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Tuerk PW, McGuire JF, Piacentini J. A Randomized Controlled Trial of OC-Go for Childhood Obsessive-Compulsive Disorder: Augmenting Homework Compliance in Exposure With Response Prevention Treatment. Behav Ther 2024; 55:306-319. [PMID: 38418042 DOI: 10.1016/j.beth.2023.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 03/01/2024]
Abstract
The current study investigates a novel digital tool designed to address barriers to out-of-session homework adherence in exposure with response prevention (ERP) for child obsessive-compulsive disorder (OCD). The OC-Go platform allows clinicians to create and push tailored interactive protocol- or symptom-specific assignments to patients on their mobile devices, providing in-the-moment step-by-step directions, encouragement, accountability, and a sense of therapeutic presence for patients during out-of-office exposures. The platform also facilitates objective measurement of homework and allows providers to support one another through a shared and searchable crowdsourced library with hundreds of assignable exposures and psychoeducation activities for specific OCD symptoms. The current study tested the usability and feasibility of the OC-Go platform with ERP stakeholders (OCD therapists, patients, and parents; N = 172) using the System Usability Scale (SUS). The study also tested the efficacy of OC-Go for augmenting homework adherence and clinical response using a randomized controlled, crossover design in a sample of 28 treatment-seeking youth with OCD. Participants randomized to standard ERP exhibited a homework adherence rate of 68.4% (95% CI [65.6, 71.0]), those randomized to ERP with OC-Go exhibited a greater adherence rate of 83.3% (95% CI [80.8, 85.6], p < .001). Both groups experienced large declines in Children's Yale-Brown Obsessive-Compulsive Scale-rated OCD (d = 1.31, p < .001), though participants randomized to begin ERP with OC-Go exhibited clinically significant greater improvement (p = .05), translating into an additional augmented treatment response at the Week 6 primary end point (d = 0.36) and the Week 12 treatment end point (d = 0.72). Stakeholders rated OC-Go in the 90th percentile for usability on the SUS, indicative of a highly usable and easy-to-learn technology. Initial evidence supports OC-Go as a feasible and effective adjunct to improve out-of-office exposure measurement, adherence, and treatment response in ERP for child OCD.
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Affiliation(s)
| | - Joseph F McGuire
- Johns Hopkins University School of Medicine and University of California, Los Angeles
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Dell L, Sbisa AM, Forbes A, O'Donnell M, Bryant R, Hodson S, Morton D, Battersby M, Tuerk PW, Elliott P, Wallace D, Forbes D. Massed v. standard prolonged exposure therapy for PTSD in military personnel and veterans: 12-month follow-up of a non-inferiority randomised controlled trial. Psychol Med 2023; 53:7070-7077. [PMID: 36911997 PMCID: PMC10719628 DOI: 10.1017/s0033291723000405] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/30/2023] [Accepted: 03/02/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND The utilisation of massed therapy for treating posttraumatic stress disorder (PTSD) is gaining strength, especially prolonged exposure. However, it is unknown whether massed prolonged exposure (MPE) is non-inferior to standard prolonged exposure (SPE) protocols in the long term. The current study aimed to assess whether MPE was non-inferior to SPE at 12 months post-treatment, and to ascertain changes in secondary measure outcomes. METHODS A multi-site non-inferiority randomised controlled trial (RCT) compared SPE with MPE in 12 clinics. The primary outcome was PTSD symptom severity (CAPS-5) at 12 months post-treatment commencement. Secondary outcome measures included symptoms of depression, anxiety, anger, disability, and quality of life at 12 weeks and 12 months post-treatment commencement. Outcome assessors were blinded to treatment allocation. The intention-to-treat sample included 138 Australian military members and veterans and data were analysed for 134 participants (SPE = 71, MPE = 63). RESULTS Reductions in PTSD severity were maintained at 12 months and MPE remained non-inferior to SPE. Both treatment groups experienced a reduction in depression, anxiety, anger, and improvements in quality of life at 12 weeks and 12 months post-treatment commencement. Treatment effects for self-reported disability in the SPE group at 12 weeks were not maintained, with neither group registering significant effects at 12 months. CONCLUSIONS The emergence of massed protocols for PTSD is an important advancement. The current study provides RCT evidence for the longevity of MPE treatment gains at 12 months post-treatment commencement and demonstrated non-inferiority to SPE. Promisingly, both treatments also significantly reduced the severity of comorbid symptoms commonly occurring alongside PTSD.
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Affiliation(s)
- Lisa Dell
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Alyssa M Sbisa
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Meaghan O'Donnell
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephanie Hodson
- Department of Veteran's Affairs, Canberra, Australian Capital Territory, Australia
| | - David Morton
- Defence, Canberra, Australian Capital Territory, Australia
| | - Malcolm Battersby
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Peter W Tuerk
- Department of Human Services, Sheila C. Jonson Center for Clinical Services, University of Virginia, Charlottesville, Virginia, USA
| | - Peter Elliott
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Duncan Wallace
- Australian Defence Force Centre for Mental Health, Sydney, New South Wales, Australia
| | - David Forbes
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
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Dell L, Sbisa AM, Forbes A, O'Donnell M, Bryant R, Hodson S, Morton D, Battersby M, Tuerk PW, Wallace D, Forbes D. Effect of massed v. standard prolonged exposure therapy on PTSD in military personnel and veterans: a non-inferiority randomised controlled trial. Psychol Med 2023; 53:4192-4199. [PMID: 35440345 PMCID: PMC10317798 DOI: 10.1017/s0033291722000927] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND A short, effective therapy for posttraumatic stress disorder (PTSD) could decrease barriers to implementation and uptake, reduce dropout, and ameliorate distressing symptoms in military personnel and veterans. This non-inferiority RCT evaluated the efficacy of 2-week massed prolonged exposure (MPE) therapy compared to standard 10-week prolonged exposure (SPE), the current gold standard treatment, in reducing PTSD severity in both active serving and veterans in a real-world health service system. METHODS This single-blinded multi-site non-inferiority RCT took place in 12 health clinics across Australia. The primary outcome was PTSD symptom severity measured by the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) at 12 weeks. 138 military personnel and veterans with PTSD were randomised. 71 participants were allocated to SPE, with 63 allocated to MPE. RESULTS The intention-to-treat sample included 138 participants, data were analysed for 134 participants (88.1% male, M = 46 years). The difference between the mean MPE and SPE group PTSD scores from baseline to 12 weeks-post therapy was 0.94 [95% confidence interval (CI) -4.19 to +6.07]. The upper endpoint of the 95% CI was below +7, indicating MPE was non-inferior to SPE. Significant rates of loss of PTSD diagnosis were found for both groups (MPE 53.8%, SPE 54.1%). Dropout rates were 4.8% (MPE) and 16.9% (SPE). CONCLUSIONS MPE was non-inferior to SPE in significantly reducing symptoms of PTSD. Significant reductions in symptom severity, low dropout rates, and loss of diagnosis indicate MPE is a feasible, accessible, and effective treatment. Findings demonstrate novel methods to deliver gold-standard treatments for PTSD should be routinely considered.
