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Active Projects

• DESTRESS-PC: A Brief Online Self-Management Tool for PTSD
  
  The broad objective of this proposed research is to improve primary care mental health services for military personnel and veterans with posttraumatic stress disorder related to war-zone trauma. The research is also relevant to providing early, high quality access to low-stigma mental health services for victims of other traumatic events, including terrorist attacks and natural or man-made disasters. The study hypothesis is that a brief Internet-based online self-management tool for posttraumatic stress disorder, DESTRESS-PC, based on empirically valid cognitive-behavioral therapy strategies, will improve posttraumatic stress disorder symptoms, related functional status, and attitudes regarding mental health treatment among veterans and military personnel with posttraumatic stress disorder who are seeking primary health care after service in Operations Iraqi Freedom or Enduring Freedom. A primary care-based randomized controlled trial is proposed to assess the feasibility and efficacy of DESTRESS-PC for reducing the posttraumatic stress disorder symptoms of war-zone exposed soldiers and veterans, increasing their mental health-related functioning; reducing depression, generalized anxiety, and somatic symptoms; and improving attitudes regarding formal mental health treatment. The DESTRESS-PC intervention will be delivered to participants via the Internet, with participants logging on to a secure Web site hosted on private (i.e., nonmilitary) servers. Participants' progression through the intervention will be monitored by nurse managers, and participants will have ad lib and routine access to their nurse manager via email and telephone. Nurse managers will be supervised by mental health professionals and will have contact with participants' primary care provider. It is hoped that the trial, which should begin in FY 2008, will show that the DESTRESS-PC intervention significantly improves symptoms of depression, generalized anxiety, and somatization at 6-week, 12-week, and 18-week follow-up, and that patients randoized to the DESTRESS-PC protocol will report significantly improved attitudes toward mental health treatment at the same follow-up timeframes.
  
  
• A Placebo-Controlled Trial of Prazosin Vs Paroxetine for Combat Stress-Induced Nightmares and Sleep Disturbance
  
  Trauma-related nightmares and sleep disruptions following exposure to life-threatening events are persistent symptoms that often cause significant impairment in social and occupational functioning. Paroxetine (marketed as Paxil) is one of only two FDA approved medications for the treatment of posttraumatic stress disorder, but its treatment efficacy remains mixed. Preliminary research shows that the medication prazosin ameliorates both nightmares and sleep disturbances in veterans from Vietnam and OEF/OIF. It is expected that results from this double-blind, 12-week randomized controlled clinical trial will support the use of prazosin over both paroxetine and placebo for the treatment of combat-related nightmares. Funded by the Department of Defense, this multi-site study is a collaboration between DHCC and researchers from Madigan Army Medical Center and the VA Puget Sound Healthcare System. The study began recruitment and enrollment in FY 2007.
  
  
• Acupuncture for the Treatment of Trauma Survivors
  
  Acupuncture, with few known side effects, has the potential to be an effective alternative treatment for posttraumatic stress disorder or an adjunct to other proven therapies. Acupuncture has been shown to improve well-being and to successfully treat stress, anxiety and pain conditions. The objective of the 12-week randomized controlled trial of active duty military personnel with PTSD is to determine the effectiveness of acupuncture for alleviating the symptoms associated with PTSD. The study received Congressional funding and the study team consists of personnel from DHCC, the Uniformed Services University of the Health Sciences, the Samueli Institute, and the University of Western Ontario. In FY 2007, 245 patients were screened, 75 were enrolled after meeting preliminary criteria, 55 were randomized, and 42 completed the study through the 3-month follow-up period. Data collection ended in October 2007. Analyses are underway and a manuscript describing the trial is in development.
  
  
• Preference-Weighed Health Status Associated with Posttraumatic Stress Disorder in Veterans: A Policy-Friendly Assessment of Illness Severity
  
  Extant symptom- and generic quality of life-focused measures used to assess the disease burden of PTSD are useful at the clinical level because they describe functioning. However, these measures are not useful at the policy level because they fail to assess how people value different health problems (e.g., what domains of health-related quality of life do people prefer most versus least). In contrast, preference-weighted health status measures can capture this information and fill in the blanks for healthcare policy makers. Policy makers can then allocate resources based in part on how well interventions can maximize the quality of life domains that society values the most. We calculated preference-weighted health status scores (PWHSS) for 840 veterans receiving VA primary care services. PWHSS scores range from 0 (death) to 1 (perfect health). As part of a different study, veterans were assessed for health-related quality of life, mental health disorders, and medical ICD-9 diagnoses. We created several groups of veterans based on their diagnoses. We then weighted their responses on the health-related quality of life measure with previously published preferences for the domains of health-related quality of life and created the PWHSS. We then compared the PWHSS among veterans diagnosed with PTSD and other disorders. Lower PWHSS significantly correlated with increased PTSD severity and number and type of mental health disorders. In other words, the analysis suggests that society at large sees the health status associated with a diagnosis of PTSD as less desirable than the health status of veterans not diagnosed with this disorder. A manuscript summarizing the study findings is being prepared.
  
