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Kim JS, Prins A, Hirschhorn EW, Legrand AC, Macia KS, Yam SS, Cloitre M. Preliminary Investigation Into the Effectiveness of Group webSTAIR for Trauma-exposed Veterans in Primary Care. Mil Med 2024:usae052. [PMID: 38442368 DOI: 10.1093/milmed/usae052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/19/2023] [Accepted: 02/07/2024] [Indexed: 03/07/2024] Open
Abstract
INTRODUCTION A substantial number of trauma-exposed veterans seen in primary care report significant symptoms of PTSD and depression. While primary care mental health integration (PCMHI) providers have been successful in delivering brief mental health treatments in primary care, few studies have evaluated interventions that combine mobile health resources with PCMHI groups. This pilot study assessed the potential benefits of webSTAIR, a 10-module transdiagnostic treatment for trauma-exposed individuals, supported by 5 biweekly group sessions delivered via telehealth. The transdiagnostic and mobile health nature of the treatment, as well as the therapist and peer support provided through group sessions, may offer an innovative approach to increasing access to patient-centered and trauma-informed treatment in primary care settings. MATERIALS AND METHODS Thirty-nine male and female veterans with trauma-related symptoms (i.e., PTSD and/or depression) participated in group webSTAIR. Mixed effects analyses were conducted to assess changes in PTSD and depression at pre-, mid-, and post-treatment. Baseline symptom severity was assessed as a predictor of module completion and group attendance. The project was part of a VHA quality improvement project, and IRB approval was waived by the affiliated university. RESULTS Analyses revealed significant pre-to-post improvement in both PTSD and depression outcomes with a large effect size for PTSD (Hedges' gav = 0.88) and medium to large for depression (Hedges' gav = 0.73). Of participants who completed the baseline assessment, 90% began webSTAIR; of those, 71% completed the program. Baseline symptoms of PTSD and depression did not predict group attendance or module completion. CONCLUSIONS Good outcomes and a satisfactory retention rate suggest that group webSTAIR may provide easily accessible, high-quality, and effective treatment for patients presenting with trauma-related problems without increasing therapist or system burdens. The results suggest the value of conducting a randomized controlled trial to test the effectiveness of group webSTAIR relative to PCMHI usual care or other evidence-based, disorder-specific (e.g., PTSD) treatments for trauma-exposed individuals in PCMHI.
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Affiliation(s)
- Jamie S Kim
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA
| | - Annabel Prins
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA
- American Lake Division, VA Puget Sound Health Care System, 9600 Veterans Drive Southwest, Tacoma, WA 98493-0003, USA 900-329-8387
| | - Elizabeth W Hirschhorn
- American Lake Division, VA Puget Sound Health Care System, 9600 Veterans Drive Southwest, Tacoma, WA 98493-0003, USA 900-329-8387
| | - Alison C Legrand
- American Lake Division, VA Puget Sound Health Care System, 9600 Veterans Drive Southwest, Tacoma, WA 98493-0003, USA 900-329-8387
| | - Kathryn S Macia
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA
| | - Sherry S Yam
- General Mental Health, VA Northern California Health Care System, 150 Muir Road, Martinez, CA 94553-4668, USA
| | - Marylene Cloitre
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA
- Department of Psychiatry and Behavioral Health Sciences, Stanford University, 401 Quarry Road, Stanford, CA 94305-5717, USA
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Godfrey LB, Cloitre M, Elwy AR, Fortuna LR, Fuchs C, Valentine SE. Study protocol for a hybrid 1 effectiveness-implementation trial of Brief Skills Training in Affective and Interpersonal Regulation (Brief STAIR) and web-administered STAIR (webSTAIR) for posttraumatic stress disorder in integrated primary care. Contemp Clin Trials 2023; 131:107241. [PMID: 37244367 PMCID: PMC10527289 DOI: 10.1016/j.cct.2023.107241] [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: 02/17/2023] [Revised: 04/06/2023] [Accepted: 05/22/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) disproportionally affects low-income, racial and ethnic minoritized communities, where prevalence is high, yet access to evidence-based treatments (EBTs) is low. As such, there is a need to identify effective, feasible, and scalable interventions for PTSD. Stepped care approaches that include brief, low-intensity treatments are one approach to improving access yet have not been developed for adults with PTSD. Our study aims to test the effectiveness of a step one PTSD treatment in primary care while gathering information on implementation to maximize sustainability in the setting. METHODS This study will be conducted in integrated primary care in the largest safety net hospital in New England using a hybrid type 1 effectiveness-implementation design. Eligible trial participants are adult primary care patients who meet full or subthreshold criteria for PTSD. Interventions include Brief clinician-administered Skills Training in Affective and Interpersonal Regulation (Brief STAIR) versus web-administered STAIR (webSTAIR) during a 15-week active treatment period. Participants complete assessments at baseline (pre-treatment), 15 weeks (post-treatment), and 9 months (follow-up) post-randomization. We will assess feasibility and acceptability post-trial using surveys and interviews with patients, study therapists, and other key informants, and will assess the preliminary effectiveness of interventions in terms of PTSD symptom change and functioning. CONCLUSION This study will provide evidence for the feasibility, acceptability, and preliminary effectiveness of brief, low-intensity interventions in safety net integrated primary care, with the aim of including these interventions in a future stepped care approach to PTSD treatment. CLINICAL TRIAL NUMBER NCT04937504.
