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Publications & resources

ACPMH articles 1994 to 2014

Please note, in this list of publications, the ACPMH authors have been emphasised.

In Press

Bryant, R., Nickerson, A., Creamer, M., O’Donnell, M., Forbes, D., Galatzer-Levy, I., McFarlane, A., Silove, D. (In press). The trajectory of posttraumatic stress disorder following traumatic injury: A longitudinal six year follow-up. British Journal of Psychiatry.

Contractor, A., Armour, C., Wang, X., Forbes, D., & Elhai, J. (In press). The mediating role of anger in the relationship between PTSD symptoms and impulsivity. Psychological Trauma: Theory, Research, Practice, and Policy.

Forbes, D., Alkemade, N., Hopcraft, D., Hawthorne, G., O'Halloran, P., Elhai, ... Lewis, V. (In press). Evaluation of the Dimensions of Anger Reactions - 5 (DAR-5) Scale in combat veterans with posttraumatic stress disorder. Journal of Anxiety Disorders.

Forbes, D., Alkemade, N., Waters, E., Gibbs, L., Gallagher, H., Pattison, P., ... Bryant R. (In press). Anger and major life stressors as predictors of psychological outcomes following the Victorian Black Saturday bushfires, Australian and New Zealand Journal of Psychiatry.

Forbes, D. & Creamer, M. (In press). Posttraumatic Stress Disorder. In R. Cautin & S. Lilienfeld, The Encyclopedia of Clinical Psychology, Wiley-Blackwell, USA.

Forbes, D., Nickerson, A., Alkemade, N., Bryant, R.A., Creamer, M., Silove, D., McFarlane, A.C., Van Hoof, M., Fletcher, S.L., & O’Donnell, M. (In press). Longitudinal analysis of latent classes of psychopathology and patterns of class migration in survivors of traumatic injury. Journal of Clinical Psychiatry.

Lloyd, D., Couineau, A.L., Hawkins, K., Kartal, D., Nixon, R., Perry, D., & Forbes, D. (In press). Preliminary outcomes of implementing Cognitive Processing Therapy for posttraumatic stress disorder across a national veterans' treatment service. Journal of Clinical Psychiatry.

Nickerson, A., Barnes, J.B., Creamer, M., Forbes, D., McFarlane, A.C., O’Donnell, M., Silove, D., Steel, Z., Bryant, R.A. (In press). The temporal relationship between posttraumatic stress disorder and alcohol use following traumatic injury. Journal of Abnormal Psychology.

O’Donnell, M., Grant, G., Alkemade, N., Spittal, M., Creamer, M., Silove, D., McFarlane, A., Bryant, R., Forbes, D., Studdert, D. (In press). Compensation seeking and disability after injury: The role of compensation-related stress and mental health. Journal of Clinical Psychiatry.

Phelps, A., Creamer, M., Hopwood, M., & Forbes, D. (In press). Features of posttraumatic dreams related to PTSD severity. Journal of Traumatic Stress Disorders & Treatment.

Pfitzer, B., Katona, L.J., Lee, S. J., O'Donnell, M., Cleland, H., Wasiak, J., & Ellen, S. (In press). Three years after Black Saturday: Long-term psychosocial adjustment of burns patients as a result of a major bushfire. Journal of Burn Care and Research.

Schweininger, S., Forbes, D., Creamer, M., McFarlane, A., Silove, D., Bryant, R., & O’Donnell, M. (In press). The temporal relationship between mental health and disability after injury. Depression and Anxiety.

Wade, D., Fletcher, S., Carty, J., & Creamer, M. (In press). Posttraumatic stress disorder in women. Cambridge University Press.


Bowman, S., Alvarez-Jimenez, M., Wade, D., Howie, L., McGorry, P. (2014). The impact of first episode psychosis on sibling quality of life. Social Psychiatry and Psychiatric Epidemiology, 49(7),1071-81. doi: 10.1007/s00127-013-0817-5

Bryant, R.A., Waters, E., Gibbs, L., Gallagher, H.C., Pattison, P., Lusher, D., ... Forbes, D. (2014). Psychological outcomes following the Victorian Black Saturday bushfires. Australian & New Zealand Journal Of Psychiatry, 48(7), 9. doi: 10.1177/0004867414534476

Forbes, D., Alkemade, N., Mitchell, D., Elhai, J., McHugh, T., Bates, G., ... Lewis, V. (2014). Utility of the Dimensions of Anger Reactions - 5 (DAR-5) Scale as a brief anger measure. Depression and Anxiety, 31, 166-173.

Forbes, D., Lockwood, E., Elhai, J., Creamer, M., Bryant, R., McFarlane, A., ... O’Donnell, M. (2015). An evaluation of the DSM-5 factor structure for posttraumatic stress disorder in survivors of traumatic injury. Journal of Anxiety Disorders, 29, 43-51.

Forbes, D., Lockwood, E., Phelps, A., Wade, D., Creamer, M., Bryant, R., ... O’Donnell, M. (2014). Trauma at the hands of another part 2: Distinguishing PTSD patterns following intimate and nonintimate interpersonal and noninterpersonal trauma in a nationally representative sample. Journal of Clinical Psychiatry,75,147-153. doi:10.4088/JCP.13m08374

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

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

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

Lloyd, D., Nixon, R., Varker, T., Elliott, P., Perry, D., Bryant, R., Creamer, M. & Forbes, D. (2014). Comorbidity in the prediction of Cognitive Processing Therapy treatment outcomes for combat-related posttraumatic stress disorder. Journal of Anxiety Disorders, 28(2), 237-240. doi: 10.1016/j.janxdis.2013.12.002

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

O’Donnell, M., Alkemade, N., Nickerson, A., Creamer, M., McFarlane, A., Silove, D., Bryant, R., & Forbes, D. (2014). The impact of the diagnostic changes to posttraumatic stress disorder for DSM-5 and the proposed changes to ICD-11.British Journal of Psychiatry, 204, 6. doi: 10.1192/bjp.bp.113.135285

Wade, D., Varker, T., Forbes, D., & O'Donnell, M. (2014). The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) in the assessment of alcohol use disorders among acute injury patients. Alcoholism: Clinical and Experimental Research, 38, 294-299. doi: 10.1111/acer.12247


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

Bowman, S., Alvarez-Jimenez, M., Wade, D., McGorry, P., & Howie, L. (2013). Forgotten family members: The importance of siblings in early psychosis. Early Intervention in Psychiatry, 7(2). doi:10.1111/eip.12068

Bryant, R., O’Donnell, M., Creamer, M., McFarlane, A., & Silove, D. (2013). A multi-site analysis of the fluctuating course of posttraumatic stress disorder. JAMA Psychiatry, 70, 8. doi: 10.1001/jamapsychiatry.2013.1137

Contractor, A., Elhai, J., Ractliffe, K., & Forbes, D. (2013). PTSD’s underlying symptom dimensions and relations with behavioral inhibition and activation. Journal of Anxiety Disorders, 27, 645-651. doi:

Forbes, D., & Bryant, R. (2013). When the violence of war comes home. The Lancet, 381, 883-84. doi:10.1016/S0140-6736(13)60629-7

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

Gibbs, L., Waters, E., Bryant, R., Pattison, P., Lusher, D., Harms, L., … Forbes, D. (2013). Beyond bushfires: Community, resilience and recovery - A longitudinal mixed method study of the medium to long term impacts of bushfires on mental health and social connectedness. BMC Public Health, 13,1036. doi:10.1186/1471-2458-13-1036

Gleeson, J., Cotton, S., Alvarez-Jimenez, M., Wade, D., Gee, D., Crisp, K., ... McGorry, P. (2013). A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients: Outcome at 30-month follow up. Schizophrenia Bulletin, 39, 436-48. doi: 10.1093/schbul/sbr165

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

Holmes, A., Williamson O., Hogg, M., Arnold, C., & O'Donnell, M. (2013). Determinants of chronic pain 3 years after moderate or serious injury. Pain Medicine, 14(1). doi: 10.1111/pme.12034

Lewis, V., Dell, L., & Matthews, L. (2013). Evaluating the feasibility of Goal Attainment Scaling as a rehabilitation outcome measure for veterans. Journal of Rehabilitation Medicine, 45, 403-409. doi: 10.2340/16501977-1131

Lewis, V., Varker, T., Forbes, D., & Phelps, A. (2013). Organizational implementation of Psychological First Aid (PFA): Training for managers and peers. Psychological Trauma: Theory, Research, Practice, and Policy. doi: 10.1037/a0032556

O'Donnell, M., Varker, T., Creamer M., Holmes, A., Ellen, S., Wade, D., ... Forbes, D. (2013). Disability after injury: The cumulative burden of physical and mental health. Journal of Clinical Psychiatry74, e137-43. doi: 10.4088/JCP.12m08011

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

O'Donnell, M., Varker, T., Creamer M., Holmes, A., Ellen, S., Wade, D., ... Forbes, D. (2013). Disability after injury: The cumulative burden of physical and mental health. Journal of Clinical Psychiatry, 74, e137-143. doi:10.4088/JCP.12m08011

O'Donnell, M., Varker, T., Perry, D., & Phelps, A. (2013). The effect of centre-based counseling for veterans and veterans' families on long-term mental health outcomes. Military Medicine, 178, 1328-34. doi: 10.7205/MILMED-D-13-00058

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

Phelps, A., & Forbes, D. (2013). Treating posttraumatic stress disorder-related dreams: What are the options? Expert Review of Neurotherapeutics, 12, 1267-69.

Reifels, L., Bassilios, B., Forbes, D., Creamer, M., Wade, D., Coates, S., ... Pirkis, J. (2013). A systematic approach to building the mental health response capacity of practitioners in a postdisaster context. Advances in Mental Health, 11, 246-256. doi: 10.5172/jamh.2013.11.3.246

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

Semage, S., Sivayogan, S., Forbes, D., O’Donnell, M., Monaragala, R., Lockwood, E., & Dunt, D. (2013). Cross-cultural and factorial validity of PTSD check list - military version (PCL-M) in Sinhalese language. European Journal of Psychotraumatology, 4, 1-8. doi: 10.3402/ejpt.v4i0.19707

Shultz, J., & Forbes, D. (2013). Psychological First Aid: Rapid proliferation and the search for evidence. Disaster Health, 1, 1-10.

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

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

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


Crane, M., Lewis, V., Cohn, A., Hodson, S., Parslow, R., Bryant, R., & Forbes, D. (2012). A protocol for the longitudinal study of psychological resilience in the Australian Defence Force. Journal of Military and Veterans’ Health, 20, 36-48.

Creamer, M., Forbes, D., & Wade, D. (2012). Psychosocial recovery following disaster: A multi-level approach. International Perspectives in Victimology, 6, 121-127. doi: 10.5364/ipiv.6.2.121

Click to read abstract
In recent years, there has been a growing expectation from both government and the broader community that psychosocial needs, as well as practical and physical needs, will be addressed following major disasters. This paper proposes an integrated three level response to be rolled out in the days, weeks, and months following the impact. Level 1 is designed for the whole population, with an emphasis on community support and building normal resilience and recovery skills. Those interventions can be delivered by a wide range of first responder personnel, lay persons, and community leaders. Level 2 is designed for delivery by primary health care providers and is targeted at low level clinical problems. It comprises a small number of core skills useful in managing psychological distress. Level 3 is designed for delivery by specialist mental health providers and targets the minority of survivors who go on to develop diagnosable psychiatric conditions. The training implications are discussed at each level. Finally, the need for effective evaluation of these programs is emphasized.

Creamer, M., Varker, T., Bisson, J., Darte, K., Greenberg, N., Lau, W., ... Forbes, D. (2012). Guidelines for peer support in high-risk organizations: An international consensus study using the Delphi Method. Journal of Traumatic Stress, 25, 134-141. doi: 10.1002/jts.21685

Click to read abstract
Despite widespread adoption of peer-support programs in organisations around the world whose employees are at high risk of exposure to potentially traumatic incidents, little consensus exists regarding even the most basic concepts and procedures for these programs. In this article, consensus refers to a group decision-making process that seeks not only agreement from most participants, but also resolution of minority objections. The aim of the current study was to develop evidence-informed peer-support guidelines for use in high-risk organisations, designed to enhance consistency around goals and procedures and provide the foundation for a systematic approach to evaluation. From 17 countries, 92 clinicians, researchers, and peer-support practitioners took part in a 3-round web-based Delphi process rating the importance of statements generated from the existing literature. Consensus was achieved for 62 of 77 (81%) statements. Based upon these, 8 key recommendations were developed covering the following areas: (a) goals of peer support, (b) selection of peer supporters, (c) training and accreditation, (d) role of mental health professionals, (e) role of peer supporters, (f) access to peer supporters, (g) looking after peer supporters, and (h) program evaluation. This international consensus may be used as a starting point for the design and implementation of future peer-support programs in high-risk organisations.

Forbes, D. (2012). Posttraumatic stress disorder: Risk and recovery. In D. Castle, S. Hood & V. Starcevic (Eds.), Anxiety Disorders: Current Understandings of Novel Treatments (pp. 83-92). Victoria: Australian Postgraduate Medicine.

Forbes, D., Creamer, M., & Wade, D. (2012). Psychological support and recovery in the aftermath of natural disaster. International Psychiatry, 9, 15-17.

Click to read abstract
Natural disasters can result in a range of mental health outcomes among the affected population. Appropriate mental health interventions are required to promote recovery. In the aftermath of the 2009 bushfires in Victoria, Australia, a collaboration of trauma experts, the Australian and Victorian state governments and health professional associations developed an evidence-informed three-level framework outlining recommended levels of care. The framework was underpinned by an education and training agenda for mental health professionals. This framework has been successfully applied after further natural disasters in Australia. This paper outlines the steps included in each of the levels.

Forbes, D., Elhai, J., Lockwood, E., Creamer, M., Frueh, B., & Magruder, K. (2012). The structure of posttraumatic psychopathology in veterans attending primary care. Journal of Anxiety Disorders, 26, 95-101. doi: 10.1016/j.janxdis.2011.09.004

Click to read abstract
This study attempted to extend research indicating that posttraumatic stress disorder (PTSD) factors of Re-experiencing, Avoidance and Hyperarousal are more related to Fear/phobic disorders, while PTSD Dysphoria is more related to Anxious-Misery disorders. Trauma exposure, PTSD and comorbidity data for 668 veteran patients were analysed using confirmatory factor analyses and relative strengths of the relationships between PTSD factors and the Fear and Anxious-Misery factors were assessed. Combining Simms, Watson, and Doebbeling’s (2002) model of PTSD symptoms and Krueger’s (1999) Fear/Anxious Misery model of mood and anxiety disorders fit the data well. Contrary to previous research, PTSD Re-experiencing, Avoidance and Hyperarousal did not correlate more with the Fear factor; nor did PTSD Dysphoria correlate more with Anxious-Misery. Hyperarousal was more closely related to Fear than was Re-experiencing; however, Avoidance was not. Dysphoria was more closely related to the Anxious-Misery factor than all other PTSD factors.

Forbes, D., Fletcher, S., Parslow, R., Phelps, A. J., O’Donnell, M., Creamer, M., ... Silove, D. (2012). Trauma at the hands of another: Differences in the PTSD symptom profile following interpersonal compared with non-interpersonal trauma. Journal of Clinical Psychiatry, 73, 372-376. doi: 10.4088/JCP.10m06640

Click to read abstract
Objective: Survivors of traumatic events of an interpersonal nature typically have higher rates of posttraumatic stress disorder (PTSD) than survivors of non-interpersonal traumatic events. Little is known about potential differences in the nature or trajectory of PTSD symptoms in survivors of these different types of traumatic events. The current study aimed to identify the specific symptom profile of survivors of interpersonal and non-interpersonal trauma, and to examine changes in differences in the symptom profile over time. Method: The paper examined PTSD symptom data from 715 traumatic injury survivors admitted to hospital between April 2004 and February 2006, who were assessed 3, 12, and 24 months after injury using the Clinician Administered PTSD scale. Multivariate analyses of variance (MANOVAs) were used to investigate differences in PTSD symptom profile over time between interpersonal and non-interpersonal trauma. Results: MANOVAs revealed significant differences between the two groups in severity of PTSD symptoms at each of the three timepoints [3 months: F(17, 696) = 5.86, p<.001; 12 months: F(17, 696) = 3.62, p<.001; 24 months: F(17, 696) = 3.09, p<.001]. Survivors of interpersonal trauma demonstrated significantly higher scores on 15 PTSD symptoms at 3 months post injury but on only 6 symptoms by 24 months. Symptoms on which differences persisted were the PTSD unique symptoms more associated with fear and threat. Conclusions: Interpersonal trauma results in more severe PTSD symptoms in the early aftermath of trauma. Over the course of time, the distinctive persisting symptoms following interpersonal trauma involve fear-based symptoms, suggesting fear conditioning may be instrumental in persistent interpersonal PTSD.

Forbes, D., Lloyd, D., Nixon, R., Elliott, P., Varker, T., Perry, D., ... Creamer, M. (2012). A multisite randomized controlled effectiveness trial of Cognitive Processing Therapy for military-related posttraumatic stress disorder. Journal of Anxiety Disorders, 26, 442-452. doi: 10.1016/j.janxdis.2012.01.006

Click to read abstract
Cognitive processing therapy (CPT) is currently applied in military veteran mental health services in many countries. This study tests the effectiveness of community-administered CPT for military-related PTSD under randomised controlled conditions. Fifty-nine treatment-seeking veterans with military-related PTSD were randomly allocated to receive 12 twice-weekly 60 minute sessions of CPT or an equivalent period of usual treatment at veterans’ community-based counselling services. Intent to treat analyses found significantly greater improvement for participants receiving CPT over usual treatment at post-treatment and 3 month follow-up. CPT also produced greater improvements in anxiety, depression, social and dyadic relationships than usual treatment. No CPT related adverse events occurred during the trial. This trial reports the first randomised controlled trial evidence that CPT is an effective treatment for military PTSD and co-morbid conditions when compared to usual treatment and delivered in community settings by clinicians from diverse disciplines, preferred treatment orientation and levels of experience.

Goodwill, R. (2012). Engaging staff communities in a knowledge transfer strategy: a case study at the University of Melbourne. Journal of Higher Education Policy and Management, 34, 285-294. doi: 10.1080/1360080X.2012.678726

Click to read abstract
Within the framework of the strategic journey undertaken between 2005 and 2010, this paper seeks to examine how the University of Melbourne sought to differentiate itself through the introduction and reconceptualisation of a ‘third stream’ of academic work. Specifically, this paper seeks to investigate, through qualitative methods, how those in leadership roles in diverse areas of the University understood and operationalised knowledge transfer as a new strategic priority from 2006; and the approaches taken leading to the University’s (subsequently refined) view of third stream activity as engagement. This paper also argues that there were multiple barriers to introducing and implementing the new strategy. However, once personal linkages were created between the changed strategy and scholarly life, an organisational story developed with the potential benefits leading to opportunities through mission differentiation, without the risk of unsustainable organisational resource demands. Finally, this paper concludes that significant change is not easy, but it is possible.

McHugh, T., Forbes, D., Bates, G., Hopwood, M., & Creamer, M. (2012). Anger in PTSD: Is there a need for a concept of PTSD-related posttraumatic anger? Clinical Psychology Review, 32, 93-104. doi: 10.1016/j.cpr.2011.07.013

Click to read abstract
Despite extensive research on posttraumatic stress disorder (PTSD), anger in PTSD has received little attention. This is surprising, given anger is a key predictor of treatment outcome in PTSD. This paper seeks to build an argument for investigating anger in PTSD as a discrete entity. A key argument is that the capacity to image visual mental phenomena is crucial to the aetiology and maintenance of anger in PTSD. Evidence is reviewed for the influence of visual imagery in anger in PTSD from the perspectives of neuropsychology, psychopathology, anger and PTSD. An argument is advanced for including visual imagery in an integrated (visual–linguistic) cognitive model of anger in PTSD. Directions for research on visual imagery in anger in PTSD and its treatment implications are discussed.

Norman, P., O’Donnell, M., Creamer, M., & Barton, J. (2012). Posttraumatic stress disorder after stroke: A review of quantitative studies. In E. E. Ovuga (Ed.), Posttraumatic stress disorders in a global context (pp. 247-268). InTech. doi: 10.5772/26799

O’Donnell, M., Lau, W., Tipping, S., Holmes, A., Ellen, S., Judson, R., ... Creamer, M. (2012). Stepped early psychological intervention for posttraumatic stress disorder, other anxiety disorders and depression and following serious injury. Journal of Traumatic Stress, 25, 125-133. doi: 10.1002/jts.21677

Click to read abstract
The best approach for implementing early psychological intervention for anxiety and depressive disorders after a traumatic event has not been established. This study aimed to test the effectiveness of a stepped model of early psychological intervention following traumatic injury. A sample of 683 consecutively admitted injury patients were screened during hospitalisation. High-risk patients were followed up at 4-weeks postinjury and assessed for anxiety and depression symptom levels. Patients with elevated symptoms were randomly assigned to receive 4–10 sessions of cognitive–behavioral therapy (n = 24) or usual care (n = 22). Screening in the hospital identified 89% of those who went on to develop any anxiety or affective disorder at 12 months. Relative to usual care, patients receiving early intervention had significantly improved mental health at 12 months. A stepped model can effectively identify and treat injury patients with high psychiatric symptoms within 3 months of the initial trauma.

Varker, T., & Devilly, G. (2012). An analogue trial of inoculation /resilience training for emergency services personnel: Proof of concept. Journal of Anxiety Disorder, 26, 696-701. doi: 10.1016/j.janxdis.2012.01.009

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Background and objectives: This analogue study served as a proof of concept trial for inoculation/resilience training with emergency services personnel. Methods: Eighty people from the general community participated in a randomized controlled trial of inoculation training to increase resilience in the mitigation of stress and trauma-type symptomatology following a stressful video of paramedics attending the scene of a car accident. Participants were randomly allocated to one of two conditions: (a) resilience training, where the participants received strategies aimed at reducing the negative effects of the event; or (b) a control ‘pragmatic training’ condition, where participants received practical training about what to do in the event of a car accident. A week later the full video was shown. All participants were assessed one month later. Results: Unlike with past studies which tested psychological debriefing, analyses revealed that inocu-lation/resilience training did not appear to have deleterious effects on psychological distress measures or memory performance. Participants who received the resilience training displayed improvements in negative affect (notable trends in depression and stress levels) suggesting a more general positive result from the intervention than normal ‘pragmatic training’. Limitations: This was an analogue trial and a full field trial is warranted. Conclusions: With organisations wishing to engage in resilience training, this analogue study suggests that inoculation training at least does no harm and may be beneficial. It is, therefore, a viable option for emergency services personnel during pre-deployment training.

Wade, D., Forbes, D., Nursey, J., & Creamer, M. (2012). A multi-level framework to guide mental health response following a natural disaster. Bereavement Care, 31, 109-113. doi: 10.1080/02682621.2012.740285

Wade, D., Varker, T., Coates, S., Fitzpatrick, T., Shann, C., & Creamer, M. (2012). A mental health training program for community members following a natural disaster. Disaster Health 1, 1-4. doi: 10.4161/dh.22658.

Wade, D., Varker, T., O’Donnell, M., & Forbes, D. (2012). Examination of the latent factor structure of the Alcohol Use Disorders Identification Test (AUDIT) in two independent trauma patient groups using Confirmatory Factor Analysis. Journal of Substance Abuse Treatment, 43, 123-128. doi:10.1016/j.jsat.2011.10.023

Click to read abstract
Recent research on the factor structure of the Alcohol Use Disorders Identification Test (AUDIT) provides support for two underlying factors: consumption and consequences. The current study sought to extend these findings to two independent and diverse trauma populations: traumatic injury patients and military veterans treated for posttraumatic stress disorder. The 2- and 3-factor solutions provided the best fit to the data, but there was a very high correlation between the second and third factors of the 3-factor solution. Parsimony suggests that the 2-factor solution is the preferred model. The 2-factor model has implications for alcohol screening using the AUDIT and supports the goal of screening to identify those with hazardous drinking and alcohol use disorders. An algorithm is proposed to inform alcohol screening protocols in a range of health settings for trauma-exposed patient groups.


Bryant, R. A., Brooks, R., Silove, D., Creamer, M., O’Donnell, M., & McFarlane, A. C. (2011). Peritraumatic dissociation mediates the relationship between acute panic and chronic posttraumatic stress disorder. Behaviour Research and Therapy, 346-351. doi:10.1016/j.brat.2011.03.003

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Although peritraumatic dissociation predicts subsequent posttraumatic stress disorder (PTSD), little is understood about the mechanism of this relationship. This study examines the role of panic during trauma in the relationship between peritraumatic dissociation and subsequent PTSD. Randomized eligible admissions to 4 major trauma hospitals across Australia (n = 244) were assessed during hospital admission and within one month of trauma exposure for panic, peritraumatic dissociation and PTSD symptoms, and subsequently re-assessed for PTSD three months after the initial assessment (n = 208). Twenty (9.6%) patients met criteria for PTSD at 3-months post injury. Structural equation modeling supported the proposition that peritraumatic derealization (a subset of dissociation) mediated the effect of panic reactions during trauma and subsequent PTSD symptoms. The mediation model indicated that panic reactions are linked to severity of subsequent PTSD via derealization, indicating a significant indirect relationship. Whereas peritraumatic derealization is associated with chronic PTSD symptoms, this relationship is influenced by initial acute panic responses.

Bryant, R. A., Creamer, M., O’Donnell, M., Silove, D., & McFarlane, A. C. (2011). Heart rate after trauma and the specificity of fear circuitry disorders. Psychological Medicine, 41, 2573-2580. doi:10.1017/S0033291711000948

Click to read abstract
Background: Fear circuitry disorders purportedly include post-traumatic stress disorder (PTSD), panic disorder, agoraphobia, social phobia and specific phobia. It is proposed that these disorders represent a cluster of anxiety disorders triggered by stressful events and lead to fear conditioning. Elevated heart rate (HR) at the time of an aversive event may reflect strength of the unconditioned response, which may contribute to fear circuitry disorders. Method: This prospective cohort study assessed HR within 48 h of hospital admission in 602 traumatically injured patients, who were assessed during hospital admission and within 1 month of trauma exposure for lifetime psychiatric diagnosis. At 3 months after the initial assessment, 526 patients (87%) were reassessed for PTSD, major depressive disorder, panic disorder, agoraphobia, social phobia, obsessive compulsive disorder and generalized anxiety disorder.Results. At the 3-month assessment there were 77 (15%) new cases of fear circuitry disorder and 87 new cases of non-fear circuitry disorder (17%). After controlling for gender, age, type of injury and injury severity, patients with elevated HR (defined as o96 beats per min) at the time of injury were more likely to develop PTSD [odds ratio (OR) 5.78, 95% confidence interval (CI) 2.32–14.43], panic disorder (OR 3.46, 95% CI 1.16–10.34), agoraphobia (OR 3.90, 95% CI 1.76–8.61) and social phobia (OR 3.98, 95% CI 1.42–11.14). Elevated HR also predicted new fear circuitry Disorders that were not co-morbid with a non-fear circuitry disorder (OR 7.28, 95% CI 2.14–24.79). Conclusions: These data provide tentative evidence of a common mechanism underpinning the onset of fear circuitry disorders.

Elhai, J. D., Contractor, A. A., Palmieri, P. A., Forbes, D., & Richardson, J. D. (2011). Exploring the relationship between underlying dimensions of posttraumatic stress disorder and depression in a national trauma exposed military sample. Journal of Affective Disorders, 133, 477-480. doi:10.1016/j.jad.2011.04.035

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Background: Posttraumatic stress disorder (PTSD) and depression are highly comorbid and intercorrelated. Yet little research has examined the underlying processes explaining their interrelationship. Method: In the present survey study, the investigators assessed the combined symptom structure of PTSD and depression symptoms, to examine shared, underlying psychopathological processes. Participants included 740 Canadian military veterans from a national, epidemiological survey, previously deployed on peacekeeping missions and administered the PTSD Checklist and Center for Epidemiological Studies-Depression Scale (CES-D). Results: An eight-factor PTSD/depression model fit adequately. In analyses validating the structure, PTSD's dysphoria factor was more related to depressive affect than to several other PTSD and depression factors. Somatic problems were more related to dysphoria than to other PTSD factors. Limitations: Only military veterans were sampled, and without the use of structured diagnostic interviews. Conclusions: Results highlight a set of interrelationships that PTSD's dysphoria factor shares with specific depression factors, shedding light on the underlying psychopathology of PTSD that emphasizes dysphoric mood.

Elhai, J. D., Naifeh, J. A., Forbes, D., Ractliffe, K., C., & Tamburrino, M. (2011). Heterogeneity in posttraumatic stress disorder’s clinical presentations among medical patients: Testing factor structure variation using factor mixture modeling. Journal of Traumatic Stress, 24, 435-443. doi:10.1002/jts.20653

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The present study used factor mixture modeling to explore empirically defined subgroups of psychological trauma victims based on confirmatory factor analysis (CFA) and latent class analysis of posttraumatic stress disorder (PTSD) symptoms. We sampled 310 medical patients with a history of trauma exposure. Confirmatory factor analysis revealed that the 4-factor emotional numbing PTSD model yielded the best model fit. Using latent factor means derived from this model and the 4-factor dysphoria PTSD model (indexing severity on PTSD factors), 3 latent classes of participants were identified using factor mixture modeling. The 3-class model fit the data very well and was validated against external measures of anxiety and rumination.

Forbes, D., Lewis, V., Varker, T., Phelps, A., O’Donnell, M., Wade, D., ... Creamer, M. (2011). Psychological first aid following trauma: Implementation and evaluation framework for high-risk organizations. Psychiatry: interpersonal and biological processes.74, 224-239. doi:10.1521/psyc.2011.74.3.224

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International clinical practice guidelines for the management of psychological trauma recommend Psychological First Aid (PFA) as an early intervention for survivors of potentially traumatic events. These recommendations are consensus-based, and there is little published evidence assessing the effectiveness of PFA. This is not surprising given the nature of the intervention and the complicating factors involved in any evaluation of PFA. There is, nevertheless, an urgent need for stronger evidence evaluating its effectiveness. The current paper posits that the implementation and evaluation of PFA within high risk organizational settings is an ideal place to start. The paper provides a framework for a phasic approach to implementing PFA within such settings and presents a model for evaluating its effectiveness using a logic- or theory-based approach which considers both pre-event and post-event factors. Phases 1 and 2 of the PFA model are pre-event actions, and phases 3 and 4 are post-event actions. It is hoped that by using the Phased PFA model and evaluation method proposed in this paper, future researchers will begin to undertake the important task of building the evidence about the most effective approach to providing PFA in high risk organizational and community disaster settings.

