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Raskin M, Keller NE, Agee LA, Shumake J, Smits JA, Telch MJ, Otto MW, Lee HJ, Monfils MH. Carbon Dioxide Reactivity Differentially Predicts Fear Expression After Extinction and Retrieval-Extinction in Rats. BIOLOGICAL PSYCHIATRY GLOBAL OPEN SCIENCE 2024; 4:100310. [PMID: 38680941 PMCID: PMC11047292 DOI: 10.1016/j.bpsgos.2024.100310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 02/11/2024] [Accepted: 03/11/2024] [Indexed: 05/01/2024] Open
Abstract
Background Cues present during a traumatic event may result in persistent fear responses. These responses can be attenuated through extinction learning, a core component of exposure therapy. Exposure/extinction is effective for some people, but not all. We recently demonstrated that carbon dioxide (CO2) reactivity predicts fear extinction memory and orexin activation and that orexin activation predicts fear extinction memory, which suggests that a CO2 challenge may enable identification of whether an individual is a good candidate for an extinction-based approach. Another method to attenuate conditioned responses, retrieval-extinction, renders the original associative memory labile via distinct neural mechanisms. The purpose of the current study was to examine whether we could replicate previous findings that retrieval-extinction is more effective than extinction at preventing the return of fear and that CO2 reactivity predicts fear memory after extinction. We also examined whether CO2 reactivity predicts fear memory after retrieval-extinction. Methods Male rats first underwent a CO2 challenge and fear conditioning and were assigned to receive either standard extinction (n = 28) or retrieval-extinction (n = 28). Then, they underwent a long-term memory (LTM) test and a reinstatement test. Results We found that retrieval-extinction resulted in lower freezing during extinction, LTM, and reinstatement than standard extinction. Using the best subset approach to linear regression, we found that CO2 reactivity predicted LTM after extinction and also predicted LTM after retrieval-extinction, although to a lesser degree. Conclusions CO2 reactivity could be used as a screening tool to determine whether an individual may be a good candidate for an extinction-based therapeutic approach.
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Affiliation(s)
- Marissa Raskin
- Institute for Neuroscience, University of Texas at Austin, Austin, Texas
| | - Nicole E. Keller
- Institute for Neuroscience, University of Texas at Austin, Austin, Texas
| | - Laura A. Agee
- Department of Neuroscience, University of Texas at Austin, Austin, Texas
| | - Jason Shumake
- Department of Psychology, University of Texas at Austin, Austin, Texas
| | - Jasper A.J. Smits
- Department of Psychology, University of Texas at Austin, Austin, Texas
| | - Michael J. Telch
- Department of Psychology, University of Texas at Austin, Austin, Texas
| | - Michael W. Otto
- Department of Psychological & Brain Sciences, Boston University, Boston, Massachusetts
| | - Hongjoo J. Lee
- Institute for Neuroscience, University of Texas at Austin, Austin, Texas
- Department of Psychology, University of Texas at Austin, Austin, Texas
| | - Marie-H. Monfils
- Institute for Neuroscience, University of Texas at Austin, Austin, Texas
- Department of Psychology, University of Texas at Austin, Austin, Texas
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2
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van den End A, Beekman ATF, Dekker J, Thomaes K. Self-rated personality disorder symptoms do not predict treatment outcome for posttraumatic stress disorder in routine clinical care. Clin Psychol Psychother 2023; 30:1338-1348. [PMID: 37985013 DOI: 10.1002/cpp.2933] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To test the hypothesis that self-rated personality disorder (PD) symptoms are a significant and clinically relevant predictor of treatment outcomes in a naturalistic treatment setting specialized in trauma-focused treatment using a single-group pretest-posttest design. METHOD Treatment-seeking patients reporting clinical levels of posttraumatic stress disorder (PTSD) symptoms filled out questionnaires at intake and after treatment. The primary outcome was change in PTSD severity after treatment, measured by the PTSD Checklist for DSM-5 (PCL-5). PD symptoms were measured with the Structured Clinical Interview for DSM-5 Screening Personality Questionnaire (SCID-5-SPQ). Secondary outcomes were general mental health problems, treatment response, number of sessions and dropout. RESULTS N = 1174 patients (59% female, baseline PCL-5 score M [SD] = 53.0 [10.8]) were included for the primary analysis. Regression analysis revealed that PD symptoms explained 0.4% of variance in PTSD symptom change (p = .066). After controlling for baseline PTSD symptoms, PD symptoms explained 0.0% of variance (p = .311). The fully adjusted model including baseline PTSD symptom severity, age, gender, cumulative exposure to potentially traumatic experiences, PD symptoms, and number of sessions together explained 5% of the observed variance in PTSD symptom change. Baseline PTSD severity was the only significant predictor and negatively predicted outcome. Sensitivity analyses with imputed data from N = 2694 cases yielded comparable results. Finally, secondary analyses showed that PD symptoms did not predict significant or clinically relevant changes in treatment response status, general mental health problems, dropout rates or number of sessions. CONCLUSION The findings provide no evidence that self-rated PD symptoms predict treatment outcomes for patients suffering from clinical levels of PTSD symptoms in a naturalistic treatment setting specializing in trauma-focused treatment. Self-report screening for these symptoms to inform clinicians about expected effects of PTSD treatment is not supported by the evidence.
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Affiliation(s)
- Arne van den End
- Department of Psychiatry, Amsterdam University Medical Center, Location Vrije Universiteit Medical Center, Amsterdam, The Netherlands
- Sinai Center, Amstelveen, The Netherlands
| | - Aartjan T F Beekman
- Department of Psychiatry, Amsterdam University Medical Center, Location Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Jack Dekker
- Department of Research, Arkin Mental Health Care, Amsterdam, The Netherlands
- Faculty of Behavioral and Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| | - Kathleen Thomaes
- Department of Psychiatry, Amsterdam University Medical Center, Location Vrije Universiteit Medical Center, Amsterdam, The Netherlands
- Sinai Center, Amstelveen, The Netherlands
- Department of Research, Arkin Mental Health Care, Amsterdam, The Netherlands
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3
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Raskin M, Malone C, Hilz EN, Smits JAJ, Telch MJ, Otto MW, Shumake J, Lee HJ, Monfils MH. CO 2 reactivity is associated with individual differences in appetitive extinction memory. Physiol Behav 2023; 266:114183. [PMID: 37031791 PMCID: PMC10840099 DOI: 10.1016/j.physbeh.2023.114183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/17/2023] [Accepted: 04/04/2023] [Indexed: 04/11/2023]
Abstract
Pavlovian conditioning can underly the maladaptive behaviors seen in psychiatric disorders such as anxiety and addiction. In both the lab and the clinic, these responses can be attenuated through extinction learning, but often return with the passage of time, stress, or a change in context. Extinction to fear and reward cues are both subject to these return of behavior phenomena and have overlap in neurocircuitry, yet it is unknown whether they share any common predictors. The orexin system has been implicated in both fear and appetitive extinction and can be activated through a CO2 challenge. We previously found that behavioral CO2 reactivity predicts fear extinction and orexin activation. Here, we sought to extend our previous findings to determine whether CO2 reactivity might also predict extinction memory for appetitive light-food conditioning. We find that the same subcomponent of behavioral CO2 reactivity that predicted fear extinction also predicts appetitive extinction, but in the opposite direction. We show evidence that this subcomponent remains stable across two CO2 challenges, suggesting it may be a stable trait of both behavioral CO2 reactivity and appetitive extinction phenotype. Our findings further the possibility for CO2 reactivity to be used as a transdiagnostic screening tool to determine whether an individual would be a good candidate for exposure therapy.
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Affiliation(s)
- Marissa Raskin
- The University of Texas at Austin, Institute for Neuroscience, United States
| | - Cassidy Malone
- The University of Texas at Austin, Department of Psychology, United States
| | - Emily N Hilz
- The University of Texas at Austin, Department of Psychology, United States
| | - Jasper A J Smits
- The University of Texas at Austin, Department of Psychology, United States; The University of Texas at Austin, Institute for Mental Health Research, United States
| | - Michael J Telch
- The University of Texas at Austin, Department of Psychology, United States; The University of Texas at Austin, Institute for Mental Health Research, United States
| | | | - Jason Shumake
- The University of Texas at Austin, Department of Psychology, United States; The University of Texas at Austin, Institute for Mental Health Research, United States
| | - Hongjoo J Lee
- The University of Texas at Austin, Institute for Neuroscience, United States; The University of Texas at Austin, Department of Psychology, United States
| | - Marie-H Monfils
- The University of Texas at Austin, Institute for Neuroscience, United States; The University of Texas at Austin, Department of Psychology, United States; The University of Texas at Austin, Institute for Mental Health Research, United States.
