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: 10.1001/jamapsychiatry.2016.3470

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: 10.1017/S0033291717000472

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: 10.1177/0004867416679737

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: 10.1037/fam0000256

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: 1835-1271

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: 10.1017/S0033291716002361

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: doi.org/10.1016/j.cpr.2017.08.009

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. doi: 10.1017/S0033291717001404

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: 10.1371/journal.pone.0171879

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: 10.3109/13668250.2016.1232379

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: 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: 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: 10.1001/jamapsychiatry.2017.1558

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: 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: 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: 10.1037/tra0000081

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: 10.1097/NMD.0000000000000417

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: 10.1016/j.psychres.2016.08.004

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: doi.org/10.1016/j.janxdis.2016.05.003

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: dx.doi.org/10.4088/JCP.15m09854

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: 10.1192/bjpo.bp.115.001321. 

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: 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: 10.4088/JCP.14m09721

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: 10.1002/jts.22070

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: 10.1176/appi.ajp.2016.16010071

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: dx.doi.org/10.4088/JCP.14m09721

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. doi.org/10.1016/j.janxdis.2016.02.001

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: 10.1037/tra0000110

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: 10.1371/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: 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.

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.

Bryant, R. A., Creamer, M., O'Donnell, M., Silove, D., McFarlane, A. C., & Forbes, D. (2015). A comparison of the capacity of DSM-IV and DSM-5 acute stress disorder definitions to predict posttraumatic stress disorder and related disorders. Journal of Clinical Psychiatry, 76(4), 7

Objective: This study addresses the extent to which DSM-IV and DSM-5 definitions of acute stress disorder (ASD) predict subsequent posttraumatic stress disorder (PTSD) and related psychiatric disorders following trauma.

Method: Patients with randomized admissions to 5 hospitals across Australia (N = 596) were assessed in hospital and reassessed for PTSD at 3 (n = 508), 12 (n = 426), 24 (n = 439), and 72 (n = 314) months using the Clinician-Administered PTSD Scale; DSM-IV definition of PTSD was used at each assessment, and DSM-5 definition was used at 72 months. The Mini-International Neuropsychiatric Interview (MINI) was used at each assessment to assess anxiety, mood, and substance use disorders.

Results: Forty-five patients (8%) met DSM-IV criteria, and 80 patients (14%) met DSM-5 criteria for ASD. PTSD was diagnosed in 93 patients (9%) at 3, 82 patients (10%) at 12, 100 patients (12%) at 24, and 26 patients (8%) at 72 months; 19 patients (6%) met DSM-5 criteria for PTSD at 72 months. Comparable proportions of those diagnosed with ASD developed PTSD using DSM-IV (3 months = 46%, 12 months = 39%, 24 months = 32%, and 72 months = 25%) and DSM-5 (43%, 42%, 33%, and 24%) ASD definitions. Sensitivity was improved for DSM-5 relative to DSM-IV for depression (0.18 vs 0.30), panic disorder (0.19 vs 0.41), agoraphobia (0.14 vs 0.40), social phobia (0.12 vs 0.44), specific phobia (0.24 vs 0.58), obsessive-compulsive disorder (0.17 vs 0.47), and generalized anxiety disorder (0.20 vs 0.47). More than half of participants with DSM-5–defined ASD had a subsequent disorder.

Conclusions: The DSM-5 criteria for ASD results in better identification of people who will subsequently develop PTSD or another psychiatric disorder relative to the DSM-IV criteria. Although prediction is modest, it suggests that the new ASD diagnosis can serve a useful function in acute trauma settings for triaging those who can benefit from either early intervention or subsequent monitoring.

Bryant, R., Nickerson, A., Creamer, M., O’Donnell, M., Forbes, D., Galatzer-Levy, I., McFarlane, A., & Silove, D. (2015). The trajectory of posttraumatic stress disorder following traumatic injury: A longitudinal six year follow-up. British Journal of Psychiatry, 206(5), 6. doi: 10.1192/bjp.bp.114.145516

Background: Traumatic injuries affect millions of patients each year, and resulting post-traumatic stress disorder (PTSD) significantly contributes to subsequent impairment.

Aims: To map the distinctive long-term trajectories of PTSD responses over 6 years by using latent growth mixture modelling.

Method: Randomly selected injury patients (n = 1084) admitted to four hospitals around Australia were assessed in hospital, and at 3, 12, 24 and 72 months. Lifetime psychiatric history and current PTSD severity and funxctioning were assessed.

Results: Five trajectories of PTSD response were noted across the 6 years: (a) chronic (4%), (b) recovery (6%), (c) worsening/recovery (8%), (d) worsening (10%) and (e) resilient (73%). A poorer trajectory was predicted by female gender, recent life stressors, presence of mild traumatic brain injury and admission to intensive care unit.

Conclusions: These findings demonstrate the long-term PTSD effects that can occur following traumatic injury. The different trajectories highlight that monitoring a subset of patients over time is probably a more accurate means of identifying PTSD rather than relying on factors that can be assessed during hospital admission.

Dennison, M., & Yucel, M. (2015). Positive minds wire our brains for tough times. Australasian Science, 36(4) 14-17.

Dennison, M., Whittle, S., Yücel, M., Byrne, M., Schwartz, O., Simmons, J., & Allen, N. (2015). Trait positive affect is associated with hippocampal volume and change in caudate volume across adolescence. Cognitive, Affective, & Behavioral Neuroscience, 15(1), 80-94. doi: 10.3758/s13415-014-0319-2

Trait positive affect (PA) in childhood confers both risk and resilience to psychological and behavioral difficulties in adolescence, although explanations for this association are lacking. Neurodevelopment in key areas associated with positive affect is ongoing throughout adolescence, and is likely to be related to the increased incidence of disorders of positive affect during this period of development. The aim of this study was to prospectively explore the relationship between trait indices of PA and brain development in subcortical reward regions during early to mid-adolescence in a community sample of adolescents. A total of 89 (46 male, 43 female) adolescents participated in magnetic resonance imaging assessments during both early and mid-adolescence (mean age at baseline = 12.6 years, SD = 0.45; mean follow-up period = 3.78 years, SD = 0.21) and also completed self-report measures of trait positive and negative affect (at baseline). To examine the specificity of these effects, the relation between negative affect and brain development was also examined. The degree of volume reduction in the right caudate over time was predicted by PA. Independent of time, larger hippocampal volumes were associated with higher PA, and negative affect was associated with smaller left amygdala volume. The moderating effect of negative affect on the development of the left caudate varied as a function of lifetime psychiatric history. These findings suggest that early to mid-adolescence is an important period whereby neurodevelopmental processes may underlie key phenotypes conferring both risk and resilience for emotional and behavioral difficulties later in life.

Forbes, D., & Creamer, M. (2015). Posttraumatic Stress Disorder. The Encyclopedia of Clinical Psychology. doi: 10.1002/9781118625392.wbecp439

Posttraumatic stress disorder (PTSD) is a mental health condition that develops in a minority of individuals following exposure to a life-threatening or other extremely distressing event. The disorder is characterized by four groups of symptoms: (a) reexperiencing the trauma; (b) avoidance and emotional numbing; (c) negative alterations in cognition and mood; and (d) persistent hyperarousal. Prevalence varies considerably depending on trauma type, with interpersonal violence (especially rape) consistently resulting in the highest rates. Risk factors for development and maintenance of PTSD include a combination of pretrauma, peritrauma, and posttrauma variables. A variety of evidence-based treatments are available, with trauma-focused psychological approaches being the treatment of choice. Pharmacological interventions provide an important second-line approach.

Forbes, D., Alkemade, N., Waters, E., Gibbs, L., Gallagher, H., Pattison, P., Lusher, D., MacDougall, C., Harms, L., Block, K., Snowdon, E., Kellett, C., Sinnott, V., Ireton, G., Richardson, J., & Bryant, R.A. (2015). The role of anger and ongoing stressors in mental health following a natural disaster. Australian and New Zealand Journal of Psychiatry, 49(8), 7. doi: 10.1177/0004867414565478

Objective: Research has established the mental health sequelae following disaster, with studies now focused on understandinfactors that mediate these outcomes. This study focused on anger, alcohol, subsequent life stressors and traumaticevents as mediators in the development of mental health disorders following the 2009 Black Saturday Bushfires Australia’s worst natural disaster in over 100 years.

Method: This study examined data from 1017 (M = 404, F = 613) adult residents across 25 communities differentiallyaffected by the fires and participating in the Beyond Bushfires research study. Data included measures of fire exposure,posttraumatic stress disorder, depression, alcohol abuse, anger and subsequent major life stressors and traumaticevents. Structural equation modeling assessed the influence of factors mediating the effects of fire exposure on mentalhealth outcomes.

Results: Three mediation models were tested. The final model recorded excellent fit and observed a direct relationshipbetween disaster exposure and mental health outcomes (b = .192, p < .001) and mediating relationships via Anger(b = .102, p < .001) and Major Life Stressors (b = .128, p < .001). Each gender was compared with multiple group analysesand while the mediation relationships were still significant for both genders, the direct relationship between exposureand outcome was no longer significant for men (p = .069), but remained significant (b = .234, p < .001) for women.

Conclusions: Importantly, anger and major life stressors mediate the relationship between disaster exposure and developmentof mental health problems. The findings have significant implications for the assessment of anger post disasterthe provision of targeted anger-focused interventions and delivery of government and community assistance and supportin addressing ongoing stressors in the post-disaster context to minimize subsequent mental health consequences.

Forbes, D., Lockwood, E., Creamer, M., Bryant, R. A., McFarlane, A. C., Silove, D., Nickerson, A., & O’Donnell, M. (2015). Latent structure of the proposed ICD-11 posttraumatic stress disorder symptoms: Implications for the diagnostic algorithm. British Journal of Psychiatry, 206(3), 7. doi: 10.1192/bjp.bp.114.150078

Background: The latent structure of the proposed ICD-11 post-traumaticstress disorder (PTSD) symptoms has not been explored.

Aims: To investigate the latent structure of the proposed ICD-11 PTSD symptoms. Method Confirmator factor analyses using data from structured clinical interviews administered to injury patients (n = 613) 6 years post-trauma. Measures of disability and psychological quality of life (QoL) were also administered.

Results: Although the three-factor model implied by the ICD-11 diagnostic criteria fit the data well, a two-factor model provided equivalent, if not superior, fit. Whereas diagnostic criteria based on this two-factor model resulted in an increase in PTSD point prevalence (5.1% v. 3.4%; z = 2.32,

P50.05), they identified individuals with similar levels of disability (P = 0.933) and QoL (P = 0.591) t those identified b the ICD-11 criteria.

Conclusions: Consistent with theorised reciprocal relationships between re-experiencing and avoidance in PTSD, these findings support an alternative diagnostic algorithm requiring at least two of any of the four re-experiencing/avoidance symptoms and at least one of the two hyperarousal symptoms.

Forbes, D., Nickerson, A., Alkemade, N., Bryant, R. A., Creamer, M., Silove, D., McFarlane, A. C., Van Hoof, M., Fletcher, S. L., & O’Donnell, M. (2015). Longitudinal analysis of latent classes of psychopathology and patterns of class migration in survivors of severe injury. Journal of Clinical Psychiatry, 9(76), 7. doi: 10.4088/JCP.14m09075

Objective: Little research to date has explored the typologies of psychopathology following trauma, beyond development of particular diagnoses such as posttraumatic stress disorder (PTSD). The objective of this study was to determine the longitudinal patterns of these typologies, especially the movement of persons across clusters of psychopathology.

