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.     

Information security: Designing a stochastic‐network for throughput and reliability

Todas information and communication network requires a design that is secure to tampering. Traditional performance measures of reliability and throughput must be supplemented with measures of security. Recognition of an adversary who can inflict damage leads toward a game‐theoretic model. Through such a formulation, guidelines for network designs and improvements are derived. We opt for a design that is most robust to withstand both natural degradation and adversarial attacks. Extensive computational experience with such a model suggests that a Nash‐equilibrium design exists that can withstand the worst possible damage. Most important, the equilibrium is value‐free in that it is stable irrespective of the unit costs associated with reliability vs. capacity improvement and how one wishes to trade between throughput and reliability. This finding helps to pinpoint the most critical components in network design. From a policy standpoint, the model also allows the monetary value of information‐security to be imputed. © 2009 Wiley Periodicals, Inc. Naval Research Logistics, 2009     

Fire truck relocation during major incidents

The effectiveness of a fire department is largely determined by its ability to respond to incidents in a timely manner. To do so, fire departments typically have fire stations spread evenly across the region, and dispatch the closest truck(s) whenever a new incident occurs. However, large gaps in coverage may arise in the case of a major incident that requires many nearby fire trucks over a long period of time, substantially increasing response times for emergencies that occur subsequently. We propose a heuristic for relocating idle trucks during a major incident in order to retain good coverage. This is done by solving a mathematical program that takes into account the location of the available fire trucks and the historic spatial distribution of incidents. This heuristic allows the user to balance the coverage and the number of truck movements. Using extensive simulation experiments we test the heuristic for the operations of the Fire Department of Amsterdam‐Amstelland, and compare it against three other benchmark strategies in a simulation fitted using 10 years of historical data. We demonstrate substantial improvement over the current relocation policy, and show that not relocating during major incidents may lead to a significant decrease in performance.     

Interdiction models for delaying adversarial attacks against critical information technology infrastructure

Information technology (IT) infrastructure relies on a globalized supply chain that is vulnerable to numerous risks from adversarial attacks. It is important to protect IT infrastructure from these dynamic, persistent risks by delaying adversarial exploits. In this paper, we propose max‐min interdiction models for critical infrastructure protection that prioritizes cost‐effective security mitigations to maximally delay adversarial attacks. We consider attacks originating from multiple adversaries, each of which aims to find a “critical path” through the attack surface to complete the corresponding attack as soon as possible. Decision‐makers can deploy mitigations to delay attack exploits, however, mitigation effectiveness is sometimes uncertain. We propose a stochastic model variant to address this uncertainty by incorporating random delay times. The proposed models can be reformulated as a nested max‐max problem using dualization. We propose a Lagrangian heuristic approach that decomposes the max‐max problem into a number of smaller subproblems, and updates upper and lower bounds to the original problem via subgradient optimization. We evaluate the perfect information solution value as an alternative method for updating the upper bound. Computational results demonstrate that the Lagrangian heuristic identifies near‐optimal solutions efficiently, which outperforms a general purpose mixed‐integer programming solver on medium and large instances.     

The politics of multinational military operations

Today, few countries fight alone; most fight as allies or partners in multilateral campaigns. The end of the Cold War opened a window of opportunity for multinational military operations (MMOs). These have seen varying degrees of participation, enthusiasm, and success. This special forum is devoted to the politics of multilateral warfare including their formation, maintenance, and durability. The introduction sketches past research and derives some key questions of continuing relevance. The contributions shed light on the domestic and international politics of MMOs, focusing on the implementation of national restrictions and their repercussions for MMOs, party politics of military intervention, the conditions under which states decide to defect from military operations, and the role of junior partners in MMOs. In sum, this forum offers a fresh look at the politics of MMOs, including conceptual contributions to the study of national restrictions, domestic constraints, and coalition warfare.     

National restrictions in multinational military operations: A conceptual framework

Recent scholarship in security studies has started to explore the causes and consequences of various forms of national restrictions in multinational military operations (MMOs). This article makes a conceptual contribution to this literature by developing a theoretical framework of national restrictions in MMOs that distinguishes between structural, procedural, and operational restrictions. I argue that these types of restrictions are governed by different causal mechanisms. Structural restrictions are relatively stable over time and effect deployment decisions irrespective of other factors. Procedural restrictions, on the other hand, can constitute veto points against deployment only in combination with distinct political preferences. Finally, operational restrictions directly affect the rules of engagement of troop contributing countries. The article illustrates the three types of restrictions and their interaction with empirical examples from a range of countries and sketches their impact on MMO deployment decisions and mandates.     

New inequalities for finite and infinite group problems from approximate lifting

In this paper, we derive new families of facet‐defining inequalities for the finite group problem and extreme inequalities for the infinite group problem using approximate lifting. The new valid inequalities for the finite group problem include two‐ and three‐slope facet‐defining inequalities as well as the first family of four‐slope facet‐defining inequalities. The new valid inequalities for the infinite group problem include families of two‐ and three‐slope extreme inequalities. These new inequalities not only illustrate the diversity of strong inequalities for the finite and infinite group problems, but also provide a large variety of new cutting planes for solving integer and mixed‐integer programming problems. © 2008 Wiley Periodicals, Inc. Naval Research Logistics, 2008     

A poissonian binomial model with constrained parameters

The article examines ways of computing cumulative probabilities for a constrained Poissonian binomial distribution arising from a model of a weapon defense system.     

Benders' cuts guided large neighborhood search for the traveling umpire problem

This article introduces the use of Benders' cuts to guide a large neighborhood search to solve the traveling umpire problem, a sports scheduling problem inspired by the real‐life needs of the officials of a sports league. At each time slot, a greedy matching heuristic is used to construct a schedule. When an infeasibility is recognized first a single step backtracking is tried to resolve the infeasibility. If unsuccessful, Benders' cuts are generated to guide a large neighborhood search to ensure feasibility and to improve the solution. Realizing the inherent symmetry present in the problem, a large family of cuts are generated and their effectiveness is tested. The resulting approach is able to find better solutions to many instances of this problem. © 2011 Wiley Periodicals, Inc. Naval Research Logistics, 2011     

Technical note: Find a hidden “treasure”

This paper deals with a two searchers game and it investigates the problem of how the possibility of finding a hidden object simultaneously by players influences their behavior. Namely, we consider the following two‐sided allocation non‐zero‐sum game on an integer interval [1,n]. Two teams (Player 1 and 2) want to find an immobile object (say, a treasure) hidden at one of n points. Each point i ∈ [1,n] is characterized by a detection parameter λ_i (μ_i) for Player 1 (Player 2) such that p_i(1 ? exp(?λ_ix_i)) (p_i(1 ? exp(?μ_iy_i))) is the probability that Player 1 (Player 2) discovers the hidden object with amount of search effort x_i (y_i) applied at point i where p_i ∈ (0,1) is the probability that the object is hidden at point i. Player 1 (Player 2) undertakes the search by allocating the total amount of effort X(Y). The payoff for Player 1 (Player 2) is 1 if he detects the object but his opponent does not. If both players detect the object they can share it proportionally and even can pay some share to an umpire who takes care that the players do not cheat each other, namely Player 1 gets q₁ and Player 2 gets q₂ where q₁ + q₂ ≤ 1. The Nash equilibrium of this game is found and numerical examples are given. © 2006 Wiley Periodicals, Inc. Naval Research Logistics, 2007