Trauma Exposure in Anxious Primary Care Patients

History of Sexual Assault as a Predictor of Response to a Self-Guided Online Program for Sexual Desire and Arousal Difficulties in Women

Sexual Interest/Arousal Disorder (distressing, long-lasting impairments in sexual desire and/or arousal) is common in women, but few have access to efficacious psychotherapies, including cognitive-behavioral therapy (CBT) and mindfulness-based therapy (MBT). eSense, an online program meant to maximize treatment access, has been shown to be a feasible, satisfactory, and potentially efficacious intervention. However, subpopulations such as sexual assault survivors may find the program less usable or efficacious. The current study compared women with and without a history of sexual assault (SA) regarding their ability to use and benefit from eSense. Forty-four women (22 with a history of SA; M age = 34.20 years) used eSense (CBT or MBT) and completed validated self-report scales of sexual function, sexual distress, treatment satisfaction, and homework compliance. A history of SA did not predict differences in attrition or changes in clinical outcomes. Exploratory analyses suggested that women with a history of SA reported slightly higher difficulty completing homework assignments, but also slightly higher treatment satisfaction. These preliminary results suggest that eSense may be usable and helpful for women with a history of SA. We discuss ways to maximize the acceptability and efficacy of online programs for women with a history of SA.

Factors associated with response and remission from depression at 6-months of treatment in a retrospective cohort treated within an integrated care program

Background

Depression causes significant morbidity, which impacts mental health, overall general health outcomes, everyday functioning and quality of life. This study aims to contribute to knowledge in the field through enhanced understanding of factors that influence depression response and remission, with consideration for design of treatment services to optimize depression outcomes within integrated care programs.

Methods

Using routine behavioral health screening and electronic health record data, we identified a retrospective cohort consisting of 615 adult patients receiving depression treatment within an integrated care program. Cohort member Patient Health Questionnaire (PHQ-9) data was analyzed for the 6 months following initiation of treatment. Multinomial regression models were estimated to identify factors associated with depression treatment response (PHQ-9 < 10) and remission (PHQ-9 < 5).

Results

At 6 months, 47% of patients demonstrated treatment response and 16% demonstrated remission. Baseline trauma symptoms and suicidal ideation were significantly associated with decreased odds of achieving remission (Odds Ratio (95% CI) [OR] = 0.45 (0.23, 0.88) and OR = 0.49 (0.29, 0.82), respectively). In fully adjusted models, baseline suicidal ideation remained significant (OR = 0.53 (0.31, 0.89)) and some evidence of an association persisted for baseline trauma symptoms (OR = 0.51 (0.25, 1.01)).

Conclusions

After controlling for baseline depression symptoms, the presence of suicidal ideation is associated with reduced likelihood of remission. Increased understanding of factors associated with depression treatment outcomes may be employed to help guide the delivery and design of clinical services. Alongside routine screening for co-morbid anxiety, suicidal ideation and traumatic stress should be assessed and considered when designing depression treatment services.

Does prior traumatization affect the treatment outcome of CBT for panic disorder? The potential role of the MAOA gene and depression symptoms

Although cognitive behavioral therapy (CBT) is highly effective in the treatment of anxiety disorders, many patients still do not benefit. This study investigates whether a history of traumatic event experience is negatively associated with outcomes of CBT for panic disorder. The moderating role of the monoamine oxidase A (MAOA) gene and depression symptoms as well as the association between trauma history and fear reactivity as a potential mechanism are further analyzed. We conducted a post-hoc analysis of 172 male and 60 female patients with panic disorder treated with CBT in a multi-center study. Treatment outcome was assessed at post-treatment using self-report and clinician rating scales. Fear reactivity before treatment was assessed via heart rate and self-reported anxiety during a behavioral avoidance test. Among females, we did not find any differences in treatment response between traumatized and non-traumatized individuals or any two-way interaction trauma history × MAOA genotype. There was a significant three-way interaction trauma history × MAOA genotype × depression symptoms on all treatment outcomes indicating that in traumatized female patients carrying the low-activity allele, treatment effect sizes decreased with increasing depression symptoms at baseline. No such effects were observed for males. In conclusion, we found no evidence for a differential treatment response in traumatized and non-traumatized individuals. There is preliminary evidence for poorer treatment outcomes in a subgroup of female traumatized individuals carrying the low-active variant of the MAOA gene. These patients also report more symptoms of depression symptomatology and exhibit a dampened fear response before treatment which warrants further investigation.