Gleeson, J., Cotton, S., Alvarez-Jimenez, M., Wade, D., Gee, D., Crisp, K., ... McGorry, P. (2011). A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients: Outcome at 30-month follow up. Schizophrenia Bulletin. Advance online publication. doi: 10.1093/schbul/sbr165

Hanley, F. T., Matthews, L. R., & Lewis, V. (2011). Exploring the meaning of best practice: A discussion on the way client-centred psychosocial rehabilitation services might address the needs of Australian veterans in the future. International Journal of Disability Management, 6, 10-21. doi: 10.1375/jdmr.6.1.10

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This article presents a summary of 10 priorities for the delivery of best practices in psychosocial rehabilitation relevant to the Australian veteran population. The first section interrogates the empirical principles characteristically identified with best practices before presenting an alternative, heuristic framework organised by three reference points and informed by principles of efficacy, external validity, and the meaning of efficacy in the context of parity. The article presents the strategy used in reviewing the literature, before presenting the findings according to 10 key priorities. The 10 priorities are described in the context of the literature informing them and are set out with regard to the centrality of the client-centred service modelin the design and delivery of pertinent and effective services into the future.

Mills, K. L., McFarlane, A. C., Slade, T., Creamer, M., Silove, D., Teesson, M., ... Bryant, R. (2011). Assessing the prevalence of trauma exposure in epidemiologic surveys. Australian and New Zealand Journal of Psychiatry, 45, 407-415. doi: 10.3109/00048674.2010.543654

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Objective: Estimates of the prevalence of exposure to potentially traumatic events (PTEs) in population surveys have increased over time. There is limited empirical evidence on the impact of changes in measurement practices on these estimates. The present study examined the effect of increasing the number of events assessed on the prevalence of exposure longitudinally. Methods: Data were ultilised from the 1997 and 2007 Australian National Surveys of Mental Health and Wellbeing. The 1997 survey assessed exposure using 11 items from the Composite International Diagnostic Interview (CIDI), version 2.1. The 2007 survey utilized 29 items from the World Mental Health CIDI. Prevalence rates of exposure to matched events among age-matched samples from both surveys were compared to determine whether differences in the estimates obtained were due to respondents having been asked about an increased number of event types in the latter survey. Results: The effect of increasing the number of event types in the CIDI from 11 to 29 was to increase the overall population prevalence of exposure to PTEs by 18%. The difference between estimates was more pronounced in women than in men. The cross-cohort analyses revealed that these differences were not indicative of an increase in trauma exposure over time; but rather the endorsement of new events that were not listed in the earlier survey. Conclusions: The findings underscore the importance of using comprehensive assessments in the measurement of exposure to PTEs. Previous epidemiological surveys may have underestimated the prevalence of traumatic and other stressful life events, particularly among women.

Rees, S., Silove, D., Chey, T., Ivancic, L., Steel, Z., Creamer, M., ... Forbes, D. (2011). Lifetime prevalence of gender-based violence in women and the relationship with mental disorders and psychosocial function. Journal of the American Medical Association, 306, 513-521. doi:10.1001/jama.2011.1098

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Context: Intimate partner physical violence, rape, sexual assault, and stalking are pervasive and co-occurring forms of gender-based violence (GBV). An association between hese forms of abuse and lifetime mental disorder and psychosocial disability among women needs to be examined. Objectives: To assess the association of GBV and mental disorder, its severity and comorbidity, and psychosocial functioning among women. Design, Setting, and Participants: A cross-sectional study based on the Australian National Mental Health and Well-being Survey in 2007, of 4451 women (65%
response rate) aged 16 to 85 years. Main Outcome Measures: The Composite International Diagnostic Interview version 3.0 of the World Health Organization’s World Mental Health Survey Initiative was used to assess lifetime prevalence of any mental disorder, anxiety, mood disorder, substance use disorder, and posttraumatic stress disorder (PTSD). Also included were indices of lifetime trauma exposure, including GBV, sociodemographic characteristics, economic status, family history of mental disorder, social supports, general mental and physical functioning, quality of life, and overall disability. Results: A total of 1218 women (27.4%) reported experiencing at least 1 type of GBV. For women exposed to 3 or 4 types of GBV (n=139), the rates of mental disorders were 77.3% (odds ratio [OR], 10.06; 95% confidence interval [CI], 5.85-17.30) for anxiety disorders, 52.5% (OR, 3.59; 95% CI, 2.31-5.60) for mood disorder, 47.1% (OR, 5.61; 95%CI, 3.46-9.10) for substance use disorder, 56.2% (OR, 15.90;95%CI, 8.32-30.20) for PTSD, 89.4% (OR, 11.00; 95% CI, 5.46-22.17) for any mental disorder, and 34.7% (OR, 14.80; 95% CI, 6.89-31.60) for suicide attempts. Gender-based violence was associated with more severe current mental disorder (OR, 4.60;95%CI, 2.93-7.22), higher rates of3ormore lifetime disorders (OR, 7.79;95%CI, 6.10-9.95), physical disability (OR, 4.00; 95% CI, 1.82-8.82), mental disability (OR, 7.14; 95% CI, 2.87-17.75), impaired quality of life (OR, 2.96;95%CI, 1.60-5.47), an increase in disability days (OR, 3.14;95% CI, 2.43-4.05), and overall disability (OR, 2.73; 95% CI, 1.99-3.75). Conclusion: Among a nationally representative sample of Australian women, GBVwas significantly associated with mental health disorder, dysfunction, and disability.

Shultz, J. M., Kelly, F., Forbes, D., Verdeli, H., Rosen., A., & Neria, Y. (2011). Triple Threat Trauma: Evidence-based mental health response for the 2011 Japan disaster. Prehospital and Disaster Medicine, 26, 141-145. doi:10.1017/S1049023X11006364

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On March 11, 2011, a Richter Magnitude 9.0 earthquake occurred in the ocean along a seismically-active tectonic plate boundary 120 km east of Japan’s main island, Honshu.  The earthquake launched a tsunami of immense magnitude, surging toward the Japanese coastline with limited time to warn coastal residents.  As the tsunami crashed ashore, several nuclear power plants were seriously damaged, precipitating a succession of explosions and subsequently, containment structure leaks that sent significant amounts of radioactive material drifting over major population centers and later discharging into the Pacific Ocean.

Phelps, A., Forbes, D., Hopwood, M., & Creamer, M. (2011). Trauma related dreams of Australian veterans with PTSD: Content, affect and phenomenology. Australian and New Zealand Journal of Psychiatry, 45, 853-860. doi: 10.3109/00048674.2011.599314

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Objective: Consensus on the parameters of trauma-related dreams required to meet criteria for post-traumatic stress disorder (PTSD) is critical when: (i) the diagnosis requires a single re-experiencing symptom; and (ii) trauma dreams are prevalent in survivors without PTSD. Method: This study investigated the phenomenology of PTSD dreams in 40 veterans,using structured interview and self-report measures. Results: Dream content varied between replay, non-replay, and mixed, but affect was largely the same as that experienced at the time of trauma across all dream types. ANOVA indicated no difference between dream types on PTSD severity or nightmare distress. Conclusions: The findings provide preliminary support for non-replay dreams to satisfy the DSM B2 diagnostic criterion when the affect associated with those dreams is the same as that experienced at the time of the traumatic event.

Couineau, A.-L. & Forbes, D. (2011). Using predictive models of behaviour change to promote evidence-based treatment for PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 266-275. doi: 10.1037/a0024980

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While there is a strong evidence base regarding effective treatment of Posttraumatic Stress Disorder (PTSD), and an increased number of treatment guidelines available internationally, research indicates that there is significant variation in clinical practice. This study aimed to identify effective ways to promote adoption of trauma-focused interventions in community services offering mental health care to people who have experienced trauma. The study sought to do so by identifying factors influencing the uptake of evidence-based practice at both an individual and organizational level, and trialing competency training and support strategies based on these factors across 6 community trauma services. The effectiveness of the training and support strategies was investigated using self-report surveys and prospective recording of clinicians’ treatment planning for PTSD clients. The study found that while lack of skills and confidence were identified as significant barriers to the uptake of trauma-focused interventions, expectations about treatment outcomes and organizational factors also influenced clinical behavior. This finding highlighted the importance of considering factors other than knowledge and skills when developing training and other interventions to support the implementation of evidence-based practice. Furthermore, it was found that a training and implementation process tailored to organizational and individual barriers, and based on currently recognized theories of behavior change, led to a significant increase in the use of imaginal exposure in the treatment plans of clients assessed as having PTSD. This change was maintained 6 months following training.

Bryant, R. A., Felmingham, K. L., Silove, D., Creamer, M., O’Donnell, M., & McFarlane, A. C. (2011). The association between menstrual cycle and traumatic memories. Journal of Affective Disorders, 131, 398-401. doi:10.1016/j.jad.2010.10.049

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Background: Women in the mid-luteal phase of the menstrual cycle have been shown to have stronger emotional memories than other women. We investigated the extent to which experiencing a traumatic event during the luteal phase of the menstrual cycle is associated with stronger traumatic flashback memories. Methods: Consecutive female patients admitted to hospital after traumatic injury (n = 138) were assessed for days since last menstruation, as well as assessment of flashbacks. Twenty three (17%) women were in the mid-luteal phase (18-24) days at the time of trauma exposure and 29 (21%) were in the mid-luteal phase at the time of assessment. Results: Women were more likely to experience flashback memories if they were in the luteal phase during the trauma (22% vs. 9%), adjusted OR: 3.64 [95%CI: 0.99-13.29] after controlling for injury severity, age, trauma type, and mild traumatic brain injury. Women in the luteal phase at assessment were 4.89 times more likely to have flashbacks. Adjusted OR: 4.89 [95%CI: 1.39-17.86]. Conclusions: Increased glucocorticoid release associated with the luteal phase of the menstrual cycle may facilitate consolidation of trauma memories.

Carty, J., O’Donnell, M., Evans, L., Kazantzis, N., & Creamer, M. (2011). Predicting posttraumatic stress disorder symptoms and pain intensity following severe injury: The role of catastrophizing. European Journal of Pscyhotraumatology, 2. Advanced online publication. doi:10.3402/ejpt.v2i0.5652

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Background: A number of theories have proposed possible mechanisms that may explain the high rates of comorbidity between posttraumatic stress disorder (PTSD) and persistent pain; however, there has been limited research investigating these factors. Objective: The present study sought to prospectively examine whether catastrophizing predicted the development of PTSD symptoms and persistent pain following physical injury. Design: Participants (N = 208) completed measures of PTSD symptomatology, pain intensity and catastrophizing during hospitalization following severe injury, and 3 and 12 months postinjury. Cross-lagged path analysis explored the longitudinal relationship between these variables. Results: Acute catastrophizing significantly predicted PTSD symptoms but not pain intensity 3 months postinjury. In turn, 3-month catastrophizing predicted pain intensity, but not PTSD symptoms 12 months postinjury. Indirect relations were also found between acute catastrophizing and 12-month PTSD symptoms and pain intensity. Relations were mediated via 3-month PTSD symptoms and 3-month catastrophizing, respectively. Acute symptoms did not predict 3-month catastrophizing and catastrophizing did not fully account for the relationship between PTSD symptoms and pain intensity. Conclusions: Findings partially support theories that propose a role for catastrophizing processes in understanding vulnerability to pain and posttrauma symptomatology and, thus, a possible mechanism for comorbidity between these conditions.

Creamer, M., Wade, D., Fletcher, S., & Forbes, D. (2011). PTSD among military personnel. International Review of Psychiatry, 23, 160-165. doi:10.3109/09540261.2011.559456

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Although symptoms characteristic of post-traumatic stress disorder (PTSD) have been noted in military personnel for many centuries, it was not until 1980 that the disorder was formally recognized and became the focus of legitimate study. This paper reviews our current state of knowledge regarding the prevalence and course of this complex condition in past and present members of the defence forces. Although rates vary across conflicts and countries, there is no doubt that PTSD affects substantial numbers of personnel and results in considerable impairment in functioning and quality of life. The paper goes on to discuss recent attempts to build resilience and to promote adjustment following deployment, noting that there is little evidence at this stage upon which to draw firm conclusions. Finally, effective treatment for PTSD is reviewed, with particular reference to the challenges posed by this population in a treatment setting.

Forbes, D. & Creamer, M. (2011). Psychological support and treatment for victims of the floods. InPsych: The Bulletin of the Australian Psychological Society Ltd, February, 24-25. Retrieved from

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The floods across the Eastern States, particularly in areas such as Toowoomba and the Lockyer Valley in Queensland–with their heavy toll on life and property–will leave thousands deeply affected. The extent of devastation has been such that, for many, it will be a long time before lives return to normal. Lessons from the Black Saturday Victorian bushfires and the 1974 floods indicate that re-establishing a sense of normality and rebuilding after such events can continue for years afterward. For those who lost loved ones, the experience of traumatic grief will have an additional major impact on their lives. The loss of homes and communities, and the security that they provide, will make the recovery process longer and more difficult. How organisations and health services support those affected by the floods may have a lasting impact on individuals’ ability to cope. While much attention in the early stages will focus on broad community interventions designed to enhance cohesion and support, there is also an important place for individual assistance.

Forbes, D., Fletcher, S., Lockwood, E., O’Donnell, M., Creamer, M., Bryant, R. A. ... Silove, D. (2011). Requiring both avoidance and emotional numbing in DSM-V PTSD: Will it help? Journal of Affective Disorders, 130, 483-486. doi:10.1016/j/jad.2010.10.032

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Objective: The proposed DSM-V criteria for posttraumatic stress disorder (PTSD) specifically require both active avoidance and emotional numbing symptoms for a diagnosis. In DSM-IV, since both are included in the same cluster, active avoidance is not essential. Numbing symptoms overlap with depression, which may result in spurious comorbidity or overdiagnosis of PTSD. This paper investigated the impact of requiring both active avoidance and emotional numbing on the rates of PTSD diagnosis and comorbidity with depression. Method: We investigated PTSD and depression in 835 traumatic injury survivors at 3 and 12months post-injury. We used the DSM-IV criteria but explored the potential impact of DSM-IV and DSM-V approaches to avoidance and numbing using comparison of proportion analyses. Results: The DSM-V requirement of both active avoidance and emotional numbing resulted in significant reductions in PTSD caseness compared with DSM-IV of 22% and 26% respectively at 3 and 12months posttrauma. By 12months, the rates of comorbid PTSD in those with depression were significantly lower (44% vs. 34%) using the new criteria, primarily due to the lack of avoidance symptoms. Conclusion: These preliminary data suggest that requiring both active avoidance and numbing as separate clusters offers a useful refinement of the PTSD diagnosis. Requiring active avoidance may help to define the unique aspects of PTSD and reduce spurious diagnoses of PTSD in those with depression.

Forbes, D., Lockwood, E., Elhai, J. D., Creamer, M., O’Donnell, M., Bryant, R.A., ... Silove, D. (2011). An examination of the structure of posttraumatic stress disorder in relation to the anxiety and depressive disorders. Journal of Affective Disorders, 132, 165-172. doi:10.1016/j.jad.2011.02.011.  

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The nature and structure of posttraumatic stress disorder (PTSD) has been the subject of much interest in recent times. This research has been represented by two streams, the first representing a substantive body of work which focuses specifically on the factor structure of PTSD and the second exploring PTSD's relationship with other mood and anxiety disorders. The present study attempted to bring these two streams together by examining structural models of PTSD and their relationship with dimensions underlying other mood and anxiety disorders. PTSD, anxiety and mood disorder data from 989 injury survivors interviewed 3-months following their injury were analyzed using a series of confirmatory factor analyses (CFA) to identify the optimal structural model. CFA analyses indicated that the best fitting model included PTSD's re-experiencing (B1–5), active avoidance (C1–2), and hypervigilance and startle (D4–5) loading onto a Fear factor (represented by panic disorder, agoraphobia and social phobia) and the PTSD dysphoria symptoms (numbing symptoms C3–7 and hyperarousal symptoms D1–3) loading onto an Anxious Misery/Distress factor (represented by depression, generalized anxiety disorder and obsessive compulsive disorder). The findings have implications for informing potential revisions to the structure of the diagnosis of PTSD and the diagnostic algorithm to be applied, with the aim of enhancing diagnostic specificity.


Bryant, R. A., Creamer, M., O’Donnell, M., Silove, D., & McFarlane, A. C. (2010). Sleep disturbance immediately prior to trauma predicts subsequent psychiatric disorder. Sleep, 33, 69-74. Retrieved from

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Study Objectives: This study investigated the extent to which sleep disturbance in the period immediately prior to a traumatic event predicted development of subsequent psychiatric disorder. Design: Prospective design cohort study. Setting: Four major trauma hospitals across Australia. Patients: A total of 1033 traumatically injured patients were initially assessed during hospital admission and followed up at 3 months (898) after injury. Measures: Lifetime psychiatric disorder was assessed in hospital with the Mini-International Neuropsychiatric Interview. Sleep disturbance in the 2 weeks prior to injury was also assessed using the Sleep Impairment Index. The prevalence of psychiatric disorder was assessed 3 months after traumatic injury. Results: There were 255 (28%) patients with a psychiatric disorder at 3 months. Patients who displayed sleep disturbance prior to the injury were more likely to develop a psychiatric disorder at 3 months (odds ratio: 2.44, 95% CI: 1.62–3.69). In terms of patients who had never experienced a prior disorder (n = 324), 96 patients (30%) had a psychiatric disorder at 3 months, and these patients were more likely to develop disorder if they displayed prior sleep disturbance (odds ratio: 3.16, 95% CI: 1.59–4.75). Conclusions: These findings provide evidence that sleep disturbance prior to a traumatic event is a risk factor for development of posttraumatic psychiatric disorder.

Bryant, R. A., O’Donnell, M., Creamer, M., McFarlane, A. C., Clark, R. C., & Silove, D. (2010). The psychiatric sequelae of traumatic injury. American Journal of Psychiatry, 167, 312-320. doi:10.1176/appi.ajp.2009.09050617

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Objective: Traumatic injury affects millions of people each year. There is little understanding of the extent of psychiatric illness that develops after traumatic injury or of the impact of mild traumatic brain injury (TBI) on psychiatric illness. The authors sought to determine the range of new psychiatric disorders occurring after traumatic injury and the influence of mild TBI on psychiatric status. Method: In this prospective cohort study, patients were drawn from recent admissions to four major trauma hospitals across Australia. A total of 1,084 traumatically injured patients were initially assessed during hospital admission and followed up 3 months (N = 932, 86%) and 12 months (N = 817, 75%) after injury. Lifetime psychiatric diagnoses were assessed in hospital. The prevalence of psychiatric disorders, levels of quality of life, and mental health service use were assessed at the follow-ups. The main outcome measures were 3- and 12-month prevalence of axis I psychiatric disorders, levels of quality of life, and mental health service use and lifetime axis I psychiatric disorders. Results: Twelve months after injury, 31% of patients reported a psychiatric disorder, and 22% developed a psychiatric disorder that they had never experienced before. The most common new psychiatric disorders were depression (9%), generalized anxiety disorder (9%), posttraumatic stress disorder (6%), and agoraphobia (6%). Patients were more likely to develop posttraumatic stress disorder (odds ratio=1.92, 95% CI=1.08-3.40), panic disorder (odds ratio=2.01, 95% CI=1.03-4.14), social phobia (odds ratio=2.07, 95% CI=1.03-4.16), and agoraphobia (odds ratio=1.94, 95% CI=1.11-3.39) if they had sustained a mild TBI. Functional impairment, rather than mild TBI, was associated with psychiatric illness. Conclusions: A significant range of psychiatric disorders occur after traumatic injury. The identification and treatment of a range of psychiatric disorders are important for optimal adaptation after traumatic injury.

Bryant, R. A., O’Donnell, M., Creamer, M., McFarlane, A. C., & Silove, D. (2010). Posttraumatic intrusive symptoms across psychiatric disorders. Journal of Psychiatric Research, 45, 842-847. doi:10.1016/j.jpsychires.2010.11.012

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Reexperiencing symptoms are a key feature of posttraumatic stress disorder (PTSD). This study investigated the pattern of reexperiencing symptoms in non-PTSD posttraumatic disorders. This study recruited 1084 traumatically injured patients during hospital admission and conducted follow-up assessment 12 months later (N = 817, 75%). Twelve months after injury, 22% of patients reported a psychiatric disorder they had never experienced prior to the traumatic injury. One-third of patients with a non-PTSD disorder satisfied the PTSD reexperiencing criteria. Whereas patients with a non-PTSD disorder were more likely to experience intrusive memories, nightmares, psychological distress and physiological reactivity to reminders, only patients with PTSD were likely to experience flashback memories (OR: 11.41, 95% CI: 6.17–21.09). The only other symptom that was distinctive to PTSD was dissociative amnesia (OR: 4.50, 95% CI: 2.09–9.71). Whereas intrusive memories and reactions are common across posttraumatic disorders, flashbacks and dissociative amnesia are distinctive to PTSD.

Cook, J. M., Harb, G. C., Gehrman, P. R., Cary, M. S., Gamble, G. M., Forbes, D., & Ross, R. J. (2010). Imagery Rehearsal for Posttraumatic Nightmares: A Randomized Controlled Trial. Journal of Traumatic Stress, 23, 553-563. doi:10.1002/jts.20569

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One hundred twenty-four male Vietnam War veterans with chronic, severe posttraumatic stress disorder (PTSD) were randomly assigned to imagery rehearsal (n = 61) or a credible active comparison condition (n = 63) for the treatment of combat-related nightmares. There was pre-post change in overall sleep quality and PTSD symptoms for both groups, but not in nightmare frequency. Intent-to-treat analyses showed that veterans who received imagery rehearsal had not improved significantly more than veterans in the comparison condition for the primary outcomes (nightmare frequency and sleep quality), or for a number of secondary outcomes, including PTSD. Six sessions of imagery rehearsal delivered in group format did not produce substantive improvement in Vietnam War veterans with chronic, severe PTSD. Possible explanations for findings are discussed.

Ehlers, A., Bisson, J., Clark, D. M., Creamer, M., Pilling, S., Richards, D., . . .  Yule, W. (2010). Do all psychological treatments really work the same in posttraumatic stress disorder? Clinical Psychology Review, 30, 269-276. doi:10.1016/j.cpr.2009.12.001

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A recent meta-analysis by Benish, Imel, and Wampold (2008, Clinical Psychology Review, 28, 746–758) concluded that all bona fide treatments are equally effective in posttraumatic stress disorder (PTSD). In contrast, seven other meta-analyses or systematic reviews concluded that there is good evidence that trauma-focused psychological treatments (trauma-focused cognitive behavior therapy and eye movement desensitization and reprocessing) are effective in PTSD; but that treatments that do not focus on the patients' trauma memories or their meanings are either less effective or not yet sufficiently studied. International treatment guidelines therefore recommend trauma-focused psychological treatments as first-line treatments for PTSD. We examine possible reasons for the discrepant conclusions and argue that (1) the selection procedure of the available evidence used in Benish et al.'s 2008) meta-analysis introduces bias, and (2) the analysis and conclusions fail to take into account the need to demonstrate that treatments for PTSD are more effective than natural recovery. Furthermore, significant increases in effect sizes of trauma-focused cognitive behavior therapies over the past two decades contradict the conclusion that content of treatment does not matter. To advance understanding of the optimal treatment for PTSD, we recommend further research into the active mechanisms of therapeutic change, including treatment elements commonly considered to be non-specific. We also recommend transparency in reporting exclusions in meta-analyses and suggest that bona fide treatments should be defined on empirical and theoretical grounds rather than by judgments of the investigators' intent.

Evans, L., Cowlishaw, S., Forbes, D., Parslow, R., & Lewis, V. (2010). Longitudinal analyses of family functioning in veterans and their partners across treatment. Journal of Consulting & Clinical Psychology, 78, 611-622. doi:10.1037/a0020457

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Objective: This study evaluated the relations between posttraumatic stress disorder (PTSD) symptoms and poor family functioning in veterans and their partners. Method: Data were collected from Caucasian veterans with PTSD (N = 1,822) and their partners (N = 702); mean age = 53.9 years, SD = 7.36. Veterans completed the Posttraumatic Checklist Military Version (PCL-M) and, along with their partners, completed the McMaster Family Assessment Device (FAD-12). Assessments were conducted at intake into a treatment program at 3 months and 9 months posttreatment. Results: Structural equation models (SEMs) were developed for veterans as well as for veterans and their partners. Poor family functioning for veterans at intake predicted intrusion (β = .08), hyperarousal (β = .07), and avoidance (β = .09) at 3 months posttreatment. At 3 months posttreatment, family functioning predicted hyperarousal (β = .09) and avoidance (β = .10) at 9 months. For veterans and their partners, family functioning at intake predicted avoidance (β = .07) at 3 months, and poor family functioning at 3 months predicted intrusion (β = .09) and hyperarousal (β = .14) at 9 months. The reverse pathways, with PTSD symptoms predicting poor family functioning, were only evident with avoidance (β = .06). Conclusion: Family functioning may play a role in treatment for veterans.

Fletcher, S., Creamer, M., & Forbes, D. (2010). Preventing posttraumatic stress disorder: Are drugs the answer? Australian and New Zealand Journal of Psychiatry, 44, 1064-1071. doi:10.3109/00048674.2010.509858

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In the field of traumatic stress, chemoprophylaxis is a term that is often used but rarely well understood. There has been no shortage of debate on the issue, but few rigorous studies to ground the discussion. The purpose of the current paper is to explore the issues surrounding this contentious area. Databases including PubMed, PsychArticles and Web of Knowledge were searched using the key words chemo or pharmaco, prevention or prophylaxis, and PTSD or post-traumatic stress. Relevant journals and reference lists of the papers obtained through this search were scanned for additional references. Studies that investigated the use of pharmacotherapy to prevent the onset of post-traumatic stress disorder were considered for this paper. Studies that examined the treatment of established PTSD were excluded. A total of 15 empirical studies were included in the review (including five randomized controlled trials), and twice as many non-data-driven papers. Evidence for the prophylactic use of alcohol, morphine, propranolol, and hydrocortisone is presented, followed by a discussion of the many challenges of using pharmacological interventions in this context. While attention to this issue has increased in recent times, the dearth of empirical data has done little to further the field. Larger studies are indicated following small trials with medications such as propranolol and hydrocortisone. There remain a number of ethical and practical questions to be answered before the widespread use of chemoprophylaxis can be recommended.

Forbes, D., Creamer, M., Bisson, J. I., Cohen, J. A., Crow, B. E., Foa, E. B., . . . Ursano, R. J. (2010). A guide to guidelines for the treatment of PTSD and related conditions. Journal of Traumatic Stress, 23, 537-552. doi:10.1002/jts.20565

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In recent years, several practice guidelines have appeared to inform clinical work in the assessment and treatment of posttraumatic stress disorder. Although there is a high level of consensus across these documents, there are also areas of apparent difference that may lead to confusion among those to whom the guidelines are targeted— providers, consumers, and purchasers of mental health services for people affected by trauma. The authors have been responsible for developing guidelines across three continents (North America, Europe, and Australia). The aim of this article is to examine the various guidelines and to compare and contrast their methodologies and recommendations to aid clinicians in making decisions about their use.

Forbes, D., Elhai, J. D., Miller, M. W., & Creamer, M. (2010). Internalizing and externalizing classes in posttraumatic stress disorder: A latent class analysis. Journal of Traumatic Stress, 23, 340-349. doi:10.1002/jts.20526

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Using latent class analysis (LCA) the typology of personality profiles of veterans with posttraumatic stress disorder (PTSD) was examined based on internalizing/externalizing dimensions of psychopathology. Latent class analysis on Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Personality Psychopathology-5 (PSY-5) scale data from 299 Australian combat veterans with PTSD supported the model, identifying an optimal 4-class solution, with PTSD externalizing class defined by aggressiveness and disconstraint, high and moderate internalizing classes differentiated on the extent of elevations in introversion and negative emotionality and elevation of psychoticism in the high internalizing class and a simple PTSD class with normal range scores. The model was validated using external self-report and psychiatric-interview-derived diagnoses. A second exploratory LCA using broader comorbidity indicators (MMPI-2 Restructured Clinical scales) demonstrated some support for, although limitations in, using nonpersonality measures to identify these classes directly.

Forbes, D., Fletcher, S., Wolfgang, B., Varker, T., Creamer, M., Brymer, M. J., . . . Bryant, R.A. (2010). Practitioner perceptions of Skills for Psychological Recovery:  A training program for health practitioners in the aftermath of the Victorian bushfires. Australian and New Zealand Journal of Psychiatry, 44, 1105-1111. doi:10.3109/00048674.2010.513674

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Objective: Following the February 2009 Victorian bushfires, Australia’s worst natural disaster, the Australian Centre for Posttraumatic Mental Health, in collaboration with key trauma experts, developed a three-tiered approach to psychological recovery initiatives for survivors with training specifi cally designed for each level. The middle level intervention, designed for delivery by allied health and primary care practitioners for survivors with ongoing mild-moderate distress, involved a protocol still in draft form called Skills for Psychological Recovery (SPR). SPR was developed by the US National Center for PTSD and US National Child Traumatic Stress Network. This study examined health practitioner perceptions of the training in, and usefulness of SPR.