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Affiliation(s)
- Lisa Dell
- Phoenix Australia – Center for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Alyssa M. Sbisa
- Phoenix Australia – Center for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Meaghan O'Donnell
- Phoenix Australia – Center for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephanie Hodson
- Department of Veteran's Affairs, Canberra, Australian Capital Territory, Australia
| | - David Morton
- Department of Defence, Canberra, Australian Capital Territory, Australia
| | - Malcolm Battersby
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Peter W. Tuerk
- Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville, Virginia, USA
| | - Duncan Wallace
- Australian Defence Force Center for Mental Health, Sydney, New South Wales, Australia
| | - David Forbes
- Phoenix Australia – Center for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
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Cox KS, Wiener D, Rauch SAM, Tuerk PW, Wangelin B, Acierno R. Individual symptom reduction and post-treatment severity: Varying levels of symptom amelioration in response to prolonged exposure for post-traumatic stress disorder. Psychol Serv 2023; 20:94-106. [PMID: 34941335 DOI: 10.1037/ser0000579] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Many patients evince significant post-traumatic stress disorder (PTSD) symptoms after a dose of an evidence-based treatment (EBT) for PTSD. Little research systematically addresses if individual PTSD symptoms are more or less resistant to change through an EBT for PTSD or have greater or lesser post-treatment severity levels. Two studies within VA medical centers provided data. Study 1 (n = 81) was drawn from a randomized clinical trial of Prolonged Exposure (PE), an EBT for PTSD. Study 2 (n = 225) was drawn from two PTSD specialty clinics employing PE. Symptoms were assessed pre- and post-treatments via semi-structured clinician interview (Study 1) and patient self-report (Studies 1 and 2). Most individual symptoms reduced about the same amount through the course of treatment except for avoidance, which showed greater reductions. High heterogeneity in post-treatment symptom severity was found with troubled sleep and hypervigilance displaying above average levels, and traumatic amnesia, foreshortened future, and flashbacks displaying below average levels. Method of symptom measurement had a modest impact on results, as semi-structured clinical interview results were moderately more differentiated than self-report measures. Results were generally consistent between an efficacy (i.e., extremely high, potentially artificial methodological control) and effectiveness (i.e., relatively more real world) context. Primary limitation is analysis of single items on semi-structured clinician interview and patient self-report scale when psychometric validation studies did not interpret measures this way. Moreover, DSM-IV criteria for PTSD were assessed. EBT augmentation and new treatment development should focus on further reducing both PTSD symptoms in general and on the specific symptoms of troubled sleep and hypervigilance, which persist to a greater degree. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Luciano MT, Norman SB, Allard CB, Acierno R, Simon NM, Szuhany KL, Baker AW, Stein MB, Martis B, Tuerk PW, Rauch SAM. The influence of posttraumatic stress disorder treatment on anxiety sensitivity: Impact of prolonged exposure, sertraline, and their combination. J Trauma Stress 2023; 36:157-166. [PMID: 36451271 PMCID: PMC9974893 DOI: 10.1002/jts.22894] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 12/05/2022]
Abstract
Trauma-informed beliefs often decrease during posttraumatic stress disorder (PTSD) treatment. This may also extend to anxiety sensitivity (AS), defined as a fear of anxiety-related sensations and beliefs that anxiety is dangerous and/or intolerable. However, little is known about how AS changes during exposure-based and psychopharmacological PTSD treatments. Further, high AS may be a risk factor for diminished PTSD symptom improvement and increased treatment dropout. To better understand how AS impacts and is impacted by PTSD treatment, we conducted a secondary analysis of a randomized clinical trial with a sample of 223 veterans (87.0% male, 57.5% White) with PTSD from four U.S. sites. Veterans were randomized to receive prolonged exposure (PE) plus placebo (n = 74), sertraline plus enhanced medication management (n = 74), or PE plus sertraline (n = 75). Veterans answered questions about PTSD symptoms and AS at baseline and 6-, 12-, 24-, 36-, and 52-week follow-ups. High baseline AS was related to high levels of PTSD severity at 24 weeks across all conditions, β = .244, p = .013, but did not predict dropout from exposure-based, β = .077, p = .374, or psychopharmacological therapy, β = .009, p = .893. AS also significantly decreased across all three treatment arms, with no between-group differences; these reductions were maintained at the 52-week follow-up. These findings suggest that high AS is a risk factor for attenuated PTSD treatment response but also provide evidence that AS can be improved by both PE and an enhanced psychopharmacological intervention for PTSD.
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Affiliation(s)
- Matthew T Luciano
- San Diego State University Research Foundation, San Diego, California, USA
- VA San Diego Healthcare System, San Diego, California, USA
| | - Sonya B Norman
- VA San Diego Healthcare System, San Diego, California, USA
- National Center for PTSD, White River Junction, Vermont, USA
| | - Carolyn B Allard
- VA San Diego Healthcare System, San Diego, California, USA
- California School of Professional Psychology, Alliant International University, San Diego, California, USA
| | - Ron Acierno
- McGovern Medical School, University of Texas Health Sciences Center, Houston, Texas, USA
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Naomi M Simon
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA
| | - Kristin L Szuhany
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA
| | - Amanda W Baker
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Murray B Stein
- VA San Diego Healthcare System, San Diego, California, USA
- Departmetn of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Brian Martis
- VA San Diego Healthcare System, San Diego, California, USA
- Departmetn of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Peter W Tuerk
- Department of Human Services, University of Virginia, Charlottesville, Virginia, USA
| | - Sheila A M Rauch
- Atlanta VA Healthcare System, Atlanta, Georgia, USA
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
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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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Rauch SA, Kim HM, Venners MR, Porter K, Norman SB, Simon NM, Rothbaum BO, Tuerk PW, Acierno R, Bui E, Powell C, Smith ER, Goetter E, McSweeney L. Change in posttraumatic stress disorder-related thoughts during treatment: Do thoughts drive change when pills are involved? J Trauma Stress 2022; 35:496-507. [PMID: 34973039 PMCID: PMC9446312 DOI: 10.1002/jts.22762] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/16/2021] [Accepted: 08/28/2021] [Indexed: 11/09/2022]
Abstract
Posttraumatic negative thoughts about one's self and the world are related to posttraumatic stress disorder (PTSD) symptom severity and change in cognitive behavioral treatment (CBT), but little is known about this association when CBT is delivered with medication. The current study presents a planned comparison of changes in negative posttraumatic thoughts during (a) prolonged exposure (PE) plus pill placebo (PE+PLB), (b) sertraline plus enhanced medication management (SERT+EMM), and (c) PE plus sertraline (PE+SERT) as part of a randomized clinical trial in a sample of 176 veterans. Lagged regression modeling revealed that change in posttraumatic negative thoughts was associated with PTSD symptom change in the conditions in which participants received sertraline, ds = 0.14-0.25, ps = 0.04-.001). However, contrary to previous research, the models that started with symptom change were also statistically significant, d = 0.23, p < .001, for the lagged effect of symptoms on negative thoughts about self in the SERT+EMM condition, indicating a bidirectional association between such thoughts and PTSD symptoms. In the PE+PLB condition, no significant association between posttraumatic thoughts and PTSD symptoms emerged in either direction. These results suggest that the previously demonstrated role of change in posttraumatic thoughts leading to PTSD symptom reduction in PE may be altered when combined with pill administration, either active or placebo.
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Affiliation(s)
- Sheila A.M. Rauch
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033,Emory University School of Medicine, 12 Executive Park, 3 Floor, Atlanta, GA, 30029
| | - H. Myra Kim
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105,University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI, 48109
| | | | - Katherine Porter
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105,University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI, 48109
| | - Sonya B. Norman
- National Center for PTSD, 215 N. Main Street, White River Junction, VT 05009,VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Drive, MC116B, San Diego, CA 92161,University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92037
| | - Naomi M. Simon
- Massachusetts General Hospital, Department of Psychiatry, One Bowdoin Square, 6th Floor, Boston, MA 02114,New York University Medical School, Department of Psychiatry, One Park Avenue 8 Floor, New York NY 10016
| | - Barbara O. Rothbaum
- Emory University School of Medicine, 12 Executive Park, 3 Floor, Atlanta, GA, 30029
| | - Peter W. Tuerk
- University of Virginia, Department of Human Services, 417 Emmet St. South, PO Box 400270, Charlottesville, VA 22903
| | - Ron Acierno
- Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC, 29401,Medical University of South Carolina, College of Nursing, Jonathan Lucas Street, Charleston, SC 29425
| | - Eric Bui
- Massachusetts General Hospital, Department of Psychiatry, One Bowdoin Square, 6th Floor, Boston, MA 02114,University of Caen Normandy & Caen University Hospital, avenue de la Côte de Nacre, 14000 Caen, France
| | - Corey Powell
- University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI, 48109
| | - Erin R. Smith
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105,University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI, 48109
| | - Elizabeth Goetter
- Massachusetts General Hospital, Department of Psychiatry, One Bowdoin Square, 6th Floor, Boston, MA 02114,Harvard Medical School, Department of Psychiatry, 25 Shattuck Street, Boston, MA 02115
| | - Lauren McSweeney
- Emory University School of Medicine, 12 Executive Park, 3 Floor, Atlanta, GA, 30029
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Beidel DC, Tuerk PW, Spitalnick J, Bowers CA, Morrison K. Treating Childhood Social Anxiety Disorder With Virtual Environments and Serious Games: A Randomized Trial. Behav Ther 2021; 52:1351-1363. [PMID: 34656191 PMCID: PMC8531536 DOI: 10.1016/j.beth.2021.03.003] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/27/2021] [Accepted: 03/04/2021] [Indexed: 11/19/2022]
Abstract
Disseminating efficacious psychological treatments remains a challenge for researchers and clinicians. In the case of social anxiety disorder (SAD), Social Effectiveness Therapy for Children (SET-C) has been demonstrated as an efficacious intervention, but elements of the protocol, such as peer generalization sessions, remain challenging to conduct in typical clinical settings. To address this need, we developed an artificially intelligent, web-based application, Pegasys-VR™, designed to replace peer generalization sessions and enhance homework compliance. The feasibility of Pegasys-VR™ was tested in a randomized controlled trial in comparison to SET-C. The results indicated that both programs were equally efficacious in decreasing anxiety and improving social skill in social encounters. Sixty-three percent (63%) of children treated with SET-C and 60% treated with Pegasys-VR™ did not meet diagnostic criteria for SAD at posttreatment. Pegasys-VR™ is a feasible, efficacious, and dissemination-friendly element of a comprehensive treatment program for social anxiety disorder in children.
