ImportanceImproved, efficient, and acceptable treatments are needed for combat-related posttrauma... more ImportanceImproved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD).ObjectiveTo determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD.Design, Setting, and ParticipantsThis randomized clinical trial was conducted among military personnel and veterans at 4 sites in Texas from 2017 to 2019. Assessors were blinded to conditions. Data were analyzed from November 2020 to October 2022.InterventionsThe interventions were massed-PE, which included 15 therapy sessions of 90 minutes each over 3 weeks, vs intensive outpatient program PE (IOP-PE), which included 15 full-day therapy sessions over 3 weeks with 8 treatment augmentations. The IOP-PE intervention was hypothesized to be superior to massed-PE.Main Outcomes and MeasuresCoprimary outcomes included the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (CAPS...
Posttraumatic headache is the most disabling complication of mild traumatic brain injury. Posttra... more Posttraumatic headache is the most disabling complication of mild traumatic brain injury. Posttraumatic stress disorder (PTSD) symptoms are often comorbid with posttraumatic headache, and there are no established treatments for this comorbidity. OBJECTIVE To compare cognitive behavioral therapies (CBTs) for headache and PTSD with treatment per usual (TPU) for posttraumatic headache attributable to mild traumatic brain injury. This was a single-site, 3-parallel group, randomized clinical trial with outcomes at posttreatment, 3-month follow-up, and 6-month follow-up. Participants were enrolled from May 1, 2015, through May 30, 2019; data collection ended on October 10, 2019. Post-9/11 US combat veterans from multiple trauma centers were included in the study. Veterans had comorbid posttraumatic headache and PTSD symptoms. Data were analyzed from January 20, 2020, to February 2, 2022. INTERVENTIONS Patients were randomly assigned to 8 sessions of CBT for headache, 12 sessions of cognitive processing therapy for PTSD, or treatment per usual for headache. MAIN OUTCOMES AND MEASURES Co-primary outcomes were headache-related disability on the 6-Item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5) assessed from treatment completion to 6 months posttreatment. RESULTS A total of 193 post-9/11 combat veterans (mean [SD] age, 39.7 [8.4] years; 167 male veterans [87%]) were included in the study and reported severe baseline headache-related disability (mean [SD] HIT-6 score, 65.8 [5.6] points) and severe PTSD symptoms (mean [SD] PCL -5 score, 48.4 [14.2] points). For the HIT-6, compared with usual care, patients receiving CBT for headache reported -3.4 (95% CI, -5.4 to -1.4; P < .01) points lower, and patients receiving cognitive processing therapy reported -1.4 (95% CI, -3.7 to 0.8; P = .21) points lower across aggregated posttreatment measurements. For the PCL-5, compared with usual care, patients receiving CBT for headache reported -6.5 (95% CI, -12.7 to -0.3; P = .04) points lower, and patients receiving cognitive processing therapy reported -8.9 (95% CI, -15.9 to -1.9; P = .01) points lower across aggregated posttreatment measurements. Adverse events were minimal and similar across treatment groups. CONCLUSIONS AND RELEVANCE This randomized clinical trial demonstrated that CBT for headache was efficacious for disability associated with posttraumatic headache in veterans and provided clinically significant improvement in PTSD symptom severity. Cognitive processing therapy was efficacious for PTSD symptoms but not for headache disability.
Extensive research has been conducted since 11 September 2001 to develop and evaluate evidence-ba... more Extensive research has been conducted since 11 September 2001 to develop and evaluate evidence-based treatments for combat-related posttraumatic stress disorder (PTSD) in active duty United States military personnel treated in the combat theater and in garrison. This chapter reviews the results of 20 PTSD clinical trials funded by the United States Department of Defense and Department of Veterans Affairs on the treatment of combat-related PTSD. All of the studies were conducted under the leadership and management of two research consortia: the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR) Consortium and the Consortium to Alleviate PTSD.