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4
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Walter KH, McCabe CT, Watrous JR, Kohen CB, Beltran JL, Kirk A, Campbell JS. Psychological comorbidity: Predictors of residential treatment response among U.S. service members with posttraumatic stress disorder. J Trauma Stress 2022; 35:1381-1392. [PMID: 35470514 PMCID: PMC9790433 DOI: 10.1002/jts.22838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/22/2022] [Indexed: 12/30/2022]
Abstract
Residential posttraumatic stress disorder (PTSD) research in military samples generally shows that in aggregate, PTSD symptoms significantly improve over the course of treatment but can remain at elevated levels following treatment. Identifying individuals who respond to residential treatment versus those who do not, including those who worsen, is critical given the extensive resources required for such programs. This study examined predictors of treatment response among 282 male service members who received treatment in a U.S. Department of Defense residential PTSD program. Using established criteria, service members were classified as improved, indeterminate (referent), or worsened in terms of self-reported PTSD symptoms. Multinomial logistic regression results showed that for PTSD symptoms, higher levels of pretreatment PTSD symptom severity were associated with significantly lower odds of being in the improved group, adjusted odds ratio (aOR) = 0.955, p = .018. In addition, service members who completed treatment were significantly more likely to be in the improved group, aOR = 2.488, p = .048. Longer average pretreatment nightly sleep duration, aOR = 1.157, p = .035, and more severe pretreatment depressive symptoms, aOR = 1.109, p = .014, were associated with significantly higher odds of being in the improved group. These findings reveal clinical characteristics better suited for residential PTSD treatment and highlight implications for comorbid conditions.
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Affiliation(s)
- Kristen H. Walter
- Health and Behavioral Sciences DepartmentNaval Health Research CenterSan DiegoCaliforniaUSA
| | - Cameron T. McCabe
- LeidosRestonVirginiaUSA,Medical Modeling, Simulation, and Mission Support DepartmentNaval Health Research CenterSan DiegoCaliforniaUSA
| | - Jessica R. Watrous
- LeidosRestonVirginiaUSA,Medical Modeling, Simulation, and Mission Support DepartmentNaval Health Research CenterSan DiegoCaliforniaUSA
| | - Casey B. Kohen
- Health and Behavioral Sciences DepartmentNaval Health Research CenterSan DiegoCaliforniaUSA,LeidosRestonVirginiaUSA
| | - Jessica L. Beltran
- Health and Behavioral Sciences DepartmentNaval Health Research CenterSan DiegoCaliforniaUSA,LeidosRestonVirginiaUSA
| | - Alex Kirk
- Directorate of Mental HealthNaval Medical Center San DiegoSan DiegoCaliforniaUSA
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5
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Farrell D, Fadeeva A, Zat Z, Knibbs L, Miller P, Barron I, Matthess H, Matthess C, Gazit N, Kiernan MD. A Stage 1 Pilot Cohort Exploring the Use of EMDR Therapy as a Videoconference Psychotherapy During COVID-19 With Frontline Mental Health Workers: A Proof of Concept Study Utilising a Virtual Blind 2 Therapist Protocol. Front Psychol 2022; 13:901855. [PMID: 35874361 PMCID: PMC9298740 DOI: 10.3389/fpsyg.2022.901855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 04/19/2022] [Indexed: 02/05/2023] Open
Abstract
Objective The COVID-19 pandemic has had a major impact on the delivery of psychological treatment. Due to social distancing requirements, the provision moved to videoconferencing psychotherapy (VCP). There is a paucity of empirical data supporting the efficacy of EMDR therapy as a VCP. This stage 1 pilot study tested an EMDR therapy scripted protocol, such as Virtual Blind 2 Therapist (VB2Tr), on frontline mental health workers as a VCP regarding fitness for purpose, distinctiveness, relevance, and efficiency. Methods A total of 24 participants were recruited for the study. The design included a one-session treatment intervention with pre, post, 1-month, and 6-month follow-up (FU) measurements. This treatment session used a “Blind 2 Therapist” EMDR therapy scripted protocol as videoconference psychotherapy that involves non-disclosure of traumatic memory. The research explored the treatment effect on the core characteristics of trauma memory, including subjective disturbance, belief systems, memory intensity (MI), vividness, and levels of emotionality. Additionally, the research explored participants’ experiences of adverse and benevolent childhood experiences (ACEs/BCEs) during their childhood. Results Regarding the four tests, namely, fitness for purpose, distinctiveness, relevance, and efficiency, results are favourably suggesting potential clinical benefits of using EMDR as videoconference psychotherapy. Although this is a proof-of-concept study showing positive results, no clinical population or control group was used. The purpose of the study is to explore the potential for scalability toward a larger clinical trial. The treatment intervention was achieved irrespective of either ACEs/BCEs during childhood. Conclusion The research tentatively supports the case for EMDR therapy as a credible treatment when used as video conference psychotherapy and in using the Blind 2 Therapist protocol. However, more research is needed to scale toward a clinical trial. Clinical Trial Registration Clinical Trial Registration:https://www.isrctn.com/ISRCTN12099530, identifier ISRCTN12099530.
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Affiliation(s)
- Derek Farrell
- Department for Violence Prevention, Trauma and Criminology (VPTC), School of Psychology, University of Worcester, Worcester, United Kingdom
| | - Anastasia Fadeeva
- Northern Hub for Veteran and Military Families' Research, Northumbria University, Newcastle upon Tyne, United Kingdom
| | - Zeynep Zat
- Department for Violence Prevention, Trauma and Criminology (VPTC), School of Psychology, University of Worcester, Worcester, United Kingdom
| | - Lorraine Knibbs
- Department for Violence Prevention, Trauma and Criminology (VPTC), School of Psychology, University of Worcester, Worcester, United Kingdom
| | - Paul Miller
- Mirabilis Health Institute, Newtownabbey, United Kingdom
| | - Ian Barron
- Centre for International Education, College of Education, University of Massachusetts, Amherst, MA, United States
| | - Helga Matthess
- Department for Violence Prevention, Trauma and Criminology (VPTC), School of Psychology, University of Worcester, Worcester, United Kingdom
| | - Cordula Matthess
- Department for Violence Prevention, Trauma and Criminology (VPTC), School of Psychology, University of Worcester, Worcester, United Kingdom
| | | | - Matthew D Kiernan
- Northern Hub for Veteran and Military Families' Research, Northumbria University, Newcastle upon Tyne, United Kingdom
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6
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Allard CB, Norman SB, Straus E, Kim HM, Stein MB, Simon NM, Rauch SAM. Reductions in guilt cognitions following prolonged exposure and/or sertraline predict subsequent improvements in PTSD and depression. J Behav Ther Exp Psychiatry 2021; 73:101666. [PMID: 34147766 DOI: 10.1016/j.jbtep.2021.101666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 04/27/2021] [Accepted: 05/28/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Reduction of trauma related negative cognitions, such as guilt, is thought to be a mechanism of change within PTSD treatments like prolonged exposure (PE). Research suggests PE can directly address guilt cognitions. However, whether pharmacotherapies for PTSD can remains unclear. METHODS Data from a randomized controlled trial of PE plus placebo (PE + PLB), sertraline plus enhanced medication management (SERT + EMM), and their combination (PE + SERT) in 195 Veterans from recent wars was analyzed. RESULTS The unadjusted means and mixed-effects model showed guilt decreased significantly over the follow-up time as expected; however, contrary to our hypothesis, PE conditions were not associated with greater reductions in guilt than the SERT + EMM condition. As hypothesized, week 12 reduction in guilt predicted post-treatment (weeks 24-52) reduction in PTSD and depression, but not impairments in function. LIMITATIONS Generalizability of findings is limited by the sample being comprised of combat Veterans who were predominantly male, not on SSRI at study entry, willing to be randomized to therapy or medication, and reporting low levels of guilt. To reduce differences in provider attention, SERT + EMM was administered over 30 min to include psychoeducation and active listening; it is unknown if this contributed to effects on guilt. CONCLUSIONS PE + PLB, SERT + EMM, and PE + SERT were equally associated with reduction in trauma related guilt. Reducing trauma related guilt may be a pathway to reducing PTSD and posttraumatic depression symptoms. Further study is needed to determine how best to treat trauma related guilt and to understand the mechanisms by which guilt improves across different treatments for PTSD.