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Affiliation(s)
- Laura B Godfrey
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
| | - Marylène Cloitre
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; National Center for PTSD, Dissemination and Training Division at VA Palo Alto Health Care, Palo Alto, CA, USA
| | - A Rani Elwy
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA; Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Lisa R Fortuna
- Department of Psychiatry and Behavioral Sciences at University of California, San Francisco, San Francisco, CA, USA
| | - Cara Fuchs
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sarah E Valentine
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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Valentine SE, Fuchs C, Olesinski EA, Sarkisova N, Godfrey LB, Elwy AR. Formative evaluation prior to implementation of a brief treatment for posttraumatic stress disorder in primary care. Implement Sci Commun 2023; 4:48. [PMID: 37143109 PMCID: PMC10161536 DOI: 10.1186/s43058-023-00426-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 04/04/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Successful implementation of evidence-based treatments (EBT) for posttraumatic stress disorder (PTSD) in primary care may address treatment access and quality gaps by providing care in novel and less stigmatized settings. Yet, PTSD treatments are largely unavailable in safety net primary care. We aimed to collect clinician stakeholder data on organizational, attitudinal, and contextual factors relevant to EBT implementation. METHODS Our developmental formative evaluation was guided by the Consolidated Framework for Implementation Research (CFIR), including (a) surveys assessing implementation climate and attitudes towards EBTs and behavioral health integration and (b) semi-structured interviews to identify barriers and facilitators to implementation and need for augmentation. Participants were hospital employees (N = 22), including primary care physicians (n = 6), integrated behavioral health clinicians (n = 8), community wellness advocates (n = 3), and clinic leadership (n = 5). We report frequency and descriptives of survey data and findings from directed content analysis of interviews. We used a concurrent mixed-methods approach, integrating survey and interview data collected simultaneously using a joint display approach. A primary care community advisory board (CAB) helped to refine interview guides and interpret findings. RESULTS Stakeholders described implementation determinants of the EBT related to the CFIR domains of intervention characteristics (relative advantage, adaptability), outer setting (patient needs and resources), inner setting (networks and communication, relative priority, leadership engagement, available resources), and individuals involved (knowledge and beliefs, cultural considerations). Stakeholders described strong attitudinal support (relative advantage), yet therapist time and capacity restraints are major PTSD treatment implementation barriers (available resources). Changes in hospital management were perceived as potentially allowing for greater access to behavioral health services, including EBTs. Patient engagement barriers such as stigma, mistrust, and care preferences were also noted (patient needs and resources). Recommendations included tailoring the intervention to meet existing workflows (adaptability), system alignment efforts focused on improving detection, referral, and care coordination processes (networks and communication), protecting clinician time for training and consultation (leadership engagement), and embedding a researcher in the practice (available resources). CONCLUSIONS Our evaluation identified key CFIR determinants of implementation of PTSD treatments in safety net integrated primary care settings. Our project also demonstrates that successful implementation necessitates strong stakeholder engagement.
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Affiliation(s)
- Sarah E Valentine
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA.
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Cara Fuchs
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | | | - Laura B Godfrey
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
| | - A Rani Elwy
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA.
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.
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Iwakabe S, Nakamura K, Thoma NC. Enhancing emotion regulation. Psychother Res 2023:1-28. [PMID: 36943017 DOI: 10.1080/10503307.2023.2183155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Emotion regulation (ER) refers to the process of modulating an affective experience or response. Objectives: This is a systematic review of the research on therapist methods to facilitate patient ER, including affect-focused, experiential methods that aim to enhance immediate patient emotion regulation, and structured psychoeducation, skills training in ER. METHOD A total of 10 studies of immediate and intermediate outcomes of emotion regulation methods were examined. A total of 38 studies were included in the meta-analysis of distal treatment effects on emotion regulation. RESULTS In eight studies with 84 clients and 33 therapists, we found evidence of positive intermediate outcomes for affect-focused therapist methods and interpretations. A meta-analysis of 26 studies showed that the average effect size of ER methods from pre- to post-treatment was large (g = 0.82). CONCLUSIONS Both affect-focused and structured skill training are associated with distal improvements in emotion regulation. When working with ER in psychotherapy, therapists must consider how patients' cultural backgrounds inform display rules, as well as what might be considered adaptive or maladaptive. The article concludes with training implications and therapeutic practices based on the research evidence.
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Affiliation(s)
- Shigeru Iwakabe
- Department of Psychology, Ritumeikan University, Ibaraki-Shi, Japan
| | - Kaori Nakamura
- Department of Psychology, Ritumeikan University, Ibaraki-Shi, Japan
| | - Nathan C Thoma
- Department of Psychology, Ritumeikan University, Ibaraki-Shi, Japan
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Sullivan KS, Ancharski K, Wortham W, Okosi M, Kaplan D, Urquiza A, Timmer S, Cloitre M, Chemtob C, Lindsey MA. Feasibility and Preliminary Impact of a Community-Based Intervention for Maternal PTSD and Parenting: Parenting-STAIR Pilot. JOURNAL OF CHILD AND FAMILY STUDIES 2023; 32:481-497. [PMID: 36685737 PMCID: PMC9842206 DOI: 10.1007/s10826-023-02534-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 06/17/2023]
Abstract
Trauma exposure and post-traumatic stress disorder (PTSD) impact emotional and physical well-being, social functioning, and parent-child relationship quality. The effect of parental trauma on parenting and child maltreatment is often overlooked by current child welfare (CW) services. The novel intervention, Parenting-STAIR, was created to address maternal mental health, parenting skills, and child well-being outcomes. Parenting-STAIR is a combination of Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Therapy and Parent-Child Care (PC-CARE). This open pilot study aimed to examine the feasibility and preliminary impact of Parenting-STAIR in reducing maternal PTSD and increasing positive parenting skills for mothers and families involved in the child welfare system. Parenting-STAIR was delivered to 111 mothers receiving family preservation services in New York City. Of these, 70 completed treatment; statistical and clinically significant changes were observed for maternal PTSD and depression as well as in parenting stress, parenting skills, and child behaviors. These findings provide encouraging initial evidence for the feasibility and impact of this novel PTSD intervention. An evaluation of maltreatment recidivism is needed, as well as implementation of a randomized controlled trial to establish efficacy of the intervention.