Forbes, D., Parslow, R., Creamer, M., O’Donnell, M., Byrant, R., McFarlane, A., . . . Shalev, A. (2010). A longitudinal analysis of posttraumatic stress disorder symptoms and their relationship with fear and anxious-misery disorders: Implications for DSM-V. Journal of Affective Disorders, 127, 147-152. doi:10.1016/j/jad.2010.05.005

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This paper examined the hypothesis that PTSD-unique symptom clusters of re-experiencing, active avoidance and hyperarousal were more related to the fear/phobic disorders, while shared PTSD symptoms of dysphoria were more closely related to Anxious-Misery disorders (MDD/GAD). Confirmatory factor and correlation analyses examining PTSD, anxiety and mood disorder data from 714 injury survivors interviewed 3, 12 and 24-months following their injury supported this hypothesis with these relationships remaining robust from 3–24 months posttrauma. Of the nine unique fear-oriented PTSD symptoms, only one is currently required for a DSM-IV diagnosis. Increasing emphasis on PTSD fear symptoms in DSM-V, such as proposed DSM-V changes to mandate active avoidance, is critical to improve specificity, ensure inclusion of dimensionally distinct features and facilitate tailoring of treatment.

Forbes, D., Parslow, R., Fletcher, S. McHugh, T., & Creamer, M. (2010). Attachment style in the prediction of recovery following group treatment in combat veterans with post-traumatic stress disorder. Journal of Nervous & Mental Disease, 198, 881-884. doi:10.1097/NMD.0b013e3181fe73fa

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Post-traumatic stress disorder (PTSD) can be difficult to treat, with gains often particularly modest in combat veterans. Although group-based treatments are commonly delivered for veterans, little is known about factors influencing their outcomes. Attachment style is known to be associated with psychopathology after trauma and is critical to group-based interventions, but has not yet been investigated in relation to treatment outcome. A better understanding of factors that influence outcome is critical in optimizing the effectiveness of such interventions. This study investigated attachment style as a predictor of outcome for 103 veterans attending group-based treatment for combat-related PTSD. Measures included the Clinician Administered PTSD Scale, PTSD Checklist, and Relationship Styles Questionnaire. Path analyses indicated preoccupied attachment style strongly negatively predicted outcome following treatment. The preoccupied attachment style impedes recovery in group-based treatment for veterans with PTSD. Potential mechanisms underlying this finding are discussed. The results suggest that greater attention should be paid at initial assessment to attachment style of veterans before entering PTSD treatment, particularly group-based interventions.

Holmes, A., Williamson, O., Hogg, M., Arnold, C., Prosser, A., Clements, J., . . . O’Donnell, M. (2010). Predictors of pain 12 months after serious injury. Pain Medicine, 11, 1599-1611.

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Objective: The majority of patients will report pain 12 months after a serious injury. Determining the independent risk factors for pain after serious injury will establish the degree to which high-risk patients can be detected in the acute setting and the viability of early triage to specialist pain services. Design: A prospective cohort study of patients following serious injury was conducted. The initial assessment comprised a comprehensive battery of known and possible risk factors for persistent pain. Patients were assessed at 12 months for pain severity and for the presence of chronic pain. Results: Two hundred ninety patients underwent an initial assessment of whom 238 (82%) were followed up at 12 months. At 12 months, 171 (72%) patients reported some pain over the past 24 hours. Thirty five patients (14.7%) reported chronic pain. Five factors independently predicted the 24-hour pain severity: preinjury physical role function, preinjury employment status, initial 24 hours pain score, higher beliefs in the need for medication, and compensable injury (R2 = 0.21, P < 0.0001). Four factors predicted the presence of chronic pain at 12 months: not working prior to injury, total Abbreviated Injury Scale, initial pain severity, and initial pain control attitudes (pseudo R2 = 0.24, P = 0.0001). Conclusions: Factors present at the time of injury can allocate patients into high- or low-risk groups.The majority of cases of chronic pain emerging from the high-risk group warrant more intense clinical attention. We recommend recording these factors in discharge documentation as indicators of persistent pain.

Ikin, J. F., Creamer, M., Sim, M. R., & McKenzie, D. P. (2010). Comorbidity of PTSD and depression in Korean War veterans: Prevalence, predictors, and impairment. Journal of Affective Disorders, 125, 279-286. doi:10.1016/j.jad.2009.12.005

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Background: Rates of PTSD and depression are high in Korean War veterans. The prevalence and impact of the two disorders occurring comorbidly, however, has not been investigated. This paper aims to investigate the extent to which PTSD and depression co-occur in Australian veterans of the Korean War, the symptom severity characteristics of comorbidity, the impact on life satisfaction and quality, and the association with war-related predictors. Methods: Veterans (N = 5352) completed self-report questionnaires including the Posttraumatic Stress Disorder Checklist, the Hospital Anxiety and Depression Scale, the Life Satisfaction Scale, the brief World Health Organisation Quality of Life questionnaire and the Combat Exposure Scale. Results: Seventeen percent of veterans met criteria for comorbid PTSD and depression, 15% had PTSD without depression, and a further 6% had depression without PTSD. Compared with either disorder alone, comorbidity was associated with impaired life satisfaction, reduced quality of life, and greater symptomseverity. Several war-related factorswere associated with comorbidity and with PTSD alone, but not with depression alone. Limitations: The reliance on self-reportedmeasures and the necessity for retrospective assessment of some deployment-related factors renders some study data vulnerable to recall bias. Conclusions: Comorbid PTSD and depression, and PTSD alone, are prevalent among Korean War veterans, are both associated with war-related factors 50 years after the Korean War, and may represent a single traumatic stress construct. The results have important implications for understanding complex psychopathology following trauma.

McKenzie, D. P., Creamer, M., Kelsall, H. L., Forbes, A. B., Ikin, J. F., Sim, M. R., McFarlane, A.C. (2010). Temporal relationships between Gulf War deployment and subsequent psychological disorders in Royal Australian Navy Gulf War veterans. Social Psychiatry and Psychiatric Epidemiology, 45, 843-852. doi:10.1007/s00127-009-0134-1

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Background: Although much has been published on the effects of the 1990/1991 Gulf War on the psychological health of veterans, few studies have addressed the pattern and timing of post-war development of psychological disorders. Our study aims to identify the most common psychological disorders that first appeared post-Gulf War, the period of peak prevalence and the sequence of multiple psychological disorders. Methods: The temporal progression of psychological disorders in male Australian naval Gulf War veterans with no prior psychological disorders was calculated across each year of the post-Gulf War period. DSM-IV diagnoses were obtained using the Composite International Diagnostic Interview. Results Psychological disorder rates peaked in the first 2 years (1991–1992) following the Gulf War. Alcohol use disorders were the most likely to appear first. Classification and regression tree analysis found that risk of disorder was exacerbated if veterans had been exposed to a high number of potential psychological stressors during their military service. Lower military rank was associated with increased risk of alcohol disorders, particularly during the first 2 years post-Gulf War. In veterans with two or more disorders, anxiety disorders and alcohol disorders tended to appear before affective disorders. Conclusions: Our study found that psychological disorders occur in sequence following Gulf War deployment. Our findings may help clinicians to anticipate, and better manage, multiple symptomatology. The findings may also assist veteran and defence organisations in planning effective mental health screening, management and prevention policy.

O’Connor, D. W. & Parslow, R. (2010). Mental health scales and psychiatric diagnoses: Responses to GHQ-12, K-10 and CIDI across the lifespan. Journal of Affective Disorders, 121, 263-267. doi:10.1016/j.jad.2009.06.038

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Background: Surveys based on complex interviews like CIDI report very low rates of affective disorder in older people, perhaps because the lengthy, convoluted questions present a special challenge to aged respondents. By contrast, mental health scales like the GHQ-12 and K-10 show much less change in score with age. Before concluding that scales present a fairer picture of aged mental health, it is important to check if scores are inflated by items that might reflect normal involutional changes in cognition, energy and social role. Methods: Secondary analysis of an Australian national survey of 10,641 adults. Results: GHQ-12 and K-10 scores declined with age to a relatively minor degree. When scores were bisected, the proportion of respondents scoring above the cutpoints fell with age but to a lesser degree than with ICD-10 diagnoses. Scores on GHQ-12 and K-10 items relating to cognition, energy and social role rose with age but, on factor analysis, these items loaded similarly in a two-factor model. Conclusion: No evidence emerged of age-related bias in either GHQ-12 or K-10. Items concerning cognition, energy and social role were associated with affect in older people, just as they were in younger ones. It seems unlikely therefore that the different trajectories over the lifespan of CIDI diagnoses and scores on GHQ-12 and K-10 are due to limitations within the scales. The possibility that CIDI minimizes affective disorder in older age-groups cannot be discounted. Limitations: Residents of aged care facilities and those with low cognitive scores were excluded.

O’Donnell, M., Creamer, M., & Cooper, J. (2010). Criterion A: Controversies and Clinical Implications. In G. M. Rosen & B. C. Frueh (Eds.), Clinician's Guide to Posttraumatic Stress Disorder. New Jersey: John Wiley & Sons.

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The diagnosis of PTSD requires that a person experience a traumatic event. In DSM-IV, it is Criterion A that defines a traumatic stressor for the purpose of a diagnosis. Defining what constitutes a traumatic event, however, is not an easy task and much heated debate has revolved around criterion A and its role in the genesis of PTSD.  With the development of DSM-V, due for release in 2013, the question of defining trauma in PTSD has been reignited and several excellent papers have appeared in recent years discussing the many complex issues associated with Criterion A (e.g., Long & Elhai, 2009; North, Suris, Davis, & Smith, 2009; Weathers & Keane, 2007).  This chapter aims to distill the key issues raised by other commentators, so as to help the clinician negotiate the complex debates over what constitutes a traumatic stressor. We will return to our case examples at the end of the chapter to help clinicians understand the application of these issues in their own practice.

O'Donnell, M., Creamer, M., Holmes, A. C. N., Ellen, S., McFarlane, A. C., Judson, R., . . . Bryant, R.A. (2010). Posttraumatic stress disorder after injury: Does admission to Intensive Care Unit increase risk? Journal of Trauma-Injury, Infection and Critical Care, 69, 627-632. doi:10.1097/TA.0b013e3181bc0923

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This study aimed to index the prevalence of posttraumatic stress disorder (PTSD) after injury requiring intensive care unit (ICU) admission to investigate whether an ICU admission after injury increases risk for PTSD and to identify predictors of PTSD after ICU admission. Methods: A two-group (those admitted to the ICU vs. those not admitted to ICU), prospective, cohort study of 829 randomly selected injury patients from five major trauma hospitals across Australia. We collected information on factors that may increase risk for PTSD including demographic variables (gender, age, income, education, and marital status), preinjury mental health status (prior trauma, psychiatric history, and prior social support), and injury characteristics (mild traumatic brain injury, injury severity, length of hospital admission, discharge destination, pain, and perceived threat). PTSD was measured at 12 months by structured clinical interview. Results: ICU patients were significantly more likely to have PTSD at 12 months than trauma controls (17% vs. 7%). Stepwise logistic regressions showed that an ICU admission significantly contributed to the development of PTSD after controlling for demographic, preinjury mental health status, and injury characteristic variables. Conclusions: Injury patients are three times more likely to develop later PTSD if they have an ICU admission. Given we controlled for many risk variables, it seems that an ICU admission itself may contribute to the development of PTSD. Mental health services such as screening and early intervention may be particularly useful for this population.

O'Donnell, M., Creamer, M., McFarlane, A. C., Silove, D., & Bryant, R. A. (2010). Does access to compensation impact on recovery outcomes after injury? Medical Journal of Australia, 192, 328-333. Retrieved from

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Objective: To conduct a descriptive study investigating the effect of access to motor vehicle accident (MVA) compensation on recovery outcomes at 24 months after injury. Design and setting: Longitudinal cohort study conducted in two Level 1 trauma hospitals in Victoria, Australia. Participants were 391 randomly selected injury patients with moderate-to-severe injuries. Compensable and non-compensable patients were compared at 24 months after injury on a number of health outcomes. Main outcome measures: Health outcomes at 24 months, including anxiety and depression severity, quality of life and disability. Results: Medical records identified two groups of compensation patients: MVA-compensable and non-compensable patients. After controlling for baseline variables, the MVA-compensable patients, at 24 months, had higher levels of post-traumatic stress disorder, anxiety and depression, and were less likely to have returned to their pre-injury number of work hours. However, some patients in the non-compensable group had accessed other forms of compensation (eg, private health care or compensation for victims of crime). When these were removed from the non-compensable group, the differences between MVA-compensable and non-compensable groups all but disappeared. Conclusion: Our findings do not support previous research showing that access to compensation is associated with poor recovery outcomes. The relationship between access to compensation and health outcomes is complex, and more high-level research is required.

O'Donnell, M., Creamer, M., McFarlane, A. C., Silove, D., & Bryant, R. A. (2010). Should A2 be a diagnostic requirement for posttraumatic stress disorder in DSM-V? Psychiatry Research, 176, 257-260. doi:10.1016/j.psychres.2009.05.012

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The requirement that trauma survivors experience fear, helplessness or horror (Criterion A2) as a part of their posttraumatic stress disorder (PTSD) diagnosis was introduced into DSM-IV. The imminent re-definition of PTSD in DSM-V highlights the need for empirical studies to validate the utility of the A2 requirement. We aimed to identify (i) how often A2 was associated with PTSD (B-F criteria) at 3 months after trauma and (ii) what was the peritraumatic emotional experience for those who met PTSD criteria but were A2 negative. In a prospective design cohort study we assessed the peritraumatic emotional experience of 535 injury patients in four Australian hospitals. These patients were followed up 3 months later and assessed for PTSD using a structured clinical interview. The majority of those who developed PTSD (B-F criterion) at 3 months met A2 criteria. A substantial minority, however (23%), did not meet A2 criteria. Those PTSD patients who were A2 negative fell into three groups: (i) those who experienced subthreshold levels of A2; (ii) those who experienced intense peritrauma emotional responses other than fear, helplessness or horror; and (iii) those who were amnesic to their peritrauma emotional experience. These findings do not support the inclusion of A2 as diagnostic requirement for DSM-V.


Australian Centre for Posttraumatic Mental Health (ACPMH). (2009). Skills for Psychological Recovery (SPR):  Australian Adaptation Brochure. Melbourne: ACPMH.  Retrieved from

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About this brochure: This brochure is a brief reference guide to Skills for Psychological Recovery (SPR). It provides an overview of the various components of SPR and describes for whom they may be useful. Traumatic Events: Events are those that (a) involve actual or threatened death or serious injury (real or perceived) to self or others (e.g., accidents, assault, natural disasters and wars); and (b) evoke feelings of fear, helplessness or horror. Certain events (e.g., interpersonal violence, direct life threat and events of prolonged duration) are more likely to result in a traumatic response. Reactions to Traumatic Events: Most people recover after a traumatic event without serious problems. Some develop more severe and persistent symptoms like PTSD, depression and substance abuse. Stepped Care: The stepped care model is a non-pathologising approach. It begins with a period of monitoring followed by the use of increasingly intensive treatments as the need for such interventions is determined. This model is resource efficient as it provides best practice care only to those who need it. It also promotes the normal recovery process.

Brooks, R., Bryant, R. A., Silove, D., Creamer, M., O'Donnell, M., McFarlane, A. C., & Marmar, C. R. (2009). The latent structure of the Peritraumatic Dissociative Experiences Questionnaire. Journal of Traumatic Stress, 22, 153-157. doi:10.1002/jts.20414

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This paper has been retracted due to a publisher's error: the order of the authors was incorrect. The Editor and Publisher of the Journal of Traumatic Stress apologize to the authors and our readership. The Peritraumatic Dissociative Experiences Questionnaire (PDEQ) is a widely used measure of peritraumatic dissociation, and is presumably a unidimensional construct. Two hundred forty-seven individuals admitted to five hospitals after traumatic injury were administered the Clinician Administered PTSD Scale, the Hospital Anxiety and Depression Scale, and the PDEQ. Factor analysis indicated that the PDEQ involved two factors containing four items each: one factor (altered awareness) indexes alterations in awareness and the other (derealization) reflects distortions in perceptions of the self and the world. Only the derealization factor was associated with acute stress, anxiety, and depression symptoms. Cross-validation with independent data provided only partial support for the 2-factor structure model. These data indicate that peritraumatic dissociation may involve two distinct constructs.

Broomhall, L. G., Clark, C. R., McFarlane, A. C., O'Donnell, M., Bryant, R., Creamer, M., & Silove, D. (2009). Early stage assessment and course of acute stress disorder after mild traumatic brain Injury. Journal of Nervous & Mental Disease, 197, 178-181. doi:10.1097/NMD.0b013e318199fe7f

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Although it has been established that acute stress disorder (ASD) and posttraumatic stress disorder occur after mild traumatic brain injury (MTBI) the qualitative differences in symptom presentation between injury survivors with and without a MTBI have not been explored in depth. This study aimed to compare the ASD and posttraumatic stress disorder symptom presentation of injury survivors with and without MTBI. One thousand one hundred sixteen participants between the ages of 17 to 65 years (mean age: 38.97 years, SD: 14.23) were assessed in the acute hospital after a traumatic injury. Four hundred seventy-five individuals met the criteria for MTBI. Results showed a trend toward higher levels of ASD in the MTBI group compared with the non-MTBI group. Those with a MTBI and ASD had longer hospital admissions and higher levels of distress associated with their symptoms. Although many of the ASD symptoms that the MTBI group scored significantly higher were also part of a postconcussive syndrome, higher levels of avoidance symptoms may suggest that this group is at risk for longer term poor psychological adjustment. Mild TBI patients may represent a injury group at risk for poor psychological adjustment after traumatic injury.

Bryant, R. A., Creamer, M., O'Donnell, M., Silove, D., Clark, R. C., & McFarlane, A. C. (2009). Post-traumatic amnesia and the nature of post-traumatic stress disorder after mild traumatic injury. Journal of the International Neuropsychological Society, 15, 862-867. doi:10.1017/S1355617709990671

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The prevalence and nature of post-traumatic stress disorder (PTSD) following mild traumatic brain injury (MTBI) is controversial because of the apparent paradox of suffering PTSD with impaired memory for the traumatic event. In this study, 1167 survivors of traumatic injury (MTBI: 459, No TBI: 708) were assessed for PTSD symptoms and post-traumatic amnesia during hospitalization, and were subsequently assessed for PTSD 3 months later (N = 920). At the follow-up assessment, 90 (9.4%) patients met criteria for PTSD (MTBI: 50, 11.8%; No-TBI: 40, 7.5%); MTBI patients were more likely to develop PTSD than no-TBI patients, after controlling for injury severity (adjusted odds ratio: 1.86; 95% confidence interval, 1.78–2.94). Longer post-traumatic amnesia was associated with less severe intrusive memories at the acute assessment. These findings indicate that PTSD may be more likely following MTBI, however, longer post-traumatic amnesia appears to be protective against selected re-experiencing symptoms.

Bryant, R. A., Creamer, M., O’Donnell, M., Silove, D., & McFarlane, A. C. (2009). A study of the protective function of acute morphine administration on subsequent posttraumatic stress disorder. Biological Psychiatry, 65, 438-440. doi:10.1016/j.biopsych.2008.10.032

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Background:To index the extent to which acute administration of morphine is protective against development of posttraumatic stress disorder (PTSD). Methods: Consecutive patients admitted to hospital after traumatic injury (n = 155) were assessed for current psychiatric disorder, pain, and morphine dose in the initial week after injury and were reassessed for PTSD and other psychiatric disorders 3 months later (n = 120). Results: Seventeen patients (14%) met criteria for PTSD at 3 months. Patients who met criteria for PTSD received significantly less morphine than those who did not develop PTSD; there was no difference in morphine levels in those who did and did not develop major depressive episode or another anxiety disorder. Hierarchical regression analysis indicated that PTSD severity at 3 months was significantly predicted by acute pain, mild traumatic brain injury, and elevated morphine dose in the initial 48 hours after trauma, after controlling for injury severity, gender, age, and type of injury. Conclusions: Acute administration of morphine may limit fear conditioning in the aftermath of traumatic injury and may serve as a secondary prevention strategy to reduce PTSD development.

Carboon, I., Creamer, M., Forbes, A. B., McKenzie, D. P., McFarlane, A. C., & Kelsall, H. L. (2009). The relationship between deployment and turnover in Australian Navy personnel. Military Psychology, 21, 233-240. doi:10.1080/08995600802574647

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Increases in the frequency of operations tempo have focused attention on the relationship between deployment and separation from military service. This retrospective study explored the association between deployment and turnover over a 10-year period in Royal Australian Navy (RAN) personnel. Participants were 2355 males who served in the RAN during the period of the 1991 Gulf War (August 1990-September 1991); approximately half had been deployed to that conflict. Data were collected 10 years later as part of the Australian Gulf War Veterans' Health Study. During that 10-year period, 61% of participants left the RAN. The likelihood of separation decreased as number of deployments increased even when controlling for age, rank, and length of service. Personnel deployed to the 1991 Gulf conflict did not have a significantly higher risk of separation. The results provide evidence that deployment is not necessarily a risk factor for separation.

Cook, F., Ciorciari, J., Varker, T., & Devilly, G. J. (2009). Changes in long term neural connectivity following psychological trauma. Clinical Neurophysiology, 120, 309-314. doi:10.1016/j.clinph.2008.11.021

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Objective: Neural connectivity differences between adults reporting childhood, adulthood or no history of trauma were examined. Methods: A total of 39 participants completed the Post-traumatic Stress Diagnostic Scale (PDS; Foa EB. Post-traumatic Stress Diagnostic Scale (PDS) Manual. Minneapolis, MN: National Computer Systems, 1995), a Word Memory Task (WMT; [McNally RJ, Metzger LJ, Lasko NB, Clancy SA, Pitman RK. Directed forgetting of trauma cues in adult survivors of childhood sexual abuse with and without post-traumatic stress disorder. J Abnorm Psychol 1998, 107: 596–601]) and EEG analysis. Intelligence was not assessed during the study. Results: As predicted, those with childhood trauma had significantly higher EEG coherence than those with either adulthood trauma or no past trauma. Conclusions: Significant differences were observed over frontal, central, temporal and parietal areas. Evidence was found suggesting that childhood psychological trauma may have a lasting impact on neuronal connectivity. Significance: This is the first study to demonstrate the suspected long term effect of trauma over central, temporal and parietal areas. Longterm neural correlates of childhood and adult trauma appear to suggest information processing differences – differences that may, eventually, lead to better interventions following trauma.

Creamer, M., O’Donnell, M. L., Carboon, I., Lewis, V., Densley, K., McFarlane, A., . . . Bryant, R. A. (2009). Evaluation of the Dispositional Hope Scale in injury survivors. Journal of Research in Personality, 43, 613-617. doi:10.1016/j.jrp.2009.03.002

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Hope is a higher-order cognitive construct that encompasses the belief in one’s ability to accomplish personal goals. Hope has been conceptualised as consisting of two constructs – Pathways (the individual’s perceived means available to achieve goals) and Agency (belief in one’s ability to succeed in using the identified Pathways). This study aimed to validate a measure of hope, the Dispositional Hope Scale (DHS: [Snyder, C. R., Harris, C., Anderson, J. R., Holleran, S. A., Irving, L. M., Sigman, S. T., et al. (1991). The will and the ways: Development and validation of an individual differences measure of hope. Journal of Personality and Social Psychology, 60(4), 570–585]) in a large sample of traumatic injury survivors (N = 1025). The findings support the psychometric properties of the scale, as well as the two-factor structure of Agency and Pathways, in this population. This study provides support for the use of the DHS as a measure of hope in traumatised populations.

Devilly, G. J., Wright, R., & Varker, T. (2009). Vicarious trauma, secondary traumatic stress or simply burnout? The effect of trauma therapy on mental health professionals. The Australian and New Zealand Journal of Psychiatry, 43, 375-387. doi:10.1080/00048670902721079

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Objectives: The aim of the present study was to perform an assessment for secondary traumatic stress (STS), vicarious trauma (VT) and workplace burnout for Australian mental health professionals involved in clinical practice. Methods: Recruited directly by mail, randomly selected participants were invited to submit a questionnaire by post or online. Of the 480 participants contacted, 152 mental health professionals completed the questionnaire, which contained measures of STS, VT and burnout. Results: Exposure to patients’ traumatic material did not affect STS, VT or burnout, contradicting the theory of the originators of STS and VT. Rather, it was found that work-related stressors best predicted therapist distress. Conclusions: These findings have significant implications for the direction of research and theory development in traumatic stress studies, calling into question the existence of secondary trauma-related phenomena and enterprises aimed at treating the consultants.

Forbes, D., Wolfgang, B., Cooper, J., Creamer, M., & Barton, D. (2009). Post-traumatic stress disorder: Best practice GP guidelines. Australian Family Physician, 38, 106-111. Retrieved from the ProQuest Central database.

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Approximately 50-65% of Australians are exposed to a traumatic event during their lifetime. Approximately 250 000 Australians suffer from post-traumatic stress disorder (PTSD) at any given time, making it one of the most common anxiety disorders. In May 2007, the Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Posttraumatic Stress Disorder was published. In order to facilitate translation of evidence regarding PTSD into busy clinical practice, and particularly for general practitioners, a more succinct version of the guidelines has been developed. This article describes a brief algorithm based on the Australian guidelines and outlines key recommendations. General practitioners are often the first point of contact with the health care system for someone who has experienced a traumatic event. Patients experiencing trauma within the past 2 weeks require psychological first aid, and monitoring and assessment for the development of acute stress disorder and symptoms of PTSD. If the patient wishes to talk about the event with you, support them in doing so. However, it is important not to push those who prefer not to talk about the event. Trauma focused psychological treatment is the first line of treatment for PTSD, although antidepressant medication may have an adjuvant role in some patients or in those with comorbidities.

Kenny, L. M., Bryant, R. A., Silove, D., Creamer, M., O’Donnell, M., & McFarlane, A. C. (2009). Distant memories: A prospective study of vantage point of trauma memories. Psychological Science, 20, 1049-1052. doi:10.1111/j.1467-9280.2009.02393.x

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Adopting an observer perspective to recall trauma memories may function as a form of avoidance that maintains posttraumatic stress disorder (PTSD). We conducted a prospective study to analyze the relationship between memory vantage point and PTSD symptoms. Participants (N = 947) identified the vantage point of their trauma memory and reported PTSD symptoms within 4 weeks of the trauma; 730 participants repeated this process 12 months later. Initially recalling the trauma from an observer vantage point was related to more severe PTSD symptoms at that time and 12 months later. Shifting from a field to an observer perspective a year after trauma was associated with greater PTSD severity at 12 months. These results suggest that remembering trauma from an observer vantage point is related to both immediate and ongoing PTSD symptoms.

Lewis, V., Creamer, M., & Failla, S. (2009). Is poor sleep in veterans a function of post-traumatic stress disorder? Military Medicine, 174, 948-951. Retrieved from the EBSCO database.

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Substantial research has demonstrated an association between post-traumatic stress disorder (PTSD) and quality of sleep, particularly in veteran populations. The exact nature of this relationship, however, is not clear. The possibility that poor sleep is a more general experience among veterans has not been explored to date, with most studies focusing only on veteran populations with PTSD. This pilot study aimed to explore whether sleep disturbance is common to veterans generally or simply those with PTSD. Data were collected from a community sample of 152 Australian Vietnam war veterans, 87 of whom did not meet criteria for PTSD. All those with PTSD and 90% of those without PTSD reported clinically significant sleep disturbance, indicating that serious sleep problems are common across the veteran population. Despite the limitations of this initial study, these results highlight the importance of ensuring that research into sleep disorders in veterans with PTSD pays attention to the potential etiological role of other military factors, including deployments.

Liedl, A., O’Donnell, M., Creamer, M., McFarlane, A., Knaevelsrud, C., & Bryant, R. A. (2009). Support for the mutual maintenance of pain and post-traumatic stress symptoms. Psychological Medicine, 40, 1215-1223. doi:10.1017/S0033291709991310

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Background: Pain and post-traumatic stress disorder (PTSD) are frequently co-morbid in the aftermath of a traumatic event. Although several models attempt to explain the relationship between these two disorders, the mechanisms underlying the relationship remain unclear. The aim of this study was to investigate the relationship between each PTSD symptom cluster and pain over the course of post-traumatic adjustment. Method: In a longitudinal study, injury patients (n = 824) were assessed within 1 week post-injury, and then at 3 and 12 months. Pain was measured using a 100-mm Visual Analogue Scale (VAS). PTSD symptoms were assessed using the Clinician-Administered PTSD Scale (CAPS). Structural equation modelling (SEM) was used to identify causal relationships between pain and PTSD. Results: In a saturated model we found that the relationship between acute pain and 12-month pain was mediated by arousal symptoms at 3 months. We also found that the relationship between baseline arousal and re-experiencing symptoms, and later 12-month arousal and re-experiencing symptoms, was mediated by 3-month pain levels. The final model showed a good fit [χ2=16.97, df=12, p>0.05, Comparative Fit Index (CFI)=0.999, root mean square error of approximation (RMSEA)=0.022]. Conclusions: These findings provide evidence of mutual maintenance between pain and PTSD.

McFarlane, A. C., Browne, D., Bryant, R. A., O’Donnell, M., Silove, D., Creamer, M., & Horsley, K. (2009). A longitudinal analysis of alcohol consumption and the risk of posttraumatic symptoms. Journal of Affective Disorders, 118, 166-172. doi:10.1016/j.jad.2009.01.017

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Background: Previous studies investigating the impact of alcohol ingestion on the emergence of posttraumatic psychological symptoms have generated contradictory findings. Methods: One thousand forty-five patients, admitted to hospital following traumatic injury were assessed during hospitalisation for patterns of alcohol consumption prior to the injury and also during the month prior to reassessment at 3 months. Anxiety, depression and posttraumatic stress disorder (PTSD) were assessed post accident and at 3 months. In a sub sample (n = 167), blood alcohol levels were measured at the time of admission to emergency departments. Results: Moderate alcohol consumption prior to and following the accident predicted lower levels of psychological distress at 1 week and 3 months. No significant relationship was found between the blood alcohol level and psychiatric outcomes. PTSD predicted the emergence of alcohol abuse following the accident, suggesting self-medication in a subgroup of survivors. Limitations: The impact of alcohol consumption upon injury severity and the nature of injury was not controlled for and some non-participation may have been related to patterns of alcohol consumption. We relied on retrospective reports of alcohol use obtained shortly after the traumatic injury to index prior alcohol use and these reports may have been influenced by mood states at the time of recall. Our follow-up was limited to 3 months and there is a need for longer-term assessment of the relationship between prior alcohol use and subsequent posttraumatic adjustment. Conclusion: Given the potential impact of alcohol use on traumatic injury and post-injury recovery, we advocate active screening and early intervention strategies that focus on moderate alcohol usage.