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Affiliation(s)
- Carolyn B Allard
- VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA, 92161, USA; California School of Professional Psychology, Alliant International University, Daley Hall, 10455 Pomerado Rd, San Diego, CA, 92131, USA.
| | - Sonya B Norman
- VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA, 92161, USA; National Center for PTSD, VA Medical Center, 215 North Main st, White River Junction, VT, 05009, USA; University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA, 92093, USA; VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Drive, MC116B, San Diego, CA, 92161, USA.
| | - Elizabeth Straus
- VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA, 92161, USA; University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA, 92093, USA.
| | - H Myra Kim
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA; University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI, 48109, USA.
| | - Murray B Stein
- VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA, 92161, USA; University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA, 92093, USA.
| | - Naomi M Simon
- Massachusetts General Hospital, Department of Psychiatry, One Bowdoin Square, 6th Floor, Boston, MA, 02114, USA; New York University Grossman School of Medicine, Department of Psychiatry, One Park Avenue 8th Floor, New York, NY, 10016, USA.
| | - Sheila A M Rauch
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA; Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033, USA; Emory University School of Medicine, 12 Executive Park, 3rd Floor, Atlanta, GA, 30029, USA.
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7
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Held P, Smith DL, Bagley JM, Kovacevic M, Steigerwald VL, Van Horn R, Karnik NS. Treatment response trajectories in a three-week CPT-Based intensive treatment for veterans with PTSD. J Psychiatr Res 2021; 141:226-232. [PMID: 34246978 PMCID: PMC8364877 DOI: 10.1016/j.jpsychires.2021.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/28/2021] [Accepted: 07/04/2021] [Indexed: 12/16/2022]
Abstract
Response to weekly evidence-based PTSD treatments varies. Little is known about response trajectories and predictors in intensive PTSD treatments. This study sought to identify different trajectories of symptom change among veterans who completed a 3-week CPT-based intensive PTSD treatment program and examined potential predictors of trajectory group membership. Four hundred fifty-two veterans completed the program. Demographics, PTSD and depression severity, negative posttrauma cognitions, and alcohol use were assessed at intake and evaluated as possible predictors of group membership. Group based trajectory modeling was used to determine distinct groups based on PTSD symptom trajectory over the course of treatment, as well as predictors of group membership. Four distinct treatment trajectories were identified: Fast responders (15.3%), steady responders (32.0%), partial responders (38.4%), and minimal responders (14.4%). Fast and steady responders reported substantial symptom reductions and dropped below the "probable PTSD" threshold, with fast responders achieving improvements after just one week of treatment. Partial responders experienced clinically significant reductions but remained above the "probable PTSD" threshold. Minimal responders reported the highest baseline PTSD symptoms and changed the least throughout treatment. Negative posttrauma cognitions as well as self-reported and clinician-rated PTSD symptom severity assessed at intake successfully predicted trajectory membership. The identified trajectories closely resemble findings in the limited existing literature on intensive PTSD treatment trajectories. Results suggest that some individuals may improve with even shorter interventions and others might benefit from additional treatment sessions. Overall, findings support the importance of evaluating individual- and group-level treatment responses.
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Affiliation(s)
- Philip Held
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, IL, USA.
| | - Dale L Smith
- Department of Behavioral Sciences, Olivet Nazarene University, IL, USA
| | - Jenna M Bagley
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, IL, USA
| | - Merdijana Kovacevic
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, IL, USA
| | - Victoria L Steigerwald
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, IL, USA
| | - Rebecca Van Horn
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, IL, USA
| | - Niranjan S Karnik
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, IL, USA
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8
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Barnett P, Goulding L, Casetta C, Jordan H, Sheridan-Rains L, Steare T, Williams J, Wood L, Gaughran F, Johnson S. Implementation of Telemental Health Services Before COVID-19: Rapid Umbrella Review of Systematic Reviews. J Med Internet Res 2021; 23:e26492. [PMID: 34061758 PMCID: PMC8335619 DOI: 10.2196/26492] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/30/2021] [Accepted: 04/30/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Telemental health care has been rapidly adopted for maintaining services during the COVID-19 pandemic, and a substantial interest is now being devoted in its future role. Service planning and policy making for recovery from the pandemic and beyond should draw on both COVID-19 experiences and the substantial research evidence accumulated before this pandemic. OBJECTIVE We aim to conduct an umbrella review of systematic reviews available on the literature and evidence-based guidance on telemental health, including both qualitative and quantitative literature. METHODS Three databases were searched between January 2010 and August 2020 for systematic reviews meeting the predefined criteria. The retrieved reviews were independently screened, and those meeting the inclusion criteria were synthesized and assessed for risk of bias. Narrative synthesis was used to report these findings. RESULTS In total, 19 systematic reviews met the inclusion criteria. A total of 15 reviews examined clinical effectiveness, 8 reported on the aspects of telemental health implementation, 10 reported on acceptability to service users and clinicians, 2 reported on cost-effectiveness, and 1 reported on guidance. Most reviews were assessed to be of low quality. The findings suggested that video-based communication could be as effective and acceptable as face-to-face formats, at least in the short term. Evidence on the extent of digital exclusion and how it can be overcome and that on some significant contexts, such as children and young people's services and inpatient settings, was found to be lacking. CONCLUSIONS This umbrella review suggests that telemental health has the potential to be an effective and acceptable form of service delivery. However, we found limited evidence on the impact of its large-scale implementation across catchment areas. Combining previous evidence and COVID-19 experiences may allow realistic planning for the future implementation of telemental health.
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Affiliation(s)
- Phoebe Barnett
- Centre for Outcomes Research and Effectiveness, Division of Psychology and Language Sciences, University College London, London, United Kingdom.,NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, United Kingdom
| | - Lucy Goulding
- King's Improvement Science, Centre for Implementation Science, King's College London, London, United Kingdom
| | - Cecilia Casetta
- NIHR Applied Research Collaboration, King's College London, London, United Kingdom
| | - Harriet Jordan
- NIHR Applied Research Collaboration, King's College London, London, United Kingdom.,Institute of Psychiatry, Psychology and Neuroscience, King's College London and South London and Maudsley NHS Trust, London, United Kingdom
| | - Luke Sheridan-Rains
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, United Kingdom
| | - Thomas Steare
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, United Kingdom
| | - Julie Williams
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, United Kingdom
| | - Lisa Wood
- Division of Psychiatry, University College London, London, United Kingdom
| | - Fiona Gaughran
- NIHR Applied Research Collaboration, King's College London, London, United Kingdom.,Institute of Psychiatry, Psychology and Neuroscience, King's College London and South London and Maudsley NHS Trust, London, United Kingdom
| | - Sonia Johnson
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, United Kingdom.,Camden and Islington NHS Foundation Trust, London, United Kingdom
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9
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Rienecke RD, Blalock DV, Duffy A, Manwaring J, Le Grange D, Johnson C, Mehler PS, McClanahan SF. Posttraumatic stress disorder symptoms and trauma-informed care in higher levels of care for eating disorders. Int J Eat Disord 2021; 54:627-632. [PMID: 33382109 DOI: 10.1002/eat.23455] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The purpose of the current study was to examine the prevalence and trajectory of posttraumatic stress disorder (PTSD) symptoms among patients with eating disorders (EDs) in higher level of ED care with trauma-informed components, but without a formal evidence-based trauma intervention. METHOD Participants were 613 adults diagnosed with EDs receiving treatment at inpatient, residential, or partial hospitalization levels of care. Participants completed the PTSD Checklist-5 (PCL-5) at admission and discharge. RESULTS Over half of patients scored above the cutoff of 33 on the PCL-5 at admission, suggestive of PTSD symptoms characteristic of a formal PTSD diagnosis. The average PCL-5 score significantly decreased for every ED diagnostic category, and there was a significant reduction in the proportion of patients above the PCL-5 cutoff score at discharge. PCL-5 subscales measuring PTSD criteria B (intrusions) and C (avoidance) improved with modest effect sizes, whereas PCL-5 subscales D (negative alterations in cognitions and mood) and E (alterations in arousal and reactivity) improved with larger effect sizes. DISCUSSION PTSD symptoms are prevalent among patients with EDs seeking higher levels of care. Despite not offering evidence-based trauma-specific interventions, PTSD symptoms decreased over the course of treatment. However, improvements cannot definitely be attributed to trauma-informed care.
