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.     

The structure of the defense industry and the security needs of the country: a differentiated products model

This paper models the interactions between the defense needs of the USA and Western Europe, which produce several heterogeneous defense goods, and the defense industry market structure. The results show that net defense costs of the USA and Europe are lower when the number of defense firms in each arms‐producing country is small and when the world prices of the defense goods are high. The model predicts that the increase in world prices will crowd‐out countries in the developing world from the market for modern weapon systems and may force them to develop and use ‘cheap and dirty’ weapon systems.     

Estimating defence budget saving from disarmament: the United States’ case

Probing the technology in the production of US national defence by using a dynamic cost‐function model with adjustment costs, this paper evaluates the effect of reducing the level of national defence on the defence budget saving. Our inquiry involves estimating the defence production structure without output data for non‐market goods that are normally unavailable. Our findings include: (i) the United States behaves rationally to minimize cost in the production of national defence; (ii) the adjustment costs are larger in disarmament than in military build‐up; (iii) due to the adjustment costs peculiar to disarmament, the defence budget saving from disarmament appears small, but cutbacks allow great savings on the defence budget.     

The two-on-one stochastic duel

The one-on-one stochastic duel is extended to the general two-on-one duel for the first time. The state equations, win probabilities, mean value, and variance functions are derived. The case where one side has Erlang (2) firing times and the other is negative exponential is compared with the corresponding “Stochastic Lanchester” and Lanchester models to demonstrate their nonequivalence.     

Aid versus sanctions for taming oppressors: theory and case study of the Iraqi Kurds

We model an oppressor aiming at victimizing an excluded group in his country, with two main variants. A foreign power affects his behaviour using either conditional aid, subject to the dictator’s participation constraint, or the threat of sanctions, broadly defined, subject to the credibility constraint. The choice between the two is either determined by the latter, or by their relative cost. Aid is preferred when the threat of sanctions is ineffective, and sanctions are too expensive. Sanctions might be imposed, if the threat is ineffective. A case study of the Iraqi Kurds after Iraq was subject to sanctions is presented.     

Notes on contributors

In 1897 and 1898, Winston Churchill participated in what late Victorian Britain termed ‘small wars’, first on India's northwest frontier and then in the vast wasteland of the Sudan. Churchill chronicled his experiences in these conflicts in personal letters, dispatches to newspapers, and in his first two books, The Story of the Malakand Field Force and The River War. These writings provide a snapshot of a particular period in the formative years of the great statesman, demonstrating through Churchill's eloquent analyses many of the contradictions concerning the conduct of small wars that have emerged in the present era.