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Maguen S, Griffin BJ, Pietrzak RH, McLean CP, Hamblen JL, Norman SB. Using the Moral Injury and Distress Scale to identify clinically meaningful moral injury. J Trauma Stress 2024. [PMID: 38655683 DOI: 10.1002/jts.23050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024]
Abstract
Despite the proliferation of moral injury studies, a remaining gap is distinguishing moral injury from normative distress following exposure to potentially morally injurious events (PMIEs). Our goal was to leverage mental health and functional measures to identify clinically meaningful and functionally impairing moral injury using the Moral Injury and Distress Scale (MIDS). Participants who endorsed PMIE exposure (N = 645) were drawn from a population-based sample of military veterans, health care workers, and first responders. Using signal detection methods, we identified the optimally efficient MIDS score for detecting clinically significant posttraumatic stress and depressive symptom severity, trauma-related guilt, and functional impairment. The most efficient cut scores across outcomes converged between 24 and 27. We recommend a cut score of 27 given that roughly 70% of participants who screened positive on the MIDS at this threshold reported clinically significant mental health symptoms, and approximately 50% reported severe trauma-related guilt and/or functional impairment. Overall, 10.2% of respondents exposed to a PMIE screened positive for moral injury at this threshold, particularly those who identified as a member of a minoritized racial or ethnic group (17.9%) relative to those who identified as White, non-Hispanic (8.0%), aOR = 2.52, 95% CI [1.45, 4.42]. This is the first known study to establish a cut score indicative of clinically meaningful and impairing moral injury. Such scores may enhance clinicians' abilities to conduct measurement-based moral injury care by enabling them to identify individuals at risk of negative outcomes and better understand risk and protective factors for moral injury.
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Affiliation(s)
- Shira Maguen
- Mental Health Services, San Francisco VA Health Care System, San Francisco, California, USA
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Brandon J Griffin
- Center for Mental Health Care and Outcomes Research, Central Arkansas VA, Little Rock, Arkansas, USA
- Psychiatric Research Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Robert H Pietrzak
- Clinical Neurosciences Division, National Center for PTSD, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, West Haven, Connecticut, USA
| | - Carmen P McLean
- Dissemination and Training Division, National Center for PTSD, Menlo Park, California, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Jessica L Hamblen
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Executive Division, National Center for PTSD, White River Junction, Vermont, USA
| | - Sonya B Norman
- Executive Division, National Center for PTSD, White River Junction, Vermont, USA
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, California, USA
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McLean CP, Foa EB. State of the Science: Prolonged exposure therapy for the treatment of posttraumatic stress disorder. J Trauma Stress 2024. [PMID: 38652057 DOI: 10.1002/jts.23046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 04/25/2024]
Abstract
Prolonged exposure therapy (PE) is a well-established first-line treatment for posttraumatic stress disorder (PTSD) that is based on emotional processing theory. PE has been rigorously evaluated and tested in a large number of clinical trials in many countries covering a wide range of trauma populations. In this review, we summarize the evidence base supporting the efficacy of PE across populations, including adults with sexual assault-related PTSD and mixed trauma-related PTSD, military populations, and adolescents. We highlight important strengths and gaps in the research on PE with individuals from marginalized communities. We discuss the efficacy of PE on associated psychopathology and in the presence of the most commonly comorbid conditions, either alone or integrated with other treatments. In addition, we provide an overview of research examining strategies to augment PE. Much of this work remains preliminary, but numerous trials have tested PE in combination with other psychological or pharmacological approaches, interventions to facilitate extinction learning, and behavioral approaches, in the hopes of further increasing the efficiency and efficacy of PE. There are now several trials testing PE in novel formats that may have advantages over standard in-person PE, such as lower dropout and increased scalability. We examine this recent work on new models of delivering PE, including massed treatment, telehealth, and brief adaptations for primary care, all of which have the potential to increase access to PE. Finally, we highlight several promising areas for future research.
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Affiliation(s)
- Carmen P McLean
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, USA
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, Stanford, California, USA
| | - Edna B Foa
- Department of Psychiatry, Perlman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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3
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McLean CP, Cook J, Riggs DS, Peterson AL, Young-McCaughan S, Borah EV, Comtois KA, Dondanville KA, Frick E, Haddock CK, Mann J, Reynolds D, Mistretta M, Neitzer A, Brzuchalski A, Clayton SP, Conforte AM, DuMars TD, Ekundayo K, Flores A, Hein J, Jinkerson J, Keith F, Kim HJ, Link JS, Nofziger D, Pollick K, Ringdahl EN, Waggoner J, Woodworth C, Rosen CS. Barriers and Potential Solutions to Implementing Evidence-Based PTSD Treatment in Military Treatment Facilities. Mil Med 2024; 189:721-731. [PMID: 35943175 DOI: 10.1093/milmed/usac240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/15/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Prolonged exposure therapy is an effective treatment for posttraumatic stress disorder that is underutilized in health systems, including the military health system. Organizational barriers to prolonged exposure implementation have been hypothesized but not systematically examined. This multisite project sought to identify barriers to increasing the use of prolonged exposure across eight military treatment facilities and describe potential solutions to addressing these barriers. MATERIALS AND METHODS As part of a larger project to increase the use of prolonged exposure therapy in the military health system, we conducted a needs assessment at eight military treatment facilities. The needs assessment included analysis of clinic administrative data and a series of stakeholder interviews with behavioral health clinic providers, leadership, and support staff. Key barriers were matched with potential solutions using a rubric developed for this project. Identified facilitators, barriers, and potential solutions were summarized in a collaboratively developed implementation plan for increasing prolonged exposure therapy tailored to each site. RESULTS There was a greater than anticipated consistency in the barriers reported by the sites, despite variation in the size and type of facility. The identified barriers were grouped into four categories: time-related barriers, provider-related barriers, barriers related to patient education and matching patients to providers, and scheduling-related barriers. Potential solutions to each barrier are described. CONCLUSIONS The findings highlight the numerous organizational-level barriers to implementing evidence-based psychotherapy in the military health system and offer potential solutions that may be helpful in addressing the barriers.
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Affiliation(s)
- Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA 94305, USA
| | - Jeffrey Cook
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David S Riggs
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX 78229, USA
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX 78229, USA
| | - Elisa V Borah
- Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX 78712, USA
| | - Katherine Anne Comtois
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, USA
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Erin Frick
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | | | - Jeffrey Mann
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David Reynolds
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Melissa Mistretta
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Andrea Neitzer
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
| | - Amy Brzuchalski
- William Beaumont Army Medical Center, El Paso, TX 79920, USA
- Kimbrough Ambulatory Care Center, Fort Meade, MD 20755, USA
| | - Spencer P Clayton
- 49th Medical Group, Holloman Air Force Base, Alamogordo, NM 88330, USA
- Nellis Air Force Base, NV 89191, USA
| | - Allison M Conforte
- Blanchfield Army Community Hospital, Fort Campbell, KY 42223, USA
- 3d Marine Division, UNIT 35840, Okinawa FPO AP 96602-5840, Japan
| | - Tyler D DuMars
- William Beaumont Army Medical Center, El Paso, TX 79920, USA
| | - Kendra Ekundayo
- 49th Medical Group, Holloman Air Force Base, Alamogordo, NM 88330, USA
| | - Araceli Flores
- William Beaumont Army Medical Center, El Paso, TX 79920, USA
| | - Jessica Hein
- Blanchfield Army Community Hospital, Fort Campbell, KY 42223, USA
| | - Jeremy Jinkerson
- 81st Medical Group, Keesler Air Force Base, Biloxi, MS 39534, USA
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX 78234, USA
| | - Felicia Keith
- David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA 94533, USA
- Spangdahlem Air Base, Spangdahlem 09123, Germany
| | - Hana J Kim
- Naval Hospital Jacksonville, Naval Air Station Jacksonville, Jacksonville, FL 32214, USA
| | - Jared S Link
- 81st Medical Group, Keesler Air Force Base, Biloxi, MS 39534, USA
| | - Debra Nofziger
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX 78234, USA
| | - Kirsten Pollick
- Naval Hospital Jacksonville, Naval Air Station Jacksonville, Jacksonville, FL 32214, USA
| | - Erik N Ringdahl
- David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA 94533, USA
| | - John Waggoner
- 81st Medical Group, Keesler Air Force Base, Biloxi, MS 39534, USA
| | - Craig Woodworth
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX 78234, USA
| | - Craig S Rosen
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA 94305, USA
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McLean CP, Miller ML, Dondanville KA, Rauch SAM, Yarvis JS, Wright EC, Hall-Clark BN, Fina BA, Litz BT, Mintz J, Young-McCaughan S, Peterson AL, Foa EB. Perceptions and experiences of web-prolonged exposure for posttraumatic stress disorder: A mixed-methods study. Psychol Trauma 2024; 16:143-148. [PMID: 35099219 DOI: 10.1037/tra0001124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Web-based prolonged exposure therapy (Web-PE) has potential to increase the reach of effective posttraumatic stress disorder (PTSD) treatment. While there is initial support for the efficacy of Web-PE, no studies have examined the perceptions and experiences of participants receiving PE in this novel, Web based format. METHOD We used a mixed-methods convergent design to examine and integrate quantitative and qualitative data of participant perceptions and experiences of Web-PE. Treatment-seeking active duty military personnel or veterans (N = 29) who received Web-PE completed posttreatment surveys about perceptions of Web-PE and a brief qualitative interview. Thematic coding was used to identify qualitative themes, which were integrated with quantitative data in a joint display. RESULTS Although many were initially skeptical of experiencing benefit, participants reported that Web-PE was helpful. They appreciated the flexibility of online therapy and reported that self-motivation was important for engagement. Web-PE therapists were well-regarded, although additional therapist support and technical improvements to the Web-PE program were suggested. Scores on the perceptions of Web-PE survey, PTSD survey, and other quantitative data corroborated the qualitative themes. CONCLUSION Perceptions and experience of Web-PE are favorable and help to highlight the strengths (e.g., flexibility) and challenges (e.g., requiring self-motivation) associated with Web-treatment for PTSD. The results of this study may inform further development of Web-PE or other Web-based treatment programs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Carmen P McLean
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System
| | - Madeleine L Miller
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | | | - Jeffrey S Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center
| | - Edward C Wright
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | - Brittany N Hall-Clark
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | - Brooke A Fina
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania
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5
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Benfer N, Grunthal B, Dondanville KA, Young-McCaughan S, Blankenship A, Abdallah CG, Back SE, Flanagan J, Foa EB, Fox PT, Krystal JH, Marx BP, McGeary DD, McLean CP, Pruiksma KE, Resick PA, Roache JD, Shiroma P, Sloan DM, Taylor DJ, Wachen JS, López-Roca AL, Nicholson KL, Schobitz RP, Schrader CC, Sharrieff AFM, Yarvis JS, Mintz J, Keane TM, Peterson AL, Litz BT. DSM-5 criterion-a-based trauma types in service members and veterans seeking treatment for posttraumatic stress disorder. Psychol Trauma 2023:2023-86330-001. [PMID: 37410416 PMCID: PMC10770283 DOI: 10.1037/tra0001537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
OBJECTIVE In posttraumatic stress disorder (PTSD), the assumption of the equipotentiality of traumas ignores potentially unique contexts and consequences of different traumas. Accordingly, Stein et al. (2012) developed a reliable typing scheme in which assessors categorized descriptions of traumatic events into six "types": life threat to self (LTS), life threat to other, aftermath of violence (AV), traumatic loss, moral injury by self (MIS), and moral injury by other (MIO). We extended this research by validating the typing scheme using participant endorsements of type, rather than assesor-based types. We examined the concordance of participant and assesor types, frequency, and validity of participant-based trauma types by examining associations with baseline mental and behavioral health problems. METHOD Interviewers enrolled military personnel and veterans (N = 1,443) in clinical trials of PTSD and helped them select the most currently distressing Criterion-A trauma. Participants and, archivally, assessors typed the distressing aspect(s) of this experience. RESULTS AV was the most frequently participant-endorsed type, but LTS was the most frequently rated worst part of an event. Although participants endorsed MIS and MIO the least frequently, these were associated with worse mental and behavioral health problems. The agreement between participants and assessors regarding the worst part of the event was poor. CONCLUSION Because of discrepancies between participant and assessor typologies, clinical researchers should use participants' ratings, and these should trump assessor judgment. Differences in pretreatment behavioral and mental health problems across some participant-endorsed trauma types partially support the validity of the participant ratings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Natasha Benfer
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Breanna Grunthal
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Katherine A. Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
| | - Abby Blankenship
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | | | - Sudie E. Back
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina, United States
| | - Julianne Flanagan
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina, United States
| | - Edna B. Foa
- Department of Psychiatry, University of Pennsylvania
| | - Peter T. Fox
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
- Research Imaging Institute, Department of Radiology, Department of Psychiatry and Behavioral Sciences, and Department of Neurology, University of Texas Health Science Center at San Antonio
| | - John H. Krystal
- Clinical Neurosciences Division, National Center for PTSD, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Department of Psychiatry, Yale University School of Medicine
| | - Brian P. Marx
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
- Department of Psychiatry, Boston University School of Medicine
| | - Donald D. McGeary
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
| | - Carmen P. McLean
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University
| | - Kristi E. Pruiksma
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | | | - John D. Roache
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
| | - Paulo Shiroma
- Minneapolis VA Medical Center, Minneapolis, Minnesota, United States
- Department of Psychiatry, University of Minnesota
| | - Denise M. Sloan
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
- Department of Psychiatry, Boston University School of Medicine
| | | | - Jennifer Schuster Wachen
- Department of Psychiatry, Boston University School of Medicine
- Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Argelio L. López-Roca
- Department of Behavioral Health, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, United States
| | - Karin L. Nicholson
- Department of Medicine, Carl R. Darnall Army Medical Center, Fort Hood, Texas, United States
| | - Richard P. Schobitz
- Department of Behavioral Health, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, United States
| | - Christian C. Schrader
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas
| | | | - Jeffrey S. Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
| | - Terence M. Keane
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
- Department of Psychiatry, Boston University School of Medicine
| | - Alan L. Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
- Department of Psychology, University of Texas at San Antonio
| | - Brett T. Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, United States
- Department of Psychiatry, Boston University School of Medicine
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McLean CP, Foa EB, Malek N, Young-McCaughan S, Peterson AL, Hanson BS, Lillard IJ, Patterson TJ, Rosado J, Scott V, Rosenfield D. A multistep mediation model examining how consultation in prolonged exposure therapy affects PTSD treatment outcomes. Psychol Serv 2023:2023-69937-001. [PMID: 37155269 PMCID: PMC10630526 DOI: 10.1037/ser0000769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Prolonged exposure therapy (PE) is an evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) that is underutilized in the military health system. Previous research suggests that postworkshop consultation is important for successful implementation. However, little is known about how consultation may relate to EBP adoption or patient outcomes. The present study addressed these gaps by examining associations between consultation, provider self-efficacy, use of PE, and patient outcomes using a multistep mediation model. This study used data from Foa et al. (2020), a two-armed randomized implementation trial comparing two PE training models: standard training (workshop only) and extended training (workshop + 6-8 months of postworkshop expert consultation) at three U.S. Army sites. Participants were patients with PTSD (N = 242) receiving care from the participating providers (N = 103). Providers who received extended training reported greater PE self-efficacy compared to standard training providers, but self-efficacy was unrelated to their use of PE components or to patient outcomes. Extended training providers used more PE components and had superior patient outcomes than standard training providers, and patient outcomes were mediated by the use of PE components. To our knowledge, this is the first study to demonstrate that EBP consultation leads to improved clinical outcomes for patients through increased use of the EBP. PE adoption (i.e., use of PE components in therapy) was not explained by increases in self-efficacy among providers who received extended training. Therefore, future research should assess how other factors may influence provider behavior in implementing EBPs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Carmen P. McLean
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, United States
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University
| | - Edna B. Foa
- Department of Psychiatry, School of Medicine, University of Pennsylvania
| | - Nadia Malek
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, United States
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Texas Health Science Center at San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
| | - Alan L. Peterson
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Texas Health Science Center at San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
- Department of Psychology, University of Texas at San Antonio
| | - Brenda S. Hanson
- William Beaumont Army Medical Center, Fort Bliss, Texas, United States
| | - Ivett J. Lillard
- Blanchfield Army Community Hospital, Fort Campbell, Kentucky, United States
| | | | - Julio Rosado
- William Beaumont Army Medical Center, Fort Bliss, Texas, United States
| | - Valerie Scott
- Blanchfield Army Community Hospital, Fort Campbell, Kentucky, United States
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McLean CP, Betsworth D, Bihday C, Daman MC, Davis CA, Kaysen D, Rosen CS, Saxby D, Smith AE, Spinelli S, Watson P. Helping the Helpers: Adaptation and Evaluation of Stress First Aid for Healthcare Workers in the Veterans Health Administration During the COVID-19 Pandemic. Workplace Health Saf 2023; 71:162-171. [PMID: 36726298 PMCID: PMC9899680 DOI: 10.1177/21650799221148650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Early interventions are needed to support the behavioral health of healthcare staff in the context of the COVID-19 pandemic. Stress First Aid (SFA) is a self-care and peer support model for reducing burnout and stress that is designed for use in high-stress occupations. METHODS We conducted a mixed-methods evaluation of an SFA program in the Veterans Health Administration (VHA). This brief, multi-session, didactic program was adapted for hospital workgroups. Program attendees completed a survey assessing implementation outcomes, burnout, stress, mood, and SFA skills at the beginning (N = 246) and end (n = 94) of the SFA program and a subgroup (n = 11) completed qualitative feedback interviews. FINDINGS Program acceptability, appropriateness, and feasibility were rated highly. From pre- to post-SFA, the impact of the pandemic on stress and anxiety, as well as proficiency in supporting peers increased. Qualitative findings suggest the program provided a shared language to discuss stress, normalized stress reactions, met a need for stress management tools, and helped staff feel valued, empowered, connected with each other. Staff reported being more aware of their stress, but SFA was insufficient to address many of the systemic sources of burnout and stress. CONCLUSIONS AND APPLICATIONS TO PRACTICE While the SFA program was well received, the impact of brief programs is likely to be modest when implemented in the middle of an ongoing pandemic and when burnout arises from chiefly from systemic sources. Lessons learned during the program implementation that may guide future efforts are discussed.
