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DHCC Clinical and Health Services Research


Background

DHCC’s deployment-related clinical research is driven largely by extramural funding. These research efforts strive to support the clinical, scientific, and policy goals of the Center. DHCC has successfully completed and continues to be engaged in a wide range of projects designed to scientifically evaluate health services for post-deployment medical concerns. Current projects are competitively funded by the National Institute of Mental Health, the Department of Defense, the Department of Veterans Affairs, the Centers for Disease Control and Prevention, and the National Institute on Aging.

The research team consists of personnel with expertise in the social and behavioral sciences, general medicine, psychiatry, epidemiology, statistics, demography, risk communication, as well as administrative personnel. The team serves a number of functions in support of the DHCC mission to improve post-deployment care, to include:

  • Clinical, epidemiological, and health services research
  • Clinical practice guideline implementation
  • Program evaluation
  • Development of surveys and mental health screening tools
  • Database creation and management
  • Research consultation to clinicians
  • Manuscript and report preparation

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    Projects Awaiting Approval In Fy 2010

    • STEPS-UP: Stepped Enhancement of PTSD Services Using Primary Care: A Randomized Effectiveness Trial

      Approximately 1/5th of returning service members from the wars in Iraq and Afghanistan have been identified as having symptoms of PTSD. Many service members with these symptoms are referred for specialty mental healthcare, but less than half actually follow through with the referral. However, 90-95% of service members visit their military primary care provider annually, and thus the primary care is an ideal platform to manage PTSD. Empirically tested strategies for depression and other mental disorders can fill the urgent need to improve access, quality, and outcomes of PTSD care in the military health system. These strategies include care manager coordination (connecting patient, provider, and specialist), collaborative care (negotiated patient-provider problem definition, monitoring of status and treatment response, self-management support, telehealth sustained follow-up), and stepped care (logical, patient-centered and guideline-concordant treatment sequencing). These strategies are unstudied in the military health system and virtually unstudied for PTSD.

      STepped Enhancement of PTSD Services Using Primary care (STEPS UP) is telephone care management with a centralized stepped and preference-based management package that offers service members with PTSD their preference of the following evidence-based interventions: 1) Web based treatment for PTSD; 2) telephonic cognitive behavioral treatment; 3) pharmacotherapy administered by within a primary care setting and in telephone consultation with a psychiatrist; and 4) in-person treatment by a psychologist or psychiatrist. The effectiveness of the STEPS UP package will be compared against optimized usual care at six Army posts. At these posts, The RESPECT-Mil collaborative care management program for depression and PTSD already exists as the standard of care. Although similar in some ways, STEPS UP is poised to offer significant enhancements to the optimized usual care by way of the stepped and evidence-based non-pharmacological interventions and centralized telephone care management.

      The STEPS UP team plans to randomize 1500 active duty OIF/OEF returnees with PTSD to either STEPS UP or optimized usual care. Research participants will be assessed five times over a 1-year period. We hypothesize that STEPS UP will improve (1) PTSD symptom severity (primary hypothesis) and (2) depression, anxiety, and somatic symptom severity, alcohol use, mental health functioning, and work functioning. We further hypothesize that (3) STEPS UP will be deemed a cost-effective PTSD management package and (4) patients, their family members, and clinicians will find the approach acceptable, effective, and a satisfying way to deliver and receive PTSD care.

      This $14.6 million project is funded through the Department of Defense Deployment Related Medical Research Program. The award was made to the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., RAND Corporation, and RTI International. Charles C. Engel, MD, MPH, COL, MC, USA is the initiating PI and partnering PI’s include Robert M. Bray, PhD from RTI International and Lisa Jaycox, PhD from RAND Corporation. Other study Co-Investigators and Collaborators are from the University of Washington, VA Boston Healthcare System, 3CM, RAND Corporation, RTI International, the Deployment Health Clinical Center, and the Uniformed Services University of the Health Sciences.

