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Szoke D, Walker E, Christ N, Smith D, Held P. Posttraumatic cognition change trajectories in veterans with PTSD who completed an intensive Cognitive Processing Therapy treatment program. Cogn Behav Ther 2024; 53:423-435. [PMID: 38477982 DOI: 10.1080/16506073.2024.2329246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 03/05/2024] [Indexed: 03/14/2024]
Abstract
Negative posttraumatic cognitions (NPCs) have been linked to symptoms of PTSD and are an important target of cognitive behavioral treatments for PTSD, including Cognitive Processing Therapy (CPT). Yet to be explored are the different change trajectories of NPCs during CPT. Knowledge of such change trajectories could elucidate common NPC change processes within CPT and their relationship to PTSD symptom severity. We examined NPC change trajectories in a group of 443 veterans who completed a 2-week intensive CPT program. We identified four NPC trajectory groups termed start high end high, start high end moderate, start moderate end low, and start low end low. Most of the groups showed an increase in NPCs at the midpoint of treatment before ultimately decreasing. As predicted, baseline PTSD symptom severity predicted change trajectory group membership. Also, NPC change trajectories were associated with PTSD severity at the end of treatment such that individuals in smaller NPC change groups had higher PTSD symptoms at the end of treatment, and vice versa. Clinicians can use this knowledge to make predictions of a particular client's NPC change trajectory and set expectations for what progress in treatment may look like, including normalizing increases in NPCs from the start of treatment.
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Affiliation(s)
- Daniel Szoke
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, USA
| | - Erin Walker
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, USA
| | - Nicole Christ
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, USA
| | - Dale Smith
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, USA
| | - Philip Held
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, USA
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Leighton SC, Rodriguez KE, Jensen CL, MacLean EL, Davis LW, Ashbeck EL, Bedrick EJ, O'Haire ME. Service Dogs for Veterans and Military Members With Posttraumatic Stress Disorder: A Nonrandomized Controlled Trial. JAMA Netw Open 2024; 7:e2414686. [PMID: 38833250 DOI: 10.1001/jamanetworkopen.2024.14686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
Importance Military members and veterans (hereafter, veterans) with posttraumatic stress disorder (PTSD) increasingly seek psychiatric service dogs as a complementary intervention, yet the effectiveness of service dogs is understudied. Objective To estimate the associations between psychiatric service dog partnership and self-reported and clinician-rated PTSD symptom severity, depression, anxiety, and psychosocial functioning after 3 months of intervention among veterans. Design, Setting, and Participants This nonrandomized controlled trial used standardized and validated assessment instruments completed by participants and administered by blinded clinicians. Recruitment, eligibility screening, and enrollment were conducted between August 2017 and December 2019. Veterans were recruited using the database of an accredited nonprofit service dog organization with constituents throughout the US. Participants were veterans with a PTSD diagnosis; they were allocated to either the intervention group (n = 81) or control group (n = 75). Outcome assessments were performed at baseline and at the 3-month follow-up. Data analyses were completed in October 2023. Interventions Participants allocated to the intervention group received a psychiatric service dog for PTSD, whereas those allocated to the control group remained on the waiting list based on the date of application submitted to the service dog organization. Both groups had unrestricted access to usual care. Main Outcomes and Measures The primary outcomes were PTSD symptom severity, depression, and anxiety after 3 months, and the secondary outcomes were psychosocial functioning, such as quality of life and social health. The self-reported PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was used to measure symptom severity, and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) was used to assess PTSD diagnosis (score range for both instruments: 0-80, with higher scores indicating greater PTSD symptoms). Results The 156 participants included in the trial had a mean (SD) age of 37.6 (8.3) years and included 117 males (75%), 17 Black or African American individuals (11%), 30 Hispanic individuals (19%), and 117 White individuals (76%). Compared with the control group, the intervention group had significantly lower PTSD symptom severity based on the PTSD Checklist for DSM-5 mean (SD) score (41.9 [16.9] vs 51.7 [16.1]; difference in means, -11.5 [95% CI, -16.2 to -6.6]; P < .001) and the CAPS-5 mean (SD) score (30.2 [10.2] vs 36.9 [10.2]; difference in means, -7.0 [95% CI, -10.8 to -4.5]; P < .001) at 3 months. The intervention group also had significantly lower depression scores (odds ratio [OR], 0.45 [95% CI, 0.23-0.86]; difference in means, -3.3 [95% CI, -6.8 to -0.6]), anxiety (OR, 0.25 [95% CI, 0.13-0.50]; difference in means, -4.4 [95% CI, -6.9 to -2.1]), and most areas of psychosocial functioning (eg, social isolation: OR, 0.34 [95% CI, 0.18-0.64]). Conclusions and Relevance This nonrandomized controlled trial found that compared with usual care alone, partnership with a trained psychiatric service dog was associated with lower PTSD symptom severity and higher psychosocial functioning in veterans. Psychiatric service dogs may be an effective complementary intervention for military service-related PTSD. Trial Registration ClinicalTrials.gov ID: NCT03245814.
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Affiliation(s)
- Sarah C Leighton
- College of Veterinary Medicine, University of Arizona, Oro Valley
| | | | - Clare L Jensen
- College of Veterinary Medicine, University of Arizona, Oro Valley
| | - Evan L MacLean
- College of Veterinary Medicine, University of Arizona, Oro Valley
| | - Louanne W Davis
- Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
- Indiana University School of Medicine, Indianapolis
| | - Erin L Ashbeck
- Statistics Consulting Lab, The BIO5 Institute, University of Arizona, Tucson
| | - Edward J Bedrick
- Department of Epidemiology and Biostatistics, College of Public Health, University of Arizona, Tucson
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Feder A, Kowalchyk ML, Brinkman HR, Cahn L, Aaronson CJ, Böttche M, Presseau C, Fred-Torres S, Markowitz JC, Litz BT, Yehuda R, Knaevelsrud C, Pietrzak RH. Randomized controlled trial of two internet-based written therapies for world trade center workers and survivors with persistent PTSD symptoms. Psychiatry Res 2024; 336:115885. [PMID: 38603979 DOI: 10.1016/j.psychres.2024.115885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/12/2024] [Accepted: 03/27/2024] [Indexed: 04/13/2024]
Abstract
Posttraumatic stress disorder (PTSD) remains prevalent among individuals exposed to the 9/11 World Trade Center (WTC) terrorist attacks. The present study compared an Internet-based, therapist-assisted psychotherapy for PTSD to an active control intervention in WTC survivors and recovery workers with WTC-related PTSD symptoms (n = 105; 75% syndromal PTSD). Participants were randomized to integrative testimonial therapy (ITT), focused on WTC-related trauma, or modified present-centered therapy (I-MPCT), each comprising 11 assigned written narratives. The primary outcome was baseline-to-post-treatment change in PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5). Secondary measures included PTSD symptom clusters, depressive/anxiety symptoms, functioning, and quality of life. A significant main effect of time was observed for the primary outcome (average "large" effect size improvement, d = 1.49). Significant and "moderate-to-large" main effects of time were also observed for all PTSD symptom clusters, depressive symptoms, quality of life, and mental health-related functioning (d range=0.62-1.33). Treatment and treatment-by-time interactions were not significant. In planned secondary analyses incorporating 3-month follow-up measures, ITT was associated with significantly greater reductions than I-MPCT in PTSD avoidance and negative alterations in cognitions and mood, anxiety, and mental health-related functioning. Both therapies significantly lowered PTSD symptoms, suggesting they may benefit hard-to-reach individuals with chronic WTC-related PTSD symptoms.
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Affiliation(s)
- Adriana Feder
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Mary L Kowalchyk
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hannah R Brinkman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Leah Cahn
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Cindy J Aaronson
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maria Böttche
- Freie Universität Berlin, Department of Clinical Psychological Intervention, Berlin, Germany
| | - Candice Presseau
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; Veterans' Administration Connecticut Healthcare System, West Haven, CT, USA
| | - Sharely Fred-Torres
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John C Markowitz
- New York State Psychiatric Institute, Department of Clinical Therapeutics, New York, NY, USA; Columbia University, Department of Psychiatry, New York, NY, USA
| | - Brett T Litz
- Boston University School of Medicine, Department of Psychiatry, Boston, MA, USA; Boston University, Boston, Department of Psychological and Brain Sciences, MA, USA; Veterans' Administration Boston Healthcare System, Epidemiological Research and Information Center, Boston, MA, USA
| | - Rachel Yehuda
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Icahn School of Medicine at Mount Sinai, Department of Neuroscience, New York, NY, USA; James J. Peters Veterans' Administration Medical Center, Bronx, New York, USA
| | - Christine Knaevelsrud
- Freie Universität Berlin, Department of Clinical Psychological Intervention, Berlin, Germany
| | - Robert H Pietrzak
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA; United States Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA
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4
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Mulvaney SW, Lynch JH, Rae Olmsted KL, Mahadevan S, Dineen KJ. The Successful Use of Bilateral 2-Level Ultrasound-Guided Stellate Ganglion Block to Improve Traumatic Brain Injury Symptoms: A Retrospective Analysis of 23 Patients. Mil Med 2024:usae193. [PMID: 38771000 DOI: 10.1093/milmed/usae193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/15/2024] [Accepted: 04/01/2024] [Indexed: 05/22/2024] Open
Abstract
PURPOSE The purpose of the study was to determine whether performing ultrasound-guided, bilateral stellate ganglion blocks (SGBs; performed on subsequent days) improved traumatic brain injury (TBI) symptoms. METHODS A retrospective chart review was conducted for the time period between August 2022 and February 2023 to identify patients who received bilateral, 2-level (C6 and C4) SGBs for PTSD symptoms but who also had a history of TBI. Neurobehavioral Symptoms Inventory (NSI) scores were collected at baseline, 1 week, and 1 month post-treatment in 14 males and 9 females. RESULTS Out of 23 patients, 22 showed improvement in their NSI scores. NSI baseline average score was 42.7; the average score at 1 week post-treatment was 18.8; 1 month post-treatment was 20.1. This represents a 53% improvement in the NSI score between baseline and 1 month. CONCLUSION The use of bilateral, 2-level SGBs may be indicated in treating patients with PTSD symptoms with concomitant diagnoses of mild-to-moderate TBI.
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Affiliation(s)
- Sean W Mulvaney
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - James H Lynch
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | | | - Sanjay Mahadevan
- Regenerative Orthopedics and Sports Medicine, Annapolis, MD 21401, USA
| | - Kyle J Dineen
- Regenerative Orthopedics and Sports Medicine, Annapolis, MD 21401, USA
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Possemato K, Mastroleo NR, Balderrama-Durbin C, King P, Davis A, Borsari B, Rauch SAM. A Randomized Controlled Pilot Trial of Primary Care Treatment Integrating Motivation and Exposure Treatment (PC-TIME) in Veterans With PTSD and Harmful Alcohol Use. Behav Ther 2024; 55:570-584. [PMID: 38670669 PMCID: PMC11056732 DOI: 10.1016/j.beth.2023.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 08/30/2023] [Accepted: 08/30/2023] [Indexed: 04/28/2024]
Abstract
Individuals with posttraumatic stress disorder (PTSD) often engage in harmful alcohol use. These co-occurring conditions are associated with negative health consequences and disability. PTSD and harmful drinking are typically experienced as closely related-thus treatments that target both simultaneously are preferred by patients. Many individuals with PTSD and harmful alcohol use receive primary care services but encounter treatment barriers in engaging in specialty mental health and substance use services. A pilot randomized controlled trial of a brief integrated treatment for PTSD and harmful drinking versus primary care treatment as usual (PC-TAU) took place in three U.S. Department of Veterans Affairs (VA) primary care clinics. The intervention (primary care treatment integrating motivation and exposure [PC-TIME]) combines motivational interviewing to reduce alcohol use and brief prolonged exposure for PTSD delivered over five brief sessions. Participants (N = 63) were veterans with PTSD and harmful drinking. Multilevel growth curve modeling examined changes in drinking (average number of drinks per drinking day and percentage of heavy drinking days) and self-reported PTSD severity at baseline, 8, 14, and 20 weeks. Participants reported high satisfaction with PC-TIME and 70% (n = 23) completed treatment. As hypothesized, a significantly steeper decrease in self-reported PTSD severity and heavy drinking was evident for participants randomized to PC-TIME compared with PC-TAU. Contrary to expectations, no significant posttreatment differences in PTSD diagnoses were observed. PC-TIME participants were less likely to exceed National Institute for Alcoholism and Alcohol Abuse (NIAAA) guidelines for harmful alcohol use posttreatment compared with PC-TAU participants. PC-TIME is a promising brief, primary care-based treatment for individuals with co-occurring PTSD and harmful alcohol use. A full-scale randomized clinical trial is needed to fully test its effectiveness.
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Affiliation(s)
- Kyle Possemato
- VA Center for Integrated Healthcare, Syracuse and Buffalo.
| | | | | | - Paul King
- VA Center for Integrated Healthcare, Syracuse and Buffalo; and University at Buffalo
| | - Ariella Davis
- VA Center for Integrated Healthcare, Syracuse and Buffalo
| | - Brian Borsari
- San Francisco VA Health Care System and University of California, San Francisco
| | - Sheila A M Rauch
- |Atlanta VA Healthcare System and Emory University School of Medicine
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Petrakis IL, Meshberg-Cohen S, Nich C, Kelly MM, Claudio T, Jane JS, Pisani E, Ralevski E. Cognitive processing therapy (CPT) versus individual drug counseling (IDC) for PTSD for veterans with opioid use disorder maintained on buprenorphine. Am J Addict 2024. [PMID: 38624259 DOI: 10.1111/ajad.13557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/28/2024] [Accepted: 04/02/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND AND OBJECTIVES There are high rates of comorbidity between posttraumatic stress disorder (PTSD) and opioid use disorder (OUD). Evidence-based trauma-focused psychotherapies such as Cognitive Processing Therapy (CPT) are a first-line treatment for PTSD. Veterans with OUD are treated primarily in substance use disorder (SUD) clinics where the standard of care is drug counseling; they often do not have access to first-line PTSD treatments. This study tested whether CPT can be conducted safely and effectively in veterans with comorbid OUD treated with buprenorphine. METHODS This 12-week, 2-site, randomized clinical trial (RCT) included open-label randomization to two groups: (a) CPT versus (b) Individual Drug Counselling (IDC) in veterans with PTSD and comorbid OUD who were maintained on buprenorphine (N = 38). RESULTS Veterans randomized to either IDC (n = 18) or CPT (n = 20) showed a significant reduction in self-reported PTSD symptoms over time as measured by the PTSD checklist (PCL-5) but there were no treatment group differences; there was some indication that reduction in PTSD symptoms in the CPT group were sustained in contrast to the IDC group. Recruitment was significantly impacted by COVID-19 pandemic, so this study serves as a proof-of-concept pilot study. DISCUSSION AND CONCLUSIONS Veterans with OUD and PTSD can safely and effectively participate in evidence-based therapy for PTSD; further work should confirm that trauma-focused treatment may be more effective in leading to sustained remission of PTSD symptoms than drug counseling. SCIENTIFIC SIGNIFICANCE This is the first study to evaluate CPT for PTSD in the context of buprenorphine treatment for OUD.
