2021 IAS Rainmaker: Posttraumatic Stress Disorder (PTSD) and Complex PTSD in Australian Defence Force Veterans

Levels of high to very high psychological distress in transitioned Australian Defence Force (ADF) members have been reported to be almost three times greater than in the general Australian population (Department of Veterans’ Affairs, 2018). Post-traumatic stress disorder (PTSD) contributes directly towards high levels of distress and has been reported in up to 25% of military veterans previously deployed in combat zones (Waller et al., 2016). Recently, two ‘sibling disorders’ have been included in the ICD-11 classification of mental disorders; PTSD and Complex PTSD (CPTSD). Although they are related, childhood trauma and multiple traumatisation is associated with CPTSD (Karatzias et al. 2016), complicating treatment. Recent evidence from the UK (Murphy et al., 2020) suggests that 71% of 117 trauma treatment seeking military veterans reported symptoms consistent with either a PTSD or CPTSD diagnosis, however CPTSD was more prevalent than PTSD in this group (76% v 24%).

Although there is a current lack of evidence in the area, it is possible that CPTSD is also highly prevalent in mental health treatment seeking ADF veterans. This is supported by analyses of the 2010 ADF Mental Health Prevalence and Wellbeing Study which found that childhood trauma and multiple trauma is more common in military employed men than in Australian civilians (Syed Sheriff et al., 2020). It is important to differentiate between CPTSD and PTSD because standardised interventions used for combat-related PTSD might not be appropriate for people with CPTSD. This is due to CPTSD having a greater number/diversity of symptoms, higher treatment discontinuation rates and the need to address emotional dysregulation (Miles and Thompson, 2016).

It is also important to consider the impact of CPTSD on functioning and associations with mental and physical health co-morbidities in an ADF veteran population, as this has direct implications for intervention targets, longer-term outcomes and health care costs. Previous studies conducted in non-military samples (Hyland et al., 2017; Karatzias et al., 2019) have shown that CPTSD is associated with greater comorbidities than PTSD and a recent UK study (Murphy et al., 2020) conducted with help-seeking military veterans also highlighted that participants with probable CPTSD were more likely to report comorbidities, such as higher anxiety and depression scores, and impaired functioning. However, it is unclear if similar relationships exist in ADF veterans, or the extent of these associations.

The International Trauma Questionnaire (ITQ) is the only validated measure for the assessment of ICD-11 PTSD and CPTSD (Karatzias et al., 2017), however its internal reliability has not yet been tested in ADF veterans. Being able to assess the reliability of the ITQ, determining the nature and extent of PTSD and CPTSD in trauma treatment-seeking ADF veterans and establishing relationships between CPTSD distress severity, functioning and psychological resilience would help to inform the planning of trauma-related treatment resources, assessments and interventions for ADF veterans. Ultimately, this would improve engagement with services and may lead to a reduction of dropout rates, thereby improving the well-being of veterans and the quality of life of their families. Therefore, this study aims to:

a) determine if there are qualitatively different groups of trauma treatment-seeking ADF veteran participants, known as ‘classes,’ with symptom endorsement that reflect PTSD and CPTSD using the ITQ;
b) assess the internal reliability of the ITQ in ADF veterans for future routine use;
c) determine how presentations vary between PTSD and CPTSD in terms of demographics, childhood adversity and adulthood traumatic life events, mental health co-morbidities, functioning and physical health;
d) examine potential moderating effect of psychological resilience on the relationships between Adverse Childhood Experiences/Trauma with PTSD/CPTSD distress severity and functioning.

Methods:

This cross-sectional survey will be conducted with 200 mental health treatment seeking ADF veterans (previous studies have demonstrated that 177 participants provided sufficient power to conduct confirmatory factor analysis to assess the latent structure of PTSD and CPTSD symptoms from ITQ data; Murphy et al., 2020). AIB Dr Mitchell will facilitate access to participants, who will be recruited using convenience sampling after being referred by clinicians and team members working in Open Arms (counselling service open to all ex-defence members and their family), NT Kookaburra Kids (not-for-profit organisation providing recreational support for kids of veterans with mental health issues) and Dr Bernie Westley at Parap Tristar Medical GP clinic. Data collection will be conducted by a trained Research Assistant in either face-to face meetings, a postal/online survey or via telephone interviews as appropriate.

How this funding will help with the undertaking of the activities to submit your external funding application?

The proposed research project (funded the rainmaker grant) will be the first in Australia to explore the nature and extent of CPTSD in trauma treatment-seeking ADF veterans. This rainmaker grant will help with applications for external funding in several respects. First, it will establish a potentially hidden group of ADF local veterans that are likely to be offered standardised treatments for PTSD but may obtain greater benefit from CPTSD treatments - hence demonstrating the need to develop and test new interventions in this client group. Second, the study will also demonstrate the internal reliability of the ITQ for the assessment of PTSD/CPTSD in this client group - the tool will be used in subsequent research projects and the external grant applications. Finally, and perhaps most importantly, the project (and its resulting academic outputs) will help to cement collaborative research relationships between CDU researchers, international experts in CPTSD, local stakeholders and ADF veteran groups. There are many lucrative re search funding opportunities available for research designed to improve veterans' mental health and well-being, therefore the development of expertise and a strong track record in the area is likely to attract funds and make a significant positive impact on veterans' lives.

How your proposed project aligns with the priorities and selection criteria of the funder

We plan to conduct two subsequent studies based on the initial findings of the current proposed study: 1) to extend the cross-sectional study beyond this relatively small local sample of treatment-seeking ADF veterans by including a larger and more representative sample of mental health treatment- seeking ADF serving members/veterans across Australia and; 2) to conduct a pilot RCT study to establish the feasibility and preliminary efficacy of a newly developed flexible multimodular treatment for CPTSD (Karatzias and Cloitre, 2019) in ADF veterans that meet the criteria for diagnosis of CPTSD.

The aims and objectives of both proposed studies highly align with the aims and objectives of the Defence Health Foundation (Opportunity 1- http://www.defencehealthfoundation.org.au/research-grants/research-priorities/), which are to research the impact of mental health co-morbidities (e.g. anxiety with obsessive compulsive disorder or post-traumatic stress disorder) on optimal treatment pathways, relapse and recovery. Our proposed studies also align well with their research objectives to establish better treatment guidelines and more sustained recovery and lower readmission rates for patients with multifaceted mental health issues. The application process opens in June 2022.

Our proposed studies also align with the funding guideline and selection criteria of the Breakthrough Foundation (Opportunity 2 - https://breakthroughfoundation.org.au/get-in-touch/apply-for-a-grant/) . This funding body supports ground-breaking research to improve the lives of people affected by mental health issues; two of their research themes are ‘early interventions’ and ‘next generation therapies’, both of which closely relate to the proposed feasibility testing of the new modular therapy for CPTSD. The opening of the application process is expected in June 2022, but this is to be confirmed.