    • A Randomized Trial of Telephonic Psychotherapy for Combat-Related Posttraumatic Stress Disorder

      Empirical studies suggest that up to 17% of Operation Iraqi Freedom (OIF) or Enduring Freedom (OEF) Veterans report clinically significant levels of Posttraumatic Stress Disorder (PTSD) symptoms and associated impairment (Hoge et al., 2004; 2006). Although efficacious, evidence-based early interventions are available, few soldiers receive any formal mental health treatment in the months following their return from the war zone. In fact, military personnel are often reluctant to seek mental health care due to a fear of career stigma, mistrust of mental health providers, and lack of confidence in psychiatric treatments (Hoge et al., 2006). Given these barriers, telephone based mental health interventions are becoming a popular health delivery mechanism. In response to the need for empirically based PTSD treatments that provide high fidelity, intensive, low stigma, and low burden psychotherapy for military personnel, the Deployment Clinical Health Center (DHCC), and its partner the VA National Center for PTSD in Boston propose to develop and evaluate Delivery of Self Training and Education for Stressful Situations - Telephone (DESTRESS-T). DESTRESS-T is a six week telephone based structured psychotherapy intervention for war-zone exposed soldiers diagnosed with PTSD. DESTRESS-T will also include a telephone care management protocol to monitor and support treatment adherence. We believe that telephone based interventions targeting the quality and outcomes of PTSD care are critical to improving the military’s functioning, readiness, and resilience. By creating sustainable, practical solutions that can improve PTSD care within the military mental health system, pathways to recovery for war-related PTSD become reality. This $1.3 million study was recently funded by the DoD Defense Medical Research and Development Program (DMRDP) under an Applied Research and Advanced Technology Development award.

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      Active Projects

    • DESTRESS-PC: A Brief Online Self-Management Tool for PTSD

      The broad objective of this study is to improve primary care mental health services for military personnel and veterans with posttraumatic stress disorder related to war-zone trauma. The research is also relevant to providing early, high quality access to low-stigma mental health services for victims of other traumatic events, including terrorist attacks and natural or man-made disasters. The study hypothesis is that a brief Internet-based online self-management tool for posttraumatic stress disorder, DESTRESS-PC, based on empirically valid cognitive-behavioral therapy strategies, will improve posttraumatic stress disorder symptoms, related functional status, and attitudes regarding mental health treatment among veterans and military personnel with posttraumatic stress disorder who are seeking primary healthcare after service in Operations Iraqi Freedom, Enduring Freedom, Desert Storm, and Desert Shield. The DESTRESS-PC intervention will be delivered to participants via the Internet, with participants logging on to a secure Web site hosted on private (i.e., nonmilitary) servers. Participants' progression through the intervention will be monitored by a DESTRESS Nurse, and participants will have scheduled and as-needed access to their nurse via e-mail and telephone. DESTRESS Nurses will be supervised by mental health professionals and will have contact with participants' primary care providers. As of FY 2009, recruitment is underway at all three study sites (two VA, and one DoD). Thus far, 95 combat veterans meeting preliminary study criteria have been consented, and 64 meeting full eligibility criteria have been randomized to study condition, putting us half-way toward our recruitment goal.

    • Prospective Study of Functional Status in Veterans at Risk for Unexplained Illness

      DHCC is collaborating with the East Orange New Jersey VA War-Related Illness and Injury Study Center on a prospective longitudinal study to understand whether stress response, ability to cope with stress, or personality affect the likelihood of developing medically unexplained symptoms after service in OIF/OEF. Measures are both self-reported and physiological and participating military personnel are tested during their pre-deployment (phase I) and post-deployment (phase II) processing. Participants also complete phone interviews and mailed surveys 3 months and a year after return from deployment (phases III and IV). The study is expected to help identify individuals at risk for developing medically unexplained symptoms after future deployments and guide future work on intervention strategies. Phase I data collection was completed in the fall of 2008. To date, 419 service members have completed phase II, 185 have completed phase III and 173 have finished phase IV.

