- Dr. Kudler received his M.D. from SUNY Downstate, trained in Psychiatry at Yale and is Adjunct Associate Professor at... moreDr. Kudler received his M.D. from SUNY Downstate, trained in Psychiatry at Yale and is Adjunct Associate Professor at Duke. He reported to Congress as co-chair of VA’s Special Committee on PTSD, served on the International Society for Traumatic Stress Studies Board of Directors, co-led development of joint VA/DoD Guidelines for Posttraumatic Stress, and advised Sesame Street’s Talk Listen Connect series for military families. He co-founded VA's Mid-Atlantic Mental Illness Research, Education, and Clinical Center on Deployment Mental Health and the North Carolina Governor’s Work Group on Service Members, Veterans and Their Families and was appointed to the NC Institute of Medicine. In 2014, he joined VA Central Office as Chief Consultant for Mental Health and served as Acting Assistant Deputy Under Secretary for Patient Care until his retirement in 2018. Dr. Kudler is currently working to integrate mental and public health efforts on behalf of service members, Veterans and their families.edit
As military operations continue in the Global War on Terror (GWOT), an estimated 1.6 million United States service men and women have deployed at least once since 2001, as part of Operation Enduring Freedom (OEF) in Afghanistan and/or... more
As military operations continue in the Global War on Terror (GWOT), an estimated 1.6 million United States service men and women have deployed at least once since 2001, as part of Operation Enduring Freedom (OEF) in Afghanistan and/or Operation Iraqi Freedom (OIF). When a military member enters the deployment cycle, so does his or her family. This five-stage cycle includes: pre-deployment, beginning with an order for the upcoming deployment and continuing with specialized preparation and training and often conducted far from home; deployment, including travel to the designated theater and performance of the assigned mission; sustainment, during which family members establish new routines and feel increasingly confident about facing the challenges of ongoing separation; redeployment to the home station or demobilization station, which is usually a period of intense anticipation, excitement, and apprehension; and finally, post-deployment to home and reintegration with family and civilian routines. Each phase of this cycle has a unique set of stressors and requires significant readjustment on the part of the war fighter and his/her family. Each completed cycle may be followed by preparation for still another. Our all-volunteer force, their parents, partners, and children have respective strengths and vulnerabilities. Each serves in different ways at different phases of the deployment cycle. Families who successfully weather one phase may struggle in the next. The GWOT reverberates throughout the nation and across generations. ABOUT THE AUTHORS Harold Kudler, MD, is Associate Clinical Director, Department of Veterans Affairs (VA) Mid-Atlantic Network Mental Illness, Education, Research and Clinical Center (MIRECC) on Post Deployment Mental Health and Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina. Kristy Straits-Tröster, PhD, ABPP, is Assistant Clinical Director, VA Mid-Atlantic Network MIRECC and Adjunct Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Duke University. Address correspondence to: Harold Kudler, MD, Durham VAMC, 508 Fulton St. (V6 MIRECC), Durham, NC 27705; harold.kudler@va.gov. Dr. Kudler and Dr. Straits-Tröster have disclosed no relevant financial relationships. EDUCATIONAL OBJECTIVES Identify readjustment issues for war zone veterans and their families related to the deployment cycle. Provide a rationale for Veterans Affairs/Department of Defense/State and Community Partnerships in support of returning war zone veterans and their families. Identify potential partners and actions in providing support and mental health services for returning war zone veterans and their families.
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This chapter presents our view of state of the art biological principles for the evaluation and treatment of traumatic stress disorders. The lion’s share of the biological literature on traumatic stress deals with patients suffering from... more
This chapter presents our view of state of the art biological principles for the evaluation and treatment of traumatic stress disorders. The lion’s share of the biological literature on traumatic stress deals with patients suffering from chronic posttraumatic stress disorder (PTSD) (APA, 1987, 1994). There are a range of mental health problems that may follow traumatic events, and it is not clear that each problem shares the same biological characteristics. Therefore, these recommendations may not be generalizable to all patients dealing with the aftermath of a traumatic event.