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Affiliation(s)
- Ismene L Petrakis
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Sarah Meshberg-Cohen
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Charla Nich
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Megan M Kelly
- Department of Psychiatry, VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Department of Psychiatry, UMass Chan Medical School, North Worcester, Massachusetts, USA
| | - Tracy Claudio
- Department of Psychiatry, VA Bedford Healthcare System, Bedford, Massachusetts, USA
| | - Jane Serrita Jane
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Emily Pisani
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Elizabeth Ralevski
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
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7
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Ennis CR, Raines AM, Boffa JW, Shapiro MO, Dornbach-Bender A, Ferrie ML, Fondren AH, Vidaurri DN, Walton JL, Chambliss JL, Franklin CL. Massed written exposure therapy delivered to veterans with posttraumatic stress symptoms on an acute inpatient mental health unit. J Trauma Stress 2024. [PMID: 38583141 DOI: 10.1002/jts.23042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 04/09/2024]
Abstract
Written exposure therapy (WET) is a brief, manualized trauma-focused treatment typically delivered in five individual weekly sessions. Given the brevity and effectiveness of WET, researchers have begun to focus on its delivery in a massed format. However, only one case study examining massed delivery has been published to date. As such, the objective of the current study was to examine the acceptability, feasibility, and preliminary effectiveness of massed WET among veterans with a trauma- and stressor-related disorder receiving care on an acute inpatient mental health unit. Veterans (N = 26) were assessed prior to, immediately after, and 1 month following massed WET. Most veterans found massed WET to be useful and acceptable. Recruitment and retention rates suggested that the treatment was feasible. Notably, the results revealed statistically significant reductions in overall posttraumatic stress symptoms, ηp 2 = .81, p < .001; depressive symptoms, ηp 2 = .71, p < .001; and functional impairment, ηp 2 = .42, p = .002. These findings add to a growing body of literature highlighting the preliminary effectiveness of WET across various settings, populations, and delivery formats. Limitations include the small sample size and uncontrolled design.
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Affiliation(s)
- Chelsea R Ennis
- Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
- South Central Mental Illness Research, Education and Clinical Center (MIRECC), New Orleans, Louisiana, USA
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Amanda M Raines
- Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
- South Central Mental Illness Research, Education and Clinical Center (MIRECC), New Orleans, Louisiana, USA
- School of Medicine, Louisiana State University, New Orleans, Louisiana, USA
| | - Joseph W Boffa
- Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
- South Central Mental Illness Research, Education and Clinical Center (MIRECC), New Orleans, Louisiana, USA
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Mary O Shapiro
- Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
- South Central Mental Illness Research, Education and Clinical Center (MIRECC), New Orleans, Louisiana, USA
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | | | - Mara L Ferrie
- Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
- South Central Mental Illness Research, Education and Clinical Center (MIRECC), New Orleans, Louisiana, USA
| | - Alana H Fondren
- Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
| | - Desirae N Vidaurri
- Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
- South Central Mental Illness Research, Education and Clinical Center (MIRECC), New Orleans, Louisiana, USA
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Jessica L Walton
- Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
- South Central Mental Illness Research, Education and Clinical Center (MIRECC), New Orleans, Louisiana, USA
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Jessica L Chambliss
- Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
| | - C Laurel Franklin
- Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
- South Central Mental Illness Research, Education and Clinical Center (MIRECC), New Orleans, Louisiana, USA
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
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Sayer NA, Kaplan A, Nelson DB, Wiltsey Stirman S, Rosen CS. Clinician Burnout and Effectiveness of Guideline-Recommended Psychotherapies. JAMA Netw Open 2024; 7:e246858. [PMID: 38630477 PMCID: PMC11024738 DOI: 10.1001/jamanetworkopen.2024.6858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/19/2024] [Indexed: 04/19/2024] Open
Abstract
Importance Clinician burnout has been associated with clinician outcomes, but the association with patient outcomes remains unclear. Objective To evaluate the association between clinician burnout and the outcomes of patients receiving of guideline-recommended trauma-focused psychotherapies for posttraumatic stress disorder (PTSD). Design, Setting, and Participants This cohort study was set at the US Veterans Affairs Health Care System and included licensed therapists who provided trauma-focused psychotherapies and responded to an online survey between May 2 and October 8, 2019, and their patients who initiated a trauma-focused therapy during the following year. Patient data were collected through December 31, 2020. Data were analyzed from May to September 2023. Exposures Therapists completing the survey reported burnout with a 5-point validated measure taken from the Physician Worklife Study. Burnout was defined as scores of 3 or more. Main Outcomes and Measures The primary outcome was patients' clinically meaningful improvement in PTSD symptoms according to the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Patient dropout, therapist adherence, and session spacing was assessed through electronic health records. Multivariable random-effects logistic regression examined the association of therapist burnout and clinically meaningful improvement, adjusted for case-mix. Results In this study, 165 of 180 (91.7%) therapists (89 [53.9%] female) completed the burnout measure and provided trauma-focused psychotherapies to 1268 patients (961 [75.8%] male) with outcome data. Fifty-eight (35.2%) therapists endorsed burnout. One third of patients (431 [34.0%]) met criterion for clinically meaningful improvement. Clinically meaningful improvement in PTSD symptoms was experienced by 120 (28.3%) of the 424 patients seen by therapists who reported burnout and 311 (36.8%) of the 844 patients seen by therapists without burnout. Burnout was associated with lower odds of clinically meaningful improvement (adjusted odds ratio [OR],0.63; 95% CI, 0.48-0.85). The odds of clinically meaningful improvement were reduced for patients who dropped out (OR, 0.15; 95% CI, 0.11-0.20) and had greater session spacing (OR, 0.80; 95% CI, 0.70-0.92). Therapist adherence was not associated with therapy effectiveness. Adjusting for dropout or session spacing did not meaningfully alter the magnitude of the association between burnout and clinically meaningful improvement. Conclusions and Relevance In this prospective cohort study, therapist burnout was associated with reduced effectiveness of trauma-focused psychotherapies. Studying when and how burnout affects patient outcomes may inform workplace interventions.
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Affiliation(s)
- Nina A. Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis
| | - Adam Kaplan
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis
| | - David B. Nelson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis
| | - Shannon Wiltsey Stirman
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division at the Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Craig S. Rosen
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division at the Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
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9
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Schnurr PP, Hamblen JL, Wolf J, Coller R, Collie C, Fuller MA, Holtzheimer PE, Kelly U, Lang AJ, McGraw K, Morganstein JC, Norman SB, Papke K, Petrakis I, Riggs D, Sall JA, Shiner B, Wiechers I, Kelber MS. The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med 2024; 177:363-374. [PMID: 38408360 DOI: 10.7326/m23-2757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
DESCRIPTION The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline (CPG) and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against. METHODS Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed. RECOMMENDATIONS The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder (PTSD) with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.
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Affiliation(s)
- Paula P Schnurr
- National Center for PTSD, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (P.P.S., J.L.H., P.E.H.)
| | - Jessica L Hamblen
- National Center for PTSD, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (P.P.S., J.L.H., P.E.H.)
| | - Jonathan Wolf
- Defense Health Agency, Falls Church, Virginia (J.W.)
| | - Rachael Coller
- Naval Medical Center San Diego, San Diego, California (R.C.)
| | - Claire Collie
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC (C.C.)
| | - Matthew A Fuller
- Veterans Health Administration Pharmacy Benefits Management Service and Case Western Reserve University School of Medicine, Cleveland, Ohio (M.A.F.)
| | - Paul E Holtzheimer
- National Center for PTSD, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (P.P.S., J.L.H., P.E.H.)
| | - Ursula Kelly
- Joseph Maxwell Cleland Atlanta VA Medical Center and Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia (U.K.)
| | - Ariel J Lang
- Center of Excellence for Stress and Mental Health at VA San Diego Healthcare System and University of California, San Diego, San Diego, California (A.J.L.)
| | - Kate McGraw
- Psychological Health Center of Excellence, Defense Health Agency, Falls Church, Virginia (K.M., M.S.K.)
| | - Joshua C Morganstein
- Uniformed Services University of the Health Sciences, Center for the Study of Traumatic Stress, Bethesda, Maryland (J.C.M.)
| | - Sonya B Norman
- National Center for PTSD, White River Junction, Vermont, and University of California, San Diego, San Diego, California (S.B.N.)
| | - Katie Papke
- National Social Work Program Office, Veterans Health Administration, Washington, DC (K.P.)
| | - Ismene Petrakis
- National Center for PTSD, West Haven, and Yale University School of Medicine, New Haven, Connecticut (I.P.)
| | - David Riggs
- Uniformed Services University of the Health Sciences, Center for Deployment Psychology, Bethesda, Maryland (D.R.)
| | - James A Sall
- Evidence Based Practice, Quality and Patient Safety, Veterans Health Administration, Washington, DC (J.A.S.)
| | - Brian Shiner
- White River Junction VA Medical Center, White River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (B.S.)
| | - Ilse Wiechers
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC; Yale University School of Medicine, New Haven, Connecticut; and University of California, San Francisco, School of Medicine, San Francisco, California (I.W.)
| | - Marija S Kelber
- Psychological Health Center of Excellence, Defense Health Agency, Falls Church, Virginia (K.M., M.S.K.)
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Fruchter E, Goldenthal N, Adler LA, Gross R, Harel EV, Deutsch L, Nacasch N, Grinapol S, Amital D, Voigt JD, Marmar CR. Amygdala-derived-EEG-fMRI-pattern neurofeedback for the treatment of chronic post-traumatic stress disorder. A prospective, multicenter, multinational study evaluating clinical efficacy. Psychiatry Res 2024; 333:115711. [PMID: 38325159 DOI: 10.1016/j.psychres.2023.115711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/26/2023] [Accepted: 12/30/2023] [Indexed: 02/09/2024]
Abstract
We conducted a prospective, single arm, multisite, multinational, open label trial assessing the safety and efficacy of a novel amygdala derived neurofeedback treatment, designated Amygdala-Derived-EFP, for chronic PTSD. Participants, including veterans and civilians, underwent screening, training, 15 neurofeedback sessions over 8 weeks and; baseline, termination (8 weeks) and 3 month post treatment assessments with validated measures. The primary endpoint was more than 50 % of the participants demonstrating a Minimally Clinically Important Difference (MCID) defined as a 6-point reduction, on the Clinician Administered PTSD Scale (CAPS-5) total score at 3 months. Secondary measures included the PCL-5, ERQ, PHQ-9, and CGI. Statistical analyses were performed using SAS®V9.4. The primary endpoint was met, with a CAPS-5 MCID response rate of 66.7 %. The average reduction in CAPS-5 total scores at 3 month follow up was 13.5 points, more than twice the MCID. Changes from baseline in CAPS-5, PCL-5, PHQ-9 scores at 8 weeks and the 3 month follow-up demonstrated statistically significant improvements in response and; demonstrated effect sizes ranging from 0.46 to 1.07. Adverse events were mild and resolved after treatment. This study builds on prior research demonstrating similar outcomes using amygdala-derived neurofeedback. Positive attributes of this therapy include monitoring by non-physician personnel, affordability, accessibility, and tolerability.
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Affiliation(s)
- Eyal Fruchter
- Rambam Medical Center, Bruss Rapaport Faculty of Medicine - Technicon - Haifa, Haifa, Israel
| | - Nadav Goldenthal
- Division of Psychiatry, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Lenard A Adler
- Department Psychiatry, New York University Grossman School of Medicine, NY, NY, United States
| | - Raz Gross
- Department of Epidemiology, School of Public Health and Department of Psychiatry, School of Medicine, Tel Aviv University, Sheba Medical Center, Tel Aviv, Isreal
| | - Eiran V Harel
- Be'er Ya'akov Mental Health Center, Tel Aviv, Israel
| | | | - Nitsa Nacasch
- Division of Psychiatry, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Shulamit Grinapol
- Department of Community Mental Health, University of Haifa, Haifa, Israel
| | - Daniela Amital
- Division of Psychology, Barzilai Medical Center, Ashkelon, Israel
| | | | - Charles R Marmar
- Department Psychiatry, New York University Grossman School of Medicine, NY, NY, United States
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11
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Schroeder RW, Bieu RK. Exploration of PCL-5 symptom validity indices for detection of exaggerated and feigned PTSD. J Clin Exp Neuropsychol 2024; 46:152-161. [PMID: 38353609 DOI: 10.1080/13803395.2024.2314728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/03/2023] [Indexed: 05/12/2024]
Abstract
INTRODUCTION There are very few symptom validity indices directly examining overreported posttraumatic stress disorder (PTSD) symptomatology, and, until recently, there were no symptom validity indices embedded within the PTSD Checklist for the DSM-5 (PCL-5), which is one of the most commonly used PTSD measures. Given this, the current study sought to develop and cross-validate symptom validity indices for the PCL-5. METHOD Multiple criterion groups comprised of Veteran patients were utilized (N = 210). Patients were determined to be valid or invalid responders based on Personality Asessment Inventory symptom validity indices. Three PCL-5 symptom validity indices were then examined: the PCL-5 Symptom Severity scale (PSS), the PCL-5 Extreme Symptom scale (PES), and the PCL-5 Rare Items scale (PRI). RESULTS Area under the curve statistics ranged from .78 to .85. The PSS and PES both met classification accuracy statistic goals, with the PES achieving the highest sensitivity rate (.39) when maintaining specificity at .90 or above across all criterion groups. When an ad hoc analysis was performed, which included only patients with exceptionally strong evidence of invalidity, sensitivity rates increased to .60 for the PES while maintaining specificity at .90. CONCLUSIONS These findings provide preliminary support for new PTSD symptom validity indices embedded within one of the most frequently used PTSD measures.
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Affiliation(s)
- Ryan W Schroeder
- Department is Behavioral Health, Robert J. Dole VA Medical Center, Wichita, KS, USA
| | - Rachel K Bieu
- Department is Behavioral Health, Robert J. Dole VA Medical Center, Wichita, KS, USA
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12
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Peterson AL, Moore BA, Evans WR, Young-McCaughan S, Blankenship AE, Straud CL, McLean CS, Miller TL, Meyer EC. Enhancing resiliency and optimizing readiness in military personnel through psychological flexibility training: design and methodology of a randomized controlled trial. Front Psychiatry 2024; 14:1299532. [PMID: 38250282 PMCID: PMC10797054 DOI: 10.3389/fpsyt.2023.1299532] [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: 09/22/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024] Open
Abstract
Background Enhancing resiliency and optimizing readiness in military personnel is a high priority for the U.S. Department of Defense. Most military resiliency-enhancement programs are evidence-informed interventions. However, few randomized studies have demonstrated efficacy of any intervention or training program to enhance resiliency and prevent the development of psychological health symptoms in military personnel when exposed to operational stressors. This manuscript provides an overview of the theoretical foundation, research design, and research methods of a preventive intervention trial designed to evaluate the efficacy of a training program to enhance resiliency and prevent psychological health symptoms in military personnel. The resiliency training intervention is based on Acceptance and Commitment Therapy (ACT), an evidence-based intervention with broad empirical support for improving functioning in those living with psychological and medical conditions. Method/design This study will evaluate the efficacy of a two-day training program based on ACT for fostering psychological flexibility, the central target in ACT, for enhancing resiliency, and for preventing the development of psychological health symptoms. The research participants will be a non-clinical population of active duty military personnel (N = 600). The ACT-based training program (n = 300) will be compared to a military resiliency training as usual, known as Master Resilience Training (n = 300). Assessment measures will be administered at the baseline assessment, after training, prior to a military deployment, and after returning from a deployment. Qualitative interviews will be conducted to provide feedback on the training program.Clinical Trial Registration: NCT05094115.