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Affiliation(s)
- Carmen P. McLean
- Dissemination and Training Division, VA
Palo Alto Healthcare System, National Center for PTSD,Department of Psychiatry and Behavioral
Sciences, Stanford University,Carmen P. McLean, PhD, National Center for
PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 795
Willow Rd, Menlo Park, CA 94025, USA;
| | | | | | | | - C. Adrian Davis
- Dissemination and Training Division, VA
Palo Alto Healthcare System, National Center for PTSD
| | - Debra Kaysen
- Dissemination and Training Division, VA
Palo Alto Healthcare System, National Center for PTSD,Department of Psychiatry and Behavioral
Sciences, Stanford University
| | - Craig S. Rosen
- Dissemination and Training Division, VA
Palo Alto Healthcare System, National Center for PTSD,Department of Psychiatry and Behavioral
Sciences, Stanford University
| | | | | | | | - Patricia Watson
- Executive Division, VA Medical Center
(116D), National Center for PTSD,Department of Psychiatry, Geisel School
of Medicine, Dartmouth University
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McLean CP, Cook J, Riggs DS, Peterson AL, Young-McCaughan S, Haddock CK, Rosen CS. Policy Recommendations for Increasing the Use of Evidence-Based Psychotherapy for Posttraumatic Stress Disorder in the Military Health System. Mil Med 2023; 188:usac429. [PMID: 36617250 DOI: 10.1093/milmed/usac429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 01/09/2023] Open
Abstract
Few service members with posttraumatic stress disorder (PTSD) receive evidence-based psychotherapy (EBP) in the military health system (MHS). Efforts to increase EBP implementation have focused on provider training but have not adequately addressed organizational barriers. Thus, although behavioral health providers are trained in EBPs, clinic-, facility-, and system-level barriers preclude widespread EBP implementation. Building on work examining barriers to EBP use for PTSD across eight military treatment facilities, we propose recommendations for increasing the implementation of EBPs for PTSD and improving the quality of behavioral health care in MHS outpatient behavioral health clinics. Increasing the use of EBPs for PTSD will require that their use is supported and prioritized through MHS policy. We recommend that psychotherapy appointments are scheduled at least once weekly, as clinically indicated, as this frequency of care is prerequisite for EBP delivery. We propose several recommendations designed to increase system capacity for weekly psychotherapy, including improved triaging of potential patients, incentivizing and supporting group psychotherapy, matching the modality (i.e., group vs. individual) and frequency of treatment to patients' needs, and using behavioral health technicians as clinician extenders. Additional recommendations include providing ongoing support for EBP implementation (e.g., protected time to participate in EBP consultation) and matching patients to providers based on patient's clinical needs and treatment preferences. The barriers to EBP implementation that these recommendations target are interrelated. Therefore, adopting multiple policy recommendations is likely necessary to yield a meaningful and sustained increase in the implementation of EBPs for PTSD in the MHS.
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Affiliation(s)
- Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA 94305, USA
| | - Jeffrey Cook
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David S Riggs
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX 78229, USA
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX 78229, USA
| | | | - Craig S Rosen
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA 94305, USA
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Peterson AL, Blount TH, Foa EB, Brown LA, McLean CP, Mintz J, Schobitz RP, DeBeer BR, Mignogna J, Fina BA, Evans WR, Synett S, Hall-Clark BN, Rentz TO, Schrader C, Yarvis JS, Dondanville KA, Hansen H, Jacoby VM, Lara-Ruiz J, Straud CL, Hale WJ, Shah D, Koch LM, Gerwell KM, Young-McCaughan S, Litz BT, Meyer EC, Blankenship AE, Williamson DE, Roache JD, Javors MA, Sharrieff AFM, Niles BL, Keane TM. Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2249422. [PMID: 36602803 PMCID: PMC9856757 DOI: 10.1001/jamanetworkopen.2022.49422] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Improved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD). OBJECTIVE To determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted among military personnel and veterans at 4 sites in Texas from 2017 to 2019. Assessors were blinded to conditions. Data were analyzed from November 2020 to October 2022. INTERVENTIONS The interventions were massed-PE, which included 15 therapy sessions of 90 minutes each over 3 weeks, vs intensive outpatient program PE (IOP-PE), which included 15 full-day therapy sessions over 3 weeks with 8 treatment augmentations. The IOP-PE intervention was hypothesized to be superior to massed-PE. MAIN OUTCOMES AND MEASURES Coprimary outcomes included the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) administered at baseline and posttreatment follow-ups. Measures ranged from 0 to 80, with higher scores indicating greater severity. Diagnostic remission and reliable change were secondary outcomes. RESULTS Among 319 military personnel and veterans screened, 234 were randomized (mean [SD] age, 39.20 [7.72] years; 182 [78%] male participants), with 117 participants randomized to IOP-PE and 117 participants randomized to massed-PE. A total of 61 participants (26%) were African American, 58 participants (25%) were Hispanic, and 102 participants (44%) were White; 151 participants (65%) were married. Linear mixed-effects models found that CAPS-5 scores decreased in both treatment groups at the 1-month follow-up (IOP-PE: mean difference, -13.85 [95% CI, -16.47 to -11.23]; P < .001; massed-PE: mean difference, -14.13 [95% CI, -16.63 to -11.62]; P < .001). CAPS-5 change scores differed from 1- to 6-month follow-ups (mean difference, 4.44 [95% CI, 0.89 to 8.01]; P = .02). PTSD symptoms increased in massed-PE participants during follow-up (mean difference, 3.21 [95% CI, 0.65 to 5.77]; P = .01), whereas IOP-PE participants maintained treatment gains (mean difference, 1.23 [95% CI, -3.72 to 1.27]; P = .33). PCL-5 scores decreased in both groups from baseline to 1-month follow-up (IOP-PE: mean difference, -21.81 [95% CI, -25.57 to -18.04]; P < .001; massed-PE: mean difference, -19.96 [95% CI, -23.56 to -16.35]; P < .001) and were maintained at 6 months (IOP-PE: mean change, -0.21 [95% CI, -3.47 to 3.06]; P = .90; massed-PE: mean change, 3.02 [95% CI, -0.36 to 6.40]; P = .08). Both groups had notable PTSD diagnostic remission at posttreatment (IOP-PE: 48% [95% CI, 36% to 61%] of participants; massed-PE: 62% [95% CI, 51% to 73%] of participants), which was maintained at 6 months (IOP-PE: 53% [95% CI, 40% to 66%] of participants; massed-PE: 52% [95% CI, 38% to 66%] of participants). Most participants demonstrated reliable change on the CAPS-5 (61% [95% CI, 52% to 69%] of participants) and the PCL-5 (74% [95% CI, 66% to 81%] of participants) at the 1-month follow-up. CONCLUSIONS AND RELEVANCE These findings suggest that PE can be adapted into compressed treatment formats that effectively reduce PTSD symptoms. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03529435.
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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
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
- Department of Psychology, University of Texas at San Antonio, San Antonio
| | - Tabatha H. Blount
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Edna B. Foa
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Lily A. Brown
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Carmen P. McLean
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
- Department of Population Health Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Richard P. Schobitz
- Department of Behavioral Health, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
| | - Bryann R. DeBeer
- VISN-17 Center of Excellence for Returning War Veterans, Central Texas Veterans Health Care System, Waco
- Rocky Mountain Mental Illness Research Education and Clinical Center for Suicide Prevention, Department of Veterans Affairs, Aurora, Colorado
| | - Joseph Mignogna
- VISN-17 Center of Excellence for Returning War Veterans, Central Texas Veterans Health Care System, Waco
- Rocky Mountain Mental Illness Research Education and Clinical Center for Suicide Prevention, Department of Veterans Affairs, Aurora, Colorado
| | - Brooke A. Fina
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Wyatt R. Evans
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Samantha Synett
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- VISN-17 Center of Excellence for Returning War Veterans, Central Texas Veterans Health Care System, Waco
- Rocky Mountain Mental Illness Research Education and Clinical Center for Suicide Prevention, Department of Veterans Affairs, Aurora, Colorado
| | - Brittany N. Hall-Clark
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Timothy O. Rentz
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
| | - Christian Schrader
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas
| | - Jeffrey S. Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas
- School of Social Work, Tulane University, New Orleans, Louisiana
| | - Katherine A. Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Hunter Hansen
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Vanessa M. Jacoby
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Jose Lara-Ruiz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Department of Psychology, University of Texas at San Antonio, San Antonio
| | - Casey L. Straud
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
- Department of Psychology, University of Texas at San Antonio, San Antonio
| | - Willie J. Hale
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Department of Psychology, University of Texas at San Antonio, San Antonio
| | - Dhiya Shah
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
| | - Lauren M. Koch
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Kelsi M. Gerwell
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
| | - Brett T. Litz
- Department of Psychiatry, School of Medicine, Boston University, Boston, Massachusetts
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston
- Department of Psychological and Brain Sciences, School of Arts and Sciences, Boston University, Boston, Massachusetts
| | - Eric C. Meyer
- VISN-17 Center of Excellence for Returning War Veterans, Central Texas Veterans Health Care System, Waco
- Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Abby E. Blankenship
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Douglas E. Williamson
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina
- Durham VA Health Care System, Durham, North Carolina
| | - John D. Roache
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio
| | - Martin A. Javors
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio
| | - Allah-Fard M. Sharrieff
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas
- Department of Homeland Security, Miami, Florida
| | - Barbara L. Niles
- Department of Psychiatry, School of Medicine, Boston University, Boston, Massachusetts
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts
| | - Terence M. Keane
- Department of Psychiatry, School of Medicine, Boston University, Boston, Massachusetts
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts
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McLean CP, Wachsman T, Morland L, Norman SB, Hooper V, Cloitre M. The mental health impact of COVID-19-related stressors among treatment-seeking trauma-exposed veterans. J Trauma Stress 2022; 35:1792-1800. [PMID: 36065487 PMCID: PMC9538243 DOI: 10.1002/jts.22874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 12/24/2022]
Abstract
Trauma-exposed veterans receiving mental health care may have an elevated risk of experiencing COVID-19-related difficulties. Using data from several ongoing clinical trials (N = 458), this study examined exposure to COVID-19-related stressors and their associations with key sociodemographic factors and mental health outcomes. The results showed that exposure to COVID-19-related stressors was common, higher among veterans who were racial/ethnic minorities d = 0.32, and associated with elevated posttraumatic stress disorder (PTSD), r = .288, and depressive symptom severity, r = .246. Women veterans experienced more difficulty accessing social support, d = 0.31, and higher levels of COVID-19-related distress, d = 0.31, than men. Qualitative data were consistent with survey findings and highlighted the broader societal context in veterans' experience of COVID-19-related distress. These findings may inform future research on the impact of the pandemic on veterans, particularly those who are women and members of minoritized racial/ethnic groups, as well as mental health treatment planning for this population.
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Affiliation(s)
- Carmen P. McLean
- Dissemination and Training Division, National Center for PTSDVA Palo Alto Health Care SystemMenlo ParkCalifornia
- Department of Psychiatry and Behavioral Sciences, School of MedicineStanford UniversityStanfordCalifornia
| | | | - Leslie Morland
- VA San Diego Healthcare SystemSan DiegoCalifornia
- National Center for PTSDPacific Islands DivisionHonoluluHawaii
- Department of PsychiatryUniversity of California San Diego School of MedicineSan DiegoCalifornia
| | - Sonya B. Norman
- VA San Diego Healthcare SystemSan DiegoCalifornia
- Department of PsychiatryUniversity of California San Diego School of MedicineSan DiegoCalifornia
- Executive DivisionNational Center for PTSDWhite River JunctionVermont
| | - Vaughan Hooper
- Dissemination and Training Division, National Center for PTSDVA Palo Alto Health Care SystemMenlo ParkCalifornia
| | - Marylene Cloitre
- Dissemination and Training Division, National Center for PTSDVA Palo Alto Health Care SystemMenlo ParkCalifornia
- Department of Psychiatry and Behavioral Sciences, School of MedicineStanford UniversityStanfordCalifornia
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McLean CP, Levy HC, Miller ML, Tolin DF. Exposure therapy for PTSD in military populations: A systematic review and meta-analysis of randomized clinical trials. J Anxiety Disord 2022; 90:102607. [PMID: 35926254 DOI: 10.1016/j.janxdis.2022.102607] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 10/16/2022]
Abstract
Military populations are disproportionally affected by posttraumatic stress disorder (PTSD) and may experience less benefit from first line psychotherapies for PTSD relative to civilians. We examined the efficacy of exposure therapy among Veterans and active duty military personnel across various control conditions and tested potential treatment-related, demographic, and clinical moderators. Randomized controlled trials of exposure-based therapies for PTSD in military populations were identified from a recent meta-analysis and through PsycINFO and Medline. Nineteen studies met inclusion criteria and were included in the meta-analysis (total N = 2905). Exposure therapy had medium to large effects compared to waitlist and treatment as usual, a small effect compared to non-trauma-focused therapy, and no effect relative to other trauma-focused therapy. The overall effect was similar at post-treatment and follow up. The effect size for exposure was larger in studies with younger participants, more women, fewer participants with comorbid major depression, and fewer participants taking psychiatric medication. Effect sizes were not impacted by treatment length or type, participant race or ethnicity, comorbid substance use, Veteran versus active duty status, or study risk of bias. Findings document the variable efficacy of exposure therapy in military populations across comparator types and point to several potentially important moderators of outcome that should be examined in future research.
