Active Research Projects focused on the health and mental health of service members and their families and children include:
Nightmares and insomnia are among the most prevalent refractory symptoms of posttraumatic stress disorder (PTSD). Current evidence-based treatments for PTSD, such as prolonged exposure and cognitive processing therapy, utilize fear memory extinction and reconsolidation but do not target sleep symptoms. Given that nightmares are thought to have an essential role in trauma memory maintenance, developing a treatment that activates trauma memory through exposure to nightmare images may facilitate trauma memory reconsolidation. This pilot trial is investigating Nightmare Deconstruction and Reprocessing (NDR), a three-stage treatment model that begins with exposure to nightmare images, moves to meaning-making and reprocessing, and then to dream reconstruction and rehearsal. In working toward our goal of conducting a large-scale randomized controlled trial, CSTS is partnering with Walter Reed National Military Medical Center, Naval Medical Center San Diego, and the National Institutes of Health to pilot test NDR’s plausibility as a treatment for PTSD-related nightmares in military service members and to test the methodologic feasibility of integrating biomarkers as objective measures of treatment efficacy and tolerability, including actigraphic data, heart-rate variability, electrodermal conductance, and genomic and inflammatory markers. Participant recruitment and data collection began in 2019 and is ongoing.
The Center for the Study of Traumatic Stress, in collaboration with Dr. Sandro Galea of Boston University, is engaged in a nation-wide research project on the health and mental health of National Guard and Reserve Service members, an at risk population that has been understudied. The study addresses the epidemiology and the trajectory of posttraumatic stress, deployment stress, health risk behaviors and health care utilization in National Guard and Reserve. The fourth wave of data collection has been completed, and the combined team is actively working on data analysis, as well as preparing to conduct a fifth wave of data collection. Four publications have resulted from this research, and several more articles are under development.
Using blood samples from suicide attempters and non-attempters, and post-mortem brain tissue from patients who had committed suicide and non-suicide controls, Center for the Study of Traumatic Stress scientists examined levels of peripheral blood mononuclear cell (PBMC) p11 mRNA to determine how these levels might help differentiate between those individuals who would attempt or complete suicide versus those who would not. The results demonstrated for the first time that PMBC p11 mRNA level is a potential adjunctive biomarker for the assessment of suicide risk in mental disorders. The Center has continued to analyze data from the collections, with a focus identifying outcomes and biomarkers for our overall genetic analyses.
In 2015, a consortium led by the Department of Veterans Affairs National Center for PTSD and co-Founded by CSTS Scientists launched a PTSD brain tissue biorepository—or "brain bank"—to support research on the causes, progression and treatment of PTSD affecting Veterans.
The national brain bank will investigate the impact of stress, trauma and PTSD on brain tissue to advance the scientific knowledge of PTSD, particularly the identification of PTSD biomarkers. The consortium is directed Dr. Matthew Friedman, who is the founder, former Executive Director, and current Senior Advisor to the National Center for PTSD in White River Junction, VT. In addition to Friedman, members of the brain bank’s Executive Committee include Ann McKee, MD, Neil W. Kowall, MD, and Christopher "Kit" Brady, PhD (Boston VA); Robert J. Ursano, MD and David M. Benedek, MD (USUHS); Ronald S. Duman, PhD (West Haven VA); and Douglas E. Williamson, PhD and Keith Young, PhD (San Antonio VA). Participating sites are located at VA medical centers in Boston, MA (Primary Receiving Site), San Antonio, TX (Secondary Receiving Site), West Haven, CT (Primary Research Site), and White River Junction, VT (Headquarters) along with the Uniformed Services University of Health Sciences at Bethesda, MD (Primary Assessment Site).
The national brain bank has a protocol for post-mortem diagnostic validation and has used this to acquired PTSD brain tissue from existing collections. The consortium will build on this foundation by following the health of enrolled participants during their lifetime through mailed surveys, telephone calls, and electronic health records. Participants in the brain bank will donate their brain and other body tissue after their death. The donated tissue, along with voluntarily participating veteran's health information, will provide crucial information about the biological basis of risk and protective factors in PTSD and related disorders.
For articles, videos, and additional information click here.
Army STARRS was an unprecedented multi-study project headed by the Center for the Study of Traumatic Stress in collaboration with leading academic institutions. Army STARRS was the largest research project of mental health risk and resilience ever conducted among Army personnel.