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Affiliation(s)
- Renee D Rienecke
- Eating Recovery Center and Pathlight Mood and Anxiety Centers, Denver, Colorado, USA.,Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, Illinois, USA
| | - Dan V Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alan Duffy
- Eating Recovery Center and Pathlight Mood and Anxiety Centers, Denver, Colorado, USA
| | - Jamie Manwaring
- Eating Recovery Center and Pathlight Mood and Anxiety Centers, Denver, Colorado, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA.,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois, USA
| | - Craig Johnson
- Eating Recovery Center and Pathlight Mood and Anxiety Centers, Denver, Colorado, USA
| | - Philip S Mehler
- Eating Recovery Center and Pathlight Mood and Anxiety Centers, Denver, Colorado, USA.,ACUTE, at Denver Health, Denver, Colorado, USA.,Department of Medicine, University of Colorado, Denver, Colorado, USA
| | - Susan F McClanahan
- Eating Recovery Center and Pathlight Mood and Anxiety Centers, Denver, Colorado, USA.,Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, Illinois, USA.,Department of Psychiatry, Rush University Medical Center, Chicago, Illinois, USA
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10
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Stevens NR, Miller ML, Soibatian C, Otwell C, Rufa AK, Meyer DJ, Shalowitz MU. Exposure therapy for PTSD during pregnancy: a feasibility, acceptability, and case series study of Narrative Exposure Therapy (NET). BMC Psychol 2020; 8:130. [PMID: 33298159 PMCID: PMC7727253 DOI: 10.1186/s40359-020-00503-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/04/2020] [Indexed: 11/17/2022] Open
Abstract
Background Prenatal posttraumatic stress disorder (PTSD) is a significant complication of pregnancy linked to increased risk of adverse perinatal outcomes. Although 1 in 5 pregnant trauma-exposed individuals have PTSD, most PTSD treatment trials exclude participants who are pregnant, and none focus on treatment specifically during pregnancy. Moreover, access to mental health treatment is particularly challenging in low-resource settings with high rates of trauma. This study examined implementation of Narrative Exposure Therapy (NET), a short-term evidence-based PTSD treatment, in an urban prenatal care setting. Partial telehealth delivery was used to increase accessibility. Study aims were to examine (a) feasibility, (b) acceptability, and (c) case-based treatment outcomes associated with NET participation. Method Eight pregnant participants (median age = 27, median gestational week in pregnancy = 22.5) received up to six sessions of NET with partial telehealth delivery. PTSD and depression symptoms were assessed at pre-treatment intake (T1), at each session (T2), and 1-week post-treatment (T3). A multiple case study approach was used to examine recruitment and engagement, retention, treatment completion, treatment barriers, use of telehealth, participants’ experiences of treatment, and PTSD and depression symptoms. Results Nine of the 16 participants (56%) who were invited to participate engaged in treatment, and one dropped out after the first session. Eight participants completed the minimum “dose” of 4 NET sessions (N = 8/9, 89%). Seven participants gave the highest ratings of treatment acceptability. The most frequently reported barriers to treatment were competing priorities of work and caring for other children. Pre-post treatment symptom measures revealed clinically meaningful change in PTSD severity for nearly all participants (7/8, 88%). Conclusions Results suggest that a brief exposure therapy PTSD treatment can be successfully implemented during pregnancy, suggesting promising results for conducting a larger-scale investigation. Trial registration ClinicalTrials.gov, NCT04525469. Registered 20 August 2020–Retrospectively registered, https://register.clinicaltrials.gov/prs/app/template/EditRecord.vm?epmode=View&listmode=Edit&uid=U00058T2&ts=3&sid=S000A59A&cx=-w1vnvn
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Affiliation(s)
- Natalie R Stevens
- Rush University Medical Center, 1645 West Jackson Blvd, Chicago, IL, 60612, USA.
| | - Michelle L Miller
- Rush University Medical Center, 1645 West Jackson Blvd, Chicago, IL, 60612, USA
| | - Christina Soibatian
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
| | - Caitlin Otwell
- Rush University Medical Center, 1645 West Jackson Blvd, Chicago, IL, 60612, USA
| | - Anne K Rufa
- Rush University Medical Center, 1645 West Jackson Blvd, Chicago, IL, 60612, USA
| | - Danie J Meyer
- Vivo International, P.O. Box, 5108D-78430, Konstanz, Germany
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11
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Allan NP, López-Castro T, Hien DA, Papini S, Killeen TK, Gros DF, Ruglass LM, Barrett E, Back SE. Response-to-Treatment for Comorbid Post-Traumatic Stress and Substance Use Disorders: The Value of Combining Person- and Variable-Centered Approaches. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2020; 42:725-738. [PMID: 33239837 PMCID: PMC7682732 DOI: 10.1007/s10862-020-09803-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Optimizing treatment for co-occurring post-traumatic stress disorder and substance use disorder (PTSD+SUD) is critically important. Whereas treatments have been designed that target PTSD+SUD with some success, these treatments do not benefit all. Data-driven approaches that combine person- and variable-centered methods, such as parallel process latent class growth analysis (PP-LCGA) can be used to identify response-to-treatment trajectories across both PTSD symptoms and substance use. The current study employed PP-LCGA separately in two randomized clinical trials (study 1 n = 81, Mean age = 40.4 years, SD = 10.7; study 2 n = 59, Mean age = 44.7 years, SD = 9.4) to examine PTSD symptom response and percentage of days using substances across treatment trials comparing Concurrent Treatment of PTSD and SUD using Prolonged Exposure and Relapse Prevention. Results revealed four PTSD+SUD profiles for study one and three PTSD+SUD profiles for study two. For PTSD symptoms, response trajectories could be broadly classified into treatment responders and non-responders across both studies. For substance use, response trajectories could be broadly classified into declining, moderately stable, and abstaining profiles. When considering PTSD symptoms and substance use trajectories together, profiles emerged that would have been missed had these treatment outcomes been considered separately.
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Affiliation(s)
| | | | - Denise A. Hien
- Gordon F. Derner Institute of Advanced Psychological Studies, Adelphi, Garden City, NY
| | | | - Therese K. Killeen
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Daniel F. Gros
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
| | - Lesia M. Ruglass
- Department of Psychology, The City College of New York, New York, NY
| | - Emma Barrett
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Sudie E. Back
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
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12
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Holder N, Shiner B, Li Y, Madden E, Neylan TC, Seal KH, Lujan C, Patterson OV, DuVall SL, Maguen S. Determining the median effective dose of prolonged exposure therapy for veterans with posttraumatic stress disorder. Behav Res Ther 2020; 135:103756. [PMID: 33157475 DOI: 10.1016/j.brat.2020.103756] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 08/14/2020] [Accepted: 10/16/2020] [Indexed: 10/23/2022]
Abstract
Prolonged exposure therapy (PE) is an effective treatment for posttraumatic stress disorder (PTSD). Identifying metrics of treatment response can guide treatment delivery. The median effective dose represents the number of sessions at which there is a 50% probability of clinically meaningful improvement (i.e., 10-point reduction in PTSD checklist). The goal of the current study was to investigate the median effective dose of PE. We identified a cohort of Iraq and Afghanistan war veterans who received psychotherapy for PTSD in the Veterans Health Administration between 2001 and 2017. From this cohort, 10,234 veterans who received PE (as identified using natural language processing) and had ≥2 PTSD symptom measures were included in analyses. To determine how the number of PE sessions and covariates affected clinically meaningful improvement, we utilized a Cox proportional hazards regression, followed by Kaplan-Meier curves to determine the median effective dose. The median effective dose of PE was four sessions. Although some covariates were found to be statistically significant predictors of clinically meaningful improvement (e.g., age, gender, PTSD medications, and depressive disorder comorbidity), these effects were small. Clinicians and patients should consider evaluating treatment response after four sessions to determine preliminary effectiveness of PE.