McKenzie, D. P., Creamer, M., Kensall, H. L., Forbes, A. B., Ikin, J. F., Sim, M. R., & McFarlane, A. C. (2009). Temporal relationships between Gulf War deployment and subsequent psychological disorders in Royal Australian Navy Gulf War veterans. Social Psychiatry and Psychiatric Epidemiology, 45, 843-852. doi:10.1007/s00127-009-0134-1

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Background: Although much has been published on the effects of the 1990/1991 gulf war on the psychological health of veterans, few studies have addressed the pattern and timing of post-war development of psychological disorders. Our study aims to identify the most common psychological disorders that first appeared post-gulf war, the period of peak prevalence and the sequence of multiple psychological disorders. Methods: The temporal progression of psychological disorders in male Australian Naval gulf war veterans with no prior psychological disorders was calculated across each year of the post-gulf war period. DSM-IV diagnoses were obtained using the composite international diagnostic interview. Results: Psychological disorder rates peaked in the first 2 years (1991-1992) following the gulf war. Alcohol use disorders were the most likely to appear first. Classification and regression tree analysis found that risk of disorder was exacerbated if veterans had been exposed to a high number of potential psychological stressors during their military service. Lower military rank was associated with increased risk of alcohol disorders, particularly during the first 2 years post-gulf war. In veterans with two or more disorders, anxiety disorders and alcohol disorders tended to appear before affective disorders. Conclusions: Our study found that psychological disorders occur in sequence following gulf war deployment. Our findings may help clinicians to anticipate, and better manage, multiple symptomatology. The findings may also assist veteran and defence organisations in planning effective mental health screening, management and prevention policy.

O'Connor, D. W. & Parslow, R. (2009). Different responses to K-10 and CIDI suggest that complex structured psychiatric interviews underestimate rates of mental disorder in old people. Psychological Medicine, 39, 1527-1531. doi:10.1017/S0033291708004728

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Background: Epidemiological surveys based on complex diagnostic interviews, such as the Composite International Diagnostic Interview (CIDI), report very low rates of anxiety and depressive disorders in older age groups. Mental health checklists show much less change over the lifespan. This paper explores the possibility that complex interviews present a special challenge to older respondents and thereby exaggerate the decline in mental disorder with age. Method: Analysis of data from an Australian national mental health survey with 10,641 community-resident adult respondents. Measures of interest included ICD-10 anxiety and depression diagnoses, scores on the Kessler Psychological Distress Scale (K-10), agreement between K-10 and CIDI anxiety and depressive questions, and changes in agreement with age. Results: Levels of inconsistency between simple and complex questions about anxiety and depression rose with age. Conclusions: Older people may have difficulty attending to and processing lengthy, complex questionnaires. When in doubt, their preferred response may be to deny having experienced symptoms, thus deflating rates of diagnosed mental disorder. We recommend that simple mental health scales be included in epidemiological studies involving older age groups.

O'Donnell, M., Creamer, M., Elliott, P., Bryant, R., McFarlane, A., & Silove, D. (2009). Prior trauma and psychiatric history as risk factors for intentional and unintentional injury. Journal of Trauma-Injury Infection & Critical Care, 66, 470-476. doi:10.1097/TA.0b013e31815d965e

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Background: Preliminary evidence suggests that injury survivors are at increased risk for having experienced traumatic events before their injury or having a lifetime psychiatric history. We aimed to extend the previous research by examining in the same sample whether trauma history or lifetime psychiatric history represented risk pathways to injury for intentional or unintentional injury survivors. We also aimed to describe the co-occurrence between trauma history and psychiatric history in unintentionally injured survivors. Methods: In this multisited study, randomly selected injury survivors admitted to five trauma services in three states of Australia (April 2004 to February 2006) completed two structured clinical interviews that assessed their history of traumatic life events and lifetime psychiatric disorder (n = 1,167). [chi]2 analyses were conducted to compare the lifetime prevalence of traumatic events and psychiatric history for intentional and unintentional injury with population norms. Results: Both intentional and unintentional injury survivors were at increased risk for reporting all types of trauma and reporting all measured psychiatric diagnoses compared with population norms. The majority of unintentional injury survivors with a psychiatric history were likely to have a trauma history. Conclusions: In this study, we identified that prior trauma or prior psychiatric illness may represent risk for injury in both intentionally and unintentionally injured survivors. The results highlight the need for injury-care services to address mental health issues in injury patients as part of routine care.

O'Donnell, M., Holmes, A. C., Creamer, M., Ellen, S., Judson, R., McFarlane, A. C., . . . Bryant, R. A. (2009). The role of post-traumatic stress disorder and depression in predicting disability after injury. Medical Journal of Australia, 190, s71-s74. Retrieved from

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Objectives: To examine the relationship between psychological response to injury at 1 week and 3 months, and disability at 12 months. Design: Multisite, longitudinal study. Participants and setting: 802 adult patients admitted to trauma services at four Australian hospitals from 13 March 2004 to 21 February 2006 were assessed before discharge and followed up at 3 and 12 months. Main outcome measure: Disability, measured with the 12-item version of the World Health Organization Disability Assessment Schedule II. Results: Logistic regression identified the degree to which high levels of depression and post-traumatic stress disorder (PTSD) at 1 week and at 3 months predicted disability at 12 months. After controlling for demographic variables and characteristics of the injury, patients with PTSD or subsyndromal PTSD at 1 week were 2.4 times more likely, and those with depression at 1 week were 1.9 times more likely to have high disability levels at 12 months. PTSD at 3 months was associated with 3.7 times, and depression at 3 months with 3.4 times the risk of high disability at 12 months. Conclusions: PTSD and depression at 1 week and at 3 months after injury significantly increased the risk of disability at 12 months. Routine assessment of symptoms of depression and PTSD in patients who have been physically injured may facilitate triage to evidence-based treatments, leading to improvement in both physical and psychological outcomes.

Phelps, A., Lloyd, D., Creamer, M., & Forbes, D. (2009). Caring for carers in the aftermath of trauma. Journal of Aggression, Maltreatment & Trauma, 18, 313-330. doi:10.1080/10926770902835899

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The potential impact on psychological well-being of working in the caring professions in the aftermath of trauma and disaster has been recognized for many years, with terms such as burnout, compassion fatigue, and vicarious traumatization coined to describe stress-related conditions. Although prevalent, these conditions do not affect all workers in the field. Various studies have investigated potential risk and protective factors. It is argued that the outcomes of this research should be used to guide practical interventions in the workplace designed to minimize stress-related problems. A framework that incorporates interventions at the primary, secondary, and tertiary prevention levels is outlined, and research investigating the efficacy of interventions at each of these levels is recommended.


Australian Centre for Posttraumatic Mental Health. (2008). Acute Stress Disorder and Posttraumatic Stress Disorder brochure [Clinical Algorithm]. ACPMH: Melbourne, Australia.

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Australia’s first treatment guidelines for acute stress disorder and posttraumatic stress disorder (ASD and PTSD) are now available. They will help policy makers and health practitioners make decisions about the best approaches to screening, assessment and treatment of posttraumatic mental health problems. They will also help people affected by trauma make informed choices about their care. The Australian Centre for Posttraumatic Mental Health developed the Guidelines in consultation with trauma experts from a range of disciplines, as well as people affected by trauma. Endorsed by the National Health and Medical Research Council, the Guidelines provide practical recommendations applicable in all healthcare settings.

Brooks, R., Silove, D., Bryant, R., O’Donnell, M., Creamer, M., & McFarlane, A. (2008). A confirmatory factor analysis of the acute stress disorder interview. Journal of Traumatic Stress, 21, 352-355. doi:10.1002/jts.20333

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Acute stress disorder (ASD) was introduced in 1994 to describe posttraumatic stress reactions that occur in the initial month after trauma exposure. Although it comprises the distinct symptom clusters of dissociation, reexperiencing, avoidance, and arousal, there have been no confirmatory factor analyses of the construct. In this study, 587 individuals admitted to five major hospitals after traumatic injury, were administered the Acute Stress Disorder Interview. Forty-four participants met criteria for ASD. Confirmatory factor analysis based on the four symptom clusters described the Acute Stress Disorder Interview responses. These data provide the first confirmatory factor analysis of the ASD symptoms, and are discussed in terms of the 4-factor models repeatedly found in samples of chronic posttraumatic stress disorder.

Bryant, R. A., Creamer, M., O’Donnell, M., Silove, D., & McFarlane, A. C. (2008). A multisite study of initial respiration rate and heart rate as predictors of posttraumatic stress disorder. Journal of Clinical Psychiatry, 69, 1694-1701. doi:10.4088/JCP.v69n1104

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Objective:Fear-conditioning models posit that increased arousal at the time of trauma predicts subsequent posttraumatic stress disorder (PTSD). This multisite study evaluated the extent to which acute heart rate and respiration rate predict subsequent chronic PTSD. Method:Traumatically injured patients admitted to 4 hospitals across Australia between April 2004 and February 2006 were initially assessed during hospital admission (N = 1105) and were reassessed 3 months later for PTSD by using the Clinician-Administered PTSD Scale-IV and for major depressive disorder (MDD) by using the Mini-International Neuropsychiatric Interview (English version 5.0.0) (N = 955). Heart rate, respiration rate, and blood pressure were assessed on the initial day of traumatic injury. Results:Ninety patients (10%) met criteria for PTSD and 159 patients (17%) met criteria for MDD at the 3-month assessment. Patients with PTSD compared to those without PTSD had higher heart rate (90.16 ± 18.66 vs. 84.84 ± 17.41, t = 2.74, p < .01) and respiration rate (20.24 ± 5.16 vs. 18.58 ± 4.29, t = 3.43, p < .001) immediately after injury. There were no heart rate or respiration rate differences between patients who did and did not develop MDD. Patients were more likely to develop PTSD at 3 months if they had a heart rate of at least 96 beats per minute (15% vs. 8%, OR = 2.12, 95% CI = 1.34 to 3.33) or respiration rate of at least 22 breaths per minute (18% vs. 8%, OR = 2.42, 95% CI = 1.48 to 3.94). Conclusions:Elevated heart rate and respiration rate are predictors of subsequent PTSD. These data underscore the need for future research into secondary prevention strategies that reduce acute arousal immediately after trauma and may limit PTSD development in some individuals.

Bryant, R. A., Creamer, M., O'Donnell, M., Silove, D., & McFarlane, A. C. (2008). A multisite study of the capacity of acute stress disorder diagnosis to predict posttraumatic stress disorder. Journal of Clinical Psychiatry, 69, 923-929. doi:10.4088/JCP.v69n0606

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Objective: Previous studies investigating the relationship between acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) have reported mixed findings and have been flawed by small sample sizes and single sites. This study addresses these limitations by conducting a large-scale and multisite study to evaluate the extent to which ASD predicts subsequent PTSD. Method: Between April 2004 and April 2005, patients admitted consecutively to 4 major trauma hospitals across Australia (N = 597) were randomly selected and assessed for ASD (DSM-IV criteria) during hospital admission (within 1 month of trauma exposure) and were subsequently reassessed for PTSD 3 months after the initial assessment (N = 507). Results: Thirty-three patients (6%) met criteria for ASD, and 49 patients (10%) met criteria for PTSD at the 3-month follow-up assessment. Fifteen patients (45%) diagnosed with ASD and 34 patients (7%) not diagnosed with ASD subsequently met criteria for PTSD. The positive predictive power of PTSD criteria in the acute phase (0.60) was a better predictor of chronic PTSD than the positive predictive power of ASD (0.46). Conclusions: The majority of people who develop PTSD do not initially meet criteria for ASD. These data challenge the proposition that the ASD diagnosis is an adequate tool to predict chronic PTSD.

Bryant, R. A., Mastrodomenico, J., Felmingham, K. L., Hopwood, S., Kenny, L., Kandris, E., . . . Creamer, M. (2008). Treatment of acute stress disorder: A randomized controlled trial. Archives General Psychiatry, 65, 659-667. doi:10.1001/archpsyc.65.6.659

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Context: Recent trauma survivors with acute stress disorder (ASD) are likely to subsequently develop chronic posttraumatic stress disorder (PTSD). Cognitive behavioral therapy for ASD may prevent PTSD, but trauma survivors may not tolerate exposure-based therapy in the acute phase. There is a need to compare nonexposure therapy techniques with prolonged exposure for ASD. Objective: To determine the efficacy of exposure therapy or trauma-focused cognitive restructuring in preventing chronic PTSD relative to a wait-list control group. Design, Setting, and Participants: A randomized controlled trial of civilians who experienced trauma and who met the diagnostic criteria for ASD (N = 90) seen at an outpatient clinic between March 1, 2002, and June 30, 2006. Intervention: Patients were randomly assigned to receive 5 weekly 90-minute sessions of either imaginal and in vivo exposure (n = 30) or cognitive restructuring (n = 30), or assessment at baseline and after 6 weeks (wait-list group; n = 30). Main Outcome Measures: Measures of PTSD at the 6-month follow-up visit by clinical interview and self-report assessments of PTSD, depression, anxiety, and trauma-related cognition. Results: Intent-to-treat analyses indicated that at posttreatment, fewer patients in the exposure group had PTSD than those in the cognitive restructuring or wait-list groups (33% vs 63% vs 77%; P = .002). At follow-up, patients who underwent exposure therapy were more likely to not meet diagnostic criteria for PTSD than those who underwent cognitive restructuring (37% vs 63%; odds ratio, 2.10; 95% confidence interval, 1.12-3.94; P = .05) and to achieve full remission (47% vs 13%; odds ratio, 2.78; 95% confidence interval, 1.14-6.83; P = .005). On assessments of PTSD, depression, and anxiety, exposure resulted in markedly larger effect sizes at posttreatment and follow-up than cognitive restructuring. Conclusions: Exposure-based therapy leads to greater reduction in subsequent PTSD symptoms in patients with ASD when compared with cognitive restructuring. Exposure should be used in early intervention for people who are at high risk for developing PTSD.

Bryant, R. A., Moulds, M. L., Guthrie, R. M., Dang, S. T., Mastrodomenico, J., Nixon, R. D., . . . Creamer, M. (2008). A randomized controlled trial of exposure therapy and cognitive restructuring for posttraumatic stress disorder. Journal of Consulting & Clinical Psychology, 76, 695-703. doi:10.1037/a0012616

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Previous studies have reported that adding cognitive restructuring (CR) to exposure therapy does not enhance treatment gains in posttraumatic stress disorder (PTSD). This study investigated the extent to which CR would augment treatment response when provided with exposure therapy. The authors randomly allocated 118 civilian trauma survivors with PTSD to receive 8 individually administered sessions of either (a) imaginal exposure (IE), (b) in vivo exposure (IVE), (c) IE combined with IVE (IE/IVE), or (d) IE/IVE combined with CR (IE/IVE/CR). There were fewer patients with PTSD in the IE/IVE/CR (31%) condition than the IE (75%), IVE (69%), and IE/IVE (63%) conditions at a 6-month follow-up assessment. The IE/IVE/CR condition resulted in larger effect sizes than each of the other conditions in terms of PTSD and depressive symptoms. These findings suggest that optimal treatment outcome may be achieved by combining CR with exposure therapy in treating PTSD patients.

Creamer, M., & O’Donnell, M. (2008). The pros and cons of psychoeducation following trauma: Too early to judge? Psychiatry: Interpersonal and biological processes, 71, 319-321. doi:10.1521/psyc.2008.71.4.319

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The paper by Wessely and colleagues raises interesting and important questions about the use of psychoeducation in the context of traumatic exposure. Psychoeducation is now so routinely used in the aftermath of large scale disaster and trauma that the public health implications of these questions are enormous. Since psychoeducation can be offered at several timepoints (before the experience for those likely to be exposed, immediately after the event for all those exposed, or later for those who develop problems), it is important to clarify what we mean by the term. Falvo (1994) defined patient education as a planned educational activity designed to produce changes in knowledge, attitudes, and skills to improve health outcomes. Wehn such education is targeted at psychological health, it is often referred to as psychoeducation (Pekkala & Merinder, 2002). Psychoeducation (in both written and verbal forms) is routinely used as a component of successful interventions for psychiatric conditions such as posttraumatic stress disorder (PTSD) (e.g., Foa & Rothbaum, 1998; Resick & Schnicke, 1993). It has demonstrated some efficacy as a standalone treatment of high prevalence disorders such as depression (Christensen, Griffiths, & Jorm, 1994).

Creamer, M., & Parslow, R. (2008). Trauma exposure and posttraumatic stress disorder in the elderly: A community prevalence study. American Journal of Geriatric Psychiatry, 16, 853-856. doi:10.1097/01.JGP.0000310785.36837.85

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Objective: Little prevalence data exist on trauma exposure and posttraumatic stress disorder (PTSD) in the elderly. The authors examined lifetime exposure to trauma and 12-month PTSD in a large community sample. Method: Data were drawn from the Australian National Survey of Mental Health. Of the total 10,641 participants, 1,792 were over the age of 65. The Composite International Diagnostic Interview provided trauma exposure and diagnostic status. Results: A curvilinear pattern of lifetime exposure to trauma across the lifespan was obtained for women, whereas men showed a linear increase. This difference was explained by combat exposure. PTSD prevalence reduced with age and participants over 65 reported negligible rates. Around 10% of the elderly reported reexperiencing symptoms. Conclusions: PTSD rates are lower in older age cohorts, although reasons for this are unclear. With 10% reporting reexperiencing symptoms associated with past events, however, greater awareness of treatments that target traumatic memories may be beneficial.

Dileo, J., Brewer, W., Hopwood, M., Anderson, V., & Creamer, M. (2008). Olfactory identification dysfunction, aggression and impulsivity in war veterans with posttraumatic stress disorder. Psychological Medicine, 38, 523-531. doi:10.1017/S0033291707001456

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Background: Due to neuropsychological conceptualizations of orbitoprefrontal cortex (OFC) dysfunction underpinning impulsive aggression and the incidence of such behaviour in post-traumatic stress disorder (PTSD), this study aimed to explore olfactory identification (OI) ability in war veterans with PTSD as a probe of putative OFC dysfunction; and to explore the utility of OI ability in predicting aggressive and impulsive behavior in this clinical population. Method: Participants comprised 31 out-patient male war veterans with PTSD (mean = 58.23 years, SD = 2.56) recruited from a Melbourne Veterans Psychiatry Unit, and 31 healthy age- and gender-matched controls (mean = 56.84 years, SD = 7.24). All participants were assessed on clinical measures of PTSD, depression, anxiety, and alcohol misuse; olfactory identification; neurocognitive measures of dorsolateral prefrontal, lateral prefrontal and mesial temporal functioning; and self-report measures of aggression and impulsivity. Results: War veterans with PTSD exhibited significant OI deficits (OIDs) compared to controls, despite uncompromised performance on cognitive measures. OIDs remained after covaring for IQ, anxiety, depression and alcohol misuse, and were significant predictors of aggression and impulsivity. Conclusions: This research contributes to emerging evidence of orbitoprefrontal dysfunction in the pathophysiology underlying PTSD. This is the first study to report OIDs as a predictor of aggression and impulsivity in this clinical population. It prompts further exploration of the potential diagnostic utility of OIDs in the assessment of PTSD. Such measures may help delineate the clinical complexity of PTSD, and support more targeted interventions for individuals with a greater susceptibility to aggressive and impulsive behaviors.

Elhai, J. D., Grubaugh, A. L., Richardson, J. D., Egede, L. E., & Creamer, M. (2008). Outpatient medical and mental healthcare utilization models among military veterans: Results from the 2001 National Survey of Veterans. Journal of Psychiatric Research, 42, 858-867. doi:10.1016/j.psychires.2007.09.006

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Using Andersen's (1995) [Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? Journal of Health and Social Behavior 1995;36:1-10] behavioral model of healthcare use as our theoretical framework, we examined predisposing (i.e., sociodemographic), enabling (i.e., access resources), and need (i.e., illness) models of outpatient medical and mental healthcare utilization among a national sample of US veterans. Participants were 20,048 nationally representative participants completing the 2001 National Survey of Veterans. Outcomes were healthcare use variables for the past year, including the number of Veterans Affairs (VA) and non-VA outpatient healthcare visits, and whether VA and non-VA mental health treatment was used. Univariate results demonstrated that numerous predisposing, enabling and need variables predicted both VA and non-VA healthcare use intensity and mental healthcare use. In multivariate analyses, predisposing, enabling and need variables demonstrated significant associations with both types of healthcare use, but accounted for more variance in mental healthcare use. Need variables provided an additive effect over predisposing and enabling variables in accounting for medical and mental healthcare use, and accounted for some of the strongest effects. The results demonstrate that need remains an important factor that drives healthcare use among veterans and does not seem to be overshadowed by socioeconomic factors that may create unfair disparities in treatment access.

Forbes, D. (2008). Minnesota Multiphasic Personality Inventory-2. In G. Reyes, J. D. Elhai & J. D. Ford (Eds.), The Encyclopedia of Psychological Trauma (pp. 430-433). Hoboken, NJ: John Wiley Press.

Forbes, D., Lewis, V., Parslow, R., Hawthorne, G., & Creamer, M. (2008). A naturalistic comparison of models of programmatic interventions for combat-related post-traumatic stress disorder. The Australian and New Zealand Journal of Psychiatry, 42, 1051-1059. doi:10.1080/00048670802512024

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Objectives: Post-traumatic stress disorder (PTSD) is a difficult-to-treat sequel of combat. Data on effectiveness of alternate treatment structures are important for planning veterans' psychiatric services. The present study compared clinical presentations and treatment outcomes for Australian veterans with PTSD who participated in a range of models of group-based treatment. Method: Participants consisted of 4339 veterans with combat-related PTSD who participated in one of five types of group-based cognitive behavioural programmes of different intensities and settings. Data were gathered at baseline (intake), as well as at 3 and 9 month follow up, on measures of PTSD, anxiety, depression and alcohol misuse. Analyses of variance and effect size analyses were used to investigate differences at intake and over time by programme type. Results: Small baseline differences by programme intensity were identified. Although significant improvements in symptoms were evident over time for each programme type, no significant differences in outcome were evident between programmes. When PTSD severity was considered, veterans with severe PTSD performed less well in the low-intensity programmes than in the moderate- or high-intensity programmes. Veterans with mild PTSD improved less in high-intensity programmes than in moderate- or low-intensity programmes. Conclusion: Comparable outcomes are evident across programme types. Outcomes may be maximized when veterans participate in programme intensity types that match their level of PTSD severity. When such matching is not feasible, moderate-intensity programmes appear to offer the most consistent outcomes. For regionally based veterans, delivering treatment in their local environment does not detract from, and may even enhance, outcomes. These findings have implications for the planning and purchasing of mental health services for sufferers of PTSD, particularly for veterans of more recent combat or peacekeeping deployments.

Forbes, D., Parslow, R., Creamer, M., Allen, N., McHugh, T., & Hopwood. M. (2008). Mechanisms of anger and treatment outcome in combat veterans with Posttraumatic Stress Disorder. Journal of Traumatic Stress, 21, 142-149. doi:10.1002/jts.20315

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Research has identified anger as prominent in, and an influence on, treatment outcome for military veterans with posttraumatic stress disorder (PTSD). This study examined factors influencing the relationship between anger and outcome to improve treatment effectiveness. Participants comprised 103 veterans attending PTSD treatment. Measures of PTSD and comorbidity were obtained at intake and 9-month follow-up. Measures also included potential mediators of therapeutic alliance, social support, problematic/undermining relationships and fear of emotion. Path analyses supported anger as a predictor of treatment outcome, with only fear of anger and alcohol comorbidity accounting for the variance between anger and outcome. To improve treatment effectiveness, clinicians need to assess veterans' anger, aggression, and alcohol use, as well as their current fear of anger and elucidate the relationship between these factors.

Hawthorne, G., Konstancja, D., Pallant, J. F., Mortimer, D., & Segal, L. (2008). Deriving utility scores from the SF-36 health instrument using Rasch analysis. Quality of Life Research, 17, 1183-1193. doi:10.1007/s11136-008-9395-5

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Background: Utility scores for use in cost-utility analysis may be imputed from the SF-36 health instrument using various techniques, typically regression analysis. This paper explored imputation using partial credit Rasch analysis. Method: Data from the Assessment of Quality of Life (AQoL) instrument validation study were re-analysed (n = 996 inpatients, outpatients and a community sample). For each AQoL item, factor analysis identified those SF-36 items forming a unidimensional scale. Rasch analysis located scale logit scores for these SF-36 items. The logit scores were used to assign AQoL item scores. The standard AQoL scoring algorithm was then applied to obtain the utility scores. Results: Many SF-36 items were limited predictors of AQoL items; some items from both instruments obtained disordered thresholds. All imputed scores were consistent with the AQoL model and fell within AQoL score boundaries. The explained variance between imputed and true AQoL scores was 61%. Discussion: Rasch-imputed mapping, unlike many regression-based algorithms, produced results consistent with the axioms of utility measurement, while the proportion of explained variance was similar to regression-based modelling. Item properties on both instruments implied that some items should be revised using Rasch analysis. The methods and results may be used by researchers needing to impute utility scores from SF-36 health scores.

Higgins, R. O., Murphy, B. M., Goble, A. J., Le Grande, M. R., Elliott, P., & Worcester, M. U. C. (2008). Cardiac rehabilitation program attendance after coronary artery bypass surgery: Overcoming the barriers. The Medical Journal of Australia, 188, 712-714. Retrieved from

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Objective: To investigate rates and predictors of cardiac rehabilitation (CR) attendance after coronary artery bypass graft surgery (CABGS) at Royal Melbourne Hospital (RMH), Victoria, where current best practice referral and recruitment strategies have been adopted. Design, setting and participants: Prospective cohort study of 184 patients who underwent CABGS at RMH between July 2001 and April 2004. Patients completed questionnaires pre-operatively, and 170 patients (92%) had their CR attendance tracked after referral to CR either at RMH or elsewhere. Main outcome measures: Rates of CR attendance among RMH patients referred to CR either at RMH or elsewhere; sociodemographic, medical, cognitive, psychosocial and geographical predictors of CR non-attendance. Results: The CR attendance rate was 72%. Patients referred to CR at RMH were more than four times more likely to attend than patients referred elsewhere (odds ratio [OR], 4.36; P=0.024). Travel time significantly predicted CR attendance (OR, 0.86; P=0.039). Conclusions : CR attendance rates were found to be higher than previously reported for CABGS patients, suggesting that best practice referral and recruitment procedures minimise common barriers to CR attendance.

Killackey, E., Jorm, A., Alvarez-Jimenez, M., McCann, T. V., Hides, L., & Couineau, A. L. (2008). Do we do what we know works, and if not why not? Australian and New Zealand Journal of Psychiatry, 42, 439-444.  doi:10.1080.00048670802050652

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There have always been a range of treatments for mental illness. Evidence exists of ancient trepanning, and through the ages other techniques have been used such as blood letting, exorcism, confinement, dietary interventions, environmental interventions, talking therapies of various modalities, industrial therapies, insulin comas, and ice baths among many others. In the past the view was held that physicians were people of such sober judgement and fine knowledge that ‘all remedies whatever are at the disposal of practitioners to reject or employ them under the sole guidance of their own judgment’. But in more recent times, for reasons of efficacy and economics, there has been greater concern with using treatments for which there is the best evidence of a positive outcome.

Le Grande, M. R., Elliott, P., Worcester, M. U. C., Murphy, B. M., & Goble, A. J. (2008). An evaluation of self-report physical activity instruments used in studies involving cardiac patients. Journal of Cardiopulmonary Rehabilitation and Prevention, 28, 358-369. doi:10.1097/HCR.0b013e318181c3d90

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Given the importance of physical activity (PA) in cardiac rehabilitation and prevention, measuring it in a valid and reliable manner is a practical challenge. Measuring self-reported PA in elderly cardiac patients can be problematic because of the need to assess many activities of short duration that may occur as part of routine daily functions. The primary purpose of this article was to identify and evaluate instruments that have been used over the last 15 years in studies of cardiac patients. A comprehensive MEDLINE search was carried out to identify articles from studies undertaken to assess PA in cardiac patients. The self-report PA instruments were subjected to evaluation concerning suitability for use with cardiac patients. The initial electronic and hand searches yielded 203 articles. After removing articles that did not meet the inclusion criteria, a total of 86 articles were selected. Twenty-three self-report instruments were identified for evaluation. Most of the instruments had problems associated with inadequate validation methods or suitability for cardiac patients. Many of the instruments failed to demonstrate adequate validity or reliability, particularly when measuring low-intensity PA. Some instruments are more suited to epidemiologic research than to clinical interventions where responsiveness to interventions is crucial. Recommendations for the constituents of an acceptable self-report PA instrument for cardiac patients are presented and the most suitable existing instruments are identified.

Murphy, B. M., Elliott, P., Higgins, R. O., Le Grande, M. R., Worcester M. U. C., Goble, A. J., & Tatoulis, J. (2008). Anxiety and depression after coronary artery bypass graft surgery: Most get better, some get worse. European Journal of Cardiovascular Prevention and Rehabilitation, 15, 434-440. doi:10.1097/HJR.0b013e3282fbc945

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Background: To target interventions, patients at risk for poor outcomes after a cardiac event need to be identified. We investigated trajectories of anxiety and depression after coronary artery bypass graft surgery (CABGS) and identified patients at risk of persistent or worsening anxiety and depression. Methods: A consecutive sample of 184 patients on the waiting list for CABGS at The Royal Melbourne Hospital completed self-report questionnaires before surgery, and at 2 and 6 months postsurgery. Anxiety and depression were measured using the Hospital Anxiety and Depression Scale. Growth mixture modelling identified trajectories of anxiety and depression. Results: Two possible trajectories emerged for anxiety, whereas three trajectories emerged for depression. Most patients (92%) followed a trajectory of minor presurgical anxiety that remitted in 6 months after CABGS, with the remainder (8%) following a trajectory of major anxiety that remitted in the same period. Minor remitted depression was also common (72% patients). Two less common depression trajectories indicated worsening or unresolved depression. One trajectory began with major presurgical depression that partially remitted by 6 months (14% patients) and the other began with minor presurgical depression that worsened by 6 months (14% patients). Unpartnered patients, smokers, those with presurgical anxiety, high cholesterol, angina, more severe disease or having repeat CABGS were at increased risk for a poor depression trajectory. Conclusion: Although initial anxiety and depression resolved or lessened for most patients, some patients experienced persistent or worsening depression after CABGS. Interventions can be targeted toward ‘at risk’ patients.