  
• Prospective Study of Functional Status in Veterans at Risk for Unexplained Illness
  
  DHCC is collaborating with the East Orange New Jersey VA War-Related Illness and Injury Study Center (WRIISC) on a prospective longitudinal study to understand whether stress response, ability to cope with stress, or personality affect the likelihood of developing medically unexplained symptoms after service in OIF/OEF. Measures are both self-reported and physiological and include pre- and post-deployment physicals as well as phone interviews and mailed surveys after return from deployment. The study is expected to help identify individuals at risk for developing medically unexplained symptoms after future deployments and guide future work on intervention strategies. To date, 393 service members have completed pre-deployment health screening (phase I). Seventy eight service members have completed post-deployment health screening (phase II); this represents an 84% completion rate for phase II.
  
  
• Veteran Status, Health and Mortality in Older Americans
  
  This study, funded by the National Institute on Aging from FY 2002 through FY 2006, was extended into FY 2008 by both Walter Reed Army Medical Center and the Uniformed Services University of the Health Sciences. Collaborations include the Uniformed Services University of the Health Sciences Department of Psychiatry, Department of Veterans Affairs Environmental Epidemiology Service, and Walter Reed Army Medical Center. It evaluates whether older veterans experience higher mortality than do their non-veteran counterparts and uses demographic modeling to see if this trend increases with age and whether physical health is more important than mental health in the process of mortality convergence and crossover between older veterans and non-veterans. Using data from the Survey of Asset and Health Dynamics among the Oldest-Old (AHEAD) and the Health and Retirement Study (HRS), the study employs such statistical techniques as the structural hazard rate model, the multinomial logit regression, and mathematical simulation. The project produced the following findings. The first finding suggests a mortality crossover between veterans and non-veterans that probably occurs just before age 70. Second, among Americans age 70 years or older, the mortality differences between veterans and non-veterans diverge at a considerable pace, with an increased excess death rate over age among older veterans. Third, while the study managed to capture much of the veteran status's effect through the two health dimensions in the "young-old" and the "old-old" demographic categories, many details regarding the mechanisms inherent in the excess mortality and transitions in functional status among older veterans remain unknown beyond age 85. Fourth, veteran status does not have significant influences on transitions in functional status among those functionally independent at baseline. Older veterans and non-veterans who are initially independent in their activities of daily living share a similar pattern of disability incidence and functional aility persistence. However, veterans who were initially disabled demonstrate much lower disability resolution than their non-veteran counterparts, and such effects increase substantially with age. Two articles have been published on this study, one is in press and two more are under review. Manuscript preparation and submission of study results will continue into FY 2008.
  
  
• Vitamin D Levels and their Correlation to Pain, Fatigue, Anxiety, and other Co-morbidities in Specialized Care Program Service Members seen at the Deployment Health Clinical Center
  
  Acquired primarily through sunlight exposure or by fortified milk consumption, Vitamin D has been long recognized as essential to bone health. As much as 5-30% of the U.S. population age 19 to 50 may have deficiency depending on a number of factors. A study in military recruits from Finland found that 5% were deficient in the summertime. Those deficient were more than three times as likely to have a stress fracture over the next 90 days, when compared to those who had adequate vitamin D stores. Vitamin D deficiency in the general population has also been linked to chronic musculoskeletal pain as well as anxiety in patients with fibromyalgia. The purpose of this study is to retrospectively analyze the diagnoses of DHCC Specialized Care Program patients, primarily OIF/OEF veterans, to see if there is a correlation with their vitamin D levels. Specifically, the focus will be on chronic musculoskeletal pain, fatigue, and anxiety, but other illnesses such as bone-related illnesses will be looked at as well. By the end of FY 2007, preliminary results on a small study cohort revealed that 30 of 61 OIF/OEF veterans experiencing chronic pain had vitamin D deficiency. Since half of these patients had deployment-related bone or joint injuries, the recommendation is made to consider screening OIF/OEF veterans with chronic musculoskeletal pain for vitamin D deficiency, so that optimum bone health can be achieved through proper supplementation.