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Affiliation(s)
- Alan L. Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, United States
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX, United States
| | - Brian A. Moore
- Department of Psychological Science, Kennesaw State University, Kennesaw, GA, United States
| | - Wyatt R. Evans
- VA North Texas Health Care System, Dallas, TX, United States
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, United States
| | - Abby E. Blankenship
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Casey L. Straud
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX, United States
| | | | - Tashina L. Miller
- 3rd Security Force Assistance Brigade, Fort Cavazos, TX, United States
| | - Eric C. Meyer
- Department of Counseling and Behavioral Health, University of Pittsburgh, Pittsburgh, PA, United States
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13
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Fine NB, Neuman Fligelman E, Carlton N, Bloch M, Hendler T, Helpman L, Seligman Z, Armon DB. Integration of limbic self-neuromodulation with psychotherapy for complex post-traumatic stress disorder: treatment rationale and case study. Eur J Psychotraumatol 2024; 15:2256206. [PMID: 38166532 PMCID: PMC10769120 DOI: 10.1080/20008066.2023.2256206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 07/24/2023] [Indexed: 01/04/2024] Open
Abstract
Treatment Rationale: Exposure to repeated sexual trauma, particularly during childhood, often leads to protracted mental health problems. Childhood adversity is specifically associated with complex posttraumatic stress disorder (PTSD) presentation, which is particularly tenacious and treatment refractory, and features severe emotion dysregulation. Augmentation approaches have been suggested to enhance treatment efficacy in PTSD thus integrating first-line psychotherapy with mechanistically informed self-neuromodulation procedures (i.e. neurofeedback) may pave the way to enhanced clinical outcomes. A central neural mechanism of PTSD and emotion dysregulation involves amygdala hyperactivity that can be volitionally regulated by neurofeedback. We outline a treatment rationale that includes a detailed justification for the potential of combining psychotherapy and NF and delineate mechanisms of change. We illustrate key processes of reciprocal interactions between neurofeedback engagement and therapeutic goals.Case Study: We describe a clinical case of a woman with complex PTSD due to early and repetitive childhood sexual abuse using adjunctive neurofeedback as an augmentation to an ongoing, stable, traditional treatment plan. The woman participated in (a) ten sessions of neurofeedback by the use of an fMRI-inspired EEG model of limbic related activity (Amygdala Electrical-Finger-Print; AmygEFP-NF), (b) traditional weekly individual psychotherapy, (c) skills group. Before and after NF training period patient was blindly assessed for PTSD symptoms, followed by a 1, 3- and 6-months self-report follow-up. We demonstrate mechanisms of change as well as the clinical effectiveness of adjunctive treatment as indicated by reduced PTSD symptoms and improved daily functioning within this single case.Conclusions: We outline an integrative neuropsychological framework for understanding the unique mechanisms of change conferring value to conjoining NF applications with trauma-focused psychotherapy in complex PTSD.
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Affiliation(s)
- Naomi B. Fine
- Faculty of Social Sciences, School of Psychological Sciences, Tel-Aviv University, Tel-Aviv, Israel
- Sagol Brain Institute Tel-Aviv, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Ellie Neuman Fligelman
- Lotem Center for Treatment of Sexual Trauma, Department of Psychiatry, Sourasky Medical Center, Tel Aviv, Israel
| | - Nora Carlton
- Lotem Center for Treatment of Sexual Trauma, Department of Psychiatry, Sourasky Medical Center, Tel Aviv, Israel
| | - Miki Bloch
- Psychiatric Department, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Talma Hendler
- Faculty of Social Sciences, School of Psychological Sciences, Tel-Aviv University, Tel-Aviv, Israel
- Sagol Brain Institute Tel-Aviv, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel
| | - Liat Helpman
- Psychiatric Department, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Department of Counseling and Human Development, University of Haifa, Haifa, Israel
| | - Zivya Seligman
- Lotem Center for Treatment of Sexual Trauma, Department of Psychiatry, Sourasky Medical Center, Tel Aviv, Israel
| | - Daphna Bardin Armon
- Lotem Center for Treatment of Sexual Trauma, Department of Psychiatry, Sourasky Medical Center, Tel Aviv, Israel
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Fenlon EE, Pinciotti CM, Jones AC, Rippey CS, Wild H, Hubert TJJ, Tipsword JM, Badour CL, Adams TG. Assessment of Comorbid Obsessive-Compulsive Disorder and Posttraumatic Stress Disorder. Assessment 2024; 31:126-144. [PMID: 37904505 DOI: 10.1177/10731911231208403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
Obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) are commonly comorbid and share prominent features (e.g., intrusions, safety behaviors, and avoidance). Excellent self-report and clinician-administered assessments exist for OCD and PTSD individually, but few assess both disorders, and even fewer provide instruction on differential diagnosis or detection of comorbid OCD and PTSD. To address this gap in the literature, the current paper aims to (1) highlight diagnostic and functional similarities and differences between OCD and PTSD to inform differential diagnosis, (2) outline assessment recommendations for individuals with suspected comorbid OCD and PTSD, OCD with a significant trauma history or posttraumatic symptoms, or PTSD with significant obsessive-compulsive symptoms, and (3) explore future directions to evaluate and improve methods for assessing co-occurring OCD and PTSD.
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Affiliation(s)
| | | | - Alyssa C Jones
- Ralph H. Johnson VA Health Care System, Charleston, SC, USA
- Medical University of South Carolina, Charleston, USA
| | | | | | | | | | | | - Thomas G Adams
- University of Kentucky, Lexington, USA
- Yale School of Medicine, New Haven, CT, USA
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15
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Dupont T, Kentish-Barnes N, Pochard F, Duchesnay E, Azoulay E. Prediction of post-traumatic stress disorder in family members of ICU patients: a machine learning approach. Intensive Care Med 2024; 50:114-124. [PMID: 38112774 DOI: 10.1007/s00134-023-07288-1] [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: 08/19/2023] [Accepted: 11/18/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE Post-traumatic stress disorder (PTSD) can affect family members of patients admitted to the intensive care unit (ICU). Easily accessible patient's and relative's information may help develop accurate risk stratification tools to direct relatives at higher risk of PTSD toward appropriate management. METHODS PTSD was measured 90 days after ICU discharge using validated instruments (Impact of Event Scale and Impact of Event Scale-Revised) in 2374 family members. Various supervised machine learning approaches were used to predict PTSD in family members and evaluated on an independent held-out test dataset. To better understand variables' contributions to PTSD predicted probability, we used machine learning interpretability methods on the best predictive algorithm. RESULTS Non-linear ensemble learning tree-based methods showed better predictive performances (Random Forest-area under curve, AUC = 0.73 [0.68-0.77] and XGBoost-AUC = 0.73 [0.69-0.78]) than regularized linear models, kernel-based models, or deep learning models. In the best performing algorithm, most important features that positively contributed to PTSD's predicted probability were all non-modifiable factors, namely, lower patient's age, longer duration of ICU stay, relative's female sex, lower relative's age, relative being a spouse/child, and patient's death in ICU. A sensitivity analysis in bereaved relatives did not alter the algorithm's predictive performance. CONCLUSION We propose a machine learning-based approach to predict PTSD in relatives of ICU patients at an individual level. In this model, PTSD is mostly influenced by non-modifiable factors.
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Affiliation(s)
- Thibault Dupont
- NeuroSpin, CEA, Université Paris-Saclay, 91191, Gif-Sur-Yvette, France
- Famirea Study Group, Médecine Intensive et Réanimation, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010, Paris, France
- Université Paris Cité, Paris, France
| | - Nancy Kentish-Barnes
- Famirea Study Group, Médecine Intensive et Réanimation, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010, Paris, France
- Université Paris Cité, Paris, France
| | - Frédéric Pochard
- Famirea Study Group, Médecine Intensive et Réanimation, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Edouard Duchesnay
- NeuroSpin, CEA, Université Paris-Saclay, 91191, Gif-Sur-Yvette, France
| | - Elie Azoulay
- Famirea Study Group, Médecine Intensive et Réanimation, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010, Paris, France.
- Université Paris Cité, Paris, France.
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16
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Byllesby BM, Palmieri PA. A Bifactor Model of General and Specific PTSD Symptom Change During Treatment. Assessment 2023; 30:2595-2604. [PMID: 36859781 DOI: 10.1177/10731911231156646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Posttraumatic stress disorder (PTSD) consists of four main components in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5): intrusions (INT), avoidance (AV), negative alterations in cognition and mood (NACM), and arousal and reactivity (AAR); however, studies do not always support this four-factor model. A sample of 348 treatment-seeking adults was assessed for PTSD symptoms at baseline (Time 1) and then 12 weeks later (Time 2). Confirmatory factor analysis (CFA) was used to examine the model fit of the DSM-5 four-factor model of PTSD with and without a general factor at both time points, and structural equation modeling allowed for examination of these associations between time points. The four-factor model did not meet the criteria for excellent model fit, and the bifactor model provided improved model fit. The NACM specific factor did not meet the criteria for unique variance above and beyond the general factor. The bifactor model of PTSD symptoms was reliable over time, and both the general factor and the AAR factor significantly predicted subsequent symptom severity.
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17
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Blanchard BE, Johnson M, Campbell SB, Reed DE, Chen S, Heagerty PJ, Marx BP, Kaysen D, Fortney JC. Minimal important difference metrics and test-retest reliability of the PTSD Checklist for DSM-5 with a primary care sample. J Trauma Stress 2023; 36:1102-1114. [PMID: 37845820 PMCID: PMC10754254 DOI: 10.1002/jts.22975] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/02/2023] [Accepted: 09/04/2023] [Indexed: 10/18/2023]
Abstract
The PTSD Checklist for DSM-5 (PCL-5) is a measure of posttraumatic stress disorder (PTSD) symptom severity that is widely used for clinical and research purposes. Although previous work has examined metrics of minimal important difference (MID) of the PCL-5 in veteran samples, no work has identified PCL-5 MID metrics among adults in primary care in the United States. In this secondary analysis, data were evaluated from primary care patients (N = 971) who screened positive for PTSD and participated in a large clinical trial in federally qualified health centers in three U.S. states. Participants primarily self-identified as women (70.2%) and White (70.3%). We calculated test-retest reliability using clinic registry data and multiple distribution- and anchor-based metrics of MID using baseline and follow-up survey data. Test-retest reliability (Pearson's r, Spearman's ρ, intraclass correlation coefficient) ranged from adequate to excellent (.79-.94), with the shortest time lag demonstrating the highest reliability estimate. The MID for the PCL-5 was estimated using multiple approaches. Distribution-based approaches indicated an MID range of 8.5-12.5, and anchor-based approaches indicated an MID range of 9.8-11.7. Taken together, the MID metrics indicate that PCL-5 change scores of 9-12 likely reflect real change in PTSD symptoms and indicate at least an MID for patients, whereas PCL-5 change scores of 5 or less likely are not reliable. These findings can help inform clinicians using the PCL-5 in similar populations to track patient responses to treatment and help researchers interpret PCL-5 score changes in clinical trials.
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Affiliation(s)
- Brittany E. Blanchard
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Morgan Johnson
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Sarah B. Campbell
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
- VA Health Services Research and Development Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - David E. Reed
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington, USA
| | - Shiyu Chen
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Patrick J. Heagerty
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington, USA
| | - Brian P. Marx
- VA Boston Healthcare System, National Center for PTSD, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Debra Kaysen
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - John C. Fortney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
- VA Health Services Research and Development Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
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18
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Stoycos SA, Straud CL, Stanley IH, Marx BP, Resick PA, Young-McCaughan S, Peterson AL, Sloan DM. Benchmarking secondary outcomes to posttraumatic stress disorder symptom change in response to cognitive processing and written exposure therapy for posttraumatic stress disorder. J Anxiety Disord 2023; 100:102794. [PMID: 37980801 DOI: 10.1016/j.janxdis.2023.102794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/16/2023] [Accepted: 11/08/2023] [Indexed: 11/21/2023]
Abstract
Posttraumatic stress disorder (PTSD) has high comorbidity with other psychiatric conditions, including depression, generalized anxiety, and suicidality. Evidence-based treatments (EBTs) for PTSD are effective at reducing PTSD symptoms. However, evidence on the impact of PTSD EBTs on comorbid conditions is mixed and often uses pre-post analyses, which disregards PTSD symptom response. This study replicated and extended prior work on benchmarking quality of life to PTSD symptom response to a broader range of secondary outcomes using a research-based metric of clinically meaningful PTSD symptom change. Ninety-five active duty military members seeking treatment for PTSD participated in a randomized noninferiority trial examining two cognitive behavioral therapies for PTSD: Written Exposure Therapy and Cognitive Processing Therapy. Participants completed clinician-administered and self-rating assessments at baseline and 10 weeks post-first treatment session and were classified as PTSD treatment responders or nonresponders. Data were analyzed using generalized linear mixed effects models with repeated measures with fixed effects of time and PTSD symptom response category. PTSD treatment responders experienced significant improvements in secondary outcomes; nonresponders demonstrated statistically significant, but not clinically meaningful, comorbid symptom change. Our findings provide evidence that successfully treating PTSD symptoms may also positively impact psychiatric comorbidity.
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Affiliation(s)
- Sarah A Stoycos
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, United States; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, United States
| | - Casey L Straud
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, United States; Research and Development Service, South Texas Veterans Health Care System, United States; Department of Psychology, University of Texas at San Antonio, United States
| | - Ian H Stanley
- Department of Emergency Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, United States; Center for COMBAT Research, University of Colorado Anschutz Medical Campus, United States
| | - Brian P Marx
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, United States; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, United States
| | - Patricia A Resick
- Department of Psychiatry and Behavioral Sciences, Duke Health, United States
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, United States; Research and Development Service, South Texas Veterans Health Care System, United States
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, United States; Research and Development Service, South Texas Veterans Health Care System, United States; Department of Psychology, University of Texas at San Antonio, United States
| | - Denise M Sloan
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, United States; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, United States.