Method: In this 6-year longitudinal study, 1,167 hospitalized severe injury patients who were recruited between April 2004-February 2006 were analyzed, with repeated measures at baseline, 3 months, 12 months, and 72 months after injury. All patients met the DSM-IV criterion A1 for PTSD. Structured clinical interviews were used to assess psychiatric disorders at each follow-up point. Latent class analysis and latent transition analysis were applied to assess clusters of individuals determined by psychopathology. The Mini International Neuropsychiatric Interview (MINI) and Clinician-Administered PTSD Scale (CAPS) were employed to complete diagnoses.

Reuslts: Four latent classes were identified at each time point: (1) Alcohol/Depression class (3 months, 2.1%; 12 months, 1.3%; and 72 months, 1.1%), (2) Alcohol class (3 months, 3.3%; 12 months, 3.7%; and 72 months, 5.4%), (3) PTSD/Depression class (3 months, 10.3%; 12 months, 11.5%; and 72 months, 6.4%), and (4) No Disorder class (3 months, 84.2%; 12 months, 83.5%; and 72 months, 87.1%). Latent transition analyses conducted across the 2 transition points (12 months and 72 months) found consistently high levels of stability in the No Disorder class (90.9%, 93.0%, respectively) but lower and reducing levels of consistency in the PTSD/Depression class (81.3%, 46.6%), the Alcohol/Depression class (59.7%, 21.5%), and the Alcohol class (61.0%, 36.5%), demonstrating high levels of between-class migration.

Conclusions: Despite the array of psychiatric disorders that may develop following severe injury, a 4-class model best described the data with excellent classification certainty. The high levels of migration across classes indicate a complex pattern of psychopathology expression over time. The findings have considerable implications for tailoring multifocused interventions to class type, as well as flexible stepped care models, and for the potential development and delivery of transdiagnostic interventions targeting underlying mechanisms.

Gibbs, L., Block, K., Harms, L., MacDougall, C., Snowdon, E., Ireton, G., Forbes, D., Richardson, J., & Waters, E. (2015). Children and young people’s wellbeing post-disaster: Safety and stability are critical.  International Journal of Disaster Risk Reduction,14, 195-201. doi:10.1016/j.ijdrr.2015.06.006

Children, young people and parents from communities affected by the February 2009 bushfires in Victoria, Australia, were interviewed four to five years post-fires as part of the Beyond Bushfires research study. Participant-guided mobile methods were used, in conjunction with interviews, with 35 people aged 4–66 years, to explore their current sense of place and community. Analysis of their stories revealed how children and young people sought safety and stability in the aftermath of a disaster experience in their home, school, social, recreational and work environments. For some families, this was a significant factor in a decision to move away from affected communities, whereas for others the familiarity of the local environment and community members counteracted the post-disaster disruption. The interplay of child, parent and grandparent mutual support and protection was evident, with friends, schools and communities also providing important support in creating safe environments for children

Harms, L., Block, K., Gallagher, C., Gibbs, L., Bryant, R., Lusher, D., Richardson, J., MacDougall, C., Snowdon, E., Sinnott, V., Ireton, G., Forbes, D., Kellett, C., & Waters, E. (2015). Conceptualising post-disaster recovery: Incorporating grief experiences. British Journal of Social Work, 45, 17. doi: 10.1093/bjsw/bcv122

In the disaster literature, psycho-social recovery is conceptualised typically as the alleviation of traumatic stress, with the alleviation of disaster-related grief as a less prominent part of this. Yet, incorporating grief understandings into recovery conceptualisations post disaster is important. This paper explores these conceptualisations by analysing participants' bereavement experiences following the Black Saturday bushfires. It draws on data from Beyond Bushfires, a mixed-methods study (n = 1,016) in which survey and interview data relating to individual loss and recovery experiences were examined. The loss through death of friends and community members was found to be predictive of poorer mental health outcomes, although prolonged grief outcomes were rare. The sense of relationships as being ‘like family’ was identified by interviewees as an important dimension of their particular communities, as was coping with multiple deaths and the hierarchy of grief that emerged, and the stress of notifying others of these deaths. The implications of these impacts are considered for social work research and practice.

Lloyd, D., Couineau, A. L., Hawkins, K., Kartal, D., Nixon, R., Perry, D., & Forbes, D. (2015). Preliminary outcomes of implementing Cognitive Processing Therapy for posttraumatic stress disorder across a national veterans’ treatment service. Journal of Clinical Psychiatry, 76(11). doi: http://dx.doi.org/10.4088/JCP.14m09139

Background: Posttraumatic stress disorder (PTSD) is a significant problem for military veterans. There is an international imperative to improve access to effective treatments, but more research is needed to ascertain the extent to which treatments found to be efficacious in research settings translate to successful national implementation efforts.

Method: This study reports the clinical outcomes for the first 100 clients treated following the implementation of cognitive processing therapy (CPT) across a national community-based veterans’ mental health service that commenced in May 2012. The implementation included training and ongoing clinical supervision, leadership support, and updates to the service’s data collection and intake system to support the delivery of CPT. The service implemented an intake screen (the Primary Care PTSD) that was used to allocate clients who screened positive for PTSD to CPT-trained therapists. An outcome measure for PTSD (the PTSD Checklist) was incorporated into the services’ computerized records system. Clients who received CPT were assessed pretreatment and posttreatment.

Results: Statistically significant and clinically large improvements were found for self-reported PTSD (effect size = 1.01, P < .001). In addition, the study obtained high levels of treatment fidelity in the delivery of the CPT treatment.

Conclusions: There is relatively little published research supporting the effectiveness of evidence-based PTSD treatments following national implementation efforts. This is the first study to systematically report CPT treatment outcomes from a national implementation effort, using service-based outcome monitoring data. Results indicate that when administered as part of routine clinical practice, CPT achieves large clinically significant improvements for PTSD comparable with those found in randomized controlled trials.

McFarlane, A. C., & Forbes, D. (2015). What has been learned about the psychological injuries of war in a century? The journey from moral inferiority to PTSD. Medical Journal of Australia, 202(7). doi: 10.5594/mja15.00201

McGuire, A., Dobson, A., Mewton, L., Varker, T., Forbes, D., & Wade, D. (2015). Mental health and service use: Men who served in the Australian military, women who received Department of Veterans’ Affairs benefits, and the general population. Australian and New Zealand Journal of Public Health, 39(6), 524-529. doi: 10.1111/1753-6405.12431

Objectives: To compare the lifetime prevalence of affective, anxiety and substance use disorders and the use of mental health services between people who had served in the Australian Defence Force (ADF) or received Department of Veterans' Affairs (DVA) benefits and the general population.

Method: The 2007 National Survey of Mental Health and Wellbeing obtained data from a nationally representative household survey of 8,841 respondents.

Results: Fewer than 20% of men who had served in the ADF reported receiving benefits from DVA. ADF men were older and more likely to report poorer health than other men. They were 50% more likely to be diagnosed with any lifetime mental disorder, any affective disorder, depression, PTSD, any substance use and alcohol disorder. Almost 90% of women who received DVA benefits had not served in the ADF. DVA women were older, and more likely to report moderate/severe psychological distress and less life satisfaction than other women. There was no evidence of greater lifetime use of mental health services by ADF men or DVA women compared to the general population.

Conclusions: Health care providers should ask their patients if they have connections with the military in order to better detect and treat potential mental health problems.

Mihalopoulos, C., Magnus, A., Lal, A., Dell, L., Forbes, D., & Phelps, A. (2015). Is implementation of the 2013 Australian treatment guidelines for posttraumatic stress disorder cost-effective compared to current practice? A cost-utility analysis using QALYs and DALYs. Australian and New Zealand Journal of Psychiatry, 4(49), 360-375. doi: 10.1177/0004867414553948

Objective: To assess, from a health sector perspective, the incremental cost-effectiveness of three treatment recommendations in the most recent Australian Clinical Practice Guidelines for posttraumatic stress disorder (PTSD). The interventions assessed are trauma-focused cognitive behavioural therapy (TF-CBT) and selective serotonin reuptake inhibitors (SSRIs) for the treatment of PTSD in adults and TF-CBT in children, compared to current practice in Australia.

Method: Economic modelling, using existing databases and published information, was used to assess cost-effectiveness. A cost-utility framework using both quality-adjusted life-years (QALYs) gained and disability-adjusted life-years (DALYs) averted was used. Costs were tracked for the duration of the respective interventions and applied to the estimated 12 months prevalent cases of PTSD in the Australian population of 2012. Simulation modelling was used to provide 95% uncertainty around the incremental cost-effectiveness ratios. Consideration was also given to factors not considered in the quantitative analysis but could determine the likely uptake of the proposed intervention guidelines.

Results: TF-CBT is highly cost-effective compared to current practice at $19,000/QALY, $16,000/DALY in adults and $8900/QALY, $8000/DALY in children. In adults, 100% of uncertainty iterations fell beneath the $50,000/QALY or DALY value-for-money threshold. Using SSRIs in people already on medications is cost-effective at $200/QALY, but has considerable uncertainty around the costs and benefits. While there is a 13% chance of health loss there is a 27% chance of the intervention dominating current practice by both saving dollars and improving health in adults.

Conclusion: The three Guideline recommended interventions evaluated in this study are likely to have a positive impact on the economic efficiency of the treatment of PTSD if adopted in full. While there are gaps in the evidence base, policy-makers can have considerable confidence that the recommendations assessed in the current study are likely to improve the efficiency of the mental health care sector.

O’Donnell, M., Alkemade, N., & Forbes, D. (2015). Is Australia in the post-traumatic stress disorder petri dish? Australian and New Zealand Journal of Psychiatry, 49(4), 1. doi: 10.1177/0004867415572413 tb

O’Donnell, M., Grant, G., Alkemade, N., Spittal, M., Creamer, M., Silove, D., McFarlane, A., Bryant, R., Forbes, D., & Studdert, D. (2015). Compensation seeking and disability after injury: The role of compensation-related stress and mental health. Journal of Clinical Psychiatry, 8(76), 5. doi: 10.4088/JCP.14m09211

Phelps, A., Kartal, D., Lau, W., & Forbes, D. (2015). The utility of moral injury.  In T. Frame (Ed.), Moral Injury: Unseen Wounds in an Age of Barbarism (Chapter 10). Sydney: University of New South Wales Press.

Ponsford, K., Lee, N., Wong, D., McKay, A., Haines, K., Alway, Y., Downing, M., Furtado, C., & O’Donnell, M. (2015). Efficacy of motivational interviewing and cognitive behavioral therapy for anxiety and depression symptoms following traumatic brain injury.  Psychological Medicine, 46(5), 1079-1090.  doi: 10.1017/S0033291715002640

Anxiety and depression are common following traumatic brain injury (TBI), often co-occurring. This study evaluated the efficacy of a 9-week cognitive behavioral therapy (CBT) program in reducing anxiety and depression and whether a three-session motivational interviewing (MI) preparatory intervention increased treatment response.