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Affiliation(s)
| | - Kelly Ancharski
- McSilver Institute for Poverty Policy and Research, Silver School of Social Work, New York University, New York, NY USA
| | - Whitney Wortham
- Silver School of Social Work, New York University, New York, NY USA
| | - Mercedes Okosi
- McSilver Institute for Poverty Policy and Research, Silver School of Social Work, New York University, New York, NY USA
| | - Debra Kaplan
- McSilver Institute for Poverty Policy and Research, Silver School of Social Work, New York University, New York, NY USA
| | - Anthony Urquiza
- CAARE Diagnostic & Treatment Center, Department of Pediatrics, University of California, Sacramento, CA USA
| | - Susan Timmer
- CAARE Diagnostic & Treatment Center, Department of Pediatrics, University of California, Sacramento, CA USA
| | - Marylene Cloitre
- Institute for Trauma and Stress, New York University Langone Medical Center, New York, NY USA
- National Center for PTSD Dissemination and Training Division, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA USA
| | - Claude Chemtob
- McSilver Institute for Poverty Policy and Research, Silver School of Social Work, New York University, New York, NY USA
- Grossman School of Medicine, New York University, New York, NY USA
| | - Michael A. Lindsey
- Silver School of Social Work, New York University, New York, NY USA
- McSilver Institute for Poverty Policy and Research, Silver School of Social Work, New York University, New York, NY USA
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McCuistian C, Kimball SL, Buitron de la Vega P, Godfrey LB, Fortuna LR, Valentine SE. Consideration of racism experiences in the implementation of trauma-focused therapy in primary care. Health Serv Res 2022; 57 Suppl 2:235-248. [PMID: 35521941 PMCID: PMC9660427 DOI: 10.1111/1475-6773.13998] [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] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To understand providers' perceptions of how a patient's experience of racism may impact the successful implementation of a brief posttraumatic stress disorder (PTSD) treatment in the safety net integrated primary care setting. To conduct a developmental formative evaluation prior to a hybrid type I effectiveness-implementation trial. DATA SOURCES AND STUDY SETTING From October 2020 to January 2021, in-depth qualitative interviews were conducted with integrated primary care stakeholders (N = 27) at the largest safety net hospital in New England, where 82% of patients identify as racial or ethnic minorities. STUDY DESIGN Interviews with clinical stakeholders were used to (a) contextualize current patient and provider experiences and responses to racism, (b) consider how racism may impact PTSD treatment implementation, (c) gather recommendations for potential augmentation to the proposed PTSD treatment (e.g., culturally responsive delivery, cultural adaptation), and (d) gather recommendations for how to shift the integrated primary care practice to an antiracist framework. DATA COLLECTION/EXTRACTION METHODS Interview data were gathered using remote data collection methods (video conferencing). Participants were hospital employees, including psychologists, social workers, primary care physicians, community health workers, administrators, and operations managers. We used conventional content analysis. PRINCIPAL FINDINGS Clinical stakeholders acknowledged the impact of racism, including racial stress and trauma, on patient engagement and noted the potential need to adapt PTSD treatments to enhance engagement. Clinical stakeholders also characterized the harms of racism on patients and providers and provided recommendations such as changes to staff training and hiring practices, examination of racist policies, and increases in support for providers of color. CONCLUSIONS This study contextualizes providers' perceptions of racism in the integrated primary care practice and provides some suggestions for shifting to an antiracist framework. Our findings also highlight how racism in health care may be a PTSD treatment implementation barrier.
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Affiliation(s)
- Caravella McCuistian
- Department of Psychiatry and Behavioral SciencesUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Sarah L. Kimball
- Section of General Internal MedicineBoston Medical CenterBostonMassachusettsUSA
- Boston University School of MedicineBostonMassachusettsUSA
| | - Pablo Buitron de la Vega
- Section of General Internal MedicineBoston Medical CenterBostonMassachusettsUSA
- Boston University School of MedicineBostonMassachusettsUSA
| | - Laura B. Godfrey
- Department of PsychiatryBoston Medical CenterBostonMassachusettsUSA
| | - Lisa R. Fortuna
- Department of Psychiatry and Behavioral SciencesUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Sarah E. Valentine
- Boston University School of MedicineBostonMassachusettsUSA
- Department of PsychiatryBoston Medical CenterBostonMassachusettsUSA
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Schleyer W, Zona K, Quigley D, Spottswood M. Group therapy in primary care settings for the treatment of posttraumatic stress disorder: A systematic literature review. Gen Hosp Psychiatry 2022; 77:1-10. [PMID: 35390567 DOI: 10.1016/j.genhosppsych.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE This systematic review aims to summarize existing literature on group therapy for the treatment of post-traumatic stress disorder (PTSD) in primary care. METHOD A PRISMA systematic literature review was performed through February 26, 2022 identifying existing studies of group trauma therapy in primary care. Articles were included if they discussed group trauma therapy for primary care patients. Bias was assessed based on sample sizes and presence of control groups. Results are presented as a weighted average of the engagement rate and a qualitative description of overlapping study traits. RESULTS Four studies of group PTSD treatment within primary care were identified with 70 total patients completing group treatment. The weighted treatment engagement rate was 65%. Each utilized distinct group trauma treatment models and reported significant patient improvements in PTSD symptoms on standardized trauma symptom scales. DISCUSSION Group trauma therapy models are available and can be disseminated within primary care settings. Limitations include both the small number of studies and participants. CONCLUSION There have been few studies of group therapy for PTSD in primary care, but these could represent a promising and scalable approach to meet the high need for trauma treatment. Further research is needed regarding implementation feasibility and impact.