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19
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Rauch SA, Kim HM, Acierno R, Ragin C, Wangelin B, Blitch K, Muzzy W, Hart S, Zivin K. Improving function through primary care treatment of posttraumatic stress disorder study outcomes: A randomized controlled trial of prolonged exposure for primary care in veterans. FAMILIES, SYSTEMS & HEALTH : THE JOURNAL OF COLLABORATIVE FAMILY HEALTHCARE 2023; 41:502-513. [PMID: 37650808 PMCID: PMC10840599 DOI: 10.1037/fsh0000823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Despite high cost and wide prevalence of posttraumatic stress disorder (PTSD) in veteran populations, and Veterans Health Administration (VA)-wide mental health provider training in evidence-based treatments for PTSD, most veterans with PTSD do not receive best practices interventions. This may be because virtually all evidence-based PTSD treatment is offered through specialty clinics, which require multiple steps and referrals to access. One solution is to offer PTSD treatment in VA primary care settings, which are often the first and only contact point for veterans. METHOD The present study, Improving Function Through Primary Care Treatment of PTSD (IMPACT), used a randomized controlled design to compare an adaptation of prolonged exposure for PTSD to primary care (PE-PC) versus best practices Primary Care Mental Health Integration (PCMHI) clinic treatment as usual (TAU) in terms of both functioning and psychological symptoms in 120 veterans recruited between April 2019 and September 2021. RESULTS Participants were mostly males (81.7%) with a mean age of 43.6 years (SD = 12.8), and more than half were non-White veterans (50.8%). Both conditions evinced significant improvement over baseline across functioning, PTSD, and depression measures, with no differences observed between groups. As observed in prior studies, PTSD symptoms continued to improve over time in both conditions, as measured by structured clinical interview. DISCUSSION Both PE-PC and best-practices TAU are effective in improving function and reducing PTSD severity and depression severity. Although we did not observe differences between the two treatments, note that this study site and two PCMHI clinics employ primarily cognitive behavioral therapies (e.g., exposure and behavioral activation). (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Sheila A.M. Rauch
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033
- Emory University School of Medicine, 12 Executive Park, 3 Floor, Atlanta, GA, 30029
| | - H. Myra Kim
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105
- University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI, 48109
| | - Ron Acierno
- Ralph H. Johnson VA Health Care System, 109 Bee Street, Charleston, SC, 29401
- University of Texas Health Science Center at Houston, Faillace Department of Psychiatry, Behavioral and Biomedical Sciences Building (BBSB), 1941 East Road, Houston, Texas 77054
| | - Carly Ragin
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033
| | - Bethany Wangelin
- Ralph H. Johnson VA Health Care System, 109 Bee Street, Charleston, SC, 29401
- Medical University of South Carolina, Department of Psychiatry & Behavioral Sciences, 67 President Street, Charleston, SC 29425
| | - Kimberly Blitch
- Ralph H. Johnson VA Health Care System, 109 Bee Street, Charleston, SC, 29401
- Medical University of South Carolina, Department of Psychiatry & Behavioral Sciences, 67 President Street, Charleston, SC 29425
| | - Wendy Muzzy
- Ralph H. Johnson VA Health Care System, 109 Bee Street, Charleston, SC, 29401
- Medical University of South Carolina, Department of Psychiatry & Behavioral Sciences, 67 President Street, Charleston, SC 29425
| | - Stephanie Hart
- Ralph H. Johnson VA Health Care System, 109 Bee Street, Charleston, SC, 29401
- Medical University of South Carolina, Department of Psychiatry & Behavioral Sciences, 67 President Street, Charleston, SC 29425
| | - Kara Zivin
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105
- University of Michigan, Department of Psychiatry, 2800 Plymouth Road, Ann Arbor, MI 48109
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20
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Nazem S, Barnes SM, Forster JE, Hostetter TA, Monteith LL, Kramer EB, Gaeddert LA, Brenner LA. Efficacy of an Internet-Delivered Intervention for Improving Insomnia Severity and Functioning in Veterans: Randomized Controlled Trial. JMIR Ment Health 2023; 10:e50516. [PMID: 37999953 DOI: 10.2196/50516] [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: 07/03/2023] [Revised: 09/26/2023] [Accepted: 10/06/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Despite a growing evidence base that internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) is associated with decreased insomnia severity, its efficacy has been minimally examined in veterans. OBJECTIVE The objective of this study was to evaluate the efficacy of an unguided iCBT-I (Sleep Healthy Using the Internet [SHUTi]) among veterans. METHODS We conducted a single-blind, randomized controlled trial in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans eligible for Veterans Health Administration care. Participants were randomly assigned (1:1) to receive SHUTi (a self-guided and interactive program) or an Insomnia Education Website (IEW) that provided nontailored and fixed insomnia information. Web-based assessments were administered at baseline, postintervention, 6 months postintervention, and 1 year postintervention. The primary outcome was self-reported insomnia severity (Insomnia Severity Index [ISI]). Secondary outcomes were self-reported mental and physical health functioning (Veterans RAND 36-item Health Survey). Exploratory outcomes comprised sleep diary parameters. RESULTS Of the 231 randomized participants (mean age 39.3, SD 7.8 years; 170/231, 73.5% male sex; 26/231, 11.3% Black; 172/231, 74.5% White; 10/231, 4.3% multiracial; and 17/231, 7.4% other; 36/231, 15.6% Hispanic) randomized between April 2018 and January 2019, a total of 116 (50.2%) were randomly assigned to SHUTi and 115 (49.8%) to the IEW. In intent-to-treat analyses, SHUTi participants experienced significantly larger ISI decreases compared with IEW participants at all time points (generalized η2 values of 0.13, 0.12, and 0.10, respectively; all P<.0001). These corresponded to estimated larger differences in changes of -3.47 (95% CI -4.78 to -2.16), -3.80 (95% CI -5.34 to -2.27), and -3.42 (95% CI -4.97 to 1.88) points on the ISI for the SHUTi group. SHUTi participants experienced significant improvements in physical (6-month generalized η2=0.04; P=.004) and mental health functioning (6-month and 1-year generalized η2=0.04; P=.009 and P=.005, respectively). Significant sleep parameter improvements were noted for SHUTi (all P<.05), though the pattern and magnitude of these reductions varied by parameter. No adverse events were reported. CONCLUSIONS Self-administered iCBT-I was associated with immediate and long-term improvements in insomnia severity. Findings suggest that leveraging technology to meet insomnia treatment demands among veterans may be a promising approach. TRIAL REGISTRATION ClinicalTrials.gov NCT03366870; https://clinicaltrials.gov/ct2/show/NCT03366870.
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Affiliation(s)
- Sarra Nazem
- Dissemination & Training Division, National Center for Posttraumatic Stress Disorder, Menlo Park, CA, United States
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
| | - Sean M Barnes
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jeri E Forster
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Trisha A Hostetter
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
| | - Lindsey L Monteith
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Emily B Kramer
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
| | - Laurel A Gaeddert
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
| | - Lisa A Brenner
- Veterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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21
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Rauch SA, Venners MR, Ragin C, Ruhe G, Lamp K, Burton M, Pomerantz A, Bernardy N, Schnurr PP, Hamblen JL, Possemato K, Sripada R, Wray LO, Dollar K, Wade M, Astin MC, Cigrang JA. Treatment of posttraumatic stress disorder with prolonged exposure for primary care (PE-PC): Effectiveness and patient and therapist factors related to symptom change and retention. Psychol Serv 2023; 20:745-755. [PMID: 37326566 PMCID: PMC10721715 DOI: 10.1037/ser0000783] [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: 06/17/2023]
Abstract
Prolonged exposure (PE) is a first-line treatment for posttraumatic stress disorder (PTSD) available in specialty mental health. PE for primary care (PE-PC) is a brief version of PE adapted for primary care mental health integration, composed of four-eight, 30-min sessions. Using retrospective data of PE-PC training cases from 155 Veterans Health Administration (VHA) providers in 99 VHA clinics who participated in a 4- to 6-month PE-PC training and consultation program, we examined patients' PTSD and depression severity across sessions via mixed effects multilevel linear modeling. Additionally, hierarchical logistic regression analysis was conducted to assess predictors of treatment dropout. Among 737 veterans, medium-to-large reductions in PTSD (intent-to-treat, Cohen's d = 0.63; completers, Cohen's d = 0.79) and small-to-medium reductions in depression (intent-to-treat, Cohen's d = 0.40; completers, Cohen's d = 0.51) were observed. The modal number of PE-PC sessions was five (SD = 1.98). Providers previously trained in both PE and cognitive processing therapy (CPT) were more likely than providers who were not trained in either PE or CPT to have veterans complete PE-PC (OR = 1.54). Veterans with military sexual trauma were less likely to complete PE-PC than veterans with combat trauma (OR = 0.42). Asian American and Pacific Islander veterans were more likely than White veterans to complete treatment (OR = 2.93). Older veterans were more likely than younger veterans to complete treatment (OR = 1.11). (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Sheila A.M. Rauch
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
- Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
- Emory University School of Medicine, Atlanta, GA, 30029
| | - Margaret R. Venners
- National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA, 94025
| | - Carly Ragin
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
| | - Gretchen Ruhe
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
| | - Kristen Lamp
- Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
| | - Mark Burton
- Emory University School of Medicine, Atlanta, GA, 30029
| | - Andrew Pomerantz
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington DC
| | - Nancy Bernardy
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, VT, 05009
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, 03755
| | - Paula P. Schnurr
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, VT, 05009
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, 03755
| | - Jessica L. Hamblen
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, VT, 05009
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, 03755
| | - Kyle Possemato
- VA Center for Integrated Healthcare, VA Medical Center, Syracuse, NY 13204
- Department of Psychology, Syracuse University, Syracuse, NY, 13244
| | - Rebecca Sripada
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, 48105
| | - Laura O. Wray
- VA Center for Integrated Healthcare, VA Medical Center, Syracuse, NY 13204
- Department of Psychology, Syracuse University, Syracuse, NY, 13244
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY
| | - Katherine Dollar
- VA Center for Integrated Healthcare, VA Medical Center, Syracuse, NY 13204
- Department of Psychology, Syracuse University, Syracuse, NY, 13244
| | - Michael Wade
- VA Center for Integrated Healthcare, VA Medical Center, Syracuse, NY 13204
| | - Millie C. Astin
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
- Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
| | - Jeffrey A. Cigrang
- School of Professional Psychology, Wright State University, Dayton, OH, 45402
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22
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Sayer NA, Wiltsey Stirman S, Rosen CS, Kehle-Forbes S, Spoont MR, Eftekhari A, Chard KM, Kaplan A, Nelson DB. The role of therapy delivery and clinic organizational factors in explaining therapist effects for trauma-focused psychotherapies in the Veterans Health Administration. J Consult Clin Psychol 2023; 91:665-679. [PMID: 37668578 PMCID: PMC10592522 DOI: 10.1037/ccp0000832] [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] [Indexed: 09/06/2023]
Abstract
OBJECTIVE This study estimated the size of therapist effects (TEs) for dropout and clinical effectiveness of two trauma-focused psychotherapies (TFPs) and evaluated whether therapy delivery and clinic organizational factors explained observed TEs. METHOD Participants were 180 therapists (54.4% psychologists, 42.2% social workers) from 137 Veterans Health Administration facilities and 1,735 patients (24.7% women; 27.2% people of color) who completed at least two TFP sessions. Outcomes were dropout (< 8 TFP sessions) and for a subsample (n = 1,273), clinically meaningful improvement and recovery based on posttraumatic stress disorder checklist for DSM-5 (PCL-5) scores. Therapist-level predictors were ascertained through survey, manual chart review, and administrative data. Multilevel models estimated TEs. RESULTS Over half (51.2%) of patients dropped out and those who dropped out were less likely to meet criteria for clinically meaningful improvement or recovery (ps < .001). Adjusting for case-mix and TFP type, therapists accounted for 5.812% (p < .001) of the unexplained variance in dropout. The average dropout rate for the 45 therapists in the top performing quartile was 27.0%, while the average dropout rate for the 45 therapists in the bottom performing quartile was 78.8%. Variation between therapists was reduced to 2.031% (p = .140) when therapists' mean of days between sessions, adherence, implementation climate, and caseload were added to multilevel models. TEs were nonsignificant for clinically meaningful improvement and recovery. CONCLUSIONS Interventions targeting therapy delivery and clinic organization have the potential to reduce variation between therapists in TFP dropout, so that more patients stay engaged long enough to experience clinical benefit. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Nina A Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - Shannon Wiltsey Stirman
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Craig S Rosen
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Shannon Kehle-Forbes
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - Michele R Spoont
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - Afsoon Eftekhari
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Kathleen M Chard
- Posttraumatic Stress Disorder and Anxiety Disorder Division, Cincinnati Veterans Affairs Medical Center
| | - Adam Kaplan
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - David B Nelson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
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23
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Taylor CT, Stein MB. Written Exposure Therapy Finds Solid Footing Alongside First-Line Psychotherapies for Posttraumatic Stress Disorder. JAMA Psychiatry 2023; 80:1091-1092. [PMID: 37610770 DOI: 10.1001/jamapsychiatry.2023.2310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Affiliation(s)
- Charles T Taylor
- Department of Psychiatry, University of California, San Diego, La Jolla
| | - Murray B Stein
- Department of Psychiatry, University of California, San Diego, La Jolla
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24
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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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25
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Sripada RK, Walters HM. "I wish people could come together like we have," patient and provider perspectives on VA residential PTSD treatment. Psychol Serv 2023; 20:809-819. [PMID: 36136833 PMCID: PMC10249047 DOI: 10.1037/ser0000713] [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: 11/08/2022]
Abstract
Although most posttraumatic stress disorder (PTSD) care in the Veterans health administration (VHA) is provided on an outpatient basis, the VHA has 40 residential rehabilitation treatment programs (RRTPs) designed to treat Veterans who require more intensive and closely monitored care. Unfortunately, the clinical outcomes of these programs are modest, and previous attempts to identify key drivers of outcomes have uncovered few modifiable factors. The present study, informed by the model of resources, life events and changes in psychological state, was designed to identify factors associated with treatment response among RRTP patients and providers. Semistructured interviews were conducted with 24 patients and 12 providers at three regional RRTPs, using interview guides based on the theoretical model. Data were analyzed using rapid analysis. Results showed that patients and providers agreed on several factors critical to RRTP success. These factors included the provision of evidence-based psychotherapy (EBP), support and understanding from fellow patients, and skill and support from providers. Patients and providers also noted the importance of psychological flexibility, openness, and willingness to change. Patients who experienced less symptom improvement over the course of treatment were more likely to report poor therapeutic alliance. These findings underscore the importance of continued emphasis on EBP delivery but also suggest that RRTPs might find additional ways to capitalize on the residential milieu to encourage engagement in treatment and a focus on therapeutic change. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Rebecca K. Sripada
- VA Center for Clinical Management Research, Ann Arbor, MI
- VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Heather M. Walters
- VA Center for Clinical Management Research, Ann Arbor, MI
- VA Ann Arbor Healthcare System, Ann Arbor, MI
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26
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Kindt M, Soeter M. A brief treatment for veterans with PTSD: an open-label case-series study. Front Psychiatry 2023; 14:1260175. [PMID: 37928919 PMCID: PMC10620904 DOI: 10.3389/fpsyt.2023.1260175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/10/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Despite the positive outcomes observed in numerous individuals undergoing trauma-focused psychotherapy for PTSD, veterans with this condition experience notably diminished advantages from such therapeutic interventions in comparison to non-military populations. Methods In a preliminary study we investigated the efficacy of an innovative treatment approach in a small sample of veterans (n = 7). Recognizing that accessing and targeting trauma memory in veterans with PTSD may be more challenging compared to other patient populations, we employed unique and personalized retrieval cues that engaged multiple senses and were connected to the context of their trauma. This was followed by a session focused on memory reconsolidation, which incorporated both psychological techniques (i.e., imagery rescripting) and a pharmacological component (i.e., 40 mg of propranolol). Results The findings from this small-scale case series cautiously indicate that this brief intervention, typically consisting of only one or two treatment sessions, shows promise in producing significant effects on symptoms of PTSD, distress and quality of life.This is particularly noteworthy given the complex symptomatology experienced by the veterans in this study. Conclusion To summarize, there are grounds for optimism regarding this brief treatment of combat-related PTSD. It appears that the potential for positive outcomes is far greater than commonly believed, as demonstrated by the encouraging results of this pilot study.