The project was designed and conducted by an interdisciplinary research team under the leadership of Co-Principal Investigators Robert J. Ursano, M.D. at the Uniformed Services University (Director of CSTS), and Murray B. Stein, M.D., M.P.H., at the University of California, San Diego. The other two major team players were site investigators Steven G. Heeringa, Ph.D., at University of Michigan, and Ronald C. Kessler, Ph.D., at Harvard Medical School. The team included Lisa J. Colpe, Ph.D., M.P.H. and Michael Schoenbaum, Ph.D., collaborating scientists at NIMH, and COL Steven Cersovsky, MD, MPH and Kenneth Cox, MD, MPH, consultants from the U.S. Army Public Health Command.
Army STARRS was a 6-year (2009-2015), 65 million dollar project funded by the U.S. Army with supplemental funding from the National Institute of Mental Health. It consisted of seven separate but integrated epidemiologic and neurobiologic studies designed to comprehensively investigate risk factors and protective factors for suicide, suicide-related behavior and other mental health issues in Army Soldiers. It emphasized the development of practical, actionable information to guide the development and refinement of suicide risk reduction efforts in and beyond the Army.
The research team created enormous databases containing more than 1.1 billion historical administrative Army/DoD records for all the Soldiers (more than 1.6 million Soldiers) on active duty from 2004 to 2009, as well as data collected directly from more than 100,000 active duty Soldiers including Regular Army, activated Army National Guard and activated Army Reserve Soldiers. The team administered more than 177,000 questionnaires, conducted roughly 400,000 neurocognitive tests, and collected approximately 77,000 tubes of blood from approximately 52,000 Soldiers for genetic and other biomarker assays.
The Scientific Advisory Board that was assembled to advise Army STARRS characterized the importance of the project:
Kerry Ressler, M.D., Ph.D., the Chair of the Army STARRS Scientific Advisory Board said: "The breadth and scope of the Army STARRS project is unique in the history of psychiatric and military research..."
LTG (Ret) Eric Schoomaker, M.D., Ph.D., who served on the Army STARRS Scientific Advisory Board, and is a former U.S. Army Surgeon General, said: "The comprehensive nature of these inquiries has provided a data base on behavioral health, social, biological, and potentially genetic pre-determinants of suicide unprecedented in its scope and depth of understanding ..."
As findings became available, the research team reported them to the Army on a regular basis through more than a dozen in-person briefings to senior Army leadership including the Secretary of the Army, the Chief of Staff of the Army, the Vice Chief of Staff of the Army, the Deputy Undersecretary of the Army, the Army Surgeon General, and other senior officials. In this way, the Army could apply the findings to its ongoing health promotion, risk reduction, and suicide prevention efforts.
In December 2013, the research team published a series of four methodological articles in the International Journal of Methods in Psychiatric Research that described the research design and methods to serve as the foundation for other publications that present findings. The first findings from Army STARRS were reported in a series of three articles published in JAMA Psychiatry in May 2014. As of the beginning of 2020, the team had published a total of 93 papers in scientific journals. The team continues to analyze the rich databases created during Army STARRS, and continues to produce and publish epidemiologic and neurobiologic findings from the multiple Army STARRS studies.
For a summary of published findings please click here.
Due to the great success of Army STARRS, the Center for the Study of Traumatic Stress received funding from the Department of Defense to continue and further develop the STARRS research. Under STARRS-LS, the research team is continuing to use the data systems and research platforms developed during the initial project period to provide further analyses and follow-up studies of the Soldiers who participated in Army STARRS. This work aims to produce additional benefits to the well-being of Service members.
This five-year (2015-2020), $30 million award is to continue analyses of Army STARRS data, expand the research by extending the historical data through 2016,conduct a longitudinal follow-up study with a cohort of more than 73,000 Service members who participated in Army STARRS and provided consent for researchers to link their STARRS survey data to their DoD and Army administrative records data, contact a subset of the cohort to administer additional waves of questionnaires to collect further follow-up data, and analyze the Army STARRS data in conjunction with the STARRS-LS data to further the goals of the STARRS family of studies. STARRS-LS is being designed and conducted by a team of researchers from USU, the University of California, San Diego (UCSD), Harvard and University of Michigan under the leadership of the two co-principal investigators, Dr. Robert J. Ursano of USU (Director of CSTS) and Dr. Murray B. Stein of UCSD.
For more information, visit the STARRS-LS website at starrs-ls.org. The research team is also designing and planning the next phases of STARRS to continue the research beyond 2020.
Understanding and Meeting the Needs of Children Following Family Member Death
This study, funded by Sesame Workshop, was the Center for the Study of Traumatic Stress’ (CSTS) Child and Family Program’s preliminary research initiative into the area of family bereavement. It studied the impact of a multimedia program produced by Sesame Workshop in families with young children affected by family member death. The study also addressed the impact of parental death on children and their caretakers in both military and civilian populations by evaluating the helpfulness of a Sesame Workshop DVD and supplemental materials designed for grieving families. The study collected data on the health and well-being of surviving children (ages 2–18). These children lost a parent after September 11, 2001 and the data were observations from their current caretaker.