A randomized parallel three-group design was employed. Following diagnosis of anxiety and/or depression using the Structured Clinical Interview for DSM-IV, 75 participants with mild-severe TBI (mean age 42.2 years, mean post-traumatic amnesia 22 days) were randomly assigned to an Adapted CBT group: (1) MI + CBT (n = 26), or (2) non-directive counseling (NDC) + CBT (n = 26); or a (3) waitlist control (WC, n = 23) group. Groups did not differ in baseline demographics, injury severity, anxiety or depression. MI and CBT interventions were guided by manuals adapted for individuals with TBI. Three CBT booster sessions were provided at week 21 to intervention groups.

Using intention-to-treat analyses, random-effects regressions controlling for baseline scores revealed that Adapted CBT groups (MI + CBT and NDC + CBT) showed significantly greater reduction in anxiety on the Hospital Anxiety and Depression Scale [95% confidence interval (CI) −2.07 to −0.06] and depression on the Depression Anxiety and Stress Scale (95% CI −5.61 to −0.12) (primary outcomes), and greater gains in psychosocial functioning on Sydney Psychosocial Reintegration Scale (95% CI 0.04–3.69) (secondary outcome) over 30 weeks post-baseline relative to WC. The group receiving MI + CBT did not show greater gains than the group receiving NDC + CBT.

Findings suggest that modified CBT with booster sessions over extended periods may alleviate anxiety and depression following TBI.

Schweininger, S., Forbes, D., Creamer, M., McFarlane, A., Silove, D., Bryant, R., & O’Donnell, M. (2015). The temporal relationship between mental health and disability after injury. Depression and Anxiety, 32(1), 64-71. doi:10.1002/da.22288

The temporal relationship between mental health and disability after injury. Depression and Anxiety, 32(1), 64-71. doi: DOI: 10.1002/da.22288 Objective: This longitudinal study investigated the temporal relationship pat-terns between disability and mental health after injury, with a focus on posttrau-matic stress disorder (PTSD), depression, and anxiety.Method: We conducteda multi-sited longitudinal cohort study with a large sample of hospital patientsadmitted after injury (N = 1,149, mean age = 37.9, 73.6% male). Data werecollected prior to discharge from hospital, and follow-up assessments took place3 and 12 months postinjury. A cross-lagged structural equation model (SEM)was used to assess the prospective relationship between posttraumatic stress, anx-iety, and depression symptoms and disability while controlling for demographiccharacteristics and objective measures of injury severity.Results: Acute de-pression significantly predicted 3-month disability, and 3-month PTSD severitysignificantly predicted 12-month disability. Premorbid disability had a signifi-cant effect on acute anxiety, depression, and posttraumatic stress symptoms, and3-month depression but disability a fter the injury did not predict 12-month psy-chopathology.Conclusions: We did not find a reciprocal relationship betweendisability and psychopathology. Rather we found that depression played a role inearly disability while PTSD played a role in contributing to long-term delaysin the recovery process. The results of this study highlight the need for mentalhealth screening for symptoms of PTSD and depression in the acute aftermathof trauma, combined with early intervention programs in injury populations.

Trethowan, V., & Nursey, J. (2015). Helping children recover from disaster: A review of teacher based support programs in Victorian schools. Australian Journal of Emergency Management, 30(4), 17.

Children and adolescents are among the most vulnerable in the aftermath of a disaster. Following the devastating Victorian bushfires in 2009 the Victorian Department of Education, in partnership with Phoenix Australia: Centre for Posttraumatic Mental Health and a child adolescent mental health expert, adapted two U.S. programs that provide teachers with knowledge and skills to support child and adolescent recovery in the school setting. This paper provides an overview of the two-phased approach to teacher training.

The first phase was the development of a manual, Psychological First Aid and Mental Health First Aid: A Guide for Teachers. The first component, Psychological First Aid, is designed to develop teacher skills in supporting children and adolescents in the first days and weeks after an emergency or disaster. The next component, Mental Health First Aid, aims to help teachers recognise signs and symptoms of mental health problems in their students in order to facilitate appropriate and timely referral to specialist services. The second phase involved the development of online training, Skills for Psychological Recovery for Teachers, designed to give teachers direction and skills for teaching children and adolescents with mild to moderate distress effective ways of coping in the weeks, months and possibly years after a disaster. This phase also included incorporating the Psychological First Aid and Mental Health First Aid programs into an online training format.

Varker, T., Forbes, D., Dell, L., Weston, A., Merlin, T., Hodson, S., & O’Donnell, M. L. (2015). Rapid evidence assessment: Increasing the transparency of an emerging methodology. Journal of Evaluation in Clinical Practice, 21(6), 5. doi: 10.1111/jep.12405

Rationale, Aims and Objectives: Within the field of evidence-based practice, policy makers, health care professionals and consumers require timely reviews to inform decisions on efficacious health care and treatments. Rapid evidence assessment (REA), also known as rapid review, has emerged in recent years as a literature review methodology that fulfils this need. It highlights what is known in a clinical area to the target audience in a relatively short time frame.

Methods: This article discusses the lack of transparency and limited critical appraisal that can occur in REA, and goes on to propose general principles for conducting a REA. The approach that we describe is consistent with the principles underlying systematic review methodology, but also makes allowances for the rapid delivery of information as required while utilizing explicit and reproducible methods at each stage.

Results: Our method for conducting REA includes: developing an explicit research question in consultation with the end-users; clear definition of the components of the research question; development of a thorough and reproducible search strategy; development of explicit evidence selection criteria; and quality assessments and transparent decisions about the level of information to be obtained from each study. In addition, the REA may also include an assessment of the quality of the total body of evidence.

Conclusions: Transparent reporting of REA methodologies will provide greater clarity to end-users about how the information is obtained and about the trade-offs that are made between speed and rigour.

Wade, D., & Dennison, M. (2015). Rapid-fire response. Australian Doctor, 2.

Wade, D., & Pham, T. (2015). New South Wales Blue Mountains Bushfire Response Training and Support Program.

Wallace, D., & Cooper, J. (2015). Update on the management of post traumatic stress disorder. Australian Prescriber, 38(2), 55-59.

Posttraumatic stress disorder occurs in people exposed to life-threatening trauma. GPs may be seeing more patients with post-traumatic stress disorder as military personnel return from overseas deployments. The condition can present in various ways. To reduce the likelihood of missed or delayed diagnosis GPs can screen at-risk populations. A comprehensive assessment is recommended. Specialist referral may be required, particularly if there are other mental health problems. Trauma-focused psychological therapies should be offered as the first line of treatment for posttraumatic stress disorder. Usually 8-12 sessions are needed for a therapeutic effect. If drug treatment is needed, selective serotonin reuptake inhibitors are the first line. Other drugs used in post-traumatic stress disorder include antipsychotics, anticonvulsants and prazosin.

Zoteyeva, V., Forbes, D., & Rickard, N. S. (2015). Military veterans’ use of music-based emotion regulation for managing mental health issues. Psychology of Music, 44(3), 307-323. doi: 10.1177/0305735614566841

Veterans commonly report listening to music as a means of self-managing their mental health, yet no research has systematically explored how veterans use music for the purpose of regulating their emotions. In the current study, surveys were completed by 205 Australian veterans (mean age 59.57, SD 0.83), assessing their affective mental health (depression and stress) and related physical and behavioral problems (self-reported general health, alcohol abuse and negative social interactions). Veterans listened to music more in their everyday life than any other leisure activity reported. Music-listening for emotion-regulation purposes significantly contributed to the prediction of depression, perceived stress and negative social interactions, when gender and positive social interactions were controlled. Veterans with mental health problems listened to music for both emotional and cognitive reasons, and the most predictive emotion-regulation strategies used with music were diversion, discharge, and mental work. Music-listening did not however assist prediction of self-reported general health or alcohol abuse. The current findings demonstrate that veterans with higher levels of affective dysfunction listened to music to manage emotional and cognitive problems. Personal music-listening therefore offers substantial promise as a self-management tool to complement professional treatment of affective disorders in this vulnerable population.

2014 PUBLICATIONS

Bowman, S., Alvarez-Jimenez, M., Wade, D., McGorry, P., & Howie, L. (2014). Forgotten family members: The importance of siblings in early psychosis. Early Intervention in Psychiatry, 7(2). doi:10.1111/eip.12068

Objective: This paper reviews the evidence on the significance of sibling inclusion in family interventions and support during early psychosis.

Method: This narrative review presents the current research related to the importance of family work during early psychosis, the needs and developmental significance of siblings during adolescence and early adulthood, the protective effects of sibling relationships, and the characteristics of early psychosis relevant to the sibling experience. It will also review the evidence of the sibling experience in chronic physical illness and disability, as well as long-term psychotic illness.

Conclusions: Despite the evidence that working with families is important during early psychosis, siblings have been largely ignored. Siblings are an important reciprocal relationship of long duration. They play an important role in development during adolescence and early adulthood. These relationships may be an underutilized protective factor due to their inherent benefits and social support. Developmental theories imply that early psychosis could negatively impact the sibling relationship and their quality of life, effecting personality development and health outcomes. The evidence shows that adolescent physical illness or disability has a significantly negative impact on the sibling's quality of life and increases the risk for the onset of mental health issues. Long-term psychotic illness also results in negative experiences for siblings. Current evidence shows that siblings in early psychosis experience psychological distress and changes in functional performance.

Bryant, R. A., Waters, E., Gibbs, L., Gallagher, H. C., Pattison, P., Lusher, D., MacDougall, C., Harms, L., Block, K., Snowdon, E., Sinnott, V., Ireton, G., Richardson, J., & Forbes, D. (2014). Psychological outcomes following the Victorian Black Saturday bushfires. Australian & New Zealand Journal of Psychiatry, 48(7), 9. doi: 10.1177/0004867414534476

Objective: We aimed to map the prevalence and predictors of psychological outcomes in affected communities 3–4 years after the Black Saturday bushfires in the state of Victoria, Australia.

Methods: Baseline assessment of a longitudinal cohort study in high-, medium-, and low-affected communities in Victoria. Participants included 1017 residents of high-, medium-, and low-affected fire communities. Participants were surveyed by means of a telephone and web-based interview between December 2011 and January 2013. The survey included measures of fire-related post-traumatic stress disorder (PTSD) and general PTSD from other traumatic events, major depressive episode, alcohol use, and general psychological distress.

Results: The majority of respondents in the high- (77.3%), medium- (81.3%), and low-affected (84.9%) communities reported no psychological distress on the K6 screening scale. More participants in the high-affected communities (15.6%) reported probable PTSD linked to the bushfires than medium- (7.2%) and low-affected (1.0%) communities (odds ratio (OR): 4.57, 95% confidence interval (CI): 2.61–8.00, p = 0.000). Similar patterns were observed for depression (12.9%, 8.8%, 6.3%, respectively) (OR: 1.83, 95% CI: 1.17–2.85, p = 0.008) and severe psychological distress (9.8%, 5.0%, 4.9%, respectively) (OR: 2.08, 95% CI: 1.23–3.55, p = 0.007). All communities reported elevated rates of heavy drinking (24.7%, 18.7%, 19.6%, respectively); however, these were higher in the high-affected communities (OR: 1.39, 95% CI: 1.01–1.89, p = 0.04). Severe psychological distress was predicted by fear for one’s life in the bushfires, death of someone close to them in the bushfires, and subsequent stressors. One-third of those with severe psychological distress did not receive mental health assistance in the previous month.