Murphy, B. M., Elliott, P., Le Grande, M. R., Higgins, R. O., Ernest, C. S., Goblea, A. J., . . . Worcester, M. U. C. (2008). Living alone predicts 30-day hospital readmission after coronary artery bypass graft surgery. European Journal of Cardiovascular Prevention and Rehabilitation, 15, 210-215. doi:10.1097/HJR.0b013e3282f2dc4e

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Background: Earlier studies show that medical factors and disease severity predict early readmission to hospital after coronary artery bypass graft surgery (CABGS). Few studies have investigated psychosocial predictors. This study investigated medical, sociodemographic and psychosocial predictors of 30-day hospital readmission. Methods: A consecutive sample of 181 patients wait-listed for CABGS completed self-report questionnaires before surgery, and at 2 and 6 months after surgery. Results: Twenty-six (14.4%) patients were readmitted within 30 days of hospital discharge. Readmitted patients were older (t = 2.12, df = 179, P = 0.035), and more likely to be unmarried (χ2 = 5.80, df = 1, P = 0.016), live alone (χ2 = 8.33, df = 1, P = 0.004), have a history of hypertension (χ2 = 2.731, df = 1, P = 0.098) and have higher anxiety before surgery (t = 1.67, df = 175, P = 0.097). When these variables were entered into a backward stepwise logistic regression, the only significant unique predictor of 30-day readmission was living alone (Wald = 7.08, odds ratio = 3.42, P = 0.008). Patients living alone were over three times more likely than those living with others to be readmitted to hospital. Disease severity and other medical factors were not associated with readmission. Conclusion: Living alone was identified as the single most important risk factor for early readmission after CABGS. Patients who live alone may benefit from additional support during early convalescence. Intervention studies could explore support options for these patients.

Murphy, B. M., Elliott, P., Worcester, C., Higgins, R. O., Le Grande, M. R., Roberts, S. B., & Goble, A. J. (2008). Trajectories and predictors of anxiety and depression in women during the 12 months following an acute cardiac event. British Journal of Health Psychology, 13, 135-153. doi:10.1348/135910707X173312

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Objectives: Many previous investigations of the recovery of emotional well-being, particularly the resolution of depression, following an acute cardiac event assume that all patients follow a similar, linear trajectory. However, it is possible that there are different groups of patients who follow different trajectories. This study tested for multiple trajectories of anxiety and depression and identified the characteristics of patients most at risk for persistent or worsening anxiety and depression in the 12 months following their cardiac event. Method: A consecutive sample of 226 women was interviewed following either acute myocardial infarction (AMI) or coronary artery bypass graft surgery (CABGS). The Hospital Anxiety and Depression Scale were administered on four occasions over 12 months. Growth curve and growth mixture modelling were used to identify trajectories of change and univariate tests were employed to establish predictors of each trajectory. Results: Most women began with relatively low levels of anxiety and/or depression that improved over the 12 month period (84% women showed this trajectory for anxiety, 89% for depression). A smaller group began with relatively high levels of anxiety and/or depression that worsened over time (16% for anxiety, 11% for depression). Patients in the latter group were more likely to report high levels of loneliness, have a first language other than English, perceive their cardiac disease as more severe (anxiety group only) and have diabetes (depression group only). Trajectories were non-linear, with most change occurring in the initial 2-month period. Conclusion: Growth modelling echniques highlight that change in anxiety and depression following an acute event follows neither a single nor linear trajectory. Most women showed early resolution of anxiety and depression following their event, indicative of a normal bereavement or adjustment response. A minority of women reported worsening anxiety and/or depression in the year following their cardiac event, particularly those who lacked social support or were from non-English speaking backgrounds. Intervention studies to explore support options for these women are warranted, both prior to and following their event.

O’Donnell, M., Bryant, R. A., Creamer, M., & Carty, J. (2008). Mental health following traumatic injury: Toward a health system model of early psychological intervention. Clinical Psychology Review, 28, 387-406. doi:10.1016/j.cpr.2007.07.008

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In 2005, over 2 million people in the United States of America were hospitalised following non-fatal injuries. The frequency with which severe injury occurs renders it a leading cause of posttraumatic stress disorder and other trauma-related psychopathology. In order to develop a health system model of early psychological intervention for this population, we review the literature that pertains to mental health early intervention. The relevant domains include prevalence of psychopathology following traumatic injury, the course of symptoms, screening, and early intervention strategies. On the basis of available evidence, we propose a health system model of early psychological intervention following traumatic injury. The model involves screening for vulnerability within the hospital setting, follow-up screening for persistent symptoms at one month posttrauma, and early psychological intervention for those who are experiencing clinical impairment. Recommendations are made to facilitate tailoring early intervention psychological therapies to the special needs of the injury population.

O'Donnell, M., & Creamer, M. (2008). Motor vehicle collisions. In G. Reyes, J. D. Elhai & J. D. Ford (Eds.), The Encyclopedia of Psychological Trauma. Hoboken, NJ: John Wiley Press.

O'Donnell, M., Creamer, M., & Ludwig, G. (2008). PTSD and associated mental health consequences of motor vehicle collisions. In M. Duckworth, T. Iezzi & W. O'Donohue (Eds.), Motor Vehicle Collisions: Medical, Psychosocial, and Legal Consequences (pp. 345-363). New York: Elsevier Inc. doi:10.1016/B978-0-08-045048-3.00013-0

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Motor vehicle collisions (MVCs) are frequently experienced as a traumatic event. Breslau et al. (1991), for example, found that 42% of people reported experiencing a serious motor vehicle crash at some time in their lives, making MVC the second most frequent traumatic event. This has been replicated in a number of epidemiological studies both in the USA (Kessler et al., 1995) and other western countries (Erkonigg et al., 2000; Creamer et al., 2001). In this chapter, we will review the literature on the psychological consequences of MVCs using a posttraumatic mental health paradigm. This paradigm focuses on the experience of an MVC as a potentially traumatic event.

O’Donnell, M., Creamer, M. C., Parslow, R., Elliott, P., Holmes, A. C. N., Ellen, S., . . . Bryant, R. A. (2008). A predictive screening index for posttraumatic stress disorder and depression following traumatic injury. Journal of Consulting and Clinical Psychology, 76, 923-932. doi:10.1037/a0012918

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Posttraumatic stress disorder (PTSD) and major depressive episode (MDE) are frequent and disabling consequences of surviving severe injury. The majority of those who develop these problems are not identified or treated. The aim of this study was to develop and validate a screening instrument that identifies, during hospitalization, adults at high risk for developing PTSD and/or MDE. Hospitalized injury patients (n = 527) completed a pool of questions that represented 13 constructs of vulnerability. They were followed up at 12 months and assessed for PTSD and MDE. The resulting database was split into 2 subsamples. A principal-axis factor analysis and then a confirmatory factor analysis were conducted on the 1st subsample, resulting in a 5-factor solution. Two questions were selected from each factor, resulting in a 10-item scale. The final model was cross-validated with the 2nd subsample. Receiver-operating characteristic curves were then created. The resulting Posttraumatic Adjustment Scale had a sensitivity of .82 and a specificity of .84 when predicting PTSD and a sensitivity of .72 and a specificity of .75 in predicting posttraumatic MDE. This 10-item screening index represents a clinically useful instrument to identify trauma survivors at risk for the later development of PTSD and/or MDE.

Pead, J., Fletcher, S., & Creamer, M. (2008). Ten challenges in posttraumatic mental health. Australian and New Zealand Journal of Occupational Health and Safety, 24, 531-539.

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The mental health effects of trauma following workplace injury have been the focus of increasing awareness for OHS professionals and insurers. Employers and third party insurers have a responsibility to ensure that the consequences of such events are managed according to agreed best practices, which are driven by the available research evidence. This article outlines 10 challenges associated with managing mental health issues following traumatic events. Three relate to people’s needs, including causation, recovery and early problem recognition.  Four relate to best practice interventions, including psychological debriefing and other immediate responses, evidence-based treatment, finding effective health practitioners, and maintaining quality of care. The final challenges relate to outcomes, emphasising physical, social and occupational goals in the context of, rather than separate to, mental health treatment. Solutions for each of these key challenges, together with evidence for each, are described.

Phelps, A., Forbes, D., & Creamer, M. (2008). Understanding posttraumatic nightmares: An empirical and conceptual Review. Clinical Psychology Review, 28, 339-356. doi:10.1016/j.cpr.2007.06.001

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Posttraumatic nightmares (PTNMs) are a highly prevalent and distressing symptom of posttraumatic stress disorder (PTSD), yet have been subject to limited phenomenological investigation. As a result, the parameters of the symptom required to meet diagnostic criterion for PTSD are unclear and their relationship with normal dreams following trauma is not known. A categorical distinction between PTNMs and normal dreams has been assumed, explicitly within dreaming theories and perhaps implicitly within the PTSD field, but lacks empirical support. This paper reviews the current understanding of PTNMs and normal dreams following trauma within the PTSD and dreaming fields respectively. It is argued that models of PTSD can readily account for repetitive PTNMs that accurately replay the traumatic event, but not those that are symbolic of the traumatic event. On the other hand, theories of dreaming that propose a psychologically adaptive function of dreams can account for both replay and symbolic nightmares that evolve over time, but not those that are stuck in repetition. It is concluded that there is no adequate explanation for the range of dreams following trauma including the PTNM of PTSD that is both symbolic and repetitive. Three alternate explanatory models are proposed that draw on existing knowledge within both the PTSD and dreaming fields to explain the full range of nightmares following trauma.


Australian Centre for Posttraumatic Mental Health (ACPMH). (2007). Australian Guidelines for the treatment of adults with Acute Stress Disorder and Posttraumatic Stress Disorder. Melbourne: ACPMH. Retrieved from

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Acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) are psychological reactions that develop in some people following the experience of traumatic events such as major disaster, war, sexual or physical assault, motor vehicle accidents, and torture. Exposure to a traumatic event is not an uncommon experience. Large community surveys in Australia and overseas reveal that 50–65 per cent of people report at least one traumatic event in their lives. Most people will have some kind of psychological reaction to trauma—feelings of fear, sadness, guilt and anger are common. However, the majority recover over time with only a small proportion developing ASD or PTSD. It is estimated that 1.3 per cent of Australians have experienced PTSD in the last year, and that between 5 and 10 per cent of people have had PTSD at some point in their lives.

Creamer, M. (2007). Posttraumatic Syndromes: Disorders or Symptoms? In D. Castle, S. Hood & M. Kyrios (Eds.), Anxiety Disorders: Current Controversies, Future Directions. Melbourne: Australian Postgraduate Medicine.

Ernest, C. S., Elliott, P., Murphy, B. M., Le Grande, M. R., Goble, A. J., Higgins, R. O., . . . Tatoulis, J. (2007). Predictors of cognitive function in candidates for coronary artery bypass graft surgery. Journal of the International Neurolopsychological Society, 13, 257-266. doi:10.1017/S1355617707070282

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Candidates for coronary artery bypass graft surgery have been found to exhibit reduced cognitive function prior to surgery. However, little is known regarding the factors that are associated with pre-bypass cognitive function. A battery of neuropsychological tests was administered to a group of patients listed for bypass surgery (n = 109). Medical, sociodemographic and emotional predictors of cognitive function were investigated using structural equation modeling. Medical factors, namely history of hypertension and low ejection fraction, significantly predicted reduced cognitive function, as did several sociodemographic characteristics, namely older age, less education, non-English speaking background, manual occupation, and male gender. One emotional variable, confusion and bewilderment, was also a significant predictor whereas anxiety and depression were not. When significant predictors from the three sets of variables were included in a combined model, three of the five sociodemographic characteristics, namely age, non-English speaking background and occupation, and the two medical factors remained significant. Apart from sociodemographic characteristics, medical factors such as a history of hypertension and low ejection fraction significantly predicted reduced cognitive function in bypass candidates prior to surgery.

Cooper, J., Forbes, D., Pead, J., & Phelps, A. (2007). Mental Health Advice Book for practitioners helping veterans with common mental health problems. Canberra: Department of Veterans’ Affairs. Retrieved from

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Veterans’ mental health problems are as varied as the conflicts in which our ex-servicemen and women have served. Health practitioners may treat an ex-prisoner of war from World War II, a Vietnam veteran or a woman in her thirties who served in Rwanda and East Timor. While their problems and the treatment they receive may be unique, veterans share a common military culture. Although it has certainly changed over the years, an understanding of this culture will greatly assist health practitioners to provide the most appropriate treatment for veterans. At the same time, practitioners can be reassured that they can help veterans with mental health problems with much the same approach as they use to help the general community. Society’s understanding and acceptance of mental health problems has improved dramatically since the men and women who served in World War I returned home to the care of dedicated repatriation hospitals. Views about where to provide mental health treatment have changed considerably since then. Like all of us, veterans benefit from being treated in the community, close to family and friends, with as little disruption as possible to their daily routines  This book provides information and advice to practitioners in all health services in recognising, assessing and treating veterans’ common mental health problems. It will also increase practitioners’ awareness and knowledge of more specialist mental health advice, services and referral options.

Forbes, D., Creamer, M., Phelps, A., Bryant, R., McFarlane, A., Devilly, G., . . . Newton, S. (2007). The Australian guidelines for the treatment of adults with acute stress disorder and post-traumatic stress disorder. Australian and New Zealand Journal of Psychiatry, 41, 637-648. Retrieved from

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Over the past 2-3 years, clinical practice guidelines (CPGs) for post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) have been developed in the USA and UK. There remained a need, however, for the development of Australian CPGs for the treatment of ASD and PTSD tailored to the national health-care context. Therefore, the Australian Centre for Posttraumatic Mental Health in collaboration with national trauma experts, has recently developed Australian CPGs for adults with ASD and PTSD, which have been endorsed by the National Health and Medical Research Council (NHMRC). In consultation with a multidisciplinary reference panel (MDP), research questions were determined and a systematic review of the evidence was then conducted to answer these questions (consistent with NHMRC procedures). On the basis of the evidence reviewed and in consultation with the MDP, a series of practice recommendations were developed. The practice recommendations that have been developed address a broad range of clinical questions. Key recommendations indicate the use of trauma-focused psychological therapy (cognitive behavioural therapy or eye movement desensitization and reprocessing in addition to in vivo exposure) as the most effective treatment for ASD and PTSD. Where medication is required for the treatment of PTSD in adults, selective serotonin re-uptake inhibitor antidepressants should be the first choice. Medication should not be used in preference to trauma-focused psychological therapy. In the immediate aftermath of trauma, practitioners should adopt a position of watchful waiting and provide psychological first aid.

Forbes, D., Creamer, M., Phelps, A., Couineau, A. L., Cooper, J. A., Bryant, R. A, . . . Raphael, B. (2007). Treating adults with acute stress disorder and posttraumatic stress disorder in general practice: A clinical update. Medical Journal of Australia, 187, 120-123. Retrieved from

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General practitioners have an important role to play in helping patients after exposure to severe psychological trauma. In the immediate aftermath of trauma, GPs should offer psychological first aid, which includes monitoring of the patient’s mental state, providing general emotional support and information, and encouraging the active use of social support networks, and self-care strategies. Drug treatments should be avoided as a preventive intervention after traumatic exposure; they may be used cautiously in cases of extreme distress that persists. Adults with acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) should be provided with trauma-focused cognitive behaviour therapy (CBT). Eye movement desensitisation and reprocessing (EMDR) in addition to in vivo exposure (confronting avoided situations, people or places in a graded and systematic manner) may also be provided for PTSD. Drug treatments should not normally replace trauma-focused psychological therapy as a first-line treatment for adults with PTSD. If medication is considered for treating PTSD in adults, selective serotonin reuptake inhibitor antidepressants are the first choice. Other new generation antidepressants and older tricyclic antidepressants should be considered as second-line pharmacological options. Monoamine oxidase inhibitors may be considered by mental health specialists for use in people with treatment-resistant symptoms.

Goldney, R., Fisher, L., Dal Grande, E., & Hawthorne, G. (2007). Have education and publicity about depression made a difference? A comparison of prevalence, service use and excess costs in South Australia: 1998 and 2004. Australian and New Zealand Journal of Psychiatry, 41, 38-53. doi:10.1080/00048670601050465

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Objective: To identify changes in depression, its management and associated excess costs, between 1998 and 2004 in South Australia. Methods: A face-to-face Health Omnibus Survey was conducted in 2004 among 3015 randomly selected participants aged 15 years and over, who were a random and representative sample of the South Australian population, and this was compared with a survey conducted in 1998 that used the same methodology. The main outcome measures were prevalence of depression detected by the Mood Module of the Primary Care Evaluation of Mental Disorders (PRIME-MD); use of health services; health-related quality of life assessed by the Assessment of Quality of Life; estimates of excess costs and demographic data. Results: There was no significant change in the overall prevalence of depression, although there was a significant decrease in respondents with other depressions, and a non-significant increase in those with major depression. No significant differences in the mean number of PRIME-MD depression symptoms were reported. Greater use of predominantly non-medical treatment services and antidepressants were reported by both those with depression and those without depression. There was a marked increase in the associated excess costs of depression. Conclusions: There has been no significant improvement in the prevalence of depression and its associated morbidity and financial burden in the South Australian community between 1998 and 2004, despite a number of professional and community education programmes. It is possible that without these efforts and the increased treatment reported on in this survey, there may have been an increase in the prevalence of depression and an even greater financial burden. However, it is also possible that community services for the provision of treatment for depression have not been able to implement research strategies that have been demonstrated to be effective.

O'Donnell, M., Creamer, M., Elliott, P., & Bryant, R. (2007). Tonic and phasic heart rate as predictors of posttraumatic stress disorder. Psychosomatic Medicine, 69, 256-261. doi:10.1097/PSY.0b013e3180417d04

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Objective: To examine the relationship between acute measures of a) heart rate (HR) immediately after traumatic injury, b) tonic (resting) HR at 1 week post injury, c) phasic (aroused) HR at 1 week post injury, and d) somatic symptoms of arousal in the prediction of subsequent posttraumatic stress disorder (PTSD). Fear conditioning models propose that HR reactivity shortly after trauma may predict PTSD. Method: In a longitudinal study, consecutive injury survivors (n = 197) admitted to a hospital trauma service were assessed within 1 week and at 12 months post injury. HR was assessed by paramedics at the site of the trauma and pulse oximetry technology at 1 week post trauma. Somatic symptoms of arousal were measured using the somatic scale on the Beck Anxiety Inventory (BAI). PTSD was assessed using the Clinician Administered PTSD Scale at 12 months. Results: At 12 months post injury, PTSD was diagnosed in 10% of participants. Only HR change scores (phasic - tonic HR) and BAI scores significantly predicted later PTSD. Conclusions: These findings question the clinical usefulness of tonic HR as a biological marker of later PTSD. The finding that HR reactivity (phasic - tonic) predicts later PTSD has theoretical importance. The strongest predictor of later PTSD was somatic arousal.

O'Donnell, M., Elliott, P., Lau, W., & Creamer, M. (2007). PTSD symptom trajectories: From acute to chronic response. Behaviour Research and Therapy, 45, 601-606. doi:10.1016/j.brat.2006.03.015

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This study aimed to identify posttraumatic stress disorder (PTSD) symptom trajectories across the first 12 months following traumatic injury. Three hundred and seven consecutively admitted injury survivors were assessed for severity of PTSD symptoms just prior to discharge, and at 3 and 12 months postinjury. Growth modeling was used to determine the curve that best fit the trajectory for each symptom cluster over the 12-month period. Individuals with 12-month PTSD showed significantly higher re-experiencing, arousal, and avoidance symptoms at eight days posttrauma relative to those without, and these symptoms escalated over time. Those without PTSD maintained their relatively low symptom levels. These findings highlight that individuals who will go onto develop PTSD have a distinctly different symptom course than those who recover.

O'Donnell, M., Elliott, P., Wolfgang, B., & Creamer, M. (2007). Posttraumatic appraisals in the development and persistence of posttraumatic stress symptoms. Journal of Traumatic Stress, 20, 173-182. doi:10.1002/jts.20198

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Cognitive models of posttraumatic stress disorder (PTSD) posit that appraisal plays an important role in the development and persistence of PTSD. This study examined posttraumatic appraisals and their relationship to the development and course of PTSD symptoms. Two hundred fifty-three injury survivors were assessed for PTSD symptoms and posttraumatic cognitions across a 12-month period. A path analytic modeling approach showed that posttraumatic appraisals were important direct and indirect predictors of later PTSD severity. The findings suggest that appraisals made in the aftermath of trauma have a significant influence on subsequent psychological adjustment.

Rushford, N., Murphy, B. M., Worcester, M. U. C., Goble, A. J., Higgins, R. O., Le Grande, M. R., . . . Elliot, P. (2007). Recall of information received in hospital by female cardiac patients. European Journal of Cardiovascular Prevention & Rehabilitation, 14, 463–469. doi: 10.1097/HJR.0b013e3280ac1507

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Background: The type and source of health information supplied to patients following cardiac events significantly improve adherence and health behaviours. The impact of health information upon female patients, however, is not well documented. This study investigates women's recall of the type and source of information provided to them in hospital about resuming daily activities after a cardiac event. It also identified women least likely to recall receiving information. Methods: Interviews were conducted with female cardiac patients consecutively admitted to four metropolitan hospitals after acute myocardial infarction or for coronary artery bypass graft surgery. The women were interviewed on admission and at 2, 4 and 12 months after discharge. Participants were asked about in-hospital information provision at the 2-month interview (n = 224). Results: Most women recalled receiving verbal information about medication, exercise and smoking cessation, but few recalled receiving verbal information about gardening, sexual activity, driving or sport. Women who were obese or physically inactive recalled limited advice about diet and physical activity, whereas women with diabetes or hypertension were no more likely than others to recall receiving information about medication, despite the personal relevance of this information. Older women were most at risk of recalling limited advice, including information about cardiac rehabilitation. Over half of the women attended a cardiac rehabilitation programme, with uptake being related to information provision. Conclusions: The findings support other research suggesting that advice about activities after a cardiac event is inadequate for some women and confirms the influence of information provision on participation in cardiac rehabilitation.

Worcester, M. U. C., Murphy, B. M., Elliot, P., Le Grande, M. R., Higgins, R. O., Goble, A., J., & Roberts, S. B. (2007). Trajectories of recovery of quality of life in women after an acute cardiac event. British Journal of Health Psychology, 12, 1-15. doi: 10.1348/135910705X90127

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Objectives: Female cardiac patients' health-related quality of life (HRQoL) during the first year after an acute cardiac event was compared with age-weighted Australian population norms. The impact of age, event type and cardiac rehabilitation (CR) programme attendance on recovery was assessed. Methods: The short form 36-item health survey (SF-36) was administered to 229 women aged from 36 to 84 years consecutively admitted to 4 hospitals after acute myocardial infarction (AMI) or to undergo coronary artery bypass graft surgery (CABGS). Data were collected at 4 time points over 12 months. SF-36 subscale scores were compared with age-weighted norms for Australian women. Mplus was used to analyse growth trajectories for SF-36 subscales. Results: Patients had impaired HRQoL at baseline (except in general health), with progressive improvement over time. Recovery to normative levels was fastest in the areas of bodily pain and mental health (by 2 months) and slowest in the area of physical functioning, and physical and emotional role limitations (by 12 months). By 4 months, general health scores had surpassed population norms. For all scales, most improvement occurred in the first 2 months, with little subsequent improvement. CABGS patients showed significantly more improvement than AMI patients in several areas, partly due to the poorer functioning of CABGS patients at baseline. Rate of improvement was not influenced by patients' age or frequency of CR attendance. Conclusion: Impairment of HRQoL in female cardiac patients is most pronounced at the time of the event, with most recovery occurring during early convalescence and full recovery in all domains by 12 months post-event.


Bowden, S. C., Weiss, L. G.,Holdnack, J. A., & Lloyd, D. (2006). Age-related invariance of abilities measured with the Wechsler Adult Intelligence Scale–III. Psychological Assessment, 18, 334-339. doi:10.1037/1040-3590.18.3.334

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Examination of measurement invariance tests the assumption that the model underlying a set of test scores is directly comparable across groups. The observation of measurement invariance provides fundamental evidence for the inference that scores on a test afford equivalent measurement of the same psychological traits among diverse groups. Groups may be derived from different psychosocial backgrounds or different clinical presentations. In the Wechsler Adult Intelligence Scale-III (WAIS-III)/Wechsler Memory Scale-III (WMS-III) Technical Manual (Psychological Corporation, 2002), there appears to be a breakdown in factor structure among the standardization cases in older adults. In this study, the authors evaluated the invariance of the measurement model of the WAIS-III across 5 age bands. All components of the measurement model were examined. Overall, the evidence pointed to invariance across age of a modified 4-factor model that included cross-loadings for the Similarities and Arithmetic subtests. These results support the utility of the WAIS-III as a measure of stable intelligence traits across a wide age range.

Carty, J., O'Donnell, M., & Creamer, M. (2006). Delayed-onset PTSD: A prospective study of injury survivors. Journal of Affective Disorders, 90, 257-261. doi:10.1016/j.jad.2005.11.011

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Background: Recent studies have indicated that delayed-onset posttraumatic stress disorder (PTSD) (i.e., the development of PTSD more than 6 months posttrauma) is generally characterised by subsyndromal diagnoses within the first 6 months. This study sought to examine the relationship between sub-clinical levels of PTSD symptoms at 3 months posttrauma and delayed onset PTSD at 12 months in a large sample of traumatic injury survivors. Methods: Three hundred and one consecutively admitted injury survivors were assessed at 3 and 12 months posttrauma. PTSD was diagnosed according to DSM-IV criteria, while partial and subsyndromal diagnoses were based on recent definitions developed by Mylle and Maes [Mylle, J., Maes, M., 2004. Partial posttraumatic stress disorder revisited. J. Affect. Disord. 78, 37-48]. Results: Eight percent of participants was diagnosed with 3-month PTSD while 10% was diagnosed with 12-month PTSD. Nearly half (47%) of 12-month PTSD cases were of delayed onset. The majority of those with delayed-onset were diagnosed with partial or subsyndromal PTSD at 3 months. Ten percent of delayed onset cases did not meet partial or subsyndromal criteria. Limitations: As symptoms were not assessed at 6 months (the DSM cut-off for delayed PTSD), it could not be conclusively determined that delayed-onset cases had not developed PTSD between 3 and 6 months posttrauma. Conclusion: A considerable proportion of 12-month PTSD diagnoses was delayed in onset. While most demonstrated 3-month morbidity in the form of partial and subsyndromal diagnoses, a minority did not. Thus, clinicians should consider subthreshold diagnoses as potential risk factors for delayed-onset PTSD. Future research is required to identify factors that may predict delayed-onset PTSD in trauma survivors without evidence of prior PTSD pathology.

Cooper, J., Creamer, M., & Forbes, D. (2006). Mental health initiatives for veterans and serving personnel. The Medical Journal of Australia, 185, 453. Retrieved from

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It has long been recognised that veterans may experience mental health problems after military deployments, and that these can be overlooked in the context of concern about physical injuries. Primary care practitioners, both military and civilian, are often the first port of call for affected veterans, and are best positioned to assess these patients and commence care when necessary. As over 85% of Australia’s trained forces are male, these health problems are particularly relevant for men’s health. American research on veterans from recent Middle East deployments shows high rates of psychological problems. Interestingly, British research on the same conflict found that problems are limited to reservists, with no elevated rates of mental health problems among regular personnel. Although local data are unavailable, it is reasonable to assume that Australian veterans from Afghanistan and Iraq will not be exempt. We learned much from the experience of Vietnam veterans, with their initial difficulties closely resembling those of younger veterans presenting today. While much attention is paid to post-traumatic stress disorder, evidence suggests that other anxiety, depression, and substance-misuse disorders are equally common. ...

Creamer, M. (2006). Acute psychological intervention for law enforcement personnel following trauma exposure: What is current best practice? The Law Enforcement Executive Forum, 6, 135-150. Retrieved from

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The nature of law enforcement work is such that police officers are regularly exposed to highly stressful or “traumatic” experiences. These may include frightening incidents (e.g., threats to the life or physical integrity of the officer, his or her colleagues, or civilians), as well as events that may elicit feelings of sadness or distress (e.g., exposure to loss of life or human suffering). It is now widely recognized that some kind of mental health intervention should be available to emergency services personnel exposed to traumatic events. The field, however, is in its infancy, with considerable disagreement regarding the nature and effectiveness of such interventions. Early interventions may take a variety of forms, ranging from low-key, practical assistance to highly specialized psychological and pharmacological intervention models. The purpose of this article is to review what is (and is not) known about the nature and efficacy of acute interventions following trauma, with particular reference to law enforcement and other emergency service personnel. Where reliable research data is available, the reference to the original publication has been provided. Where relevant research does not exist, recommendations and conclusions have been based on my clinical experience and knowledge of international practice; it is important that the reader interpret the content of this article in that context. It is acknowledged that, in the absence of a strong empirical evidence base, decisions regarding appropriate models may have to rely more on a consensus view of best practices than on research data. ...

Creamer, M., Carboon, I., Forbes, A. B., McKenzie, D. P., McFarlane, A. C., Kelsall, H. L., & Sim, M. R. (2006). Psychiatric disorder and separation from military service: A 10 year retrospective study. American Journal of Psychiatry, 163, 733-734. doi:10.1176/appi.ajp.163.4.733

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Objective: This study investigated the association between the onset of psychiatric morbidity and separation from military service over a 10-year period (1991-2001). Method: The prevalence of affective, anxiety, somatic, and substance use disorders was assessed in 2,215 male Australian Navy personnel with the Composite International Diagnostic Interview. Results: The onset of a psychiatric disorder during military service was related to a 19% greater risk of separation overall. The majority of those leaving military service did so in the first year after symptom onset. Personnel who remained in service past this period had no significantly elevated risk of separation in subsequent years. Conclusions: Psychiatric morbidity represents a significant potential cost to defense forces. Improved recognition and early management of mental health problems among military personnel may improve retention rates.