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Affiliation(s)
- William Schleyer
- Cambridge Health Alliance/Harvard Medical School, Department of Psychiatry, 1493 Cambridge Street, Cambridge, MA 02139, USA
| | - Kate Zona
- Cambridge Health Alliance/Harvard Medical School, Department of Psychiatry, 1493 Cambridge Street, Cambridge, MA 02139, USA
| | - Dan Quigley
- Smith College School for Social Work Lilly Hall, 23 West St, Northampton, MA 01063, United States of America
| | - Margaret Spottswood
- Community Health Centers of Burlington, 617 Riverside Ave., Burlington, VT 05401, United States of America; University of Vermont, Department of Psychiatry, 1 South Prospect Street, Burlington, VT 05401, United States of America.
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Lindsey M, Sullivan K, Chemtob C, Ancharski K, Jaccard J, Cloitre M, Urquiza A, Timmer S, Okosi M, Kaplan D. A randomized controlled trial to assess the efficacy of Parenting-STAIR in treating maternal PTSD to reduce maltreatment recidivism: protocol for the Safe Mothers, Safe Children study. Trials 2022; 23:432. [PMID: 35606818 PMCID: PMC9125354 DOI: 10.1186/s13063-022-06354-1] [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: 10/12/2021] [Accepted: 04/25/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Child maltreatment recidivism substantially increases the likelihood of adverse life outcomes, but there is little evidence that family preservation services are effective at reducing recidivism. Mothers in child welfare have very high rates of trauma exposure; maternal post-traumatic stress disorder (PTSD) is an intervention target that has the potential to reduce abuse and neglect. The Safe Mothers, Safe Children (SMSC) intervention program involves the delivery of an innovative combination of interventions, including Skills Training in Affective and Interpersonal Regulation (STAIR) and Parent-Child Interaction Therapy (PCIT). The combined intervention, Parenting-STAIR (P-STAIR), targets maternal PTSD and comorbid depression symptoms to reduce the adverse effects of PTSD on parenting, improve positive parenting skills, and prevent maltreatment recidivism. METHODS This study is a two-arm randomized controlled trial: P-STAIR (23 sessions) versus supportive counseling (23 sessions). Participants are mothers receiving child welfare family preservation services (FPS), with a child in the age range of 1-8 years old and meeting diagnostic criteria for PTSD (with/without depression). Clinical assessment occurs at pre-treatment (baseline), two in-treatment assessments (mid-assessment #1 after module 9 and mid-assessment #2 after module 15), post-treatment, and at a 6-month follow-up. Recidivism will be measured using the New York State Child Welfare Registry (NYSCWR). We will enroll a total of 220 participants over 4 years: half (N = 110) randomly assigned to the P-STAIR condition and half (N = 110) to the supportive counseling condition. DISCUSSION This is the first RCT to investigate the efficacy of P-STAIR. The findings for the trial have the potential to contribute to the expansion of evidence-based practices for maternal PTSD, maltreatment, and child welfare.
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Affiliation(s)
- Michael Lindsey
- Silver School of Social Work, New York University, New York, NY, USA. .,McSilver Institute for Poverty Policy and Research, Silver School of Social Work, New York University, New York, NY, USA.
| | - Kathrine Sullivan
- grid.137628.90000 0004 1936 8753Silver School of Social Work, New York University, New York, NY USA
| | - Claude Chemtob
- grid.137628.90000 0004 1936 8753Silver School of Social Work, New York University, New York, NY USA ,grid.137628.90000 0004 1936 8753Grossman School of Medicine, New York University, New York, NY USA
| | - Kelly Ancharski
- grid.137628.90000 0004 1936 8753McSilver Institute for Poverty Policy and Research, Silver School of Social Work, New York University, New York, NY USA
| | - James Jaccard
- grid.137628.90000 0004 1936 8753Silver School of Social Work, New York University, New York, NY USA
| | - Marylène Cloitre
- grid.240324.30000 0001 2109 4251Institute for Trauma and Stress, New York University Langone Medical Center, New York, NY USA ,grid.168010.e0000000419368956National Center for PTSD Dissemination and Training Division, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA USA
| | - Anthony Urquiza
- grid.27860.3b0000 0004 1936 9684CAARE Diagnostic & Treatment Center, Department of Pediatrics, University of California, Sacramento, CA USA
| | - Susan Timmer
- grid.27860.3b0000 0004 1936 9684CAARE Diagnostic & Treatment Center, Department of Pediatrics, University of California, Sacramento, CA USA
| | - Mercedes Okosi
- grid.137628.90000 0004 1936 8753McSilver Institute for Poverty Policy and Research, Silver School of Social Work, New York University, New York, NY USA
| | - Debra Kaplan
- grid.137628.90000 0004 1936 8753McSilver Institute for Poverty Policy and Research, Silver School of Social Work, New York University, New York, NY USA
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Cloitre M, Amspoker AB, Fletcher TL, Hogan JB, Jackson C, Jacobs A, Shammet R, Speicher S, Wassef M, Lindsay J. Comparing the Ratio of Therapist Support to Internet Sessions in a Blended Therapy Delivered to Trauma-Exposed Veterans: Quasi-experimental Comparison Study. JMIR Ment Health 2022; 9:e33080. [PMID: 35475777 PMCID: PMC9096630 DOI: 10.2196/33080] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Blended models of therapy, which incorporate elements of both internet and face-to-face methods, have been shown to be effective, but therapists and patients have expressed concerns that fewer face-to-face therapy sessions than self-guided internet sessions may be associated with lower therapeutic alliance, lower program completion rates, and poorer outcomes. OBJECTIVE A multisite quasi-experimental comparison study with a noninferiority design implemented in routine clinical care was used to assess webSTAIR, a 10-module blended therapy derived from STAIR (skills training in affective and interpersonal regulation) for trauma-exposed individuals delivered with 10 weekly therapist sessions (termed Coach10) compared to 5 biweekly sessions (Coach5). It was hypothesized that Coach5 would be as good as Coach10 in a range of outcomes. METHODS A total of 202 veterans were enrolled in the study with 101 assigned to Coach5 and 101 to Coach10. Posttraumatic stress disorder (PTSD) symptoms, depression, emotion regulation, interpersonal problems, and social functioning measures were collected pre-, mid-, and posttreatment, and at a 3-month follow-up. Noninferiority analyses were conducted on symptom outcome measures. Comparisons were made of continuous and categorical measures regarding participant and therapist activities. RESULTS Participants reported moderate to severe levels of baseline PTSD, depression, or both. Significant reductions were obtained in all symptom measures posttreatment and at the 3-month follow up. Coach5 was not inferior to Coach10 in any outcome. Therapeutic alliance was at an equivalently high level across the 2 treatment conditions; completion rates and web usage were similar. Total session time was substantially less for the Coach5 therapists than the Coach10 therapists. Both programs were associated with a low, but equal number of therapist activities related to scheduling and crisis or motivational sessions. CONCLUSIONS A blended model delivered with 5 sessions of therapist support was noninferior to 10 sessions in individuals with moderate to severe symptoms. Future studies identifying patient characteristics as moderators of outcomes with high versus low doses of therapist support will help create flexible, technology-based intervention programming.