Conclusions: Several years following the Black Saturday bushfires the majority of affected people demonstrated resilience without indications of psychological distress. A significant minority of people in the high-affected communities reported persistent PTSD, depression, and psychological distress, indicating the need for promotion of the use of health and complementary services, community-based initiatives, and family and other informal supports, to target these persistent problems.

Cooper, J., Metcalf, O., & Phelps, A. (2014). PTSD – an update for general practitioners. Australian Family Physician, 43(11), 4.

Background: Australians are commonly exposed to traumatic events, which can lead to the development of post-traumatic stress disorder (PTSD). Several recent developments in the trauma field have led to significant changes in how PTSD is diagnosed and treated.

Objective: This article provides up-to-date guidance for general practitioners (GPs) in the recognition of PTSD and the current best practice recommendations for pharmacological and psychological treatment.

Discussion: Often the first port-of-call, GPs are well placed to help patients who have recently experienced a potentially traumatic event and are at risk of developing PTSD. The role of the GP can include initial support, assessment, treatment and, where indicated, appropriate specialist referral. There are recent clinical practice guidelines that GPs can use to assess and determine appropriate treatment for their patients with PTSD.

Forbes, D., Alkemade, N., Hopcraft, D., Hawthorne, G., O’Halloran, P., Elhai, J. D., McHugh, A. F., Novaco, R. W., Bryant, R. A., & Lewis, V. (2014). Evaluation of the Dimensions of Anger Reactions - 5 (DAR-5) Scale in combat veterans with posttraumatic stress disorder. Journal of Anxiety Disorders, 28(8), 830–835. doi: http://dx.doi.org/10.1016/j.janxdis.2014.09.015

After a traumatic event many people experience problems with anger which not only results in significant distress, but can also impede recovery. As such, there is value to include the assessment of anger in routine post-trauma screening procedures. The Dimensions of Anger Reactions-5 (DAR-5), as a concise measure of anger, was designed to meet such a need, its brevity minimizing the burden on client and practitioner. This study examined the psychometric properties of the DAR-5 with a sample of 163 male veterans diagnosed with Posttraumatic Stress Disorder. The DAR-5 demonstrated internal reliability (α = .86), along with convergent, concurrent and discriminant validity against a variety of established measures (e.g. HADS, PCL, STAXI). Support for the clinical cut-point score of 12 suggested by Forbes et al. (2014, Utility of the dimensions of anger reactions-5 (DAR-5) scale as a brief anger measure. Depression and Anxiety, 31 , 166–173) was observed. The results support considering the DAR-5 as a preferred screening and assessment measure of problematic anger.

Forbes, D., Alkemade, N., Mitchell, D., Elhai, J. D., McHugh, T., Bates, G., Novaco, R. W., Bryant, R. B., & Lewis, V. (2014). Utility of the Dimensions of Anger Reactions - 5 (DAR-5) Scale as a brief anger measure. Depression and Anxiety, 34(2), 8. doi: 10.1002/da.22148

Anger is a common emotional sequel in the aftermath of traumatic experience. As it is associated with significant distress and influences recovery, anger requires routine screening and assessment. Most validated measures of anger are too lengthy for inclusion in self-report batteries or as screening tools. This study examines the psychometric properties of a shortened 5-item version of the Dimensions of Anger Reactions (DAR), an existing screening tool.

Methods: Responses to the DAR-5 were analysed from a sample of 486 college students with and without a history of trauma exposure.

Results: The DAR-5 demonstrated strong internal reliability and concurrent validity with the State Trait Anger Expression Inventory-2 (STAXI-2). Confirmatory factor analysis supported a single factor model of the DAR-5 for the trauma-exposed and nontrauma subsamples. A screening cut-off point of 12 on the DAR-5 successfully differentiated high and low scorers on STAXI-2 Trait Anger and PCL posttraumatic stress scores. Further discriminant validity was found with depression symptom scores.

Conclusions: The results support use of the DAR-5 for screening for anger when a short scale is required.

Forbes, D., Lockwood, E., Elhai, J., Creamer, M., Bryant, R., McFarlane, A., Silove, D., Miller, M., Nickerson, A., & O’Donnell, M. (2014). An evaluation of the DSM-5 factor structure for posttraumatic stress disorder in survivors of traumatic injury. Journal of Anxiety Disorders, (29), 43-51. doi: http://dx.doi.org/10.1016/j.janxdis.2014.11.004

Confirmatory factor analytic studies of the latent structure of DSM-5 PTSD symptoms using self-report data (Elhai et al., 2012; Miller et al., 2013) have found that the four-factor model implied by the DSM-5 diagnostic criteria provided adequate fit to their data. However, the fit of this model is yet to be assessed using data derived from gold standard structured interview measures. This study evaluated the fit of the DSM-5 four-factor model and an alternative four-factor model in 570 injury survivors six years post-injury using the Clinician Administered PTSD Scale (Blake et al., 1990), updated to include items measuring new DSM-5 symptoms. While both four-factor models fitted the data well, very high correlations between the ‘Intrusions’ and ‘Avoidance’ factors in both models and between the ‘Negative Alterations in Cognitions and Mood’ and ‘Arousal and Reactivity’ factors in the DSM-5 model and the ‘Dysphoria’ and ‘Hyperarousal’ factors in the alternative model were evident, suggesting that a more parsimonious two-factor model combining these pairs of factors may adequately represent the latent structure. Such a two-factor model fitted the data less well according to χ 2 difference testing, but demonstrated broadly equivalent fit using other fit indices. Relationships between the factors of each of the four-factor models and the latent factors of Fear and Anxious-Misery/Distress underlying Internalizing disorders (Krueger, 1999) were also explored, with findings providing further support for the close relationship between the Intrusion and Avoidance factors. However, these findings also suggested that there may be some utility to distinguishing Negative Alterations in Cognition and Mood symptoms from Arousal and Reactivity symptoms, and/or Dysphoria symptoms from Hyperarousal symptoms. Further studies are required to assess the potential discriminant validity of the two four-factor models.

Forbes, D., Lockwood, E., Phelps, A., Wade, D., Creamer, M., Bryant, R. A., McFarlane, A. C., Silove, D., Rees, S., Chapman, C., Slade, T., Mills, K., Teesson, M., & O’Donnell, M. (2014). Trauma at the hands of another part 2: Distinguishing PTSD patterns following intimate and non-intimate interpersonal and non-interpersonal trauma in a nationally representative sample. Journal of Clinical Psychiatry, 75(2), 153. doi: 10.4088/JCP.13m08374

Objective: Interpersonal trauma and violence is currently considered a global public health emergency. However, studies have not differentiated between intimate interpersonal trauma and nonintimate interpersonal trauma in their impact on posttraumatic stress disorder (PTSD) symptomatology. This cross-sectional study based on epidemiologic data examined the differential likelihoods of endorsing PTSD symptoms following 3 categories of trauma: noninterpersonal (eg, accidents, natural disasters), nonintimate interpersonal (physical assaults perpetrated by nonintimates), and intimate interpersonal (physical assaults perpetrated by intimates or caregivers and sexual assaults).

Method: DSM-IV PTSD symptom data drawn from a weighted subsample (N = 1,012) of people reporting "most severe" reactions following one of the above types of trauma in the 2007 Australian National Survey of Mental Health and Well-Being (NSMHWB) were analyzed using binary logistic regression.

Results: Participants reporting intimate interpersonal compared with noninterpersonal trauma were significantly (P < .001) more likely to endorse core symptoms (intrusive reexperiencing, avoidance of reminders, hypervigilance, and startle response) of PTSD. The intimate interpersonal trauma group members were significantly more likely than the nonintimate interpersonal trauma group members to endorse distress at reminders (odds ratio [OR] = 3.2; P < .001; 99.7% CI, 1.3-7.9), avoiding thinking about the event (OR = 3.2; P < .001; 99.7% CI, 1.3-7.7), detachment from others (OR = 3.2; P < .001; 99.7% CI, 1.2-8.9), and restricted affect (OR = 4.1; P < .001; 99.7% CI, 1.5-11.3). Participants reporting nonintimate interpersonal and noninterpersonal traumas did not significantly differ except in endorsement of behavioral avoidance (OR = 2.8; P < .001; 99.7% CI, 1.2-6.6), hypervigilance (OR = 2.5; P = .002; 99.7% CI, 1.0-6.3), and exaggerated startle response (OR = 3.5; P < .001; 99.7% CI, 1.7-7.4).

Conclusions: Survivors of intimate trauma appear to experience particularly severe intrusive memories and reminders of past trauma and suppression of emotional responsivity. The unique impact of interpersonal trauma, however, intimate or otherwise, compared with noninterpersonal trauma, is the experience of an environment as unsafe and unpredictable, due to the potential of human threat. Such findings have significant implications for the assessment of and interventions for survivors of interpersonal violence.

Gibbs L., Snowdon E., Block K., Gallagher C., MacDougall C., Ireton G., Pirrone A., Forbes D., Richardson J., Harms L., & Waters, E. (2014). Where do we start? A proposed post disaster intervention framework for children and young people. Pastoral Care and Education, 32(1), 19. doi: 10.1080/02643944.2014.881908

The impact of disasters on the mental health, wellbeing and social inclusion of children and young people is well established. However, there is very limited evidence about effective community-based interventions to support positive outcomes. In this paper, we review the empirical and theoretical evidence and propose a conceptual framework to guide longer term community-based interventions, modified from an already developed multidimensional framework for refugee integration. We demonstrate its relevance, with some adjustments, through alignment with the disaster literature, particularly as it relates to children and young people. We also pilot the framework by applying it to an analysis of the services and initiatives delivered to support children and young people following the 2009 Victorian

bushfires in Australia. The results suggested a concentration of funding on individually oriented, mental health programmes targeting secondary school-aged students. This may indicate under-resourcing of initiatives for younger children. There also appeared to be very limited inclusion of programmes aiming to re-establish a sense of safety and stability. Despite recognition of the important role of schools in supporting children and young people post-disaster, the analysis of initiatives indicated there was limited external funding support for school-based programmes. There were promising indications of programmes providing opportunities for children and young people to develop citizenship in the post-disaster recovery context, and scope for this to be extended to preparedness and response roles.

Grant, G., O’Donnell, M., Spittal, M., Creamer, M., & Studdert, D. (2014). Relationship between stressfulness of claiming for injury compensation and long-term recovery: A prospective cohort study. JAMA Psychiatry, 71(2). doi: 10.1001/jamapsychiatry.2013.4023

Objective: To determine aspects of claims processes that claimants to transport accident and workers’ compensation schemes find stressful and whether such stressful experiences are associated with poorer long-term recovery.

Design, Setting, and Participants:  Prospective cohort study of a random sample of 1010 patients hospitalized in 3 Australian states for injuries from 2004 through 2006. At 6-year follow-up, we interviewed 332 participants who had claimed compensation from transport accident and workers’ compensation schemes (“claimants”) to determine which aspects of the claiming experience they found stressful. We used multivariable regression analysis to test for associations between compensation-related stress and health status at 6 years, adjusting for baseline determinants of long-term health status and predisposition to stressful experiences (via propensity scores).

Main Outcomes and Measures:  Disability, quality of life, anxiety, and depression.