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Affiliation(s)
- Merel Kindt
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, Netherlands
| | - Marieke Soeter
- Work Health Technology, The Netherlands Organization for Applied Scientific Research TNO, Leiden, Netherlands
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27
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Tsang VWL, Ragazan DC, Kryskow P, Walsh Z, Dames S. A Pilot Study Comparing a Community of Practice Program with and without Concurrent Ketamine-Assisted Therapy. J Psychoactive Drugs 2023:1-10. [PMID: 37655532 DOI: 10.1080/02791072.2023.2253798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/21/2023] [Accepted: 08/03/2023] [Indexed: 09/02/2023]
Abstract
The prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) has increased among healthcare providers, while the effectiveness of conventional treatments remains limited. Ketamine-assisted therapy offers a promising alternative; however, few have integrated ketamine with a group-based therapeutic modality. We report a retrospective, secondary analysis of a 12-week pilot of a Community of Practice (CoP) oriented group therapy program with optional, adjunct ketamine for depression, anxiety, and PTSD in a sample of 57 healthcare providers. All participants moved through the treatment as one group, with 38 electing to also receive three adjunct ketamine sessions in addition to the weekly CoP. Symptoms were assessed at baseline and pilot completion with the PHQ-9 for depression, GAD-7 for anxiety, and PCL-5 for PTSD. We observed significant reductions in the mean change among all participants, suggesting that benefit was derived from the CoP component, with or without ketamine as an adjunct. PHQ-9 scores decreased by 6.79 (95% CI: 5.09-8.49, p < .001), GAD-7 scores decreased by 5.57 (CI: 4.12-7.00, p < .001), and PCL-5 scores decreased by 14.83 (CI: 10.27-19.38, p < .001). Reductions were larger, but statistically nonsignificant, among those receiving ketamine. Further research is required to assess the impact of ketamine as an adjunct in group-based therapies.
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Affiliation(s)
- Vivian W L Tsang
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Dragos C Ragazan
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Pamela Kryskow
- Health and Human Services, Vancouver Island University, Nanaimo, BC, Canada
- Department of Family Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Zach Walsh
- Department of Psychology, University of British Columbia, Kelowna, BC, Canada
| | - Shannon Dames
- Health and Human Services, Vancouver Island University, Nanaimo, BC, Canada
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28
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Herodes M, Le N, Anderson LJ, Migula D, Miranda G, Paulsen L, Garcia JM. Metabolic and quality of life effects of growth hormone replacement in patients with TBI and AGHD: A pilot study. Growth Horm IGF Res 2023; 71:101544. [PMID: 37295336 PMCID: PMC10527000 DOI: 10.1016/j.ghir.2023.101544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/25/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Traumatic brain injury (TBI), a common cause of adult growth hormone deficiency (AGHD), affects 20% of Veterans returning from Iraq and Afghanistan (OEF/OIF/OND). Growth hormone replacement therapy (GHRT) improves quality of life (QoL) in AGHD but remains unexplored in this population. This pilot, observational study investigates the feasibility and efficacy of GHRT in AGHD following TBI. DESIGN In this 6-month study of combat Veterans with AGHD and TBI starting GHRT (N = 7), feasibility (completion rate and rhGH adherence) and efficacy (improvements in self-reported QoL) of GHRT were measured (primary outcomes). Secondary outcomes included body composition, physical and cognitive function, psychological and somatic symptoms, physical activity, IGF-1 levels and safety parameters. It was hypothesized that participants would adhere to GHRT and that QoL would significantly improve after six months. RESULTS Five subjects (71%) completed all study visits. All patients administered daily rhGH injections, 6 (86%) of whom consistently administered the clinically-prescribed dose. While QoL demonstrated numeric improvement, this change did not reach statistical significance (p = 0.17). Significant improvements were observed in total lean mass (p = 0.02), latissimus dorsi strength (p = 0.05), verbal learning (Trial 1, p = 0.02; Trial 5, p = 0.03), attention (p = 0.02), short-term memory (p = 0.04), and post-traumatic stress disorder (PTSD) symptoms (p = 0.03). Body weight (p = 0.02) and total fat mass (p = 0.03) increased significantly. CONCLUSION GHRT is a feasible and well-tolerated intervention for U.S. Veterans with TBI-related AGHD. It improved key areas impacted by AGHD and symptoms of PTSD. Larger, placebo-controlled studies testing the efficacy and safety of this intervention in this population are warranted.
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Affiliation(s)
- Megan Herodes
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Division of Gerontology and Geriatric Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Nancy Le
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Lindsey J Anderson
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Dorota Migula
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Gary Miranda
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Division of Gerontology and Geriatric Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Lauren Paulsen
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Jose M Garcia
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Division of Gerontology and Geriatric Medicine, University of Washington School of Medicine, Seattle, WA, USA.
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29
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Kottler J, Gingell MJ, Khosla S, Kordzikowski M, Raszewski R, Chestek D, Maki K. Exploring physical and biological manifestations of burnout and post-traumatic stress disorder symptoms in healthcare workers: a scoping review protocol. BMJ Open 2023; 13:e074887. [PMID: 37479518 PMCID: PMC10364163 DOI: 10.1136/bmjopen-2023-074887] [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: 07/23/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic has strained the mental and physical well-being of healthcare workers (HCW). Increased work-related stress and limited resources have increased symptoms of anxiety, depression, insomnia and post-traumatic stress disorder (PTSD) in this population. Stress-related disorders have been strongly associated with long-term consequences, including cardiometabolic disorders, endocrine disorders and premature mortality. This scoping review aims to explore available literature on burnout, PTSD, and other mental health-associated symptoms in HCW to synthesise relationships with physiological and biological biomarkers that may be associated with increased risk of disease, creating an opportunity to summarise current biomarker knowledge and identify gaps in this literature. METHODS AND ANALYSIS This scoping review uses the Arksey and O'Malley six-step scoping review methodology framework. The research team will select appropriate primary sources using a search strategy developed in collaboration with a health sciences librarian. Three reviewers will initially screen the title and abstracts obtained from the literature searches, and two reviewers will conduct independent reviews of full-text studies for inclusion. The research team will be reviewing literature focusing on which burnout and/or PTSD-associated physiological and biological biomarkers have been studied, the methodologies used to study them and the correlations between the biomarkers and HCW experiencing burnout/PTSD. Data extraction forms will be completed by two reviewers for included studies and will guide literature synthesis and analysis to determine common themes. ETHICS AND DISSEMINATION This review does not require ethical approval. We expect results from this scoping review to identify gaps in the literature and encourage future research regarding improving biological and physiological biomarker research in HCW. Preliminary results and general themes will be communicated back to stakeholders. Results will be disseminated through peer-reviewed publications, policy briefs and conferences as well as presented to stakeholders to an effort to invest in HCW mental and physical health.
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Affiliation(s)
- Janey Kottler
- Department of Emergency Medicine, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, USA
| | - Monica J Gingell
- Department of Population Health Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, Illinois, USA
| | - Shaveta Khosla
- Department of Emergency Medicine, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, USA
| | - Mitchell Kordzikowski
- Department of Population Health Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, Illinois, USA
| | - Rebecca Raszewski
- Library of the Health Sciences Chicago, University of Illinois at Chicago, Chicago, Illinois, USA
| | - David Chestek
- Department of Emergency Medicine, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, USA
| | - Katherine Maki
- Translational Biobehavioral and Health Disparities Branch, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
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Gahnfelt H, Carlsson PFG, Blomdahl C. Is it safe enough? A pilot feasibility study of an 8-day intensive treatment for severe PTSD. Front Psychiatry 2023; 14:1200411. [PMID: 37547221 PMCID: PMC10397389 DOI: 10.3389/fpsyt.2023.1200411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
Intensive treatments for posttraumatic stress disorder (PTSD) are gaining increased research support. Treatment models targeting Complex PTSD and previously treatment-resistant PTSD have shown a good effect. A pilot study was performed to assess the feasibility of an 8-day intensive treatment program for severe PTSD in a Swedish public healthcare setting. Eleven participants completed treatment, and overall, the reduction in PTSD symptoms was considerable. Also, loss of diagnosis at 3-month follow-up was 100%. No adverse events occurred, and no elevation of suicidal intentions was reported. Symptom exacerbation could not be observed in the data and dropout due to the intensity of the treatment format did not occur. Based on these positive results, it is recommended that further research with larger samples is conducted. If found safe and effective, the 8-day treatment program could be an important addition to psychiatric healthcare.
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Affiliation(s)
- Hannes Gahnfelt
- Department of Research, Education and Innovation, Södra Älvsborg Hospital, Region Västra Götaland, Borås, Sweden
| | - Per F. G. Carlsson
- Department of Research, Education and Innovation, Södra Älvsborg Hospital, Region Västra Götaland, Borås, Sweden
| | - Christina Blomdahl
- R&D Centre Södra Älvsborg, Research, Education, Development & Innovation, Region Västra Götaland, Borås, Sweden
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Walter KH, Otis NP, Hose MK, Ober KM, Glassman LH. The effectiveness of the National Veterans Summer Sports Clinic for veterans with probable posttraumatic stress disorder. Front Psychol 2023; 14:1207633. [PMID: 37492451 PMCID: PMC10363688 DOI: 10.3389/fpsyg.2023.1207633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/16/2023] [Indexed: 07/27/2023] Open
Abstract
Introduction Recreational and adaptive sports programs may be beneficial therapeutic interventions for improving psychological outcomes among veterans and service members with posttraumatic stress disorder (PTSD) because they provide opportunities for exercise, socialization, respite, and time outdoors. Although there are an increasing number of sports programs for veterans and service members with PTSD, data evaluating the outcomes of such programs are limited. Materials and methods The sample included 74 U.S. veterans who participated in the National Veterans Summer Sports Clinic (NVSSC), an annual, week-long adaptive sports program in San Diego, California. Participants were categorized into two subgroups: those who met criteria for probable PTSD using the PTSD Checklist for DSM-5 (n = 20) and those who did not (n = 54). Participants completed self-report assessments before and after each daily activity, before and after the program, and 3 months following program completion. Results Over the course of NVSSC program participation, the diagnostic subgroups (probable PTSD vs. no PTSD) did not significantly differ on changes in depression, positive affect, negative affect, or insomnia. Compared to those without PTSD, veterans with PTSD experienced greater reduction in generalized anxiety during the program (MD = -3.07, p = 0.034). Veterans with PTSD also experienced significant improvements in PTSD symptoms at postprogram (MD = -23.76, p < 0.001). For both groups, significant benefits were shown during the program but rebounded by the 3-month follow-up. Over the course of each daily activity, positive affect (MD = 2.71, p < 0.001) and depression/anxiety scores significantly decreased (MD = -0.75, p < 0.001), with no differences between PTSD diagnostic groups across time (ps = 0.714 and 0.961, respectively). Conclusion Veterans with and without PTSD benefited from participation in the NVSSC. Participants with probable PTSD experienced greater improvements in generalized anxiety at postprogram only; there were no other significant differences between the two groups at postprogram or at 3-month follow-up. In line with prior research, benefits for those with PTSD were lost by 3-month follow-up, suggesting that regular engagement in recreational and adaptive sports may be necessary to sustain psychological health improvements.
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Affiliation(s)
- Kristen H. Walter
- Health and Behavioral Sciences, Naval Health Research Center, San Diego, CA, United States
- VA San Diego Healthcare System, San Diego, CA, United States
| | - Nicholas P. Otis
- Health and Behavioral Sciences, Naval Health Research Center, San Diego, CA, United States
- VA San Diego Healthcare System, San Diego, CA, United States
- Leidos, Inc., San Diego, CA, United States
| | | | | | - Lisa H. Glassman
- Health and Behavioral Sciences, Naval Health Research Center, San Diego, CA, United States
- VA San Diego Healthcare System, San Diego, CA, United States
- Leidos, Inc., San Diego, CA, United States
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Nillni YI, Baul TD, Paul E, Godfrey LB, Sloan DM, Valentine SE. Written exposure therapy for treatment of perinatal PTSD among women with comorbid PTSD and SUD: A pilot study examining feasibility, acceptability, and preliminary effectiveness. Gen Hosp Psychiatry 2023; 83:66-74. [PMID: 37119780 PMCID: PMC10587907 DOI: 10.1016/j.genhosppsych.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/10/2023] [Accepted: 04/21/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVE This pilot open trial examined the feasibility, acceptability, and preliminary effectiveness of Written Exposure Therapy (WET), a 5-session evidence-based intervention for posttraumatic stress disorder (PTSD) during pregnancy. Participants were pregnant women with comorbid PTSD and substance use disorder (SUD) receiving prenatal care in a high risk obstetrics-addictions clinic. METHODS A total of 18 participants with probable PTSD engaged in the intervention, and 10 completed the intervention and were included in outcome analyses. Wilcoxon's Signed-Rank analyses were used to evaluate PTSD and depression symptoms and craving at pre-intervention to post-intervention and pre-intervention to the 6-month postpartum follow-up. Engagement and retention in WET and therapist fidelity to the intervention manual were used to assess feasibility. Quantitative and qualitative measures of patient satisfaction were used to assess acceptability. RESULTS PTSD symptoms significantly decreased from pre-intervention to post-intervention (S = 26.6, p = 0.006), which sustained at the 6-month postpartum follow-up (S = 10.5, p = 0.031). Participant satisfaction at post-intervention was high. Therapists demonstrated high adherence to the intervention and excellent competence. CONCLUSIONS WET was a feasible and acceptable treatment for PTSD in this sample. Randomized clinical trial studies with a general group of pregnant women are needed to expand upon these findings and perform a full-scale test of effectiveness of this intervention.