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Research Interests: Psychiatry, Mental Health, Depression, Environmental Health, Medicine, and 15 moreHumans, Iraq War, North Carolina, United States, Female, Alcohol Drinking, Male, Veterans, Adult, Virginia, Occupational Diseases, Logistic Models, Surveys and Questionnaires, Psychology and Cognitive Sciences, and Medical and Health Sciences
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The present study investigated self‐reported and interpersonal hostility in 70 Vietnam combat veterans with and without posttraumatic stress disorder (PTSD) and 60 comparison community volunteer subjects. Veterans were 50 help‐seeking,... more
The present study investigated self‐reported and interpersonal hostility in 70 Vietnam combat veterans with and without posttraumatic stress disorder (PTSD) and 60 comparison community volunteer subjects. Veterans were 50 help‐seeking, male Vietnam combat veterans with PTSD and 20 non‐help‐seeking male combat veterans without PTSD. Vietnam veterans with PTSD not only reported more hostility than non‐PTSD veterans and healthy community volunteers, but also reacted behaviorally with more hostility during an interpersonal interaction. Compared to veterans without PTSD, veterans with PTSD reported significantly higher levels of hostility and demonstrated significantly greater non‐verbal expressions of hostility during an interpersonal task. These results suggest that the level of hostility in PTSD combat veterans may be high as compared to comparison groups. The implications of these results and possible research directions are presented.
Research Interests: Psychology, Clinical Psychology, Psychiatry, Interpersonal Communication, Traumatic Stress, and 15 moreVietnam, Medicine, Humans, Posttraumatic stress disorder, North Carolina, Male, Veterans, Interpersonal Relations, Help Seeking, Middle Aged, Interpersonal Interaction, Hostility, Traumatic, Case Control Studies, and Psychiatric Status Rating Scales
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The pharmacological treatment of two female adolescent patients meeting DSM-III criteria for psychotic depression is described. A combined antipsychotic and tricyclic antidepressant regimen led to clinical remission. However, a... more
The pharmacological treatment of two female adolescent patients meeting DSM-III criteria for psychotic depression is described. A combined antipsychotic and tricyclic antidepressant regimen led to clinical remission. However, a recrudescence in both psychotic and depressive symptoms developed as plasma desipramine levels rose 4 times higher than anticipated from the oral doses prescribed. Clinical improvement occurred in both cases when plasma desipramine levels were reestablished below 200 ng/ml. Thus, we recommend prospective monitoring of desipramine plasma levels, especially when an antipsychotic agent that inhibits the metabolism of the tricyclic antidepressant is also used. We further suggest that deterioration with the reemergence of the presenting clinical syndrome, without signs of delirium, represents a distinct manifestation of antidepressant toxicity. Finally, these cases support the existence of a therapeutic upper limit for desipramine plasma concentrations, above which clinical deterioration occurs.
Research Interests: Psychology, Drug interactions, Adolescent, Medicine, Humans, and 12 moreAntidepressant, Female, Psychotic Depression, Combination drug therapy, Antipsychotic, Clinical Psychopharmacology, Imipramine, desipramine, Antipsychotic agents, Psychology and Cognitive Sciences, Exacerbation, and Medical and Health Sciences
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Anger is a commonly reported problem among returning veterans, yet little attention has been devoted to studying treatment engagement among veterans who report anger problems but do not have posttraumatic stress disorder (PTSD). This... more
Anger is a commonly reported problem among returning veterans, yet little attention has been devoted to studying treatment engagement among veterans who report anger problems but do not have posttraumatic stress disorder (PTSD). This study compares Iraq-Afghanistan veterans with anger/no PTSD (n = 159) to others reporting significant PTSD symptoms (n = 285) and those reporting neither anger nor PTSD (n = 716) on rates of treatment utilization, perceived barriers to treatment, and preferences for care. Relative to the PTSD group, the anger/no-PTSD group was significantly less likely to have received mental health treatment in the last year, despite endorsing barriers to treatment at a lower rate. Furthermore, the anger/no-PTSD group endorsed fewer preferences than the PTSD group. Results suggest that the anger/no-PTSD group is a unique subgroup that may be less likely to identify a need for treatment. Implications are discussed.
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Research Interests: Afghanistan, Iraq, Medicine, Counseling, Multivariate Analysis, and 15 moreHumans, Alcoholism, Female, Male, Prevalence, Middle Aged, Adult, Risk Reduction, Clinical Psychiatry, Alcohol Use, Cross Sectional Studies, Logistic Models, Psychology and Cognitive Sciences, mass Screening, and Medical and Health Sciences
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ABSTRACT
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This chapter traces the history of Veterans health care in the United States with a focus on how the development of American psychiatry informed the creation of the modern Veterans Affairs (VA) medical system and vice versa. This review... more
This chapter traces the history of Veterans health care in the United States with a focus on how the development of American psychiatry informed the creation of the modern Veterans Affairs (VA) medical system and vice versa. This review demonstrates the singular and irreplaceable role which VA plays in American health care and sets the stage for recommendations for the future of mental health care for Veterans and for all Americans.