In order to determine how combat injury affects family members and their children, three studies were conducted. Families participated in (1) a study conducted at the National Military Family Association Operation Purple Healing Adventures Camps, (2) a longitudinal study comparing combat injured and non-injured families from Walter Reed National Military Medical Center, San Antonio Military Medical Center and Fort Stewart, GA, and (3) FOCUS-CI, a pilot randomized-controlled trial that tested the effectiveness of a newly-developed family-centered, strength-based intervention to be used with severely combat-injured service members and their families. Data collected from these three sources will inform programmatic intervention that can better address the needs of service members and their families.
This study examines the impact of severe combat injury on military families through interviews conducted at Operation Purple Healing Adventures (OPHA), an annual summer camp program for combat injured service members and their families sponsored by The National Military Family Association (NMFA). Forty families were assessed in summers 2009 and 2010. Qualitative data is being collected from focus groups to assess the issues related to combat injury and family functioning. Among the issues to be studied is how combat injury effects family life.
The goal of this study was to describe the characteristics of substantiated child neglect cases in the Army, and to identify factors within the family, the military community and the civilian community that contribute either to family health or child maltreatment. Data were collected from 1,088 questionnaires representing 26 Army installations in the United States, and 400 records of substantiated child neglect cases around the country. Analyses of these data defined the types, subtypes and severity of neglect occurring within families, highlighting the importance of varied public health strategies to minimize risk.
Troop Education for Army Morale is an innovative early intervention designed to examine and facilitate post deployment readjustment in U.S. Army Mortuary Affairs Soldiers and their spouses. TEAM is one of the few intervention studies in the history of the Center and also one of the longest ongoing studies at the Center — recruitment began in 2009 and concluded in 2014. A total of 126 soldiers were recruited in 10 cohorts. Participants were randomized either into an educational intervention or a no-intervention comparison group. The intervention is based on the five evidence informed principles of Psychological First Aid: safety (physical and psychological), calming, connectedness, self-efficacy, and hope/optimism. These concepts were delivered through four interactive group workshops, informational handouts, a dedicated website, and supported through concierge phone and email services. Ongoing data analysis includes examination of the impact of TEAM on symptoms of PTSD and depression and quality of life. Results have been presented at several professional meetings, including: the International Society for Traumatic Stress Studies Annual Meeting and the Association of Behavioral and Cognitive Therapies Annual Meeting. Several manuscripts are currently in process. Findings from TEAM will inform future interventions with military and civilian populations.
U.S. Army mortuary affairs (MA) soldiers recover, identify, and evacuate the remains of the deceased from the theater of war. This study examines the individual, unit and family stressors, risk factors and resiliency of MA soldiers returning from deployment to the Middle East compared to MA soldiers anticipating deployment and those not deployed. Survey are administered to MA units approximately one month prior to and one month after return from deployment to the Middle East. The surveys assess MA soldiers’ exposures during deployment as well as pre and post deployment mental health and well-being. This study has implications for early intervention, training, education, leadership and health surveillance. Findings will target resiliency, preparation, training and education of troops for the stressors of deployment and working with the dead.
The Daily Diary Study uses a novel ecological momentary assessment methodology to monitor post-traumatic stress symptoms (PTSS) in current and former Service members. The study examines the association between variability in PTSS, collected four times daily over a 15-day period, and day of week, sleep disturbances (e.g., short sleep duration, frequent awakenings, poor sleep quality, trouble falling asleep, difficulty staying asleep), health risk behaviors (e.g., alcohol and tobacco use), and other areas of health and functioning in Service members with and without PTSD. In Phase I of the study, Service members complete daily assessments on paper questionnaires. Recruitment for Phase I began in 2013 and closed with enrollment of 50 Service members. Recruitment for Phase II began in 2014 and is ongoing. In Phase II, Service members complete assessments using electronic tablets programmed with a sophisticated application developed specifically for this project through the collaboration of CSTS and the National Center for Telehealth and Technology (T2). Data analyses and dissemination of the findings is in process. This important study will increase our understanding of the relationship between daily variability in post-traumatic stress symptoms, sleep, and mental health conditions, as well as inform future use of technology in psychiatric assessment, treatment, and research.
To determine whether military family survivors of suicide, accident and combat deaths use similar or different coping strategies following a death, participant data from the National Military Bereavement Study will be examined in combination with their current measures of grief, depression, coping, hopelessness and reasons for living that will be obtained during an additional follow-up data collection. Changes in coping between the first (NMFBS) data collection and the current one will be assessed in order to identify actionable targets for intervention programs to serve survivors.