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Completed Projects

• A Single-Item PTSD Screener (SIPS) for Primary Care
  
  Posttraumatic stress disorder (PTSD) among recently deployed Soldiers is a critical psychiatric problem facing the Department of Defense. Research indicates that while most mental healthcare is delivered in primary care, primary care providers often do not recognize symptoms of PTSD. The goal of this study was to develop and test a simple screening tool for use in a primary care setting for rapid identification of patients with symptoms of PTSD. The Single-Item PTSD Screener (SIPS) for Primary Care was being compared to a longer, existing PTSD screening tool. Responses to the SIPS were evaluated against the criterion, PTSD diagnosis, determined by a diagnostic interview. Sensitivity, specificity and likelihood ratios of the SIPS are being evaluated. Of the 3258 primary care patients at three DoD primary care clinics who completed the SIPS, 213 received a diagnostic interview. In patients with "Bothered a Little" responses the, sensitivity and specificity were 0.76 and 0.79, respectively. Positive endorsement of the SIPS was indicative of PTSD status. The SIPS is expected to improve the primary care provider's ability to recognize PTSD symptomatology in their patients and to facilitate early intervention to reduce the burden of this disorder within the DoD. A manuscript is in preparation and plans are underway to evaluate a refined version of the question to see if we can improve upon the operating characteristics.
  
  
• A Randomized Clinical Trial of Health-e VOICE-An Optimized Clinical Practice Guideline Training Tool
  
  Many patients have concerns related to environmental, occupational, or other potential toxic exposures. Currently, there is little known about how to improve health risk communication in clinical settings. DHCC collaborated with the Centers for Disease Control and Prevention, National Center for Environmental Health and consultants to develop and evaluate an interactive, Web-based distance-learning tool called Health-e VOICE. Comprised of six electronic patient-care vignettes, it was designed to improve Department of Defense (DoD) healthcare providers' effectiveness when communicating with veterans, military personnel, and family members about their deployment-related health concerns. The objective of this trial was to evaluate the impact of HeV training on the ability of primary care providers to appropriately address these concerns. All 2,110 participants were enrolled through the Family Practice Residency Clinic at Womack Army Medical Center, Fort Bragg. Forty primary care providers-21 in the Health-e VOICE treatment condition and 19 in the control condition-were enrolled. Of a total of 2,063 patients, 1,197 were patients of providers in the treatment condition and 866 were patients of providers in the control condition. The Health-e VOICE training was not significantly associated with any trial outcomes. Interestingly, patients with war-related health concerns with a Health-e VOICE trained provider reported lower satisfaction than those who received services from providers with standard patient-provider communication training. This difference, while statistically significant, was small, unexpected, and of unclear clinical significance. Internet-based risk communication training for primary care providers seeing war veterans with health concerns is not sufficient to improve outcomes. A presentation on this study was made at the 10th Annual Force Health Protection Conference.
  
  
• CSP 494: A Randomized Controlled Trial of Military Women with Post-Traumatic Stress Disorder (PTSD)
  
  This VA Cooperative Study included 11 VA sites and Walter Reed Army Medical Center. It was a randomized single-blind clinical trial that compared two types of individual psychotherapies for the treatment of posttraumatic stress disorder (PTSD) in women. The efficacy of prolonged exposure therapy for treating PTSD and associated problems in active duty and veteran women was evaluated. The study hypothesis was that prolonged exposure therapy would be more effective than present centered therapy for the treatment of PTSD in female veterans and active duty personnel. The primary outcome variable was PTSD severity at the 3-month follow-up assessment as measured by the Clinician Administered PTSD Scale (CAPS), a diagnostic interview that captures PTSD symptom severity. A total of 284 participants were randomized in the multi-site trial. Two hundred-one (71%) completed all treatment sessions. Two hundred thirty-five participants (83%) completed the post-treatment assessment, 230 (81%) completed the three-month follow-up assessment, and 213 (75%) completed the six-month follow-up assessment. Women who received prolonged exposure experienced greater reduction of PTSD symptoms relative to women who received present-centered therapy (effect size, 0.27; P = .03). The prolonged exposure group was more likely than the present-centered therapy group to no longer meet PTSD diagnostic criteria (41.0% vs 27.8%; odds ratio, 1.80; 95% confidence interval, 1.10-2.96; P = .01) and achieve total remission (15.2% vs 6.9%; odds ratio, 2.43; 95% confidence interval, 1.10-5.37; P = .01). Effects were consistent over time in longitudinal analyses, although in cross-sectional analyses most differences occurred immediately after treatment. We concluded that prolonged exposure is an effective treatment for PTSD in female veterans and active-duty military personnel. It is feasible to implement prolonged exposure across a range of clinical settings. These findings were recently reported in the Journal of the American Medical Association (JAMA) in 2007.
  