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The study investigated barriers to the utilization of Veterans Affairs (VA) health care services among female veterans who served in served in Iraq and Afghanistan, including reasons for not choosing VA health care, reasons for not... more
The study investigated barriers to the utilization of Veterans Affairs (VA) health care services among female veterans who served in served in Iraq and Afghanistan, including reasons for not choosing VA health care, reasons for not seeking mental health treatment, and types of desired VA services. Female respondents to a survey assessing Operation Enduring Freedom/Operation Iraqi Freedom veterans' needs and health (N = 186) completed measures of military history, posttraumatic stress disorder, depression, barriers to VA health care, and preferences for services. Barriers to use of VA health care endorsed by female veterans included receiving care elsewhere and logistical issues. Barriers to utilization of mental health services among female veterans who screened positive for depression or posttraumatic stress disorder included negative treatment biases and concerns about stigma, privacy, and cost. Female veterans endorsed preferences for services related to eligibility education...
Alcohol misuse is associated with negative mental and physical health outcomes, which presents a public health concern in veterans. However, less is known regarding outcomes among veterans with low to moderate alcohol consumption. This... more
Alcohol misuse is associated with negative mental and physical health outcomes, which presents a public health concern in veterans. However, less is known regarding outcomes among veterans with low to moderate alcohol consumption. This study included veterans with military service in Iraq and/or Afghanistan (N = 1083) who resided in the VA Mid-Atlantic region catchment area (North Carolina, Virginia, and parts of West Virginia). Participants completed a mailed survey that inquired about demographics, past-year alcohol consumption, self-rated physical health, and psychiatric symptoms. Logistic regression was used to evaluate associations between alcohol consumption and posttraumatic stress disorder (PTSD), depression, and self-rated physical health. In both bivariate results and adjusted models, non-drinkers and hazardous drinkers were more likely to endorse clinically significant PTSD and depression symptoms than moderate drinkers. Moderate drinkers were also less likely to report f...
Research Interests: Psychiatry, Depression, Humans, Iraq War, North Carolina, and 14 moreUnited States, Female, Alcohol Drinking, Male, Veterans, Young Adult, Adult, Virginia, West Virginia, Occupational Diseases, Logistic Models, Surveys and Questionnaires, Psychology and Cognitive Sciences, and Medical and Health Sciences
The United States (US) Department of Veterans Affairs (VA) Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) Post-Deployment Mental Health (PDMH) multi-site study examines post-deployment mental health in US... more
The United States (US) Department of Veterans Affairs (VA) Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) Post-Deployment Mental Health (PDMH) multi-site study examines post-deployment mental health in US military Afghanistan/Iraq-era veterans. The study includes the comprehensive behavioral health characterization of over 3600 study participants and the genetic, metabolomic, neurocognitive, and neuroimaging data for many of the participants. The study design also incorporates an infrastructure for a data repository to re-contact participants for follow-up studies. The overwhelming majority (94%) of participants consented to be re-contacted for future studies, and our recently completed feasibility study indicates that 73-83% of these participants could be reached successfully for enrollment into longitudinal follow-up investigations. Longitudinal concurrent cohort follow-up studies will be conducted (5-10+ years post-baseline) to examine predictors of...
Research Interests: Adolescent, Humans, Iraq War, United States, Female, and 8 moreMale, Veterans, Young Adult, Mental Disorders, Clinical Sciences, Aged, Middle Aged, and Adult
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This study examined health care barriers and preferences among a self-selected sample of returning U.S. veterans drawn from a representative, randomly selected frame surveyed about posttraumatic stress disorder (PTSD) symptomatology and... more
This study examined health care barriers and preferences among a self-selected sample of returning U.S. veterans drawn from a representative, randomly selected frame surveyed about posttraumatic stress disorder (PTSD) symptomatology and mental health utilization in the prior year. Comparisons between treated (n = 160) and untreated (n = 119) veterans reporting PTSD symptoms were conducted for measures of barriers and preferences, along with logistic models regressing mental health utilization on clusters derived from these measures. Reported barriers corroborated prior research findings as negative beliefs about treatment and stigma were strongly endorsed, but only privacy concerns were associated with lower service utilization (B = -0.408, SE = 0.142; p = .004). The most endorsed preference (91.0%) was for assistance with benefits, trailed by help for physical problems, and particular PTSD symptoms. Help-seeking veterans reported stronger preferences for multiple interventions, and desire for services for families (B = 0.468, SE = 0.219; p = .033) and specific PTSD symptoms (B = 0.659, SE = 0.302; p = .029) were associated with increased utilization. Outcomes of the study suggested PTSD severity drove help-seeking in this cohort. Results also support the integration of medical and mental health services, as well as coordination of health and benefits services. Finally, the study suggested that outreach about privacy protections and treatment options could well improve engagement in treatment.