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Affiliation(s)
- Nicholas Holder
- San Francisco Veterans Affairs Health Care System, United States; Sierra Pacific Mental Illness Research, Education, and Clinical Center, United States; University of California San Francisco School of Medicine, United States.
| | - Brian Shiner
- White River Junction Veterans Affairs Medical Center, United States; Geisel School of Medicine at Dartmouth, United States; National Center for Posttraumatic Stress Disorder, Executive Division, United States
| | - Yongmei Li
- San Francisco Veterans Affairs Health Care System, United States
| | - Erin Madden
- San Francisco Veterans Affairs Health Care System, United States
| | - Thomas C Neylan
- San Francisco Veterans Affairs Health Care System, United States; Sierra Pacific Mental Illness Research, Education, and Clinical Center, United States; University of California San Francisco School of Medicine, United States
| | - Karen H Seal
- San Francisco Veterans Affairs Health Care System, United States; University of California San Francisco School of Medicine, United States
| | - Callan Lujan
- San Francisco Veterans Affairs Health Care System, United States
| | - Olga V Patterson
- Department of Veterans Affairs Salt Lake City Health Care System, United States; University of Utah School of Medicine, United States
| | - Scott L DuVall
- Department of Veterans Affairs Salt Lake City Health Care System, United States; University of Utah School of Medicine, United States
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System, United States; Sierra Pacific Mental Illness Research, Education, and Clinical Center, United States; University of California San Francisco School of Medicine, United States
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13
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Maguen S, Holder N, Li Y, Madden E, Neylan TC, Seal KH, Lujan C, Patterson OV, DuVall SL, Shiner B. Factors associated with PTSD symptom improvement among Iraq and Afghanistan veterans receiving evidenced-based psychotherapy. J Affect Disord 2020; 273:1-7. [PMID: 32421589 DOI: 10.1016/j.jad.2020.04.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/02/2020] [Accepted: 04/24/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite availability of evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), not all veterans who initiate EBPs experience benefit. Better understanding factors associated with clinically significant improvement can help ameliorate care. METHODS A cohort of Iraq and Afghanistan War veterans who initiated an EBP was identified (N = 32,780) with ≥1 post-deployment psychotherapy visit at the Veterans Health Administration from 10/2001-6/2017, a post-deployment PTSD diagnosis, and ≥2 PTSD symptom measures. We used random-effects logistic regression to assess whether patient-level, diagnostic, and treatment factors were associated with achieving symptom improvement. RESULTS Increased odds of PTSD symptom improvement were seen in women (OR = 1.19; 95% CI: 1.09--1.29), those who initiated EBP within a year of engaging in mental healthcare compared with the delayed EBP group (OR = 1.20; 95% CI: 1.14--1.28), those who completed at least 8 EBP sessions in 16 weeks (OR = 1.23; 95% CI:1.11--1.36), those who received PE only (vs. CPT or both; OR = 2.23; 95% CI: 1.86--2.68) or CPT individual therapy only (vs. CPT group or both; OR = 1.34; 95% CI: 1.22--1.48), and those with a drug dependence diagnosis (OR = 1.24; 95% CI: 1.11--1.39). Decreased odds of improvement were seen in Black veterans (OR=0.75; 95% CI: 0.69--0.81) and those with service-connected disability (OR = 0.61; 95% CI: 0.52--0.71). LIMITATIONS Diagnoses were from medical charts and not confirmed with gold standard assessment tools; we only included veterans with at least two PTSD measurements, which may cause bias. CONCLUSION Modifiable factors associated with PTSD improvement (timing, dose, and modality) can be used to improve EBP outcomes.
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Affiliation(s)
- Shira Maguen
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine.
| | - Nicholas Holder
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine
| | - Yongmei Li
- San Francisco Veterans Affairs Health Care System
| | - Erin Madden
- San Francisco Veterans Affairs Health Care System
| | - Thomas C Neylan
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine
| | - Karen H Seal
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center
| | - Callan Lujan
- San Francisco Veterans Affairs Health Care System
| | - Olga V Patterson
- Department of Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine
| | - Scott L DuVall
- Department of Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine
| | - Brian Shiner
- White River Junction Veterans Affairs Medical Center; Geisel School of Medicine at Dartmouth; National Center for Posttraumatic Stress Disorder, Executive Division
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14
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Kaltenbach E, Hermenau K, Schauer M, Dohrmann K, Elbert T, Schalinski I. Trajectories of posttraumatic stress symptoms during and after Narrative Exposure Therapy (NET) in refugees. BMC Psychiatry 2020; 20:312. [PMID: 32552778 PMCID: PMC7298826 DOI: 10.1186/s12888-020-02720-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 06/09/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Trauma-focused therapy approaches are recommended as treatment for posttraumatic stress disorder (PTSD). This includes the treatment of trauma-related suffering in refugee populations. However, there is a lack of knowledge about symptom trajectories in refugees living in volatile conditions. This has led to fear of "retraumatisation" and general skepticism in clinicians concerning the use of exposure therapy. METHODS To test the relevance of this concern, we investigated PTSD symptom trajectories and potentially influencing factors during the course of Narrative Exposure Therapy (NET) in a refugee sample living in Germany. Refugees filled out the PTSD Checklist prior to each treatment session and also during follow-up interviews. Therapists continuously documented positive and negative life events as well as the content of the treatment sessions. Additionally, structured clinical interviews were conducted pre-treatment and at follow-up time points. RESULTS On average, clients presented with substantial decreases in PTSD symptoms already during and after NET. However, symptom trajectories differed and ranged from fast responders to slow responders to no immediate response during treatment. Importantly, a persistent worsening of symptoms was not observed, also not after exposure to the most distressing events. In contrast, stressful life experiences seemed to aggravate PTSD symptoms. CONCLUSIONS Consistent with earlier studies, NET leads to clinically and behaviorally relevant reductions in PTSD symptoms both throughout and following treatment in refugees living in volatile conditions. Concerns about imaginal exposure in refugees were not substantiated. While stressful life events contributed to transient symptom increases, they weren't found to prevent the overall effectiveness of NET. TRIAL REGISTRATION NCT02852616.
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Affiliation(s)
- Elisa Kaltenbach
- Department of Psychology, University of Konstanz, Konstanz, Germany. .,Centre for Research in Family Health, IWK Health Centre, Halifax, NS, Canada. .,Vivo International e.V., Konstanz, Germany.
| | - Katharin Hermenau
- grid.9811.10000 0001 0658 7699Department of Psychology, University of Konstanz, Konstanz, Germany ,Vivo International e.V., Konstanz, Germany
| | - Maggie Schauer
- grid.9811.10000 0001 0658 7699Department of Psychology, University of Konstanz, Konstanz, Germany ,Vivo International e.V., Konstanz, Germany
| | - Katalin Dohrmann
- grid.9811.10000 0001 0658 7699Department of Psychology, University of Konstanz, Konstanz, Germany ,Vivo International e.V., Konstanz, Germany
| | - Thomas Elbert
- grid.9811.10000 0001 0658 7699Department of Psychology, University of Konstanz, Konstanz, Germany ,Vivo International e.V., Konstanz, Germany
| | - Inga Schalinski
- grid.9811.10000 0001 0658 7699Department of Psychology, University of Konstanz, Konstanz, Germany ,Vivo International e.V., Konstanz, Germany ,Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Medical Psychology, Berlin, Germany
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15
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van Veen SC, van Schie K, van de Schoot R, van den Hout MA, Engelhard IM. Making eye movements during imaginal exposure leads to short-lived memory effects compared to imaginal exposure alone. J Behav Ther Exp Psychiatry 2020; 67:101466. [PMID: 30885389 DOI: 10.1016/j.jbtep.2019.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/01/2019] [Accepted: 03/01/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES A plethora of eye movement desensitization and reprocessing (EMDR) analogue studies has shown that, in the short term, making eye movements (EM) during brief imaginal exposure ("recall + EM") blurs memories more than just imaginal exposure ("recall only"). Yet, results of the few studies that included a follow-up test are inconsistent. We improved this paradigm's ecological validity by including an extended intervention phase and multiple assessments per phase. We hypothesized that recall + EM results in larger immediate and 24 h reductions in memory vividness, negative valence, and distress than recall alone. We explored the persistence of the effects, as well as the predictive value of memory characteristics and individual differences. METHODS Students (N = 100) selected a negative autobiographical memory and were randomized to recall + EM or recall alone; both interventions lasted 32 intervals of 24s. During the interventions they rated the memory after every four intervals. RESULTS After 4 × 24s intervention, recall + EM resulted in memory deflation, while recall only caused memory inflation. After the full intervention (i.e., 32 × 24s), both conditions resulted in immediate and 24 h reductions on all outcome measures. Crucially, memory effects in the recall + EM condition partially relapsed 24 h later, while the effects in the recall only condition persisted. Change patterns were hardly explained by predictive variables. LIMITATIONS We used a non-clinical sample; replication in clinical samples is warranted. CONCLUSION Making EM during imaginal exposure leads to short-lived effects compared to imaginal exposure alone. However, EM may offer a response aid for those who avoid imaginal exposure.