Posttraumatic headache (PTH) is a common debilitating condition arising from head injury and is h... more Posttraumatic headache (PTH) is a common debilitating condition arising from head injury and is highly prevalent among military service members and veterans with traumatic brain injury (TBI). Diagnosis and treatment for PTH is still evolving, and surprisingly little is known about the putative mechanisms that drive these headaches. This manuscript describes the design of a randomized clinical trial of two nonpharmacological (i.e., behavioral) interventions for posttraumatic headache. Design of this trial required careful consideration of PTH diagnosis and inclusion criteria, which was challenging due to the lack of standard clinical characteristics in
Posttraumatic stress disorder (PTSD) and alcohol use disorders (AUD) are two of the most common m... more Posttraumatic stress disorder (PTSD) and alcohol use disorders (AUD) are two of the most common mental health disorders affecting civilians as well as military populations. If left untreated, individuals with co-occurring PTSD/AUD are at increased risk for developing other mental health problems (e.g., depression, anxiety), physical health problems, reduced resiliency and military readiness, and vocational and social impairment. Substantial gaps in the treatment of co-occurring PTSD/AUD exist and there is a critical need to develop more effective pharmacological treatments. The current study addresses this gap in the literature by testing the efficacy and safety of doxazosin, a long-acting and selective alpha-1 adrenergic antagonist, as compared to placebo in reducing PTSD and AUD severity among U.S. military veterans. Noradrenergic dysregulation has been implicated in the development and maintenance of PTSD and AUD, and pilot studies examining doxazosin in PTSD-only or AUD-only sam...
Suicide rates among veterans have increased markedly since the onset of Operations Enduring Freed... more Suicide rates among veterans have increased markedly since the onset of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF; LeardMann et al., 2013). Identification of factors with the greatest contribution to suicide risk among veterans is needed to inform risk assessment and to identify intervention targets. This study examined predictors of suicide attempts among participants in the Veterans After-Discharge Longitudinal Registry; a nationwide cohort of OEF/OIF veterans enrolled in Department of Veterans Affairs (VA) services. Veterans with and without probable posttraumatic stress disorder (PTSD) were sampled at a 3:1 ratio, and male and female veterans were sampled at a 1:1 ratio. Participants (N = 1,649) were assessed at two time points, roughly 2 years apart (M = 28.74 months, SD = 8.72). Seventy-four participants (4.49%) attempted suicide during the follow-up period. The strongest predictors of suicide attempts among the full sample were suicidal intent, attempt history,...
Background: Posttraumatic stress disorder (PTSD) diagnostic criteria have been criticized for inc... more Background: Posttraumatic stress disorder (PTSD) diagnostic criteria have been criticized for including symptoms that overlap with commonly comorbid disorders, which critics argue undermines the validity of the diagnosis and inflates psychiatric comorbidity rates. In response, the upcoming 11th edition of the International Classification of Diseases (ICD-11) will offer PTSD diagnostic criteria that are intended to promote diagnostic accuracy. However, diagnostic utility analyses have not yet assessed whether these criteria minimize diagnostic errors. The present study examined the diagnostic utility of each PTSD symptom in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) for males and females. Methods: Participants were 1,347 individuals enrolled in a longitudinal national registry of returning veterans receiving care at a Department of Veterans Affairs (VA) facility. Doctoral level clinicians assessed all participants using the PTSD module of the Structured Clinical Interview for DSM. Results: Of the 20 symptoms examined, the majority performed in the fair to poor range on test quality indices. Although a few items did perform in the good (or better) range, only half were ICD-11 symptoms. None of the 20 symptoms demonstrated good quality of efficiency. Results demonstrated few sex differences across indices. There were no differences in the proportion of comorbid psychiatric disorders or functional impairment between DSM-5 and ICD-11 criteria. Conclusions: ICD-11 PTSD criteria demonstrate neither greater diagnostic specificity nor reduced rates of comorbidity relative to DSM-5 criteria and, as such, do not perform as intended. Modifications to existing symptoms or new symptoms may improve differential diagnosis.
Public reporting burden for this collection of information is estimated to average 1 hour per res... more Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time fo r reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing this collection of information. Send comments regarding this burde n estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS.
Public reporting burden for this collection of information is estimated to average 1 hour per res... more Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing this collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS.
Recent proposals for revisions to the 11th edition of the International Classification of Disease... more Recent proposals for revisions to the 11th edition of the International Classification of Diseases (ICD-11) posttraumatic stress disorder (PTSD) diagnostic criteria have argued that the current symptom constellation under the Diagnostic and Statistical Manual of Mental Disorders-5 is unwieldy and includes many symptoms that overlap with other disorders. The newly proposed criteria for the ICD-11 include only 6 symptoms. However, restricting the symptoms to those included in the ICD-11 has implications for PTSD diagnosis prevalence estimates, and it remains unclear whether these 6 symptoms are most strongly associated with a diagnosis of PTSD. Network analytic methods, which assume that psychiatric disorders are networks of interrelated symptoms, provide information regarding which symptoms are most central to a network. We estimated network models of PTSD in a national sample of veterans of the Iraq and Afghanistan wars. In the full sample, the most central symptoms were persistent ...
