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.     

US paramilitary programs in comparative perspective: CIA,the US Army Special Forces,and the question of organizational form

Assumed in the long-standing debate over which agency, CIA or the Department of Defense, should conduct US paramilitary operations is the idea that these organizations’ paramilitary programs are fundamentally the same kinds of things. This article questions that assumption by investigating the organizational forms underlying these agencies’ paramilitary programs in four empirical cases drawn from South Vietnam and post-9/11 Afghanistan. A typology is constructed around two identified organizational forms: “franchising” for CIA vs. “company ownership” for the US Army Special Forces. Different paramilitary organizational forms are found to have significant operational implications that should inform the paramilitary transfer debate.     

Optimal location of public facilities

Location of both public and private facilities has become an important consideration in today's society. Progress in solution of location problems has been impeded by difficulty of the fixed charge problem and the lack of an efficient algorithm for large problems. In this paper a method is developed for solving large-scale public location problems. An implicit enumeration scheme with an imbedded transportation algorithm forms the basis of the solution technique.     

An extension of the (szwarc) truck assignment problem

In this journal in 1967. Szware presented an algorithm for the optimal routing of a common vehicle fleet between m sources and n sinks with p different types of commodities. The main premise of the formulation is that a truck may carry only one commodity at a time and must deliver the entire load to one demand area. This eliminates the problem of routing vehicles between sources or between sinks and limits the problem to the routing of loaded trucks between sources and sinks and empty trucks making the return trip. Szwarc considered only the transportation aspect of the problem (i. e., no intermediate points) and presented a very efficient algorithm for solution of the case he described. If the total supply is greater than the total demand, Szwarc shows that the problem is equivalent to a (mp + n) by (np + m) Hitchcock transportation problem. Digital computer codes for this algorithm require rapid access storage for a matrix of size (mp + n) by (np + m); therefore, computer storage required grows proportionally to p². This paper offers an extension of his work to a more general form: a transshipment network with capacity constraints on all arcs and facilities. The problem is shown to be solvable directly by Fulkerson's out-of-kilter algorithm. Digital computer codes for this formulation require rapid access storage proportional to p instead of p². Computational results indicate that, in addition to handling the extensions, the out-of-kilter algorithm is more efficient in the solution of the original problem when there is a mad, rate number of commodities and a computer of limited storage capacity.     

Modeling and analyzing multiple station baggage screening security system performance

In the aftermath of the tragic events of 11 September 2001, numerous changes have been made to aviation security policy and operations throughout the nation's airports. The allocation and utilization of checked baggage screening devices is a critical component in aviation security systems. This paper formulates problems that model multiple sets of flights originating from multiple stations (e.g., airports, terminals), where the objective is to optimize a baggage screening performance measure subject to a finite amount of resources. These measures include uncovered flight segments (UFS) and uncovered passenger segments (UPS). Three types of multiple station security problems are identified and their computational complexity is established. The problems are illustrated on two examples that use data extracted from the Official Airline Guide. The examples indicate that the problems can provide widely varying solutions based on the type of performance measure used and the restrictions imposed by the security device allocations. Moreover, the examples suggest that the allocations based on the UFS measure also provide reasonable solutions with respect to the UPS measure; however, the reverse may not be the case. This suggests that the UFS measure may provide more robust screening device allocations. © 2004 Wiley Periodicals, Inc. Naval Research Logistics, 2005.     

Reinventing the Revolution: Technological Visions,Counterinsurgent Criticism,and the Rise of Special Operations

Two big ideas have shaped recent debate about military doctrine: the Revolution in Military Affairs (RMA) and Counterinsurgency (COIN). These ‘network centric’ and ‘population centric’ worldviews appear contradictory, but this is a false dichotomy. American forces have actively developed RMA concepts in COIN environments during recent wars in Iraq and Afghanistan; the exemplar par excellence is innovation by US Special Operations Command (SOCOM) in doctrine, technology, and organization for counterterrorism. Ironically, SOCOM's reimagining of the RMA managed to both improve the strengths and underscore the weaknesses of the American military's technological prowess.     

Governmental Re-organization in Counterinsurgency Context: Foreign Policy Program Transfer and Operation Switchback in South Vietnam

Foreign policy program transfer, the shifting of implementation responsibility for a foreign policy program from one organization to another, is a ubiquitous, yet under-studied, counterinsurgency phenomenon. This article conceptually develops program transfer as an important object of study; analyzes, using archival sources, an empirical case of program transfer, Operation Switchback, drawn from US counterinsurgency practice in South Vietnam; and formulates two preliminary theoretical claims related to program transfer: (1) transferred programs will tend to be altered in accordance with the characteristics of the gaining organization, and (2) program transfer may act as a signal or early-warning indicator of foreign policy change.