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Affiliation(s)
- Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, United States; Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Stanford, CA 94305-5717, United States.
| | - Hannah C Levy
- Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, United States
| | - Madeleine L Miller
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, United States
| | - David F Tolin
- Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, United States; Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, United States
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McLean CP, Foa EB, Dondanville KA, Haddock CK, Miller ML, Rauch SAM, Yarvis JS, Wright EC, Hall-Clark BN, Fina BA, Litz BT, Mintz J, Young-McCaughan S, Peterson AL. "The effects of web-prolonged exposure among military personnel and veterans with posttraumatic stress disorder": Correction. Psychol Trauma 2022; 14:804. [PMID: 35324230 DOI: 10.1037/tra0001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
UNLABELLED Reports an error in "The effects of web-prolonged exposure among military personnel and veterans with posttraumatic stress disorder" by Carmen P. McLean, Edna B. Foa, Katherine A. Dondanville, Christopher K. Haddock, Madeleine L. Miller, Sheila A. M. Rauch, Jeffery S. Yarvis, Edward C. Wright, Brittany N. Hall-Clark, Brooke A. Fina, Brett T. Litz, Jim Mintz, Stacey Young-McCaughan and Alan L. Peterson (Psychological Trauma: Theory, Research, Practice, and Policy, 2021[Sep], Vol 13[6], 621-631). In the original article, "for the STRONG STAR Consortium" was missing from the end of the author line. In addition, the numbering and text of the affiliations for Edward C. Wright, Brittany N. Hall-Clark, Brooke A. Fina, Brett T. Litz, Jim Mintz, Stacey Young-McCaughan, and Alan L. Peterson were incorrect because of duplicated affiliation details and associated typographical errors. Finally, in the References, "for the STRONG STAR Consortium" and "on behalf of the STRONG STAR Consortium" were missing from the ends of the author lists for Foa et al. (2018) and Resick et al. (2015), respectively. The online version of this article has been corrected. (The following abstract of the original article appeared in record 2020-86687-001). OBJECTIVE Web-based treatments address many of the logistical and stigma-related barriers to in-person behavioral health care. Prior studies of web-based treatments for posttraumatic stress disorder (PTSD) did not employ gold-standard treatments and have not compared to in-person therapy. METHOD We compared a web version of Prolonged Exposure Therapy, "Web-PE," to in-person Present-Centered Therapy (PCT) in a randomized controlled trial (RCT) with 40 military personnel with PTSD seeking treatment at Fort Hood, Texas. Due to recruitment challenges, we terminated the RCT and subsequently examined the effects of Web-PE in an uncontrolled open trial with 34 service members and veterans recruited nationwide. Both studies assessed PTSD, depressive symptoms, and health functioning at baseline and 1 and 3 months posttreatment; the RCT also included a 6-month assessment. RESULTS Results of the RCT showed no differential impact for Web-PE and PCT, although more PCT participants achieved clinically significant change at one of the follow-up assessments. Both treatment conditions significantly reduced self-reported and blind independent interviewer-assessed symptoms of PTSD. Results of the open trial showed that Web-PE was associated with significant reductions in self-reported PTSD symptoms, with a much larger effect size than in the RCT. CONCLUSIONS Web-PE significantly reduced PTSD symptoms in both studies, although the reductions in PTSD symptoms were greater among open trial participants, who were specifically seeking a web-based treatment. Future research should evaluate Web-PE relative to another web-based treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences
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13
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Foa EB, Bredemeier K, Acierno R, Rosenfield D, Muzzy W, Tuerk PW, Zandberg LJ, Hart S, Young-McCaughan S, Peterson AL, McLean CP. The efficacy of 90-min versus 60-min sessions of prolonged exposure for PTSD: A randomized controlled trial in active-duty military personnel. J Consult Clin Psychol 2022; 90:503-512. [PMID: 35771512 DOI: 10.1037/ccp0000739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Prolonged exposure (PE) therapy is a first-line posttraumatic stress disorder (PTSD) treatment, but the manualized 90-min session format constitutes a barrier to adopting PE in most settings because they use 60-min sessions for scheduling and billing. We examined whether 60-min PE sessions were as effective and efficient as 90-min PE sessions. METHOD In total, 160 active-duty military personnel with PTSD were randomized to 8-15 sessions of 60- or 90-min PE sessions and assessed pre- and posttreatment, and 3- and 6-month posttreatment, using the Clinician Administered PTSD Scale for Diagnostic and Statistical Manual for Mental Disorders, 5th edition [DSM-5] (CAPS-5). Participants were also assessed weekly during treatment using the PTSD Checklist for DSM-5 (PCL-5). A 60-min PE was hypothesized to be noninferior to 90-min PE based on preliminary studies. RESULTS Using intent-to-treat analyses, the 95% CI for the difference between 60- and 90-min PE was less than the noninferiority margin (4.69 for the CAPS-5 and 7.38 for the PCL-5) at all three endpoints, suggesting that the efficacy of 60-min PE was noninferior to that of 90-min PE. Similarly, the rate of improvement per session for 60-min PE was noninferior to the rate for 90-min sessions for the PCL-5. Sensitivity analyses and Bayes factors were consistent with these results. CONCLUSIONS 60-min sessions of PE are noninferior to 90-min sessions with regard to both efficacy and efficiency. Thus, PE can be effectively delivered in shorter sessions, making it easier for behavioral health providers to implement within the military health system and in other mental health systems that use 60-min session appointments. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
- Edna B Foa
- Department of Psychiatry, Perlman School of Medicine, University of Pennsylvania
| | - Keith Bredemeier
- Department of Psychiatry, Perlman School of Medicine, University of Pennsylvania
| | - Ron Acierno
- Faillace Department of Psychiatry, University of Texas Health Sciences Center
| | | | - Wendy Muzzy
- Department of Psychiatry, Medical University of South Carolina
| | - Peter W Tuerk
- Sheila C. Johnson Center for Clinical Services, University of Virginia
| | - Laurie J Zandberg
- Department of Psychiatry, Perlman School of Medicine, University of Pennsylvania
| | - Stephanie Hart
- Department of Psychiatry, Medical University of South Carolina
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | - Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System
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McLean CP, Back SE, Capone C, Morland L, Norman SB, Rauch SAM, Schnurr PP, Teng E, Acierno R. The Impact of COVID-19 on Psychotherapy Participation Among Individuals With Posttraumatic Stress Disorder Enrolled in Treatment Research. J Trauma Stress 2022; 35:308-313. [PMID: 34291832 PMCID: PMC8426668 DOI: 10.1002/jts.22718] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 12/25/2022]
Abstract
The onset of the COVID-19 pandemic disrupted many aspects of daily life and required a rapid and unprecedented shift in psychotherapy delivery from in-person to telemental health. In the present study, we explored the impact of the pandemic on individuals' ability to participate in posttraumatic stress disorder (PTSD) psychotherapy and the association between the impact of COVID-19 impact on health and financial well-being and psychotherapy participation. Participants (N = 161, 63.2% male, Mage = 42.7 years) were United States military veterans (n = 108), active duty military personnel (n = 12), and civilians (n = 6), who were participating in one of nine PTSD treatment trials. The results indicate a predominately negative COVID-19 impact on therapy participation, although some participants (26.1%) found attending therapy sessions through telehealth to be easier than in-person therapy. Most participants (66.7%) reported that completing in vivo exposure homework became harder during the pandemic. Moreover, the impact of the pandemic on PTSD symptom severity and daily stress were each associated with increased difficulty with aspects of therapy participation. The findings highlight the unique challenges to engaging in PTSD treatment during the pandemic as well as a negative impact on daily stress and PTSD severity, both of which were related to treatment engagement difficulties.
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Affiliation(s)
- Carmen P. McLean
- Dissemination and Training Division, National Center for PTSDVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA,Department of Psychiatry and Behavioral Sciences, School of MedicineStanford UniversityStanfordCaliforniaUSA
| | - Sudie E. Back
- Department of Psychiatry and Behavioral SciencesMedical University of South CarolinaCharlestonSouth CarolinaUSA,Ralph H. Johnson Veterans Affairs Medical CenterCharlestonSouth Carolina
| | - Christy Capone
- Providence VA Medical CenterProvidenceRhode IslandUSA,Department of Psychiatry and Human BehaviorCenter for Alcohol and Addiction StudiesBrown UniversityProvidenceRhode IslandUSA
| | - Leslie Morland
- VA San Diego Healthcare SystemSan DiegoCaliforniaUSA,National Center for PTSD Pacific Islands DivisionHonoluluHawaiiUSA,Department of PsychiatryUniversity of California San Diego School of MedicineSan DiegoCaliforniaUSA
| | - Sonya B. Norman
- VA San Diego Healthcare SystemSan DiegoCaliforniaUSA,Department of PsychiatryUniversity of California San Diego School of MedicineSan DiegoCaliforniaUSA,Executive DivisionNational Center for PTSDWhite River JunctionVermontUSA
| | - Sheila A. M. Rauch
- Health Service LineAtlanta VA Medical CenterAtlantaGeorgiaUSA,Department of Psychiatry and Behavioral SciencesEmory University School of MedicineAtlantaGeorgiaUSA
| | - Paula P. Schnurr
- Executive DivisionNational Center for PTSDWhite River JunctionVermontUSA,Geisel School of Medicine at DartmouthHanoverNew HampshireUSA
| | - Ellen Teng
- Department of Psychiatry and Behavioral SciencesBaylor College of MedicineHoustonTexasUSA,Michael E. DeBakey VA Medical CenterHoustonTexasUSA
| | - Ron Acierno
- Louis Faillace Department of PsychiatryMcGovern Medical School at UTHealth HoustonHoustonTexas
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Kaniuka AR, Cramer RJ, Wilsey CN, Langhinrichsen-Rohling J, Mennicke A, Patton A, Zarwell M, McLean CP, Harris YJ, Sullivan S, Gray G. COVID-19 Exposure, Stress, and Mental Health Outcomes: Results From a Needs Assessment Among Low Income Adults in Central North Carolina. Front Psychiatry 2022; 12:790468. [PMID: 35126202 PMCID: PMC8812254 DOI: 10.3389/fpsyt.2021.790468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/25/2021] [Indexed: 01/11/2023] Open
Abstract
This study focuses on identifying COVID-19 related exposure, stress, and mental health concerns in the larger Charlotte, North Carolina region, an area with many low-income and under resourced communities. A community-academic partnership conducted a regional COVID-19 needs assessment. Low-income adults (N = 156) completed an online-administered survey of demographic information, COVID-19 exposure, stress, coping-related factors, and mental health. Frequency data showed that common COVID-19 related stressors included job exposure, lost job/income, and increased home responsibilities. Frequency data further showed elevated screening risk rates for mental health concerns were observed for post-traumatic stress (83.3%), depression (52.2%), problematic drinking (50.0%), generalized anxiety (43.0%), and suicide (40.4%). Bivariate correlation and multivariate regression models identified robust mental health risk factors including COVID-19 related stress affecting close persons, fear/worry reaction to the pandemic, and use of venting as a coping strategy; protective factors included active coping and problem-focused coping beliefs. Findings are discussed with respect to informing regional public health efforts during the pandemic.
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Affiliation(s)
- Andréa R. Kaniuka
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, United States
| | - Robert J. Cramer
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, United States
| | - Corrine N. Wilsey
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, United States
| | | | - Annelise Mennicke
- School of Social Work, University of North Carolina at Charlotte, Charlotte, NC, United States
| | - Alexandra Patton
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, United States
| | - Meagan Zarwell
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, United States
| | - Carmen P. McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, Menlo Park, CA, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States
| | | | | | - Glori Gray
- Psychology for All, Charlotte, NC, United States
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16
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McLean CP, Levy HC, Miller ML, Tolin DF. Exposure therapy for PTSD: A meta-analysis. Clin Psychol Rev 2021; 91:102115. [PMID: 34954460 DOI: 10.1016/j.cpr.2021.102115] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/26/2021] [Accepted: 12/16/2021] [Indexed: 11/03/2022]
Abstract
Posttraumatic stress disorder (PTSD) is associated with high morbidity and functional impairment in the absence of effective treatment. Exposure therapy for PTSD is a trauma-focused treatment that typically includes in vivo and/or imaginal exposure. The goal of this meta-analysis was to examine the overall efficacy of exposure therapy for PTSD compared to various control conditions. We also assessed the efficacy of individual exposure-based treatments and the potentially moderating impact of various demographic, clinical, and treatment-related factors. PsycINFO and Medline were searched for randomized controlled trials of exposure-based therapies for adult PTSD. A total of 934 abstracts were screened for initial eligibility; of these, 65 articles met inclusion criteria and were included in the meta-analysis (total N = 4929 patients). Exposure therapy showed large effects relative to waitlist and treatment-as-usual, a small effect relative to non-trauma-focused comparators and a negligible effect relative to other trauma-focused treatments or medication. At follow-up most effects sizes were stable, except for a medium effect favoring exposure over medication. The individual exposure-based therapies examined were similarly effective. Moderator analyses revealed larger effect sizes in studies with fewer sessions, younger samples, fewer participants diagnosed with substance use disorder, and fewer participants on psychiatric medication. Effect sizes were also larger in studies of refugees and civilians compared to military samples, studies of PTSD related to natural disasters and transportation accidents vs. other traumatic events, and studies of individual vs. group therapy. Findings support the overall efficacy of exposure therapy and highlight that there are a number of efficacious exposure-based therapies available.
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Affiliation(s)
- Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Stanford, CA 94305-5717, USA.
| | - Hannah C Levy
- Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA
| | - Madeleine L Miller
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA
| | - David F Tolin
- Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA; Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
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17
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Peterson AL, Young-McCaughan S, Roache JD, Mintz J, Litz BT, Williamson DE, Resick PA, Foa EB, McGeary DD, Dondanville KA, Taylor DJ, Wachen JS, Fox PT, Bryan CJ, McLean CP, Pruiksma KE, Yarvis JS, Niles BL, Abdallah CG, Averill LA, Back SE, Baker MT, Blount TH, Borah AM, Borah EV, Brock MS, Brown LA, Burg MM, Cigrang JA, DeBeer BB, DeVoe ER, Fina BA, Flanagan JC, Fredman SJ, Gardner CL, Gatchel RR, Goodie JL, Gueorguieva R, Higgs JB, Jacoby VM, Kelly KM, Krystal JH, Lapiz-Bluhm MD, López-Roca AL, Marx BP, Maurer DM, McDevitt-Murphy ME, McGeary CA, Meyer EC, Miles SR, Monson CM, Morilak DA, Moring JC, Mysliwiec V, Nicholson KL, Rauch SAM, Riggs DS, Rosen CS, Rudd MD, Schobitz RP, Schrader CC, Shinn AM, Shiroma PR, Sloan DM, Stern SL, Strong R, Vannoy SD, Young KA, Keane TM. STRONG STAR and the Consortium to Alleviate PTSD: Shaping the future of combat PTSD and related conditions in military and veteran populations. Contemp Clin Trials 2021; 110:106583. [PMID: 34600107 DOI: 10.1016/j.cct.2021.106583] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 10/20/2022]
Abstract
The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators.
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Affiliation(s)
- Alan L Peterson
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; South Texas Veterans Health Care System, San Antonio, TX, USA; University of Texas at San Antonio, San Antonio, TX, USA.
| | - Stacey Young-McCaughan
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - John D Roache
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - Jim Mintz
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - Brett T Litz
- VA Boston Healthcare System, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA; Boston University, Boston, MA, USA.
| | - Douglas E Williamson
- Duke University, Durham, NC, USA; Durham VA Health Care System, Durham, NC, USA.
| | | | - Edna B Foa
- University of Pennsylvania, Philadelphia, PA, USA.
| | - Donald D McGeary
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; South Texas Veterans Health Care System, San Antonio, TX, USA; University of Texas at San Antonio, San Antonio, TX, USA.
| | | | | | - Jennifer Schuster Wachen
- VA Boston Healthcare System, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA; National Center for PTSD, Women's Health Sciences Division, Boston, MA, USA.
| | - Peter T Fox
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - Craig J Bryan
- Ohio State University College of Medicine, Columbus, OH, USA.
| | - Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, Menlo Park, CA, USA; Stanford University, Stanford, CA, USA.
| | - Kristi E Pruiksma
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; South Texas Veterans Health Care System, San Antonio, TX, USA.
| | | | - Barbara L Niles
- VA Boston Healthcare System, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA; National Center for PTSD, Behavioral Science Division, Boston, MA, USA.
| | - Chadi G Abdallah
- National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA.
| | - Lynnette A Averill
- National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA.
| | - Sudie E Back
- Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
| | - Monty T Baker
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; 59th Medical Wing, Joint Base San Antonio-Lackland, San Antonio, TX, USA
| | - Tabatha H Blount
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Adam M Borah
- Carl R Darnall Army Medical Center, Fort Hood, TX, USA.
| | - Elisa V Borah
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Matthew S Brock
- 59th Medical Wing, Joint Base San Antonio-Lackland, San Antonio, TX, USA.
| | - Lily A Brown
- University of Pennsylvania, Philadelphia, PA, USA.
| | | | | | - Bryann B DeBeer
- VA VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA; Central Texas Veterans Health Care System, Temple, TX, USA.
| | | | - Brooke A Fina
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Julianne C Flanagan
- Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
| | | | - Cubby L Gardner
- 59th Medical Wing, Joint Base San Antonio-Lackland, San Antonio, TX, USA.
| | | | - Jeffrey L Goodie
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | | | - Jay B Higgs
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX, USA
| | - Vanessa M Jacoby
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Kevin M Kelly
- Carl R Darnall Army Medical Center, Fort Hood, TX, USA.
| | - John H Krystal
- National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA.
| | - M Danet Lapiz-Bluhm
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | | | - Brian P Marx
- VA Boston Healthcare System, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA; National Center for PTSD, Behavioral Science Division, Boston, MA, USA.
| | | | | | - Cindy A McGeary
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - Eric C Meyer
- VA VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA; Central Texas Veterans Health Care System, Temple, TX, USA.
| | - Shannon R Miles
- James A. Haley Veterans' Affairs Hospital, Tampa, FL, USA; University of South Florida, Tampa, FL, USA.
| | | | - David A Morilak
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - John C Moring
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Vincent Mysliwiec
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | | | - Sheila A M Rauch
- Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Healthcare System, Atlanta, GA, USA.
| | - David S Riggs
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Craig S Rosen
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, Menlo Park, CA, USA; Stanford University, Stanford, CA, USA.
| | | | - Richard P Schobitz
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX, USA.
| | | | - Antoinette M Shinn
- 59th Medical Wing, Joint Base San Antonio-Lackland, San Antonio, TX, USA.
| | - Paulo R Shiroma
- Minneapolis VA Health Care System, Minneapolis, MN, USA; University of Minnesota, Minneapolis, MN, USA.
| | - Denise M Sloan
- VA Boston Healthcare System, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA; National Center for PTSD, Behavioral Science Division, Boston, MA, USA.
| | - Stephen L Stern
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - Randy Strong
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; South Texas Veterans Health Care System, San Antonio, TX, USA.
| | | | - Keith A Young
- VA VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA; Central Texas Veterans Health Care System, Temple, TX, USA; Texas A&M University College of Medicine, Bryan, TX, USA.
| | - Terence M Keane
- VA Boston Healthcare System, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA; National Center for PTSD, Behavioral Science Division, Boston, MA, USA.