    • A Study of Prazosin as an Augmentation Treatment for the Relief of Combat Stress-Induced Nightmares and Sleep Disturbance

      Trauma-related nightmares and sleep disturbances following exposure to life-threatening events are persistent symptoms that often cause significant impairment in social and occupational functioning. Preliminary research shows that the medication prazosin ameliorates both nightmares and sleep disturbances in veterans from Vietnam and OEF/OIF. We expect that results from this 4-year, double-blind, placebo-controlled, 15-week clinical trial will support the use of prazosin treatment of combat-related nightmares in OEF/OIF returnees. Because many service members with combat-stress related nightmares are being prescribed other medications first, with limited success, we believe that augmenting their treatment to include prazosin will decrease nightmares and improve sleep to a greater degree than if they remained on the other medication alone. Funded by the Department of Defense, this multi-site study is a collaboration among DHCC researchers and researchers from VA Puget Sound Healthcare System / University of Washington School of Medicine, Madigan Army Medical Center, and other researchers from Walter Reed Army Medical Center. The protocol has been approved by the IRB and researchers are actively recruiting participants for this study.

    • A Single-Item PTSD Screener (SIPS) for Primary Care

      Posttraumatic stress disorder (PTSD) among recently deployed Soldiers is a critical psychiatric problem facing the Department of Defense. Research indicates that while most mental healthcare is delivered in primary care, primary care providers often do not recognize symptoms of PTSD. The goal of this study was to develop and test a simple screening tool for use in a primary care setting for rapid identification of patients with symptoms of PTSD. The Single-Item PTSD Screener (SIPS) for Primary Care was being compared to a longer, existing PTSD screening tool. Responses to the SIPS were evaluated against the criterion, PTSD diagnosis, determined by a diagnostic interview. Sensitivity, specificity and likelihood ratios of the SIPS are being evaluated. Of the 3258 primary care patients at three DoD primary care clinics who completed the SIPS, 213 received a diagnostic interview. In patients with "Bothered a Little" responses the, sensitivity and specificity were 0.76 and 0.79, respectively. Positive endorsement of the SIPS was indicative of PTSD status. The SIPS is expected to improve the primary care provider's ability to recognize PTSD symptomatology in their patients and to facilitate early intervention to reduce the burden of this disorder within the DoD. A manuscript describing study results was published in 2008 in the General Hospital Psychiatry. Efforts are now underway to evaluate a refined version of the question to see if we can improve upon the operating characteristics. Gore K., Engel C. C., Freed M. C., Liu X., Armstrong III, D. Test of a single-item posttraumatic stress disorder screener in a military primary care setting. General Hospital Psychiatry, 2008 Sep-Oct;30(5):391

    • Acupuncture for the Treatment of Trauma Survivors

      Acupuncture, with few known side effects, has the potential to be an effective alternative treatment for posttraumatic stress disorder or an adjunct to other proven therapies. Acupuncture has been shown to improve well-being and to successfully treat stress, anxiety and pain conditions. The objective of this 12-week randomized controlled trial of active duty military personnel with PTSD is to determine the effectiveness of acupuncture for alleviating the symptoms associated with PTSD. The study received Congressional funding and the study team consists of personnel from DHCC, the Uniformed Services University of the Health Sciences, the Samueli Institute, and the University of Western Ontario. Two-hundred forty-five patients were screened, 75 were enrolled after meeting preliminary criteria, 55 were randomized, and 43 (78%) provided complete follow-up data. Primary analyses indicate that compared to Optimized Usual Care (UC), Acupuncture (ACU) was associated with a significantly greater decrease in PTSD symptoms, which was maintained through the 12-week follow-up (treatment X time, F (3, 128) = 10.92, p < .001); mean pcl decreases were 19.4 (±11.7) at end treatment and 19.8 (±13.6) at 12-week follow-up in acu vs. 4.0 (±12.3) at end treatment and 9.7 (±13.1) at 12-week follow-up in uc. similar patterns of improvement were seen with symptoms of depression and psychological functioning. results of this study are expected to be published within the next year.