Results: Among claimants, 33.9% reported high levels of stress associated with understanding what they needed to do for their claim; 30.4%, with claim delays; 26.9%, with the number of medical assessments; and 26.1%, with the amount of compensation they received. Six years after their injury, claimants who reported high levels of stress had significantly higher levels of disability (+6.94 points, World Health Organization Disability Assessment Schedule sum score), anxiety and depression (+1.89 points and +2.61 points, respectively, Hospital Anxiety and Depression Scale), and lower quality of life (−0.73 points, World Health Organization Quality of Life instrument, overall item), compared with other claimants. Adjusting for claimants’ vulnerability to stress attenuated the strength of these associations, but most remained strong and statistically significant.

Conclusions and Relevance:  Many claimants experience high levels of stress from engaging with injury compensation schemes, and this experience is positively correlated with poor long-term recovery. Intervening early to boost resilience among those at risk of stressful claims experiences and redesigning compensation processes to reduce their stressfulness may improve recovery and save money.

Injury is an important contributor to the burden of disease, accounting for 10% of deaths and 11% of disability-adjusted life years globally in 2010. A substantial proportion of nonfatal injuries occur on the road or in the workplace. In developed and middle-income countries, persons who sustain injuries in these settings are often eligible to claim monetary benefits from injury compensation schemes. Although a central goal of such schemes is to help return injured persons to work and health, there are growing concerns that they may have the opposite effect.

By comparing the postinjury health status of patients who claim compensation with that of patients who do not claim, more than 100 studies have concluded that recovery trajectories are worse among claimants. Other studies have linked receipt of certain benefits from compensation schemes to slower recoveries. Commentators have posited a causal relationship between “exposure” to compensation systems and ill health. One explanation for this effect focuses on claimants’ choices and behaviors. Another points to stressful aspects of the claims process itself, including adversarialism and clinical scrutiny, as independent determinants of poor health outcomes.

The nature, extent, and cause of compensation-related health effects remain unclear, largely as a result of fundamental limitations in the extant research. This study was designed to avoid these limitations. We observed a cohort of injured patients for 6 years and then interviewed those who had pursued claims in transport accident and workers’ compensation schemes about their experience. Our analysis investigated compensation-related health effects within this sample of claimants. The study aims were to determine which aspects of the process claimants found stressful and whether stressful experiences were associated with poorer long-term recovery.

Holmes, A. C., O'Donnell, M., Williamson, O., Hogg, M., & Arnold, C. (2014). Persistent disability is a risk factor for late-onset mental disorder after serious injury. Australian and New Zealand Journal of Psychiatry, 48(12), 7. doi: 10.1177/0004867414533836

Background: Most of what we know about the psychiatric consequences of injury is limited to the first year. Determining the prevalence of and risk factors for psychiatric morbidity beyond one year will aid service development and facilitate timely diagnosis and treatment. The aim of this prognostic study was to determine the prevalence of mental disorders in the three years following serious injury and to identify risk factors for the onset of new disorders after 1 year.

Methods: Of 272 patients assessed in hospital following serious injury, 196 (72.1%) were reassessed at 3 years. Assessment involved gold standard semi-structured interviews for psychiatric diagnoses, risk factors for mental disorder, injury measures and pain scores.

Results: More than a quarter of all patients were diagnosed with at least one mood or anxiety disorder at some stage during the three years following their injury. The most common diagnoses were major depression (20.0%), generalised anxiety disorder (6.7%) and panic disorder (6.7%). For a third of these patients, the disorder appeared after 12 months, for which persistent physical disability was an independent risk factor.

Conclusion: Although there is a necessary focus on the early detection and treatment of mental disorders after injury, attention to later onset disorders is also required for those with persistent pain and physical disability.

Lewis, V., Varker, T., Forbes, D., & Phelps, A. (2014). Organizational implementation of Psychological First Aid (PFA) training for managers and peers. Psychological Trauma: Theory, Research and Practice, 6(6), 5. doi: 10.1037/a0032556

International guidelines for the management of psychological trauma recommend psychological first aid (PFA) as an early intervention for survivors of potentially traumatic events. Forbes et al. (2011) proposed a Phased PFA model for organizations whose employees are at high-risk of exposure to potentially traumatic incidents (PTEs; i.e., “high-risk organizations”). One of the central elements of the Phased PFA model is the allocation of roles for implementation of PFA to staff at various levels of the organization, including managers as well as those staff with special support roles. This article describes an evaluation of training provided to 321 managers and 261 peer supporters within an Australian high-risk organization. The results demonstrate that training led to increases in 3 key domains: knowledge related to PTEs and PFA, self-reported skills required to respond appropriately to a PTE, and confidence to respond to PTEs. Following the training, both managers and peer supporters had significantly higher mean scores in all 3 domains than prior to training. This study demonstrates that the provision of PFA training to managers and peer supporters is likely to lead to increased capacity to implement a PFA response within the organization through increases in relevant knowledge, skills, and confidence.

Lloyd, D., Nixon, R., Varker, T., Elliott, P., Perry, D., Bryant, R. A., Creamer, M., & Forbes, D. (2014). Comorbidity in the prediction of Cognitive Processing Therapy treatment outcomes for combat-related posttraumatic stress disorder. Journal of Anxiety Disorders, 28(2), 4.

This paper examines clinical predictors of posttraumatic stress disorder (PTSD) treatment outcomes following Cognitive Processing Therapy (CPT) in Australian military veterans. Fifty nine treatment seeking veterans were enrolled in a randomized controlled trial comparing 12 sessions of CPT (n = 30) with usual treatment (n = 29) at three community-based veterans counseling centers. PTSD and key co-morbidities (depression, anxiety, anger and alcohol use) were measured. Growth curve modeling was used to examine factors which influenced PTSD severity post-treatment. For the CPT condition, baseline anger was the only co-morbidity predictive of change in PTSD severity over time. Participants with higher anger scores showed less of a decrease in PTSD severity over time. Higher anxiety in participants in treatment as usual was significantly associated with better treatment gains. This research suggests that veterans experiencing high levels of anger might benefit from targeted anger reduction strategies to increase the effectiveness of CPT treatment for PTSD.

Lockwood, E., & Forbes, D. (2014). Posttraumatic stress disorder and comorbidity: Untangling the Gordian knot. Psychological Injury and Law, 7, 108-121. doi 10.1007/s12207-014-9189-8

The high rates of psychiatric comorbidity for individuals with posttraumatic stress disorder (PTSD) have long been noted. The conceptual, clinical and aetiological relationships between PTSD and other disorders are so interwoven and multi-determined that understanding and treating posttraumatic psychopathology can feel like trying to untangle the legendary Gordian knot. This paper examines the varying streams of research seeking to better understand this extensive comorbidity. These streams of research include examination of the bi-directional relationships in the development of PTSD and key mood, anxiety and substance use disorders; the study of the shared manifest and common higher order features across these disorders and investigations of underlying biopsychosocial vulnerabilities. Finally, the paper examines the preliminary findings emerging using the new DSM-5 criteria for PTSD and queries whether these revised criteria will address the issue of comorbidity and assist in untangling the knot of posttraumatic comorbidity.

Nickerson, A., Barnes, J. B., Creamer, M., Forbes, D., McFarlane, A. C., O’Donnell, M., Silove, D., Steel, Z., & Bryant, R. A. (2014). The temporal relationship between posttraumatic stress disorder and alcohol use following traumatic injury. Journal of Abnormal Psychology, 123(4), 14. doi: 10.1037/a0037920

Chronic alcohol abuse is a major public health concern following trauma exposure; however, little is known about the temporal association between posttraumatic stress disorder (PTSD) symptoms and problem alcohol use. The current study examined the temporal relationship between PTSD symptom clusters (re-experiencing, effortful avoidance, emotional numbing, and hyperarousal) and problem alcohol use following trauma exposure. This study was a longitudinal survey of randomly selected traumatic injury patients interviewed at baseline, 3 months, 12 months, and 24 months following injury. Participants were 1,139 injury patients recruited upon admission from 4 Level 1 trauma centers across Australia. Participants were assessed using the Clinician Administered PTSD Scale and Alcohol Use Disorders Identification Test. Results indicated that high levels of re-experiencing, effortful avoidance, and hyperarousal symptoms at 12 months were associated with greater increases (or smaller decreases) in problem alcohol use between 12 and 24 months. Findings also suggested that high levels of problem alcohol use at 12 months were associated with greater increases (or smaller decreases) in emotional numbing symptoms between 12 and 24 months. These findings highlight the critical importance of the chronic period following trauma exposure in the relationship between PTSD symptoms and problem alcohol use.

O’Donnell, M., Alkemade, N., Nickerson, A., Creamer, M., McFarlane, A., Silove, D., Bryant, R., &  Forbes, D. (2014). The impact of the diagnostic changes to posttraumatic stress disorder for DSM-5 and the proposed changes to ICD-11. British Journal of Psychiatry, 205(3), 5. doi: 10.1192/bjp.bp.113.135285

Background: There have been changes to the criteria for diagnosing post-traumatic stress disorder (PTSD) in DSM-5 and changes are proposed for ICD-11.

Aims: To investigate the impact of the changes to diagnostic criteria for PTSD in DSM-5 and the proposed changes in ICD-11 using a large multisite trauma-exposed sample and structured clinical interviews.

Method: Randomly selected injury patients admitted to four hospitals were assessed 72 months post trauma (n = 510). Structured clinical interviews for PTSD and major depressive episode, as well as self-report measures of disability and quality of life were administered.

Results: Current prevalence of PTSD under DSM-5 scoring was not significantly different from DSM-IV (6.7% v. 5.9%, z = 0.53, P = 0.59). However, the ICD-11 prevalence was significantly lower than ICD-10 (3.3% v. 9.0%, z = –3.8, P<0.001). The PTSD current prevalence was significantly higher for DSM-5 than ICD-11 (6.7% v. 3.3%, z = 2.5, P = 0.01). Using ICD-11 tended to show lower rates of comorbidity with depression and a slightly lower association with disability.

Conclusions: The diagnostic systems performed in different ways in terms of current prevalence rates and levels of comorbidity with depression, but on other broad key indicators they were relatively similar. There was overlap between those with PTSD diagnosed by ICD-11 and DSM-5 but a substantial portion met one but not the other set of criteria. This represents a challenge for research because the phenotype that is studied may be markedly different according to the diagnostic system used.

Pfitzer, B., Katona, L. J., Lee, S. J., O’Donnell, M., Cleland, H., Wasiak, J., & Ellen, S. (2014). Three years after Black Saturday: Long-term psychosocial adjustment of burns patients as a result of a major bushfire. Journal of Burn Care and Research, 37(3). doi: 10.1097/BCR.0000000000000223

Despite increasing evidence that burn injuries can result in multiple psychological sequelae, little is known about the long-term psychosocial adjustment to burns sustained in a major bushfire. The aim of the present study was to assess long-term psychological distress and health-related quality of life in Australian burns patients as a result of the 2009 Black Saturday bushfires. Eight male and five female burns patients with a mean age of 53.92 (SD = 11.82) years who received treatment at a statewide burns service participated in the study. A battery of standardized questionnaires was administered to assess general psychological distress, burns-specific and generic health-related quality of life, alcohol use, and specific psychological symptoms of posttraumatic stress disorder, depression, and anxiety. The results revealed that more than 3 years after Black Saturday 33% of the burns patients still suffered “high” to “very high” levels of general distress, whereas 58% fulfilled partial or full criteria for posttraumatic stress disorder. Furthermore, participants still experienced significantly impaired physical health functioning as compared to their preinjury status including limitations in work-based activities, increased bodily pain, and lower vitality overall. The trajectory of distress varied for participants. Some individuals experienced little distress overall, whereas others displayed a decline in their stress levels over time. Notwithstanding, some patients maintained high levels of distress throughout or experienced an increase in distress at a later stage of recovery. The results point to the importance of psychosocial screening to identify distress early. Follow-up assessments are crucial to diagnose individuals with chronic or late onset of distress.