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18
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Abstract
The corona virus (COVID-19) continues to have a devastating health, economic, and social impact on our local and international communities. Cognitive and Behavioral Therapies (CBTs), as a family of therapies that posit cognitive, behavioral, emotional, and interpersonal change processes in the understanding and successful treatment of mental health disorders, have risen to the challenge. This special issue represents contributions from CBT experts on the impact on psychopathology, new assessment methods, adaptations of integrated behavioral health, telehealth, psychology training, and discusses a public health framework. The issue includes a series of articles offering guidance for the clinician on interventions for those impacted by trauma, CBT for youth and families, and telehealth for psychotic spectrum disorders and group therapy for social anxiety.
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Affiliation(s)
- Nikolaos Kazantzis
- Cognitive Behavior Therapy Research Unit, Melbourne, Australia, and Beck Institute for Cognitive Behavior Therapy and Research USA
| | | | - Carmen P McLean
- VA National Center for Post Traumatic Stress Disorder, Dissemination and Training Division, USA
| | - Susan E Sprich
- Massachusetts General Hospital and Harvard Medical School
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19
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Sookman D, Phillips KA, Anholt GE, Bhar S, Bream V, Challacombe FL, Coughtrey A, Craske MG, Foa E, Gagné JP, Huppert JD, Jacobi D, Lovell K, McLean CP, Neziroglu F, Pedley R, Perrin S, Pinto A, Pollard CA, Radomsky AS, Riemann BC, Shafran R, Simos G, Söchting I, Summerfeldt LJ, Szymanski J, Treanor M, Van Noppen B, van Oppen P, Whittal M, Williams MT, Williams T, Yadin E, Veale D. Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder. Psychiatry Res 2021; 303:113752. [PMID: 34273818 DOI: 10.1016/j.psychres.2021.113752] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 01/21/2021] [Indexed: 12/19/2022]
Abstract
Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.
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Affiliation(s)
- Debbie Sookman
- Department of Psychology, McGill University Health Center, 1025 Pine Ave W, Montreal, Quebec, H3A 1A1, Canada; Department of Psychiatry, McGill University, 845 Sherbrooke St W, Montreal, Quebec, H3A 0G4, Canada.
| | - Katharine A Phillips
- Department of Psychiatry, Weill Cornell Medicine, 1300 York Ave, New York, NY 10065, United States.
| | - Gideon E Anholt
- Department of Psychology, Marcus Family Campus, Ben-Gurion University of the Negev, Beer Sheva, P.O.B. 653 Beer-Sheva, 8410501, Israel.
| | - Sunil Bhar
- Department of Psychological Sciences, Faculty of Health, Arts and Design, Swinburne University of Technology, 1 John St, Hawthorn, Victoria, 3122, Australia.
| | - Victoria Bream
- Oxford Health Specialist Psychological Interventions Clinic and Oxford Cognitive Therapy Centre, Warneford Hospital, Oxford, OX3 7JX, United Kingdom.
| | - Fiona L Challacombe
- Institute of Psychiatry, Psychology and Neuroscience, Kings College London, De Crespigny Park, London, SE5 8AF, United Kingdom.
| | - Anna Coughtrey
- Great Ormond Street Hospital for Children, London WC1N 3JH, United Kingdom; UCL Great Ormond Street Institute of Child Health, 30 Guilford St, Holborn, London, WC1N 1EH, United Kingdom.
| | - Michelle G Craske
- Anxiety and Depression Research Center, Depression Grant Challenge, Innovative Treatment Network, Staglin Family Music Center for Behavioral and Brain Health, UCLA Department of Psychology and Department of Psychiatry and Biobehavioral Sciences, Box 951563, 1285 Franz Hall, Los Angeles, CA, United States.
| | - Edna Foa
- Center for the Treatment and Study of Anxiety, University of Pennsylvania Perelman SOM, 3535 Market Street, Philadelphia, PA 19104, United States.
| | - Jean-Philippe Gagné
- Department of Psychology, Concordia University, 7141 Sherbrooke St, West, Montreal, Quebec H4B 1R6, Canada.
| | - Jonathan D Huppert
- Department of Psychology, The Hebrew University of Jerusalem, Mt. Scopus, Jerusalem, 91905, Israel.
| | - David Jacobi
- Rogers Behavioral Health, 34700 Valley Road, Oconomowoc, WI, 53066, United States.
| | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom; Manchester Academic Health Science Centre, Greater Manchester Mental Health NHS Foundation Trust, Manchester, M13 9PL, United Kingdom.
| | - Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 795 Willow Road, Menlo Park, CA, 94025, United States; Department of Psychiatry and Behavioral Sciences, Stanford University, 450 Serra Mall, Stanford, CA, 94305, United States.
| | - Fugen Neziroglu
- Bio-Behavioral Institute, 935 Northern Boulevard, Suite 102, Great Neck, NY, 11021, United States.
| | - Rebecca Pedley
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, United Kingdom.
| | - Sean Perrin
- Department of Psychology, Lund University, Box 213, 22100, Lund, Sweden.
| | - Anthony Pinto
- Zucker School of Medicine at Hofstra/Northwell, Zucker Hillside Hospital - Northwell Health, 265-16 74th Avenue, Glen Oaks, NY, 11004, United States.
| | - C Alec Pollard
- Center for OCD and Anxiety-Related Disorders, Saint Louis Behavioral Medicine Institute, 1129 Macklind Ave, St. Louis, MO, 63110, United States; Department of Family and Community Medicine, Saint Louis University School of Medicine, Saint Louis, MO, 63110, United States.
| | - Adam S Radomsky
- Department of Psychology, Concordia University, 7141 Sherbrooke St, West, Montreal, Quebec H4B 1R6, Canada.
| | - Bradley C Riemann
- 34700 Valley Road, Rogers Behavioral Health, Oconomowoc, WI, 53066, United States.
| | - Roz Shafran
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Hospital Institute of Child Health, Holborn, London, WC1N 1EH, United Kingdom.
| | - Gregoris Simos
- Department of Educational and Social Policy, University of Macedonia, 156 Egnatia Street, 54636 Thessaloniki, Greece.
| | - Ingrid Söchting
- Departments of Psychology, University of British Columbia, 2136 West Mall, Vancouver, British Columbia, V6T 1Z4, Canada.
| | - Laura J Summerfeldt
- Department of Psychology, Trent University, 1600 West Bank Drive, Peterborough, K9L 0G2 Ontario, Canada.
| | - Jeff Szymanski
- International OCD Foundation, 18 Tremont Street, #308, Boston MA, 02108, United States.
| | - Michael Treanor
- Anxiety and Depression Research Center, University of California, Los Angeles, Box 951563, 1285 Franz Hall, Los Angeles, CA, United States.
| | - Barbara Van Noppen
- Clinical Psychiatry and Behavioral Sciences, OCD Southern California, 2514 Jamacha Road Ste, 502-35 El Cajon, CA, 92019, United States; Department of Psychiatry and Behavioral Sciences, Keck School of Medicine, University of Southern California, 2250 Alcazar Street, Suite 2200, Los Angeles, CA, 90033, United States.
| | - Patricia van Oppen
- Department of Psychiatry, Amsterdam UMC, location VUmc, Netherlands; Amsterdam Public Health Research Institute - Mental Health, Netherlands; GGZ inGeest Specialized Mental Health Care, Netherlands.
| | - Maureen Whittal
- Vancouver CBT Centre, 302-1765 W8th Avenue, Vancouver, British Columbia, V6J5C6, Canada; Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Monnica T Williams
- School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier Pvt, Ottawa, K1N 6N5, Ontario, Canada.
| | - Timothy Williams
- Department of Psychology, University of Reading, PO Box 217, Reading, Berkshire, RG6 6AH, United Kingdom.
| | - Elna Yadin
- Department of Psychiatry, University of Pennsylvania, 3535 Market Street, 2nd Floor, Philadelphia, PA 19104, United States.
| | - David Veale
- South London and the Maudsley NHS Foundation Trust & King's College London, Denmark Hill, London, SE5 8 AZ, United Kingdom.
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20
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Straud CL, Blount TH, Foa EB, Brown LA, McLean CP, McGeary CA, Koch LM, Schobitz RP, Peterson AL. Intensive Outpatient Program Using Prolonged Exposure for Combat-Related PTSD: A Case Study. Cognitive and Behavioral Practice 2021. [DOI: 10.1016/j.cbpra.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Boden M, Zimmerman L, Azevedo KJ, Ruzek JI, Gala S, Abdel Magid HS, Cohen N, Walser R, Mahtani ND, Hoggatt KJ, McLean CP. Addressing the mental health impact of COVID-19 through population health. Clin Psychol Rev 2021; 85:102006. [PMID: 33714167 PMCID: PMC7934657 DOI: 10.1016/j.cpr.2021.102006] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 12/17/2022]
Abstract
The COVID-19 pandemic has and will continue to result in negative mental health outcomes such as depression, anxiety and traumatic stress in people and populations throughout the world. A population mental health perspective informed by clinical psychology, psychiatry and dissemination and implementation science is ideally suited to address the broad, multi-faceted and long-lasting mental health impact of the pandemic. Informed by a systematic review of the burgeoning empirical research on the COVID-19 pandemic and research on prior coronavirus pandemics, we link pandemic risk factors, negative mental health outcomes and appropriate intervention strategies. We describe how social risk factors and pandemic stressors will contribute to negative mental health outcomes, especially among vulnerable populations. We evaluate the scalability of primary, secondary and tertiary interventions according to mental health target, population, modality, intensity and provider type to provide a unified strategy for meeting population mental health needs. Traditional models, in which evidence-based therapies delivered are delivered in-person, by a trained expert, at a specialty care location have proved difficult to scale. The use of non-traditional models, tailoring preventive interventions to populations based on their needs, and ongoing coordinated evaluation of intervention implementation and effectiveness will be critical to refining our efforts to increase reach.
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Affiliation(s)
- Matt Boden
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, United States of America.
| | - Lindsey Zimmerman
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Care Healthcare System, United States of America; Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States of America; Department of Psychiatry and Behavioral Science, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Kathryn J Azevedo
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Care Healthcare System, United States of America
| | - Josef I Ruzek
- Center for m2 Health, Palo Alto University, Palo Alto, CA, United States of America; Department of Psychology, University of Colorado, Colorado Springs, United States of America
| | - Sasha Gala
- Mission Rock Enterprise, LLC, United States of America
| | - Hoda S Abdel Magid
- Department of Epidemiology and Population Health, Stanford University, United States of America
| | - Nichole Cohen
- Department of Psychology, University of Kansas, United States of America
| | - Robyn Walser
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Care Healthcare System, United States of America; University of California, Berkeley, United States of America
| | - Naina D Mahtani
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, United States of America; School of Behavioral Health, Loma Linda University, United States of America
| | - Katherine J Hoggatt
- San Francisco VA Health Care System, United States of America; Department of Medicine, University of California, San Francisco, United States of America
| | - Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Care Healthcare System, United States of America; Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States of America
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22
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Brown LA, Bryan CJ, Butner JE, Tabares JV, Young-McCaughan S, Hale WJ, Fina BA, Foa EB, Resick PA, Taylor DJ, Coon H, Williamson DE, Dondanville KA, Borah EV, McLean CP, Wachen JS, Pruiksma KE, Hernandez AM, Litz BT, Mintz J, Yarvis JS, Borah AM, Nicholson KL, Maurer DM, Kelly KM, Peterson AL. Identifying suicidal subtypes and dynamic indicators of increasing and decreasing suicide risk in active duty military personnel: Study protocol. Contemp Clin Trials Commun 2021; 21:100752. [PMID: 33748530 PMCID: PMC7973131 DOI: 10.1016/j.conctc.2021.100752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 10/16/2020] [Accepted: 02/09/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives Several recent studies have demonstrated that posttraumatic stress disorder (PTSD) and insomnia treatments are associated with significant reductions in suicidal ideation (SI) among service members. However, few investigations have evaluated the manner in which suicide risk changes over time among military personnel receiving PTSD or insomnia treatments. This paper describes the study protocol for a project with these aims: (1) explore potential genetic, clinical, and demographic subtypes of suicide risk in a large cohort of deployed service members; (2) explore subtype change in SI as a result of evidence-based psychotherapies for PTSD and insomnia; (3) evaluate the speed of change in suicide risk; and (4) identify predictors of higher- and lower-risk for suicide. Methods Active duty military personnel were recruited for four clinical trials (three for PTSD treatment and one for insomnia treatment) and a large prospective epidemiological study of deployed service members, all conducted through the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR Consortium). Participants completed similar measures of demographic and clinical characteristics and subsets provided blood samples for genetic testing. The primary measures that we will analyze are the Beck Scale for Suicide Ideation, Beck Depression Inventory, and the PTSD Checklist for DSM-IV. Discussion Results from this study will offer new insights into the presence of discrete subtypes of suicide risk among active duty personnel, changes in risk over time among those subtypes, and predictors of subtypes. Findings will inform treatment development for military service members at risk for suicide.