    • Veteran Status, Health and Mortality in Older Americans


    • This study was funded by the National Institute on Aging and extended by Walter Reed Army Medical Center and the Uniformed Service University of the Health Sciences. Using data from the Survey of Asset and Health Dynamics among the Oldest-Old (AHEAD) and the Survey of Health and Retirement Study (HRS), the study employed such statistical techniques as the structural hazard rate model, the multinomial logit regression, mathematical simulation, and mixed models with repeated measures. Project findings suggest that a mortality crossover between veterans and non-veterans that probably occurs just before age 70. Since this crossover does not tend to happen abruptly, the two mortality schedules might experience a long-standing process of convergence. At age 70, variations in physical health and mental disorders account for approximately 61% of the total effect of veteran status on the mortality of older Americans. At age 75, the portion of such indirect effects falls to 42%. At age 85, only one-fifth of the excess mortality among veterans is captured by physical health conditions and mental disorders. However, veteran status does not have significant influences on transitions in functional status among those functionally independent at baseline. Application of different statistical models leads to distinct variations in the predicted values of health transition scores at a series of time points, providing evidence that without considering the selection bias in the process of health transitions, estimation of the effects on health transitions of older persons can be severely biased. At present, the study team is attempting to construct an unbiased longitudinal model on health transitions in older persons using updated data of health dynamics, and a newly developed longitudinal model was presented at the International Network on Health Expectancy (REVES) 2009 meeting, held in Copenhagen, Denmark. To date, three manuscripts have been published in scientific journals and four additional papers are currently under review or in preparation. The project will continue into FY 2010.
      Liu X, Engel C Jr, Kang H, Armstrong DW. Veterans and functional status transitions in older Americans. Military Medicine 2006; 171(10):943-9
      Liu, X., Engel, C.C., Kang, H., & Gore, K.(2010). Reducing Selection Bias in Analyzing Longitudinal Health Data with High Mortality Rates. Journal of Modern Applied Statistical Methods, in press.

    • Vitamin D Levels and their Correlation to Pain, Fatigue, Anxiety, and Other Co-morbidities in Specialized Care Program Service Members Seen at the Deployment Health Clinical Center

      Acquired primarily through sun-light exposure or by fortified milk consumption, Vitamin D has been long recognized as essential to bone health. As much as 5-30% of the U.S. population age 19 to 50 may have deficiency depending on a number of factors. A study in military recruits from Finland found that 5% were deficient in the summertime. Those deficient were more than three times as likely to have a stress fracture over the next 90 days, when compared to those who had adequate vitamin D stores. Vitamin D deficiency in the general population has also been linked to chronic musculoskeletal pain as well as anxiety in patients with fibromyalgia. The purpose of this study is to retrospectively analyze the diagnoses of Specialized Care Program patients, primarily OIF/OEF veterans, to see if there is a correlation with their vitamin D levels, as determined during their routine care. Specifically, the focus will be on chronic musculoskeletal pain, fatigue, and anxiety. However, other illnesses such as bone-related illnesses will be looked at as well. The degree of vitamin D deficiency present in this segment of the OIF/OEF veteran military population will be determined. By the end of FY 2009, preliminary results on a small study cohort revealed that 30 of 61 OIF/OEF veterans who had chronic pain also had vitamin D deficiency. Since half of these patients suffered from deployment-related bone or joint injuries, the recommendation is made to consider screening OIF/OEF veterans with chronic musculoskeletal pain for vitamin D deficiency, so that optimum bone health can be achieved through proper supplementation. At present, data abstraction for a total of 99 OIF/OEF veterans has been completed and data analysis is underway.
      Roesel T. (Letter to Editor) “Does the central nervous system play a role in vitamin D deficiency related chronic pain?” Pain, 2009 Jan;141(1-2):
      Roesel T. (2009). Does vitamin D potentiate gabapentin and pregabalin efficacy in vitamin D deficiency related chronic musculoskeletal pain? Journal of Bone and Mineral Research, 24 (Suppl 1)

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    Completed Projects

    • Preference-Weighed Health Status Associated with Posttraumatic Stress Disorder in Veterans: A Policy-Friendly Assessment of Illness Severity