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The present study investigated self-reported and interpersonal hostility in 70 Vietnam combat veterans with and without posttraumatic stress disorder (PTSD) and 60 comparison community volunteer subjects. Veterans were 50 help-seeking,... more
The present study investigated self-reported and interpersonal hostility in 70 Vietnam combat veterans with and without posttraumatic stress disorder (PTSD) and 60 comparison community volunteer subjects. Veterans were 50 help-seeking, male Vietnam combat veterans with PTSD and 20 non-help-seeking male combat veterans without PTSD. Vietnam veterans with PTSD not only reported more hostility than non-PTSD veterans and healthy community volunteers, but also reacted behaviorally with more hostility during an interpersonal interaction. Compared to veterans without PTSD, veterans with PTSD reported significantly higher levels of hostility and demonstrated significantly greater non-verbal expressions of hostility during an interpersonal task. These results suggest that the level of hostility in PTSD combat veterans may be high as compared to comparison groups. The implications of these results and possible research directions are presented.
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Research Interests: Psychology, Demography, Depression, Comorbidity, Post traumatic stress disorder, and 15 moreMotivation, High Frequency, Humans, Personality Assessment Inventory, Smoking, Posttraumatic stress disorder, North Carolina, Male, Incidence, Help Seeking, Middle Aged, Adult, Cross Sectional Studies, Personality Inventory, and Macho
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... MEDICALLY ILL OLDER MEN: DOCUMENTATION, MANAGEMENT, AND OUTCOME HAROLD G. KOENIG,* VEERAINDAR GOLI,? ... Received 24 April 1991 Accepted 1 August 1991 Page 2. 26 H. G. KOENIG, V. GOLI, F. SHELP ET AL. Popkin, 1987). ...
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Thalamic dysfunction has been found in patients with posttraumatic stress disorder (PTSD), suggesting that the thalamus may be implicated in the etiology of PTSD. However, no studies have explored the functional connectivity between the... more
Thalamic dysfunction has been found in patients with posttraumatic stress disorder (PTSD), suggesting that the thalamus may be implicated in the etiology of PTSD. However, no studies have explored the functional connectivity between the thalamus and other brain regions during resting-state. The objective of the present study was to investigate the resting-state functional connectivity of the thalamus in recent onset medication-naive PTSD sufferers who went through an earthquake in the Sichuan province of China. Fifty-four participants with PTSD and seventy-two age and gender matched traumatized controls without PTSD recruited from the 2008 Sichuan earthquake were scanned by 3T functional magnetic resonance imaging (fMRI) in resting state. Region of interest (ROI)-based functional connectivity analysis was employed to identify the potential differences in the functional connectivity of the thalamus between the two groups. In the PTSD group, the thalamus-ROIs showed decreased positive functional connectivity to particular brain regions including right medial frontal gyrus and left anterior cingulate cortex. Importantly, we also found increased positive functional connectivity of thalamus-ROIs with bilateral inferior frontal and left middle frontal gyri, left inferior parietal lobule as well as right precuneus in the PTSD participants when compared to traumatized controls without PTSD. The results provide evidence that abnormal resting state functional connections linking the thalamus to cortical regions may be involved in the underlying pathology in PTSD.
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To evaluate the hypothalamic-pituitary-adrenal (HPA) axis in patients with posttraumatic stress disorder (PTSD), we measured adrenocorticotropin hormone (ACTH) and cortisol responses following administration of corticotropin-releasing... more
To evaluate the hypothalamic-pituitary-adrenal (HPA) axis in patients with posttraumatic stress disorder (PTSD), we measured adrenocorticotropin hormone (ACTH) and cortisol responses following administration of corticotropin-releasing hormone (CRH) in 8 combat veterans with chronic PTSD. The PTSD patients had a significantly lower ACTH response to CRH compared to a control group of normal volunteers. Blunted ACTH responses occurred in patients with PTSD alone, as well as those PTSD patients who also had major depression. The cortisol response, although reduced, was not significantly different from normal. The blunted ACTH response to CRH in PTSD patients is similar to that seen in other psychiatric disorders, such as depression, panic disorder, and anorexia nervosa.