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Affiliation(s)
- Lily A Brown
- Center for the Treatment and Study of Anxiety, University of Pennsylvania, 3535 Market Street, 6th Floor, Philadelphia, PA, 19104, USA
| | - Craig J Bryan
- National Center for Veterans Studies, 260 S. Central Campus Dr., Suite 3525, Gardner Commons, Salt Lake City, UT, 84112, USA.,Department of Psychology, The University of Utah, 380 S 1530 E BEH S 502, Salt Lake City, UT, 84112, USA
| | - Jonathan E Butner
- Department of Psychology, The University of Utah, 380 S 1530 E BEH S 502, Salt Lake City, UT, 84112, USA
| | - Jeffrey V Tabares
- National Center for Veterans Studies, 260 S. Central Campus Dr., Suite 3525, Gardner Commons, Salt Lake City, UT, 84112, USA.,Department of Psychology, The University of Utah, 380 S 1530 E BEH S 502, Salt Lake City, UT, 84112, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7792, San Antonio, TX, 78229, USA
| | - Willie J Hale
- Department of Psychology, The University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, 78249-1644, USA.,Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7792, San Antonio, TX, 78229, USA
| | - Brooke A Fina
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7792, San Antonio, TX, 78229, USA
| | - Edna B Foa
- Center for the Treatment and Study of Anxiety, University of Pennsylvania, 3535 Market Street, 6th Floor, Philadelphia, PA, 19104, USA
| | - Patricia A Resick
- Department of Psychiatry & Behavioral Sciences, Duke University, 1121 West Chapel Hill Road, Suite 201, Durham, NC, 27701, USA
| | - Daniel J Taylor
- Department of Psychology, University of Arizona, 1503 E University Blvd., Tucson, AZ, 85721, USA
| | - Hillary Coon
- Department of Psychiatry, University of Utah School of Medicine, 30 N. 1900 E, Salt Lake City, UT, 84132, USA
| | - Douglas E Williamson
- Department of Psychiatry & Behavioral Sciences, Duke University, 1121 West Chapel Hill Road, Suite 201, Durham, NC, 27701, USA.,Durham VA Health Care System, Medical Center, 508 Fulton Street, Durham, NC, 27705, USA
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7792, San Antonio, TX, 78229, USA
| | - Elisa V Borah
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7792, San Antonio, TX, 78229, USA.,Steve Hicks School of Social Work, The University of Texas at Austin, 1717 W. 6th Street, Suite 335 Austin, TX, 78703, USA
| | - Carmen P McLean
- National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Rd., Palo Alto, CA, 94305, USA
| | - Jennifer Schuster Wachen
- National Center for PTSD, VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA, 02130, USA.,Boston University School of Medicine, Department of Psychiatry, 720 Harrison Avenue, Boston, MA, 02118, USA
| | - Kristi E Pruiksma
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7792, San Antonio, TX, 78229, USA
| | - Ann Marie Hernandez
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7792, San Antonio, TX, 78229, USA.,Valiant Mental Health PLLC, 219 E. Locust Street, San Antonio, TX, 78212, USA
| | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA, 02130, USA.,Boston University School of Medicine, Department of Psychiatry, 720 Harrison Avenue, Boston, MA, 02118, USA.,Department of Psychological & Brain Sciences, Boston University, 64 Cummington Mall, Boston, MA, 02215, USA
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7792, San Antonio, TX, 78229, USA
| | - Jeffrey S Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, 36065 Santa Fe Avenue Fort Hood, TX, 76544-4752, USA
| | - Adam M Borah
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, 36065 Santa Fe Avenue Fort Hood, TX, 76544-4752, USA.,Department of Behavioral Medicine and Health Services, Central Texas Veterans Health Care System, 1901 Veterans Memorial Dr, Temple, TX, 76504, USA
| | - Karin L Nicholson
- Department of Medicine, Carl R. Darnall Army Medical Center, 36065 Santa Fe Avenue Fort Hood, Texas, 76544-4752, USA
| | - Douglas M Maurer
- Department of Family Medicine, Carl R. Darnall Army Medical Center, 36065 Santa Fe Avenue Fort Hood, TX, 76544-4752, USA.,Army Medical Education Directorate, Office of the Surgeon General, Defense Health Headquarters, 7700 Arlington Blvd., Falls Church, VA, 22042, USA
| | - Kevin M Kelly
- Department of Family Medicine, Carl R. Darnall Army Medical Center, 36065 Santa Fe Avenue Fort Hood, TX, 76544-4752, USA.,Office of the Army Surgeon General, Falls Church, VA, USA
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7792, San Antonio, TX, 78229, USA.,Research and Development Service, South Texas Veterans Health Care System, 7400 Merton Minter, San Antonio, TX, 78229, USA.,Department of Psychology, The University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, 78249-1644, USA
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23
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McLean CP, Foa EB, Dondanville KA, Haddock CK, Miller ML, Rauch SAM, Yarvis JS, Wright EC, Hall-Clark BN, Fina BA, Litz BT, Mintz J, Young-McCaughan S, Peterson AL. The effects of web-prolonged exposure among military personnel and veterans with posttraumatic stress disorder. Psychol Trauma 2020; 13:621-631. [PMID: 33211517 DOI: 10.1037/tra0000978] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Web-based treatments address many of the logistical and stigma-related barriers to in-person behavioral health care. Prior studies of web-based treatments for posttraumatic stress disorder (PTSD) did not employ gold-standard treatments and have not compared to in-person therapy. METHOD We compared a web version of Prolonged Exposure Therapy, "Web-PE," to in-person Present-Centered Therapy (PCT) in a randomized controlled trial (RCT) with 40 military personnel with PTSD seeking treatment at Fort Hood, Texas. Due to recruitment challenges, we terminated the RCT and subsequently examined the effects of Web-PE in an uncontrolled open trial with 34 service members and veterans recruited nationwide. Both studies assessed PTSD, depressive symptoms, and health functioning at baseline and 1 and 3 months posttreatment; the RCT also included a 6-month assessment. RESULTS Results of the RCT showed no differential impact for Web-PE and PCT, although more PCT participants achieved clinically significant change at one of the follow-up assessments. Both treatment conditions significantly reduced self-reported and blind independent interviewer-assessed symptoms of PTSD. Results of the open trial showed that Web-PE was associated with significant reductions in self-reported PTSD symptoms, with a much larger effect size than in the RCT. CONCLUSIONS Web-PE significantly reduced PTSD symptoms in both studies, although the reductions in PTSD symptoms were greater among open trial participants, who were specifically seeking a web-based treatment. Future research should evaluate Web-PE relative to another web-based treatment. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences
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24
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Rauch SAM, Sripada R, Burton M, Michopoulos V, Kerley K, Marx CE, Kilts JD, Naylor JC, Rothbaum BO, McLean CP, Smith A, Norrholm SD, Jovanovic T, Liberzon I, Williamson DE, Yarvis CJS, Dondanville KA, Young-McCaughan S, Keane TM, Peterson AL. Neuroendocrine biomarkers of prolonged exposure treatment response in military-related PTSD. Psychoneuroendocrinology 2020; 119:104749. [PMID: 32554173 DOI: 10.1016/j.psyneuen.2020.104749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 04/16/2020] [Accepted: 05/29/2020] [Indexed: 11/16/2022]
Abstract
Posttraumatic stress disorder (PTSD) is associated with dysregulation of the neuroendocrine system, including cortisol, allopregnanolone, and pregnanolone. Preliminary evidence from animal models suggests that baseline levels of these biomarkers may predict response to PTSD treatment. We report the change in biomarkers over the course of PTSD treatment. Biomarkers were sampled from individuals participating in (1) a randomized controlled trial comparing a web-version of Prolonged Exposure (Web-PE) therapy to in-person Present-Centered Therapy (PCT) and (2) from individuals participating in a nonrandomized effectiveness study testing PE delivered in-person as part of an intensive outpatient PTSD program. We found that higher cortisol reactivity during script-driven imagery was associated with higher baseline PTSD severity and that baseline allopregnanolone, pregnanolone, and cortisol reactivity were associated with PTSD treatment responder status over the course of intensive outpatient treatment. These findings demonstrate that peripherally assessed biomarkers are associated with PTSD severity and likelihood of successful treatment outcome of PE delivered daily over two weeks. These assessments could be used to determine which patients are likely to respond to treatment and which patients require augmentation to increase the likelihood of optimal response to PTSD treatment.
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Affiliation(s)
- Sheila A M Rauch
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033, USA; Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, 12 Executive Park, 3rd Floor, Atlanta, GA, 30029, USA.
| | - Rebecca Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA; University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA.
| | - Mark Burton
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, 12 Executive Park, 3rd Floor, Atlanta, GA, 30029, USA.
| | - Vasiliki Michopoulos
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, 12 Executive Park, 3rd Floor, Atlanta, GA, 30029, USA.
| | - Kimberly Kerley
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, 12 Executive Park, 3rd Floor, Atlanta, GA, 30029, USA.
| | - Christine E Marx
- Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, 40 Duke Medicine Circle, Durham, NC, 27710, USA; Durham Veterans Administration Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Durham, NC, 27705, USA.
| | - Jason D Kilts
- Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, 40 Duke Medicine Circle, Durham, NC, 27710, USA; Durham Veterans Administration Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Durham, NC, 27705, USA.
| | - Jennifer C Naylor
- Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, 40 Duke Medicine Circle, Durham, NC, 27710, USA; Durham Veterans Administration Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Durham, NC, 27705, USA.
| | - Barbara O Rothbaum
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, 12 Executive Park, 3rd Floor, Atlanta, GA, 30029, USA.
| | - Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Rd, Menlo Park, CA, 94025, USA; Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 291 Campus Dr., Stanford, CA, 94305, USA.
| | - Alicia Smith
- Emory University School of Medicine, Department of Obstetrics and Gynecology, 101 Woodruff Circle NE, Ste 4217, Atlanta, 30322, USA.
| | - Seth D Norrholm
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033, USA; Wayne State University, 3901 Chrysler Dr, Detroit, MI, 48201, USA.
| | - Tanja Jovanovic
- Wayne State University, 3901 Chrysler Dr, Detroit, MI, 48201, USA.
| | - Israel Liberzon
- Texas A&M University, 8447 Riverside Parkway, Bryan, TX, 77808-3260, USA.
| | - Douglas E Williamson
- Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, 40 Duke Medicine Circle, Durham, NC, 27710, USA; Durham Veterans Administration Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Durham, NC, 27705, USA.
| | - Col Jeffrey S Yarvis
- Carl R. Darnall Army Medical Center, Department of Behavioral Health, 36065 Santa Fe Ave., Fort Hood, TX, 76544, USA.
| | - Katherine A Dondanville
- University of Texas Health Science Center at San Antonio, Department of Psychiatry and Behavioral Sciences, 7703 Floyd Curl Dr., San Antonio, TX, 78229, USA.
| | - Stacey Young-McCaughan
- University of Texas Health Science Center at San Antonio, Department of Psychiatry and Behavioral Sciences, 7703 Floyd Curl Dr., San Antonio, TX, 78229, USA.
| | - Terence M Keane
- VA Boston Healthcare System, National Center for PTSD (116B-2), 150 South Huntington Avenue, Boston, MA, 02130, USA; Boston University School of Medicine, Department of Psychiatry, 720 Harrison Avenue, Room 906, Boston, MA, 02118, USA.
| | - Alan L Peterson
- University of Texas Health Science Center at San Antonio, Department of Psychiatry and Behavioral Sciences, 7703 Floyd Curl Dr., San Antonio, TX, 78229, USA; South Texas Veterans Health Care System, Research and Development Service, 7400 Merton Minter, San Antonio, TX, 78229, USA; University of Texas at San Antonio, Department of Psychology, One UTSA Circle, San Antonio, TX, 78249, USA.
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25
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Wells SY, Morland LA, Wilhite ER, Grubbs KM, Rauch SA, Acierno R, McLean CP. Delivering Prolonged Exposure Therapy via Videoconferencing During the COVID-19 Pandemic: An Overview of the Research and Special Considerations for Providers. J Trauma Stress 2020; 33:380-390. [PMID: 32881116 PMCID: PMC7461321 DOI: 10.1002/jts.22573] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 11/11/2022]
Abstract
Leveraging technology to provide evidence-based therapy for posttraumatic stress disorder (PTSD), such as prolonged exposure (PE), during the COVID-19 pandemic helps ensure continued access to first-line PTSD treatment. Clinical video teleconferencing (CVT) technology can be used to effectively deliver PE while reducing the risk of COVID-19 exposure during the pandemic for both providers and patients. However, provider knowledge, experience, and comfort level with delivering mental health care services, such as PE, via CVT is critical to ensure a smooth, safe, and effective transition to virtual care. Further, some of the limitations associated with the pandemic, including stay-at-home orders and physical distancing, require that providers become adept at applying principles of exposure therapy with more flexibility and creativity, such as when assigning in vivo exposures. The present paper provides the rationale and guidelines for implementing PE via CVT during COVID-19 and includes practical suggestions and clinical recommendations.
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Affiliation(s)
- Stephanie Y. Wells
- Durham VA Health Care SystemDurhamNorth CarolinaUSA,VISN‐6 Mid‐Atlantic MIRECCDurhamNorth CarolinaUSA,Department of PsychiatryDuke UniversityDurhamNorth CarolinaUSA
| | - Leslie A. Morland
- VA San Diego Healthcare SystemSan DiegoCaliforniaUSA,Department of PsychiatryUniversity of California San DiegoSan DiegoCaliforniaUSA,National Center for PTSDPacific Islands DivisionHonoluluHawaiiUSA
| | | | | | - Sheila A.M. Rauch
- VA Atlanta Healthcare SystemAtlantaGeorgiaUSA,Department of Psychiatry Emory University School of MedicineAtlantaGeorgiaUSA
| | - Ron Acierno
- Faillace Department of PsychiatryUniversity of Texas Health Sciences CenterHouston TexasUSA,Ralph H. Johnson VA Medical CenterCharlestonSouth CarolinaUSA
| | - Carmen P. McLean
- National Center for PTSDVA Palo Alto Health Care SystemPalo AltoCaliforniaUSA,Stanford UniversityPalo AltoCaliforniaUSA
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26
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Rosen CS, Davis CA, Riggs D, Cook J, Peterson AL, Young-McCaughan S, Comtois KA, Haddock CK, Borah EV, Dondanville KA, Finley EP, Jahnke SA, Poston WSC, Wiltsey-Stirman S, Neitzer A, Broussard CR, Brzuchalski MA, Clayton MSP, Conforte LAM, Flores A, Hein J, Keith CF, Jinkerson CJ, Letendre M, Nofziger D, Pollick K, Santiago CK, Waggoner LCJ, Woodworth C, McLean CP. Targeted Assessment and Context-Tailored Implementation of Change Strategies (TACTICS) to increase evidence based psychotherapy in military behavioral health clinics: Design of a cluster-randomized stepped-wedge implementation study. Contemp Clin Trials 2020; 93:106008. [PMID: 32330670 DOI: 10.1016/j.cct.2020.106008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/21/2020] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Despite efforts by the U.S. Department of Defense to train behavioral health (BH) providers in evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), numerous barriers limit EBP implementation. A context-tailored implementation approach called TACTICS (Targeted Assessment and Context-Tailored Implementation of Change Strategies) holds promise for increasing the use of EBPs such as prolonged exposure therapy (PE) in military treatment facilities. TACTICS combines a needs assessment, a rubric for selecting implementation strategies based on local barriers, an implementation toolkit, and external facilitation to support local champions and their implementation teams in enacting changes. This paper describes the rationale for and design of a study that will evaluate whether TACTICS can increase implementation of PE for PTSD and improve patient outcomes in military BH clinics relative to provider training in PE alone. METHODS The study is a multi-site, cluster randomized, stepped-wedge trial, with the military treatment facility as the unit of analysis. Eight facilities undergo a provider-training phase, followed by 5 months of TACTICS implementation. The timing of TACTICS at each facility is randomly assigned to begin 9, 14, or 19 months after beginning the provider-training phase. Primary analyses will compare the proportion of PTSD patients receiving PE and patients' mean improvement in PTSD symptoms before and after the onset of TACTICS. DISCUSSION TACTICS endeavors to balance standardization of empirically-supported implementation strategies with the flexibility of application necessary for success across varied clinical settings. If successful, TACTICS may represent a systematic and scalable method of promoting and supporting EBP implementation. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT03663452.