      Extant symptom- and generic quality of life-focused measures used to assess the disease burden of PTSD are useful at the clinical level because they describe functioning. However, these measures are not useful at the policy level because they fail to assess how people value different health problems (e.g., what domains of health-related quality of life do people prefer most versus least). In contrast, preference-weighted health status measures can capture this information and fill in the blanks for healthcare policy makers. Policy makers can then allocate resources based in part on how well interventions can maximize the quality of life domains that society values the most. We calculated preference-weighted health status scores (PWHSS) for 840 veterans receiving VA primary care services. PWHSS scores range from 0 (death) to 1 (perfect health). As part of a different study, veterans were assessed for health-related quality of life, mental health disorders, and medical ICD-9 diagnoses. We created several groups of veterans based on their diagnoses. We then weighted their responses on the health-related quality of life measure with previously published preferences for the domains of health-related quality of life and created the PWHSS. We then compared the PWHSS among veterans diagnosed with PTSD and other disorders. Lower PWHSS significantly correlated with increased PTSD severity and number and type of mental health disorders. In other words, the analysis suggests that society at large sees the health status associated with a diagnosis of PTSD as less desirable than the health status of veterans not diagnosed with this disorder. A manuscript summarizing the study findings was published in the journal, Psychiatric Services, in 2009.
      Freed M. C., Yeager D., Liu X., Gore K. L., Engel C. C., Magruder K. M. (2009). Preference-weighted health status of veterans with posttraumatic stress disorder (PTSD): Toward creating an outcome for cost-effectiveness analysis using clinical data. Psychiatric Services, 60(9), 1230-1238.

    • A Randomized Clinical Trial of Health-e VOICE-An Optimized Clinical Practice Guideline Training Tool

      Many patients have concerns related to environmental, occupational, or other potential toxic exposures. Currently, there is little known about how to improve health risk communication in clinical settings. DHCC collaborated with the Centers for Disease Control and Prevention, National Center for Environmental Health and consultants to develop and evaluate an interactive, Web-based distance-learning tool called Health-e VOICE. Comprised of six electronic patient-care vignettes, it was designed to improve Department of Defense (DoD) healthcare providers' effectiveness when communicating with veterans, military personnel, and family members about their deployment-related health concerns. The objective of this trial was to evaluate the impact of HeV training on the ability of primary care providers to appropriately address these concerns. All 2,110 participants were enrolled through the Family Practice Residency Clinic at Womack Army Medical Center, Fort Bragg. Forty primary care providers-21 in the Health-e VOICE treatment condition and 19 in the control condition-were enrolled. Of a total of 2,063 patients, 1,197 were patients of providers in the treatment condition and 866 were patients of providers in the control condition. The Health-e VOICE training was not significantly associated with any trial outcomes. Interestingly, patients with war-related health concerns with a Health-e VOICE trained provider reported lower satisfaction than those who received services from providers with standard patient-provider communication training. This difference, while statistically significant, was small, unexpected, and of unclear clinical significance. Internet-based risk communication training for primary care providers seeing war veterans with health concerns is not sufficient to improve outcomes. A presentation on this study was made at the 10th Annual Force Health Protection Conference.

    • CSP 494: A Randomized Controlled Trial of Military Women with Post-Traumatic Stress Disorder (PTSD)

      This VA Cooperative Study included 11 VA sites and Walter Reed Army Medical Center. It was a randomized single-blind clinical trial that compared two types of individual psychotherapies for the treatment of posttraumatic stress disorder (PTSD) in women. The efficacy of prolonged exposure therapy for treating PTSD and associated problems in active duty and veteran women was evaluated. The study hypothesis was that prolonged exposure therapy would be more effective than present centered therapy for the treatment of PTSD in female veterans and active duty personnel. The primary outcome variable was PTSD severity at the 3-month follow-up assessment as measured by the Clinician Administered PTSD Scale (CAPS), a diagnostic interview that captures PTSD symptom severity. A total of 284 participants were randomized in the multi-site trial. Two hundred-one (71%) completed all treatment sessions. Two hundred thirty-five participants (83%) completed the post-treatment assessment, 230 (81%) completed the three-month follow-up assessment, and 213 (75%) completed the six-month follow-up assessment. Women who received prolonged exposure experienced greater reduction of PTSD symptoms relative to women who received present-centered therapy (effect size, 0.27; P = .03). The prolonged exposure group was more likely than the present-centered therapy group to no longer meet PTSD diagnostic criteria (41.0% vs 27.8%; odds ratio, 1.80; 95% confidence interval, 1.10-2.96; P = .01) and achieve total remission (15.2% vs 6.9%; odds ratio, 2.43; 95% confidence interval, 1.10-5.37; P = .01). Effects were consistent over time in longitudinal analyses, although in cross-sectional analyses most differences occurred immediately after treatment. We concluded that prolonged exposure is an effective treatment for PTSD in female veterans and active-duty military personnel. It is feasible to implement prolonged exposure across a range of clinical settings. These findings were reported in the Journal of the American Medical Association (JAMA) in 2007.
      Schnurr PP, Friedman MJ, Engel CC, Foa EB, Shea MT, Chow BK, Resick PA, Thurston V, Orsillo SM, Haug R, Turner C, Bernardy N. Cognitive-behavioral therapy for Posttraumatic Stress Disorder in women: a randomized controlled trial. JAMA. 2007; 297:820-830