The World Health Organization's posttraumatic stress disorder (PTSD) work group has published... more The World Health Organization's posttraumatic stress disorder (PTSD) work group has published a proposal for the forthcoming edition of the International Classification of Diseases (ICD-11) that would yield a very different diagnosis relative to DSM-5. This study examined the impact of the proposed ICD-11 changes on PTSD prevalence relative to the ICD-10 and DSM-5 definitions and also evaluated the extent to which these changes would accomplish the stated aim of reducing the comorbidity associated with PTSD. Diagnostic prevalence estimates were compared using a U.S. national community sample and two U.S. Department of Veterans Affairs clinical samples. The ICD-11 definition yielded prevalence estimates 10-30% lower than DSM-5 and 25% and 50% lower than ICD-10 with no reduction in the prevalence of common comorbidities. Findings suggest that by constraining the diagnosis to a narrower set of symptoms, the proposed ICD-11 criteria set would substantially reduce the number of indiv...
This study examined the psychometric properties of the posttraumatic stress disorder (PTSD) Check... more This study examined the psychometric properties of the posttraumatic stress disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5; Weathers, Litz, et al., 2013b) in 2 independent samples of veterans receiving care at a Veterans Affairs Medical Center (N = 468). A subsample of these participants (n = 140) was used to define a valid diagnostic cutoff score for the instrument using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, et al., 2013) as the reference standard. The PCL-5 test scores demonstrated good internal consistency (α = .96), test-retest reliability (r = .84), and convergent and discriminant validity. Consistent with previous studies (Armour et al., 2015; Liu et al., 2014), confirmatory factor analysis revealed that the data were best explained by a 6-factor anhedonia model and a 7-factor hybrid model. Signal detection analyses using the CAPS-5 revealed that PCL-5 scores of 31 to 33 were optimall...
A longitudinal life span model of factors contributing to later-life positive adjustment was test... more A longitudinal life span model of factors contributing to later-life positive adjustment was tested on 567 American repatriated prisoners from the Vietnam War. This model encompassed demographics at time of capture and attributes assessed after return to the United States (reports of torture and mental distress) and approximately three decades later (later-life stressors, perceived social support, positive appraisal of military experiences, and positive adjustment). Age and education at time of capture and physical torture were associated with repatriation mental distress, which directly predicted poorer adjustment 30 years later. Physical torture also had a salutary effect, enhancing later-life positive appraisal of military experiences. Later-life events were directly and indirectly (through concerns about retirement) associated with positive adjustment. Results suggest that the personal resources of older age and more education and early-life adverse experiences can have cascadin...
This study sought to further examine the relationship between compensation-seeking status and rep... more This study sought to further examine the relationship between compensation-seeking status and reporting of symptoms among combat veterans who were evaluated for posttraumatic stress disorder (PTSD). Archival data were drawn for 320 adult male combat veterans who were consecutively evaluated at a Department of Veterans Affairs (VA) PTSD outpatient clinic from 1995 to 1999. The veterans were compared on variables from their clinical evaluation, including diagnostic status and self-report measures such as the Minnesota Multiphasic Personality Inventory-2, which includes scales designed to detect feigned or exaggerated psychopathology. Compensation-seeking veterans reported significantly more distress across domains of psychopathology, even after the effects of income had been controlled for and despite an absence of differences in PTSD diagnoses between groups. However, compensation-seeking veterans also were much more likely to overreport or exaggerate their symptoms than were non-com...
The diagnostic criteria for posttraumatic stress disorder (PTSD) were substantially revised for D... more The diagnostic criteria for posttraumatic stress disorder (PTSD) were substantially revised for Diagnostic and Statistical Manual of Mental Disorders-5th edition (DSM-5). This in turn necessitated revision of DSM-correspondent assessment measures of PTSD. We describe the various changes to the PTSD diagnostic criteria and the corresponding changes to National Center for PTSD measures. We also discuss the implications of the new criteria for assessment of trauma exposure and PTSD. Although the DSM-5 version of PTSD departs significantly in some respects from previous versions, we conclude that there is fundamental continuity with the original DSM-III conceptualization of PTSD as a chronic, debilitating mental disorder that develops in response to catastrophic life events.