  
• Project DE-STRESS: Brief Cognitive-Behavioral Intervention for Victims of Mass Violence
  
  This study, funded by the National Institute of Mental Health (NIMH), began in June 2002 in collaboration with Dr. Brett Litz at Boston University School of Medicine, Boston VAMC and the National Center for PTSD, and Dr. Richard Bryant at the University of New South Wales, Sydney, Australia. This randomized controlled trial evaluated an Internet-based cognitive-behavioral treatment self-management intervention for individuals with PTSD. Thirty-nine victims of mass violence were randomly assigned to receive Web-based cognitive-behavioral treatment or supportive care, each requiring 56 login visits. Participants reported daily PTSD and depression symptoms and accessed self-help materials electronically. Results of this study indicated that participants who received cognitive-behavioral treatment reported greater gains than those who received supportive care. One-third of those who received cognitive-behavioral treatment achieved high end-state functioning 6 months after treatment (one quarter of the intent-to-treat group). The intervention was tolerated well, and the dropout rate was similar to that of face-to-face trials. We concluded that self-management cognitive-behavioral treatment may be a way of delivering effective treatment to large numbers with unmet needs and barriers to care. With intensive therapist input during a single session of therapy, supplemented systematically with self-directed Web-based guidance for daily homework activity, patients with PTSD can benefit from strategies that have demonstrated efficacy in reducing PTSD symptoms. A presentation on this study was given at the 10th Annual Force Health Protection Conference. A follow-on clinical trial, DESTRESS-PC: A Brief Online Self-Management Tool for PTSD, intended to treat primary care patients with nurse oversight, awaits approval.
  
  
• Yoga as an Adjunctive Treatment for PTSD-A Feasibility Study
  
  Yoga practice is one of the complementary and alternative therapies that might ameliorate the symptoms of posttraumatic stress disorder (PTSD). The style of yoga chosen for this study, Yoga Nidra, is practiced while the participant lies on his or her back, which is more comfortable for many than seated meditation. Emphasizing the less strenuous practices of yoga including deep relaxation, deep breathing, and meditation, the practice can reduce physical, emotional, mental, and even subconscious tension while stimulating the parasympathetic nervous system. The study investigated the feasibility of offering this practice and its effectiveness in reducing anxiety and symptoms of PTSD in a military population. Feasibility was measured by ease of recruitment for study participation, attendance in yoga classes, and compliance with daily homework. DHCC collaborated with the Samueli Institute on this study. Participation involved completion of 18 classes over a 10-week period, with daily home practice and homework logs. Approximately 100 subjects were screened for eligibility, 7 participants entered the study, and six completed the classes. Overall class attendance was 67%, and overall home practice adherence was 43%. Thus, early findings reveal it is feasible to offer this type of intervention to active duty service members with PTSD and that participants are largely compliant with the prescribed program. A presentation on this study was given at the 10th Annual Force Health Protection Conference.
  
  
• RESPECT-Mil: Primary Care-Based Management of Depression
  
  Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) is a project designed to improve the primary care implementation of DoD clinical practice guidelines that are integral to post-deployment care. The treatment model, based on MacArthur Foundation-funded research with collaborators in the VA, Duke University School of Medicine, and Dartmouth Medical School, leads to better treatment outcomes and increased satisfaction with post-deployment primary care. The RESPECT-Mil quality improvement initiative utilizes a Three Component Model (3CM) approach to care that incorporates RESPECT-Mil Care Facilitators (RCFs) to foster improved implementation of practice guideline recommendations for particular conditions after deployment. The RESPECT-Mil protocol is modeled after the RESPECT-Depression protocol, which has been proven effective in multi-site randomized controlled trials in the civilian sector. For RESPECT-Mil, primary care providers are trained to screen for and communicate with their patients about posttraumatic stress disorder and depression. If treatment is initiated, RCFs track patients through periodic phone contact to determine their progress in following their treatment plan and convey relevant information to primary care providers and mental health supervisors. DHCC collaborated with investigators from Dartmouth Medical School, Duke University School of Medicine, Indiana University, and the Regenstrief Institute to develop the training programs and research protocol. During pilot testing at Womack Army Medical Center, Fort Bragg, 4,159 primary care patients received depression/posttraumatic stress disorder primary care screenings; about 10% screened positive for depression or posttraumatic stress disorder (1 or both); about two thirds of patients with moderate to severe depression and/or posttraumatic stress disorder (PTSD) achieved a clinically significant drop in symptom severity at 6-10 weeks; about 70% with moderate to severe depression achieved a drop in symptom severity drop at 12 weeks or more; and about 90% of those with PTSD achieved a drop in symptom severity at 12 weeks or more. A paper summarizing the findings of this pilot project has been submitted for publication.
  