    • Project DE-STRESS: Brief Cognitive-Behavioral Intervention for Victims of Mass Violence

      This study, funded by the National Institute of Mental Health (NIMH), began in June 2002 in collaboration with Dr. Brett Litz at Boston University School of Medicine, Boston VAMC and the National Center for PTSD, and Dr. Richard Bryant at the University of New South Wales, Sydney, Australia. This randomized controlled trial evaluated an Internet-based cognitive-behavioral treatment self-management intervention for individuals with PTSD. Thirty-nine victims of mass violence were randomly assigned to receive Web-based cognitive-behavioral treatment or supportive care, each requiring 56 login visits. Participants reported daily PTSD and depression symptoms and accessed self-help materials electronically. Results of this study indicated that participants who received cognitive-behavioral treatment reported greater gains than those who received supportive care. One-third of those who received cognitive-behavioral treatment achieved high end-state functioning 6 months after treatment (one quarter of the intent-to-treat group). The intervention was tolerated well, and the dropout rate was similar to that of face-to-face trials. We concluded that self-management cognitive-behavioral treatment may be a way of delivering effective treatment to large numbers with unmet needs and barriers to care. With intensive therapist input during a single session of therapy, supplemented systematically with self-directed Web-based guidance for daily homework activity, patients with PTSD can benefit from strategies that have demonstrated efficacy in reducing PTSD symptoms. Results of this trial were published in the American Journal of Psychiatry in 2007.
      Litz B, Engel CC, Bryant R, Papa A. A Randomized Controlled Proof of Concept Trial of an Internet-based Therapist-assisted Self-management Treatment for Posttraumatic Stress Disorder. American Journal of Psychiatry 2007 Nov; 164:1-8.

    • Yoga as an Adjunctive Treatment for PTSD-A Feasibility Study

      Yoga practice is one of the complementary and alternative therapies that might ameliorate the symptoms of posttraumatic stress disorder (PTSD). The style of yoga chosen for this study, Yoga Nidra, is practiced while the participant lies on his or her back, which is more comfortable for many than seated meditation. Emphasizing the less strenuous practices of yoga including deep relaxation, deep breathing, and meditation, the practice can reduce physical, emotional, mental, and even subconscious tension while stimulating the parasympathetic nervous system. The study investigated the feasibility of offering this practice and its effectiveness in reducing anxiety and symptoms of PTSD in a military population. Feasibility was measured by ease of recruitment for study participation, attendance in yoga classes, and compliance with daily homework. DHCC collaborated with the Samueli Institute on this study. Participation involved completion of 18 classes over a 10-week period, with daily home practice and homework logs. Approximately 100 subjects were screened for eligibility, 7 participants entered the study, and six completed the classes. Overall class attendance was 67%, and overall home practice adherence was 43%. Thus, early findings reveal it is feasible to offer this type of intervention to active duty service members with PTSD and that participants are largely compliant with the prescribed program. A presentation on this study was given at the 10th Annual Force Health Protection Conference.