The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reformulated... more The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reformulated posttraumatic stress disorder (PTSD) based partially on research showing there were 4 main factors that underlie the symptoms of the disorder. The primary aim of this study was to examine the temporal stability of the DSM-5 factors as measured by the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5; Weathers et al., 2010). Confirmatory factor analyses were conducted to examine the structure of DSM-5 PTSD, and temporal stability over 3 time points was examined to determine if the measure reflects a consistent construct over time. Our sample was 507 combat-exposed veterans of Iraq and Afghanistan who enrolled in an online intervention for problem drinking and combat-related stress (Brief et al., 2013). We administered the PCL-5 at baseline, 8-week postintervention, and 3-month follow-up assessments. The DSM-5 model provided an adequate fit to the data at baseline. Tests of equalit...
Posttraumatic stress disorder (PTSD) is a psychiatric disorder that affects 7-8% of the general U... more Posttraumatic stress disorder (PTSD) is a psychiatric disorder that affects 7-8% of the general U.S. population at some point during their lifetime; however, the prevalence is much higher among certain subgroups, including active duty military personnel and veterans. In this article, we review the empirical literature on the epidemiology and screening of PTSD in military and veteran populations, including the availability of sensitive and reliable screening tools. Although estimates vary across studies, evidence suggests that the prevalence of PTSD in deployed U.S. military personnel may be as high as 14 -16%. Prior studies have identified trauma characteristics and pre-and posttrauma factors that increase risk of PTSD among veterans and military personnel. This information may help to inform prevention and screening efforts, as screening programs could be targeted to high-risk populations. Large-scale screening efforts have recently been implemented by the U.S. Departments of Defense and Veterans Affairs. Given the prevalence and potential consequences of PTSD among veterans and active duty military personnel, development and continued evaluation of effective screening methods is an important public health need.
This study examined the psychometric properties of the Minnesota Multiphasic Personality Inventor... more This study examined the psychometric properties of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Restructured Clinical Scales (RCSs) in individuals with posttraumatic stress disorder (PTSD) receiving clinical services at Veterans Affairs medical centers. Study 1 included 1,098 men who completed the MMPI-2 and were assessed for a range of psychological disorders via structured clinical interview. Study 2 included 136 women who completed the MMPI-2 and were interviewed with the Clinician Administered Scale for PTSD. The utility of the RCSs was compared to that of the Clinical Scales (CSs) and the Keane PTSD (PK) scale. The RCSs demonstrated good psychometric properties along with patterns of associations with other measures of psychopathology that corresponded to current theory regarding the structure of comorbidity. A notable advantage of the RCSs compared to the MMPI-2 CSs was their enhanced construct validity and clinical utility in the assessment of comorbid internalizing and externalizing psychopathology. The PK scale demonstrated incremental validity in the prediction of PTSD beyond that of the RCSs or CSs.
This study examined the latent structure of psychiatric disorders in a sample with a high prevale... more This study examined the latent structure of psychiatric disorders in a sample with a high prevalence of PTSD. A series of confirmatory factor analyses tested competing models for the covariation between Structured Clinical Interview for DSM‐III‐R diagnoses among 1,325 Vietnam veterans. The best‐fitting solution was a 3‐factor model that included two correlated internalizing factors: anxious‐misery, defined by PTSD and major depression, and fear, defined by panic disorder/agoraphobia and obsessive‐compulsive disorder. The third factor, externalizing, was defined by antisocial personality disorder, alcohol abuse/dependence, and drug abuse/dependence. Both substance‐related disorders also showed significant, albeit smaller, cross‐loadings on the anxious‐misery factor. These findings shed new light on the structure of psychiatric comorbidity in a treatment‐seeking sample characterized by high rates of PTSD.
The Journal of Rehabilitation Research and Development, 2012
Assessment in mental health research has evolved from focusing on symptoms and diagnosis to addre... more Assessment in mental health research has evolved from focusing on symptoms and diagnosis to addressing a broad range of change, including psychosocial functioning. This is consistent with developments in the areas of psychosocial rehabilitation and the increase in recovery-oriented intervention models for mental disorders. We reviewed the status of assessment in mental health research, providing an overview of symptom and diagnostic assessment that is the cornerstone of most mental health research assessment. We then focused on measurement that can be applied across diagnostic groups and on functioning as a key mental health outcome. We reviewed the International Classification of Functioning, Disability, and Health and its implications for improvements in assessment. We provided an example of a new assessment, the Inventory of Psychosocial Functioning, which highlights key issues in the measurement of functioning. We then addressed improving research assessment, including issues of assessment in diverse populations and the need to capitalize on new data sources and new assessment technologies to advance assessment in mental health research. Finally, we reviewed and discussed areas for research and quality improvement, drawing on examples from the Department of Veterans Affairs to illustrate potential opportunities.
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Papers by Terence Keane