  
• Adverse Childhood Experiences Study
  
  This one-year DoD, VA, and CDC collaborative effort examines the acceptability of collecting adverse childhood event data as a part of routine military health surveillance (see CDC ACE Study and CACES PowerPoint Presentation 2007). It consists of three components: (1) a focus group-based study to assess the views of service members and their spouses regarding the collection of adverse childhood event data, (2) a panel of subject matter experts who will convene to discuss the acceptability, practicality, legal, and ethical aspects of using adverse childhood event data as a part of routine health surveillance, and (3) a review of past efforts in the military to collect adverse childhood event data anonymously. Seven-hundred eighty-four participants have been screened thus far and 40 participants been consented and interviewed with data analyses of the interviews currently underway The Collaborative Adverse Childhood Experiences Study Conference (Component 2) convened February 2-3, 2006. A report outlining the recommendations of the panel is complete. The third component, a review of past efforts in the military to collect adverse childhood event data anonymously, is also complete. The study team developed a manuscript based on this effort that is currently under review by the journal, Military Medicine.
  
  

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Publications

2007

Davis J. D., Engel C. C., Mishkind M., Jaffer A., Sjoberg T., Tinker T., McGough M., Tipton S., Armstrong D., O'Leary T. (2007). Provider and patient perspectives regarding health care for war-related health concerns. Patient Education and Counseling; 68, 1, 52-60.

Engel CC, Barsky AJ, Reissman DB, DeMartino R, Kutz I, McDonald M, Locke S for the Working Group on Psychiatric Screening and Triage During Terrorist Attack. Terrorism, Trauma, and Mass Casualty Triage: How might we solve the latest Mind-Body Problem? Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 2007; 5(2):155-163.

Engel CC, Locke S, Reissman DB, DeMartino R, Kutz I, McDonald M, Barsky AJ. Terrorism, trauma, and mass casualty triage: how might we solve the latest mind-body problem? Biosecurity and Bioterrorism 2007 Jun;5(2):155-63.

Freed MC, Bamberger MJ, Rugh J, Mabry L. RealWorld Evaluation Working Under Budget, Time, Data, and Political Constraints. Sage Publications Inc.: CA. Evaluation and Program Planning 2007; 30(3):320-321.

Freed MC, Rohan KJ, Yates BT. Estimating Health Utilities and Quality Adjusted Life Years in Seasonal Affective Disorder Research. Journal of Affective Disorders 2007; 100(1-3):83-89.

Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC. Association of Posttraumatic Stress Disorder with Somatic Symptoms, Health Care Visits, and Absenteeism Among Iraq War Veterans. American Journal of Psychiatry 2007; 164(1):150-153

Litz B, Engel CC, Bryant R, Papa A. A Randomized Controlled Proof of Concept Trial of an Internet-based Therapist-assisted Self-management Treatment for Posttraumatic Stress Disorder. American Journal of Psychiatry 2007 Nov; 164:1-8.

Riddle JR, Smith TC, Smith B, Corbeil TE, Engel CC, Wells TS, Hoge CW, Adkins J, Zamorski M, Blazer D, For the Millennium Cohort Study Team. Millennium Cohort: The 2001-2003 baseline prevalence of mental disorders in the US military. Journal of Clinical Epidemiology, 2007; 60:192-201. Epub 2006 Sep 28

Schnurr PP, Friedman MJ, Engel CC, Foa EB, Shea MT, Chow BK, Resick PA, Thurston V, Orsillo SM, Haug R, Turner C, Bernardy N. Cognitive-behavioral therapy for Posttraumatic Stress Disorder in women: a randomized controlled trial. JAMA. 2007; 297:820-830

Ursano, RJ, Benedek DM, Engel CC. Mental illness in deployed soldiers. British Medical Journal 2007 Sept; 335(7620), 571-572.

Wilson R. DoD Deployment Health Clinical Center. Air Force Psychologist Newsletter July 30, 2007; 26(3).

2006

Armstrong DW, Bradley D. (2006). Hormonal responses to opioid receptor blockade during rest and exercise in cold and hot environments. European Journal of Applied Physiology 2006; 97(1): 43-51.

Crowley B. "Assessing Civil Competences: A Case Vignette," in American Academy of Psychiatry and Law Newsletter, September 2006, pages 14-15.

Engel CC, Hyams KC, Scott K. Managing Future War Syndromes: International Approaches to War-Related Idiopathic Symptoms Since the 1991 Gulf War. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences 2006; 361:707-720

Engel CC. "Mirror, Mirror�" Whose Explanation is the Fairest? Evolving Notions of Somatization and Idiopathic Physical Symptoms. CNS Spectrums 2006; 11(3):187-188

Engel CC. Explanatory and pragmatic perspectives regarding idiopathic physical symptoms and related syndromes. CNS Spectrums 2006; 11(3):225-232

Gifford RK, Ursano RJ, Stuart JS, Engel CC. Stress and Stressors of the Early Phases of the Persian Gulf War. Philosophical Transactions of the Royal Society of London. Series B, Biological sciences. 2006; 361:585-591

Grieger TA, Cozza SJ, Ursano RJ, Hoge C, Martinez PE, Engel CC, Wain HJ. Posttraumatic stress disorder and depression in battle-injured soldiers. American Journal of Psychiatry. 2006 Oct; 163(10):1777-83; quiz 1860.

