Clinical Characterization of Insomnia among Veterans with PTSD: Identifying Risk Factors for Diagnosis and Treatment with Sedative-Hypnotics

Abstract

Insomnia is prevalent among Veterans with post-traumatic stress disorder (PTSD), it exacerbates PTSD symptoms, and it contributes to impaired functioning and quality of life. To improve treatment outcomes, it is important to identify risk factors for insomnia and sedative-hypnotic use. Classification and regression trees and logistic regression models were used to identify variables associated with insomnia or sedative-hypnotic use. Key findings include low insomnia diagnosis rates (3.5–5.6%) and high rates of sedative-hypnotics (44.2–49.0%). Younger Veterans and those without a breathing-related sleep disorder (BRSD) were more likely to receive an insomnia diagnosis. Veterans with greater service connection and those with an alcohol/substance use disorder were more likely to be prescribed sedative-hypnotics. Interaction terms may have identified potential groups at risk of being under-diagnosed with insomnia (i.e. non-black Veterans with psychiatric co-morbidity, black Veterans without psychiatric co-morbidity) as well as groups at risk for sedative-hypnotic use (i.e. younger Veterans without BRSD). In sum, Veterans with PTSD have high rates of sedative-hypnotic use despite minimal evidence they are effective. This is counter to recommendations indicating behavioral interventions are the first-line treatment. Policy changes are needed to reduce use of sedative-hypnotics and increase access to behavioral insomnia interventions.     

On the treatment of force-level constraints in times-equential combat problems

The treatment of force-level constraints in time-sequential combat optimization problems is illustrated by further studying the fire-programming problem of Isbell and Marlow. By using the theory of state variable inequality constraints from modern optimal control theory, sharper results are obtained on necessary conditions of optimality for an optimal fire-distribution policy (in several cases justifying conjectures made in previous analysis). This leads to simplification of the determination of the domains of controllability for extremals leading to the various terminal states of combat. (Additionally, some new results for the determination of boundary conditions for the adjoint variables in optimal control problems with state variable inequality constraints have arisen from this work.) Some further extensions of previous analysis of the fire-programming problem are also given. These clarify some key points in the solution synthesis. Some important military principles for target selection and the valuation of combat resources are deduced from the solution. As a result of this work, more general time-sequential combat optimization problems can be handled, and a more systematic solution procedure is developed.     

A computation procedure for the exact solution of location-allocation problems with rectangular distances

A method is presented to locate and allocate p new facilities in relation to n existing facilities. Each of the n existing facilities has a requirement flow which must be supplied by the new facilities. Rectangular distances are assumed to exist between all facilities. The algorithm proceeds in two stages. In the first stage a set of all possible optimal new facility locations is determined by a set reduction algorithm. The resultant problem is shown to be equivalent to finding the p-median of a weighted connected graph. In the second stage the optimal locations and allocations are obtained by using a technique for solving the p-median problem.     

(Re-)emergent orders: understanding the negotiation(s) of rebel governance

Abstract

The concept of order is often neglected in the study of conflict – seemingly such a ‘disordering’ process. With the recent increase in the examination of rebel governance however, bringing order back into our understanding of rebel and insurgent groups has much to offer in exploring the everyday politics which connect authorities, rebel movements and the population itself, in a complex mass of intersubjective and power-based interactions and negotiations. Rebels both shape and are shaped by existing forms of order in complex and ongoing ways. This article explores how varying elements interact in the negotiation, framing and enforcement of order and develops an original analytical framework to examine the perpetual negotiations of rebel movements in their attempts to cement their control.     

Reassessing Military Assistance to the Civil Powers: Are Traditional British Anti-Terrorist Responses Still Effective?

The provision of Military Assistance to the Civil Powers (MACP) encapsulates the traditional approach towards countering terrorism on the British mainland, which emphasises minimum force, proportionality, police primacy and the rule of law, with the military retained as a supporting instrument, being employed only as a measure of last resort. Recent terrorist incidents in major urban centres do, however, question the effectiveness of these established methods. This analysis initially codifies the conceptual issues that underscore the tensions between civil policing and military anti-terrorist approaches in the UK, and proceeds to evaluate and compare a number of operations that indicate the nature of the challenges facing the MACP apparatus. In particular, potential shortcomings in the MACP provisions are identified in the form of threat perception and deployment and enforcement gaps. The assessment finds that there are facets of MACP that are of enduring relevance in the current era, yet a continuing need persists to reconcile police and military imperatives toward serious civil disorder contingencies and conditions of emergency.     

Croatia's bitter harvest: Total National Defence's role in the Croatian War of Independence

Croatia's successful bid for independence was one of the defining moments of the immediate post-Cold War period. Nevertheless, the means that Croatia used to obtain independence remains relatively unexamined by academics. This article focuses on the early period of Croatia's bid for secession, and specifically the role that Yugoslavia's policy of Total National Defence played in facilitating its independence. Unlike in Slovenia, where the legacies of Total National Defence facilitated Slovenia's bid for secession, in Croatia the decision of its political leaders meant that the country largely neglected its positive legacies, resulting in a protracted four-year struggle.