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Affiliation(s)
| | - Peter W Tuerk
- Department of Human Services, University of Virginia
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9
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Salas J, Gebauer S, Gillis A, van den Berk-Clark C, Schneider FD, Schnurr PP, Friedman MJ, Norman SB, Tuerk PW, Cohen BE, Lustman PJ, Scherrer JF. Increased Smoking Cessation among Veterans with Large Decreases in Posttraumatic Stress Disorder Severity. Nicotine Tob Res 2021; 24:178-185. [PMID: 34477205 DOI: 10.1093/ntr/ntab179] [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] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 09/01/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Improvement in posttraumatic stress disorder (PTSD) is associated with better health behavior such as better medication adherence and greater use of nutrition and weight loss programs. However, it is not known if reducing PTSD severity is associated with smoking cessation, a poor health behavior common in patients with PTSD. METHODS Veterans Health Affairs (VHA) medical record data (2008 to 2015) were used to identify patients with PTSD diagnosed in specialty care. Clinically meaningful PTSD improvement, was defined as ≥20 point PTSD Checklist (PCL) decrease from the first PCL ≥ 50 and the last available PCL within 12 months and at least 8 weeks later. The association between clinically meaningful PTSD improvement and smoking cessation within 2-years after baseline among 449 smokers was estimated in Cox proportional hazard models. Entropy balancing controlled for confounding. RESULTS On average, patients were 39.4 (SD=12.9) years of age, 86.6% were male and 71.5% were white. We observed clinically meaningful PTSD improvement in 19.8% of participants. Overall, 19.4% quit smoking in year 1 and 16.6% in year 2. More patients with vs. without clinically meaningful PTSD improvement stopped smoking (n=36, cumulative incidence=40.5% vs. 111, cumulative incidence=30.8%; respectively). After controlling for confounding, patients with vs. without clinically meaningful PTSD improvement were more likely to stop smoking within 2-years (HR=1.57; 95%CI:1.04-2.36). CONCLUSIONS Patients with clinically meaningful PTSD improvement were significantly more likely to stop smoking. Further research should determine if targeted interventions are needed or whether improvement in PTSD symptoms is sufficient to enable smoking cessation. IMPLICATIONS Patients with PTSD are more likely to develop chronic health conditions such as heart disease and diabetes. Poor health behaviors, including smoking, partly explain the risk for chronic disease in this patient population. Our results demonstrate that clinically meaningful PTSD improvement is followed by greater likelihood of smoking cessation. Thus, PTSD treatment may enable healthier behaviors and reduce risk for smoking related disease.
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Affiliation(s)
- Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104, United States.,Harry S. Truman Veterans Administration Medical Center. Columbia, MO, United States
| | - Sarah Gebauer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104, United States.,Harry S. Truman Veterans Administration Medical Center. Columbia, MO, United States
| | - Auston Gillis
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104, United States
| | - Carissa van den Berk-Clark
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104, United States
| | - F David Schneider
- Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Paula P Schnurr
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, United States
| | - Matthew J Friedman
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, United States
| | - Sonya B Norman
- National Center for PTSD and Department of Psychiatry, University of California San Diego, United States
| | - Peter W Tuerk
- Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville, VA. United States
| | - Beth E Cohen
- Department of Medicine, University of California San Francisco School of Medicine and San Francisco VAMC, United States
| | - Patrick J Lustman
- Department of Psychiatry, Washington University School of Medicine, St. Louis MO. and The Bell Street Clinic Opioid Addiction Treatment Programs, VA St. Louis Healthcare System, St. Louis, MO, United States
| | - Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104, United States.,Harry S. Truman Veterans Administration Medical Center. Columbia, MO, United States
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10
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Rauch SAM, Kim HM, Lederman S, Sullivan G, Acierno R, Tuerk PW, Simon NM, Venners MR, Norman SB, Allard CB, Porter KE, Martis B, Bui E, Baker AW. Predictors of Response to Prolonged Exposure, Sertraline, and Their Combination for the Treatment of Military PTSD. J Clin Psychiatry 2021; 82. [PMID: 34133087 DOI: 10.4088/jcp.20m13752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Indexed: 10/21/2022]
Abstract
Objective: The current study is an analysis of predictors of posttraumatic stress disorder (PTSD) treatment response in a clinical trial comparing (1) prolonged exposure plus placebo (PE + PLB), (2) PE + sertraline (PE + SERT), and (3) sertraline + enhanced medication management (SERT + EMM) with predictors including time since trauma (TST), self-report of pain, alcohol use, baseline symptoms, and demographics. Methods: Participants (N = 196) were veterans with combat-related PTSD (DSM-IV-TR) of at least 3 months' duration recruited between 2012 and 2016 from 4 sites in the 24-week PROlonGed ExpoSure and Sertraline (PROGrESS) clinical trial (assessments at weeks 0 [intake], 6, 12, 24, 36, and 52). Results: Across treatment conditions, (1) longer TST was predictive of greater week 24 PTSD symptom improvement (β = 1.72, P = .01) after adjusting for baseline, (2) higher baseline pain severity was predictive of smaller symptom improvement (β = -2.96, P = .003), and (3) Hispanic patients showed greater improvement than non-Hispanic patients (β = 12.33, P = .03). No other baseline characteristics, including alcohol consumption, were significantly predictive of week 24 improvement. Comparison of TST by treatment condition revealed a significant relationship only in those randomized to the PE + SERT condition (β = 2.53, P = .03). Longitudinal analyses showed similar results. Conclusions: The finding that longer TST shows larger symptom reductions is promising for PTSD patients who might not seek help for years following trauma. Higher baseline pain severity robustly predicted attenuated and slower response to all treatment conditions, suggesting a common neuropathologic substrate. Finally, in the current study, alcohol use did not impede the effectiveness of pharmacotherapy for PTSD. Trial Registration: ClinicalTrials.gov identifier: NCT01524133.