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Affiliation(s)
- Craig S Rosen
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 795 Willow Rd, Menlo Park, CA, United States of America; Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Rd, Palo Alto, CA 94305, United States of America.
| | - C Adrian Davis
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 795 Willow Rd, Menlo Park, CA, United States of America.
| | - David Riggs
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, United States of America.
| | - Jeffery Cook
- Center for Deployment Psychology, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, United States of America.
| | - Alan L Peterson
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, United States of America; Research and Development Service, South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, United States of America; Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249, United States of America.
| | - Stacey Young-McCaughan
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, United States of America.
| | - Katherine Anne Comtois
- Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, United States of America.
| | - Christopher K Haddock
- Social Sciences Innovations Corporation, 71 W 23rd St 4th Floor, New York, NY 10010, United States of America.
| | - Elisa V Borah
- University of Texas at Austin, Steve Hicks School of Social Work, 1925 San Jacinto Blvd, Austin, TX 78712, United States of America.
| | - Katherine A Dondanville
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, United States of America.
| | - Erin P Finley
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, United States of America; Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, United States of America; Veterans Evidence-based Research Dissemination and Implementation Center (VERDICT), South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, United States of America.
| | - Sara A Jahnke
- Social Sciences Innovations Corporation, 71 W 23rd St 4th Floor, New York, NY 10010, United States of America.
| | - Walker S C Poston
- Social Sciences Innovations Corporation, 71 W 23rd St 4th Floor, New York, NY 10010, United States of America.
| | - Shannon Wiltsey-Stirman
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 795 Willow Rd, Menlo Park, CA, United States of America; Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Rd, Palo Alto, CA 94305, United States of America.
| | - Andrea Neitzer
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 795 Willow Rd, Menlo Park, CA, United States of America.
| | - Capt Rachel Broussard
- David Grant United States Air Force Medical Center, Travis Air Force Base, 101 Bodin Cir, Fairfield, CA, 94533, United States of America.
| | - Maj Amy Brzuchalski
- William Beaumont Army Medical Center, Ft. Bliss, 5005 N Piedras St, El Paso, TX 79920, United States of America.
| | - Maj Spencer P Clayton
- 49th Medical Group, Holloman Air Force Base, 280 1st St, Alamogordo, NM 88330, United States of America.
| | - Lt Allison M Conforte
- Naval Hospital Jacksonville, Naval Air Station Jacksonville, 2080 Child St, Jacksonville, FL 32214, United States of America.
| | - Araceli Flores
- William Beaumont Army Medical Center, Ft. Bliss, 5005 N Piedras St, El Paso, TX 79920, United States of America.
| | - Jessica Hein
- Blanchfield Army Community Hospital, Ft. Campbell, 650 Joel Dr, Fort Campbell, KY 42223, United States of America.
| | - Capt Felicia Keith
- David Grant United States Air Force Medical Center, Travis Air Force Base, 101 Bodin Cir, Fairfield, CA, 94533, United States of America.
| | - Capt Jeremy Jinkerson
- 81st Medical Group, Keesler Air Force Base, 500 Fisher St, Biloxi, MS 39534, United States of America.
| | - Margaret Letendre
- Bassett Army Community Hospital, Ft. Wainwright, 4076 Neely Rd, Fairbanks, AK 99703, United States of America.
| | - Debra Nofziger
- Brooke Army Medical Center, Joint Base San Antonio-Ft. Sam Houston, 3551 Roger Brooke Dr, San Antonio, TX, 78234, United States of America.
| | - Kirsten Pollick
- Naval Hospital Jacksonville, Naval Air Station Jacksonville, 2080 Child St, Jacksonville, FL 32214, United States of America.
| | - Capt Kyra Santiago
- 49th Medical Group, Holloman Air Force Base, 280 1st St, Alamogordo, NM 88330, United States of America.
| | - Lt Col John Waggoner
- 81st Medical Group, Keesler Air Force Base, 500 Fisher St, Biloxi, MS 39534, United States of America.
| | - Craig Woodworth
- Brooke Army Medical Center, Joint Base San Antonio-Ft. Sam Houston, 3551 Roger Brooke Dr, San Antonio, TX, 78234, United States of America.
| | - Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, 795 Willow Rd, Menlo Park, CA, United States of America; Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Rd, Palo Alto, CA 94305, United States of America.
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27
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Taylor DJ, Pruiksma KE, Hale W, McLean CP, Zandberg LJ, Brown L, Mintz J, Young-McCaughan S, Peterson AL, Yarvis JS, Dondanville KA, Litz BT, Roache J, Foa EB. Sleep problems in active duty military personnel seeking treatment for posttraumatic stress disorder: presence, change, and impact on outcomes. Sleep 2020; 43:5815720. [DOI: 10.1093/sleep/zsaa065] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 03/21/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
Study Objectives
To examine sleep disorder symptom reports at baseline and posttreatment in a sample of active duty U.S. Army Soldiers receiving treatment for posttraumatic stress disorder (PTSD). Explore sleep-related predictors of outcomes.
Methods
Sleep was evaluated in 128 participants in a parent randomized clinical trial comparing Spaced formats of Prolonged Exposure (PE) or Present Centered Therapy and a Massed format of PE. In the current study, Spaced formats were combined and evaluated separately from Massed.
Results
At baseline, the average sleep duration was < 5 h per night on weekdays/workdays and < 6 h per night on weekends/off days. The majority of participants reported clinically significant insomnia, clinically significant nightmares, and probable sleep apnea and approximately half reported excessive daytime sleepiness at baseline. Insomnia and nightmares improved significantly from baseline to posttreatment in all groups, but many patients reported clinically significant insomnia (>70%) and nightmares (>38%) posttreatment. Excessive daytime sleepiness significantly improved only in the Massed group, but 40% continued to report clinically significant levels at posttreatment. Short sleep (Spaced only), clinically significant insomnia and nightmares, excessive daytime sleepiness, and probable sleep apnea (Massed only) at baseline predicted higher PTSD symptoms across treatment course. Short weekends/off days sleep predicted lower PTSD symptom improvement in the Spaced treatments.
Conclusions
Various sleep disorder symptoms were high at baseline, were largely unchanged with PTSD treatment, and were related to worse PTSD treatment outcomes. Studies are needed with objective sleep assessments and targeted sleep disorders treatments in PTSD patients.
Clinical Trial Registration
NCT01049516.
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Affiliation(s)
- Daniel J Taylor
- Department of Psychology, University of North Texas, Denton, TX
| | - Kristi E Pruiksma
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Willie Hale
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX
| | - Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo Park, CA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Laurie J Zandberg
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Lily Brown
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX
| | - Jeffrey S Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, TX
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Brett T Litz
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA
- Department of Psychological and Brain Sciences, Boston University, Boston, MA
| | - John Roache
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX
- Department of Pharmacology, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
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McLean CP, Miller ML, Gengler R, Henderson J, Sloan DM. The efficacy of written exposure therapy versus imaginal exposure delivered online for posttraumatic stress disorder: Design of a randomized controlled trial in Veterans. Contemp Clin Trials 2020; 91:105990. [PMID: 32184198 DOI: 10.1016/j.cct.2020.105990] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/28/2020] [Accepted: 03/11/2020] [Indexed: 11/17/2022]
Abstract
Adapting evidence-based treatments for online delivery has potential to significantly increase the reach of effective care to Veterans with posttraumatic stress disorder (PTSD). This paper describes the rationale for and methods of a randomized controlled trial comparing the efficacy and efficiency of written exposure therapy versus imaginal exposure for PTSD delivered in a novel online and variable length format. Participants will be 300 Veterans seeking treatment for clinically significant symptoms of PTSD. Participants will be randomly assigned to either written exposure or imaginal exposure via verbal recounting and will complete between 4 and 8 online therapy sessions facilitated by trained peer support specialists. Treatment is terminated before session 8 if the PTSD symptom improvement criterion is met. Assessments will be conducted at baseline, post-treatment, and at 3-month follow-up. The primary hypotheses are that written exposure therapy will be noninferior to imaginal exposure with respect to treatment efficacy and efficiency. Secondary hypotheses relate to identifying and comparing potential mediators of PTSD treatment outcome, including trauma-related cognitions and emotion regulation.
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Affiliation(s)
- Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA; Stanford University, Department of Psychiatry and Behavioral Sciences, School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA.
| | - Madeleine L Miller
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA
| | - Richard Gengler
- Prevail Health Solutions, LLC, 105 W Chicago Ave #203, Chicago, IL 60642, USA
| | - Jason Henderson
- Prevail Health Solutions, LLC, 105 W Chicago Ave #203, Chicago, IL 60642, USA
| | - Denise M Sloan
- National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130, USA; Boston University School of Medicine, 72 E Concord St, Boston, MA 02118, USA
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29
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McLean CP, Zang Y, Gallagher T, Suzuki N, Yarvis JS, Litz BT, Mintz J, Young-McCaughan S, Peterson AL, Foa EB. Trauma-Related Cognitions and Cognitive Emotion Regulation as Mediators of PTSD Change Among Treatment-Seeking Active-Duty Military Personnel With PTSD. Behav Ther 2019; 50:1053-1062. [PMID: 31735241 DOI: 10.1016/j.beth.2019.03.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 03/21/2019] [Accepted: 03/29/2019] [Indexed: 11/29/2022]
Abstract
Trauma-related cognitions about the self and the world have been identified as a mediator of posttraumatic stress disorder (PTSD) change during prolonged exposure (PE) therapy. However, the extent to which negative cognitions mediate PTSD change in other PTSD treatments is unclear. In addition, previous studies have not tested alternate mediators of PTSD change during PE. In a sample of 216 treatment-seeking active-duty military personnel with PTSD, the present study examined the specificity of the negative cognition mediation effect in both PE and present-centered therapy (PCT). In addition, we examined another possible mediator, cognitive emotion regulation. Lagged mediational analyses indicated that negative cognitions about the self and world and the unhelpful cognitive emotion regulation strategy of catastrophizing each significantly mediated change in PTSD from baseline to 6-month follow-up. In a combined model, the mediating effect of catastrophizing was greater than negative cognitions about the world, and similar to negative cognitions about the self. Moderated mediation analyses revealed that the effect of catastrophizing was greater in PE than in PCT. Findings show that trauma-related cognitions and, to a greater degree, the emotion regulation strategy catastrophizing, both mediate PTSD change. Further research is needed to determine whether these mediating variables represent mechanisms of therapeutic change.
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Affiliation(s)
- Carmen P McLean
- National Center for PTSD, VA Palo Alto Health Care System; Stanford University.
| | - Yinyin Zang
- University of Pennsylvania School of Medicine.
| | | | - Noah Suzuki
- University of Pennsylvania School of Medicine
| | | | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System; Boston University School of Medicine
| | - Jim Mintz
- University of Texas Health Science Center at San Antonio
| | | | - Alan L Peterson
- University of Texas Health Science Center at San Antonio; South Texas Veterans Health Care System; University of Texas at San Antonio
| | - Edna B Foa
- University of Pennsylvania School of Medicine
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30
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Litz BT, Berke DS, Kline NK, Grimm K, Rusowicz-Orazem L, Resick PA, Foa EB, Wachen JS, McLean CP, Dondanville KA, Borah AM, Roache JD, Young-McCaughan S, Yarvis JS, Mintz J, Peterson AL. Patterns and predictors of change in trauma-focused treatments for war-related posttraumatic stress disorder. J Consult Clin Psychol 2019; 87:1019-1029. [DOI: 10.1037/ccp0000426] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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31
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Zang Y, Su YJ, McLean CP, Foa EB. Predictors for Excellent Versus Partial Response to Prolonged Exposure Therapy: Who Needs Additional Sessions? J Trauma Stress 2019; 32:577-585. [PMID: 31265187 DOI: 10.1002/jts.22412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 01/20/2019] [Accepted: 01/30/2019] [Indexed: 11/09/2022]
Abstract
In practice, the duration of psychotherapy is determined by the patient's response to treatment. Identifying predictors for treatment responses is of great clinical utility to guide clinicians in their treatment planning. Demographic characteristics, trauma history, comorbidity, and early reduction of posttraumatic stress disorder (PTSD) symptoms were examined as predictors of excellent versus partial response to prolonged exposure therapy (PE) for PTSD. Participants were 96 female assault survivors with chronic PTSD who received at least eight PE sessions with or without cognitive restructuring. Participants were classified as excellent responders (n = 27) or partial responders (n = 69) based on whether they achieved at least 70% improvement in self-reported PTSD severity on the PTSD Symptom Scale-Self-Report at the end of Session 8. Excellent responders terminated therapy after Session 9, and partial responders were offered up to three additional sessions. Logistic regression was conducted to investigate predictors of response to PE. Results showed that prior interpersonal violence and comorbid alcohol use disorder were associated with partial response. Comorbid depressive disorder and early PTSD symptom reduction were associated with excellent response. Being treated by a cognitive behavioral therapy expert predicted higher excellent response for patients with a history of prior interpersonal violence. The model accounted for 56.6% of the variance in treatment response and correctly predicted responder status for 83.3% of the sample. These findings contribute to the field's understanding of factors that predict or moderate response to PE and have implications for treatment planning.
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Affiliation(s)
- Yinyin Zang
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yi-Jen Su
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Graduate Institute of Behavioral Sciences, Chang Gung University, Taoyuan, Taiwan, ROC.,Department of Psychiatry, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Carmen P McLean
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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32
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McLean CP, Zandberg L, Brown L, Zang Y, Benhamou K, Dondanville KA, Yarvis JS, Litz BT, Mintz J, Young-McCaughan S, Peterson AL, Foa EB. Guilt in the Treatment of Posttraumatic Stress Disorder Among Active Duty Military Personnel. J Trauma Stress 2019; 32:616-624. [PMID: 31356703 DOI: 10.1002/jts.22416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 02/01/2019] [Accepted: 02/14/2019] [Indexed: 11/09/2022]
Abstract
The current study examined the role of trauma-related guilt on posttraumatic stress disorder (PTSD) symptom change during prolonged exposure therapy (PE) as well as the efficacy of PE in reducing three dimensions of guilt (responsibility, wrongdoing, and lack of justification) during treatment. Participants were 331 active duty U.S. military personnel seeking treatment for PTSD who were randomized to one of four groups: massed PE (10 sessions delivered over 2 weeks), spaced PE (10 sessions delivered over 8 weeks), present-centered therapy (PCT; 10 sessions delivered over 8 weeks), or minimal contact control (MCC; weekly therapist phone check-in for 4 weeks). The results showed that baseline guilt did not predict reductions in PTSD symptoms for spaced PE or for PCT, ps = .178-.387, ds = -0.02-0.07. Treatment condition (massed PE vs. MCC; spaced PE vs. PCT) did not moderate reductions in guilt for spaced PE versus PCT. Guilt decreased significantly over treatment in all groups, p < .001 to p = .038, ds = -0.19 to -0.42, except concerning justification in the spaced PE and PCT groups, p = .140, d = -0.10. The findings suggest that guilt may be reduced significantly following active PTSD treatment and attention control and that PTSD recovery is not impacted by baseline levels of trauma-related guilt in military personnel with PTSD, although reported levels of guilt were low to moderate in this sample.
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Affiliation(s)
- Carmen P McLean
- National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, USA.,Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laurie Zandberg
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lily Brown
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yinyin Zang
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathy Benhamou
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katherine A Dondanville
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jeffrey S Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas, USA
| | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jim Mintz
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Department of Epidemiology and Biostatistics, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Alan L Peterson
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,South Texas Veterans Health Care System, San Antonio, Texas, USA.,Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, USA
| | - Edna B Foa
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Brown LA, McLean CP, Zang Y, Zandberg L, Mintz J, Yarvis JS, Litz BT, Peterson AL, Bryan CJ, Fina B, Petersen J, Dondanville KA, Roache JD, Young-McCaughan S, Foa EB. Does prolonged exposure increase suicide risk? Results from an active duty military sample. Behav Res Ther 2019; 118:87-93. [PMID: 31022593 DOI: 10.1016/j.brat.2019.04.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 12/19/2018] [Accepted: 04/05/2019] [Indexed: 11/30/2022]
Abstract
The efficacy of prolonged exposure (PE) on suicide ideation (SI) as a secondary outcome among individuals with posttraumatic stress disorder (PTSD) is unclear. The purpose of this study was to compare the efficacy of PE in two formats (spaced, S-PE, 10 sessions over 8 weeks, and massed, M-PE, 10 sessions over 2 weeks) to Present Centered Therapy (PCT) and minimal contact control (MCC) on SI exacerbation among patients without suicide intent or plans. Active duty military personnel (n = 335) were randomized to: (1) S-PE vs. PCT and (2) M-PE vs. MCC. All participants completed the Beck Scale for Suicide Ideation and the Beck Depression Inventory (Suicide item) at baseline, posttreatment, and follow-ups. S-PE and PCT had significant and comparable reductions in SI during treatment. M-PE had significantly steeper reductions in SI during treatment compared to MCC. Specifically, more participants in M-PE compared to MCC had reliable improvement versus reliable exacerbation. Reduction in PTSD symptoms was significantly associated with reduction of SI. PE was associated with significant reductions in SI over time that were comparable to PCT and superior to MCC. These findings suggest that both trauma- and non-trauma-focused treatments are associated with reductions in SI, and that trauma-focused treatments improve SI relative to waitlist.