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Affiliation(s)
- Marylene Cloitre
- National Center for PTSD Dissemination and Training Division, Veterans Administration Palo Alto Health Care System, Palo Alto, CA, United States
| | - Amber Bush Amspoker
- Veterans Administration Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Baylor Medical College, Houston, TX, United States
| | - Terri L Fletcher
- Veterans Administration Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Baylor Medical College, Houston, TX, United States
| | - Julianna B Hogan
- Veterans Administration Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Baylor Medical College, Houston, TX, United States
| | - Christie Jackson
- National Center for PTSD Dissemination and Training Division, Veterans Administration Palo Alto Health Care System, Palo Alto, CA, United States
| | - Adam Jacobs
- National Center for PTSD Dissemination and Training Division, Veterans Administration Palo Alto Health Care System, Palo Alto, CA, United States
| | - Rayan Shammet
- National Center for PTSD Dissemination and Training Division, Veterans Administration Palo Alto Health Care System, Palo Alto, CA, United States
| | - Sarah Speicher
- National Center for PTSD Dissemination and Training Division, Veterans Administration Palo Alto Health Care System, Palo Alto, CA, United States
| | - Miryam Wassef
- Veterans Administration Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Baylor Medical College, Houston, TX, United States
| | - Jan Lindsay
- Veterans Administration Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Baylor Medical College, Houston, TX, United States
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Sripada RK, Walters HM, Ganoczy D, Avallone KM, Cigrang JA, Rauch SAM. Feasibility and Acceptability of Prolonged Exposure in Primary Care (PE-PC) for Posttraumatic Stress Disorder in Federally Qualified Health Centers: A Pilot Study. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2022; 49:722-734. [PMID: 35445362 PMCID: PMC9020756 DOI: 10.1007/s10488-022-01195-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 12/05/2022]
Abstract
Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder that affects 6% of U.S. adults, yet is treated in only 30% of affected individuals and even fewer low-income individuals. One third of the nation’s low-income individuals are treated in Federally Qualified Health Centers (FQHCs). Most of these facilities lack capacity to provide their patients with first-line, evidence-based treatments for PTSD such as Prolonged Exposure (PE). To address this problem, PE has been adapted for use in a primary care setting and demonstrated efficacy in a brief model for military service members (PE in Primary Care: PE-PC). The effectiveness of this treatment in civilian, low-resource settings such as FQHCs is unknown. This pilot study tested the feasibility and acceptability of PE-PC in 30 Michigan FQHC patients. High rates of therapy participation suggest that the intervention was feasible and acceptable. Semi-structured interview data from 10 patients and 5 FQHC providers indicated that the intervention was helpful and filled a critical need for effective PTSD treatment in the FQHC setting. Interviews also elucidated barriers such as transportation, provider training, and time commitment for patients and providers. These findings set the stage for a full-scale randomized controlled trial to test the effectiveness of PE-PC on PTSD symptoms in this low-resource, high-need setting. Trial registry ClinicalTrials.gov Identifier: NCT03711266. October 18, 2018.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA. .,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
| | - Heather M Walters
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA
| | | | | | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA.,Atlanta VA Medical Center, Atlanta, GA, USA
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11
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Redesign of a brief PTSD treatment in safety net integrated primary care: Supporting implementation in the context of the COVID-19 pandemic. Gen Hosp Psychiatry 2022; 74:94-101. [PMID: 34924217 PMCID: PMC8662839 DOI: 10.1016/j.genhosppsych.2021.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/23/2021] [Accepted: 12/07/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE We conducted a formative evaluation to understand the impact of the COVID-19 pandemic on the safety net integrated primary care setting and to identify (and respond to) new implementation barriers prior to a hybrid type I effectiveness-implementation trial of a posttraumatic stress disorder (PTSD) treatment. METHOD We used surveys and qualitative interviews with employee stakeholders (N = 27) to (1) understand pandemic-related factors that may influence implementation, including changes in patient needs, provider experiences, and the practice, and (2) assess the need for augmentation to study design, implementation plan, or intervention. RESULTS Conventional content analysis and survey findings suggest that patient acuity and volume increased provider burden, leading to high burnout. Although the shift to telehealth improved behavioral health access, issues with technology access and literacy were common. Changes to the study design and implementation plan, based on findings, included the provision of multi-modality treatments (in person, telehealth, web-administered), technology and administrative support, and other strategies for reducing provider burnout. CONCLUSIONS This study describes how an ongoing research study adapted to major changes to the implementation setting during the pandemic. Changes to study design and implementation plan were responsive to the shift to telehealth and therapist burden (and burnout) concerns.