Phelps, A. J., Creamer, M., Hopwood, M., & Forbes, D. (2014). Features of posttraumatic dreams related to PTSD severity. Journal of Traumatic Stress Disorders & Treatment, 3(3), 6. doi: http://dx.doi.org/10.4172/2324-8947.1000127

Objective: As a first step towards understanding the difference between PTSD dreams (a distressing symptom of psychological disorder) and non-PTSD dreams (possibly serving an adaptive emotional processing function) following trauma, this research investigated which features of PTSD dreams are associated with PTSD severity.

Method: The sample comprised 40 veterans and 20 civilians with PTSD. Dream phenomenology (structured interview), as well as dream related sleep disturbance and the individual’s response tothe dream were assessed.

Results: A series of linear multivariate regression analyses demonstrated that dreams associated with the most severe PTSD were distinguished by the individual’s response to the experience of the dream.

Conclusions: The individual’s response to their dreams – prior to sleep, on awakening and throughout the day – may serve tomaintain posttraumatic dreams in a dysfunctional cycle of fear, arousal and avoidance, and may explain why some posttraumatic dreams persist while others resolve over time. The findings have the potential to enhance the assessment and treatment of this complex condition.

Rees, S., Steel, Z., Creamer, M., Teesson, M., Bryant, R. A., McFarlane, A. C., Mills, K. L., Slade, T., Carragher, N., O'Donnell, M., Forbes, D., & Silove, D. (2014). Onset of common mental disorders and suicidal behavior following women's first exposure to gender based violence: A retrospective, population-based study. BMC Psychiatry, 24(1), 8. doi: 10.1186/s12888-014-0312-x

Background: This analysis is based on a survey questionnaire designed to describe medical educators' views of psychiatry and psychiatrists. Our goals in this paper were to assess the psychometric properties of the survey questions by (a) using exploratory factor analysis to identify the basic factor structure underlying 37 survey items; (b) testing the resulting factor structure using confirmatory factor analysis; and (c) assessing the internal reliability of each identified factor. To our knowledge, this is the first attempt to use these techniques to psychometrically assess a scale measuring the strength of stigma that medical educators attached to psychiatry.

Methods: Survey data were collected from a random sample of 1,059 teaching faculty in 23 academic teaching sites in 15 countries. We conducted exploratory and confirmatory factor analysis to identify the scale structure and Cronbach's alpha to assess internal consistency of the resulting scales.

Results: Results showed that a two-factor solution was the best fit for the data. Following exploratory factor analysis, we conducted confirmatory factor analysis on a split half of the sample. Results highlighted several items with low loadings. Excluding factors with low correlations and allowing for several correlated variances resulted in a good fitting model explaining 95% of the variance in the data.

Conclusions: We identified two unidimensional scales. The Images Scale contained 11 items measuring stereotypic content concerning psychiatry and psychiatrists. The Efficacy of Psychiatry Scale contained 5 items addressing perceptions of the challenges and effectiveness of psychiatry as a discipline.

Wade, D., Crompton, D., Howard, A., Stevens, N., Metcalf, O., Brymer, M., Ruzek, J., Watson, P., Bryant, R., & Forbes, D. (2014). Skills for Psychological Recovery: Evaluation of a post-disaster mental health training program. Disaster Health, 2(3-4). doi: 10.1080/21665044.2015.1085625

Skills for Psychological Recovery (SPR) is a brief skills-based approach to assist community members to better cope after a disaster or other tragedy. This paper reports on an evaluation of a large SPR training and support program following floods and cyclones in Queensland, Australia. The program sought to recruit, train and support competent SPR trainers; provide systematic high-quality training in SPR skills for practitioners; improve the confidence of a large number of practitioners to use SPR; and encourage practitioners' use of SPR with community members. Trainers recruited to the program facilitated 49 training sessions for 788 practitioners across Queensland. Trainers were assessed by practitioners to have high-level competencies to run training sessions. Practitioners reported improved confidence to use each SPR intervention following training and at 6 months post-training. Based on available data, more than 6 out of 10 practitioners used an SPR intervention during the follow up period, with each intervention used by over half of the practitioners at both 3 and 6 months. The most frequently reported barrier to using SPR was not having seen a community member with problems requiring SPR. For trainers, a psychology background and cognitive-behavioral therapy (CBT) orientation were unrelated to their competencies to facilitate practitioner training sessions. For practitioners, a psychology background and to some extent a CBT orientation were related to confidence to use SPR interventions. In summary, this study provides details of an evaluation of a large-scale mental health training and support program to enhance response to meet the mental health needs of those affected by disaster.

Wade, D., Fletcher, S., Carty, J., & Creamer, M. (2014). Posttraumatic stress disorder in women. In D. Castle, J. Kulkarni, and K. Abel (Eds.), Mood and Anxiety in Women. New York: Cambridge University Press

2013 PUBLICATIONS

Biehn, T. L., Elhai, J. D., Seligman, L. D., Tamburrino, M., Armour, C., & Forbes, D. (2013). Underlying dimensions of DSM-5 posttraumatic stress disorder and major depressive disorder symptoms. Psychological Injury and Law, 6(4), 290-298. doi: 10.1007/s12207-013-9177-4

This study examined the relationship between the underlying latent factors of major depression symptoms and DSM-5 posttraumatic stress disorder (PTSD) symptoms (American Psychiatric Association, 2013). A nonclinical sample of 266 participants with a trauma history participated in the study. Confirmatory factor analyses were conducted to evaluate the fit of the DSM-5 PTSD model and dysphoria model, as well as a depression model comprised of somatic and nonsomatic factors. The DSM-5 PTSD model demonstrated somewhat better fit over the dysphoria model. Wald tests indicated that PTSD’s negative alterations in cognitions and mood factor was more strongly related to depression’s nonsomatic factor than its somatic factor. This study furthers a nascent line of research examining the relationship between PTSD and depression factors in order to better understand the nature of the high comorbidity rates between the two disorders. Moreover, this study provides an initial analysis of the new DSM-5 diagnostic criteria for PTSD.

Bryant, R., O'Donnell M., Creamer M., Mc Farlane, A., & Silove, D. (2013). A multisite analysis of the fluctuating course of posttraumatic stress disorder. JAMA psychiatry, 70(8), 8. doi: 10.1001/jamapsychiatry.2013.1137

Objective:  To test the roles of initial psychiatric reactions, mild traumatic brain injury (MTBI), and ongoing stressors on delayed-onset PTSD. Design, Setting, and Participants  In this prospective cohort study, patients were selected from recent admissions to 4 major trauma hospitals across Australia. A total of 1084 traumatically injured patients were assessed during hospital admission from April 1, 2004, through February 28, 2006, and 785 (72.4%) were followed up at 3, 12, and 24 months after injury.

Main Outcome and Measure:  Severity of PTSD was determined at each assessment with the Clinician-Administered PTSD Scale.

Results:  Of those who met PTSD criteria at 24 months, 44.1% reported no PTSD at 3 months and 55.9% had subsyndromal or full PTSD. In those who displayed subsyndromal or full PTSD at 3 months, PTSD severity at 24 months was predicted by prior psychiatric disorder, initial PTSD symptom severity, and type of injury. In those who displayed no PTSD at 3 months, PTSD severity at 24 months was predicted by initial PTSD symptom severity, MTBI, length of hospitalization, and the number of stressful events experienced between 3 and 24 months.

Conclusions and Relevance:  These data highlight the complex trajectories of PTSD symptoms over time. This study also points to the roles of ongoing stress and MTBI in delayed cases of PTSD and suggests the potential of ongoing stress to compound initial stress reactions and lead to a delayed increase in PTSD symptom severity. This study also provides initial evidence that MTBI increases the risk of delayed PTSD symptoms, particularly in those with no acute symptoms.One of the most poorly understood presentations of posttraumatic stress disorder (PTSD) is delayed-onset PTSD, which is defined as the onset of symptoms at least 6 months after trauma exposure. Meta-analyses estimated that delayed-onset PTSD occurs in approximately 25% of cases of PTSD. Delayed-onset PTSD is more likely after a period of subsyndromal PTSD (usually defined as meeting at least 2 of the 3 symptom clusters) in the acute symptom period. In addition, however, meta-analyses indicate that PTSD can develop after a protracted symptom-free period. Hence, questions remain about the sequencing of symptom development over time in the pathway to delayed-onset PTSD.Data concerning the mechanisms of delayed-onset PTSD are scant. In terms of acute predictors, delayed-onset cases have been associated with stronger PTSD reactions in the period immediately after trauma exposure, as well as elevated heart rate after trauma4 (relative to asymptomatic people in the acute phase). Cumulative stressors in the aftermath of trauma are greater in those who develop delayed-onset PTSD relative to those who maintain their symptom-free status over time, although not all studies have observed this pattern. These findings suggest that delayed reactions after a period of apparent absence of symptoms may be fueled by acute fear reactions that are subsequently compounded by stressors in the subsequent period. The evidence is limited, however, by the cross-sectional design of studies that rely on retrospective recall of symptoms, small sample sizes, and/or abbreviated or self-reported measurement of PTSD symptoms.The aims of this study were to examine longitudinally the trajectory of PTSD symptoms and to identify the factors associated with delayed-onset PTSD symptoms. The current study describes a multisite, longitudinal investigation of trauma injury survivors who were assessed for PTSD symptoms during hospitalization and again at 3, 12, and 24 months after the trauma. To evaluate delayed-onset posttraumatic stress to the initial trauma, we ensured that PTSD symptoms (particularly reexperiencing and avoidance) were indexed in relation to the initiating traumatic event.

Contractor, A. A., Armour, C., Wang, X., Forbes, D., & Elhai, J. D. (2013). The mediating role of anger in the relationship between PTSD symptoms and impulsivity. Psychological Trauma: Theory, Research, Practice, and Policy, 7(2), 8. doi: 10.1037/a0037112

Research indicates a significant relationship between posttraumatic stress disorder (PTSD) and anger (Olatunji, Ciesielski, & Tolin, 2010; Orth & Wieland, 2006). Individuals may seek urgent coping to deal with the distress of anger, which is a mobilizing and action-oriented emotion (Novaco & Chemtob, 2002); possibly in the form of impulsive actions consistent with impulsivity's association with anger (Milligan & Waller, 2001; Whiteside & Lynam, 2001). This could be one of the explanations for the relationship between PTSD and impulsivity (Kotler, Julian, Efront, & Amir, 2001; Ledgerwood & Petry, 2006). The present study assessed the mediating role of anger between PTSD (overall scores and subscales of arousal and negative alterations in mood/cognitions) and impulsivity, using gender as a covariate of impulsivity. The PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), Dimensions of Anger Reaction scale-5, and the UPPS Impulsivity Scale were administered to a sample of 244 undergraduate students with a trauma history. Results based on 1000 bootstrapped samples indicated significant direct effects of PTSD (overall and 2 subscales) on anger, of anger on impulsivity, and of PTSD (overall and 2 subscales) on impulsivity. Further, anger significantly mediated the relationship between PTSD (overall and 2 subscales) and impulsivity, consistent with the hypothesized models. Results suggest that impulsivity aims at coping with distressing anger, possibly explaining the presence of substance usage, and other impulsive behaviors in people with PTSD. Further, anger probably serves as a mobilizing and action-oriented emotion coupled with PTSD symptoms.