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Affiliation(s)
- Lily A Brown
- Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 600 North, Philadelphia, PA, USA.
| | - Carmen P McLean
- Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 600 North, Philadelphia, PA, USA; (b)National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Rd., Menlo Park, CA, USA
| | - Yinyin Zang
- Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 600 North, Philadelphia, PA, USA
| | - Laurie Zandberg
- Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 600 North, Philadelphia, PA, USA
| | - Jim Mintz
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 8300 Floyd Curl Dr., San Antonio, TX, USA; Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., San Antonio, TX, USA
| | - Jeffrey S Yarvis
- Headquarters, Carl R. Darnall Army Medical Center, 36065 Santa Fe Avenue, Fort Hood, TX, USA
| | - Brett T Litz
- Massachusetts Veterans Epidemiological Research Center, VA Boston Health Care System, 150 S Huntington Ave, Boston, MA, USA; Department of Psychiatry, Boston University School of Medicine, 720 Harrison Ave., Boston, MA, USA; Department of Psychological and Brain Sciences, Boston University, 64 Cummington Mall, Boston, MA, USA
| | - Alan L Peterson
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 8300 Floyd Curl Dr., San Antonio, TX, USA; Research and Development Service, South Texas Veterans Health Care System, 7400 Merton Minter, San Antonio, TX, USA; Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, USA
| | - Craig J Bryan
- National Center for Veterans Studies, 332 S 1400 E, Building 73, Salt Lake City, UT, USA; Department of Psychology, The University of Utah, 1721 Campus Center Drive Saec, 3220 S, Salt Lake City, UT, USA
| | - Brooke Fina
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 8300 Floyd Curl Dr., San Antonio, TX, USA
| | - Julie Petersen
- Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 600 North, Philadelphia, PA, USA
| | - Katherine A Dondanville
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 8300 Floyd Curl Dr., San Antonio, TX, USA
| | - John D Roache
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 8300 Floyd Curl Dr., San Antonio, TX, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 8300 Floyd Curl Dr., San Antonio, TX, USA
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 600 North, Philadelphia, PA, USA
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Foa EB, Zandberg LJ, McLean CP, Rosenfield D, Fitzgerald H, Tuerk PW, Wangelin BC, Young-McCaughan S, Peterson AL. The efficacy of 90-minute versus 60-minute sessions of prolonged exposure for posttraumatic stress disorder: Design of a randomized controlled trial in active duty military personnel. ACTA ACUST UNITED AC 2019; 11:307-313. [DOI: 10.1037/tra0000351] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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35
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McLean CP, Zandberg L, Roache JD, Fitzgerald H, Pruiksma KE, Taylor DJ, Dondanville KA, Litz BT, Mintz J, Young-McCaughan S, Yarvis JS, Peterson AL, Foa EB, Strong Star Consortium FT. Caffeine Use in Military Personnel With PTSD: Prevalence and Impact on Sleep. Behav Sleep Med 2019; 17:202-212. [PMID: 28609150 DOI: 10.1080/15402002.2017.1326920] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background: Caffeine use is highly prevalent among active duty military personnel and can be beneficial to performance in the short term. However, regular caffeine use has been found to contribute to sleep disturbances, which are elevated among the significant number of military personnel with posttraumatic stress disorder (PTSD). The current study is the first to examine caffeine use and its relationship with sleep disturbances in military personnel seeking treatment for PTSD. Participants: Active duty military personnel (N = 366) who had returned from deployments to Afghanistan or Iraq and were seeking treatment for PTSD. Methods: Pearson correlations were used to examine the relationships between caffeine use, sleep disturbances, and PTSD symptom clusters. Results: The majority of the sample (89%) reported some caffeine use, with coffee being the largest contributor to total caffeine intake. Contrary to hypotheses, higher caffeine use was associated with lower insomnia symptom severity; follow-up analysis indicated that this was due to elevated insomnia symptom severity in those reporting no caffeine use. Caffeine use was not associated with any other measures of sleep disturbance or with PTSD symptoms. Conclusions: Caffeine use was not associated with greater reported sleep disturbances in this sample, possibly because those with elevated insomnia symptom severity abstained from any caffeine, or because insomnia symptoms were elevated in this sample.
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Affiliation(s)
- Carmen P McLean
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurie Zandberg
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John D Roache
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Hayley Fitzgerald
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristi E Pruiksma
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Daniel J Taylor
- Department of Psychology, University of North Texas, Denton, Texas
| | - Katherine A Dondanville
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts.,Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
| | - Jim Mintz
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas.,Department of Epidemiology & Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Stacey Young-McCaughan
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Jeffrey S Yarvis
- Headquarters, Carl R. Darnall Army Medical Center, Fort Hood, Texas
| | - Alan L Peterson
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas.,Research & Development Service, South Texas Veterans Health Care System, San Antonio, Texas.,Department of Psychology, University of Texas at San Antonio, San Antonio, Texas
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
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Zang Y, Gay NG, Kaczkurkin AN, McLean CP, Wachen JS, Yarvis JS, Litz BT, Yadin E, Mintz J, Roache JD, Young-McCaughan S, Peterson AL, Foa EB, Resick PA. Factor Structure and Psychometric Properties of the Peritraumatic and Posttraumatic Emotions Questionnaires Among Active Duty Military Personnel With Posttraumatic Stress Disorder. J Trauma Stress 2018; 31:826-836. [PMID: 30548330 DOI: 10.1002/jts.22350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 07/18/2018] [Accepted: 08/10/2018] [Indexed: 11/11/2022]
Abstract
The Peritraumatic Emotions Questionnaire (Peri-TEQ) and Posttraumatic Emotions Questionnaire (Post-TEQ) are self-report measures of emotions experienced during and after a traumatic event, respectively. The factor structure and psychometric properties of the Peri- and Post-TEQ were investigated among 474 military personnel with posttraumatic stress disorder (PTSD) following deployment. Exploratory factor analysis and confirmatory factor analysis were conducted to test the factor structure of the scales. Internal consistency, composite reliability, convergent validity, and discriminant validity were also assessed. Four factors were identified for the Peri-TEQ (Fear, Humiliation, Anger, and Sadness), and three factors were identified for the Post-TEQ (Fear, Anger-Hurt, and Humiliation). The full scales and all subscales demonstrated adequate-to-good internal consistency, Cronbach's αs = .722-.893. The subscales demonstrated adequate-to-good composite reliability, Cronbach's αs = .763-.861. The Peri- and Post-TEQ demonstrated good convergent validity with measures of PTSD symptoms, rs = .229-.601, ps < .001, and depressive symptoms, rs = .284-.470, ps < .001, and good discriminate validity with measures of resilience, ps = .116-.940, and unit cohesion, Peri-TEQ, p = .304 and Post-TEQ, r = -.123, p = .008. The Humiliation subscales demonstrated good convergent validity with guilt cognitions, rs = .315-.341, ps < .001, and the Anger subscales demonstrated good convergent validity with state anger, rs = .260-.347, ps < .001. The Peri- and Post-TEQ are reliable, valid self-report measures of emotions during and in response to remembering a trauma. The results support the use of these measures in research investigating trauma-related emotions.
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Affiliation(s)
- Yinying Zang
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Natalie G Gay
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Antonia N Kaczkurkin
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carmen P McLean
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Schuster Wachen
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jeffrey S Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas, USA
| | - Brett T Litz
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA.,Massachusetts Veterans Epidemiological Research Center, VA Boston Healthcare System, Boston, Massachusetts
| | - Elna Yadin
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jim Mintz
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - John D Roache
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Alan L Peterson
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patricia A Resick
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
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Peterson AL, Foa EB, Blount TH, McLean CP, Shah DV, Young-McCaughan S, Litz BT, Schobitz RP, Castillo DT, Rentz TO, Yarvis JS, Dondanville KA, Fina BA, Hall-Clark BN, Brown LA, DeBeer BR, Jacoby VM, Hancock AK, Williamson DE, Evans WR, Synett S, Straud C, Hansen HR, Meyer EC, Javors MA, Sharrieff AFM, Lara-Ruiz J, Koch LM, Roache JD, Mintz J, Keane TM. Intensive prolonged exposure therapy for combat-related posttraumatic stress disorder: Design and methodology of a randomized clinical trial. Contemp Clin Trials 2018; 72:126-136. [PMID: 30055335 DOI: 10.1016/j.cct.2018.07.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/22/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
Combat-related posttraumatic stress disorder (PTSD) is the most common psychological health condition in military service members and veterans who have deployed to the combat theater since September 11, 2001. One of the highest research priorities for the Department of Defense and the Department of Veterans Affairs is to develop and evaluate the most efficient and efficacious treatments possible for combat-related PTSD. However, the treatment of combat-related PTSD in military service members and veterans has been significantly more challenging than the treatment of PTSD in civilians. Randomized clinical trials have demonstrated large posttreatment effect sizes for PTSD in civilian populations. However, recent randomized clinical trials of service members and veterans have achieved lesser reductions in PTSD symptoms. These results suggest that combat-related PTSD is unique. Innovative approaches are needed to augment established evidence-based treatments with targeted interventions that address the distinctive elements of combat-related traumas. This paper describes the design, methodology, and protocol of a randomized clinical trial to compare two intensive prolonged exposure therapy treatments for combat-related PTSD in active duty military service members and veterans and that can be administered in an acceptable, efficient manner in this population. Both interventions include intensive daily treatment over a 3-week period and a number of treatment enhancements hypothesized to result in greater reductions in combat-related PTSD symptoms. The study is designed to advance the delivery of care for combat-related PTSD by developing and evaluating the most potent treatments possible to reduce PTSD symptomatology and improve psychological, social, and occupational functioning.
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Affiliation(s)
- Alan L Peterson
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; South Texas Veterans Health Care System, San Antonio, TX, USA; University of Texas at San Antonio, San Antonio, TX, USA.
| | - Edna B Foa
- University of Pennsylvania, Philadelphia, PA, USA.
| | - Tabatha H Blount
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Carmen P McLean
- VA Palo Alto Health Care System, Menlo Park, CA, USA; Stanford University School of Medicine, Stanford, CA, USA.
| | - Dhiya V Shah
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | | | - Brett T Litz
- VA Boston Healthcare System, Boston, MA, USA; Boston University, Boston, MA, USA.
| | - Richard P Schobitz
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX, USA.
| | - Diane T Castillo
- VA VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA.
| | - Timothy O Rentz
- South Texas Veterans Health Care System, San Antonio, TX, USA.
| | | | | | - Brooke A Fina
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | | | - Lily A Brown
- University of Pennsylvania, Philadelphia, PA, USA.
| | - Bryann R DeBeer
- VA VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA.
| | - Vanessa M Jacoby
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Allison K Hancock
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Douglas E Williamson
- Duke University, Durham, NC, USA; Durham VA Health Care System, Durham, NC, USA.
| | - Wyatt R Evans
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Samantha Synett
- VA VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA.
| | - Casey Straud
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Hunter R Hansen
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Eric C Meyer
- VA VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA.
| | - Martin A Javors
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | | | - Jose Lara-Ruiz
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; University of Texas at San Antonio, San Antonio, TX, USA.
| | - Lauren M Koch
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - John D Roache
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Jim Mintz
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Terence M Keane
- VA Boston Healthcare System, Boston, MA, USA; Boston University, Boston, MA, USA.
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Affiliation(s)
- Edna B Foa
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia
| | - Carmen P McLean
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia
| | - Alan L Peterson
- Department of Psychiatry, University of Texas Health Science Center, San Antonio
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Foa EB, McLean CP, Zang Y, Rosenfield D, Yadin E, Yarvis JS, Mintz J, Young-McCaughan S, Borah EV, Dondanville KA, Fina BA, Hall-Clark BN, Lichner T, Litz BT, Roache J, Wright EC, Peterson AL. Effect of Prolonged Exposure Therapy Delivered Over 2 Weeks vs 8 Weeks vs Present-Centered Therapy on PTSD Symptom Severity in Military Personnel: A Randomized Clinical Trial. JAMA 2018; 319:354-364. [PMID: 29362795 PMCID: PMC5833566 DOI: 10.1001/jama.2017.21242] [Citation(s) in RCA: 194] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Effective and efficient treatment is needed for posttraumatic stress disorder (PTSD) in active duty military personnel. OBJECTIVE To examine the effects of massed prolonged exposure therapy (massed therapy), spaced prolonged exposure therapy (spaced therapy), present-centered therapy (PCT), and a minimal-contact control (MCC) on PTSD severity. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted at Fort Hood, Texas, from January 2011 through July 2016 and enrolling 370 military personnel with PTSD who had returned from Iraq, Afghanistan, or both. Final follow-up was July 11, 2016. INTERVENTIONS Prolonged exposure therapy, cognitive behavioral therapy involving exposure to trauma memories/reminders, administered as massed therapy (n = 110; 10 sessions over 2 weeks) or spaced therapy (n = 109; 10 sessions over 8 weeks); PCT, a non-trauma-focused therapy involving identifying/discussing daily stressors (n = 107; 10 sessions over 8 weeks); or MCC, telephone calls from therapists (n = 40; once weekly for 4 weeks). MAIN OUTCOMES AND MEASURES Outcomes were assessed before and after treatment and at 2-week, 12-week, and 6-month follow-up. Primary outcome was interviewer-assessed PTSD symptom severity, measured by the PTSD Symptom Scale-Interview (PSS-I; range, 0-51; higher scores indicate greater PTSD severity; MCID, 3.18), used to assess efficacy of massed therapy at 2 weeks posttreatment vs MCC at week 4; noninferiority of massed therapy vs spaced therapy at 2 weeks and 12 weeks posttreatment (noninferiority margin, 50% [2.3 points on PSS-I, with 1-sided α = .05]); and efficacy of spaced therapy vs PCT at posttreatment. RESULTS Among 370 randomized participants, data were analyzed for 366 (mean age, 32.7 [SD, 7.3] years; 44 women [12.0%]; mean baseline PSS-I score, 25.49 [6.36]), and 216 (59.0%) completed the study. At 2 weeks posttreatment, mean PSS-I score was 17.62 (mean decrease from baseline, 7.13) for massed therapy and 21.41 (mean decrease, 3.43) for MCC (difference in decrease, 3.70 [95% CI,0.72 to 6.68]; P = .02). At 2 weeks posttreatment, mean PSS-I score was 18.03 for spaced therapy (decrease, 7.29; difference in means vs massed therapy, 0.79 [1-sided 95% CI, -∞ to 2.29; P = .049 for noninferiority]) and at 12 weeks posttreatment was 18.88 for massed therapy (decrease, 6.32) and 18.34 for spaced therapy (decrease, 6.97; difference, 0.55 [1-sided 95% CI, -∞ to 2.05; P = .03 for noninferiority]). At posttreatment, PSS-I scores for PCT were 18.65 (decrease, 7.31; difference in decrease vs spaced therapy, 0.10 [95% CI, -2.48 to 2.27]; P = .93). CONCLUSIONS AND RELEVANCE Among active duty military personnel with PTSD, massed therapy (10 sessions over 2 weeks) reduced PTSD symptom severity more than MCC at 2-week follow-up and was noninferior to spaced therapy (10 sessions over 8 weeks), and there was no significant difference between spaced therapy and PCT. The reductions in PTSD symptom severity with all treatments were relatively modest, suggesting that further research is needed to determine the clinical importance of these findings. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01049516.
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Affiliation(s)
- Edna B. Foa
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia
| | - Carmen P. McLean
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia
- Currently with the National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California
| | - Yinyin Zang
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia
| | - David Rosenfield
- Department of Psychology, Southern Methodist University, Dallas, Texas
| | - Elna Yadin
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Jim Mintz
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio
- Department of Epidemiology and Biostatistics, School of Medicine, University of Texas Health Science Center at San Antonio
| | - Stacey Young-McCaughan
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio
| | - Elisa V. Borah
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio
- Currently with The University of Texas at Austin School of Social Work
| | - Katherine A. Dondanville
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio
| | - Brooke A. Fina
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio
| | - Brittany N. Hall-Clark
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio
| | - Tracey Lichner
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia
| | - Brett T. Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - John Roache
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio
| | - Edward C. Wright
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio
- Currently with Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Alan L. Peterson
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio
- South Texas Veterans Health Care System, San Antonio
- Department of Psychology, University of Texas at San Antonio
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Chang C, Kaczkurkin AN, McLean CP, Foa EB. Emotion regulation is associated with PTSD and depression among female adolescent survivors of childhood sexual abuse. Psychol Trauma 2017; 10:319-326. [PMID: 28682105 DOI: 10.1037/tra0000306] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Sexual abuse experienced in childhood and adolescence is associated with severity of posttraumatic stress disorder (PTSD), depressive symptoms, and emotion regulation difficulties. The current study examined the relationships among these factors in a sample of adolescents with sexual abuse-related PTSD. It was hypothesized that (a) self-perceived emotion regulation difficulties would predict severity of PTSD and depressive symptoms, and that (b) depressive symptoms would mediate the relationship between emotion regulation difficulties and PTSD. METHOD Ninety treatment-seeking female adolescents with a history of sexual abuse were evaluated using the Child PTSD Symptom Scale-Interview and completed the Negative Mood Regulation Questionnaire and the Beck Depression Inventory as part of a baseline evaluation. RESULTS Greater emotion regulation difficulties were associated with greater severity of PTSD and depressive symptoms. In addition, the relationship between emotion regulation difficulties and PTSD severity was mediated by depressive symptoms. However, the reverse was also true: the relationship between emotion regulation difficulties and depressive symptoms was mediated by PTSD symptoms. CONCLUSIONS Mediation analyses showed that emotion regulation difficulties were associated with both PTSD and depressive symptoms rather than fitting a unidirectional model. These findings are consistent with and extend previous research and highlight the importance of emotion regulation in adolescent survivors of sexual abuse. (PsycINFO Database Record
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Affiliation(s)
- Cindy Chang
- Department of Psychology, University of Pennsylvania
| | | | | | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania
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Zoellner LA, Telch M, Foa EB, Farach FJ, McLean CP, Gallop R, Bluett EJ, Cobb A, Gonzalez-Lima F. Enhancing Extinction Learning in Posttraumatic Stress Disorder With Brief Daily Imaginal Exposure and Methylene Blue: A Randomized Controlled Trial. J Clin Psychiatry 2017; 78:e782-e789. [PMID: 28686823 DOI: 10.4088/jcp.16m10936] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 10/24/2016] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The memory-enhancing drug methylene blue (MB) administered after extinction training improves fear extinction retention in rats and humans with claustrophobia. Robust findings from animal research, in combination with established safety and data showing MB-enhanced extinction in humans, provide a foundation to extend this work to extinction-based therapies for posttraumatic stress disorder (PTSD) such as prolonged exposure (PE). METHODS Patients with chronic PTSD (DSM-IV-TR; N = 42) were randomly assigned to imaginal exposure plus MB (IE + MB), imaginal exposure plus placebo (IE + PBO), or waitlist (WL/standard PE) from September 2011 to April 2013. Following 5 daily, 50-minute imaginal exposure sessions, 260 mg of MB or PBO was administered. Waitlist controls received PE following 1-month follow-up. Patients were assessed using the independent evaluator-rated PTSD Symptom Scale-Interview version (primary outcome), patient-rated PTSD, trauma-related psychopathology, and functioning through 3-month follow-up. RESULTS Both IE + MB and IE + PBO showed strong clinical gains that did not differ from standard PE at 3-month follow-up. MB-augmented exposure specifically enhanced independent evaluator-rated treatment response (number needed to treat = 7.5) and quality of life compared to placebo (effect size d = 0.58). Rate of change for IE + MB showed a delayed initial response followed by accelerated recovery, which differed from the linear pattern seen in IE + PBO. MB effects were facilitated by better working memory but not by changes in beliefs. CONCLUSIONS The findings provide preliminary efficacy for a brief IE treatment for PTSD and point to the potential utility of MB for enhancing outcome. Brief interventions and better tailoring of MB augmentation strategies, adjusting for observed patterns, may have the potential to reduce dropout, accelerate change, and improve outcomes. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01188694.