(http://militarysurvivorstudy.org) The NMFBS is the first scientific study to examine the impact of a U.S. military service death on surviving family members. The goal of the study is to build upon the civilian research literature on bereavement and its impact on survivors and determine how psychological, physical and/or behavioral outcomes of the grieving process are influenced by family members’ pre-existing psychological and physical health, social and grief support, and military-specific factors. The study consisted of three parts: archival data analysis, questionnaire/interviews and biosample (saliva) collection over a period of three years, and focus groups. The longitudinal portion of the study, which consisted of annual interviews over a three-year period, was completed in 2017. Approximately 850 adults and 120 children completed the longitudinal portion of the study, and 981 participants provided saliva samples for analysis of genetic biomarkers associated with bereavement-related outcomes. Findings from the study have informed ongoing discussion to better define diagnostic criteria for a condition of impairing grief. As part a result of this groundbreaking work, the CSTS has partnered with colleagues at Columbia University, New York University, University of Pittsburgh, and the University of California San Diego into developing a proposal for alternate and more clinically-relevant criteria of a persistent grief disorder to be included in future editions of the DSM.
(http://steppingforwardstudy.org/) The Stepping Forward in Grief Study tested two online/app programs that were developed in response to findings from the National Military Family Bereavement Study, which suggested that grief-related challenges among bereaved military survivors can continue, even many years following a loss, and that many survivors desire additional support. This prolonged distress puts them at risk for harmful long-term changes in physical and mental health. Recognizing the need to help bereaved military families and friends, the research team at USU formed a partnership with the Center for Complicated Grief at Columbia University to create a program for bereaved military families and friends to adapt to their loss. Participants who enrolled were randomly assigned to one of two online programs, GriefSteps or WellnessSteps. Both groups had access to guides who could answer questions about the intervention. The goal of the study is to compare whether people vary across groups in grief severity and adaptation to loss. If these programs are successful, they would be a helpful resource for current and future survivors.
The Center for Study of Traumatic Stress and VOICES of September 11 partnered to examine long-term positive and negative bereavement outcomes (including grief, traumatic symptoms, resilience characteristics and post-traumatic growth) following a terrorism-related death. Participants were family members bereaved by the bombing of Air India Flight 182 on June 23, 1985 or by the events of September 11, 2001. Participants completed an online questionnaire about their experiences related to the aftermath of these events and the death of their family member(s). The questionnaire assessed the following: background factors; characteristics of the death; availability of post-death resources; media involvement; memorialization; psychological functioning; and life changes. This information will be used to develop preliminary working models for understanding risk and protective factors for bereaved family members of terrorism-related deaths. These results will inform ongoing research and guide training and counsel for disaster and terrorism victims and their families. Specifically, this work will help identify at-risk groups within the community, and will provide guidance for future policy regarding the delivery of notifications involving human remains identification, which has complex consequences for the traumatically bereaved relatives of terrorism and/or disaster victims.
Current recommended medications for combat-related posttraumatic stress disorder (PTSD), which increase the availability of serotonin (SSRIs) or serotonin and norepinephrine (SNRIs) in the brain, do not adequately relieve symptoms for many patients. There is therefore an urgent need to investigate other types of medications that may be more effective. Riluzole is a medication that reduces glutamate activity in—and may help reverse damage to—regions of the brain (amygdala, anterior cingulate cortex, and hippocampus) where an excess of glutamate is believed to contribute to PTSD symptoms. The Center for the Study of Traumatic Stress has completed data collection for clinical trial investigating riluzole augmentation treatment for SSRI/SNRI-resistant PTSD. Seventy-three veterans of the Global War on Terrorism with combat-related PTSD were recruited at Walter Reed National Military Medical Center and Syracuse VA Medical Center. For this randomized controlled, double-blind trial, participants continued on their current SSRI or SNRI and were assigned to receive either riluzole or placebo augmentation for 8 weeks. Symptoms of PTSD, depression, anxiety, and disability were assessed at pre-, mid-, and post-treatment. Magnetic resonance spectroscopy (1H MRS) studies of areas in the amygdala and anterior cingulate were done pre- and post-treatment. It is hypothesized that (1) participants who receive riluzole will demonstrate greater improvement in PTSD symptoms compared to those who receive placebo; (2) participants who receive riluzole will have more improvement in depression and anxiety symptoms and overall functioning compared to those who receive placebo; and (3) pre- to post-treatment changes in amygdala and anterior cingulate cortex measured using 1H MRS, will be consistent with treatment with riluzole versus placebo. Results to date demonstrate no significant effect in overall PTSD, depression or anxiety symptoms, but improvement in PTSD hyperarousal symptoms. This study is closed to recruitment and additional analyses are currently under way.
