Advancing health equity by understanding race disparities and other factors associated with PTSD symptom improvement following evidence-based psychotherapy

Reliable symptom worsening among veterans receiving cognitive processing therapy or prolonged exposure therapy for posttraumatic stress disorder in routine VHA care

Clinical practice guidelines recommend trauma-focused evidence-based psychotherapy (EBP) to treat posttraumatic stress disorder (PTSD). Some veterans and clinicians report concerns that discussion of trauma will make PTSD symptoms worse. We studied the frequency and correlates of reliable symptom worsening during PTSD EBPs in routine clinical practice. Using national electronic health record data from the Veterans Health Administration, we identified veterans (n = 25,768) who initiated PTSD EBP between 1/2018-1/2023 and had PTSD symptom measurements (i.e., PTSD Checklist for DSM-5; PCL-5). We defined reliable symptom worsening as a 10-point PCL-5 increase from baseline. Using hierarchical Bayesian zero inflated binomial logistic regression, we modeled the probability of experiencing reliable symptom worsening across demographic, military, clinical and service delivery characteristics. In our sample, 22.9 % of veterans experienced reliable symptom worsening. However, most demographic, military, clinical, and service delivery characteristics were poorly associated with reliable symptom worsening. One exception was receipt of a first PTSD EBP session in an inpatient setting, which was associated with a lower likelihood of experiencing reliable symptom worsening (MPOR = 0.73, 90 % CI = 0.66, 0.81; 2 % in ROPE). Reliable symptom worsening was an uncommon (but not rare) occurrence during PTSD EBPs and assessed correlates were poorly related to likelihood of experiencing reliable worsening. Further research is needed to understand the drivers of reliable symptom worsening and to compare rates observed in the current study to reliable symptom worsening that occurs naturally over time and that occurs during any PTSD treatment.

The Middle-Out Approach to reconceptualizing, assessing, and analyzing traumatic stress reactions

Alternative models of traumatic stress and broader psychopathology have been proposed to address issues of heterogeneity, comorbidity, clinical utility, and equitable representation. However, systematic and practical methods and guidelines to organize and apply these models remain scarce. The Middle-Out Approach is a novel, integrative, contextually informed framework for organizing and applying existing empirical methods to evaluate current and alternative traumatic stress reactions. Rather than beginning to identify traumatic stress reactions from the top-down (i.e., disorder-first approach) or bottom-up (i.e., symptom-first approach), constructs are evaluated from the middle out (i.e., presentation-first approach), unconstrained by higher-order disorders or lower-order diagnostic symptoms. This approach provides innovation over previous methods at multiple levels, including the conceptualization of traumatic stress reactions as well as the type of assessments and data sources used and how they are used in statistical analyses. Conceptualizations prioritize the identification of middle-order phenotypes, representing person-centered clinical presentations, which are informed by the integration of multidimensional, transdiagnostic, and multimodal (e.g., psychosocial, physiological) assessments and/or data sources. Integrated data are then analyzed concurrently using person-centered statistical models to identify precise, discrete, and representative health outcomes within broader heterogeneous samples. Subsequent variable-centered analyses are then used to identify culturally sensitive and contextually informed correlates of phenotypes, their clinical utility, and the differential composition within and between broader traumatic stress reactions. Examples from the moral injury literature are used to illustrate practical applications that may increase clinical utility and the accurate representation of health outcomes for diverse individuals and communities.