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Affiliation(s)
- Sheila A M Rauch
- Mental Health Service Line, VA Atlanta Healthcare System, Decatur, Georgia.,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia.,Corresponding author: Sheila A. M. Rauch, PhD, Emory University School of Medicine, 12 Executive Park, 3rd Floor, Atlanta, GA 30329
| | - H Myra Kim
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, Michigan
| | | | | | - Ron Acierno
- Mental Health Service Line, Ralph H. Johnson VA Medical Center, Charleston, South Carolina.,Department of Psychiatry & Behavioral Sciences, McGovern Medical School, University of Texas Health Sciences, Houston, Texas
| | - Peter W Tuerk
- Department of Human Services, University of Virginia, Charlottesville, Virginia
| | - Naomi M Simon
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Margaret R Venners
- National Center for PTSD, VA Palo Alto Medical Center, Menlo Park, California.,Research Service Line, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Sonya B Norman
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont.,Department of Psychiatry, University of California, San Diego, School of Medicine, La Jolla, California.,VA Center of Excellence for Stress and Mental Health, San Diego, California
| | - Carolyn B Allard
- PhD Program, California School of Professional Psychology, Alliant International University, San Diego, California.,Research Service, VA San Diego Healthcare System, San Diego, California
| | - Katherine E Porter
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Mental Health Service Line, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Brian Martis
- Mental Health Care Line, VA San Diego Healthcare System, San Diego, California
| | - Eric Bui
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, University of Caen Normandy & Caen University Hospital, Caen, France
| | - Amanda W Baker
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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11
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Dell L, Sbisa AM, O'Donnell M, Tuerk PW, Bryant R, Hodson S, Morton D, Battersby M, Forbes A, Forbes D. Massed versus standard prolonged exposure for posttraumatic stress disorder in Australian military and veteran populations (RESTORE trial): Study protocol for a non-inferiority randomized controlled trial. Contemp Clin Trials 2021; 107:106478. [PMID: 34119717 DOI: 10.1016/j.cct.2021.106478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/03/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Abstract
Posttraumatic stress disorder (PTSD) can be a severe problem, affecting veterans and military personnel at higher rates than the general community. First-line treatment for PTSD, prolonged exposure (PE), is typically delivered weekly for 10-12 weeks, however this duration can pose a barrier to accessing and completing the treatment, particularly for current serving military. This paper presents the RESTORE trial protocol, the first randomized controlled trial of massed PE therapy outside of the United States and by an independent research group. One hundred and thirty-five Australian Defence Force members and veterans (18-80 years) who meet criteria for PTSD related to a military trauma will be randomly allocated to one of two conditions: standard PE (SPE; 10 weekly 90-min sessions) or massed PE (MPE; 10 daily 90-min sessions). Across eight sites, patients will be assessed at pre-treatment, and at 4 weeks, 12 weeks, and 12 months post-treatment commencement. The primary outcome is clinician-measured and self-reported PTSD symptom severity at the 12 week assessment. We hypothesize that MPE will be as effective as SPE in reducing PTSD severity at 12 weeks post-treatment commencement. The adaptation and testing of evidence-based interventions is critical to reduce barriers to treatment uptake among veterans and military personnel. Outcomes of this study have the potential to result in international, cross-service uptake and delivery of this rapid treatment for veterans and military members, as well as civilians, thereby improving clinical outcomes for patients and their families.
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Affiliation(s)
- Lisa Dell
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Carlton, VIC, Australia.
| | - Alyssa M Sbisa
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Carlton, VIC, Australia
| | - Meaghan O'Donnell
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Carlton, VIC, Australia
| | - Peter W Tuerk
- Sheila C. Jonson Centre for Clinical Services, Department of Human Services, University of Virginia, Charlottesville, VA, USA
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | | | | | - Malcolm Battersby
- College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Andrew Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - David Forbes
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Carlton, VIC, Australia
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12
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Salas J, Norman SB, Tuerk PW, van den Berk-Clark C, Cohen BE, Schneider FD, Chard KM, Lustman PJ, Schnurr PP, Friedman MJ, Grucza R, Scherrer JF. PTSD improvement and substance use disorder treatment utilization in veterans: Evidence from medical record data. Drug Alcohol Depend 2021; 218:108365. [PMID: 33109460 PMCID: PMC7750304 DOI: 10.1016/j.drugalcdep.2020.108365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 06/23/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Clinical trials reveal posttraumatic stress disorder (PTSD) improvement leads to decreased substance use among patients with comorbid substance use disorder (SUD). Using administrative medical record data, we determined whether clinically meaningful PTSD Checklist (PCL) (≥20 points) score decreases were positively associated with SUD treatment utilization. METHODS We used a retrospective cohort of Veterans Health Affairs (VHA) medical record data (2008-2015). PTSD Checklist (PCL) scores were used to categorize patients into those with a clinically meaningful PTSD improvement (≥20 point decrease) or not (<20 point decrease or increase). PTSD and SUD were measured by ICD-9 codes. Propensity score weighting controlled for confounding in logistic and negative binomial models that estimated the association between clinically meaningful PTSD improvement and use of SUD treatment and number of SUD clinic visits. RESULTS The 699 eligible patients were, on average, 40.4 (±13.2) years old, 66.2% white and 33.1% were married. After controlling for confounding, there was a 56% increased odds of any SUD treatment utilization among those with a PCL decrease ≥20 vs < 20 (OR = 1.56; 95%CI = 1.04-2.33) but there was no association with number of SUD treatment visits. CONCLUSIONS Clinically meaningful reductions in PTSD symptoms were associated with any SUD treatment utilization but not amount of utilization. Improvement in PTSD symptoms, independent of the treatment modality, may enable SUD treatment seeking.
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Affiliation(s)
- Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO 63104, United States; Harry S. Truman Veterans Administration Medical Center, Columbia, MO, United States.
| | - Sonya B. Norman
- National Center for PTSD and Department of Psychiatry,
University of California San Diego, United States
| | - Peter W. Tuerk
- Sheila C. Johnson Center for Clinical Services, Department
of Human Services, University of Virginia, Charlottesville, VA. United States
| | - Carissa van den Berk-Clark
- Department of Family and Community Medicine, Saint Louis
University School of Medicine, St. Louis MO. 63104, United States
| | - Beth E. Cohen
- Department of Medicine, University of California San
Francisco School of Medicine and San Francisco VAMC, United States
| | - F. David Schneider
- Department of Family and Community Medicine, University of
Texas Southwestern Medical Center, Dallas, TX, United States
| | - Kathleen M. Chard
- Trauma Recovery Center Cincinnati VAMC and Department of
Psychiatry and Behavioral Neuroscience, University of Cincinnati, United
States
| | - Patrick J. Lustman
- Department of Psychiatry, Washington University School of
Medicine, St. Louis MO. and The Bell Street Clinic Opioid Addiction Treatment
Programs, VA St. Louis Healthcare System, St. Louis, MO, United States
| | - Paula P. Schnurr
- National Center for PTSD and Department of Psychiatry,
Geisel School of Medicine at Dartmouth, United States
| | - Matthew J. Friedman
- National Center for PTSD and Department of Psychiatry,
Geisel School of Medicine at Dartmouth, United States
| | - Richard Grucza
- Department of Family and Community Medicine, Saint Louis
University School of Medicine, St. Louis MO. 63104, United States
| | - Jeffrey F. Scherrer
- Department of Family and Community Medicine, Saint Louis
University School of Medicine, St. Louis MO. 63104, United States,Harry S. Truman Veterans Administration Medical Center.
Columbia, MO, United States
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13
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Thomas JG, Goldstein CM, Bond DS, Hadley W, Tuerk PW. Web-based virtual reality to enhance behavioural skills training and weight loss in a commercial online weight management programme: The Experience Success randomized trial. Obes Sci Pract 2020; 6:587-595. [PMID: 33354337 PMCID: PMC7746971 DOI: 10.1002/osp4.451] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/30/2020] [Accepted: 08/09/2020] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Commercial online weight management programmes are popular and easily accessible but often lack training in empirically validated behaviour change strategies and produce suboptimal outcomes. This study evaluated the effects of a Web-based virtual reality (VR) programme for enhancing behavioural skills training and weight loss when offered as an adjunct to a commercial online weight management programme. METHODS N = 146 adults with overweight/obesity (body mass index [BMI] 27-40 kg/m2) were randomized to 6 months of no-cost access to the Weight Watchers (WW) online platform alone or enhanced with the Experience Success (WW + ES) programme, consisting of four Web-based VR sessions for training in behavioural weight-loss skills related to the home environment, the workplace, physical activity and social situations (i.e., a party at a friend's house). Weight was measured at the research centre at baseline, 3 and 6 months. RESULTS Both groups achieved statistically significant weight loss across the trial, with no difference in mean ± standard error (SE) weight loss between WW and WW + ES at 3 months (2.7 ± 1.1 kg vs. 4.2 ± 1.1 kg, respectively; P = .086) but greater weight loss in WW + ES at 6 months (2.6 ± 1.3 kg vs. 4.9 ± 1.3 kg, respectively; P = .042). CONCLUSIONS This study demonstrates the potential of Web-based VR skills training to enhance outcomes of commercial online weight management programmes that are widely accessible. Compared with traditional didactic methods for online skills training, VR simulation provides opportunities to learn behavioural skills via modelling and experiment with skills in real-world situations. More research is needed to identify specific behavioural mechanisms by which ES may improve outcomes.