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Affiliation(s)
- Suzanne C van Veen
- Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.
| | - Kevin van Schie
- Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands; Department of Psychology, Education and Child Studies, Erasmus University, Rotterdam, the Netherlands
| | - Rens van de Schoot
- Department of Methods and Statistics, Utrecht University, Utrecht, the Netherlands
| | | | - Iris M Engelhard
- Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands
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16
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Karst A, Colvard M, Bean J, Patel E, Pate R, Lister J. Impact of a mental health trainee interdisciplinary program on a veteran population. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Allison Karst
- Department of Pharmacy, VA Tennessee Valley Healthcare System Murfreesboro Tennessee
| | - Michelle Colvard
- Department of Pharmacy, VA Tennessee Valley Healthcare System Murfreesboro Tennessee
| | - Jennifer Bean
- Department of Pharmacy, VA Tennessee Valley Healthcare System Murfreesboro Tennessee
- University of Tennessee Memphis Tennessee
- Union University Jackson Tennessee
- Lipscomb University Nashville Tennessee
- Belmont University Nashville Tennessee
| | - Erin Patel
- Department of Psychology, Tennessee Valley Healthcare System Murfreesboro Tennessee
- Vanderbilt University Nashville Tennessee
| | - Rebecca Pate
- VA Alexandria Healthcare System Alexandria Louisiana
- University of Tennessee Health Science Center Knoxville Tennessee
| | - Jonathan Lister
- Department of Pharmacy, VA Tennessee Valley Healthcare System Murfreesboro Tennessee
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17
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Dewar M, Paradis A, Fortin CA. Identifying Trajectories and Predictors of Response to Psychotherapy for Post-Traumatic Stress Disorder in Adults: A Systematic Review of Literature. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2020; 65:71-86. [PMID: 31535576 PMCID: PMC6997973 DOI: 10.1177/0706743719875602] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE There exists considerable individual variability in the development and progression of pathological stress reactions after experiencing trauma, as well as in individuals' response to psychological interventions. Yet until recently, such individual differences had not been considered when evaluating the efficacy of therapeutic interventions for post-traumatic stress disorder (PTSD). This systematic review aims to examine the emerging literature on this subject and, specifically, to identify trajectories and predictors of psychotherapeutic response in adults with PTSD. METHOD Four databases were searched using specific keywords without date or language restrictions. For each study, independent reviewers systematically evaluated whether it met eligibility criteria and assessed risk of bias. For included studies, reviewers completed data extraction using standard formats. Those examining how subgroups of adults respond to therapy for clinical PTSD using trajectory modeling were deemed eligible. Demographic, PTSD, clinical, and trauma-related factors associated to particular trajectories were also examined. RESULTS Of the 1,727 papers identified, 11 were included in this analysis. Of these studies, six focused on military-related traumas and five on civilian ones. Although studies found between two and five trajectories, most supported a three-trajectory model of response categorized as responders, nonresponders, and subclinical participants. Over 22 predictors of treatment trajectories were examined. Comorbid depression, anxiety, and alcohol abuse were the strongest predictors of poor therapeutic response. Age, combat exposure, social support, and hyperarousal were moderate predictors. CONCLUSION This review provides valuable insight into the treatment of PTSD, as it supports the heterogeneous trajectories of psychotherapeutic responses and provides avenues for the development of interventions that consider individual-level factors in treatment response.
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Affiliation(s)
- Michelle Dewar
- Psychology Department, University of Quebec in Montreal, Quebec,
Canada
| | - Alison Paradis
- Psychology Department, University of Quebec in Montreal, Quebec,
Canada
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18
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Sripada RK, Ready DJ, Ganoczy D, Astin MC, Rauch SAM. When to Change the Treatment Plan: An Analysis of Diminishing Returns in VA Patients Undergoing Prolonged Exposure and Cognitive Processing Therapy. Behav Ther 2020; 51:85-98. [PMID: 32005342 DOI: 10.1016/j.beth.2019.05.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 12/15/2022]
Abstract
Evidence-based treatments for posttraumatic stress disorder (PTSD) often produce significant symptom reduction within eight sessions. However, some patients take longer to respond and a better understanding of predictors of later response can help guide treatment. In the current study, the cohort consisted of all VA patients with a PTSD diagnosis who received at least eight sessions of documented evidence-based treatment within a 6-month period in FY16-FY17 and had at least two PTSD symptom assessments. We examined the proportion of patients who achieved meaningful change (defined as at least 50% reduction in self-reported PTSD symptoms), both within the first eight sessions and subsequently. Fourteen percent of patients achieved meaningful change within eight sessions and 10% subsequently. Symptom change within the first eight sessions was highly predictive of subsequent change. Those who experienced at least 20% symptom reduction by session eight were twice as likely to subsequently achieve meaningful change as compared with all patients who continued treatment. Patients receiving service-connected disability compensation were less likely and White patients more likely to achieve meaningful change. Without some degree of symptom reduction by session eight, patients are unlikely to achieve meaningful change if treatment is not enhanced or changed.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research VA Ann Arbor Health Care System; University of Michigan.
| | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research and Veterans Affairs Ann Arbor Health Care System
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19
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Brown LA, Clapp JD, Kemp JJ, Yarvis JS, Dondanville KA, Litz BT, Mintz J, Roache JD, Young-McCaughan S, Peterson AL, Foa EB. The pattern of symptom change during prolonged exposure therapy and present-centered therapy for PTSD in active duty military personnel. Psychol Med 2019; 49:1980-1989. [PMID: 30220261 DOI: 10.1017/s0033291718002714] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Few studies have investigated the patterns of posttraumatic stress disorder (PTSD) symptom change in prolonged exposure (PE) therapy. In this study, we aimed to understand the patterns of PTSD symptom change in both PE and present-centered therapy (PCT). METHODS Participants were active duty military personnel (N = 326, 89.3% male, 61.2% white, 32.5 years old) randomized to spaced-PE (S-PE; 10 sessions over 8 weeks), PCT (10 sessions over 8 weeks), or massed-PE (M-PE; 10 sessions over 2 weeks). Using latent profile analysis, we determined the optimal number of PTSD symptom change classes over time and analyzed whether baseline and follow-up variables were associated with class membership. RESULTS Five classes, namely rapid responder (7-17%), steep linear responder (14-22%), gradual responder (30-34%), non-responder (27-33%), and symptom exacerbation (7-13%) classes, characterized each treatment. No baseline clinical characteristics predicted class membership for S-PE and M-PE; in PCT, more negative baseline trauma cognitions predicted membership in the non-responder v. gradual responder class. Class membership was robustly associated with PTSD, trauma cognitions, and depression up to 6 months after treatment for both S-PE and M-PE but not for PCT. CONCLUSIONS Distinct profiles of treatment response emerged that were similar across interventions. By and large, no baseline variables predicted responder class. Responder status was a strong predictor of future symptom severity for PE, whereas response to PCT was not as strongly associated with future symptoms.
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Affiliation(s)
- Lily A Brown
- Department of Psychiatry, University of Pennsylvania, 3535 Market Street Suite 600 N, Philadelphia, PA 19104,USA
| | | | | | | | | | - Brett T Litz
- VA Boston Healthcare System and Boston University School of Medicine, Boston, MA,USA
| | - Jim Mintz
- University of Texas Health Science Center at San Antonio, San Antonio, TX,USA
| | - John D Roache
- University of Texas Health Science Center at San Antonio, San Antonio, TX,USA
| | | | - Alan L Peterson
- University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, TX,USA
| | - Edna B Foa
- University of Pennsylvania, Philadelphia, PA,USA
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20
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Murphy D, Turgoose D. Evaluating an Internet-based video cognitive processing therapy intervention for veterans with PTSD: A pilot study. J Telemed Telecare 2019; 26:552-559. [PMID: 31208264 DOI: 10.1177/1357633x19850393] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION There remain a number of UK military veterans who are not able to access psychological therapies for post-traumatic stress disorder (PTSD). Some of these barriers are practical, including the need to balance work and other life commitments with attendance at residential or outpatient appointments. There is a need to investigate more accessible and flexible methods of delivering psychological therapies to veterans. One such alternative is to use remote-access video technology, often referred to as tele-therapy. The aims of the present study were to explore the feasibility of using tele-therapy in this population, whilst also reporting mental health outcomes for those who accessed the intervention. METHODS Participants were recruited from a UK veterans mental health charity. The intervention consisted of 12 sessions of cognitive processing therapy delivered via Skype. Participants completed various measures of mental health, including PTSD at three time points: pre-treatment, post-treatment and at three months follow-up. A measure of therapeutic alliance was also completed by participants and the clinician. RESULTS A total of 27 participants engaged in tele-therapy, with a treatment completion rate of 79% and a 'did not attend' rate of 12%, which compared well against similar outpatient services. All mental health outcomes showed maintained improvement at three months follow-up, with the highest effect size recorded for PTSD. Therapeutic alliance was also rated highly by both participants and the clinician. DISCUSSION The findings suggest that tele-therapy could provide a viable alternative format for delivering trauma-focused psychological therapies to veterans. Limitations and recommendations for future research are also presented.