Creamer, M., & Carty, J. (2006). Posttraumatic Stress Disorder. In M. C. McNulty (Ed.), Handbook of Adult Clinical Psychology: An Evidence Based Practice Approach (pp. 523-557). London: Brunner Routledge.

Creamer, M., & Carty, J. (2006). Posttraumatic stress disorder in women. In D. Castle, J. Kulkarni, K. M. Abel, & Goldstein, J. (Eds.), Mood and Anxiety in Women (pp. 75-91). Cambridge: Cambridge University Press. doi:10.1017/CBO9780511543647

Creamer, M., Elliott, P., Forbes, D., Biddle, D., & Hawthorne, G. (2006). Treatment for combat-related posttraumatic stress disorder: Two year follow-up. Journal of Traumatic Stress, 19, 675-685. doi:10.1002/jts.20155

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This study reports on outcomes 2 years following completion of specialist veteran posttraumatic stress disorder (PTSD) treatment programs in 2,223 (reduced to 1,508 at 24 months) consecutive admissions. Self-report measures of PTSD, anxiety, depression, anger, alcohol use, and general functioning were obtained at admission, 6, 12, and 24 months after admission. Significant improvements were demonstrated at 6 months, with smaller gains continuing through to 24-month assessment. Within subject effect sizes of around 0.8 were obtained for PTSD and around 0.5 for anxiety and depression. Although lack of a control group limits the extent to which improvements can be attributed to the treatment program, the data suggest that specialized treatment programs for combat-related PTSD continue to be of value.

Forbes, D., & Creamer, M. (2006). The treatment of chronic posttraumatic stress disorder. In G. Kearney, M. Creamer, R. Marshall & A. Goyne (Eds.), Military stress and performance (pp. 206-218). Melbourne: Melbourne University Press.

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Chronic posttraumatic stress disorder (PTSD) s a complex condition requiring a multi-staged intervention. The core components of treatment are not new, and they overlap with interventions used in the treatment of many other anxiety disorders. The purpose of this chapter is to discuss the application of those strategies to the specific challenge of chronic, combat-related PTSD. A detailed therapeutic manual is beyond the scope of this chapter and the interested reader is referred to more comprehensive texts such as Andrews, Creamer, Crino, Hunt, Lampe and Page (2002) or Foa and Rothbaum (1998).

Forbes, D., Carty, J., Elliott, P., Creamer, M., McHugh, T., Hopwood, M., & Chemtob, C. M. (2006). Is mixed handedness a marker of treatment response in posttraumatic stress disorder?: A pilot study. Journal of Traumatic Stress, 19, 961-966. doi:10.1002/jts.20160

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Recent studies suggest that mixed-handedness is a risk factor for posttraumatic stress disorder (PTSD). This study examined whether mixed-handed veterans with combat-related PTSD respond more poorly to psychosocial treatment. Consistency of hand preference was assessed in 150 Vietnam combat veterans with PTSD using the Edinburgh Handedness Inventory (R. C. Oldfield, 1971). Growth modeling analyses using Mplus (L. K. Muthén & B. Muthén, 2002) identified that PTSD veterans with mixed-handedness reported significantly less treatment improvement on the PTSD Checklist (F. W. Weathers, B. T. Litz, D. S. Herman, J. A. Huska, & T. M. Keane, 1993) than did veterans with consistent handedness. These data suggest that mixed-handedness is associated with poorer PTSD treatment response. Several possible explanations for this finding are discussed.

Hawthorne, G. (2006). Measuring social isolation in older adults: Development and initial validation of the Friendship Scale. Social Indicators Research, 77, 521 - 548. doi:10.1007/s11205-005-7746-y

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Although there are many excellent published scales measuring social isolation, there is need for a short, user-friendly, stand alone scale measuring felt social isolation with good psychometric properties. This study reports the development and preliminary validation of a short, user-friendly scale, the Friendship Scale. The six items measure six of the seven important dimensions that contribute to social isolation and it’s opposite, social connection. The psychometric properties suggest that it has excellent internal structures as assessed by structural equation modelling (CFI = 0.99, RMSEA = 0.02), that it possesses reliability (Cronbach α = 0.83) and discrimination when assessed against two other short social relationship scales. Tests of concurrent discriminate validity suggest it is sensitive to the known correlates of social isolation. Although further work is needed to validate it in other populations, the results of this study suggest researchers may find the Friendship Scale particularly useful in epidemiology, population surveys or in health-related quality of life evaluation studies where a parsimonious measure of felt social support or social isolation is needed.

Hawthorne, G., Herrman, H., & Murphy, B. (2006). Interpreting the WHOQOL-Brèf: Preliminary population norms and effect sizes. Social Indicators Research, 77, 37 - 59.

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Since publication use of the WHOQOL-Brèf has rapidly risen. However, as yet no population norms have been published as a reference point against which researchers can interpret their findings. This study provides preliminary population norms for this purpose. Randomly sampled community residents from two studies were pooled and used to examine the properties of the WHOQOL-Brèf by age group, gender and health status. The results showed that general norms for the WHOQOL-Brèf domains were 73.5 (SD=18.1) for the Physical health domain, 70.6 (14.0) for Psychological wellbeing, 71.5 (18.2) for Social relationships and 75.1 (13.0) for the Environment domain. In general scores declined slightly by age group. For females scores were stable across the lifespan with an accelerated decline after the age of 60 years. Males exhibited a more consistent and even decline across the lifespan. There were significant differences in WHOQOL-Brèf scores when reported by health status, with those in poor health obtaining scores that were up to 50% lower than those in excellent health. Effect sizes between different health status levels are reported. These preliminary norms and effect sizes may be used as reference points for interpreting WHOQOL-Brèf scores. They provide additional information to the numerous national studies already reporting on the validity of the WHOQOL-Brèf.

Hawthorne, G., Mouthaan, J., Forbes, D., & Novaco, R. W. (2006). Response categories and anger measurement: Do fewer categories result in poorer measurement?: Development of the DAR5. Social Psychiatry and Psychiatric Epidemiology, 41, 164-172. doi:10.1007/s00127-005-0986-y

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Background: Anger is a key long-term outcome from trauma exposure, regardless of trauma type, and it is implicated as a moderator of response to treatment. It therefore seems important that anger is assessed in both epidemiological studies of trauma sequelae and in intervention evaluation research. This study explored the measurement properties of a recently investigated anger scale, the Dimensions of Anger Reactions (DAR) Scale. In our previous study, the DAR was found to be a measure of trait anger, but although brief, the nine response categories per item may have confused respondents, suggesting fewer response categories may work equally well. Additionally, our previous analysis suggested there were two redundant items within the DAR. Methods: Three samples of Australian veterans were used to investigate the psychometric properties associated with alterations to the response categories of the DAR; veterans who participated in the DAR validation study, those participating in group therapy programmes for post-traumatic stress disorder, and veterans participating in lifestyle programmes. Item response theory analysis was used to explore the internal properties of competing DAR models, and models were assessed against external criteria. Results: The results showed that the number of item responses in the DAR exceeded channel capacity, and that response bias occurred in the second half of the instrument. We hypothesized that this was due to respondents not discriminating among the many response categories. Based on a modelling exercise in which we reduced the number of DAR items from 7 to 5 and the number of response categories from 9 to 5, validation tests showed that there was no loss of sensitivity, reliability or validity. To avoid confusion with the DAR, we have referred to the revised version of the DAR as the DAR5. Conclusions: We conclude that the DAR5, which abbreviates the original DAR to half its original length, has similar psychometric properties and is therefore to be preferred especially for use with persons who are under stress, cognitively impaired or less mature. The study findings regarding the optimum number of response categories have implications for the development of other instruments.

Le Grande, M. R., Elliott, P., Murphy, B. M., Worcester, M. U. C., Higgins, R. O., Ernest, C. S., & Goble, A. J. (2006). Health related quality of life trajectories and predictors following coronary artery bypass surgery. Health and Quality of Life Outcomes, 4, 49. doi:10.1186/1477-7525-4-49

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Background: Many studies have demonstrated that health related quality of life (HRQoL) improves, on average, after coronary artery bypass graft surgery (CABGS). However, this average improvement may not be realized for all patients, and it is possible that there are two or more distinctive groups with different, possibly non-linear, trajectories of change over time. Furthermore, little is known about the predictors that are associated with these possible HRQoL trajectories after CABGS. Methods: 182 patients listed for elective CABGS at The Royal Melbourne Hospital completed a postal battery of questionnaires which included the Short-Form-36 (SF-36), Profile of Mood States (POMS) and the Everyday Functioning Questionnaire (EFQ). These data were collected on average a month before surgery, and at two months and six months after surgery. Socio-demographic and medical characteristics prior to surgery, as well as surgical and post-surgical complications and symptoms were also assessed. Growth curve and growth mixture modelling were used to identify trajectories of HRQoL. Results: For both the physical component summary scale (PCS) and the mental component summary scale (MCS) of the SF-36, two groups of patients with distinct trajectories of HRQoL following surgery could be identified (improvers and non-improvers). A series of logistic regression analyses identified different predictors of group membership for PCS and MCS trajectories. For the PCS the most significant predictors of non-improver membership were lower scores on POMS vigor-activity and higher New York Heart Association dyspnoea class; for the MCS the most significant predictors of non-improver membership were higher scores on POMS depression-dejection and manual occupation. Conclusion: It is incorrect to assume that HRQoL will improve in a linear fashion for all patients following CABGS. Nor was there support for a single response trajectory. It is important to identify characteristics of each patient, and those post-operative symptoms that could be possible targets for intervention to improve HRQoL outcomes.

McFarlane, A. C., & Creamer, M. (2006). Current knowledge about psychological trauma: A response to Milton. ADF Health,7, 78-82. Retrieved from

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We rebut a number of the assertions made by Milton in the October 2005 issue of ADF Health. 1. A substantial body of epidemiological research informs about the prevalence, risks and burden of disease associated with post-traumatic stress disorder (PTSD). To suggest that PTSD is created by treatment and the possibility of compensation denies the complexity of the issues at stake. 2. There is effective treatment for PTSD and the Australian Defence Force has an important duty of care to ensure the early identification and treatment of ADF members adversely affected by their service. 3. Equally,many service personnel benefit and are not damaged by the deployment experience, and the challenge is to build resilience and assist those who are injured. 4. Early identification and treatment of psychological morbidity in the ADF is critical to operational effectiveness in an age of technological warfare. These disorders are known to have major detrimental effects on the information processing capacity of individuals, and this presents a major risk for the survival of the individual and the group.

McKenzie, D. P., McFarlane, A. C., Creamer, M., Ikin, J. F., Forbes, A. B., Kelsall, H. L., . . . Sim, M. R. (2006). Hazardous or harmful alcohol use in Royal Australian Navy veterans of the 1991 Gulf War: Identification of high risk subgroups. Addictive Behaviors, 31, 1683-1694. doi:10.1016/j.addbeh.2005.12.027

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Elevated alcohol use disorders have been observed in 1991 Gulf War veterans from a variety of countries. This study used a self-report instrument, the Alcohol Use Disorders Identification Test (AUDIT), to ascertain whether any subgroups of 1232 male Royal Australian Navy (RAN) Gulf War veterans were at higher risk of hazardous or harmful alcohol use. Recursive partitioning/classification and regression tree (CART) analysis, followed by logistic regression, found five subgroups among the veterans, with differing risks of AUDIT caseness. The highest risk subgroup comprised current smokers. The other two high risk groups both consisted of former or never smokers of lower rank who were (1) not married, or (2) married, with a current diagnosis of major depression. The above subgroups were over three times as likely to exhibit AUDIT caseness, than those who were former or never smokers of higher rank. The findings have important implications for effective development of public health initiatives designed to encourage safe alcohol use among veterans.

O'Donnell, M., Creamer, M., Bryant, R. A., Schnyder, U., & Shalev, A. (2006). Posttraumatic Stress Disorder following injury: Assessment and other methodological considerations. In G. Young, A. Kane, & K. Nicholson (Eds.), Psychological Knowledge In Court: PTSD, Pain, and TBI (pp.70-84). New York: Springer Publishing Co. doi:10.1007/0-387-25610-5_4

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Physical injury in civilian populations is a frequent event. In 2000, 11% of the U.S. population (approximately 30 million people) were treated in emergency departments following nonfatal injuries (National Centre for Injury Prevention and Control−Electronic Database, 2000). Not only does injury occur frequently, but it often occurs at a severity to be classified as a traumatic event. Breslau et al. (1991) found that a lifetime prevalence of serious injury or serious motor vehicle crash was 41.9%, rating second in frequency of traumatic events. The conditional risk of developing Posttraumatic Stress Disorder (PTSD) following serious accidents and injury is relatively low (Kessler et al., 1995); that is, the risk of developing PTSD in all those who are exposed to traumatic injury is low relative to other traumatic events such as interpersonal violence (Breslau et al., 1998). Nevertheless, serious injury is a leading cause of PTSD because of the frequency with which injury occurs. . . . This chapter aims to orient both practitioner and researcher to the current status of research regarding PTSD following injury.

Scott, C. K., Sonis, J., Creamer, M., & Dennis, M. L. (2006). Maximizing follow-up in longitudinal studies of traumatized populations. Journal of Traumatic Stress, 19, 757-769. doi:10.1002/jts.20186

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Although longitudinal research is essential in understanding the nature and course of posttraumatic mental health problems, high rates of attrition often threaten the internal validity of such studies and make results hard to interpret. C. K. Scott (2004) developed an approach to minimizing attrition in longitudinal studies that consistently yielded retention rates in excess of 90% through to 2-year follow-up. In this article, the authors discuss the interface between trauma exposure and participation in longitudinal research, before describing in detail a model to address those effects. The effectiveness of the model is examined with reference to traumatic stress in a large community sample (N = 887) with eight waves of data over 2 years


Biddle, D., Hawthorne, G., Forbes, D., & Coman, G. (2005). Problem gambling in Australian PTSD treatment-seeking veterans. Journal of Traumatic Stress, 18, 759-767. doi:10.1002/jts.20084

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This study explored gambling among Australian veterans entering posttraumatic stress treatment programs (n = 153). Twenty-eight percent reached the South Oaks Gambling Screen (SOGS) criteria for probable problem gambling, as did 17% on the DSM-IV gambling scale (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; American Psychiatric Association, 1994). Almost all problem gamblers reported gambling to escape problems in other areas of their lives. The strongest independent predictor of problem gambling was gambling weekly or more often on electronic gaming machines. There was no significant relationship between problem gambling, posttraumatic stress disorder (PTSD), anxiety, depression, or alcohol use. The study identified an entrenched gambling culture among PTSD treatment-seeking veterans, finding these veterans indulge in many different forms of gambling and that these forms are mediated by situational factors that provide both casual and formal gambling opportunities.

Carboon, I., Anderson, V. A., Pollard, A., Szer, J., & Seymour, J. F. (2005). Posttraumatic growth following a cancer diagnosis: Do world assumptions contribute? Traumatology, 11, 269-283. doi:10.1177/153476560501100406

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This longitudinal study explored cognitive predictors of posttraumatic growth (PTG) among 62 adults undergoing treatment for newly diagnosed cancer. Examined, were the contribution of assumptive world beliefs, cognitive avoidance, cognitive intrusions, socio-demographic and illness-related factors to PTG. All predictors were measured during treatment (M: 37 days post-diagnosis) for a hematologic cancer (T1). World assumptions were measured again along with PTG following primary treatment completion (M: 184 days post-diagnosis [T2]). Multiple regression analyses were conducted to predict the five domains of PTG. The results of the analyses indicated that assumptions of justice and luck positively predicted PTG while lower self worth and self control were related to higher growth. Assumptions did not change between T1 and T2. Contrary to expectations cognitive avoidance positively predicted growth. There was no association between intrusions and growth. On the basis of this study, it is concluded that stronger beliefs in the predictability of life events and less favorable self-views promote PTG early in the cancer experience.

Coman, G., Evans, B. J., & Burrows, G. D. (2005). An innovative cognitive strategy to assist problem gamblers. British Journal of Guidance and Counselling, 33, 129-140. doi:10.1080/03069880412331335867

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The clinical and research literature suggests that cognitive and behavioural therapies are particularly helpful in assisting clients overcome problem gambling behaviour. Several articles have described the efficacy of a range of cognitive interventions, especially provision of information regarding rates of return and the odds of games and the exploration of irrational beliefs and myths and misconceptions regarding gambling activity. This paper describes in detail an innovative cognitive strategy which focuses on problem gambling clients' financial status. The strategy incorporates the use of illustrations, generally using a whiteboard, to highlight how problem gambling behaviour negatively impacts on financial wealth over time. Step by step instructions are provided, together with illustrations, to allow clinicians to incorporate the strategy in treatment with their own clients.

Cooper, J., Carty, J., & Creamer, M. (2005). Pharmacotherapy for posttraumatic stress disorder: Empirical review and clinical recommendations. Australian and New Zealand Journal of Psychiatry, 39, 674-682. doi: 10.1111/j.1440-1614.2005.01651.x

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Objective: Growing awareness of the psychological effects of trauma has emphasized the need for clinicians across a range of practice settings to be aware of evidence-based treatment options for posttraumatic stress disorder (PTSD). The purpose of this article is to review the available empirical data on pharmacological approaches to PTSD and to provide recommendations for clinical practice. Method: Although a comprehensive search of PsychInfo and Medline databases revealed a multitude of case reports and open-label trials, this paper focuses primarily on evidence obtained from randomized controlled trials to determine the most effective pharmacological treatments for PTSD. Results: The research data overwhelmingly supports antidepressant medication as the first-line pharmacotherapy for PTSD, with selective serotonin re-uptake inhibitors having the strongest body of empirical support. Other medications, and with care, combination pharmacotherapy, may also have a role in the management of certain presentations. Cautions for clinicians in treating this complex disorder are provided. Conclusions: Despite a substantial increase in the amount and quality of research into pharmacological treatments for PTSD in recent years, there is still a pressing need for more data to guide routine clinical practice. In particular, future research regarding the psychobiological basis of PTSD may guide the development of a PTSD-specific drug, designed to treat the unique characteristics of this disorder.

Creamer, M., McFarlane, A. C., & Burgess, P. (2005). Psychopathology following trauma: The role of subjective experience. Journal of Affective Disorders, 86, 175-182. doi:10.1016/j.jad.2005.01.15

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Background: The DSM-IV definition of posttraumatic stress disorder (PTSD) widened the stressor criterion to include objective (A1) and subjective (A2) components. The prevalence of Criterion A2, and its association with traumatic memory and psychopathology, was examined in a large community sample. Method: The presence of Criterion A2 and traumatic memories, as well as DSM-IV anxiety, affective and substance use disorders, were examined in a community sample of 6104 adults with a history of traumatic exposure.Results: Most individuals met Criterion A2 (76%), with higher prevalence in females (81%) than males (69%). A2 was more common following certain traumas (such as assaultive violence). Excluding those people with PTSD, prevalence of most psychiatric disorders was higher in those who met Criterion A2 than in those who only met Criterion A1. Only 3% of those who did not meet A2 went on to suffer persistent traumatic memories. The prevalence of psychiatric disorders was higher in those with A2 and traumatic memories than in those with A2 and no traumatic memories. Limitations: The retrospective nature of the data raises the potential for reporting biases. The data set allowed only one of several possible predictors of posttraumatic adjustment to be examined and only 12-month, and not lifetime, prevalence of psychiatric conditions was available. Conclusions: The experience of powerful emotions at the time of traumatic exposure is common and is associated with increased prevalence not only of PTSD, but also of a range of other psychiatric conditions. Traumatic memories may mediate this association.

Creamer, M., O'Donnell, M., & Pattison, P. (2005). Amnesia, traumatic brain injury, and posttraumatic stress disorder: A methodological enquiry. Behaviour Research and Therapy, 43, 1383-1389. doi:10.1016/j.brat.2004.11.001

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This study explored the relationship between mild traumatic brain injury (MTBI), amnesia, and posttraumatic stress disorder (PTSD). MTBI status and amnesia for the event were assessed in 307 consecutive admissions to a Level 1 Trauma Center. Amnesia did not always occur concurrently with MTBI: 18% of those with MTBI had full recall and over half had partial recall of the event. Just over 10% of participants developed PTSD by 12 months post-injury, with prevalence comparable across MTBI and non-MTBI groups. Non-significant differences in incidence of PTSD were apparent between those with full recall (9%), partial recall (14%) and no recall (7%). These data highlight the fact that PTSD may develop following trauma despite amnesia for the event, and illustrate the importance in both clinical and research settings of carefully examining the extent of amnesia.

Elliott, P., Biddle, D., Hawthorne, G., Forbes, D., & Creamer, M. (2005). Patterns of treatment response in chronic posttraumatic stress disorder: An application of latent variable growth mixture modeling. Journal of Traumatic Stress, 18,303-311. doi:10.1002/jts.20041

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This study attempts to differentiate groups of individuals who exhibit different patterns of recovery following treatment for chronic posttraumatic stress disorder (PTSD) and describes these groups in terms of relevant characteristics at program intake. A sample of 2,219 Vietnam veterans who had completed a 12-week treatment program was followed up at 6, 12, and 24 months post admission using self-report measures. With change in PTSD symptoms over time as the focus, latent growth mixture modeling was used to assign individual veterans to subgroups. A three-group solution provided the best account of the data. Two groups showed moderate and consistent improvement over time although the larger group (n = 1,380) began treatment with more PTSD symptoms and improved more quickly over time. The smallest group (n = 87) showed a substantially different trajectory, with almost no net change in symptom levels over the 24-month period. The groups also varied significantly in terms of their characteristics, with symptom severity and improvements over time reflecting greater comorbidity and younger age. The results have both research and clinical implications.

Elliott, P. & Hawthorne, G. (2005). Imputing missing repeated measures data: How should we proceed? Australian & New Zealand Journal of Psychiatry, 39, 575-582.

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Objective: This paper compares six missing data methods that can be used for carrying out statistical tests on repeated measures data: listwise deletion, last value carried forward (LVCF), standardized score imputation, regression and two versions of a closest match method. Method: The efficacy of each was investigated under a variety of sample sizes and with differing levels of missingness. Randomly selected samples from a dataset (n = 804) were used to compare the methods using t-tests. Efficacy was defined as the closeness of the estimated t-values to the true t-values from the complete dataset. Results: The results suggest a reliable and efficacious basis for imputation method for repeated measures data is to substitute a missing datum with a value from another individual who has the closest scores on the same variable measured at other time-points, or the average value of four individuals who have the closest scores on the same variable at other time-points. The LVCF and standardized score methods performed relatively poorly, which is of concern since these are often recommended. List-wise deletion was also an inefficient missing data method. Conclusions: Researchers should consider using closest match missing data imputation. Since listwise deletion performed poorly, is widely reported and is the default method in many statistical software packages, the findings have broad implications.

Forbes, D., Bennett, N., Biddle, D., Crompton, D., McHugh, T., Elliott, P., & Creamer, M. (2005). Clinical presentations and treatment outcome for peacekeeper veterans with PTSD: Preliminary findings. American Journal of Psychiatry, 162, 2188-2190. doi:10.1176/appi.ajp.162.11.2188

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Objective: Despite evidence of potential psychiatric sequelae following peacekeeping operations, no data have appeared on treatment outcome for this population. This study examined intake and treatment outcome data for a group of peacekeepers with posttraumatic stress disorder (PTSD). Method: Participants were 63 Australian Vietnam veterans and 66 Australian peacekeepers attending specialized PTSD treatment units. Measures of PTSD, depression, anxiety, alcohol use, and anger were obtained at intake and 3-month follow-up. Results: PTSD scores were more severe for peacekeepers than Vietnam veterans at intake, primarily in reexperiencing symptoms. In terms of comorbidity, only anger was higher among peacekeepers. No differences were apparent in treatment outcome. Initial anger predicted change in PTSD severity for peacekeepers. Conclusions: The finding of differences between peacekeepers and Vietnam veterans in anger and reexperiencing symptoms, in addition to the attenuating role of anger on treatment outcome, suggests that modification to standard PTSD treatment models may be warranted for peacekeepers.

Forbes, D., Haslam, N., Williams, B. J., & Creamer, M. (2005). Testing the latent structure of posttraumatic stress disorder: A taxometric study of combat veterans. Journal of Traumatic Stress, 18,647-656. doi:10.1002/jts.20073

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Since the diagnosis of posttraumatic stress disorder (PTSD) first appeared in the psychiatric nomenclature in 1980, considerable debate has revolved around the nature of the condition. Specifically, is PTSD best conceptualized as one end of a continuum of human response to traumatic stress or does it represent a discontinuous latent category? Two taxometric procedures were used to investigate this issue in a random community sample of 692 Australian combat veterans, using structured interview and self-report instruments to assess PTSD symptomatology. Findings favored a dimensional model of PTSD, consistent with previous taxometric work on treatment-seeking samples (A. Ruscio, Ruscio, & Keane, 2002). Implications are drawn for the conceptualization, etiology, and assessment of PTSD.

Hawthorne, G., & Elliott, P. (2005). Imputing cross-sectional missing data: A comparison of common techniques. Australian & New Zealand Journal of Psychiatry, 39, 583-590.

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Objective: Increasing awareness of how missing data affects the analysis of clinical and public health interventions has led to increasing numbers of missing data procedures. There is little advice regarding which procedures should be selected under different circumstances. This paper compares six popular procedures: listwise deletion, item mean substitution, person mean substitution at two levels, regression imputation and hot deck imputation. Method: Using a complete dataset, each was examined under a variety of sample sizes and differing levels of missing data. The criteria were the true t-values for the entire sample. Results: The results suggest important differences. If missing data are from a scale where about half the items are present, hot deck imputation or person mean substitution are best. Because person mean substitution is computationally simpler, similar in its efficiency, advocated by other researchers and more likely to be an option on statistical software packages, it is the method of choice. If the missing data are from a scale where more than half the items are missing, or with single-item measures, then hot deck imputation is recommended. The findings also showed that listwise deletion and item mean substitution performed poorly. Conclusions: Person mean and hot deck imputation are preferred. Since listwise deletion and item mean substitution performed poorly, yet are the most widely reported methods, the findings have broad implications.

Hawthorne, G., & Osborne, R. (2005). Population norms and meaningful differences for the Assessment of Quality of Life (AQoL) measure. Australian and New Zealand Journal of Public Health, 29, 136-142. doi: 10.1111/j.1467-842X.2005.tb00063.x

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Objective: The Assessment of Quality of Life (AQoL) instrument is widely used in Australian health research. To assist researchers interpret and report their work, this paper reports population and health status norms, general minimal important differences (MIDs) and effect sizes. Method: Data from the 1998 South Australian Health Omnibus Survey (n = 3,010 population-based respondents) were analysed by gender, age group and health status. Data from four other longitudinal studies were analysed to obtain estimated MIDs. Results: The mean (SD) AQoL utility score was 0.83 (0.20). Gender and age subgroup differences were apparent; the mean scores for women were consistent until their 50s, when scores declined. Greater variability was observed for males whose scores declined more slowly but consistently between 40–80 years. For both genders, those aged 80+ years had the lowest scores When assessed by health status, those reporting excellent health obtained the highest utility scores; progressive declines were observed with decreasing health status. Effect sizes of 0.13 or greater may reflect important differences between groups A difference in AQoL scores of 0.06 utility points over time suggests a general MID. Conclusions: AQoL population norms, MIDs and effect sizes can be used as reference points for the interpretation of AQoL data. These findings add to the growing evidence that the AQoL is a robust and sensitive measure that has wide applicability. Implications: The availability of population norms will assist researchers using the AQoL to more easily interpret and report their work.

Ikin, J. F., McKenzie, D. P., Creamer, M., McFarlane, A. C., Kelsall, H. L., Glass, D. C., Forbes, A. B., Horsley, K. W. A., Harrex, W. K., & Sim, M. R. (2005). War zone stress without direct combat: The Australian naval experience of the Gulf War. Journal of Traumatic Stress, 18, 193-204. doi:10.1002/jts.20028

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This study examines psychological stressors reported by Australian Navy Gulf War veterans in relation to the 1991 Gulf War and other military service. Using a 44-item questionnaire, veterans reported few direct-combat encounters during the Gulf War; however, they reported many other stressful experiences, including fear of death and perceived threat of attack, more frequently in relation to the Gulf War than other military service. Reporting of stressful experiences was associated with younger age, lower rank, and deployment at the height of the conflict. These experiences may partly explain increased rates of psychological disorders previously demonstrated in this Navy veteran population. Findings highlight the importance of documenting war experiences in close proximity to deployment, and developing war exposure instruments which include naval activities and which reflect stressors other than those related to direct combat.

O'Donnell, M., & Creamer, M. (2005). Letter to the Editor - Drs. O'Donnell and Creamer Reply. American Journal of Psychiatry, 162, 630 - 631. Retrieved from

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To the Editor: We thank Drs. Esposito and Mellman for their interest in our recent study. They raise an important point concerning the potential underdiagnosis of acute stress disorder if persistent dissociation, rather than peritraumatic dissociation, is adopted as the diagnostic criterion. In response to this concern, it is important to consider the rationale underlying of the diagnosis of acute stress disorder. The introduction of acute stress disorder in DSM-IV was an attempt to differentiate individuals experiencing "normal" stress responses from those experiencing abnormal stress responses and to identify individuals vulnerable to developing later PTSD. We would argue that in the context of injury survivors, the use of persistent relative to peritraumatic dissociation is more consistent with the rationale behind the acute stress disorder diagnosis.

O'Donnell, M., Creamer, M., Elliott, P., & Atkin, C. (2005). Health costs following motor vehicle accidents: The role of posttraumatic stress disorder. Journal of Traumatic Stress, 18, 557-561. doi:10.1002/jts.20064

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This pilot study examined whether posttraumatic stress disorder (PTSD) was associated with increased health costs following severe injury caused by motor vehicle accidents. Three groups of injury survivors were created from a larger sample—PTSD only, no-PTSD–low physical function, and no-PTSD–high physical function—and these groups were compared on health cost outcomes at 12 and 24 months. The presence of PTSD was associated with increased total health costs for both Year 1 and Year 2. However, PTSD, per se, did not independently contribute to total health costs. This study suggests that ongoing physical health problems must be considered in order to accurately assess the unique contribution that PTSD makes to health costs in the physically injured population.