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Affiliation(s)
- Yael I Nillni
- National Center for PTSD, Women's Health Sciences Division at VA Boston Healthcare System, Boston, MA, USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Tithi D Baul
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA.
| | - Emilie Paul
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA; College of Liberal Arts and Sciences, St. John's University, Queens, NY, USA.
| | - Laura B Godfrey
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA.
| | - Denise M Sloan
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA; National Center for PTSD, Behavioral Science Division at VA Boston Healthcare System, Boston, MA, USA.
| | - Sarah E Valentine
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA; Department of Psychiatry, Boston Medical Center, Boston, MA, USA.
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Sripada RK, Smith K, Walters HM, Ganoczy D, Kim HM, Grau PP, Nahum-Shani I, Possemato K, Kuhn E, Zivin K, Pfeiffer PN, Bohnert KM, Cigrang JA, Avallone KM, Rauch SAM. Testing adaptive interventions to improve PTSD treatment outcomes in Federally Qualified Health Centers: Protocol for a randomized clinical trial. Contemp Clin Trials 2023; 129:107182. [PMID: 37044157 PMCID: PMC10349653 DOI: 10.1016/j.cct.2023.107182] [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: 02/27/2023] [Revised: 04/02/2023] [Accepted: 04/08/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) disproportionately affects low-income individuals and is untreated in 70% of those affected. One third of low-income Americans are treated in Federally Qualified Health Centers (FQHCs), which do not have the capacity to provide all patients with first-line treatments such as Prolonged Exposure (PE). To address this problem, FQHCs could use low-intensity interventions (e.g., Clinician-Supported PTSD Coach: CS PTSD Coach) and medium-intensity interventions (e.g., PE for Primary Care: PE-PC) to treat PTSD with fewer resources. However, some patients will still require high-intensity treatments (e.g., full-length PE) for sustained clinical benefit. Thus, there is a critical need to develop stepped-care models for PTSD in FQHCs. METHOD We are conducting a Sequential, Multiple Assignment, Randomized Trial (SMART) with 430 adults with PTSD in FQHCs. Participants are initially randomized to CS PTSD Coach or PE-PC. After four sessions, early responders step down to lower frequency interaction within their assigned initial treatment strategy. Slow responders are re-randomized to either continue their initial treatment strategy or step up to Full PE for an additional eight weeks. The specific aims are to test the effectiveness of initiating treatment with PE-PC versus CS PTSD Coach in reducing PTSD symptoms and to test the effectiveness of second-stage strategies (continue versus step-up to Full PE) for slow responders. CONCLUSIONS This project will provide critical evidence to inform the development of an effective stepped-care model for PTSD. Testing scalable, sustainable sequences of PTSD treatments delivered in low-resource community health centers will improve clinical practice for PTSD.
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Affiliation(s)
- Rebecca K Sripada
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America.
| | - Kayla Smith
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America
| | - Heather M Walters
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - Dara Ganoczy
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - H Myra Kim
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America; Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, MI, United States of America
| | - Peter P Grau
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - Inbal Nahum-Shani
- Data-Science for Dynamic Decision-making Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, United States of America
| | - Kyle Possemato
- VA Center for Integrated Healthcare, Syracuse, NY, United States of America
| | - Eric Kuhn
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, CA, United States of America; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Kara Zivin
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - Paul N Pfeiffer
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - Kipling M Bohnert
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI, United States of America
| | - Jeffrey A Cigrang
- School of Professional Psychology, College of Health Education and Human Services, Wright State University, Fairborn, OH, United States of America
| | - Kimberly M Avallone
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America
| | - Sheila A M Rauch
- VA Atlanta Healthcare System, Decatur, GA, United States of America; Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
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Davis JP, Pedersen ER, Borsari B, Bowen S, Owen J, Sedano A, Fitzke R, Delacruz J, Tran DD, Buch K, Saba S, Canning L, Bunyi J. Development of a mobile mindfulness smartphone app for post-traumatic stress disorder and alcohol use problems for veterans: Beta test results and study protocol for a pilot randomized controlled trial. Contemp Clin Trials 2023; 129:107181. [PMID: 37059261 PMCID: PMC10225328 DOI: 10.1016/j.cct.2023.107181] [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: 01/30/2023] [Revised: 04/04/2023] [Accepted: 04/08/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) are highly prevalent, and co-occurring among post-9/11 veterans. Mobile health (mHealth) applications, specifically those focused on mindfulness-based techniques, may be an effective avenue to intervene with veterans who cannot or will not seek care at traditional in-person settings. Thus, to address areas of improvement in mHealth for veterans, we developed Mind Guide and prepared it for testing in a pilot randomized controlled trial (RCT) with veterans. METHODS We have completed phase 1 (treatment development) and Phase 2 (beta test) of our mobile mHealth app, Mind Guide. In this paper we describe the methods for Phase 1 as well as results for our beta test (n = 16; inclusion criteria included screen for PTSD, AUD, a post-9/11 veteran, and not currently receiving treatment) for Mind Guide as well as outline procedures for our pilot RCT of Mind Guide (Phase 3). The PTSD Checklist, self-reported alcohol use, the Perceived Stress Scale, Penn Alcohol Craving Scale, and the Emotion Regulation Questionnaire were used. RESULTS Results of our beta test of Mind Guide show promising past 30 day effects on PTSD (d = -1.12), frequency of alcohol use (d = -0.54), and alcohol problems (d = -0.44), and related mechanisms of craving (d = -0.53), perceived stress (d = -0.88), and emotion regulation (d = -1.22). CONCLUSION Our initial beta-test of Mind Guide shows promise for reducing PTSD and alcohol related problems among veterans. Recruitment is ongoing for our pilot RCT in which 200 veterans will be recruited and followed up for 3 months. CLINICALTRIALS gov Identifier: NCT04769986.
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Affiliation(s)
- Jordan P Davis
- University of Southern California, Suzanne Dworak-Peck School of Social Work, Los Angeles, CA, USA.
| | - Eric R Pedersen
- University of Southern California, Keck School of Medicine, Department of Psychiatry and Behavioral Sciences, Los Angeles, CA, USA
| | - Brian Borsari
- Mental Health Service, San Francisco VA Health Care System, San Francisco, CA, USA; Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | | | - Jason Owen
- National Center for PTSD, Veteran Affairs Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Angeles Sedano
- University of Southern California, Suzanne Dworak-Peck School of Social Work, Los Angeles, CA, USA
| | - Reagan Fitzke
- University of Southern California, Keck School of Medicine, Department of Psychiatry and Behavioral Sciences, Los Angeles, CA, USA
| | - Joannalyn Delacruz
- Mental Health Service, San Francisco VA Health Care System, San Francisco, CA, USA; Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Denise D Tran
- University of Southern California, Keck School of Medicine, Department of Psychiatry and Behavioral Sciences, Los Angeles, CA, USA
| | - Keegan Buch
- University of Southern California, Keck School of Medicine, Department of Psychiatry and Behavioral Sciences, Los Angeles, CA, USA
| | - Shaddy Saba
- University of Southern California, Suzanne Dworak-Peck School of Social Work, Los Angeles, CA, USA
| | - Liv Canning
- University of Southern California, Suzanne Dworak-Peck School of Social Work, Los Angeles, CA, USA
| | - John Bunyi
- University of Southern California, Suzanne Dworak-Peck School of Social Work, Los Angeles, CA, USA
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Gill JL, Schneiders JA, Stangl M, Aghajan ZM, Vallejo M, Hiller S, Topalovic U, Inman CS, Villaroman D, Bari A, Adhikari A, Rao VR, Fanselow MS, Craske MG, Krahl SE, Chen JWY, Vick M, Hasulak NR, Kao JC, Koek RJ, Suthana N, Langevin JP. A pilot study of closed-loop neuromodulation for treatment-resistant post-traumatic stress disorder. Nat Commun 2023; 14:2997. [PMID: 37225710 PMCID: PMC10209131 DOI: 10.1038/s41467-023-38712-1] [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: 01/03/2023] [Accepted: 05/12/2023] [Indexed: 05/26/2023] Open
Abstract
The neurophysiological mechanisms in the human amygdala that underlie post-traumatic stress disorder (PTSD) remain poorly understood. In a first-of-its-kind pilot study, we recorded intracranial electroencephalographic data longitudinally (over one year) in two male individuals with amygdala electrodes implanted for the management of treatment-resistant PTSD (TR-PTSD) under clinical trial NCT04152993. To determine electrophysiological signatures related to emotionally aversive and clinically relevant states (trial primary endpoint), we characterized neural activity during unpleasant portions of three separate paradigms (negative emotional image viewing, listening to recordings of participant-specific trauma-related memories, and at-home-periods of symptom exacerbation). We found selective increases in amygdala theta (5-9 Hz) bandpower across all three negative experiences. Subsequent use of elevations in low-frequency amygdala bandpower as a trigger for closed-loop neuromodulation led to significant reductions in TR-PTSD symptoms (trial secondary endpoint) following one year of treatment as well as reductions in aversive-related amygdala theta activity. Altogether, our findings provide early evidence that elevated amygdala theta activity across a range of negative-related behavioral states may be a promising target for future closed-loop neuromodulation therapies in PTSD.
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Affiliation(s)
- Jay L Gill
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
- Medical Scientist Training Program, University of California, Los Angeles, CA, USA
| | - Julia A Schneiders
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
- Research and Development Service; Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Matthias Stangl
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Zahra M Aghajan
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
| | - Mauricio Vallejo
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Sonja Hiller
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Uros Topalovic
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
- Department of Electrical and Computer Engineering, University of California, Los Angeles, CA, USA
| | - Cory S Inman
- Department of Psychology, University of Utah, Salt Lake City, UT, USA
| | - Diane Villaroman
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Ausaf Bari
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
| | - Avishek Adhikari
- Department of Psychology, University of California, Los Angeles, CA, USA
| | - Vikram R Rao
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Michael S Fanselow
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
- Department of Psychology, University of California, Los Angeles, CA, USA
| | - Michelle G Craske
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
- Department of Psychology, University of California, Los Angeles, CA, USA
| | - Scott E Krahl
- Research and Development Service; Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
| | - James W Y Chen
- Neurology Service; Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Neurology, University of California, Los Angeles, CA, USA
| | | | - Nicholas R Hasulak
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
- Phoenix Research Consulting LLC, Gilbert, AZ, USA
| | - Jonathan C Kao
- Department of Electrical and Computer Engineering, University of California, Los Angeles, CA, USA
| | - Ralph J Koek
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
- Psychiatry and Mental Health Service; Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Nanthia Suthana
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA.
- Department of Neurosurgery, University of California, Los Angeles, CA, USA.
- Department of Psychology, University of California, Los Angeles, CA, USA.
- Department of Bioengineering, University of California, Los Angeles, CA, USA.
| | - Jean-Philippe Langevin
- Department of Neurosurgery, University of California, Los Angeles, CA, USA.
- Neurosurgery Service; Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
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Woodward SH, Jamison AL, Gala S, Lawlor C, Villasenor D, Tamayo G, Puckett M. Heart Rate During Sleep in PTSD Patients: Moderation by Contact with a Service Dog. Biol Psychol 2023; 180:108586. [PMID: 37187229 DOI: 10.1016/j.biopsycho.2023.108586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 04/12/2023] [Accepted: 05/12/2023] [Indexed: 05/17/2023]
Abstract
There is growing interest in the potential health benefits of dog ownership in both the lay and scientific communities. Large reductions in risk for cardiovascular disease and all-cause mortality in dog owners relative to non-owners have been observed in epidemiological samples. Persons diagnosed with posttraumatic stress disorder exhibit elevated risk for cardiovascular disease. The current study tested a sample of 45 U.S. military veterans with deployment-related posttraumatic stress disorder employing an intensive, longitudinal, within-subjects design contrasting sleep heart rate on nights with and without a service dog. As participants were engaged in residential psychiatric treatment, sleep opportunities, waking activities, meals, and medications, were consistently scheduled. The primary recording methodology, mattress actigraphy, enabled passive quantification of heart rate over a total sample of 1097 nights. Service dog contact was associated with reduced sleep heart rate especially in participants with more severe PTSD. Longer-term longitudinal studies will be needed to assess the durability and asymptotic magnitude of this effect. An unexpected effect of nights in study was associated with increased heart rate consistent with hospitalization-associated deconditioning.
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Affiliation(s)
- Steven H Woodward
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 3801 Miranda Ave, Palo Alto, CA 94304.
| | - Andrea L Jamison
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 3801 Miranda Ave, Palo Alto, CA 94304
| | - Sasha Gala
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 3801 Miranda Ave, Palo Alto, CA 94304
| | - Catherine Lawlor
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 3801 Miranda Ave, Palo Alto, CA 94304
| | - Diana Villasenor
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 3801 Miranda Ave, Palo Alto, CA 94304
| | - Gisselle Tamayo
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 3801 Miranda Ave, Palo Alto, CA 94304
| | - Melissa Puckett
- Trauma Recovery Programs and Recreation Service, VA Palo Alto Healthcare System. 3801 Miranda Ave, Palo Alto, CA 94304
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Niedermann C, Anheyer D, Seeligmüller E, Ostermann T. Traces of health-A landscape design task as a diagnostic aid for detecting mental burden? A qualitative focus group study. Front Psychol 2023; 14:1015169. [PMID: 37251067 PMCID: PMC10213701 DOI: 10.3389/fpsyg.2023.1015169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Background Mental disorders are most common causes of illness worldwide. Studies on art and drawing tasks, such as the tree-drawing test have already proven their prognostic quality for the diagnosis of Alzheimer's disease, depression or trauma. In the depiction of art in public space, gardens and landscapes are one of the oldest human forms of artistic expression. This study thus aims at exploring the impact of a landscape design task as a prognostic tool to detect mental burden. Materials and methods A total of 15 individuals (eight female) aged between 19 and 60 years completed the Brief Symptom Inventory BSI-18 and the State Trait Anxiety Inventory (STAI-S) before being asked to design a landscape in a 3 × 3 m squared area. Material to be used included plants, flowers, branches, and stones. The complete process of landscape design was videotaped and the tapes were analyzed in a two-step focus group analysis from a group of gardening trainees, psychology students and students of arts therapies. Results were condensed in a second step into major categories. Results Scores of the BSI-18 showed a range of 2-21 points and STAI-S scores ranged between 29 and 54 points indicating a light to moderate mental burden. Focus group participants identified three mutually perpendicular major components associated with mental health: "Movement and Activity," "Material Selection and Design," and "Connectedness to the task." In a subsample of the three least and three most mentally stressed subjects (based on their GSI and STAI-S scorings), clear differences were found in body posture, action planning and the choice of material and aspects of design. Discussion In addition to the well-known therapeutic potential of gardening, this study for the first time showed that gardening and landscape design contains diagnostic elements. Our preliminary findings are in coherence with similar research indicating a high association of movement and design patterns with mental burden. However, due to the pilot nature of the study, the results should be interpreted cautiously. Based on the findings further studies are currently planned.