Liu X, Engel C Jr, Kang H, Armstrong DW. Veterans and functional status transitions in older Americans. Military Medicine 2006; 171(10):943-9

Mori DL, Sogg S, Guarino P, Skinner J, Williams D, Barkhuizen A, Engel C, Clauw D, Donta S, Peduzzi P. Predictors of exercise compliance in individuals with Gulf War veterans illnesses: Department of Veterans Affairs Cooperative Study 470. Military Medicine 2006; 171(9):917-23

2005

Caldwell JY, Davis JD, DuBois B, Echo-Hawk H, Erickson JS, Goins RT, et al. Culturally competent research with American Indians and Alaska Natives: Findings and Recommendations of the First Symposium of the Work Group on American Indian Research and Program Evaluation Methodology (AIRPEM). American Indian and Alaska Native Mental Health Research: The Journal of the National Center 2005; 12(1):1-21. Available online: http://aianp.uchsc.edu/ncaianmhr/journal_online.htm

Clymer R. How I Crossed the Road. Voices: the Art and Science of Psychotherapy 2005; 41(2):36-40.

Engel, CC Improving Primary Care for Military Personnel and Veterans with Posttraumatic Stress Disorder-The Road Ahead. General Hospital Psychiatry 2005; 27(3):158-60.

Liu X, Engel CC, Kang HK, Cowan D.The effect of veteran status on mortality among older Americans and its pathways. Population Research and Policy Review 2005; 24(6):573-592.

Newby JH, Ursano RJ, McCarrroll JE, Liu X, et al. Post-deployment Domestic Violence by US Army Soldiers. Military Medicine 2005; 170(8): 643-648.

Roesel TR. To the Editor: Dengue in Travelers. New England Journal of Medicine 2005; 353(23):2512.

Schnurr PP, Friedman MJ, Engel CC, Foa EB, Shea MT, Resick PM, James K, Chow BK. Issues in the Design of Multisite Clinical Trials of Psychotherapy: VA Cooperative Study No. 494 as an Example. Contemporary Clinical Trials 2005; 26:626-636

2004

Almond D, Armstrong DW, Shakir KM. Bone Mineral Density and Total Body Bone Mineral Content in 18- to 22-Year-Old Women. Bone 2004; 34(6):1037-1043.

Armstrong DW, Rue JP, Wilckens J, Frassica F. Stress Fracture Injury in Young Military Men and Women. Bone 2004; 35:806-816.

Castro CA, Engel CC, Adler AB. Mental health prevention and early intervention in the US military. In B Litz, Early Intervention for Trauma and Traumatic Loss: Evidence-based Directions. New York, NY:Guilford Press. 2004; pp. 301-318.

Donta ST, Engel CC, Collins JF, Baseman JB, Dever LL, Taylor T, Boardman KD, Kazis LE, Martin SE, Horney RA, Wiseman AL, Kernodle DS, Smith RP, Baltch AL, Handanos C, Catto B, Montalvo L, Everson M, Blackburn W, Thakore M, Brown ST, Lutwick L, Norwood D, Bernstein J, Bacheller C, Ribner B, Church LW, Wilson KH, Guduru P, Cooper R, Lentino J, Hamill RJ, Gorin AB, Gordan V, Wagner D, Robinson C, DeJace P, Greenfield R, Beck L, Bittner M, Schumacher HR, Silverblatt F, Schmitt J, Wong E, Ryan MA, Figueroa J, Nice C, Feussner JR and the VA Cooperative #475 Study Group. Benefits and harms of doxycycline treatment for Gulf War veterans' illnesses: a randomized, double-blind, placebo-controlled trial. Ann Intern Med 2004; 141(2):85-94.

Engel CC, Jaffer A, Adkins J, Riddle, Gibson R. Can We Prevent A Second "Gulf War Syndrome"? Population-based Healthcare for Chronic Idiopathic Pain & Fatigue After War. Clark MR, Treisman GJ (eds): Pain and Depression. An Interdisciplinary Patient-Centered Approach. Advances in Psychosomatic Medicine. Basel, Karger, 2004; 25:102-122

Engel CC. Post-War Syndromes: Illustrating the Impact of the Social Psyche On Notions of Risk, Responsibility, Reason, & Remedy. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry. 2004; 32(2):321-334

Engel CC. Social Psyche and Post-War Syndromes: Response to Sheila Hafter Gray's Commentary. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 2004; 32(2):341-343.

Engel CC. Somatization and Multiple Idiopathic Physical Symptoms: Relationship to Traumatic Events and Post-traumatic Stress Disorder. In Trauma and health: Physical health consequences of exposure to extreme stress. Schnurr PP, Green BL, editors. Washington, DC: American Psychological Association, 2004; pp 191-215.

