However, since item-total correlations supported their usefulness, they were kept. The subsequent Rasch analysis indicated that five of the seven worst fitting items were reverse-scored items. We concluded that using reversed items with disturbed patients can cause confusion that reduces reliability. Deleting them improved validity without loss of reliability. The study supports the use of Rasch analysis over TST in health research since it indicated ways to reduce respondent burden while maintaining reliability and improving validity.

McFall M, Malte C, Fontana A, Rosenheck RA. · Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA. · Psychiatr Serv. · Pubmed #10686246 links to  free full text

Abstract: OBJECTIVE: The study examined the effectiveness of an outreach intervention designed to increase access to mental health treatment among veterans disabled by chronic posttraumatic stress disorder (PTSD) and identified patient-reported barriers to care associated with failure to seek the treatment offered. METHODS: Participants were 594 male Vietnam veterans who were not enrolled in mental health care at a Department of Veterans Affairs (VA) medical center but who were receiving VA disability benefits for PTSD. Half the sample was randomly assigned to an outreach intervention, and the other half was assigned to a control group. Veterans in the intervention group received a mailing that included a brochure describing PTSD treatment available at an urban VA medical center, along with a letter informing them about how to access care. Participants in the intervention group were subsequently telephoned by a study coordinator who encouraged them to enroll in PTSD treatment and who administered a survey assessing barriers to care. RESULTS: Veterans in the intervention group were significantly more likely than those in the control group to schedule an intake appointment (28 percent versus 7 percent), attend the intake (23 percent versus 7 percent), and enroll in treatment (19 percent versus 6 percent). Several patient-identified barriers were associated with failure to seek VA mental health care, such as personal obligations that prevented clinic attendance, inconvenient clinic hours, and current receipt of mental health treatment from a non-VA provider. CONCLUSIONS: Utilization of mental health services among underserved veterans with PTSD can be increased by an inexpensive outreach intervention, which may be useful with other chronically mentally ill populations.

Jakupcak M, Luterek J, Hunt S, Conybeare D, McFall M. · VA Puget Sound Health Care System, Seattle, Washington, USA. · J Nerv Ment Dis. · Pubmed #18477887 No free full text.

Abstract: The relationship between posttraumatic stress and physical health functioning was examined in a sample of Iraq and Afghanistan War veterans seeking postdeployment VA care. Iraq and Afghanistan War veterans (N = 108) who presented for treatment to a specialty postdeployment care clinic completed self-report questionnaires that assessed symptoms of posttraumatic stress disorder (PTSD), chemical exposure, combat exposure, and physical health functioning. As predicted, PTSD symptom severity was significantly associated with poorer health functioning, even after accounting for demographic factors, combat and chemical exposure, and health risk behaviors. These results highlight the unique influence of PTSD on the physical health in treatment seeking Iraq and Afghanistan War veterans.

McFall M, Saxon AJ, Thaneemit-Chen S, Smith MW, Joseph AM, Carmody TP, Beckham JC, Malte CA, Vertrees JE, Boardman KD, Lavori PW. · Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA. · Clin Trials. · Pubmed #17456521 No free full text.

Abstract: BACKGROUND: Post-traumatic stress disorder (PTSD) is associated with a high prevalence of smoking, heavy cigarette consumption and low cessation rates. PURPOSE: This manuscript describes the design of a randomized, multisite effectiveness trial to test whether integrating smoking cessation treatment into mental health care (integrated care) improves prolonged abstinence rates among veterans with PTSD, compared with referral to specialized smoking cessation clinics (usual standard of care). Secondary objectives are to assess the cost-effectiveness of integrated care relative to usual standard of care, identify treatment variables that mediate differences between conditions in outcome and determine whether smoking cessation is associated with worsening PTSD and/or depression. METHODS: Following randomization, subjects (projected n = 1400) from 10 Veterans Health Administration (VHA) medical centers complete follow-up assessments every three or six months for up to four years. Endpoints include 1-year prolonged abstinence at 18 months postrandomization, 7- and 30-day point-prevalence abstinence and measures of depression, PTSD and economic outcomes. RESULTS: This study is unique in providing the largest scale test of the feasibility and effectiveness of having mental health clinicians implement evidence-based smoking cessation treatment in psychiatric care settings for veterans with PTSD. It incorporates methodological features that are desirable for cessation treatment trials, including: a) assessment of clinically meaningful long-term smoking outcomes; b) a manual guiding delivery of the experimental intervention; c) independent ratings of clinician competence and treatment adherence and d) methods for training clinicians that would enhance implementation of tobacco cessation treatment in large health care systems. LIMITATIONS: Use of an exclusively VHA sample with few females limits generalizability. CONCLUSIONS: The process for meeting challenges in designing this study may provide planning of other large-scale clinical effectiveness trials in tobacco control.Findings have potential to initiate system-wide change in clinical practice patterns for tobacco cessation treatment involving patients with mental disorders.