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12
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Gidzgier PA, Bari M, López-Atanes M, Lotzin A, Grundmann J, Hiller P, Schneider B, Schäfer I. Improving care for SUD patients with complex trauma-relationships between childhood trauma, dissociation, and suicidal behavior in female patients with PTSD and SUD. Front Psychiatry 2022; 13:1047274. [PMID: 36713892 PMCID: PMC9878321 DOI: 10.3389/fpsyt.2022.1047274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 12/28/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Posttraumatic disorders are among the most frequent co-occurring diagnoses in patients with substance use disorders (SUD). Individuals with this dual diagnosis often present with special treatment needs, especially after childhood traumatic experiences (CT). Along with posttraumatic stress disorder (PTSD) and dissociative symptoms, suicidal behaviors belong to the clinical challenges in this group of patients and may influence the course and outcome of SUD treatment. Therefore, a better understanding of the relationships between different forms of CT, psychopathology and suicidal behaviors seems to be important to tailor adequate concepts of care. MATERIALS AND METHODS We examined 343 female patients with SUD and Posttraumatic stress disorder (PTSD). All patients completed the Childhood Trauma Questionnaire (CTQ), the Dissociative Experiences Scale-Taxon (DES-T) and the Structured Clinical Interview Axis I Disorders (SCID-I). To determine relationships between different symptoms with potential importance for concepts of treatment, we conducted analyses of moderated mediation for different models. We examined the direct and indirect effects of associations between the type of CT, dissociation and suicidal behavior, as well as the moderation effect of PTSD. RESULTS All participants met DSM-criteria for either full PTSD (75.2%) or subsyndromal PTSD (24.8%). Almost all (94.5%) received at least one substance dependence diagnosis and the remaining 5.5% met substance abuse criteria. Most participants (93.3%) reported at least one type of childhood trauma. In all models, dissociation was a risk factor for suicidal ideation (SI) and for suicide attempts (SA). In both, participants with subsyndromal PTSD and participants with full PTSD, dissociation mediated the relationship between childhood sexual abuse and SI as well as SA. Moreover, we report direct effects between different childhood traumas and SI and SA. Furthermore, emotional abuse was a significant predictor of dissociation. DISCUSSION In our sample of female patients with SUD and co-occurring PTSD, dissociation significantly increased suicidal behavior and served as a mediator of the relationship between childhood sexual abuse and suicidal behavior. Our findings underline the need to include interventions to address dissociative symptoms and other more complex consequences of childhood trauma into concepts of care for patients with SUD.
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Affiliation(s)
- Piotr A Gidzgier
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Melav Bari
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mayte López-Atanes
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annett Lotzin
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johanna Grundmann
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Hiller
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Barbara Schneider
- Department of Addictive Disorders and Psychiatry, LVR-Klinik Cologne, Hamburg, Germany
| | - Ingo Schäfer
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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13
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Powers A, Mekawi Y, Fickenwirth M, Nugent NR, Dixon HD, Minton S, Kim YJ, Gluck R, Carter S, Fani N, Schwartz AC, Bradley B, Umpierrez GE, Pace TWW, Jovanovic T, Michopoulos V, Gillespie CF. Emotion dysregulation and dissociation contribute to decreased heart rate variability to an acute psychosocial stressor in trauma-exposed Black women. J Psychiatr Res 2021; 142:125-131. [PMID: 34352557 PMCID: PMC8429185 DOI: 10.1016/j.jpsychires.2021.07.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/12/2021] [Accepted: 07/21/2021] [Indexed: 11/26/2022]
Abstract
Reduced heart rate variability (HRV) in response to stress is a biomarker of emotion dysregulation (ED) and is related to posttraumatic stress disorder (PTSD), yet less is known about its role with dissociation in trauma-exposed adults. The goals of the current study were to examine unique patterns of associations between ED, dissociation, and PTSD with HRV at 15, 30, and 45 min (T1, T2, T3) following an acute psychosocial stressor task in a sample of 49 trauma-exposed, urban-dwelling Black women. Associations with baseline psychophysiology measures were also examined. ED and dissociation were assessed using self-report; PTSD was determined using a semi-structured interview. Heart rate (HR) and HRV, indexed with low frequency/high frequency (LF/HF) ratio and respiratory sinus arrhythmia (RSA), were measured with electrocardiogram recordings. ED and dissociation were positively correlated with LF/HF ratio at T3 (p < .05). There were no significant differences between individuals with PTSD versus those without PTSD in HR or HRV following acute stressor; PTSD diagnosis was related to higher HR at baseline. Latent growth modeling revealed that ED was associated with higher LF/HF ratio directly following acute stressor, while dissociation was associated with increase in LF/HF ratio over time. These findings demonstrate that ED is related to higher sympathetic reactivity for a prolonged period of time following stress exposure, while dissociation shows a delayed association with LF/HF ratio, suggesting a distinct impaired parasympathetic activation pattern exists for dissociation.