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Affiliation(s)
- Dominic Murphy
- Combat Stress, King's Centre for Military Health Research, Leatherhead, Surrey, UK
| | - David Turgoose
- Combat Stress, King's Centre for Military Health Research, Leatherhead, Surrey, UK
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21
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Rauch SAM, Kim HM, Powell C, Tuerk PW, Simon NM, Acierno R, Allard CB, Norman SB, Venners MR, Rothbaum BO, Stein MB, Porter K, Martis B, King AP, Liberzon I, Phan KL, Hoge CW. Efficacy of Prolonged Exposure Therapy, Sertraline Hydrochloride, and Their Combination Among Combat Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2019; 76:117-126. [PMID: 30516797 PMCID: PMC6439753 DOI: 10.1001/jamapsychiatry.2018.3412] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/08/2018] [Indexed: 12/30/2022]
Abstract
Importance Meta-analyses of treatments for posttraumatic stress disorder (PTSD) suggest that trauma-focused psychotherapies produce greater benefits than antidepressant medications alone. Objective To determine the relative efficacy of prolonged exposure therapy plus placebo, prolonged exposure therapy plus sertraline hydrochloride, and sertraline plus enhanced medication management in the treatment of PTSD. Design, Setting, and Participants The Prolonged Exposure and Sertraline Trial was a randomized, multisite, 24-week clinical trial conducted at the Veterans Affairs Ann Arbor Healthcare System, Veterans Affairs San Diego Healthcare System, Ralph H. Johnson Veterans Affairs Medical Center, and Massachusetts General Hospital Home Base Veterans Program between January 26, 2012, and May 9, 2016. Participants and clinicians were blinded to pill condition, and outcome evaluators were blinded to assignment. Participants completed assessments at weeks 0 (intake), 6, 12, 24, and 52 (follow-up). Participants (N = 223) were service members or veterans of the Iraq and/or Afghanistan wars with combat-related PTSD and significant impairment (Clinician-Administered PTSD Scale score, ≥50) of at least 3 months' duration. Analyses were on an intent-to-treat basis. Intervention Participants completed up to thirteen 90-minute sessions of prolonged exposure therapy by week 24. Sertraline dosage was titrated during a 10-week period and continued until week 24; medication management was manualized. Main Outcomes and Measures The primary outcome was symptom severity of PTSD in the past month as assessed by the Clinician-Administered PTSD Scale score at week 24. Results Of 223 randomized participants, 149 completed the study at 24 weeks, and 207 (180 men and 27 women; mean [SD] age, 34.5 [8.3 years]) were included in the intent-to-treat analysis. Modified intent-to-treat analysis using a mixed model of repeated measures showed that PTSD symptoms decreased significantly during the 24 weeks (sertraline plus enhanced medication management, 33.8 points; prolonged exposure therapy plus sertraline, 32.7 points; and prolonged exposure therapy plus placebo, 29.4 points; β,-9.39; 95% CI, -11.62 to -7.16; P < .001); however, slopes did not differ by treatment group (prolonged exposure therapy plus placebo group, -9.39; sertraline plus enhanced medication management group, -10.37; and prolonged exposure therapy plus sertraline group, -9.99; P = .81). Conclusions and Relevance No difference in change in PTSD symptoms or symptom severity at 24 weeks was found between sertraline plus enhanced medication management, prolonged exposure therapy plus placebo, and prolonged exposure therapy plus sertraline. Trial Registration ClinicalTrials.gov Identifier: NCT01524133.
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Affiliation(s)
- Sheila A. M. Rauch
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - H. Myra Kim
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor
| | - Corey Powell
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor
| | - Peter W. Tuerk
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
- Department of Psychiatry, Medical University of South Carolina, Charleston
| | - Naomi M. Simon
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Psychiatry, New York University School of Medicine, New York
| | - Ron Acierno
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
- College of Nursing, Medical University of South Carolina, Charleston
| | - Carolyn B. Allard
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
| | - Sonya B. Norman
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
- Veterans Affairs Center of Excellence for Stress and Mental Health, San Diego, California
| | - Margaret R. Venners
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
| | - Barbara O. Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Murray B. Stein
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
| | - Katherine Porter
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - Brian Martis
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
| | - Anthony P. King
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - Israel Liberzon
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - K. Luan Phan
- Department of Psychiatry, University of Illinois at Chicago
- Mental Health Service Line, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
| | - Charles W. Hoge
- Walter Reed Army Institute of Research, Silver Spring, Maryland
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22
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Fowler JC, Clapp JD, Madan A, Allen JG, Frueh BC, Fonagy P, Oldham JM. A naturalistic longitudinal study of extended inpatient treatment for adults with borderline personality disorder: An examination of treatment response, remission and deterioration. J Affect Disord 2018; 235:323-331. [PMID: 29665515 DOI: 10.1016/j.jad.2017.12.054] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/02/2017] [Accepted: 12/27/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Experts express reluctance to hospitalize patients with borderline personality disorder (BPD) for more than a few days, arguing that extended inpatient care leads to deterioration and adverse events. To date, there is no empirical support for these assertions. AIMS The current study examined the assumption of iatrogenic effects among BPD adults. METHODS Clinically significant and reliable change in symptoms, functional capacities, and adverse events were quantified for both inpatients with BPD (n = 245) and a well-matched inpatient reference (n = 220) sample. Latent growth curve (LGC) models were used to evaluate moderators of the trajectory of PHQ-9 depression scores over the course of hospitalization. RESULTS Large effect size improvements were observed in depression, anxiety, suicidal ideation and functional disability among patients with BPD (Cohen's d ≥ 1.0) and those in the reference sample (Cohen's d ≥ .80). Clinical deterioration and adverse events were rare (occurring in no more than 1.1% of BPD and reference patients on any outcome) with no difference across patient cohorts. BPD diagnosis failed to influence the trajectory of continuous depression severity. Rather, trait emotion dysregulation was associated with initial depression severity. CONCLUSIONS Twenty-five years ago it was assumed that adults with BPD could not benefit from psychiatric treatment. Today there are a number of effective evidence-based outpatient treatments for BPD, but beliefs about extended inpatient treatment have changed little. Current results indicate that extended inpatient treatment can result in significant and clinically meaningful symptomatic and functional improvement in BPD patients without iatrogenic effects.
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Affiliation(s)
- J Christopher Fowler
- The Menninger Clinic, 12301 Main Street, Houston, TX 77035, United States; Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States; Houston Methodist Hospital, United States.