Fontana A, Rosenheck R, Ruzek J, McFall M. · Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06518, USA. · J Nerv Ment Dis. · Pubmed #17041291 No free full text.

Abstract: This study investigated the hypotheses that the general disposition to be satisfied is more influential than the nature of service delivery in determining satisfaction with treatment, and that there is a specificity to satisfaction with the delivery of care and with clinical outcome of care that makes their ratings distinct. Data were obtained by questionnaire at intake into treatment and 4 months later from 154 male veterans. There were statistically significant relationships between the general disposition to be satisfied and satisfaction with treatment, but they had only a trivial effect on the relationships between treatment satisfaction and other variables. There was, however, a specificity to satisfaction ratings such that a major feature of the delivery of care, the experience of friendliness and caring from staff, was related more highly to satisfaction with care than to satisfaction with outcome, while measures of clinical outcome were related more highly to satisfaction with outcome than to satisfaction with care. A general disposition to be satisfied, therefore, appears not to have a major biasing effect on satisfaction with treatment. Further, patients appear to make valid differentiations between satisfaction with the delivery of care and the clinical outcome of care when their attention is focused specifically on satisfaction with these features.

McFall M, Atkins DC, Yoshimoto D, Thompson CE, Kanter E, Malte CA, Saxon AJ. · Northwest Network Mental Illness Research, Education and Clinical Center, Seattle, Washington, USA. · Am J Addict. · Pubmed #16966189 No free full text.

Abstract: The integration of tobacco cessation treatment into mental health care for posttraumatic stress disorder (PTSD), known as Integrated Care (IC), was evaluated in an uncontrolled feasibility and effectiveness study. Veterans (N = 107) in PTSD treatment at two outpatient clinics received IC delivered by mental health practitioners. Outcomes were seven-day point prevalence abstinence measured at two, four, six, and nine months post-enrollment and repeated seven-day point prevalence abstinence (RPPA) obtained across three consecutive assessment intervals (four, six, and nine months). Abstinence rates at the four assessment intervals were 28%, 23%, 25%, and 18%, respectively, and RPPA was 15%. The number of IC sessions and a previous quit history greater than six months predicted RPPA. Stopping smoking was not associated with worsening PTSD or depression.

Jakupcak M, Osborne T, Michael S, Cook J, Albrizio P, McFall M. · Seattle Division, Puget Sound Health Care System, and Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98108, USA. · J Trauma Stress. · Pubmed #16929501 No free full text.

Abstract: A study was conducted among 45 male veterans seeking inpatient treatment for posttraumatic stress disorder (PTSD) to test whether the relationship between PTSD and somatic complaints was accounted for by depression and anxiety sensitivity. Posttraumatic stress disorder symptom severity, depression symptom severity, and anxiety sensitivity were each positively and significantly related to veterans' self-reported severity of somatic complaints. Results of hierarchical regression analyses indicated that anxiety sensitivity and depression severity account for the relationship between PTSD and veterans' somatic complaints, suggesting PTSD influences somatic complaints by virtue of underlying symptoms of depression and anxiety sensitivity.

Schnurr PP, Hayes AF, Lunney CA, McFall M, Uddo M. · National Center for Post-Traumatic Stress Disorder, US Veterans Affrais Medical Center, VT 05009, USA. · J Consult Clin Psychol. · Pubmed #16881778 No free full text.

Abstract: This study examined how change in posttraumatic stress disorder (PTSD) symptoms relates to change in quality of life. The sample consisted of 325 male Vietnam veterans with chronic PTSD who participated in a randomized trial of group psychotherapy. Latent growth modeling was used to test for synchronous effects of PTSD symptom change on psychosocial and physical health-related quality of life within the same time period and lagged effects of initial PTSD symptom change on later change in quality of life. PTSD symptoms were associated with reduced quality of life before treatment. There were synchronous effects of symptom change on change in quality of life but no significant lagged effects. Results indicate the importance of measuring quality of life in future investigations of PTSD treatment.

McFall M, Tackett J, Maciejewski ML, Richardson RD, Hunt SC, Roberts L. · VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA 98108, USA. · Mil Med. · Pubmed #15724858 No free full text.