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Affiliation(s)
- Abigail Powers
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA.
| | - Yara Mekawi
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Maximilian Fickenwirth
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Nicole R Nugent
- Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA
| | - H Drew Dixon
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Sean Minton
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Ye Ji Kim
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Rachel Gluck
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Sierra Carter
- Department of Psychology, Georgia State University, Atlanta, GA, USA
| | - Negar Fani
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Ann C Schwartz
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Bekh Bradley
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA; Mental Health Service Line, Atlanta VA Medical Center, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Thaddeus W W Pace
- College of Nursing, College of Medicine (Psychiatry), & College of Science (Psychology), University of Arizona, Tucson, AZ, USA
| | - Tanja Jovanovic
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI, USA
| | - Vasiliki Michopoulos
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA; Yerkes National Primate Research Center, Atlanta, GA, USA
| | - Charles F Gillespie
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
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14
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Cloitre M, Hyland P, Prins A, Shevlin M. The international trauma questionnaire (ITQ) measures reliable and clinically significant treatment-related change in PTSD and complex PTSD. Eur J Psychotraumatol 2021; 12:1930961. [PMID: 34211640 PMCID: PMC8221157 DOI: 10.1080/20008198.2021.1930961] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The International Trauma Questionnaire (ITQ) is a validated measure that assesses ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD). An important task is to determine whether the ITQ is an appropriate evaluative measure for clinical trials. Objective: To assess the psychometric properties of the ITQ in the context of treatment and determine if the ITQ measures reliable and clinically significant change over the course of a psychosocial intervention. Method: Analyses were based on data from an online skills training programme delivered to 254 U.S. Veterans. Reliability and validity of the ITQ scores were assessed at baseline. Changes in symptom scores and probable diagnostic rates were compared at pre-, mid- and post-treatment. A reliable change index (RCI) score was computed to classify participants as improved, unchanged, or worsened. The PCL-5 was used as a comparison measure. Results: Baseline concurrent and factorial validity was similar to previous studies. Internal consistency at each assessment was excellent and comparable to the PCL-5. Decline in symptoms from pre-to-post-treatment was significant for PTSD and CPTSD symptom profiles. Rate of probable disorder (PTSD or CPTSD) declined significantly from pre-treatment to post-treatment. Pre-to-post treatment declines exceeded the critical RCI values for the ITQ. Clinically significant changes were observed where most participants improved, some stayed the same, and few worsened. The performance of the ITQ was consistent with the PCL-5 regarding sensitivity to change. Conclusion: This study provides the first demonstration that the ITQ measures reliable and clinically significant treatment-related change of ICD-11 PTSD and CPTSD symptoms.
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Affiliation(s)
- Marylène Cloitre
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Philip Hyland
- Department of Psychology, National University of Ireland Maynooth, Kildare, Ireland.,Trinity Centre for Global Health, University of Dublin, Trinity College, Dublin, Ireland
| | - Annabel Prins
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Mark Shevlin
- School of Psychology Derry, Ulster University, Coleraine, Northern Ireland
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15
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Macia KS, Blonigen DM, Shaffer PM, Cloitre M, Smelson DA. Trauma-related differences in socio-emotional functioning predict housing and employment outcomes in homeless veterans. Soc Sci Med 2021; 281:114096. [PMID: 34126293 DOI: 10.1016/j.socscimed.2021.114096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/29/2021] [Accepted: 05/29/2021] [Indexed: 01/10/2023]
Abstract
RATIONALE Mental health and substance use disorders are strong risk factors for homelessness. Understanding the role of transdiagnostic factors could help inform efforts to reduce homelessness among veterans with a range of disorders. Homeless veterans have high rates of trauma exposure, which can result in the depletion of social and emotional resources that may contribute to housing and employment stability. In this study, we evaluated the role of problems with emotional lability and interpersonal closeness as transdiagnostic socio-emotional factors that might interfere with efforts to achieve housing and employment stability. METHODS The sample consisted of 346 homeless veterans with co-occurring disorders that were admitted to a U.S. Department of Veterans Affairs (VA) residential treatment program between 2004 and 2009. Assessments were conducted at treatment entry (baseline) and two follow-up timepoints (6- and 12-months). Variables used in the current analyses included history of interpersonal trauma exposure, emotional lability and interpersonal closeness at baseline and 6-months, and homelessness and employment problems during follow-up. Data were analyzed using structural equation modeling and counterfactually-defined mediation effects. RESULTS Veterans exposed to more trauma types experienced more baseline impairment and less improvement during treatment in emotional lability and interpersonal closeness. Problems with interpersonal closeness mediated 73% of the relationship between exposure to multiple traumas and homelessness, and 32%-61% of the relationship between trauma exposure and employment problems. Emotional lability mediated 36% of the relationship between exposure to multiple traumas and employment problems. Decomposition of indirect pathways revealed that indirect effects were primarily transmitted through changes during treatment, and not baseline levels. CONCLUSION Findings support a cumulative effect of trauma on persistence of socio-emotional deficits across treatment, which increased risk of homelessness and employment problems during follow-up. Greater attention and more targeted efforts should be directed at helping trauma-exposed veterans build socio-emotional resources during treatment.
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Affiliation(s)
- Kathryn S Macia
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, 94304, USA.
| | - Daniel M Blonigen
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, 94304, USA; Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA
| | - Paige M Shaffer
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, 01655, USA
| | - Marylène Cloitre
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, 94304, USA
| | - David A Smelson
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, 01655, USA; Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, 01730, USA
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16
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Ametaj AA, Smith AM, Valentine SE. A Stakeholder-Engaged Process for Adapting an Evidence-Based Intervention for Posttraumatic Stress Disorder for Peer Delivery. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2021; 48:793-809. [PMID: 33813717 DOI: 10.1007/s10488-021-01129-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Peer providers represent a growing sector of the U.S. workforce, yet guidance is needed on best practices for adapting behavioral health interventions for peer delivery. METHODS We utilized the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME; Wiltsey Stirman et al. 2013, 2019) to describe how we systematically adapted Skills Training in Affective and Interpersonal Regulation (STAIR) for posttraumatic stress disorder (PTSD) for peer delivery. Our process was iterative and relied on engagement of multiple stakeholders, including a work group of organizational leaders (N = 5), peer interventionists (N = 4), intervention experts (N = 2), and trial participants (N = 18). The FRAME was used to guide rapid coding across multiple data sources, including researcher field notes, meeting minutes, and intervention manual documents, and content analysis of semi-structured interviews with peer interventionists and trial participants. RESULTS Phase 1 (pre-trial) focused on modifications for fit with the local context and peer model. Key modifications focused on improving intervention design and packaging, removing clinical and stigmatizing language, and addressing peer interventionist training gaps. We used a hybrid approach to delivery, whereby we integrated peer model principles (self-disclosure, mutuality) into a directive approach. Phase 2 (trial) included reactive fidelity-consistent adaptations, such as additional educational resources. Phase 3 (post-trial) focused on adaptations to support roll-out of the intervention at the peer organization (e.g., group format). CONCLUSION Our stakeholder-engaged process may serve as a helpful exemplar to others tailoring interventions for peer delivery. Future research is needed to understand the role of stakeholder engagement and adaptation in implementation success.