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Affiliation(s)
- Christina Niedermann
- Department of Psychosomatic Medicine, Die Filderklinik, Filderstadt, Germany
- Department of Psychology and Psychotherapy, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Dennis Anheyer
- Department of Psychology and Psychotherapy, Faculty of Health, Witten/Herdecke University, Witten, Germany
- Department of General Practice and Interprofessional Care, University Hospital Tübingen, Tübingen, Germany
| | - Emily Seeligmüller
- Department of Psychology and Psychotherapy, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Thomas Ostermann
- Department of Psychology and Psychotherapy, Faculty of Health, Witten/Herdecke University, Witten, Germany
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Riblet NB, Matsunaga S, Shiner B, Schnurr PP, Watts BV. Are suicide risk scales sensitive to change? A scoping review. J Psychiatr Res 2023; 161:170-178. [PMID: 36931135 PMCID: PMC10149613 DOI: 10.1016/j.jpsychires.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 02/24/2023] [Accepted: 03/02/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Clinician- or self-administered scales are frequently used to assist in detecting risk of death by suicide and to determine the effectiveness of interventions. No recent review studies have examined whether these scales are sensitive to change. We conducted a scoping review to identify suicide risk scales that are sensitive to change. MATERIAL AND METHODS We searched Medline and Excerpta Medica Database from inception through March 17, 2022, to identify randomized trials, pooled analysis, quasi-experimental studies, and cohort studies reporting on sensitivity to change of suicide risk scales. We assessed sensitivity to change by examining internal and external responsiveness. Internal responsiveness evaluates whether the scale measures changes in suicide-related symptoms in response to an intervention while external responsiveness assess whether changes in the scale correspond to changes in risk of suicide. We summarized findings across studies using descriptive analysis. RESULTS Among 38 eligible scales, we identified 27 scales that included items that were modifiable to change. However, only 7 scales had been studied to determine their sensitivity to change based on internal or external responsiveness. While the results of studies suggested that 6 scales have internal responsiveness, none of the included studies confirmed that scales have external responsiveness. DISCUSSION A few suicide risk scales are internally responsive and may be useful in a clinical or research setting. It is unclear, however, whether changes in scores correspond to an actual change in suicide risk. Future research should confirm the external responsiveness of scales using robust metrics including suicide mortality.
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Affiliation(s)
- Natalie B Riblet
- Veterans Affairs Medical Center, Mental Health Service, 215 North Main Street, White River Junction, VT, 05009, USA; Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Road, Hanover NH, 03755, USA.
| | - Sarah Matsunaga
- Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Road, Hanover NH, 03755, USA
| | - Brian Shiner
- Veterans Affairs Medical Center, Mental Health Service, 215 North Main Street, White River Junction, VT, 05009, USA; Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Road, Hanover NH, 03755, USA; National Center for PTSD, 215 North Main Street, White River Junction, VT, 05009, USA
| | - Paula P Schnurr
- Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Road, Hanover NH, 03755, USA; National Center for PTSD, 215 North Main Street, White River Junction, VT, 05009, USA
| | - Bradley V Watts
- Veterans Affairs Medical Center, Mental Health Service, 215 North Main Street, White River Junction, VT, 05009, USA; Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Road, Hanover NH, 03755, USA; Veterans Rural Health Resource Center, White River Junction VA Medical Center, White River Junction, VT, 05009, USA
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Löw A, Lotar Rihtarić M, Vrselja I. Resource loss, coping strategies and post-traumatic stress disorder symptoms in survivors of the 2020 Croatia earthquake. BMC Psychol 2023; 11:128. [PMID: 37095565 PMCID: PMC10125855 DOI: 10.1186/s40359-023-01176-5] [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: 01/19/2023] [Accepted: 04/18/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Conservation of resources theory (COR) establishes a link between resource loss and the stress response. The aim of this study was to assess the contribution of resource loss in the form of home damage and the choice of active or passive coping strategies to PTSD symptoms in survivors of the 2020 Petrinja (Croatia) earthquake. METHODS A total of 374 adults (29.9% men) aged 18-64 years living in the counties surrounding the epicenter of the Petrinja (Croatia) earthquake participated in an online cross-sectional survey. The questionnaire included the PTSD Checklist for DSM-5 (PCL-5), the Coping Inventory, and the binary item assessing whether or not the participants' home was damaged. RESULTS Hierarchical regression analysis showed that home damage was a significant predictor of PTSD symptoms. Participants whose homes were damaged by the earthquake were significantly more likely to use passive coping strategies, namely avoidance and emotional venting, and one active coping strategy, action, than those whose homes were spared. Finally, more frequent use of passive coping was associated with a higher risk of PTSD symptoms. CONCLUSIONS The study corroborates the COR theory link between resource loss and the stress response, as well as the general consensus that passive coping is a less adaptive strategy than active coping. In addition to passive coping, individuals who lacked resources may have been inclined to take some active steps because they either needed to repair or relocate their homes and because most buildings were only moderately to minimally damaged in the Petrinja earthquake.
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Affiliation(s)
- Ajana Löw
- Faculty of Education and Rehabilitation Sciences, University of Zagreb, University Campus Borongaj, Borongajska cesta 83f, 10000, Zagreb, Croatia
| | - Martina Lotar Rihtarić
- Faculty of Education and Rehabilitation Sciences, University of Zagreb, University Campus Borongaj, Borongajska cesta 83f, 10000, Zagreb, Croatia.
| | - Ivana Vrselja
- Department of Psychology, Catholic University of Croatia, Zagreb, Croatia
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Kottler J, Gingell MJ, Khosla S, Kordzikowski M, Raszewski R, Chestek D, Maki KA. Exploring Physical and Biological Manifestations of Burnout and Post-Traumatic Stress Disorder Symptoms in Healthcare Workers: A Scoping Review Protocol. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.16.23288657. [PMID: 37205368 PMCID: PMC10187352 DOI: 10.1101/2023.04.16.23288657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Introduction The COVID-19 pandemic has strained the mental and physical well-being of healthcare workers (HCW). Increased work-related stress and limited resources has increased symptoms of anxiety, depression, insomnia, and post-traumatic stress disorder (PTSD) in this population. Stress-related disorders have been strongly associated with long-term consequences including cardiometabolic disorders, endocrine disorders and premature mortality. This scoping review aims to explore available literature on burnout, PTSD, and other mental health-associated symptoms in HCW to synthesize relationships with physiological and biological biomarkers that may be associated with increased risk of disease, creating an opportunity to summarize current biomarker knowledge and identify gaps in this literature. Methods and Analysis This scoping review uses the Arksey and O'Malley six-step scoping review methodology framework. The research team will select appropriate primary sources using a search strategy developed in collaboration with a health sciences librarian. Three reviewers will initially screen the title and abstracts obtained from the literature searches, and two reviewers will conduct independent reviews of full-text studies for inclusion. The research team will be reviewing literature focusing on which burnout and/or PTSD-associated physiological and biological biomarkers have been studied, the methodologies used to study them and the correlations between the biomarkers and HCW experiencing burnout/PTSD. Data extraction forms will be completed by two reviewers for included studies and will guide literature synthesis and analysis to determine common themes. Ethics and Dissemination This review does not require ethical approval. We expect results from this scoping review to identify gaps in the literature and encourage future research regarding improving biologic and physiologic biomarker research in HCW. Preliminary results and general themes will be communicated back to stakeholders. Results will be disseminated through peer-reviewed publications, policy briefs, and conferences, as well as presented to stakeholders to an effort to invest in HCW mental and physical health. Strengths and Limitations of This Study This will be the first scoping review to assess the current understanding of the biologic and physiological impact of burnout on healthcare workers. The target population is restricted to healthcare workers; however, identified research gaps may be used to guide future studies in other high-burnout occupations and industries.This scoping review will be guided by the Arksey and O'Malley six-step methodological framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review checklist.Both peer reviewed manuscript and pre-prints/abstracts will be evaluated, but studies that have not been peer reviewed will be notated in the summary table. Conference abstracts are excluded.Preliminary and final themes and results identified by this scoping review will be communicated to stakeholders, including hospital staff and HCW, to ensure agreement with our interpretation and to convey knowledge gained with our population of interest.This review will advance the field's current understanding of mechanisms connecting the burnout and pathogenic stress to biologic and physiologic outcomes in healthcare workers and provide researchers with gaps in the literature to inform opportunities for future research.
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Brewerton TD, Gavidia I, Suro G, Perlman MM. Eating disorder patients with and without PTSD treated in residential care: discharge and 6-month follow-up results. J Eat Disord 2023; 11:48. [PMID: 36973828 PMCID: PMC10044735 DOI: 10.1186/s40337-023-00773-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION We studied whether provisional posttraumatic stress disorder (PTSD) moderated discharge (DC) and 6-month follow-up (FU) outcomes of multi-modal, integrated eating disorder (ED) residential treatment (RT) based upon principles of cognitive processing therapy (CPT). METHODS ED patients [N = 609; 96% female; mean age (± SD) = 26.0 ± 8.8 years; 22% LGBTQ +] with and without PTSD completed validated assessments at admission (ADM), DC and 6-month FU to measure severity of ED, PTSD, major depressive disorder (MDD), state-trait anxiety (STA) symptoms, and eating disorder quality of life (EDQOL). We tested whether PTSD moderated the course of symptom change using mixed models analyses and if ED diagnosis, ADM BMI, age of ED onset and LGBTQ + orientation were significant covariates of change. Number of days between ADM and FU was used as a weighting measure. RESULTS Despite sustained improvements with RT in the total group, the PTSD group had significantly higher scores on all measures at all time points (p ≤ .001). Patients with (n = 261) and without PTSD (n = 348) showed similar symptom improvements from ADM to DC and outcomes remained statistically improved at 6-month FU compared to ADM. The only significant worsening observed between DC and FU was with MDD symptoms, yet all measures remained significantly lower than ADM at FU (p ≤ .001). There were no significant PTSD by time interactions for any of the measures. Age of ED onset was a significant covariate in the EDI-2, PHQ-9, STAI-T, and EDQOL models such that an earlier age of ED onset was associated with a worse outcome. ADM BMI was also a significant covariate in the EDE-Q, EDI-2, and EDQOL models, such that higher ADM BMI was associated with a worse ED and quality of life outcome. CONCLUSIONS Integrated treatment approaches that address PTSD comorbidity can be successfully delivered in RT and are associated with sustained improvements at FU. Improving strategies to prevent post-DC recurrence of MDD symptoms is an important and challenging area of future work.
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Affiliation(s)
- Timothy D Brewerton
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.
- Timothy D. Brewerton, MD, LLC, Mount Pleasant, SC, USA.
- Monte Nido and Affiliates, Miami, FL, USA.
| | | | | | - Molly M Perlman
- Monte Nido and Affiliates, Miami, FL, USA
- Department of Psychiatry and Behavioral Health, Florida International University College of Medicine, Miami, FL, USA
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Sippel LM, Gross GM, Spiller TR, Duek O, Smith N, Hoff R, Harpaz-Rotem I. Comparative effectiveness of evidence-based psychotherapies for PTSD delivered in VA residential PTSD treatment. Psychol Med 2023:1-8. [PMID: 36971021 DOI: 10.1017/s0033291723000375] [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: 06/18/2023]
Abstract
BACKGROUND Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are first-line treatments for posttraumatic stress disorder (PTSD). There have been few direct comparisons of CPT and PE intended to determine their comparative effectiveness, none of which have examined outcomes among military veterans receiving these treatments in a residential setting such as the Department of Veterans Affairs (VA) residential rehabilitation treatment programs (RRTPs). Such work is essential given that these veterans are among the most complex and severely symptomatic patients with PTSD treated in VA. In this study we compared changes in PTSD and depressive symptoms across admission, discharge, four months and 12 months following discharge among veterans who received CPT or PE within VA RRTPs. METHODS Using linear mixed models conducted on program evaluation data derived from the electronic medical record and follow-up surveys, we compared self-reported PTSD and depressive symptom outcomes among 1130 veterans with PTSD who were treated with individual CPT (n = 832, 73.5%) or PE (n = 297, 26.5%) in VA PTSD RRTPs in fiscal years 2018-2020. RESULTS PTSD and depressive symptom severity did not significantly differ at any time points. The CPT and PE groups both showed large-sized reductions in PTSD (CPT d = 1.41, PE d = 1.51) and depression (CPT d = 1.01, PE d = 1.09) from baseline to 12-month follow-up. CONCLUSIONS Outcomes for PE and CPT do not differ among a highly complex population of veterans with severe PTSD and several comorbid conditions that can make it difficult to engage in treatment.
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Affiliation(s)
- Lauren M Sippel
- Northeast Program Evaluation Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH 03755, USA
- National Center for PTSD, Evaluation Division, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Georgina M Gross
- Northeast Program Evaluation Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- National Center for PTSD, Evaluation Division, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- Department of Psychiatry, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Tobias R Spiller
- Department of Psychiatry, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Or Duek
- Department of Psychiatry, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
- Department of Epidemiology, Biostatistics and Community Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Noelle Smith
- Northeast Program Evaluation Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- Department of Psychiatry, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Rani Hoff
- Northeast Program Evaluation Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- National Center for PTSD, Evaluation Division, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- Department of Psychiatry, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Ilan Harpaz-Rotem
- Northeast Program Evaluation Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- National Center for PTSD, Evaluation Division, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- Department of Psychiatry, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
- Department of Psychology and the Wu Tsai Institute, Yale University, New Haven, CT 06510, USA
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Possemato K, Johnson E, Barrie K, Ghaus S, Noronha D, Wade M, Greenbaum MA, Rosen C, Cloitre M, Owen J, Jain S, Beehler G, Prins A, Seal K, Kuhn E. A Randomized Clinical Trial of Clinician-Supported PTSD Coach in VA Primary Care Patients. J Gen Intern Med 2023:10.1007/s11606-023-08130-6. [PMID: 36932268 PMCID: PMC10022983 DOI: 10.1007/s11606-023-08130-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 03/01/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) is common in primary care patients; however, evidence-based treatments are typically only available in specialty mental healthcare settings and often not accessed. OBJECTIVE To test the effectiveness of a brief primary care-based treatment, Clinician-Supported PTSD Coach (CS PTSD Coach) was compared with Primary Care Mental Health Integration-Treatment as Usual (PCMHI-TAU) in (1) reducing PTSD severity, (2) engaging veterans in specialty mental health care, and (3) patient satisfaction with care. DESIGN Multi-site randomized pragmatic clinical trial. PARTICIPANTS A total of 234 veterans with PTSD symptoms who were not currently accessing PTSD treatment. INTERVENTION CS PTSD Coach was designed to be implemented in Veterans Affairs PCMHI and combines mental health clinician support with the "PTSD Coach" mobile app. Four 30-min sessions encourage daily use of symptom management strategies. MAIN MEASURES PTSD severity was measured by clinician-rated interviews pre- and post-treatment (8 weeks). Self-report measures assessed PTSD, depression, and quality of life at pretreatment, posttreatment, and 16- and 24-week follow-ups, and patient satisfaction at post-treatment. Mental healthcare utilization was extracted from medical records. KEY RESULTS Clinician-rated PTSD severity did not differ by condition at post-treatment. CS PTSD Coach participants improved more on patient-reported PTSD severity at post-treatment than TAU participants (D = .28, p = .021). Coach participants who continued to have problematic PTSD symptoms at post-treatment were not more likely to engage in 2 sessions of specialty mental health treatment than TAU participants. Coach participants engaged in 74% more sessions in the intervention and reported higher treatment satisfaction than TAU participants (p < .001). CONCLUSIONS A structured 4-session intervention designed to align with patient preferences for care resulted in more patient-reported PTSD symptom relief, greater utilization of mental health treatment, and overall treatment satisfaction than TAU, but not more clinician-rated PTSD symptom relief or engagement in specialty mental health.