Abstract: Measures of post-traumatic stress disorder (PTSD) and depression were used to predict Veterans Affairs outpatient treatment costs among Persian Gulf War veterans with medically unexplained physical symptoms. Patients (N = 206) enrolled in a Veterans Affairs primary care clinic for Persian Gulf War veterans completed study assessments at the initial appointment or at a proximal follow-up visit. Costs of care for mental health, medical, and pharmacy services for these veterans were computed for the subsequent 6-month period. Depression and PTSD symptoms explained a significant share of variance in costs of mental health care and pharmacy services, after adjustment for covariates. None of the mental status measures was significantly related to costs of medical care. Models using global measures of mental health status were as robust as models using disorder-specific measures of PTSD and depression in predicting mental health care and pharmacy costs. The implications of these findings for anticipating costs of care for Persian Gulf War veterans are discussed.

Dobie DJ, Kivlahan DR, Maynard C, Bush KR, McFall M, Epler AJ, Bradley KA. · Mental Illness Research Education and Clinical Center, VA Puget Sound Health Care System and Department of Medicine, University of Washington, Seattle, WA 98195, USA. · Gen Hosp Psychiatry. · Pubmed #12490337 No free full text.

Abstract: We evaluated the screening validity of a self-report measure for post traumatic stress disorder (PTSD), the PTSD Checklist (PCL), in female Veterans Affairs (VA) patients. All women seen for care at the VA Puget Sound Health Care system from October 1996-January 1999 (n=2,545) were invited to participate in a research interview. Participants (n=282) completed the 17-item PCL, followed by a gold standard diagnostic interview for PTSD, the Clinician Administered PTSD Scale (CAPS). Thirty-six percent of the participants (n=100) met CAPS diagnostic criteria for current PTSD. Receiver Operating Characteristic (ROC) analysis was used to evaluate the screening performance of the PCL. The area under the ROC curve was 0.86 (95% CI 0.82-0.90). A PCL score of 38 optimized the performance of the PCL as a screening test (sensitivity 0.79, specificity 0.79). The PCL performed well as a screening measure for the detection of PTSD in female VA patients.

Richardson RD, Engel CC, Hunt SC, McKnight K, McFall M. · Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA. · Psychosom Med. · Pubmed #12140358 links to  free full text

Abstract: OBJECTIVE: This study compared Gulf War veterans seeking VA primary care with Gulf War veterans seeking treatment from a Department of Defense primary care clinic on measures of physical symptoms, psychiatric complaints, and functional status. Additionally, the association between employment status and health was examined. METHODS: Analysis was based on the responses of consecutive patients attending the Gulf War Primary Care clinics at either the VA Puget Sound Health Care System in Seattle, WA (N= 223), or the Walter Reed Army Medical Center in Washington, DC (N= 153), between March 1998 and September 1999. RESULTS: After controlling for demographic variables, Gulf War veterans who sought VA care reported significantly more anxiety and PTSD symptoms than active duty military personnel. The groups did not differ on somatic complaints or summary scores from the SF-36. Employment status was significantly, independently, and consistently associated with greater psychiatric symptoms, physical symptoms, and decreased functional status. CONCLUSIONS: Our findings reveal important differences in health status between veterans seeking primary care at a VA and a Department of Defense facility, differences that are in part related to employment status. Both groups report symptoms of psychiatric distress and decreased functional status, though VA patients are more impaired. Research findings based on clinical samples of veterans at VA sites may not generalize to Gulf War veterans still on active duty (and vice versa).

McFall M, Fontana A, Raskind M, Rosenheck R. · Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA. · J Trauma Stress. · Pubmed #10467558 No free full text.

Abstract: This study tested the hypothesis that male Vietnam veterans seeking inpatient treatment for PTSD (n = 228) exhibit more violent behavior compared with a mixed diagnostic group of male psychiatric inpatients without PTSD (n = 64) and a community sample of Vietnam veterans with PTSD not undergoing inpatient treatment (n = 273). Violent acts assessed included property destruction, threats without a weapon, physical fighting, and threats with a weapon. PTSD inpatients engaged in more types of violent behavior than both comparison conditions. Correlates of violence among PTSD inpatients included PTSD symptom severity and, to a lesser degree, measures of substance abuse. These findings justify routine assessment of violent behavior among inpatient with PTSD, as well as application of specialized interventions for anger dyscontrol and aggression.

Hunt SC, Richardson RD, McFall M. · No affiliation provided · Lancet. · Pubmed #10210000 No free full text.

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