Contractor, A. A., Elhai, J., Ractliffe, K. C., & Forbes, D. (2013). PTSD’s underlying symptom dimensions and relations with behavioral inhibition and activation. Journal of Anxiety Disorders, 27(7), 645-651. doi: http://dx.doi.org/10.1016/j.janxdis.2013.07.007

Reinforcement sensitivity theory (RST) stipulates that individuals have a behavioral activation system (BAS) guiding approach (rewarding) behaviors (Gray 1971), and behavioral inhibition system (BIS) guiding conflict resolution between approach and avoidance (punishment) behaviors (Gray & McNaughton, 2000). Posttraumatic stress disorder (PTSD) severity overall relates to both BIS (e.g., Myers, VanMeenen, & Servatius, 2012; Pickett, Bardeen, & Orcutt, 2011) and BAS (Pickett et al., 2011). Using a more refined approach, we assessed specific relations between PTSD's latent factors (Simms, Watson, & Doebbeling, 2002) and observed variables measuring BIS and BAS using 308 adult, trauma-exposed primary care patients. Confirmatory factor analysis and Wald chi-square tests demonstrated a significantly greater association with BIS severity compared to BAS severity for PTSD's dysphoria, avoidance, and re-experiencing factors. Further, PTSD's avoidance factor significantly mediated relations between BIS/BAS severity and PTSD's dysphoria factor.

Forbes, D. (2013). Mental trauma - a workplace casualty. Fire Australia, Summer, 42-43.

Forbes, D., & Bryant, R. A. (2013). When the violence of war comes home. Lancet, 381(9869 ), 2. doi:10.1016/S0140-6736(13)60629-7

Forbes, D., Fletcher, S., Phelps, A., Wade, D. J., O'Donnell, M., & Creamer, M. (2013). Impact of combat and non-military trauma exposure on symptom reduction following treatment for veterans with posttraumatic stress disorder. Psychiatry Research, 206(1), 3. doi: 10.1016/j.psychres.2012.09.037

Military veterans with posttraumatic stress disorder (PTSD) frequently report exposure to multiple other traumas in addition to their military experiences. This study aimed to examine the impact of exposure-related factors for military veterans with PTSD on recovery after participation in a group-based treatment program. Subjects included 1548 military veterans with PTSD participating in specialist veterans' PTSD programs across Australia. The study included measures of PTSD, depression, anxiety and alcohol use. Analyses of variance found higher combat exposure was associated with more severe PTSD at intake. No differences in PTSD intake severity were evident in those with additional non-military trauma. Severity of combat exposure did not affect treatment outcomes, although those with low combat exposure and additional non-military trauma (which included high rates of molestation) did report reduced symptom improvement. These findings have implications for considerations of optimal interventions for those with lower levels of combat exposure and additional non-military trauma.

Gibbs, L., Waters, E., Bryant, R., Pattison, P., Lusher, D., Harms, L., Richardson, J., MacDougall, C., Block, K., Snowdon, E., Gallagher, H C., Sinnott, V., Ireton, G., & Forbes, D. (2013). Beyond Bushfires: Community, Resilience and Recovery - A longitudinal mixed method study of the medium to long term impacts of  bushfires on mental health and social connectedness. BMC Public Health, 13, 1036. https://doi.org/10.1186/1471-2458-13-1036

Background: Natural disasters represent an increasing threat both in terms of incidence and severity as a result of climate change. Although much is known about individual responses to disasters, much less is known about the social and contextual response and how this interacts with individual trajectories in terms of mental health, wellbeing and social connectedness. The 2009 bushfires in Victoria, Australia caused much loss of life, property destruction, and community disturbance. In order to progress future preparedness, response and recovery, it is crucial to measure and understand the impact of disasters at both individual and community levels.

Methods: This study aims to profile the range of mental health, wellbeing and social impacts of the Victorian 2009 bushfires over time using multiple methodologies and involving multiple community partners. A diversity of communities including bushfire affected and unaffected will be involved in the study and will include current and former residents (at the time of the Feb 2009 fires). Participants will be surveyed in 2012, 2014 and, funding permitting, in 2016 to map the predictors and outcomes of mental health, wellbeing and social functioning. Ongoing community visits, as well as interviews and focus group discussions in 2013 and 2014, will provide both contextual information and evidence of changing individual and community experiences in the medium to long term post disaster. The study will include adults, adolescents and children over the age of 5.

Discussion: Conducting the study over five years and focussing on the role of social networks will provide new insights into the interplay between individual and community factors and their influence on recovery from natural disaster over time. The study findings will thereby expand understanding of long term disaster recovery needs for individuals and communities.

Gleeson, J. F. M., Cotton, S. M., Alvarez-Jimenez, M., Wade, D., Gee, D., Crisp, K., Pearce, P., Spiliotacopoulos, D., Newman, B., & McGorry, P. (2013). A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients: Outcome at 30-months follow up. Schizophrenia Bulletin, 39(2), 436-448. doi: 10.1093/schbul/sbr165

The effectiveness of a novel 7-month psychosocial treatment designed to prevent the second episode of psychosis was evaluated in a randomized controlled trial at 2 specialist first-episode psychosis (FEP) programs. An individual and family cognitive behavior therapy for relapse prevention was compared with specialist FEP care. Forty-one FEP patients were randomized to the relapse prevention therapy (RPT) and 40 to specialist FEP care. Participants were assessed on an array of measures at baseline, 7- (end of therapy), 12-, 18-, 24-, and 30-month follow-up. At 12-month follow-up, the relapse rate was significantly lower in the therapy condition compared with specialized treatment alone (P = .039), and time to relapse was significantly delayed for those in the relapse therapy condition (P = .038); however, such differences were not maintained. Unexpectedly, psychosocial functioning deteriorated over time in the experimental but not in the control group; these differences were no longer statistically significant when between-group differences in medication adherence were included in the model. Further research is required to ascertain if the initial treatment effect of the RPT can be sustained. Further research is needed to investigate if medication adherence contributes to negative outcomes in functioning in FEP patients who have reached remission, or, alternatively, if a component of RPT is detrimental.

Harb, G. C., Phelps, A. J., Forbes, D., Ross, R. J., Gehrman, P. R., & Cook, J. M. (2013). A critical review of the evidence base of imagery rehearsal for posttraumatic nightmares: Pointing the way for future research. Journal of Traumatic Stress, 26(5), 9. doi: 10.1002/jts.21854

In this article, the authors provide information on key characteristics of imagery rehearsal treatment protocols and examine the quality of reporting of randomized controlled and uncontrolled trials of imagery rehearsal for treating posttraumatic nightmares. Using a reliable and valid scale, two independent psychologists rated 16 trials. Most reports provided insufficient information on a range of variables including the definition of treatment delivery (e.g., therapist supervision, treatment fidelity), description of the participant sample, data analysis (e.g., determination of sample size), and treatment assignment (e.g., randomization procedures). Low methodological quality and poor reporting can lead to inflation of estimates of treatment effects and inadequately substantiated conclusions, such as inflated effect sizes in meta-analytic studies. Numerous imagery rehearsal protocols exist, but in some cases are given different names and tested in pilot studies, slowing progression in the field. Randomized controlled trials of imagery rehearsal with credible comparison conditions, examination of predictors of dropout and outcome, as well as dismantling studies of imagery rehearsal treatment components are needed.

Holmes, A., Williamson O., Hogg, M., Arnold, C., & O'Donnell, M. (2013). Determinants of chronic pain 3 years after moderate or serious injury. Pain Medicine, 14(3), 8. doi: 10.1111/pme.12034

Objective: Patients with pain 3 years after injury are at risk of lifetime pain. It is not known if the predictors of chronic pain at 3 years are the same as those for earlier time points or whether other factors become important. Clarifying these factors will aid our understanding of the development of long-term pain and further inform the development of models for screening and early intervention for pain in the aftermath of injury.

Design: Patients admitted to two trauma centers underwent a comprehensive physical and psychological assessment of known and potential risk factors for chronic pain during their index admission. Three years after injury, these patients were assessed for the presence of chronic pain (score was ≥5 on an 11-point numerical rating scale during the last episode of pain, and present in the last month and at least two times in the past week) and pain-related disability. Logistic regression was used to identify independent risk factors for the presence of chronic pain and disability.

Results: Two hundred and twenty patients (75.9% of the original cohort) were assessed at 3 years. Of these, 146 (66.7%) reported some pain and 52 (23.7%) reported chronic pain. Factors (present at the time of injury) that predicted chronic pain were lower socioeconomic status, pain severity, and injury severity. The predictive power of these combined factors was modest.

Conclusions: Three years after serious injury, almost a quarter of patients report chronic pain, and more than a third report at least moderate pain-related disability. The predicative power of measures taken in the acute setting is not enough to support discharge screening alone as a method of triaging high-risk patients to early intervention.

O'Donnell, M. L., Varker, T., Creamer M.C., Holmes, A. C., Ellen, S., Wade, D., Silove, D., McFarlane, A., Bryant, R. A., & Forbes, D. (2013). Disability after injury: The cumulative burden of physical and mental health.  Journal of Clinical Psychiatry, 74(2), 7. doi:10.4088/JCP.12m08011

Objective: The main aim of the study was to model the direct and indirect pathways to long-term disability after injury. specifically, the relationships between 3 groups of variables and long-term disability were examined over time. these included physical factors (including injury characteristics and premorbid disability), pain severity (including pain at 1 week and 12 months), and psychiatric symptoms (including psychiatric history and posttraumatic stress, depression, and anxiety symptoms at 1 week and 12 months).

Design, Setting,and Participants: a multisite, longitudinal cohort study of 715 randomly selected injury patients (from april 2004 to february 2006). participants were assessed just prior to discharge (mean = 7.0 days, sd = 7.8 days) and reassessed at 12 months postinjury. injury patients who experienced moderate/severe traumatic brain injury and spinal cord injury were excluded from the study.

Main Outcome Measure: the world health organization disability assessment schedule 2.0 was used to assess disability at 12 months after injury.

Results: disability at 12 months was up to 4 times greater than community norms, across all age groups. the development and maintenance of long-term disability occurred through a complex interaction of physical factors, pain severity across time, and psychiatric symptoms across time. while both physical factors and pain severity contributed significantly to 12-month disability (pain at 1 week: total effect [te] = 0.2, standard error [se] < 0.1; pain at 12 months: te = 0.3, se < 0.1; injury characteristics: te = 0.3, se < 0.1), the total effects of psychiatric symptoms were substantial (psychiatric symptoms 1 week: te = 0.30, se < 0.1; psychiatric symptoms 12 months: te = 0.71, se < 0.1). taken together, psychiatric symptoms accounted for the largest proportion of the variance in disability at 12 months.