O'Donnell, M., Creamer, M., Elliott, P., Atkins, C., & Kossmann, T. (2005). Determinants of quality of life and role-related disability after injury: Impact of acute psychological responses. Journal of Trauma-Injury Infection & Critical Care, 59, 1328-1335. doi:10.1097/01.ta.0000197621.94561.4e

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Background: The factors that determine quality of life (QOL) and disability after traumatic injury are poorly understood. This study identified the unique contributions that characteristics about the injury/hospital admission and acute psychological adjustment make in determining 12-month role-related disability and QOL. Methods: Consecutive admissions (n = 363) to a Level I trauma service were assessed just before discharge and followed up at 12 months. Structural equational modeling was used to examine the relationships between the acute factors and 12-month outcomes. Results: Characteristics of the individual's injuries measured in the acute setting significantly predicted 12-month disability but only indirectly predicted 12-month QOL. An individual's acute psychological response directly predicted both the level of disability and QOL at 12 months. Conclusions: Both characteristics about an individual's injury and acute psychological responses play important roles in determining later QOL and role-related disability outcomes. Trauma care systems must consider both physical and psychological injury to offer effective and comprehensive healthcare management.


Creamer, M., & Forbes, D. (2004). Military Populations. In S. Taylor (Ed.), Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-Behavioral Perspectives (pp. 153-174). New York: Springer.

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The development of mental health problems, particularly posttraumatic stress disorder (PTSD) and related conditions, is a major issue for defence forces around the world, with serious implications for operational performance, readiness to deploy, retention rates, and compensation. Although little adequately controlled treatment research exists with the military population, there is evidence to suggest that cognitive-behavioral treatments for military-related PTSD may be beneficial, albeit perhaps less so than for other populations. This chapter commences with some contextual information designed to assist clinicians in formulating such cases and in understanding some of the complexities relevant to the treatment of PTSD in this population. The chapter goes on to provide a brief review of literature on cognitive-behavioral therapy (CBT) outcome research with military populations, before discussing specific aspects of treatment and foreshadowing future directions.

Creamer, M., & Forbes, D. (2004). Treatment of posttraumatic stress disorder in military and veteran populations. Psychotherapy: Theory, Research, Practice, Training, 41, 388-398.

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While concerns about the psychological effects of war are not new, only recently has systematic attention been paid to such problems among past and present military personnel. There is increasing recognition that mental health has serious implications for operational performance, retention and compensation. Although little controlled research exists with this population, preliminary evidence suggests that psychological treatments for posttraumatic stress disorder may be beneficial, albeit less so than for civilian populations. This article reviews evidence for each of several psychological treatment stages: stabilization and engagement, psychoeducation, symptom management, prolonged exposure, cognitive restructuring, and relapse prevention, with particular reference to the clinical issues raised by military personnel. Possible explanations for reduced treatment effects in this population compared with civilians are discussed.

Creamer, M., O'Donnell, M., & Pattison, P. (2004). The relationship between acute stress disorder and posttraumatic stress disorder in severely injured trauma survivors. Behaviour Research and Therapy, 42, 315-328. doi:10.1016/S0005-7967(03)00141-4

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This prospective longitudinal study was designed to investigate the relationship between acute stress disorder (ASD) and the subsequent development of posttraumatic stress disorder (PTSD) in a population of severely injured hospitalised trauma survivors. Symptoms of ASD were assessed just prior to discharge in 307 consecutive admissions to a Level 1 Trauma Centre, with PTSD assessments completed at 3 and 12 months post-injury. A well-established structured clinical interview was adopted for both assessments. Only 1% of the sample met criteria for an ASD diagnosis (at a mean of 8 days post-injury), while the incidence of PTSD was 9% at 3 months and 10% at 12 months. Although all ASD symptom clusters contributed to the prediction of subsequent PTSD severity, logistic regression indicated that only re-experiencing and arousal predicted a categorical PTSD diagnosis. The dissociative symptoms that form the core of ASD were rarely endorsed and showed high specificity but low sensitivity, resulting in a high proportion of false negative diagnoses. Reducing the number of dissociative symptoms required for a diagnosis ameliorated, but did not resolve, the problem. In this particular population, the low sensitivity of the ASD diagnosis renders it a poor screening test for use in identifying high risk individuals for early intervention and prevention strategies.

Forbes, D., Hawthorne, G., Elliott, P., McHugh, T., Biddle, D., Creamer, M., & Novaco, R. W. (2004). A concise measure of anger in combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 17, 249-256. doi:10.1023/

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There is a need for a brief specific measure of anger for use in assessment of posttraumatic mental health problems. One unpublished short scale is the Dimensions of Anger Reactions (DAR; R. Novaco, 1975). This study examined the psychometric properties of the DAR using intake and 12-month data for 192 Australian Vietnam veterans with combat-related PTSD. Results showed the DAR to be unidimensional, reliable, and sensitive to change over time, and removal of two items improved the scale's properties. The DAR measures anger disposition directed towards others. Assessment of convergent validity indicated that the DAR primarily measures Trait Anger. Results suggest that the DAR is a psychometrically strong measure, potentially useful for the evaluation of anger in PTSD.

Goldney, R., Hawthorne, G., & Fisher, L. (2004). Is the Australian National Survey of Mental Health a reliable guide for health planners? A methodological note on the prevalence of depression. Australian & New Zealand Journal of Psychiatry, 38, 635-638. doi:10.1111/j.1440-1614.2004.01425.x

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Objective: To consider whether the prevalence of depression reported in the Australian National Survey of Mental Health and Wellbeing is a reliable guide for mental health planners. Method: A comparison of methodologies for the detection of depression in the Australian National Survey and a South Australian survey. Results: The Australian National Survey using the Composite International Diagnostic Interview (CIDI) reported considerably less depression than a South Australian survey, which used the mood module of the PRIME-MD 1000 study. Although the PRIME-MD may over-diagnose depression, it is probable that the preclusion criteria of the CIDI result in an under-reporting of depression. Conclusions: It is probable that the Australian National Survey under-estimates the prevalence of depression in the community. This has implications not only in assessing the morbidity and economic burden of depression, but also for the planning of future mental health services.

Hawthorne, G., Hayes, L. M., Kelly, C., & Creamer, M. (2004). Pathways to care in veterans recently compensated for a mental health condition. Canberra: Department of Veterans’ Affairs.

Ikin, J. F., Sim, M. R., Creamer, M., Forbes, A. B., McKenzie, D. P., Kelsall, H. L., . . . Schwarz, H. (2004). War-related psychological stressors and risk of psychological disorders in Australian veterans of the 1991 Gulf War. The British Journal of Psychiatry, 185, 116-126. doi:10.1192/bjp.185.2.116

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Background: Questions remain about the long-term health impacts of the 1991 Gulf War on its veterans. Aims: To measure psychological disorders in Australian Gulf War veterans and a military comparison group and to explore any association with exposure to Gulf War-related psychological stressors. Method: Prevalences of DSM-IV psychological disorders were measured using the Composite International Diagnostic Interview. Gulf War-related psychological stressors were measured using a service experience questionnaire. Results: A total of 31% of male Gulf War veterans and 21% of the comparison group met criteria for a DSM-IV disorder first present in the post-Gulf War period. The veterans were at greater risk of developing post-Gulf War anxiety disorders including post-traumatic stress disorder, affective disorders and substance use disorders. The prevalence of such disorders remained elevated a decade after deployment. The findings can be explained partly as a ‘war-deployment effect’. There was a strong dose-response relationship between psychological disorders and number of reported Gulf War-related psychological stressors. Conclusions: Service in the 1991 Gulf War is associated with increased risk of psychological disorders and these are related to stressful experiences.

McKenzie, D. P., Ikin, J. F., McFarlane, A. C., Creamer, M., Forbes, A. B., Kelsall, H. L., . . . Sim, M. R. (2004). Psychological health of Australian veterans of the 1991 Gulf War: An assessment using the SF-12, GHQ-12 and PCL-S. Psychological Medicine, 34, 1419-1430. doi:10.1017/S0033291704002818

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Background: Elevated rates of psychological morbidity and symptomatology have been widely reported in 1991 Gulf War veterans. The present study used brief self-report instruments to compare the psychological health of Australian Gulf War veterans with that of a randomly sampled military comparison group. Method: The 12-item Short Form Health Survey (SF-12), 12-item General Health Questionnaire (GHQ-12), Posttraumatic Stress Disorder Checklist – Specific (PCL-S) and Military Service Experience (MSE) questionnaire were administered to 1424 male Australian Gulf War veterans and 1548 male Australian Defence Force members who were operational at the time of the Gulf War conflict, but were not deployed there. Results: The Gulf War veterans exhibited poorer psychological health, as measured by the above three instruments, than the comparison group members. For Gulf War veterans, the number of stressful experiences, as measured by the MSE questionnaire, was correlated with scores on the three instruments. SF-12 mental health component summary scores and PCL-S caseness, but not GHQ-12 caseness, differed significantly between Gulf War veterans and comparison group members who had been on at least one active deployment. Conclusions: More than a decade after the 1991 Gulf War, Australian Gulf War veterans are exhibiting higher levels of current (past month) psychological ill-health, as measured using the GHQ-12 and PCL-S, as well as lower mental health status, as measured by the SF-12, than the comparison group. Although not a replacement for formal psychiatric diagnosis, instruments such as those above may aid in the assessment of veterans' psychological health.

O'Donnell, M. (2004). Early intervention for trauma and traumatic loss. Behaviour Change, 21, 283-285. Retrieved from the ProQuest database.

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The recent monograph Early Intervention for Trauma and Traumatic Loss, edited by Brett Litz is essential reading for all clinicians and researchers with an interest in early psychological intervention following traumatic events. In his introduction to this timely book, Litz expertly summarizes the challenges that face mental health professionals working in the field of acute psychological trauma. He emphasizes that while there is consensus regarding the importance of early intervention, the trauma field is currently faced with crucial questions concerning how, with whom and when intervention should take place. To address these concerns, Litz has gathered together an outstanding cast of leading researchers and clinicians who comprehensively address the conceptual, empirical and applied matters pertaining to early intervention following trauma and traumatic loss. The book successfully synthesizes current knowledge to provide recommendations for evidence-based practice.

O'Donnell, M., Creamer, M., & Pattison, P. (2004). Posttraumatic stress disorder and depression following trauma: Understanding comorbidity. American Journal of Psychiatry, 161, 1390-1396. doi:10.1176/appi.ajp.161.8.1390

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Objective: Posttraumatic stress disorder (PTSD) and major depression occur frequently following traumatic exposure, both as separate disorders and concurrently. This raises the question of whether PTSD and depression are separate disorders in the aftermath of trauma or part of a single general traumatic stress construct. This study aimed to explore the relationships among PTSD, depression, and comorbid PTSD/depression following traumatic injury. Method: A group of 363 injury survivors was assessed just prior to discharge from hospital and 3 and 12 months postinjury. Canonical correlations were used to examine the relationship between PTSD and depression symptom severity and a set of predictor variables. Multinomial logistic regression was used to identify whether the diagnostic categories of PTSD, depression, and comorbid PTSD/depression were associated with different groups of predictors. Results: The majority of psychopathology in the aftermath of trauma was best conceptualized as a general traumatic stress factor, suggesting that when PTSD and depression occur together, they reflect a shared vulnerability with similar predictive variables. However, there was also evidence that in a minority of cases at 3 months, depression occurs independently from PTSD and was predicted by a different combination of variables. Conclusions: While PTSD and comorbid PTSD/depression are indistinguishable, the findings support the existence of depression as a separate construct in the acute, but not the chronic, aftermath of trauma.

O'Donnell, M., Creamer, M., Pattison, P., & Atkin, C. (2004). Psychiatric morbidity following injury. American Journal of Psychiatry, 161, 507-514. doi:10.1176/appi.ajp.161.3.507

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Objective: Accurate information regarding the psychopathological consequences of surviving traumatic injury is of great importance for effective health service design and planning. Regrettably, existing studies vary dramatically in reported prevalence rates of psychopathology within this population. The aim of this study was to identify the prevalence of psychiatric morbidity following severe injury by adopting a longitudinal design with close attention to optimizing the research methodology. Method: Consecutive admissions (N = 363) to a level 1 trauma service, excluding those with moderate or severe traumatic brain injury, were assessed at three time periods: just before discharge and 3 and 12 months after their injury. Structured clinical interviews were used to assess anxiety disorders, depressive disorders, and substance use disorders. Results: Posttraumatic stress disorder (PTSD) and major depressive disorder were the most frequent diagnoses at both 3 and 12 months, with 10% of participants meeting diagnostic criteria for each disorder at 12 months. Over 20% of the group met criteria for at least one psychiatric diagnosis 12 months after their injury. Comorbidity was common, with the most frequent being PTSD with major depressive disorder. Conclusions: Psychopathology following injury is a frequent and persistent occurrence. Despite the adoption of a rigorous and potentially conservative methodology, one-fifth of participants met criteria for one or more psychiatric diagnoses 12 months after their injury. These findings have major implications for injury health care providers.


Andrews, G., Creamer, M., Crino, R., Hunt, C., Lampe, L., & Page, A. (2003). The treatment of anxiety disorders: Clinician guides and patient manuals (2nd ed.). Cambridge: Cambridge University Press.

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The Treatment of Anxiety Disorders brought together concise yet thorough theoretical reviews with practical guides to treatment. In this completely revised second edition Gavin Andrews and his co-authors review new developments in the research and treatment of anxiety disorders and provide up-to-date treatment materials. Over half the material in the second edition is new, and there is an entirely new section covering posttraumatic stress disorder. This is a unique and authoritative overview of the recognition and treatment of anxiety disorders, giving Clinician Guides and Patent Treatment Manuals for each. The Clinician Guides describe how to create treatment programs, drawing upon materials and methods that the authors have used successfully in clinical practice for 15 years. The Patient Treatment Manuals provide session-by-session resources for clinician and patient to work through, enabling each patient to better understand and put into effect the strategies of cognitive behaviour therapy.

Coman, G., Evans, B. J., & Burrows, G. D. (2003). Gambling counselling in Australia: Focus on cognitive counselling techniques. British Journal of Guidance & Counselling, 31, 163-175. doi:10.1080/0306988031000102342

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A number of specialised counselling services are now available to assist individuals who experience difficulties as a result of problem gambling behaviour. Clinicians within these services may utilise one or a number of counselling approaches depending on their own preferences and their assessment of the counselling style suitable for use with particular clients. The purpose of this paper is twofold. The first is to describe the range of specialised gambling counselling services now available in Australia. The second aim is to provide clinicians in the field with a range of practical cognitive counselling strategies that may be used to good effect to assist clients to reassess their attitudes towards and thoughts about gambling.

Creamer, M., Bell, R., & Failla, S. (2003). Psychometric properties of the Impact of Event Scale−Revised. Behaviour Research and Therapy, 41, 1489-1496.

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This study investigated the psychometric properties of the Impact of Event Scale—Revised (IES-R) in two samples of male Vietnam veterans: a treatment-seeking sample with a confirmed posttraumatic stress disorder (PTSD) diagnosis (N ¼ 120) and a community sample with varying levels of traumatic stress symptomatology (N ¼ 154). The scale showed high internal consistency (α ¼ 0:96). Confirmatory factor analysis did not provide support for a three-factor solution corresponding to the three subscales of intrusion, avoidance, and hyperarousal. Exploratory factor analysis suggested that either a single, or a two-factor solution (intrusion/hyperarousal and avoidance), provided the best account of the data. However, correlations among the subscales were higher in the community sample than in the treatment sample, suggesting that the IES-R may be sensitive to a more general construct of traumatic stress in those with lower symptom levels. The correlation between the IES-R and the PTSD Checklist was high (0.84) and a cutoff of 1.5 (equivalent to a total score of 33) was found to provide the best diagnostic accuracy.

Creamer, M., & Forbes, D. (2003). The long term effects of traumatic stress. In G. Kearney, M. Creamer, R. Marshall & A. Goyne (Eds.), Military Stress and Performance: The Australian Defence Force Experience. Melbourne: Melbourne University Press.

Creamer, M., & Singh, B. (2003). An integrated approach to veteran and military mental health: An overview of the Australian Centre for Posttraumatic Mental Health. Australasian Psychiatry, 11, 225-227. doi:10.1046/j.1039-8562.2003.00514.x

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Objective: To provide an overview of the development of mental health services for veterans and currently serving military personnel in Australia, with reference to the role of the Australian Centre for Posttraumatic Mental Health (ACPMH). Conclusions: Recent years have seen significant changes in attitudes to the mental health sequelae of military service. The ACPMH, working in collaboration with the Department of Veterans’ Affairs (DVA) and the Australian Defence Force (ADF), as well as with clinicians, researchers, and consumers around Australia, acts as a focus for an integrated approach to veteran and military mental health. The active involvement of both the ADF and DVA in the challenge of mental health provides new opportunities to address psychiatric morbidity at every stage, from recruitment, through deployments and discharge, to veteran status. The ACPMH is in a unique position to facilitate an integrated approach to prevention, intervention, policy development, training, research, and evaluation in order to ensure that Australia remains at the forefront of world's best practice in veteran and military psychiatry. The Centre is also uniquely placed to offer those same services in the field of traumatic stress to the broader community.

Elhai, J. D., Forbes, D., Creamer, M., McHugh, T. F., & Frueh, C. B. (2003). Clinical symptomatology of posttraumatic stress disorder-diagnosed Australian and United States Vietnam combat veterans: An MMPI-2 comparison. The Journal of Nervous and Mental Disease, 191, 458-464. doi:10.1097/01.NMD.0000081614.30361.3D

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The authors compared MMPI-2 scores of 95 Australian and 96 US Vietnam combat veterans diagnosed with posttraumatic stress disorder (PTSD) from structured PTSD clinical interviews. Groups were strikingly similar on the MMPI-2 clinical and validity scales but were different on two content scales, with higher scores on FRS (fears) and BIZ (bizarre mentation) for the US sample. Employment status was included as a factor, because it too discriminated groups, but it did not interact with the veteran group variable to produce scale differences. The roles of employment status and disability payments are considered in accounting for differences in the psychiatric presentations of the groups. Results suggest that American and Australian Vietnam combat PTSD samples are very similar to each other, with implications for the treatment outcome literature.

Evans, B. J., & Coman, G. (2003). Hypnosis with treatment for the anxiety disorders. Australian Journal of Clinical and Experimental Hypnosis, 31, 1-31.

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This paper describes the research and clinical literature relating to the anxiety disorders. It begins with a review of the general nature, classification, and aetiology of anxiety disorders, using DSM-IV criteria. Approaches to the treatment of each anxiety disorder are then discussed, including information-giving, cognitive-behavioural techniques, and pharmacological interventions. The broad range of suggestions for effective management highlights the need for an eclectic approach to client management. The particular relevance of hypnosis as an adjunct to the range of therapeutic approaches suitable for these disorders is then discussed, focusing on the evidence for the higher hypnotisability of at least some types of anxiety disorder sufferers. The clinical material suggests that hypnosis has a range of applications in anxiety disorder management.

Forbes, D., Cooper, J., & Creamer, M. (2003). Posttraumatic Stress: Presentation and management in General Practice. GP Review, 7, 22-23.

Forbes, D., & Creamer, M. (2003). The treatment of chronic posttraumatic stress disorder. In G. Kearney, M. Creamer, R. Marshall & A. Goyne (Eds.), Military Stress and Performance: The Australian Defence Force Experience (pp. 206-220). Melbourne: Melbourne University Press.

Forbes, D., Creamer, M., Allen, N., Elliott, P., McHugh, T., Debenham, P., & Hopwood, M. (2003). MMPI-2 based subgroups of veterans with combat-related PTSD: Differential patterns of symptom change after treatment. Journal of Nervous and Mental Disease, 191, 531-537. doi:10.1097/01.nmd.0000082181.79051.83

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Considerable research has focused on the use of the MMPI to assess posttraumatic stress disorder (PTSD) through identification of mean profile configurations and the development of PTSD subscales. Little work, however, has addressed the heterogeneity of profiles evident in PTSD populations. This study investigated the MMPI-2 profiles of 158 Australian treatment-seeking Vietnam veterans with combat-related PTSD to identify distinct subgroups. Three robust subgroups were identified on the basis of their MMPI-2 profile and compared on PTSD and associated symptomatology. These subgroups consisted of a mild PTSD group with subclinical personality pathology, and two severe PTSD groups that differed in levels of personality disturbance and general psychopathology. Most notably, differences between these latter two groups occurred in the areas of externalization, alienation, and propensity for acting out. These groups were labeled as subclinical, trauma profile, and global. The groups demonstrated significant differences in the patterns of recovery after treatment. The subclinical group demonstrated little change after treatment. In contrast, the trauma profile and global groups both improved, although the trauma profile group demonstrated greater PTSD symptom reduction than the global group

Forbes, D., Creamer, M., Allen, N., McHugh, T., Debenham, P., & Hopwood, M. (2003). MMPI-2 as a predictor of change in PTSD symptom clusters: A further analysis of the Forbes et al. (2002) data set. Journal of Personality Assessment, 81, 183-186. doi:10.1207/S15327752JPA8102_10

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In this study, we reanalyzed the Forbes et al. (2002) data set to examine the Minnesota Multiphasic Personality Inventory (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) as a differential predictor of change across posttraumatic stress disorder symptom clusters following treatment in 141 Vietnam veterans. A series of partial correlation and linear multivariate regression analyses, controlling for initial symptom severity, identified several scales predictive of symptom change. None of the MMPI-2 scales, however, emerged as predictors of change in reexperiencing symptoms. Social alienation and marital distress were the most potent predictors for avoidance symptoms. Anger, alcohol use, and hypomania were the most potent predictors for the hyperarousal symptoms. Of the personality disorders, borderline personality was the strongest predictor of change in the avoidance and hyperarousal clusters. Further replication of the findings of this article and those reported by Forbes et al. (2002) is required.

Forbes, D., Creamer, M., Hawthorne, G., Allen, N., & McHugh, T. (2003). Comorbidity as a predictor of symptom change after treatment in combat-related posttraumatic stress disorder. The Journal of Nervous and Mental Disease, 191, 93-99. doi:10.1097/01.NMD.0000051903.60517.98

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Posttraumatic stress disorder (PTSD) is a difficult condition to treat, and existing studies show considerable variability in outcome. Investigations of factors that influence outcome have the potential to inform alternate treatment approaches to maximize benefits gained from interventions for the disorder. Because PTSD is commonly associated with comorbidity, it is important to investigate the influence of comorbidity on symptom change after treatment. This article examines pretreatment and 9-month follow-up data for 134 Australian Vietnam veterans who attended a treatment program for combat-related PTSD. A series of analyses were conducted to investigate the influence of the comorbid factors of anxiety, depression, anger, and alcohol use on PTSD symptom change after treatment. Analyses identified anger, alcohol, and depression as significant predictors of symptom change over time, independent of the effect of initial PTSD severity. Further analyses indicated that anger at intake was the most potent predictor of symptom change. Further investigations of anger as an influence on symptom change after treatment of combat-related PTSD is recommended.

Forbes, D., Phelps, A., McHugh, A. F., Debenham, P., Hopwood, M., & Creamer, M. (2003). Imagery rehearsal in the treatment of posttraumatic nightmares in Australian veterans with chronic combat-related PTSD: 12-month follow-up data. Journal of Traumatic Stress, 16, 509-513. doi:10.1023/A:1025718830026

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Nightmares are often a distressing symptom for veterans with chronic combat-related posttraumatic stress disorder (PTSD). A psychological treatment that has recently shown considerable promise is Imagery Rehearsal Therapy (IRT). In a pilot study by the current authors, IRT was demonstrated to be effective in the treatment of posttraumatic nightmares in a group of combat veterans up to 3-month posttreatment. This study reports the 12-month follow-up data of the pilot study, examining the longer term outcome of the IRT treatment. Twelve Australian Vietnam veterans with chronic combat-related PTSD were treated with 6 once weekly sessions of imagery rehearsal and assessed using standardised measures of nightmare frequency and intensity, PTSD, depression, anxiety and broader symptomatology at intake, posttreatment, and 3-and 12-month follow-up. Significant improvements in targeted nightmare frequency and intensity were evident to 12-month posttreatment. Similarly, improvements in overall PTSD, depression, anxiety, and broader based symptomatology were also maintained to 12-months. This study provides preliminary evidence that the positive treatment effects of IRT on posttraumatic nightmares, PTSD, and broader symptomatology in males with chronic combat-related PTSD are maintained in the longer term.

Hawthorne, G. (2003). The effect of different methods of collecting data: Mail, telephone and filter data collection issues in utility measurement. Quality of Life Research, 12, 1081-1088. doi:10.1023/A:1026103511161

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When collecting data researchers can interview participants, conduct telephone interviews, or mailout questionnaires. Often mixed methods are used. Whether these methods produce equivalent data is under-researched in the health-related quality of life (HRQoL) field. In addition, the effect of using filter questions has not been researched among HRQoL multi-attribute utility instruments. This study randomly sampled from Melbourne, Australia, and employed a test–retest design to investigate whether mail or telephone interview made any difference to Assessment of Quality of Life (AQoL) instrument utility scores. A filter question AQoL version investigated the effect of filters on scores. There was no significant difference in standard AQoL scores between mail self-completion and telephone interview, regardless of which was administered first. Inclusion of filter questions encouraged respondents to select the best response category thereby screening out minor health conditions. The effect was to increase utility scores by 0.06 or 7%. This effect has not been previously reported in utility instruments and has profound implications for economic evaluations using cost-utility analysis; there are implications for researchers using filter questions in general. In conclusion, researchers should feel confident that utility scores elicited from the standard AQoL through self-completion mail and telephone interview administrations are directly comparable.

Hawthorne, G., Cheok, F., Goldney, R., & Fisher, L. (2003). The excess cost of depression in South Australia: A population-based study. Australian and New Zealand Journal of Psychiatry, 37, 362-373. doi:10.1046/j.1440-1614.2003.01189.x

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Objective: To establish excess costs associated with depression in South Australia, based on the prevalence of depression (from the Primary Care Evaluation of Mental Disorders (PRIME-MD)) and associated excess burden of depression (BoD) costs. Method: Using data from the 1988 South Australian (SA) Health Omnibus Survey, a properly weighted cross-sectional survey of SA adults, we calculated excess costs using two methods. First, we estimated the excess cost based on health service provision and loss of productivity. Second, we estimated it from loss of utility. Results: We found symptoms of major depression in 7% of the SA population, and 11% for other depression. Those with major depression reported worse health status, took more time off work, reported more work performance limitations, made greater use of health services and reported poorer health-related quality-of-life. Using the service provision perspective excess BoD costs were AUD$1921 million per annum. Importantly, this excluded non-health service and other social costs (e.g. family breakdown, legal costs). With the utility approach, using the Assessment of Quality of Life (AQoL) instrument and a very modest life-value (AUD$50 000), the estimate was AUD$2800 million. This reflects a societal perspective of the value of illness, hence there is no particular reason the two different methods should agree as they provide different kinds of information. Both methods suggest estimating the excess BoD from the direct service provision perspective is too restrictive, and that indirect and societal costs ought be taken into account. Conclusions: Despite the high ranking of depression as a major health problem, it is often unrecognized and undertreated. The findings mandate action to explore ways of reducing the BoD borne by individuals, those affected by their illness, the health system and society generally. Given the limited information on the cost-effectiveness of different treatments, it would seem important that resources be allocated to evaluating alternative depression treatments.

Hawthorne, G., Osborne, R. H., & Elliott, P. (2003). Commentary on: A psychometric analysis of the measurement level of the rating scale, time-trade off and standard gamble, by Cook et al. Social Science & Medicine, 56, 895-897. doi:10.1016/S0277-9536(02)00077-1

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The recent paper by Cook et al. (2001) reporting the interval properties of utility weights obtained from time-trade off (TTO), standard gamble (SG) and rating scale (RS) is an important paper as it is one of the first that attempts to subject these methods to direct psychometric scrutiny. It is one of the axioms of utility measurement that one quality adjusted life year (QALY) is equivalent to 1 year of full health, as valued by respondents. This axiom implies two levels of interval property, defined by Richardson as the ‘weak’ and ‘strong’ intervals (Richardson, 1994). The weak interval property is the conventional psychometric property of equal interval increments between units on any given scale, while the strong interval property is where an ‘x’ increment in utility is equivalent to an ‘x’ increment in life length. If QALYs are to correctly reflect utility axioms, then both properties are required. Thus the property of interval measurement is a foundation of economic evaluation employing cost–utility analysis. As we recently reported, based on our validation study of the world's leading utility instruments, it is likely that no multi-attribute utility instrument possesses both the weak and strong interval properties.

Kearney, G., Creamer, M., Marshall, R., & Goyne, A. (Eds.), (2003). Military Stress and Performance: The Australian Defence Force Experience. Melbourne: Melbourne University Press.

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People comprise the backbone of any military force. But what happens when the stress of operations becomes overwhelming and those people fail to cope? Stress can have negative consequences for the individual, the organisation, and even for overall combat effectiveness. The Australian Defence Force has spent many years researching how to maximise individual resilience and performance in the face of extreme stress. For the first time this wealth of knowledge and experience has been brought together in one volume. This work examines the impact of highly stressful events, such as combat and peacekeeping operations, on individual troops and leaders, with a particular focus on factors that build resilience and maximise performance under stress. Managing stress is an important issue not only for the military, but equally for other high-risk professions such as the police and emergency services. This work provides a unique synthesis of a wide range of research, and clinical and personal experience, providing a coherent, integrated approach to the subject. Of particular use to mental health professionals, it will also be of interest to general readers of military and psychology books.