    • RESPECT-Mil: Primary Care-Based Management of Depression

      Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) is a project designed to improve the primary care implementation of DoD clinical practice guidelines that are integral to post-deployment care. The treatment model, based on MacArthur Foundation-funded research with collaborators in the VA, Duke University School of Medicine, and Dartmouth Medical School, leads to better treatment outcomes and increased satisfaction with post-deployment primary care. The RESPECT-Mil quality improvement initiative utilizes a Three Component Model (3CM) approach to care that incorporates RESPECT-Mil Care Facilitators (RCFs) to foster improved implementation of practice guideline recommendations for particular conditions after deployment. The RESPECT-Mil protocol is modeled after the RESPECT-Depression protocol, which has been proven effective in multi-site randomized controlled trials in the civilian sector. For RESPECT-Mil, primary care providers are trained to screen for and communicate with their patients about posttraumatic stress disorder and depression. If treatment is initiated, RCFs track patients through periodic phone contact to determine their progress in following their treatment plan and convey relevant information to primary care providers and mental health supervisors. DHCC collaborated with investigators from Dartmouth Medical School, Duke University School of Medicine, Indiana University, and the Regenstrief Institute to develop the training programs and research protocol. During pilot testing at Womack Army Medical Center, Fort Bragg, 4,159 primary care patients received depression/posttraumatic stress disorder primary care screenings; about 10% screened positive for depression or posttraumatic stress disorder (1 or both); about two thirds of patients with moderate to severe depression and/or posttraumatic stress disorder (PTSD) achieved a clinically significant drop in symptom severity at 6-10 weeks; about 70% with moderate to severe depression achieved a drop in symptom severity drop at 12 weeks or more; and about 90% of those with PTSD achieved a drop in symptom severity at 12 weeks or more. A paper summarizing the findings of this pilot project was published in the journal, Military Medicine.
      Engel C. C, Oxman T., Yamamoto C., Gould D., Barry S., Stewart P., et al . RESPECT-Mil: Feasibility of a systems-level collaborative care approach to depression and posttraumatic stress disorder in military primary care. Military Medicine, 2008 Oct; 173(10): 935-940

    • Adverse Childhood Experiences Study

      This one-year DoD, VA, and CDC collaborative effort examines the acceptability of collecting adverse childhood event data as a part of routine military health surveillance (see CDC ACE Study and CACES PowerPoint Presentation 2007). It consists of three components: (1) a focus group-based study to assess the views of service members and their spouses regarding the collection of adverse childhood event data, (2) a panel of subject matter experts who will convene to discuss the acceptability, practicality, legal, and ethical aspects of using adverse childhood event data as a part of routine health surveillance, and (3) a review of past efforts in the military to collect adverse childhood event data anonymously. Seven-hundred eighty-four participants have been screened thus far and 40 participants been consented and interviewed with data analyses of the interviews currently underway The Collaborative Adverse Childhood Experiences Study Conference (Component 2) convened February 2-3, 2006. A report outlining the recommendations of the panel is complete. The third component, a review of past efforts in the military to collect adverse childhood event data anonymously, is also complete. The study team developed a manuscript based on this effort that was published in the journal, Military Medicine. Robinson R., Davis J., Krueger M., Gore K., Freed M. C., Kuesters P., Dube S., Engel C. C. Acceptability of adverse childhood experiences questions for health surveillance in U.S. Armed Forces. Military Medicine, 2008 Sep;173(9):853-9)

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    Publications

    2010

    Griffith, J. (2010). Citizens coping as soldiers: A review of deployment stress symptoms among reservists. Military Psychology, 22, 176-206.

    Griffith, J. (2010). When do soldier nationalism or patriotism matter? The role of transformational leadership. Journal of Applied Social Psychology, 40(5), 1235-1257.

    Mansfield AJ, Kaufman JS, Marshall SW, Gaynes BN, Morrissey JP, Engel CC. Deployment and the use of mental health services among U.S. Army wives. N Engl J Med. 2010
    Jan 14;362(2):101-9.

    2009

    Engel C. C. (Commentary) Multiple-session trauma-focused CBT within 3 months of event reduces symptoms in acute stress disorder and PTSD. Evidence-Based Medicine, 2009 May

    Feliciano M. An overview of PTSD for the adult primary care provider. Journal Nurse Practitioners, 2009 Jul-Aug; 5(7): 516-522.

    Freed M. C., Yeager D., Liu X., Gore K. L., Engel C. C., Magruder K. M. (2009). Preference-weighted health status of veterans with posttraumatic stress disorder (PTSD): Toward creating an outcome for cost-effectiveness analysis using clinical data. Psychiatric Services, 60(9), 1230-1238.

    Griffith, J. (2009). “Being a reserve soldier: A matter of social identity?” Armed Forces and Society, 36 (1), 38-64.