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Affiliation(s)
- John Graham Thomas
- Department of Psychiatry and Human BehaviorWarren Alpert Medical School of Brown University, The Miriam Hospital/Weight Control and Diabetes Research CenterProvidenceRhode IslandUSA
| | - Carly M. Goldstein
- Department of Psychiatry and Human BehaviorWarren Alpert Medical School of Brown University, The Miriam Hospital/Weight Control and Diabetes Research CenterProvidenceRhode IslandUSA
| | - Dale S. Bond
- Department of Psychiatry and Human BehaviorWarren Alpert Medical School of Brown University, The Miriam Hospital/Weight Control and Diabetes Research CenterProvidenceRhode IslandUSA
| | - Wendy Hadley
- College of EducationUniversity of OregonEugeneOregonUSA
| | - Peter W. Tuerk
- Virtually Better, Inc.DecaturGeorgiaUSA
- Department of Human Services, Sheila C. Johnson Center for Clinical ServicesUniversity of VirginiaCharlottesvilleVirginiaUSA
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14
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Cox KS, Wangelin BC, Keller SM, Lozano BE, Murphy MM, Maher EK, Cobb AR, Tuerk PW. Emotional Processing of Imaginal Exposures Predicts Symptom Improvement: Therapist Ratings Can Assess Trajectory in Prolonged Exposure for Posttraumatic Stress Disorder. J Trauma Stress 2020; 33:338-344. [PMID: 32103546 DOI: 10.1002/jts.22493] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 08/18/2019] [Accepted: 08/25/2019] [Indexed: 11/07/2022]
Abstract
Research on mechanisms of change in prolonged exposure therapy (PE), an evidence-based treatment for posttraumatic stress disorder (PTSD), is ongoing. Two putative mechanisms of change are engagement during imaginal exposure and trauma-related belief change. The PE Therapist Questionnaire (PETQ), a novel measure based on the emotional processing theory underlying PE, was developed as a practical tool for therapists to use to assess (a) patient engagement during imaginal exposures and (b) perspective shifts during postimaginal processing. Patients (N = 151) at a U.S. Veterans Affairs medical center PTSD specialty clinic completed self-report measures of PTSD and depression symptoms prior to sessions. Study therapists (n = 17) completed the PETQ postsession. Rational construction and psychometric analyses suggested a two-component solution for the PETQ: imaginal and processing. The imaginal factor did not relate to PTSD and depression symptoms. The processing factor correlated with current and next-session PTSD and depression symptoms, with medium effect sizes, rs = -.41 to -.45, ps < .001. Controlling for current-session PTSD and depression, a higher level of processing predicted lower next-session PTSD severity, with a small effect size, β = -.38, p < .04. Postexposure emotional processing, which supports positive changes in maladaptive trauma-related beliefs and tolerance of emotional distress, predicted future symptom improvement, highlighting the importance of processing components in PE. Further, the use of therapist observations may offer ancillary methods less influenced by correlation of within-patient subjective ratings and concomitant risk of construct overlap in mechanisms research.
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Affiliation(s)
- Keith S Cox
- Psychology Department, University of North Carolina-Ashville, Asheville, North Carolina, USA.,Ralph H. Johnson VA Medical Center Charleston, South Carolina, USA
| | - Bethany C Wangelin
- Ralph H. Johnson VA Medical Center Charleston, South Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Stephanie M Keller
- Ralph H. Johnson VA Medical Center Charleston, South Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian E Lozano
- Ralph H. Johnson VA Medical Center Charleston, South Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mark M Murphy
- Ralph H. Johnson VA Medical Center Charleston, South Carolina, USA
| | - Edward K Maher
- Ralph H. Johnson VA Medical Center Charleston, South Carolina, USA
| | - Adam R Cobb
- Ralph H. Johnson VA Medical Center Charleston, South Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Peter W Tuerk
- Ralph H. Johnson VA Medical Center Charleston, South Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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15
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Morland LA, Mackintosh MA, Glassman LH, Wells SY, Thorp SR, Rauch SAM, Cunningham PB, Tuerk PW, Grubbs KM, Golshan S, Sohn MJ, Acierno R. Home-based delivery of variable length prolonged exposure therapy: A comparison of clinical efficacy between service modalities. Depress Anxiety 2020; 37:346-355. [PMID: 31872563 DOI: 10.1002/da.22979] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [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: 07/03/2019] [Revised: 10/24/2019] [Accepted: 11/06/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE This study examined clinical and retention outcomes following variable length prolonged exposure (PE) for posttraumatic stress disorder (PTSD) delivered by one of three treatment modalities (i.e., home-based telehealth [HBT], office-based telehealth [OBT], or in-home-in-person [IHIP]). METHOD A randomized clinical trial design was used to compare variable-length PE delivered through HBT, OBT, or IHIP. Treatment duration (i.e., number of sessions) was determined by either achievement of a criterion score on the PTSD Checklist for Diagnostic and Statistical Manual-5 (DSM-5; PTSD Checklist for DSM-5) for two consecutive sessions or completion of 15 sessions. Participants received PE via HBT (n = 58), OBT (n = 59) or IHIP (n = 58). Data were collected between 2012 and 2018, and PTSD was diagnosed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), administered at baseline, posttreatment, and 6 months following treatment completion. The primary clinical outcome was CAPS-5 PTSD severity. Secondary outcomes included self-reported PTSD and depression symptoms, as well as treatment dropout. RESULTS The clinical effectiveness of PE did not differ by treatment modality across any time point; however, there was a significant difference in treatment dropout. Veterans in the HBT (odds ratio [OR] = 2.67; 95% confidence interval [CI] = 1.10, 6.52; p = .031) and OBT (OR = 5.08; 95% CI = 2.10; 12.26; p < .001) conditions were significantly more likely than veterans in IHIP to drop out of treatment. CONCLUSIONS Providers can effectively deliver PE through telehealth and in-home, in-person modalities although the rate of treatment completion was higher in IHIP care.
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Affiliation(s)
- Leslie A Morland
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | | | - Lisa H Glassman
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Stephanie Y Wells
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Steven R Thorp
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Sheila A M Rauch
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Phillippe B Cunningham
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Peter W Tuerk
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Kathleen M Grubbs
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Shahrokh Golshan
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Min Ji Sohn
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Ron Acierno
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
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16
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Badour CL, Cox KS, Goodnight JR, Flores J, Tuerk PW, Rauch SA. Sexual Desire among Veterans Receiving Prolonged Exposure Therapy for PTSD: Does Successful PTSD Treatment Also Yield Improvements in Sexual Desire? Psychiatry 2020; 83:70-83. [PMID: 31577915 PMCID: PMC7083685 DOI: 10.1080/00332747.2019.1672439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Indexed: 10/25/2022]
Abstract
Objective: People with posttraumatic stress disorder (PTSD) commonly report difficulties with sexual desire and other aspects of sexual functioning, but it is currently unknown if people who respond to psychotherapy for PTSD also report improvements in sexual desire. Method: One hundred and eighty-seven veterans with PTSD received prolonged exposure (PE) therapy at two outpatient PTSD specialty clinics and completed measures of PTSD symptoms (the PTSD Checklist - Military Version) and sexual desire (item 21 of the Beck Depression Inventory - Second Edition) repeatedly throughout the course of treatment. Results: The results of a conditional generalized mixed ordinal regression model showed a significant interaction between weeks in treatment and PTSD treatment response in predicting change in sexual desire across the course of treatment. Specifically, PTSD treatment responders reported improvement in sexual desire over the course of treatment, whereas nonresponders did not show changes in sexual desire over time. However, the effect of PTSD treatment response was no longer significant when accounting for severity of depression at the start of treatment. Participants reporting more severe depression at the start of treatment reported less improvement in sexual desire, regardless of PTSD symptom response. Conclusions: People with PTSD who respond to PE also report improvements in sexual desire over time, indicating that response to PE is associated with improved sexual desire, but the effect is complicated by the presence of co-occurring depression symptomatology.