Hunt SC, Richardson RD, Engel CC, Atkins DC, McFall M. Gulf War Veterans' Illnesses: A Pilot Study of the Relationship of Illness Beliefs to Symptom Severity and Functional Health Status. J Occup Environ Med 2004 Aug;46(8):818-827.

Litz BT, Williams L, Wang J, Bryant R, Engel CC. A Therapist-Assisted Internet Self-Help Program for Traumatic Stress. Professional Psychology: Research and Practice 2004: 35(6):628-634.

Messer SC, Liu X, Hoge CW, Cowan DN, Engel CC. Projecting Mental Disorder Prevalence from National Surveys to Populations-of-Interest: An Illustration Using ECA Data and the US Army. Social Psychiatry & Psychiatric Epidemiology 2004; 39:419-426.

Osuch E, Engel CC. Research on the Treatment of Trauma Spectrum Responses: The Role of the Optimal Healing Environment and Neurobiology. Journal of Alternative and Complementary Medicine 2004; 10(S1):S211-S221.

Richardson R, Engel CC: Evaluation and management of medically unexplained symptoms. The Neurologist 2004; 10(1):18-30.

Rue JP, Armstrong DW, Frassica FJ, CAPT Deafenbaugh M, Wilckens JH. The Effect of Pulsed Ultrasound in the Treatment of Tibial Stress Fractures. Orthopedics 2004; 27(11):1192-5.

2003

Carter MM, Sbrocco T, Watt Marin N, Gore K, Lewis EL. A preliminary investigation of cognitive-behavioral therapy in the treatment of African-Americans with panic disorder. Cognitive Research and Therapy 2003; 27(5): 505-518.

Clauw DJ, Engel CC, Aronowitz R, Jones E, Kipen HM, Kroenke K, Ratzan S, Sharpe M, Wessely S. Unexplained symptoms after terrorism and war: an expert consensus statement. J Occup Environ Med 2003; 45(10):1040-8.

Crowley B. The Assessment of Danger in Everyday Practice. Psychiatric Times 2003; 20(6):74-78.

Crowley B. Measures to Take After Diagnosis of Violence or Danger. Psychiatric Times 2003; 20(7):15-17.

Crowley B. Book Essay and Review on Clinicians in Court, in Psychiatry: Interpersonal and Biological Processes 2003; 66(4):368-69.

Donta ST, Clauw DJ, Engel CC, Guarino P, Peduzzi P, Williams DA, Skinner JS, Barkhuizen A, Taylor T, Kazis LE, Sogg S, Hunt SC, Dougherty CM, Richardson RD, Kunkel C, Rodriguez W, Alicea E, Chiliade P, Ryan M, Gray GC, Lutwick L, Norwood D, Smith S, Everson M, Blackburn W, Martin W, Griffiss JM, Cooper R, Renner E, Schmitt J, McMurtry C, Thakore M, Mori D, Kerns R, Park M, Pullman-Mooar S, Bernstein J, Hershberger P, Salisbury DC, Feussner. Cognitive behavioral therapy and aerobic exercise for gulf war veterans' illnesses: a randomized controlled trial. JAMA 2003; 289(11):1396-404.

Gore K, Carter MM. Incorporating the family in the cognitive-behavioral treatment of an African-American female suffering from panic disorder with agoraphobia. Journal of Family Psychotherapy 2003; 14(4):73-92.

Hoge CW, Messer SC, Engel CC, Krauss M, Amoroso P, Ryan MAK, Orman DT. Priorities for Psychiatric Research in the US Military: An Epidemiological Approach. Military Medicine 2003; 168(3):182-185.

Jackson JL, O'Malley PG, Hemmer P, Inouye L, Pangaro L, Tofferi J, Engel CC, Omori D, Roy MJ. Measuring Outcomes for Military Medical Education. Military Medicine 2003; 168(S1):51-58.

McCarroll JE, Ursano RJ, Newby JH, Liu X, et al. Domestic Violence and Deployment In US Army Soldiers. The Journal of Nervous and Mental Disease 2003;191:3-9.

Ralph R, Engel CC. Evaluation and Management of Medically Unexplained Physical Symptoms. The Neurologist 2004; 10(1): 18-30

2002

Adkins JA, Weiss H. Evaluating organizational health programs. In Quick JC, Tetrick L (Eds) The Occupational Health Psychology Handbook. Washington, DC, American Psychological Association; 2002.

Collins JF, Donta ST, Engel CC Jr, Baseman JB, Dever LL, Taylor T, Boardman KD, Martin SE, Wiseman AL, Feussner JR. The antibiotic treatment trial of Gulf War Veterans' Illnesses: issues, design, screening, and baseline characteristics. Controlled Clinical Trials 2002 Jun;23(3):333-53.