    Griffith, J. (2009). “After 9/11, what kind of reserve soldier? Considerations given to emerging demands, organizational orientation, and individual commitment,” Armed Forces and Society, 35 (2), 214-240.

    Griffith, J. (2009). "Volunteerism among youth: Community service among a panel of beginning college students -- Its prevalence and relationship to having been required and to supporting ‘capital,” Nonprofit Volunteer Sector Quarterly, June, 2009.

    Kang H., Li B., Mahan C., Eisen S., Engel C. C. Health of US veterans of 1991 Gulf War: A follow-up survey in 10 years. Journal of Occupational and Environmental Medicine, 2009 Apr;51(4):401-10

    Roesel T. (Letter to Editor) “Does the central nervous system play a role in vitamin D deficiency related chronic pain?” Pain, 2009 Jan;141(1-2):

    Roesel T. (2009). Does vitamin D potentiate gabapentin and pregabalin efficacy in vitamin D deficiency related chronic musculoskeletal pain? Journal of Bone and Mineral Research, 24 (Suppl 1)

    2008

    Engel C. C, Oxman T., Yamamoto C., Gould D., Barry S., Stewart P., etal . RESPECT-Mil: Feasibility of a systems-level collaborative care approach to depression and posttraumatic stress disorder in military primary care. Military Medicine, 2008 Oct; 173(10): 935-940

    Gore K., Engel C. C., Freed M. C., Liu X., Armstrong III, D. Test of a single-item posttraumatic stress disorder screener in a military primary care setting. General Hospital Psychiatry, 2008 Sep-Oct;30(5):391

    Hoffman J., Nemes S., Weil J., Zack S. (2008) Evaluation of the ASCENT Smoking Cessation Program for Adolescents. Journal of Smoking Cessation, p 2-8.

    Hoge C. W., McGurk D., Thomas J. L., Cox A. L., Engel C. C., Castro C. A. Mild traumatic brain injury in U.S. Soldiers returning from Iraq. New England Journal of Medicine, 2008 Jan 31;358(5):453-63

    Hoge C. W., Engel C. C., Castro, C. (Letter) The authors’ reply. New England Journal of Medicine, 2008; 358(20):2179

    Liu X., Engel C. C., Armstrong D. W., Kang H. Survival convergence and the preceding mortality crossover for two population subgroups. Population Research and Policy Review, 2008;27(3):293-306

    Robinson R., Davis J., Krueger M., Gore K., Freed M. C., Kuesters P., Dube S., Engel C. C. Acceptability of adverse childhood experiences questions for health surveillance in U.S. Armed Forces. Military Medicine, 2008 Sep;173(9):853-9)

    Roesel, T. Vitamin D deficiency in Iraq and Afghanistan veterans with chronic musculoskeletal pain. Journal of Occupational and Environmental Medicine, 2008 June;50(6): 613-614

    Roesel, T. (Abstract) A novel hypothesis explains the syndrome of chronic musculoskeletal pain and comorbid painful healed fractures sites in vitamin D deficiency. Journal of Bone and Mineral Research, 2008 Sept;23:S223

    Terhakopian A., Sinaii N., Schnurr P. P., Engel C. C., Hoge C. W. Estimating population prevalence of PTSD: An example using the PTSD checklist. Journal of Traumatic Stress, 2008; 21(3):290-300

    Ursano R. J., Engel C. C. The importance of assessing exposure to trauma. Psychiatric Services, 2008; 59(3):229

    2007

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

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

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

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

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

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

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

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

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

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

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

    2006

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

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

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

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

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

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

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

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

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

    2005

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

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

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

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

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

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

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

    2004

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    2003

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

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

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

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

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

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

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

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

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

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

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

    2002

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

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

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

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

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

    Dremsa TL, Engel CC Jr, Liu X, Johantgen M, Smith S. Do mental disorders matter? A study of absenteeism among care seeking Gulf War veterans with ill defined conditions and musculoskeletal disorders. Occupational & Environmental Medicine 2002 Aug;59(8):532-6.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Quick JC, Tetrick L, Adkins JA, Klunder C. Occupational Health Psychology. In Nezu A, Nezu C (Eds) Handbook of Health Psychology. Chichester, UK, Wiley;2002.

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

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