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Affiliation(s)
- Lori A Zoellner
- Department of Psychology, Box 351525, University of Washington, Seattle, WA 98195. .,Department of Psychology, University of Washington, Seattle, Washington, USA
| | - Michael Telch
- Department of Psychology, University of Texas at Austin, Austin, Texas, USA
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frank J Farach
- Department of Psychology, University of Washington, Seattle, Washington, USA
| | - Carmen P McLean
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Gallop
- Department of Mathematics, West Chester University, West Chester, Pennsylvania, USA
| | - Ellen J Bluett
- Department of Psychology, Utah State University, Logan, Utah, USA
| | - Adam Cobb
- Department of Psychology, University of Texas at Austin, Austin, Texas, USA
| | - F Gonzalez-Lima
- Department of Psychology, University of Texas at Austin, Austin, Texas, USA
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McLean CP, Gay NG, Metzger DA, Foa EB. Psychiatric Symptoms and Barriers to Care in HIV-Infected Individuals Who Are Lost to Care. J Int Assoc Provid AIDS Care 2017; 16:423-429. [PMID: 28578611 DOI: 10.1177/2325957417711254] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Past studies of barriers to HIV care have not comprehensively assessed psychiatric symptoms, and few have assessed barriers to care among people living with HIV (PLWH) who are lost to care (LTC). We examined psychiatric symptoms, barriers to HIV care, and immune functioning in PLWH who were retained in care (RIC; n = 21) or LTC (n = 21). Participants completed diagnostic interviews for posttraumatic stress disorder (PTSD) and other psychiatric disorders, self-report measures of HIV risk behaviors and psychiatric symptoms, and a blood draw to assess viral load. Compared to RIC participants, LTC participants met criteria for a greater number of psychiatric disorders and reported greater depressive symptoms and more barriers to HIV care. There were no group differences in PTSD severity, risk behaviors, or viral load, suggesting that LTC individuals experience greater psychiatric problems and perceive more barriers to care than RIC participants, but are not less likely to have achieved viral suppression.
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Affiliation(s)
- Carmen P McLean
- 1 Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Natalie G Gay
- 1 Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Metzger
- 1 Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Edna B Foa
- 1 Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
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McLean CP, Foa EB. Emotions and emotion regulation in posttraumatic stress disorder. Curr Opin Psychol 2017; 14:72-77. [DOI: 10.1016/j.copsyc.2016.10.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/26/2016] [Accepted: 10/28/2016] [Indexed: 01/15/2023]
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Zang Y, Gallagher T, McLean CP, Tannahill HS, Yarvis JS, Foa EB. The impact of social support, unit cohesion, and trait resilience on PTSD in treatment-seeking military personnel with PTSD: The role of posttraumatic cognitions. J Psychiatr Res 2017; 86:18-25. [PMID: 27886636 DOI: 10.1016/j.jpsychires.2016.11.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 11/04/2016] [Accepted: 11/15/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The personal resources of social support, unit cohesion, and trait resilience have been found to be associated with posttraumatic stress disorder (PTSD) severity among military personnel. However, the underlying mechanisms of these relationships are unclear. We hypothesized that negative posttraumatic cognitions, which are associated with PTSD, mediate the relationships between these personal resources and PTSD. METHODS The relationship between PTSD symptom severity and a latent factor comprised of social support, unit cohesion, and trait resilience was evaluated using cross-sectional data from 366 treatment-seeking active duty military personnel with PTSD following deployments to or near Iraq or Afghanistan. Structural equation modeling (SEM) was used to test whether posttraumatic cognitions mediated this relationship. RESULTS The SEM model indicated that (1) a robust latent variable named personal resources (indicated by social support, unit cohesion, and trait resilience) was negatively associated with PTSD severity; (2) personal resources were negatively associated with negative posttraumatic cognitions; (3) negative posttraumatic cognitions fully mediated the association between personal resources and PTSD severity. The final SEM mediation model showed a highly satisfactory fit [χ2 (22) = 16.344, p = 0.798; χ2/df = 0.743; CFI = 1; RMSEA = 0.000]. CONCLUSIONS These findings suggest that among active duty military personnel seeking treatment for PTSD, personal resources (social support, unit cohesion, and trait resilience) may mitigate PTSD severity by reducing negative posttraumatic cognitions.
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Affiliation(s)
- Yinyin Zang
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA.
| | - Thea Gallagher
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Carmen P McLean
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Hallie S Tannahill
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey S Yarvis
- Headquarters, Carl R. Darnall Army Medical Center, Fort Hood, TX, USA
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
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Asnaani A, Kaczkurkin AN, Alpert E, McLean CP, Simpson HB, Foa EB. The effect of treatment on quality of life and functioning in OCD. Compr Psychiatry 2017; 73:7-14. [PMID: 27838572 PMCID: PMC5263110 DOI: 10.1016/j.comppsych.2016.10.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 09/20/2016] [Accepted: 10/07/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Given that obsessive compulsive disorder (OCD) is associated with impaired quality of life (QoL) and functioning, it is important examine whether therapeutic recovery from OCD leads to improvements on these important secondary outcomes. Only a few studies have examined how measures of OCD symptom severity relate to QoL and functioning among patients receiving treatment for OCD. METHODS OCD severity was measured with the Obsessive-Compulsive Inventory-Revised (OCI-R), a self-report scale of OCD, and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), an interview measure of OCD. Participants were 100 adults with a primary diagnosis of OCD on serotonin reuptake inhibitors (SRIs) enrolled in a randomized clinical trial comparing SRI augmentation with either exposure and response prevention (EX/RP) therapy, risperidone, or pill placebo. At baseline, mid-treatment, and post-treatment, patients completed assessments for OCD symptoms and QoL/functioning measures. Multilevel modeling was used to assess changes in QoL/functioning over the course of treatment and to compare such changes across treatment conditions. RESULTS Improvements in QoL/functioning were significantly greater among those receiving EX/RP compared to those receiving risperidone. Compared to pill placebo, EX/RP performed better on measures of functioning but not QoL. Greater improvement in individual OCI-R scores was associated with greater improvements in QoL/functioning, regardless of condition. In addition, Y-BOCS scores appeared to moderate improvements in QoL over the course of all treatment conditions, such that those with higher Y-BOCS scores showed the greatest improvements in QoL over time. CONCLUSIONS Improvements in QoL/functioning were associated with reduction in OCD symptom severity. The implications on OCD treatment and clinical research are discussed.
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Affiliation(s)
- Anu Asnaani
- University of Pennsylvania, Philadelphia, PA.
| | | | | | | | - H. Blair Simpson
- Columbia University, NYC, NY,New York State Psychiatric Institute, NYC, NY
| | - Edna B. Foa
- University of Pennsylvania, Philadelphia, PA
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McLean CP, Zang Y, Zandberg L, Bryan CJ, Gay N, Yarvis JS, Foa EB. Predictors of suicidal ideation among active duty military personnel with posttraumatic stress disorder. J Affect Disord 2017; 208:392-398. [PMID: 27810723 DOI: 10.1016/j.jad.2016.08.061] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/24/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Given the alarming rate of military suicides, it is critical to identify the factors that increase risk of suicidal thoughts and behaviors among active duty military personnel. METHODS This study examined a predictive model of suicidal ideation among 366 treatment-seeking active duty military personnel with posttraumatic stress disorder (PTSD) following deployments to or near Iraq or Afghanistan. Structural equation modeling was employed to examine the relative contribution of combat exposure, social support, PTSD severity, depressive symptoms, guilt, and trauma-related cognitions on suicidal ideation. RESULTS The final structural equation model had a highly satisfactory fit [χ2 (2) =2.023, p=.364; RMSEA =.006; CFI =1; GFI =.998]. PTSD severity had an indirect effect on suicidal ideation via trauma-related cognitions. Depression had a direct positive effect on suicidal ideation; it also had an indirect effect via trauma-related cognitions and interpersonal support. Among participants who had made a previous suicide attempt, only depression symptom severity was significantly linked to suicidal ideation. LIMITATIONS Data are cross-sectional, precluding causal interpretations. Findings may only generalize to treatment seeking active duty military personnel with PTSD reporting no more than moderate suicidal ideation. CONCLUSIONS These findings suggest that depression and trauma-related cognitions, particularly negative thoughts about the self, play an important role in suicidal ideation among active duty military personnel with PTSD. Negative cognitions about the self and interpersonal support may be important targets for intervention to decrease suicidal ideation.
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Affiliation(s)
- Carmen P McLean
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States
| | - Yinyin Zang
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States.
| | - Laurie Zandberg
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States
| | - Craig J Bryan
- National Center for Veterans Studies, Salt Lake City, UT, United States; Department of Psychology, University of Utah, Salt Lake City, UT, United States
| | - Natalie Gay
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States
| | - Jeffrey S Yarvis
- Headquarters, Carl R. Darnall Army Medical Center, Fort Hood, TX, United States
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States
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Brownlow JA, McLean CP, Gehrman PR, Harb GC, Ross RJ, Foa EB. Influence of Sleep Disturbance on Global Functioning After Posttraumatic Stress Disorder Treatment. J Trauma Stress 2016; 29:515-521. [PMID: 27859588 DOI: 10.1002/jts.22139] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 07/18/2016] [Accepted: 08/27/2016] [Indexed: 11/06/2022]
Abstract
Chronic insomnia and recurrent nightmares are prominent features of posttraumatic stress disorder (PTSD). Evidence from adult research indicates that these sleep disturbances do not respond as well to cognitive-behavioral therapies for PTSD and are associated with poorer functional outcomes. This study examined the effect of prolonged exposure therapy for adolescents versus client-centered therapy on posttraumatic sleep disturbance, and the extent to which sleep symptoms impacted global functioning among adolescents with sexual abuse-related PTSD. Participants included 61 adolescent girls seeking treatment at a rape crisis center. The Child PTSD Symptom Scale-Interview (Foa, Johnson, Feeny, & Treadwell, 2001) was used to assess PTSD diagnosis and severity of symptoms, including insomnia and nightmares. The Children's Global Assessment Scale (Shaffer et al., 1983) was used to assess global functioning. There were significant main effects of time and treatment on insomnia symptoms. Additionally, there was a main effect of time on nightmares. Results also showed that insomnia and nightmares significantly predicted poorer global functioning posttreatment (R2 = .21). Despite significant improvements in posttraumatic sleep disturbance, there were still clinically significant insomnia symptoms after treatment, suggesting that additional interventions may be warranted to address residual sleep disturbance in PTSD.
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Affiliation(s)
- Janeese A Brownlow
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carmen P McLean
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Philip R Gehrman
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gerlinde C Harb
- Behavioral Health Service/Research, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Richard J Ross
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Behavioral Health Service/Research, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Edna B Foa
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Zandberg L, Kaczkurkin AN, McLean CP, Rescorla L, Yadin E, Foa EB. Treatment of Adolescent PTSD: The Impact of Prolonged Exposure Versus Client-Centered Therapy on Co-Occurring Emotional and Behavioral Problems. J Trauma Stress 2016; 29:507-514. [PMID: 27859619 PMCID: PMC7367099 DOI: 10.1002/jts.22138] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 07/20/2016] [Accepted: 08/21/2016] [Indexed: 11/07/2022]
Abstract
The present study evaluated secondary emotional and behavioral outcomes among adolescents who received prolonged exposure (PE-A) or client-centered therapy (CCT) for posttraumatic stress disorder (PTSD) in a randomized controlled trial. Participants were 61 adolescent girls (age: M = 15.33, SD = 1.50 years) with sexual abuse related PTSD seeking treatment at a community mental health clinic. Multilevel modeling was employed to evaluate group differences on the Youth Self-Report (YSR) over acute treatment and 12-month follow-up. Both treatment groups showed significant improvements on all YSR scales from baseline to 12-month follow-up. Adolescents who received PE-A showed significantly greater reductions than those receiving CCT on the Externalizing subscale (d = 0.70), rule-breaking behavior (d = 0.63), aggressive behavior (d = 0.62), and conduct problems (d = 0.78). No treatment differences were found on the Internalizing subscale or among other YSR problem areas. Both PE-A and CCT effectively reduced many co-occurring problems among adolescents with PTSD. Although PE-A focuses on PTSD and not on disruptive behaviors, PE-A was associated with greater sustained changes in externalizing symptoms, supporting broad effects of trauma-focused treatment on associated problem areas.
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Affiliation(s)
- Laurie Zandberg
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Antonia N. Kaczkurkin
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carmen P. McLean
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leslie Rescorla
- Department of Psychology, Bryn Mawr College, Bryn Mawr, Pennsylvania, USA
| | - Elna Yadin
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Edna B. Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Foa EB, McLean CP, Zang Y, Zhong J, Rauch S, Porter K, Knowles K, Powers MB, Kauffman BY. Psychometric properties of the Posttraumatic Stress Disorder Symptom Scale Interview for DSM–5 (PSSI–5). Psychol Assess 2016; 28:1159-1165. [DOI: 10.1037/pas0000259] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
The prevalence rate of posttraumatic stress disorder (PTSD) among people living with HIV (PLWH) is significantly higher than the rate among the general population. Moreover, PTS symptoms have been linked with numerous negative health-related outcomes in PLWH. While these findings suggest that studies evaluating the efficacy of treatments for PTS symptoms among PLWH are sorely needed, according to prior reviews, such studies are lacking. The purpose of the present systematic review was to provide an updated critical evaluation of treatment studies that targeted PTS among PLWH. Following PRIMSA guidelines, we searched PubMed and PsycINFO and identified eight articles (representing seven studies) evaluating the impact of various individual and group treatments on PTS symptoms. The limited evidence base to date precludes clinical recommendations for this population. Future studies should examine the efficacy of existing evidence-based treatments for PTSD among PLWH and then, if necessary, evaluate the impact of any treatment modifications for this population.
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Affiliation(s)
- Carmen P. McLean
- Department of Psychiatry, University of Pennsylvania, Center for the Treatment and Study of Anxiety, 3535 Market St., Suite 600 North, Philadelphia, PA 19104, USA
| | - Hayley Fitzgerald
- Department of Psychiatry, University of Pennsylvania, Center for the Treatment and Study of Anxiety, 3535 Market St., Suite 600 North, Philadelphia, PA 19104, USA
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