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Affiliation(s)
- Kyle Possemato
- VA Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, USA.
| | - Emily Johnson
- VA Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, USA
| | - Kimberly Barrie
- VA Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, USA
| | | | | | - Michael Wade
- VA Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, USA
| | - Mark A Greenbaum
- National Center for PTSD, Palo Alto, CA, USA
- Mental Illness Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Craig Rosen
- National Center for PTSD, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Marylene Cloitre
- National Center for PTSD, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Jason Owen
- National Center for PTSD, Palo Alto, CA, USA
| | - Shaili Jain
- National Center for PTSD, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory Beehler
- VA Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, USA
| | | | - Karen Seal
- San Francisco VA Health Care System, San Francisco, USA
- University of California San Francisco, San Francisco, CA, USA
| | - Eric Kuhn
- National Center for PTSD, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
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Lewis AM. Modified Prolonged Exposure Therapy for Posttraumatic Stress Disorder with an 85-Year-Old Native American Cajun Man With Late-Onset Deafness: A Case Report. Clin Gerontol 2023:1-8. [PMID: 36732327 DOI: 10.1080/07317115.2023.2173693] [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: 02/04/2023]
Abstract
OBJECTIVES Few studies of exposure therapy with adults 85 years and older exist. This case report presents results of prolonged exposure (PE) for posttraumatic stress disorder (PTSD) modified for an 85-year-old Native American Cajun man with late-onset deafness, who used a cochlear implant, and reported high Western/non-Native American acculturation. The following modifications were made primarily in response to the client's individual, disability-related barriers to completing the standard PE protocol: (a) inclusion of the client's spouse in aspects of treatment planning and homework assignments; (b) variable session length and frequency; (c) homework was limited to the daily practice of breathing retraining and in vivo exposure to triggering images; and (d) therapist reliance on nonverbal indicators of distress during imaginal exposures. METHODS The PTSD Checklist for DSM-5 (PCL-5) and 15-item Geriatric Depression Scale (GSD-15) were primary progress and outcome measures. RESULTS The modified treatment was associated with clinically significant decreases in baseline PTSD (19 points) and depressive (8 points) symptoms. CONCLUSIONS PE protocol modifications did not compromise treatment outcomes for this client. CLINICAL IMPLICATIONS PE protocols should be modified based on the individual needs of diverse older adults underrepresented in efficacy research.
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Affiliation(s)
- Adam M Lewis
- Alexandria VA Health Care System, Pineville, Louisiana
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Hamrick L, Larsen SE, Sippel LM, Sherman K, Resick P, Galovski T. Benchmarking quality of life to posttraumatic stress disorder symptom changes in cognitive processing therapy. J Anxiety Disord 2023; 93:102647. [PMID: 36436386 DOI: 10.1016/j.janxdis.2022.102647] [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: 05/11/2022] [Revised: 10/24/2022] [Accepted: 11/07/2022] [Indexed: 11/10/2022]
Abstract
Although there is ample evidence that PTSD is effectively treated by first-line therapies such as Cognitive Processing Therapy (CPT), it is less clear to what degree these treatments improve quality of life (QOL), a common presenting concern of treatment-seeking individuals (Rosen et al., 2013). Only two studies, both conducted in military veteran samples, have examined the magnitude of PTSD symptom change needed in order to achieve corresponding changes in QOL during treatment. The current study aimed to replicate and extend these two previous studies by benchmarking multi-faceted QOL in a civilian sample of primarily female interpersonal violence survivors (N = 115) treated with CPT. We grouped participants into categories of increasingly greater PTSD symptom change: no response, response, loss of diagnosis, and remission. Outcomes were clinically meaningful change and good endpoint across five measures of QOL. Some QOL measures showed clinically meaningful change and/or good endpoint after a response to treatment or loss of diagnosis, but only remission from PTSD was associated with both clinically meaningful change and a good endpoint across all QOL indicators. These findings add to the emerging literature showing that treating PTSD to remission may maximize the likelihood of improvements in quality of life.
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Affiliation(s)
- Lauren Hamrick
- Bruce W. Carter VAMC, 1201 NW 16th Street, Miami, FL 33125, USA; Clement J. Zablocki VAMC, 5000 W National Avenue, Milwaukee, WI 53295, USA
| | - Sadie E Larsen
- Clement J. Zablocki VAMC, 5000 W National Avenue, Milwaukee, WI 53295, USA; Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
| | - Lauren M Sippel
- VA Northeast Program Evaluation Center, 950 Campbell Avenue, West Haven, CT 06516, USA; Department of Psychiatry, Geisel School of Medicine at Dartmouth, 1 Hope Ferry Road, Hanover, NH 03755, USA; National Center for PTSD (Evaluation Division), 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Kate Sherman
- Clement J. Zablocki VAMC, Research Division, 5000 W National Avenue, Milwaukee, WI 53295, USA
| | - Patricia Resick
- Duke Psychiatry & Behavioral Sciences, 2400 Pratt Street Room 7001, DUMC Box 102508, Durham, NC 27710, USA
| | - Tara Galovski
- National Center for PTSD (Women's Health Sciences Division), Boston, MA, USA; Boston University, One Sibler Way, Boston, MA 02215, USA
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Chang CH, Liu CY, Chen SJ, Tsai HC. Accelerated theta-burst transcranial magnetic stimulation of the bilateral dorsolateral prefrontal cortex in a patient with post-traumatic stress disorder and major depressive disorder: Case report. Front Psychiatry 2023; 14:1061088. [PMID: 36816401 PMCID: PMC9932662 DOI: 10.3389/fpsyt.2023.1061088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/04/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Theta-burst transcranial magnetic stimulation has demonstrated promising effectiveness as treatment for post-traumatic stress disorder (PTSD) and depression. However, the effect of accelerated theta-burst stimulation (TBS) in comorbid with PTSD and depression remains unknown. CASE PRESENTATION We report a case of a 25-year-old woman with PTSD and depression whose symptoms markedly improved after continuous TBS of the right dorsolateral prefrontal cortex (DLPFC) and intermittent TBS (iTBS) over the left DLPFC, and then with 20 min break before the 2nd iTBS session. CONCLUSIONS Accelerated TBS over the bilateral DLPFC may improve severe PTSD and depression. Accelerated TBS may have more improvement of depression symptoms than PTSD symptoms. Further trials are warranted to investigate the effect and safety for patients with complicated PTSD and depression.
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Affiliation(s)
- Chun-Hung Chang
- Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan.,Department of Psychiatry and Brain Disease Research Center, China Medical University Hospital, Taichung, Taiwan.,An Nan Hospital, China Medical University, Tainan, Taiwan
| | - Chieh-Yu Liu
- Biostatistical Consulting Laboratory, Department of Speech Language Pathology and Audiology, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Shaw-Ji Chen
- Department of Psychiatry, Taitung MacKay Memorial Hospital, Taitung, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei, Taiwan
| | - Hsin-Chi Tsai
- Department of Psychiatry, Tzu-Chi General Hospital, Hualien, Taiwan.,Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
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Zolfa R, Moradi A, Mahdavi M, Parhoon H, Parhoon K, Jobson L. Feasibility and acceptability of written exposure therapy in addressing posttraumatic stress disorder in Iranian patients with breast cancer. Psychooncology 2023; 32:68-76. [PMID: 36116086 DOI: 10.1002/pon.6037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 07/18/2022] [Accepted: 07/26/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study examined the feasibility and acceptability of written exposure therapy (WET) in reducing symptoms of posttraumatic stress disorder (PTSD) in Iranian women with breast cancer. Secondary aims included examining the influence of WET on quality of life (QoL), overgeneral memory and illness perceptions. METHOD Forty-six females with breast cancer and clinical symptoms of PTSD referred to the Razi Hospital in Rasht, Iran were randomly assigned to either WET (n = 23) or control (n = 23) groups. WET is a 5-session low-intensity exposure-based intervention for treating PTSD. The control group had no additional contact. Measures assessing PTSD, illness perceptions, overgeneral memory, and QoL were administered at baseline, post-intervention and 3-month follow-up. RESULTS Acceptability of WET was high; all participants completed all WET sessions. At post-intervention, 95.65% of the WET group met criteria for reliable change and 100% met criteria for minimal clinically important difference (MCID) and clinically significant change in PTSD symptom improvement. At follow-up, all WET participants met criteria for reliable change, MCID and clinically significant change in PTSD symptom improvement. No participants in the control group met reliable change, MCID or clinically significant change. The WET group had improved QoL and memory specificity and decreased threatening illness perceptions at post-intervention and follow-up when compared to controls. CONCLUSION WET may be a useful intervention for use with breast cancer patients with PTSD symptoms and may be an important adjunct to medical and pharmacological treatments, particularly in low- and middle-income countries. This study indicates further research in this area is warranted.
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Affiliation(s)
- Reihane Zolfa
- Department of Clinical Psychology, Kharazmi University, Tehran, Iran
| | - Alireza Moradi
- Kharazmi University and Institute for Cognitive Science Studies, Tehran, Iran
| | - Mohammad Mahdavi
- Kharazmi University and Institute for Cognitive Science Studies, Tehran, Iran
| | - Hadi Parhoon
- Department of Psychology, Razi University, Kermanshah, Iran
| | - Kamal Parhoon
- Postdoc Researcher in Cognitive Psychology, Kharazmi University, Tehran, Iran
| | - Laura Jobson
- Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
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Meyer EC, Coe E, Pennington ML, Cammarata C, Kimbrel NA, Ostiguy W, Leto F, Gulliver SB. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Delivered to Firefighters via Videoconferencing: Pilot Outcomes Highlighting Improvements in Alcohol Use Disorder and Posttraumatic Stress Disorder Symptoms. COGNITIVE AND BEHAVIORAL PRACTICE 2022. [DOI: 10.1016/j.cbpra.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Forehand JA, Dufort V, Gradus JL, Maguen S, Watts BV, Jiang T, Holder N, Shiner B. Association between post-traumatic stress disorder severity and death by suicide in US military veterans: retrospective cohort study. Br J Psychiatry 2022; 221:1-7. [PMID: 35997207 PMCID: PMC9947187 DOI: 10.1192/bjp.2022.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is mixed evidence regarding the direction of a potential association between post-traumatic stress disorder (PTSD) and suicide mortality. AIMS This is the first population-based study to account for both PTSD diagnosis and PTSD symptom severity simultaneously in the examination of suicide mortality. METHOD Retrospective study that included all US Department of Veterans Affairs (VA) patients with a PTSD diagnosis and at least one symptom severity assessment using the PTSD Checklist (PCL) between 1 October 1999 and 31 December 2018 (n = 754 197). We performed multivariable proportional hazards regression models using exposure groups defined by level of PTSD symptom severity to estimate suicide mortality rates. For patients with multiple PCL scores, we performed additional models using exposure groups defined by level of change in PTSD symptom severity. We assessed suicide mortality using the VA/Department of Defense Mortality Data Repository. RESULTS Any level of PTSD symptoms above the minimum threshold for symptomatic remission (i.e. PCL score >18) was associated with double the suicide mortality rate at 1 month after assessment. This relationship decreased over time but patients with moderate to high symptoms continued to have elevated suicide rates. Worsening PTSD symptoms were associated with a 25% higher long-term suicide mortality rate. Among patients with improved PTSD symptoms, those with symptomatic remission had a substantial and sustained reduction in the suicide rate compared with those without symptomatic remission (HR = 0.56; 95% CI 0.37-0.88). CONCLUSIONS Ameliorating PTSD can reduce risk of suicide mortality, but patients must achieve symptomatic remission to attain this benefit.
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Affiliation(s)
| | - Vincent Dufort
- Veterans Affairs Medical Center, White River Junction, Vermont
| | - Jaimie L. Gradus
- Boston University School of Public Health, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Shira Maguen
- Veterans Affairs Medical Center, San Francisco, California
- University of California, San Francisco
| | - Bradley V. Watts
- Veterans Affairs Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Tammy Jiang
- Boston University School of Public Health, Boston, Massachusetts
| | - Nicholas Holder
- Veterans Affairs Medical Center, San Francisco, California
- University of California, San Francisco
| | - Brian Shiner
- Veterans Affairs Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- National Center for Posttraumatic Stress Disorder, White River Junction, Vermont
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50
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Shiner B, Huybrechts K, Gui J, Rozema L, Forehand J, Watts BV, Jiang T, Hoyt JE, Esteves J, Schnurr PP, Ray K, Gradus JL. Comparative Effectiveness of Direct-Acting Antivirals for Posttraumatic Stress Disorder in Veterans Affairs Patients With Hepatitis C Virus Infection. Am J Epidemiol 2022; 191:1614-1625. [PMID: 35689641 PMCID: PMC9989349 DOI: 10.1093/aje/kwac104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 05/26/2022] [Accepted: 06/08/2022] [Indexed: 01/29/2023] Open
Abstract
We recently conducted an exploratory study that indicated that several direct-acting antivirals (DAAs), highly effective medications for hepatitis C virus (HCV) infection, were also associated with improvement in posttraumatic stress disorder (PTSD) among a national cohort of US Department of Veterans Affairs (VA) patients treated between October 1, 1999, and September 30, 2019. Limiting the same cohort to patients with PTSD and HCV, we compared the associations of individual DAAs with PTSD symptom improvement using propensity score weighting. After identifying patients who had available baseline and endpoint PTSD symptom data as measured with the PTSD Checklist (PCL), we compared changes over the 8-12 weeks of DAA treatment. The DAAs most prescribed in conjunction with PCL measurement were glecaprevir/pibrentasvir (GLE/PIB; n = 54), sofosbuvir/velpatasvir (SOF/VEL; n = 54), and ledipasvir/sofosbuvir (LDV/SOF; n = 145). GLE/PIB was superior to LDV/SOF, with a mean difference in improvement of 7.3 points on the PCL (95% confidence interval (CI): 1.1, 13.6). The mean differences in improvement on the PCL were smaller between GLE/PIB and SOF/VEL (3.0, 95% CI: -6.3, 12.2) and between SOF/VEL and LDV/SOF (4.4, 95% CI: -2.4, 11.2). While almost all patients were cured of HCV (92.5%) regardless of the agent received, PTSD outcomes were superior for those receiving GLE/PIB compared with those receiving LDV/SOF, indicating that GLE/PIB may merit further investigation as a potential PTSD treatment.
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Affiliation(s)
- Brian Shiner
- Correspondence to Dr. Brian Shiner, VA Medical Center, 215 N. Main Street, White River Junction, VT 05009 (e-mail: )
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