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Affiliation(s)
| | - Keith S. Cox
- University of North Carolina, Asheville, Department of Psychology
| | | | | | | | - Sheila A.M. Rauch
- Emory University, Department of Psychiatry and Behavioral Sciences,VA Atlanta Healthcare System, Mental Health Service Line
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17
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Grubaugh AL, Myers US, Keller SM, Wangelin BC, Lozano BE, Tuerk PW. An adjunctive human-animal interaction intervention for veterans with PTSD: study protocol for a randomized controlled trial. Trials 2019; 20:786. [PMID: 31881993 PMCID: PMC6935088 DOI: 10.1186/s13063-019-3877-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 11/04/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) rarely remits over time, and if left untreated, leads to significant distress, functional impairment, and increased health care costs. Fortunately, effective evidence-based treatments (EBTs) for PTSD, such as Prolonged Exposure (PE), exist. Despite their availability and efficacy, a significant number of individuals with PTSD do not initiate treatment when offered or dropout prematurely. One proposed theory suggests that the emotional-numbing symptoms of PTSD (e.g., blunted affect, apathy) can serve as a barrier to engaging in, and successfully completing, treatment; and the broad human-animal interaction (HAI) literature available suggests that HAI can potentially reduce emotional numbing related to PTSD. Accordingly, this manuscript describes an ongoing, federally funded, randomized controlled trial testing the efficacy of RESCUE, an HAI intervention, as a viable adjunctive treatment component for PE. METHODS/DESIGN The study will include 70 veterans with PTSD treated at a Southeastern Veterans Affairs Medical Center (VAMC). All participants in the trial receive up to 12 sessions of PE. Participants are randomly assigned 1:1 to (1) volunteer at a local animal shelter or (2) volunteer at a community agency of their choice as part of their in-vivo exposure exercises for PE. Outcomes will be examined via standard clinical interviews, self-report questionnaires, and thematic interviews. DISCUSSION It is hypothesized that participants in the HAI condition will report greater decreases in emotional-numbing symptoms and increased treatment compliance and completion rates relative to those in the community volunteer condition. If successful, RESCUE, could be easily incorporated into standard PE and broadly disseminated. TRIAL REGISTRATION ClinicalTrials.gov. ID: NCT03504722. Retrospectively registered on 2 May 2017.
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Affiliation(s)
- Anouk L Grubaugh
- Ralph H. Johnson Veterans Affairs Medical Center and Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 109 Bee Street, Charleston, SC, 29401, USA.
| | - Ursula S Myers
- Ralph H. Johnson Veterans Affairs Medical Center and Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 109 Bee Street, Charleston, SC, 29401, USA
| | - Stephanie M Keller
- Ralph H. Johnson Veterans Affairs Medical Center and Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 109 Bee Street, Charleston, SC, 29401, USA
| | - Bethany C Wangelin
- Ralph H. Johnson Veterans Affairs Medical Center and Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 109 Bee Street, Charleston, SC, 29401, USA
| | - Brian E Lozano
- Ralph H. Johnson Veterans Affairs Medical Center and Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 109 Bee Street, Charleston, SC, 29401, USA
| | - Peter W Tuerk
- Sheila C. Johnson Center for Clinical Services, Department of Human Services, Curry School of Education, University of Virginia, 417 Emmet Street South, 400270, Charlottesville, VA, 22904, USA
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18
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Beidel DC, Neer SM, Bowers CA, Newins AR, Tuerk PW, Cunningham CA, Mooney SR, Hauck HN, Jett M. Trauma Management Therapy and Prolonged Exposure Therapy for PTSD in an active duty sample: Design and methodology of a randomized clinical trial. Contemp Clin Trials Commun 2019; 17:100491. [PMID: 31799476 PMCID: PMC6881668 DOI: 10.1016/j.conctc.2019.100491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 02/04/2019] [Revised: 11/04/2019] [Accepted: 11/09/2019] [Indexed: 11/30/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) resulting from military service is a common, yet often chronic condition. Treatment outcome often is attenuated by programs that are (a) lengthy in nature and (b) constricted in their target outcomes. These limitations leave much of the emotional and behavioral impairment that accompanies PTSD unaddressed and/or unassessed. Typical PTSD treatment programs are 3–4 months in length, which is challenging for the pace of the nation's military. In this investigation, we will compare two treatments, Trauma Management Therapy (TMT) and Prolonged Exposure (PE), both redesigned to address the needs of active duty personnel (300 participants at 3 military installations). Specifically, we will compare the TMT Intensive Outpatient Program (IOP; 3 weeks) to PE's compressed (2 week) format. Both interventions will be compared to a standard course of PE (12 weeks). In addition to PTSD symptomatology, outcome measurement includes other aspects of psychopathology as well as changes in social, occupational, and familial impairment. Potential negative outcomes of massed treatment, such as increased suicidal ideation or increased alcohol use, will be assessed, as will genetic predictors of PTSD subtype and treatment outcome. This study will inform the delivery of care for military-related PTSD and particularly the use of intensive or compressed treatments for active duty personnel.
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Affiliation(s)
| | | | | | | | - Peter W Tuerk
- Department of Human Services, University of Virginia, USA
| | | | | | | | - Marti Jett
- US Army Center for Environmental Health Research, Fort Detrick, MD, USA
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19
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Tuerk PW, Schaeffer CM, McGuire JF, Adams Larsen M, Capobianco N, Piacentini J. Adapting Evidence-Based Treatments for Digital Technologies: a Critical Review of Functions, Tools, and the Use of Branded Solutions. Curr Psychiatry Rep 2019; 21:106. [PMID: 31584124 DOI: 10.1007/s11920-019-1092-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE OF REVIEW We provide a critical review of digital technologies in evidence-based treatments (EBTs) for mental health with a focus on the functions technologies are intended to serve. The review highlights issues related to clarity of purpose, usability, and assumptions related to EBT technology integration, branding, and packaging. RECENT FINDINGS Developers continue to use technology in creative ways, often combining multiple functions to convey existing EBTs or to create new technology-enabled EBTs. Developers have a strong preference for creating and investigating whole-source, branded solutions related to specific EBTs, in comparison to developing or investigating technology tools related to specific components of behavior change, or developing specific clinical protocols that can be delivered via existing technologies. Default assumptions that new applications are required for each individual EBT, that EBTs are best served by the use of only one technology solution rather than multiple tools, and that an EBT-specific technology product should include or convey all portions of an EBT slow scientific progress and increase risk of usability issues that negatively impact uptake. We contend that a purposeful, functions-based approach should guide the selection, development, and application of technology in support of EBT delivery.
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Affiliation(s)
- Peter W Tuerk
- Sheila C. Johnson Center for Clinical Services, University of Virginia, Charlottesville, VA, USA.
- Department of Human Services, University of Virginia, 417 Emmet St. South, Charlottesville, VA, 22904, USA.
| | - Cindy M Schaeffer
- Division of Child and Adolescent Psychiatry, University of Maryland-Baltimore, Baltimore, MD, USA
| | - Joseph F McGuire
- Division of Child and Adolescent Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
| | | | - Nicole Capobianco
- Department of Human Services, University of Virginia, Charlottesville, VA, USA
| | - John Piacentini
- UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, 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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Meis LA, Noorbaloochi S, Campbell EMH, Erbes CR, Polusny MA, Velasquez TL, Bangerter A, Cutting A, Eftekhari A, Rosen C, Tuerk PW, Burmeister LB, Spoont MR. Sticking it out in trauma-focused treatment for PTSD: It takes a village. J Consult Clin Psychol 2019; 87:246-256. [PMID: 30777776 PMCID: PMC6548182 DOI: 10.1037/ccp0000386] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE One in 3 veterans will dropout from trauma-focused treatments for posttraumatic stress disorder (PTSD). Social environments may be particularly important to influencing treatment retention. We examined the role of 2 support system factors in predicting treatment dropout: social control (direct efforts by loved ones to encourage veterans to participate in treatment and face distress) and symptom accommodation (changes in loved ones' behavior to reduce veterans' PTSD-related distress). METHOD Veterans and a loved one were surveyed across 4 VA hospitals. All veterans were initiating prolonged exposure therapy or cognitive processing therapy (n = 272 dyads). Dropout was coded through review of VA hospital records. RESULTS Regression analyses controlled for traditional, individual-focused factors likely to influence treatment dropout. We found that, even after accounting for these factors, veterans who reported their loved ones encouraged them to face distress were twice as likely to remain in PTSD treatment than veterans who denied such encouragement. CONCLUSIONS Clinicians initiating trauma-focused treatments with veterans should routinely assess how open veterans' support systems are to encouraging veterans to face their distress. Outreach to support networks is warranted to ensure loved ones back the underlying philosophy of trauma-focused treatments. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Laura A. Meis
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
- University of Minnesota, Medical School, Department of Medicine
| | - Siamak Noorbaloochi
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
- University of Minnesota, Medical School, Department of Medicine
| | - Emily M. Hagel Campbell
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
| | - Christopher R. Erbes
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
- University of Minnesota, Medical School, Department of Psychiatry
| | - Melissa A. Polusny
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
- University of Minnesota, Medical School, Department of Psychiatry
| | - Tina L. Velasquez
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
| | - Ann Bangerter
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
| | - Andrea Cutting
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
| | - Afsoon Eftekhari
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Craig Rosen
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Peter W. Tuerk
- University of Virginia, Sheila C Johnson Center for Human Services
| | | | - Michele R. Spoont
- Minneapolis Veterans Affairs Health Care System, Center for Care Delivery & Outcomes Research
- University of Minnesota, Medical School, Department of Medicine
- University of Minnesota, Medical School, Department of Psychiatry
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Tuerk PW, Rauch SAM, Rothbaum BO. Effect size matters: a key neglected indicator of comparative trial quality. Lancet Psychiatry 2019; 6:e4. [PMID: 30686400 DOI: 10.1016/s2215-0366(18)30505-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Peter W Tuerk
- Department of Human Services, University of Virginia, Charlottesville, VA 22904, USA.