Collins TL, Engel CC Jr, Liu X, Johantgen M, Smith S. Do mental disorders matter? A study of absenteeism among care-seeking Gulf War veterans with ill-defined conditions and musculoskeletal disorders. Occupational & Environmental Medicine 2002; 59(8):532-536.

Cowan DN, Cunnion SO, Swift TM. A Review of Selected Articles on the Safety of Reprocessing Single-Use Medical Devices. Medical Devices and Diagnostic Industry 2002; 24:124-135.

Cowan DN, Lange JL, Heller J, Kirkpatrick J, DeBakey S. A Case-Control Study of Asthma among Gulf War Veterans and Modeled Exposure to Oil Well Fire Smoke. Military Medicine 2002; 167:777-792 .

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Engel CC Jr, Adkins JA, Cowan DN. Caring for medically unexplained physical symptoms after toxic environmental exposures: effects of contested causation. Environmental Health Perspective 2002 Aug;110 (Suppl 4):641-7.

Engel CC Jr, Liu X, Hoge CW, Smith SG. Multiple Idiopathic Physical Symptoms in the ECA Study: Competing Risks Analysis of One-Year Incidence, Mortality, and Resolution. American Journal of Psychiatry 2002; 159:998-1004.

Engel CC, Liu X, Hoge CW, Smith SG. Competing risks analysis of the relationship between multiple idiopathic physical symptoms and mortality. American Journal of Psychiatry 2002; 159(6):998-1004.

Engel CC Jr, Liu X, Miller RF, McCarthy BD, Ursano RJ: Relationship of physical symptoms to Post-Traumatic Stress Disorder among veterans seeking care for Gulf War-related health concerns. In, Essential Readings on Political Terrorism: Analyses of Problems and Prospects for the 21st Century, Kushner HW editor. Altschuler & Associates, New York, NY, 2002; pp. 334-348.

Hoge CW, Engel CC Jr, Orman DT, Crandell EO, Patterson VJ, Cox AL, Tobler SK, Ursano RJ. Development of a brief questionnaire to measure mental health outcomes among Pentagon employees following the September 11, 2001 attack. Military Medicine 2002 Sep;167(Suppl 9):60-3.

Hoge CW, Lesikar SE, Guevara R, Lange J, Brundage JF, Engel CC Jr, Messer SC, Orman DT. Mental disorders among US military personnel in the 1990s: association with high levels of health care utilization and early military attrition. American Journal of Psychiatry 2002 Sep;159(9):1576-83.

Hoge CW, Orman DT, Robichaux RJ, Crandell EO, Patterson VJ, Engel CC Jr, Ritchie EC, Milliken CS. Operation Solace: overview of the mental health intervention following the September 11, 2001 Pentagon attack. Military Medicine 2002 Sep;167(Suppl 9):44-7.

Hunt SC, Richardson RD, Engel CC Jr. Clinical management of Gulf War veterans with medically unexplained physical symptoms. Military Medicine 2002 May;167(5):414-20.

Hyams KC, Barrett DH, Duque D, Engel CC Jr, Friedl K, Gray G, Hogan B, Kaforski G, Murphy F, North R, Riddle J, Ryan MA, Trump DH, Wells J. The Recruit assessment Program: a program to collect comprehensive baseline health data from US military personnel. Military Medicine 2002 Jan;167(1):44-7.

Liu X, Engel CC Jr, Cowan DN, McCarroll JE. Using General Population Data to Project Idiopathic Physical Symptoms in the Army. Military Medicine 2002; 167(7):576-580.

McCarroll JE, Ursano RJ, Fullerton CS, Liu X, Lundy A. Somatic Symptoms in Gulf War Mortuary Workers. Psychosomatic Medicine 2002; 64:29-33.

Orman DT, Robichaux RJ, Crandell EO, Patterson VJ, Hoge CW, Engel CC, Ritchie EC, Milliken CS. "Operation Solace": Overview of the mental health intervention following the 11 September 2001 Pentagon attack. Military Medicine September 2002; 167(Suppl 4):44-47

Peduzzi P, Guarino P, Donta ST, Engel CC Jr, Clauw DJ, Feussner JR. Making informed consent meaningful: from theory to practice. Controlled Clinical Trials 2002; 23:178-181.

Peduzzi P, Guarino P, Donta ST, Engel CC Jr, Clauw DJ, Feussner JR. Research on informed consent: investigator-developed versus focus group-developed consent documents, a VA cooperative study. Controlled Clinical Trials 2002;23(2):184-97.

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Richardson RD, Engel CC Jr, Hunt SC, McKnight K, McFall M. Are Veterans Seeking VA Primary Care as Healthy as Those Seeking DoD Primary Care? A Look at Gulf War Veterans' Symptoms and Functional Status. Psychosomatic Medicine 2002; 64:676-683.

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