PTSD is a prevalent, disabling, and costly condition, and the current need for effective PTSD treatments is great. Current pharmacologic therapies such as selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) provide substantial benefit to only 30% to 40% of patients and often produce side effects that limit adherence. Therefore, there is a need to investigate other types of medications to offer more effective options to patients with PTSD. The renin-angiotensin system is a biochemical pathway essential for cardiovascular regulation, and targeting this pathway using angiotensin receptor blockers (ARBs) and angiotensin converting enzyme (ACE-I) inhibitors has been an effective treatment for hypertension for many years. Increasing evidence supports the role of the renin-angiotensin pathway in stress-related psychiatric disorders independent of its cardiovascular effects. Losartan is an ARB commonly used to treat high blood pressure that showed potential in both laboratory and epidemiologic studies to reduce PTSD symptoms by reducing fear memory and regulating the stress response. The Center for the Study of Traumatic Stress, under a subaward from the University of California San Diego, recently completed recruitment of a clinical trial at Walter Reed National Military Medical Center testing the efficacy of losartan in individuals with a diagnosis of PTSD. This randomized controlled double-blind trial treated participants with losartan or placebo for 10 weeks. Study hypotheses include: (1) participants who receive losartan will have greater PTSD symptom improvement than those who receive placebo; and (2) participants receiving losartan with a specific variant of the angiotensin converting enzyme gene (rs4311 - CC genotype) will show better PTSD symptom improvement with losartan treatment than participants with other variants. This study is closed to recruitment and data analysis is underway.
Sleep disturbances and posttraumatic stress disorder (PTSD) are prevalent and often co-occur among Servicemembers with combat experience. There is wide variability in the response to treatments for sleep disturbances, and little is known about how various factors, including co-occurring PTSD, combine to predict treatment response, hampering efforts to select effective treatments for individuals. COL Gary H. Wynn, MD, senior center scientist, is leading an effort to identify factors that predict variation in sleep disorder treatment response, with the goal of developing predictive analytic models. The effort, in collaboration with Harvard Medical School, will utilize data from the Army Study to Assess Risk and Resilience in Servicemembers (STARRS), as well as data from the Sleep Disorders Center at the Walter Reed National Military Medical Center. Heterogeneity of treatment effects (HTE) analyses will be used to identify predictors of variation in sleep disturbance treatment response. This work will form the basis for future efforts to develop clinical tools for practitioners, which will improve treatment selection for individuals with PTSD-related and other sleep disturbances.
The Center, in collaboration with the University of California, Irvine (UCI), established a multi-species methodology for evaluating potential new compounds to treat PTSD. The effort, led by senior center scientist COL Gary H. Wynn, MD, uses a non-mammalian model (zebrafish) for high-throughput screening in conjunction with a long established rodent model. The zebrafish colony will provide an abundance of potential research opportunities in drug development and beyond. The zebrafish lab recently began testing large chemical libraries both to create standard drug profiles within the zebrafish system, and to find promising candidates for drug repurposing. In addition to high throughput embryo testing the lab has begun ramping up efforts to perform testing in adult zebrafish which have over 100 testable characterized behaviors. Once fully established, the lab will begin high throughput testing of novel compounds and coordinate with its collaborators regarding future directions for screening. Several novel compounds are pending testing currently and successful compounds will then be evaluated in the established rodent model at UCI.
The overall objective of this study is to identify risk and protective factors for child maltreatment (i.e., physical abuse, sexual abuse, emotional abuse, and neglect) in military families. Phase I of the project involved a case-control comparison study of military families with dependent children under age 18 in FY 2014 to identify the family, service member, and military characteristics associated with heightened and diminished risk of substantiated child maltreatment incidents. Phase II of the study will build on findings from Phase I to develop a life course model of military family child maltreatment. Using data on active duty service member families with one or more dependent children in FY 2009 through FY 2018, survival analyses will be conducted to investigate the contribution of family demographics (e.g., parental ages, military rank, child age, child gender), family events (e.g., marriages, births, divorces), military events (e.g., promotions, demotions, disciplinary events, change of station, deployments), and family health (e.g., new diagnoses, hospitalizations, ER visits, medication usage) to the timing of the first incident of substantiated child maltreatment in active duty families. Results from this congressionally mandated research will inform DoD’s policy and practice approaches related to child maltreatment prevention and respond to House Report 114-577.