| | - Sheila A M Rauch
- Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA
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Rauch SAM, Kim HM, Powell C, Tuerk PW, Simon NM, Acierno R, Allard CB, Norman SB, Venners MR, Rothbaum BO, Stein MB, Porter K, Martis B, King AP, Liberzon I, Phan KL, Hoge CW. Efficacy of Prolonged Exposure Therapy, Sertraline Hydrochloride, and Their Combination Among Combat Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2019; 76:117-126. [PMID: 30516797 PMCID: PMC6439753 DOI: 10.1001/jamapsychiatry.2018.3412] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [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: 05/28/2018] [Accepted: 08/08/2018] [Indexed: 12/30/2022]
Abstract
Importance Meta-analyses of treatments for posttraumatic stress disorder (PTSD) suggest that trauma-focused psychotherapies produce greater benefits than antidepressant medications alone. Objective To determine the relative efficacy of prolonged exposure therapy plus placebo, prolonged exposure therapy plus sertraline hydrochloride, and sertraline plus enhanced medication management in the treatment of PTSD. Design, Setting, and Participants The Prolonged Exposure and Sertraline Trial was a randomized, multisite, 24-week clinical trial conducted at the Veterans Affairs Ann Arbor Healthcare System, Veterans Affairs San Diego Healthcare System, Ralph H. Johnson Veterans Affairs Medical Center, and Massachusetts General Hospital Home Base Veterans Program between January 26, 2012, and May 9, 2016. Participants and clinicians were blinded to pill condition, and outcome evaluators were blinded to assignment. Participants completed assessments at weeks 0 (intake), 6, 12, 24, and 52 (follow-up). Participants (N = 223) were service members or veterans of the Iraq and/or Afghanistan wars with combat-related PTSD and significant impairment (Clinician-Administered PTSD Scale score, ≥50) of at least 3 months' duration. Analyses were on an intent-to-treat basis. Intervention Participants completed up to thirteen 90-minute sessions of prolonged exposure therapy by week 24. Sertraline dosage was titrated during a 10-week period and continued until week 24; medication management was manualized. Main Outcomes and Measures The primary outcome was symptom severity of PTSD in the past month as assessed by the Clinician-Administered PTSD Scale score at week 24. Results Of 223 randomized participants, 149 completed the study at 24 weeks, and 207 (180 men and 27 women; mean [SD] age, 34.5 [8.3 years]) were included in the intent-to-treat analysis. Modified intent-to-treat analysis using a mixed model of repeated measures showed that PTSD symptoms decreased significantly during the 24 weeks (sertraline plus enhanced medication management, 33.8 points; prolonged exposure therapy plus sertraline, 32.7 points; and prolonged exposure therapy plus placebo, 29.4 points; β,-9.39; 95% CI, -11.62 to -7.16; P < .001); however, slopes did not differ by treatment group (prolonged exposure therapy plus placebo group, -9.39; sertraline plus enhanced medication management group, -10.37; and prolonged exposure therapy plus sertraline group, -9.99; P = .81). Conclusions and Relevance No difference in change in PTSD symptoms or symptom severity at 24 weeks was found between sertraline plus enhanced medication management, prolonged exposure therapy plus placebo, and prolonged exposure therapy plus sertraline. Trial Registration ClinicalTrials.gov Identifier: NCT01524133.
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Affiliation(s)
- Sheila A. M. Rauch
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - H. Myra Kim
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor
| | - Corey Powell
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor
| | - Peter W. Tuerk
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
- Department of Psychiatry, Medical University of South Carolina, Charleston
| | - Naomi M. Simon
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Psychiatry, New York University School of Medicine, New York
| | - Ron Acierno
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
- College of Nursing, Medical University of South Carolina, Charleston
| | - Carolyn B. Allard
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
| | - Sonya B. Norman
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
- Veterans Affairs Center of Excellence for Stress and Mental Health, San Diego, California
| | - Margaret R. Venners
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
| | - Barbara O. Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Murray B. Stein
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
| | - Katherine Porter
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - Brian Martis
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
| | - Anthony P. King
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - Israel Liberzon
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - K. Luan Phan
- Department of Psychiatry, University of Illinois at Chicago
- Mental Health Service Line, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
| | - Charles W. Hoge
- Walter Reed Army Institute of Research, Silver Spring, Maryland
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Tuerk PW, Keller SM, Acierno R. Treatment for Anxiety and Depression via Clinical Videoconferencing: Evidence Base and Barriers to Expanded Access in Practice. Focus (Am Psychiatr Publ) 2018; 16:363-369. [PMID: 31975928 DOI: 10.1176/appi.focus.20180027] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This review summarizes six decades of clinical outcome research relevant to evidence-based practices for depression and anxiety delivered via clinical videoconferencing. The authors conducted a literature search of previous systematic reviews and an updated search of publications specific to anxiety and depression. Overall, strong evidence supports the safety and clinical effectiveness of administering evidence-based psychotherapy for anxiety and depression via clinical videoconferencing among heterogeneous populations and age ranges, and in multiple care settings, with similar outcomes to in-person care. Despite the overall clinical effectiveness of the modality, the authors discuss common logistical and institutional barriers to long-term effective implementation. Future systems-level research is required to investigate replicable and sustainable models for implementing and expanding access to evidence-based psychotherapies via clinical videoconferencing.