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Affiliation(s)
- Amantia A Ametaj
- Department of Epidemiology, Harvard Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
| | - Ash M Smith
- Department of Psychiatry, Boston Medical Center, 720 Harrison Ave, Suite 1150, Boston, MA, 02118, USA
| | - Sarah E Valentine
- Department of Psychiatry, Boston Medical Center, 720 Harrison Ave, Suite 1150, Boston, MA, 02118, USA. .,Department of Psychiatry, Boston University School of Medicine, 72 E Concord St, Boston, MA, 02118, USA.
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17
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Bauer A, Amspoker AB, Fletcher TL, Jackson C, Jacobs A, Hogan J, Shammet R, Speicher S, Lindsay JA, Cloitre M. A Resource Building Virtual Care Programme: improving symptoms and social functioning among female and male rural veterans. Eur J Psychotraumatol 2021; 12:1860357. [PMID: 34025913 PMCID: PMC8128123 DOI: 10.1080/20008198.2020.1860357] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background: Veterans have higher rates of PTSD and depression compared to the general population and experience substantial functional impairment. Impairment in social functioning has been a significant concern among Veterans, particularly rural Veterans, who have limited access to mental health care and are at risk for social isolation. Objective: A mixed-method study was implemented to evaluate the feasibility and effectiveness of webSTAIR, a web-based skills training programme, paired with home-based telehealth sessions. It was hypothesized that the programme would lead not only to reductions in PTSD and depression but also to improvements in social functioning. Method: Participants were 80 trauma-exposed Veterans enrolled in rural-serving VHA facilities with clinically elevated symptoms of either PTSD or depression. The study directed substantial outreach efforts to rural women Veterans and those who have experienced military sexual trauma (MST). Results: Significant improvements were obtained with PTSD and depression symptoms as well as in social functioning, emotion regulation, and interpersonal problems at post-treatment and 3-month follow-up. Ratings of therapeutic alliance were high as were reports of overall satisfaction in the programme. There were no differences by gender or MST status in symptom outcomes or satisfaction. Conclusions: The results support the feasibility and effectiveness of this integrated telehealth web-based skills training programme for both male and female Veterans as well as for those with and without MST. The focus on resource building and improved functioning make this programme of particular interest. Further testing is warranted.
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Affiliation(s)
- Ashley Bauer
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Amber B Amspoker
- VA HSR&D Houston Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Terri L Fletcher
- VA HSR&D Houston Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA
| | | | - Adam Jacobs
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Julianna Hogan
- VA HSR&D Houston Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA
| | - Rayan Shammet
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Sarah Speicher
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Jan A Lindsay
- VA HSR&D Houston Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA
| | - Marylène Cloitre
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, CA, USA.,Department of Psychiatry and Behavioural Sciences, Stanford University, Stanford, CA, USA
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18
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Smith AM, Stewart K, Baul T, Valentine SE. Peer delivery of a brief cognitive-behavioral treatment for posttraumatic stress disorder: A hybrid effectiveness-implementation pilot study. J Clin Psychol 2020; 76:2133-2154. [PMID: 32632945 PMCID: PMC7665989 DOI: 10.1002/jclp.23020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/02/2020] [Accepted: 06/04/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) treatment delivery by peer specialist providers could increase access to and engagement with PTSD treatment in low resource settings. The current pilot study tested the feasibility, acceptability, and initial effectiveness of a peer-delivered, brief cognitive-behavioral therapy for PTSD. METHOD Four certified peer specialists delivered the intervention to 18 participants with probable PTSD. We assessed PTSD symptoms weekly and administered surveys and interviews at baseline and posttreatment. RESULTS Our mixed-methods approach suggests that the intervention was feasible and acceptable, demonstrating high client satisfaction. We also found significant improvements in PTSD, depressive, anxiety, and general stress symptoms. CONCLUSIONS Peer-delivered interventions may be a good fit for addressing posttraumatic stress symptoms for people accessing care in low resource settings. Future research should evaluate peer-delivered PTSD treatment as a strategy for both reducing symptoms and improving access and engagement in professional care.
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Affiliation(s)
- Ashley M. Smith
- Department of Psychiatry, Boston Medical Center, 720 Harrison Avenue, Suite 1150, Boston, MA, 02118, U.S
| | - Kaylee Stewart
- Department of Psychiatry, Boston Medical Center, 720 Harrison Avenue, Suite 1150, Boston, MA, 02118, U.S
| | - Tithi Baul
- Department of Psychiatry, Boston Medical Center, 720 Harrison Avenue, Suite 1150, Boston, MA, 02118, U.S
| | - Sarah E. Valentine
- Department of Psychiatry, Boston Medical Center, 720 Harrison Avenue, Suite 1150, Boston, MA, 02118, U.S
- Department of Psychiatry, Boston University School of Medicine, 720 Harrison Avenue, Suite 1150, Boston, MA, 02118, U.S
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