Suicidality in Subjects With Anxiety or Obsessive-Compulsive and Related Disorders: Recent Advances

PURPOSE OF REVIEW

Historically, anxiety disorders have not been considered as important determinants of suicide, but in the last years, many works have challenged this assumption. Here, we will review the available evidence on the relationship between suicide and anxiety disorders (e.g., obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, panic disorder, and body dysmorphic disorder), with special emphasis on findings published in the last years.

RECENT FINDINGS

Overall, anxiety disorders increase the risk of suicide. Specifically, 16% of patients with social anxiety disorder reported suicidal ideation in the previous month, and 18% of them had a history of suicide attempts. Similarly, in patients with panic disorder, suicidal ideation prevalence ranged between 17 and 32%, and 33% of them had a history of suicide attempts. Generalized anxiety disorder (GAD) was the most frequent anxiety disorder in completed suicides (present in 3% of people who committed suicide) and also subthreshold GAD was clearly linked to suicide ideation. Post-traumatic stress disorder was positively associated with suicidal ideation, and in patients with obsessive-compulsive disorder, suicide ideation rates ranged from 10 to 53% and suicide attempts from 1 to 46%. Body dysmorphic disorders presented a suicide ideation prevalence of about 80%. Suicide risk is increased in subjects with anxiety disorder. This risk is higher in the presence of comorbidities, but it is not clear whether it is independent from such comorbidities in some disorders.

The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and Evaluation Within a Veteran Primary Care Sample

BACKGROUND

Posttraumatic Stress Disorder (PTSD) is associated with increased health care utilization, medical morbidity, and tobacco and alcohol use. Consequently, screening for PTSD has become increasingly common in primary care clinics, especially in Veteran healthcare settings where trauma exposure among patients is common.

OBJECTIVE

The objective of this study was to revise the Primary Care PTSD screen (PC-PTSD) to reflect the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for PTSD (PC-PTSD-5) and to examine both the diagnostic accuracy and the patient acceptability of the revised measure.

DESIGN

We compared the PC-PTSD-5 results with those from a brief psychiatric interview for PTSD. Participants also rated screening preferences and acceptability of the PC-PTSD-5.

PARTICIPANTS

A convenience sample of 398 Veterans participated in the study (response rate = 41 %). Most of the participants were male, in their 60s, and the majority identified as non-Hispanic White.

MEASURES

The PC-PTSD-5 was used as the screening measure, a modified version of the PTSD module of the MINI-International Neuropsychiatric Interview was used to diagnose DSM-5 PTSD, and five brief survey items were used to assess acceptability and preferences.

KEY RESULTS

The PC-PTSD-5 demonstrated excellent diagnostic accuracy (AUC = 0.941; 95 % C.I.: 0.912- 0.969). Whereas a cut score of 3 maximized sensitivity (κ[1]) = 0.93; SE = .041; 95 % C.I.: 0.849-1.00), a cut score of 4 maximized efficiency (κ[0.5] = 0.63; SE = 0.052; 95 % C.I.: 0.527-0.731), and a cut score of 5 maximized specificity (κ[0] = 0.70; SE = 0.077; 95 % C.I.: 0.550-0.853). Patients found the screen acceptable and indicated a preference for administration by their primary care providers as opposed to by other providers or via self-report.

CONCLUSIONS

The PC-PTSD-5 demonstrated strong preliminary results for diagnostic accuracy, and was broadly acceptable to patients.