O'Donnell, M., Creamer, M., Bryant, R. A., Schnyder, U., & Shalev, A. (2003). Posttraumatic disorders following injury: An empirical and methodological review. Clinical Psychology Review, 23, 587-603. doi:10.1016/S0272-7358(03)00036-9

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Although there has been a marked increase in research on psychological disorders following physical injury in recent years, there are many discrepancies between the reported findings. This paper reviews the prevalence outcomes of recent studies of the mental health sequelae of physical injury with a focus on posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and depression. The review critically outlines some of the methodological factors that may have contributed to these discrepancies. The phenomenological overlap between organic and psychogenic symptoms, the use of narcotic analgesia, the role of brain injury, the timing and content of assessments, and litigation are discussed in terms of their potential to confound findings with this population. Recommendations are proposed to clarify methodological approaches in this area. It is suggested that a clearer understanding of the psychological effects of physical injury will require the widespread adoption of more rigorous, standardized and transparent methodological procedures.

Osborne, R. H., Hawthorne, G., Lew, E. A., & Gray, L. C. (2003). Quality of Life assessment in the community-dwelling elderly: Validation of the Assessment of Quality of Life (AQoL) Instrument and comparison with the SF-36. Journal of Clinical Epidemiology, 56, 138-147.

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Measurement of Health-Related Quality of Life (HRQoL) of the elderly requires instruments with demonstrated sensitivity, reliability, and validity, particularly with the increasing proportion of older people entering the health care system. This article reports the psychometric properties of the 12-item Assessment of Quality of Life (AQoL) instrument in chronically ill community-dwelling elderly people with an 18-month follow-up. Comparator instruments included the SF-36 and the OARS. Construct validity of the AQoL was strong when examined via factor analysis and convergent and divergent validity against other scales. Receiver Operator Characteristic (ROC) curve analyses and relative efficiency estimates indicated the AQoL is sensitive, responsive, and had the strongest predicative validity for nursing home entry. It was also sensitive to economic prediction over the follow-up. Given these robust psychometric properties and the brevity of the scale, AQoL appears to be a suitable instrument for epidemiologic studies where HRQoL and utility data are required from elderly populations.

Sim, M., Abramson, M., Forbes, A., Glass, D., Ikin, J., . . . Creamer, M., & Fritischi, L. (2003). Australian Gulf War veteran’s health study, 1-3. Melbourne: Monash University Publishing.

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The study investigated the physical and psychological health of 1871 Australian veterans of the 1991 Gulf War compared with a randomly sampled comparison group of Australian Defence Force personnel who were operational at the time of the Gulf War but who did not deploy to that conflict (n = 2924). Recruitment and data collection for the study commenced in August 2000 and concluded in April 2002. Participation included completing a postal questionnaire and undertaking a comprehensive medical assessment at one of ten Health Services Australia clinics located around Australia. Health effects across several body systems were investigated including psychological health, symptoms and medical conditions, factor analysis of reported symptoms, respiratory health, neurological health, chronic fatigue syndrome, laboratory investigations, reproductive health, mortality and cancer. A cohort was established to measure mortality and cancer incidence into the future. The study also investigated whether health effects were associated with medical, chemical and environmental exposures or stressful military service experiences that may have occurred during the Gulf War deployment.

Steindl, S. R., Young, R. M., Creamer, M., & Crompton, D. (2003). Hazardous alcohol use and treatment outcome in male combat veterans with posttraumatic stress disorder. Journal of Traumatic Stress, 16, 27-34. doi:10.1023/A:1022055110238

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The relationship between alcohol problems and posttraumatic stress disorder (PTSD) remains unclear. Six hundred and eight combat veterans diagnosed with PTSD were assessed for PTSD symptoms and alcohol problems prior to group cognitive–behavioral treatment. They were reassessed 3 and 9 months after treatment. Participants were classified into low-risk and hazardous drinkers at each time point. Drinking status at intake did not predict PTSD symptoms at intake or follow-up. However, drinking status was associated with PTSD symptoms when both were assessed at follow-up. PTSD arousal symptoms were the only symptom cluster to differentiate drinking groups.


Andrews, G., Creamer, M., Crino, R., Hunt, C., Lampe, L., & Page, A. (2002). The Treatment of Anxiety Disorders (2nd Ed.) New York: Cambridge University Press.

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This book is about the treatment of anxiety disorders, about helping people with chronic anxiety disorders to become well and stay well. It contains discussions of the nature and treatment of each syndrome, it describes the problems commonly encountered during treatment, and it outlines some management strategies. Of greatest value, it contains Patient Treatment Manuals for the common anxiety disorders. Anxiety disorders are not simply about being too anxious, they are about irrational worry and avoidance of situations that are the focus of this worry. Persons with panic disorder worry that their panic will result in shame; and those with specific phobias fear personal harm. Those with obsessive-compulsive disorder (OCD) worry that their obsessions will come true; those with posttraumatic stress disorder (PTSD) worry that their flashbacks will be real; and those with generalized anxiety disorder (GAD) worry that, despite their worry, disaster will occur. People with chronic anxiety disorders are very sensitive to additional stress, and quickly become anxious or upset. They can develop additional symptoms, including those of other anxiety and depressive disorders.

Biddle, D., Elliott, P., Creamer, M., Forbes, D., & Devilly, G. J. (2002). Self-reported problems: A comparison between PTSD-diagnosed veterans, their spouses, and clinicians. Behaviour Research and Therapy, 40, 853-865. doi:10.1016/S0005-7967(01)00084-5

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This study investigated self-reported problems in a sample of help-seeking Vietnam veterans, comparing the veteran’s own view with clinician and spouse perspectives, with the aim of examining convergence in reports across different informants. Veterans with PTSD (N = 459) were asked to list and rate their five most serious problems. Spouses and treating clinicians completed the same questionnaire in relation to the veteran. Rates of endorsement for each problem area, and levels of agreement between raters, were calculated. Veterans, spouses, and clinicians were all likely to rate anger as a high priority, with veterans also likely to nominate anxiety and depression. Spouses were likely to nominate more observable behavioural problems such as interpersonal difficulties and avoidance, while clinicians were likely to nominate indications of psychopathology, such as anxiety, depression, and intrusive thoughts. Agreement across raters was generally high, although interpretation of agreement levels was complex.

Coman, G., Evans, B. J., & Burrows, G. D. (2002). Group counselling for problem gambling. British Journal of Guidance & Counselling, 30,145-158. doi:10.1080/03069880220128029

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Group counselling offers clients a number of therapeutic benefits and is used widely to provide general emotional support or assist participants to overcome specific personal difficulties in their lives. Group counselling has been used to assist individuals to overcome difficulties associated with problem gambling behaviour; however, there are few reports of this application in the clinical and research literature. This paper provides a brief review of group counselling, including the therapeutic benefits available to participants involved in this modality of counselling delivery. A description of counselling approaches and strategies commonly used in group counselling settings is also provided. The application of group counselling to assist individuals with gambling problems is then described. Both self-help and counsellor-led groups are discussed.

Creamer, M., Forbes, D., Biddle, D., & Elliott, P. (2002). Inpatient versus day hospital treatment for chronic, combat-related posttraumatic stress disorder: A naturalistic comparison. Journal of Nervous and Mental Disease, 190, 183-189. doi:10.1097/00005053-200203000-00007

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This study adopted a quasi-experimental design to compare the treatment outcomes of inpatient-outpatient programs and day hospital programs for chronic, combat-related posttraumatic stress disorder. Data were drawn from 202 Vietnam veterans who had completed treatment at four programs across Australia. The veterans were assessed on a range of psychological and social variables at intake to the programs and followed up at 3 and 9 months after discharge. A significant main effect was found for time, with veterans from both program models demonstrating improvements that were maintained over the 9-month follow-up period. Group by time effects were not significant, which suggests that inpatient-outpatient programs are not more efficacious than the less expensive day hospital alternatives. In line with current mental health policy directions, the current study lends broad support to the recommendation that treatment services for veterans with posttraumatic stress disorder be delivered in the least restrictive environment.

Creamer, M., & O'Donnell, M. (2002). Post-traumatic stress disorder. Current Opinion in Psychiatry, 15, 163-168. Retrieved from the Ovid database.

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This paper provides an overview of recent developments in the literature on post-traumatic stress disorder. Epidemiological studies indicate that approximately 15-25% of individuals experiencing a significant trauma will go on to develop post-traumatic stress disorder, although approximately half will recover without formal intervention. Potential vulnerability factors for post-traumatic stress disorder have been identified, but the mechanisms and complexities require further exploration, with recent research suggesting that prevalence rates and risk factors may differ across populations. Studies of psychological treatment have demonstrated prolonged exposure and cognitive therapies to be equally beneficial, whereas eye movement desensitization and reprocessing may be useful but perhaps less effective in the long term. Pharmacological treatment studies indicate that selective serotonin reuptake inhibitors may be the first choice of drug treatments for post-traumatic stress disorder. Non-selective primary prevention strategies remain contentious, although secondary prevention, in the form of cognitive behavioural interventions for acutely symptomatic survivors, appears to reduce the subsequent development of post-traumatic stress disorder.

Forbes, D., Creamer, M., Allen, N., Elliott, P., McHugh, T., Debenham, P., & Hopwood, M. (2002). The MMPI-2 as a predictor of symptom change following treatment for posttraumatic stress disorder. Journal of Personality Assessment,79, 321-336. doi:10.1207/S15327752JPA7902_13

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This study sought to examine the impact of personality factors on symptom change following treatment for 141 Vietnam veterans with chronic combat-related posttraumatic stress disorder (PTSD) using the Minnesota Multiphasic Personality Inventory-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989). A series of partial correlation and linear multivariate regression analyses identified social alienation, associated with anger and substance use, as the most potent negative predictor of symptom change. Of the scales assessing personality disorder, Borderline Personality was identified as the strongest negative predictor of outcome. Regression analyses examining the most salient scales identified 5 items that contributed 14% of the variance in the prediction of change scores independently of the 21% accounted for by pretreatment PTSD severity.

Herrman, H., Hawthorne, G., & Thomas, R. (2002). Quality of life assessment in people living with psychosis. Social Psychiatry and Psychiatric Epidemiology, 37, 510-518.

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Background: The value of measuring health-related quality of life (HRQoL) among people with persisting psychotic disorders is contentious, despite the call for it in treatment outcome and economic evaluation. Our aim was to investigate the validity of psychotic patients' self-report regarding their HRQoL, using the WHOQOL-Brèf, a generic measure, and the Assessment of Quality of Life (AQoL), a utility instrument. Methods: Community-dwelling patients (N = 173) with a long-standing psychotic disorder who were attending an inner-city mental health service completed the WHOQOL and AQoL, and measures of their symptoms, disability and living conditions. Case managers completed the measures as proxies. Results: Both instruments were acceptable and completed readily. There were significant differences by instrument dimension, with social relationships obtaining the worst scores. Patients' and case managers' scores correlated moderately, with case managers' being lower. When examined by other study instruments, correlations varied according to who completed the instrument, which suggested bias by instrument completer. Patients' scores correlated better with a neutral estimator of health status, suggesting there are areas of patients' lives that clinicians know little about. When examined against population data, patients experienced significantly worse HRQoL. Conclusions: The WHOQOL-Brèf and AQoL are sensitive to the HRQoL status of those with long-term mental illness. We found no evidence to reject patient self-reports. Given systematic differences between patient and case manager reports, patient perspectives should be preferred in evaluation research. Utility measurement and generic HRQoL assessment are feasible and important in this population.


Cobelas, C., Cooper, C., Ell, M., Hawthorne, G., Kennedy, M., & Leach, D. (2001). Quality management and the Emergency Services Enhancement Program. Journal of Quality in Clinical Practice, 21, 80-85. doi:10.1046/j.1440-1762.2001.00408.x

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Since the introduction of the Emergency Services Enhancement Program (ESEP) in Victoria in 1995, improvements have been demonstrated in the indicators relating to Emergency waiting times, ambulance bypass rates and inpatient bed access block. This study focuses on staff perceptions of changes in these indicators, factors perceived to influence performance improvements and the extent to which ESEP is perceived to have contributed to overall patient care. A questionnaire was directed at four focus groups within each of the hospitals participating in ESEP. These were Chief Executive Officers, Emergency Department Directors and Nurse Unit Managers, bed coordinators and personnel from the Emergency Department floor. A total of 101 staff responded. Emergency Department staff were generally accurate in their perceptions of performance changes. The most important factors effecting the changes were perceived to be changes in staff profile, management of patient flow t hrough the department, changes in administrative policies and changes in work practices. Staff perceived that patient care has improved by 10% since 1995 and that ESEP has contributed 8% of this improvement. Staff perceived improvements in ESEP performance indicators consistent with actual changes. The possible mechanisms by which these changes have occurred are presented and discussed. Factor analysis indicated that changes perceived to be most likely to result in improvements were: changes in staff profile (seniority), managing the flow of patients through emergency departments, changing administrative policies, changes in work practices and changes in staff numbers. Improvements in patient care were considered partly due to ESEP. In addition, ESEP has raised awareness of quality management issues.

Creamer, M., Burgess, P., & McFarlane, A. C. (2001). Post-traumatic stress disorder: Findings from the Australian National Survey of Mental Health and Well-Being. Psychological Medicine, 31, 1237-1247. doi:10.1017/S0033291701004287

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Background: We report on the epidemiology of post-traumatic stress disorder (PTSD) in the Australian community, including information on lifetime exposure to trauma, 12-month prevalence of PTSD, socio-demographic correlates and co-morbidity. Methods: Data were obtained from a stratified sample of 10641 participants as part of the Australian National Survey of Mental Health and Well-being. A modified version of the Composite International Diagnostic Interview was used to determine the presence of PTSD, as well as other DSM-IV anxiety, affective and substance use disorders. Results: The estimated 12-month prevalence of PTSD was 1•33%, which is considerably lower than that found in comparable North American studies. Although females were at greater risk than males within the subsample of those who had experienced trauma, the large gender differences noted in some recent epidemiological research were not replicated. Prevalence was elevated among the never married and previously married respondents, and was lower among those aged over 55. For both men and women, rape and sexual molestation were the traumatic events most likely to be associated with PTSD. A high level of Axis 1 co-morbidity was found among those persons with PTSD. Conclusions: PTSD is a highly prevalent disorder in the Australian community and is routinely associated with high rates of anxiety, depression and substance disorders. Future research is needed to investigate rates among other populations outside the North American continent.

Forbes, D., Creamer, M., & Biddle, D. (2001). The validity of the PTSD checklist as a measure of symptomatic change in combat-related PTSD. Behaviour Research and Therapy, 39,977-986. doi:10.1016/S0005-7967(00)00084-X

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Little research to date has examined the ability of self-report measures to assess changes in symptom severity and diagnostic status as a function of treatment. This study investigated the validity of the posttraumatic stress disorder (PTSD) checklist (PCL) as a measure of symptomatic change following programmatic treatment. A sample of 97 Vietnam veterans with combat-related PTSD was assessed using the clinician-administered PTSD scale (CAPS) and the PCL prior to, and 9 months following, participation in a PTSD treatment program. Using the CAPS as the “gold standard” measure of PTSD symptomatology, the PCL demonstrated high diagnostic accuracy pre- and posttreatment. However, significant variations in accuracy were evident in the ability of the PCL to determine the presence and severity of individual symptoms at each time point. In addition, as symptoms improved from pre- to posttreatment, and approached the threshold criteria, the PCL demonstrated reductions in diagnostic accuracy. As a measure of overall symptomatic change, the PCL underrated improvement in comparison to the CAPS. The results supported the use of an overall cut-off score of 50 on the PCL for a diagnosis, and an item score of 3 for symptom criterion, in this population.

Forbes, D., Phelps, A., & McHugh, T. (2001). Treatment of combat-related nightmares using imagery rehearsal: a pilot study. Journal of Traumatic Stress, 14, 433-442. doi:10.1023/A:1011133422340

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Posttraumatic nightmares are a hallmark of PTSD and distinct from general nightmares as they are often repetitive and faithful representations of the traumatic event. This paper presents data from a pilot study that examined the use of Imagery Rehearsal in treating combat-related nightmares of 12 Vietnam veterans with PTSD. Three treatment groups, comprising 4 veterans in each, completed standardised treatment across 6 sessions. Treatment effects were investigated using nightmare diaries and established instruments, including the IES-R, BDI, BAI, and SCL-90-R. The data demonstrate significant reductions in nightmares targeted, and improvements in PTSD and comorbid symptomatology. The paper recommends that, on the basis of the promising preliminary data, a randomised control trial be established to assess imagery ability and attitude toward nightmares.

Hawthorne, G., & Richardson, J. (2001). Measuring the value of program outcomes: A review of multiattribute utility measures. Expert Review of Pharmacoeconomics & Outcomes Research, 1, 215-228. doi:10.1586/14737167.1.2.215

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Selection of a multiattribute utility instrument for economic evaluation is complex due to competition between developers and inflated claims for instrument properties. This review presents multiattribute utility theoretical requirements and assesses leading multiattribute utility instruments against these. Instruments reviewed are: the QWB, HUI3, 15D, EQ5D, AQoL and SF6D. The key finding is that no current instrument satisfies all the requirements for multiattribute utility measurement. We recommend that users should choose instruments most relevant to their circumstances and that studies should include two instruments. Rigorous sensitivity analyses should be conducted and both results reported. Subject to these caveats, preference should be given to instruments best meeting multiattribute utility theoretical requirements, viz., the AQoL or HUI3. However, we recognise that other instruments may perform as well, or even better, under certain circumstances.

Hodgins, G., Creamer, M., & Bell, R. (2001). Risk factors for posttrauma reactions in police officers: A longitudinal study. Journal of Nervous and Mental Disease, 189, 541-547.

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This prospective, longitudinal study investigated risk factors in the development of psychological ill health and posttraumatic stress symptoms in a sample of 223 junior police officers. Participants were assessed using a self-report methodology during training and again 12 months later on a range of personality, trauma exposure, and symptom measures. Risk factors for general psychological ill health at phase 2 of the research were found to comprise mostly stable, pre-existing characteristics such as personality style, gender, and trait dissociation. Conversely, specific traumatic stress symptoms were more heavily influenced by experiences in the intervening 12- months, such as severity of incident exposure and peri-traumatic dissociation. The implications for differential intervention are discussed.

Kearney , G., Creamer, M., Marshall, R., & Goyne, A. (Eds.), (2001). The Management of Stress in the Australian Defence Force: Human factors, families, and the welfare of military personnel away from the combat zone. Canberra: Defence Publishing Service.

O’Donnell, M. (2001). Getting over it: coping with serious injury. A guide for injury survivors and their families. Melbourne: Australian Centre for Posttraumatic Mental Health.


Creamer, M. (2000). Posttraumatic stress disorder following violence and aggression. Aggression and Violent Behavior, 5,431-449. ACPMH articlesdoi:10.1016/S1359-1789(98)00017-2

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Posttraumatic stress disorder (PTSD) has been the focus of considerable attention, and some controversy, since it was formally recognized in 1980. The disorder appears to be relatively common among survivors of violent crime, particularly rape victims. In its more serious forms, it is a chronic and disabling psychiatric disorder associated with high co-morbidity and impairment of functioning. This article provides a review of PTSD following violence and aggression, beginning with a description of the clinical characteristics and diagnostic criteria. A multifaceted approach to assessment is described, designed to improve diagnostic accuracy, with particular reference to psycho-legal settings. Psychological treatment for PTSD is discussed in the context of the available outcome literature. Finally, the issue of prevention and early intervention in traumatic stress is addressed


Creamer, M., & McFarlane, A. C. (1999). Posttraumatic stress disorder. Australian Prescriber, 22, 32-36. Retrieved from

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Post-traumatic stress disorder (PTSD) has been the focus of considerable attention, and some controversy, since it was formally recognised in 1980. It is a common anxiety disorder in Australia with a 12-month prevalence of 3.3%. In its more serious forms, it is a chronic and disabling psychiatric disorder associated with high comorbidity and impairment of functioning. The possible existence of the disorder can be ascertained with a few simple questions. Several strategies may be adopted by primary health care providers to assist patients with both acute and chronic forms of the disorder. Referral for intensive treatment should be made in more severe cases.

Creamer, M., Morris, P., Biddle, D., & Elliott, P. (1999). Treatment outcome in Australian veterans with combat-related posttraumatic stress disorder: A cause for cautious optimism? Journal of Traumatic Stress, 12, 545-558. doi:10.1023/A:1024702931164

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This study investigated treatment outcome in combat-related posttraumatic stress disorder (PTSD). Participants were 419 Australian Vietnam veterans who completed a 12-week hospital-based program. A comprehensive protocol assessed PTSD, comorbidity, and social functioning at admission and at 3 and 9 months posttreatment. Overall, the group showed significant improvements in core PTSD symptoms, anxiety, depression, alcohol abuse, social dysfunction, and anger. Changes occurred mostly between admission and 3 months posttreatment, with gains maintained at 9 months. Ratings by patients and their partners indicated perceived improvement and strong satisfaction with treatment. Nevertheless, treatment gains were variable and, for most veterans, considerable pathology remained following the programs. The current study provides grounds for cautious optimism in the treatment of combat-related PTSD.

Forbes, D., Creamer, M., & McHugh, T. (1999). MMPI-2 data for Australian Vietnam veterans with combat-related PTSD. Journal of Traumatic Stress, 12, 371-378.  doi:10.1023/A:1024740929231

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Considerable attention has been devoted to the MMPI in the assessment of combat-related PTSD. To date, published data have focused almost exclusively on American Vietnam veterans. This study investigated MMPI-2 profiles of 100 Australian Vietnam veterans admitted to an intensive PTSD treatment program. Comparisons with United States (U.S.) data suggested strong similarities between the American and Australian populations in terms of F-scale elevations and typical 3-point code types (8-7-2). However, the American samples showed relatively higher elevations of Scales 4 and 6, suggesting social alienation and a tendency to externalize, while a subgroup of Australian veterans showed a greater propensity for somatization (Scale 1). The results provide overall support for the generalizability of American MMPI data to an alternative cultural group of combat veterans


Coman, G., & Burrows, G. D. (1998). Your Guide to Responsible Gambling. Richmond, Vic: Options Project; Mental Health Foundation of Victoria.

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The Options Project promoting mental health and human rights in the community auspiced by: The Mental Health Foundation of Victoria and Liberty Victoria funded by the Victorian Health Promotion Foundation.

Creamer, M., & Manning, C. (1998). Acute stress disorder following an industrial accident. Australian Psychologist, 33, 125-129. doi:10.1080/00050069808257393

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Acute stress disorder (ASD) was introduced as a new diagnostic category in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994). Despite some controversy regarding the symptom criteria of ASD, little empirical data have yet been published on this new category. The current research was designed to investigate the prevalence, course, and phenomenology of this disorder following an industrial accident. Acute stress reactions were investigated in 47 males following an explosion in an oil refinery. Assessments were conducted by experienced clinicians at two points in time (2 weeks and 3 months posttrauma). Measures included a standardised structured interview (Sl-PTSD) and three self-report scales assessing traumatic stress (IES), anxiety (BAI), and depression (BDI). Six per cent of the sample met criteria for ASD at 2 weeks posttrauma. This lower-than-expected prevalence appeared to be a function of low levels of avoidance behaviour. Those people present at the time of the explosion scored higher than those who were not present on clinician-rated measures of symptom severity, but not on self-report measures. A significant reduction in symptoms occurred between 2 weeks and 3 months posttrauma, and no subjects went on to develop PTSD. While the current study largely supports the diagnostic criteria for ASD, considerable research remains to be done on this new category of traumatic stress reaction. In particular, the impact of early interventions in ameliorating the symptoms of acute stress disorder and preventing the progression to PTSD should be the focus of future research.


Creamer, M., & Kelly, J. (1997). Information processing in combat veterans: The role of avoidance. In
J. D. Read & D. Lindsay (Eds.), Recollections Of Trauma: Scientific Evidence And Clinical Practice (pp. 441-447). NATO Advanced Institute series (Life Sciences, Vol. 291). New York: Plenum Press.

Morris, P., & Creamer, M. (1997). Cormorbid posttraumatic stress disorder and depressive illness. Depression Awareness Journal, 2, 3-4.


Creamer, M. (1996). Posttraumatic stress disorder: nature and treatment. Psychotherapy In Australia, 3, 8-15. Retrieved from documentSummary;dn=551896643500780;res=IELHEA

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While human beings appear to have known about psychological response to trauma for many thousands of years, it was not until early this century that the condition became the focus of significant interest. According to Trimble (1981), wartime experiences, notably the American Civil War and the First World War, prompted physicians to speculate on the nature and cause of post-trauma reactions. The condition was thought initially to be a result of physical damage to the brain caused by explosions on the battlefield and thus the term “shell shock” was coined. It was not until later that the psychological basis of the disorder was widely accepted and clinicians began to recognise that terms such as “shell shock”, “war neurosis” and “combat fatigue” all referred to the same phenomenon. Gradually, it was acknowledged also that these disorders were essentially no different from traumatic stress reactions seen in civilians following non-military traumas such as transport accidents, fires and natural disasters (Trimble, 1985).

Creamer, M. (1996). The prevention of posttraumatic stress. In P. Cotton & H. J. Jackson (Eds.), Early intervention and prevention in mental health (pp. 229-246). Melbourne: Australian Psychological Society.

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The purpose of this chapter is to discuss early-intervention strategies for survivors of traumatic incidents, with the aim of reducing the severity and prevalence of any subsequent psychopathology. The unpredictable nature of trauma is such that little time is available for planning interventions; it is hoped that this chapter contains sufficient detail to assist mental health professionals in the provision of early interventions following a range of traumatic incidents and disasters.

Creamer, M. (1996).The nature and treatment of posttraumatic reactions. In B. Hawyward & A. Lowe (Eds.), Applied Aviation Psychology: Achievement, Change and Challenge (pp. 299-307). Aldershot: Ashgate Publishing.

Creamer, M. (1996). Treatment interventions for posttraumatic stress. In D. Paton & N. Long (Eds.), Psychological Aspects of Disaster: Impact, Coping, And Intervention (pp. 177-192). Palmerston: Dunmore Press.

Creamer, M., Jackson, A., & Ball, A. (1996). A profile of help-seeking Australian Veterans. Journal of Traumatic Stress, 9, 569-575. doi:10.1002/jts.2490090312

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While considerable information is available regarding American Vietnam veterans, surprisingly little has appeared concerning veterans of other nationalities who served in the Vietnam War. This paper provides a preliminary profile of help-seeking Australian veterans in order to afford a comparison with the available American data. Collected in the context of a review of the Vietnam Veterans Counselling Service (VVCS), demographic data suggest that the client population is similar in many ways to that of the American posttraumatic stress disorder (PTSD) Clinical Teams. Problems commonly reported by clients of VVCS included posttraumatic stress, relationship difficulties, anxiety, depression, and problems with pensions and benefits. A postal survey of a sub-sample of current clients revealed a mean score on the Combat Exposure Scale of 19.27 and a mean score on the Mississipi Scale for PTSD of 118.43. Again, these findings are broadly comparable with those of American help-seeking veterans.


Creamer, M., Foran, J., & Bell, R. (1995). The Beck Anxiety Inventory in a non-clinical sample. Behaviour Research and Theory, 33, 477-485. doi:10.1016/0005-7967(94)00082-U

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This study investigated the properties of the Beck Anxiety Inventory (BAI) in a sample of 326 undergraduate students. Scores on the BAI were compared with data from the State-Trait Anxiety Inventory and the Beck Depression Inventory. The BAI demonstrated good psychometric properties, with a high level of internal consistency. Relatively low test-retest correlations, in comparison with the STAI-Trait, suggested that the scale was functioning as a state measure. Factor analysis revealed a unifactorial solution on the first administration (a time of low stress), but a two factor solution similar to that proposed initially by Beck, Epstein, Brown and Steer (Journal of Consulting and Clinical Psychology, 56, 893-897, 1988) at the second administration (hypothesised to be a time of increased stress). Thus, the two factor structure of the BAI (characterised by physical and cognitive symptoms) may not be distinguishable in the normal population in the absence of an external stressor. An apparent strength of the BAI was its superior ability in differentiating anxiety from depression when compared with the STAI. A combined factor analysis of the BAI and STAI-State revealed two distinct factors, suggesting that the scales may actually be measuring separate, although not necessarily independent, constructs. It is suggested that the high discriminate validity demonstrated by the BAI may have been achieved at the expense of some construct validity.


Creamer, M. (1994). Community recovery from trauma. In Watts, R. & Horne, D. J. (Eds.) Coping with trauma: The victim and the helper (pp. 37-51). Bowen Hills: Australian Academic Press.

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It has become common practice, both in Australia and overseas, to use community-based interventions following disasters of both human and natural origin (Lystad, 1988; Raphael, 1986). The purpose of this chapter is to discuss the fundamental issues to be considered in the implementation of a community-based mental health recovery program following disaster. These general principles apply not only to geographically defined neighbourhoods (villages, towns, and cities), but also to smaller units of the population, such as workplaces. The major points of this chapter are illustrated by reference to a recovery program implemented following a multiple shooting in a city office block. The unique nature of disasters demands that interventions are tailored to the specific needs of the affected community. While there are, of course, guiding principles, the challenge is frequently one of adapting interventions to the unique characteristics of the particular disaster. A central theme, however, is that recovery from trauma is an active process; mental health recovery programs should aim to involve people from all levels of the community.

Forbes, D., Creamer, M., & Rycroft, P. (1994). Eye movement desensitization and reprocessing in posttraumatic stress disorder: A pilot study using assessment measures. Journal of Behavior Therapy and Experimental Psychiatry, 25, 113-120. doi:10.1016/0005-7916(94)90003-5

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Spectacular claims have been made regarding the efficacy of eye movement desensitization and reprocessing (EMDR) in the treatment of posttraumatic stress disorder (PTSD), but almost entirely on the basis of patients’ reports and without objective criteria. This study reports on the treatment of eight patients with a diagnosis of PTSD who received EMDR treatment over four sessions. Assessment measures included two structured interviews, three self-report inventories, and the electromyogram (EMG). Assessments were conducted pre and posttreatment, and at 3-month follow-up. Despite some residual pathology at posttreatment and follow-up, significant improvements were obtained on all measures and across all PTSD symptom clusters. Compared with other treatments of PTSD, change was achieved in far fewer sessions.