| | - Joshua D Clapp
- University of Wyoming, 1000 E. University Ave., Laramie, WY 82071, United States
| | - Alok Madan
- The Menninger Clinic, 12301 Main Street, Houston, TX 77035, United States; Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States; Houston Methodist Hospital, United States
| | - Jon G Allen
- Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States
| | | | - Peter Fonagy
- Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States; University College London, Gower Street, London WC1E 6BT, United Kingdom
| | - John M Oldham
- Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States
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23
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Hendriks L, de Kleine RA, Broekman TG, Hendriks GJ, van Minnen A. Intensive prolonged exposure therapy for chronic PTSD patients following multiple trauma and multiple treatment attempts. Eur J Psychotraumatol 2018; 9:1425574. [PMID: 29410776 PMCID: PMC5795659 DOI: 10.1080/20008198.2018.1425574] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 12/23/2017] [Indexed: 11/15/2022] Open
Abstract
Background: Suboptimal response and high dropout rates leave room for improvement of trauma-focused treatment (TFT) effectiveness in ameliorating posttraumatic stress disorder (PTSD) symptoms. Objective: To explore the effectiveness and safety of intensive prolonged exposure (iPE) targeting chronic PTSD patients with a likely diagnosis of ICD-11 Complex PTSD following multiple interpersonal trauma and a history of multiple treatment attempts. Method: Participants (N = 73) received iPE in 12 × 90-minute sessions over four days (intensive phase) followed by four weekly 90-minute booster prolonged exposure (PE) sessions (booster phase). The primary outcomes, clinician-rated severity of PTSD symptoms, and diagnostic status (Clinician-Administered PTSD Scale; CAPS-IV) were assessed at baseline, post-treatment, and at three and six months. Treatment response trajectories were identified and predictors of these trajectories explored. Results: Mixed model repeated measures analysis of CAPS-IV scores showed a baseline-to-posttreatment decrease in PTSD symptom severity (p < .001) that persisted during the three- and six-month follow-ups with large effect sizes (Cohen's d > 1.2); 71% of the participants responded. None of the participants dropped out during the intensive phase and only 5% during the booster phase. Adverse events were extremely low and only a minority showed symptom exacerbation. Cluster analysis demonstrated four treatment response trajectories: Fast responders (13%), Slow responders (26%), Partial responders (32%), and Non-responders (29%). Living condition and between-session fear habituation were found to predict outcome. Participants living alone were more likely to belong to the Partial responders than to the Non-responders cluster, and participants showing more between-session fear habituation were more likely to belong to the Fast responders than to the Non-responders cluster. Conclusions: The results of this open study suggest that iPE can be effective in PTSD patients with multiple interpersonal trauma and after multiple previous treatment attempts. In addition, in this chronic PTSD population iPE was safe.
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Affiliation(s)
- Lotte Hendriks
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands.,Behavioural Science Institute, NijCare, Radboud University, Nijmegen, The Netherlands
| | - Rianne A de Kleine
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands., Institute of Psychology, Leiden University, Leiden, The Netherlands
| | | | - Gert-Jan Hendriks
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands.,Behavioural Science Institute, NijCare, Radboud University, Nijmegen, The Netherlands.,Department of Psychiatry, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Agnes van Minnen
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands.,Behavioural Science Institute, NijCare, Radboud University, Nijmegen, The Netherlands.,Psychotrauma Expertise Centre (PSYTREC), Bilthoven, The Netherlands
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24
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Held P, Klassen BJ, Brennan MB, Zalta AK. Using Prolonged Exposure and Cognitive Processing Therapy to Treat Veterans with Moral Injury-Based PTSD: Two Case Examples. COGNITIVE AND BEHAVIORAL PRACTICE 2017; 25:377-390. [PMID: 30147290 DOI: 10.1016/j.cbpra.2017.09.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Moral injury refers to acts of commission or omission that violate individuals' moral or ethical standards. Morally injurious events are often synonymous with psychological trauma, especially in combat situations; thus, morally injurious events are often implicated in the development of PTSD for military service members and veterans. Although Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) have been well-established as effective treatments for veterans who are struggling with posttraumatic stress disorder (PTSD), it has been suggested that these two evidence-based therapies may not be sufficient for treating veterans whose PTSD resulted from morally injurious events. The purpose of this manuscript is to detail how the underlying theories of PE and CPT can account for moral-injury based PTSD and to describe two case examples of veterans with PTSD stemming from morally injurious events who were successfully treated with PE and CPT. The manuscript concludes with a summary of challenges that clinicians may face when treating veterans with PTSD resulting from moral injury using either PE or CPT.
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Affiliation(s)
- Philip Held
- Department of Psychiatry, Rush University Medical Center
| | | | | | - Alyson K Zalta
- Department of Psychiatry, Rush University Medical Center
- Department of Behavioral Sciences, Rush University Medical Center
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25
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Kennis PhD M, van Rooij PhD SJH, Reijnen MSc A, Geuze PhD E. The predictive value of dorsal cingulate activity and fractional anisotropy on long-term PTSD symptom severity. Depress Anxiety 2017; 34:410-418. [PMID: 28294478 DOI: 10.1002/da.22605] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 12/17/2016] [Accepted: 12/26/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) can be treated with trauma-focused therapy, although only about 50% of the patients recover on the short-term. In order to improve response rates it is important to identify who will and will not recover from trauma-focused therapy. Although previous studies reported dorsal anterior cingulate cortex (ACC) activity, as well as dorsal cingulum bundle white matter microstructure integrity as markers for the persistence of PTSD symptoms on the short-term, it remains unclear whether these markers also predict long-term PTSD symptom severity. METHODS PTSD patients (n = 57) were investigated with clinical interviews and an MRI protocol before the start of treatment. Clinical interviews were repeated after 6-8 months of treatment (short-term follow-up), and on average 4 years later (long-term follow-up). Twenty-eight PTSD patients returned for the long-term follow-up. Dorsal ACC activity in response to negative images, and fractional anisotropy (FA) of the dorsal cingulum were the neural markers investigated. RESULTS In this long-term follow-up sample (n = 28), dorsal ACC activity and dorsal cingulum FA values significantly predicted CAPS scores on short- and long-term follow-up. The results remained significant after controlling for baseline CAPS score, early trauma, and comorbidity. CONCLUSION This study confirms the importance of the cingulate cortex activation and white matter integrity not only for short-term treatment outcome, but also for PTSD long-term symptom severity. Future treatments should target ACC function in particular during treatment in order to improve response rates.
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Affiliation(s)
- Mitzy Kennis PhD
- Research Centre Military Mental Healthcare, Dutch Ministry of Defence, Utrecht, The Netherlands.,Brain Center Rudolf Magnus, Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
| | - Sanne J H van Rooij PhD
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Alieke Reijnen MSc
- Research Centre Military Mental Healthcare, Dutch Ministry of Defence, Utrecht, The Netherlands.,Brain Center Rudolf Magnus, Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| | - Elbert Geuze PhD
- Research Centre Military Mental Healthcare, Dutch Ministry of Defence, Utrecht, The Netherlands.,Brain Center Rudolf Magnus, Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands
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26
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Szafranski DD, Smith BN, Gros DF, Resick PA. High rates of PTSD treatment dropout: A possible red herring? J Anxiety Disord 2017; 47:91-98. [PMID: 28117192 DOI: 10.1016/j.janxdis.2017.01.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 11/23/2016] [Accepted: 01/05/2017] [Indexed: 01/04/2023]
Abstract
Few studies have examined symptom change among dropouts from posttraumatic stress disorder (PTSD) treatment. However, dropout is widely considered a negative event needing to be addressed. The present study investigated PTSD and depression symptom change in patients with PTSD who discontinued psychotherapy. Female civilians (n=321) diagnosed with PTSD participated in two randomized clinical trials examining PTSD treatment outcomes. Of those, 53 were identified as dropouts and included in this study. Symptom change was assessed by clinically significant change (CSC) criteria and symptom end-state criteria. Results demonstrated that considerable proportions of participants (35.85-55.56%) displayed significant improvement and/or met good end-state criteria for PTSD and depression. Results also revealed that participants who displayed symptom improvement were younger, attended more treatment sessions, were married or partnered, and had higher annual household income. Although preliminary, these findings contradict belief that treatment dropouts do not display symptom improvement.
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Affiliation(s)
- Derek D Szafranski
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, United States.
| | - Brian N Smith
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, United States; Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States.
| | - Daniel F Gros
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, United States; Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States.
| | - Patricia A Resick
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, United States.
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27
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Feasibility of Training Frontline Therapists in Prolonged Exposure: A Randomized Controlled Pilot Study of Treatment of Complex Trauma in Diverse Victims of Crime and Violence. J Nerv Ment Dis 2017; 205:283-293. [PMID: 28157725 DOI: 10.1097/nmd.0000000000000659] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The study aims were to determine whether prolonged exposure (PE) improved mental health and was feasible to implement by frontline clinicians in a culturally diverse sample with complex trauma. Seventy-one individuals were randomly assigned to PE or person-centered therapy (PCT). Outcome measures were administered at baseline and sessions 3, 6, 9, and 12. Mixed modeling was used to regress outcome measures on time, treatment group, and number of visits. Individuals who received PE showed significant moderate association with decline in reported posttraumatic stress disorder (PTSD) symptoms as noted by the PTSD Checklist for DSM-5 (p = 0.05) compared with PCT. Results indicated improved scores on all measures at each follow-up time point compared with baseline (p ≤ 0.01). PE was feasible, shown by positive recruitment and ability of clinicians to effectively implement and maintain treatment fidelity. Findings suggest that PE can be effective for treating complex trauma when used by clinicians in community settings.
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