Conclusions: while the physical and pain consequences of injury contribute significantly to enduring disability after injury, psychiatric symptoms play a greater role. early interventions targeting psychiatric symptoms may play an important role in improving functional outcomes after injury.

O’Donnell, M. L., Varker, T., Creamer, M., Fletcher, S., McFarlane, A. C., Silove, D., Bryant, R. A., & Forbes, D. (2013). Exploration of delayed-onset posttraumatic stress disorder after severe injury. Psychosomatic Medicine, 75(1), 68-75. doi: 10.1097/PSM.0b013e3182761e8b

Objective: The first aim of this work was to conduct a rigorous longitudinal study to identify rates of delayed-onset posttraumatic stress disorder (PTSD) in a sample of patients with severe injury. The second aim was to determine what variables differentiated delayed-onset PTSD from chronic PTSD.

Methods: Randomly selected patients with injury who were admitted to four hospitals around Australia were recruited to the study (N = 834) and assessed in the acute care hospital, at 3 months, and at 12 months. A structured clinical interview was used to assess PTSD at each time point.

Results: Seventy-three patients (9%; n = 73) had PTSD at 12 months. Of these, 39 (53%) were classified as having delayed-onset PTSD. Furthermore, 22 (56%) patients with delayed-onset PTSD had minimal PTSD symptoms at 3 months (i.e., they did not have partial/subsyndromal PTSD at 3 months). The variables that differentiated delayed-onset PTSD from chronic PTSD were greater injury severity (odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.02–1.26), lower anxiety severity at 3 months (OR = 0.73; 95% CI = 0.61–0.87), and greater pain severity at 3 months (OR = 1.39; 95% CI = 1.06–1.84).

Conclusions: Delayed-onset PTSD occurred frequently in this sample. Approximately half of the patients with delayed-onset PTSD had minimal PTSD symptoms at 3 months; therefore, their delayed-onset PTSD could not be accounted for by a small number of fluctuating symptoms. As we move toward DSM-V, it is important that research continues to explore the factors that underpin the development of delayed-onset PTSD

Phelps, A., & Forbes, D. (2013). Treating posttraumatic stress disorder-related dreams: What are the options? Expert Review of Neurotherapeutics, 12(11), 1267-1269.

Phelps, A., Dell, L., & Forbes, D. (2013). New guidelines for treatment of acute stress disorder and posttraumatic stress disorder. Update for psychologists. InPsych, 35, 32-33.

Reifels, L., Bassilios, B., Forbes, D., Creamer, M., Wade, D., Coates, S., Hopwood, M., & Pirkis, J. (2013). A systematic approach to building the mental health response capacity of practitioners in a postdisaster context. Advances in Mental Health, 11(3), 10. doi: 10.5172/jamh.2013.11.3.246

This paper presents the results of a summative evaluation of the training component of the Australian Government Mental Health Response to the 2009 bushfires in Victoria, Australia. With very little evidence available to date on comprehensive attempts at implementing multilevel training frameworks in the wake of natural disasters, the evaluation provides valuable insights into an effort that sought to build the capacity of practitioners to respond to the psychosocial and mental health consequences of a significant bushfire disaster at various levels of the response system. Key findings of the evaluation are discussed with regards to their relevance for the training of mental health practitioners in a broader range of disaster circumstances.

Reifels, L., Pietrantoni, L., Prati, G., Kim, Y., Kilpatrick, D., Halpern, J., Olff, M., Brewin, C., & O’Donnell, M. (2013). Lessons learned about psychosocial responses to disaster and mass trauma: An international perspective. European Journal of Psychotraumatology, 4. doi: 10.3402/ejpt.v4i0.22897

At the 13th meeting of the European Society for Traumatic Stress Studies in 2013, a symposium was held that brought together international researchers and clinicians who were involved in psychosocial responses to disaster. A total of six disasters that occurred in five countries were presented and discussed. Lessons learned from these disasters included the need to: (1) tailor the psychosocial response to the specific disaster, (2) provide multi-dimensional psychosocial care, (3) target at-risk population groups, (4) proactively address barriers in access to care, (5) recognise the social dimensions and sources of resilience, (6) extend the roles for mental health professionals, (7) efficiently coordinate and integrate disaster response services, and (8) integrate research and evaluation into disaster response planning.

Semage, S., Sivayogan, S., Forbes, D., O’Donnell, M., Monaragala, R., Lockwood, E., & Dunt, D. (2013). Cross-cultural and factorial validity of PTSD check list—military version (PCL-M) in Sinhalese language.  European Journal of Psychotraumatology, 4, 1-8. doi: A1510.3402/ejpt.v4i0.19707

Objective: The purpose of this research was to establish the cross-cultural and structural validity of the PTSD Check List—Military Version (PCL-M) translated into Sinhalese.

Methods: Expert committee consensus generation as well as translation–back translation approaches were used to establish the semantic, conceptual, and content equivalence of the Sinhalese and English versions of the PCL-M. Four translations of each item were made. In the absence of any “gold standard” psychometric instrument in Sinhalese to establish the criterion validity for the PCL-M (SIN), the study utilized more informal checks for assessment of validity and Sri Lankan cutoffs for caseness for PTSD to establish the psychometric strength of the translated instrument along with standard reliability analysis.

Confirmatory factor analysis was performed on PCL-M scoring of a random sample of 1,586 soldiers to examine construct validity.

Results: Thirteen of the 17 items were selected by popular vote, and the remaining 4 through discussion and consensus. Reliability measured by Cronbach’s-α was 0.944 for the total scale and 0.812, 0.869, and 0.895 for the three DSM-IV sub-scales (re-experiencing, avoidance/numbing, and hyperarousal), respectively. The desired cutoff point for the translated instrument was determined to be 44.

The five-factor model by Elhai et al. and the four-factor model by King et al. fitted best, demonstrating good fit to all three fit indices, while the four-factor model and the DSM-IV three-factor model by Simms et al. only had acceptable levels of fit for root mean squared error of approximation. χ2 difference test comparing the two better-fitting models suggests that the five-factor model by Elhai et al. has the better fit.

Conclusion: The PCL-M (SIN) version is suitable for use in the study of PTSD in the Sri Lankan military forces, as judged by cross-cultural and construct validity as well as reliability.

Shultz, J. M., & Forbes, D. (2013). Psychological First Aid: Rapid proliferation and the search for evidence. 10. doi: http://dx.doi.org/10.4161/dish.26006

Psychological First Aid (PFA) has become the flagship early intervention for disaster survivors, with recent adaptations for disaster responders, in the post-9/11 era. PFA is broadly endorsed by expert consensus and integrated into guidelines for mental health and psychosocial support in disasters and extreme events. PFA frameworks are proliferating, with increasing numbers of models developed for delivery by a range of providers for use with an expanding array of target populations. Despite popularity and promotion there remains a dearth of evidence for effectiveness and recent independent reviews of PFA have highlighted this important gap. This commentary juxtaposes the current propagation of PFA against the compelling need to produce evidence for effectiveness and suggests a series of actions to prioritize and expedite real-time, real-event field evaluation of PFA.

Shultz, J. M., Forbes, D., Wald, D., Kelly, F., Solo-Gabriele, H. M., Rosen, A., Espinel, Z., McLean, A., Bernal, O., & Neria, Y. (2013). Trauma signature of the Great East Japan Disaster provides guidance for psychological consequences in the affected population. Disaster Medicine and Public Health Preparedness, 7(2), 14. doi:10.1017/dmp.2013.21

Objectives: On March 11, 2011, Japan experienced the largest earthquake in its history. The undersea earthquake launched a tsunami that inundated much of Japan's eastern coastline and damaged nuclear power plants, precipitating multiple reactor meltdowns. We examined open-source disaster situation reports, news accounts, and disaster-monitoring websites to gather event-specific data to conduct a trauma signature analysis of the event.

Methods: The trauma signature analysis included a review of disaster situation reports; the construction of a hazard profile for the earthquake, tsunami, and radiation threats; enumeration of disaster stressors by disaster phase; identification of salient evidence-based psychological risk factors; summation of the trauma signature based on exposure to hazards, loss, and change; and review of the mental health and psychosocial support responses in relation to the analysis.

Results: Exposure to this triple-hazard event resulted in extensive damage, significant loss of life, and massive population displacement. Many citizens were exposed to multiple hazards. The extremity of these exposures was partially mitigated by Japan's timely, expert-coordinated, and unified activation of an evidence-based mental health response.

Conclusions: The eastern Japan disaster was notable for its unique constellation of compounding exposures. Examination of the trauma signature of this event provided insights and guidance regarding optimal mental health and psychosocial responses. Japan orchestrated a model response that reinforced community resilience. (Disaster Med Public Health Preparedness. 2013;0:1-14)

Varker, T., Phelps, A., & Forbes, D. (2013). Principles for peer support programs in high-risk organisations. National Emergency Response, 26(1 ), 26-28.

Wade, D., Howard, A., Cooper, J., & Forbes, D. (2013). GP online learning program 'Managing disaster and trauma-related mental health problems'.

Wade, D., Howard, A., Fletcher, S., Cooper, J., & Forbes, D. (2013). Early response to psychological trauma: What GPs can do. Australian Family Physician, 42(9), 5.

Background: There is a high prevalence of psychological trauma exposure among primary care patients. General practitioners are well placed to provide appropriate support for patients coping with trauma.

Objective: This article outlines an evidence-based early response to psychological trauma.

Discussion: Psychological first aid is the preferred approach in providing early assistance to patients who have experienced a traumatic event. General practitioners can be guided by five empirically derived principles in their early response: promoting a sense of safety, calming, self efficacy, connectedness and hope. Structured psychological interventions, including psychological debriefing, are not routinely recommended in the first few weeks following trauma exposure. General practitioner self care is an important aspect of providing posttrauma patient care.

Wade, D., Varker, T., Forbes, D., & O'Donnell, M. (2014). The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) in the assessment of alcohol use disorders among acute injury patients. Alcoholism: Clinical and Experimental Research, 38(1), 6. doi: 10.1111/acer.12247

The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is a brief alcohol screening test and a candidate for inclusion in recommended screening and brief intervention protocols for acute injury patients. The objective of the current study was to examine the performance of the AUDIT-C to risk stratify injury patients with regard to their probability of having an alcohol use disorder.

Methods: Participants (n = 1,004) were from a multisite Australian acute injury study. Stratum-specific likelihood ratio (SSLR) analysis was used to examine the performance of previously recommended AUDIT-C risk zones based on a dichotomous cut-point (0 to 3, 4 to 12) and risk zones derived from SSLR analysis to estimate the probability of a current alcohol use disorder.

Results: Almost a quarter (23%) of patients met criteria for a current alcohol use disorder. SSLR analysis identified multiple AUDIT-C risk zones (0 to 3, 4 to 5, 6, 7 to 8, 9 to 12) with a wide range of posttest probabilities of alcohol use disorder, from 5 to 68%. The area under receiver operating characteristic curve (AUROC) score was 0.82 for the derived AUDIT-C zones and 0.70 for the recommended AUDIT-C zones. A comparison between AUROCs revealed that overall the derived zones performed significantly better than the recommended zones in being able to discriminate between patients with and without alcohol use disorder.

Conclusions: The findings of SSLR analysis can be used to improve estimates of the probability of alcohol use disorder in acute injury patients based on AUDIT-C scores. In turn, this information can inform clinical interventions and the development of screening and intervention protocols in a range of settings.