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Affiliation(s)
- Peter W Tuerk
- Dr. Tuerk and Dr. Keller are with the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston; Dr. Acierno is with the College of Nursing, Medical University of South Carolina. Dr. Tuerk is also with the Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville; Dr. Keller and Dr. Acierno are also with the Ralph H. Johnson VA Medical Center, Charleston, South Carolina
| | - Stephanie M Keller
- Dr. Tuerk and Dr. Keller are with the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston; Dr. Acierno is with the College of Nursing, Medical University of South Carolina. Dr. Tuerk is also with the Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville; Dr. Keller and Dr. Acierno are also with the Ralph H. Johnson VA Medical Center, Charleston, South Carolina
| | - Ron Acierno
- Dr. Tuerk and Dr. Keller are with the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston; Dr. Acierno is with the College of Nursing, Medical University of South Carolina. Dr. Tuerk is also with the Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville; Dr. Keller and Dr. Acierno are also with the Ralph H. Johnson VA Medical Center, Charleston, South Carolina
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Tuerk PW, Wangelin BC, Powers MB, Smits JAJ, Acierno R, Myers US, Orr SP, Foa EB, Hamner MB. Augmenting treatment efficiency in exposure therapy for PTSD: a randomized double-blind placebo-controlled trial of yohimbine HCl. Cogn Behav Ther 2018; 47:351-371. [DOI: 10.1080/16506073.2018.1432679] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Peter W. Tuerk
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Bethany C. Wangelin
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Mark B. Powers
- Department of Psychology, University of Texas at Austin, Austin, TX, USA
| | - Jasper A. J. Smits
- Department of Psychology, University of Texas at Austin, Austin, TX, USA
| | - Ron Acierno
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | | | - Scott P. Orr
- Department of Psychiatry Service, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Edna B. Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
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Rauch SA, Simon NM, Kim HM, Acierno R, King AP, Norman SB, Venners MR, Porter K, Phan KL, Tuerk PW, Allard C, Liberzon I, Rothbaum BO, Martis B, Stein MB, Hoge CW. Integrating biological treatment mechanisms into randomized clinical trials: Design of PROGrESS (PROlonGed ExpoSure and Sertraline Trial). Contemp Clin Trials 2018; 64:128-138. [DOI: 10.1016/j.cct.2017.10.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/21/2017] [Accepted: 10/23/2017] [Indexed: 01/07/2023]
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Holland-Carter L, Tuerk PW, Wadden TA, Fujioka KN, Becker LE, Miller-Kovach K, Hollander PL, Garvey WT, Weiss D, Rubino DM, Kushner RF, Malcolm RJ, Raum WJ, Hermayer KL, Veliko JL, Rost SL, Sora ND, Salyer JL, O'Neil PM. Impact on psychosocial outcomes of a nationally available weight management program tailored for individuals with type 2 diabetes: Results of a randomized controlled trial. J Diabetes Complications 2017; 31:891-897. [PMID: 28319001 DOI: 10.1016/j.jdiacomp.2017.01.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 01/19/2017] [Accepted: 01/31/2017] [Indexed: 12/15/2022]
Abstract
AIMS Type 2 diabetes mellitus (T2DM) can substantially decrease quality of life (QOL). This study examined the effects on QOL-relevant psychosocial measures of a widely available commercial weight loss program enhanced for individuals with T2DM. METHODS A year-long multi-site randomized clinical trial compared the Weight Watchers (WW) approach, supplemented with phone and email counseling with a certified diabetes educator (CDE), to brief standard diabetes nutrition counseling and education (Standard Care; SC). Participants were 400 women and 163 men (N=279 WW; 284 SC) with T2DM [mean (±SD) HbA1c 8.32±1%; BMI=37.1±5.7kg/m2; age=55.1 ± 9.1years]. Psychosocial outcomes were assessed at baseline, month 6, and month 12 using a diabetes specific psychosocial measure (Diabetes Distress Scale [DDS]), Impact of Weight on Quality of Life-Lite scale (IWQOL), a generic QOL measure (SF-36), and a depression screen (PHQ-9). RESULTS WW participants showed significantly greater improvements than did SC participants on all DDS subscales and total score and on IWQOL total score and physical function, sex life and work domains (all ps<.05). There was no significant treatment effect on SF-36 scores or PHQ-9. CONCLUSIONS WW enhanced for individuals with T2DM was superior to SC in improving psychosocial outcomes most specific to T2DM and obesity. Available commercial WL programs, combined with scalable complementary program-specific diabetes counseling, may have benefits that extend to diabetes-related distress and weight-relevant QOL.
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Affiliation(s)
- Lauren Holland-Carter
- Weight Management Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Suite 410 South, Charleston, SC, 29425.
| | - Peter W Tuerk
- Weight Management Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Suite 410 South, Charleston, SC, 29425; Mental Health Service, Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC, 29401.
| | - Thomas A Wadden
- Center for Weight and Eating Disorders, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, Suite 3029, Philadelphia, PA, 19104.
| | - Ken N Fujioka
- Scripps Clinical Research, 11025 N. Torrey Pines Road, Suite 200, LaJolla, CA 92037.
| | - Lynne E Becker
- Weight Management Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Suite 410 South, Charleston, SC, 29425.
| | - Karen Miller-Kovach
- Weight Watchers International, 11 Madison Avenue 17th Floor, New York, NY 10010.
| | - Priscilla L Hollander
- Baylor Endocrine Center, 3600 Gaston Avenue, Wadley Tower, Suite 656, Dallas, TX 75246.
| | - W Timothy Garvey
- Department of Nutrition Sciences, 1675 University Blvd, University of Alabama at Birmingham, Birmingham, AL 35294; Birmingham Veterans Administration Medical Center.
| | - Daniel Weiss
- Your Diabetes Endocrine Nutrition Group, 8300 Tyler Blvd Suite 102, Mentor, OH 44060.
| | - Domenica M Rubino
- Washington Center for Weight Management & Research, 2800 S. Shirlington Road, Arlington, VA 22206.
| | - Robert F Kushner
- Northwestern University, Feinberg School of Medicine, Rubloff Building 10th Floor, 750 N. Lake Shore Drive, Chicago, IL 60611.
| | - Robert J Malcolm
- Weight Management Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Suite 410 South, Charleston, SC, 29425
| | - William J Raum
- Oregon Weight Loss Surgery, 1040 NW 22nd Avenue, Suite 500, Portland, OR 97210.
| | - Kathie L Hermayer
- Division of Endocrinology, Diabetes and Medical Genetics, College of Medicine, Clinical Science Building, 8th Floor, 96 Jonathan Lucas Street, Medical University of South Carolina, Charleston, SC 29425.
| | - Jan L Veliko
- Weight Watchers International, 11 Madison Avenue 17th Floor, New York, NY 10010.
| | - Stephanie L Rost
- Weight Watchers International, 11 Madison Avenue 17th Floor, New York, NY 10010.
| | - Nicoleta D Sora
- Division of Endocrinology, Diabetes and Medical Genetics, College of Medicine, Clinical Science Building, 8th Floor, 96 Jonathan Lucas Street, Medical University of South Carolina, Charleston, SC 29425.
| | - Jonny L Salyer
- Lovelace Scientific Resources, 2441 Ridgecrest Drive, SE, Albuquerque, NM 87108
| | - Patrick M O'Neil
- Weight Management Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Suite 410 South, Charleston, SC, 29425.
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Bunnell BE, Davidson TM, Hamblen JL, Cook DL, Grubaugh AL, Lozano BE, Tuerk PW, Ruggiero KJ. Protocol for the evaluation of a digital storytelling approach to address stigma and improve readiness to seek services among veterans. Pilot Feasibility Stud 2017; 3:7. [PMID: 28239485 PMCID: PMC5314584 DOI: 10.1186/s40814-017-0121-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 01/02/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Research suggests that at least 10% of veterans returning from Iraq and Afghanistan meet criteria for posttraumatic stress disorder (PTSD) related to their military experiences. National dissemination initiatives have increased veterans' access to best-practice interventions. However, treatment-seeking remains low among veterans with PTSD, often due to perceived stigma and other associated barriers. The National Center for PTSD recently developed and launched AboutFace, a digital storytelling (DST) resource designed to help veterans recognize PTSD and motivate them to seek evidence-based treatment. The Ralph H. Johnson Veterans Affairs Medical Center (VAMC) and the National Center for PTSD have partnered to conduct pilot work to evaluate veterans' reactions to AboutFace to set the stage for a large-scale study to examine whether AboutFace effectively reduces stigma and improves attitudes toward treatment-seeking among veterans. If effective, this DST approach may serve as a valuable national model for a variety of treatment-seeking populations. METHODS During the first phase of the pilot, in-person usability assessments of AboutFace will be conducted via semi-structured interviews with 20 veterans. Audio recordings of interviews will undergo transcription and coding. A report of the results of qualitative analyses of these interviews will be provided to the National Center for PTSD and will inform revisions to the site. In the second phase of the pilot, 60 veterans referred to a specialized PTSD clinic will be recruited to demonstrate and refine the methodology that we propose to use in a larger randomized controlled trial evaluation of AboutFace. Veterans will be randomly assigned to receive AboutFace plus standard education vs. standard education alone. Baseline and 2-week telephone assessments will be conducted with participating veterans to measure stigma, attitudes toward seeking mental health services, and treatment access/engagement. DISCUSSION The feedback we receive in this pilot will be used to strengthen the quality of the DST website in preparation for a large-scale evaluation. Future work will involve evaluation of reach and impact of the site relative to stigma, attitudes toward seeking mental health service, and utilization of care. If AboutFace is found to increase access to care, this finding would have broad and significant implications for overcoming barriers to care for veterans and other populations with stigmatized conditions. TRIAL REGISTRATION Clinicaltrials.gov, NCT02486692.
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Affiliation(s)
- Brian E. Bunnell
- Ralph H. Johnson VAMC, Charleston, SC USA
- Department of Nursing, Medical University of South Carolina, 99 Jonathan Lucas St., MSC 160, Charleston, SC 29425 USA
| | - Tatiana M. Davidson
- Ralph H. Johnson VAMC, Charleston, SC USA
- Department of Nursing, Medical University of South Carolina, 99 Jonathan Lucas St., MSC 160, Charleston, SC 29425 USA
| | - Jessica L. Hamblen
- VA National Center for PTSD, White River Junction, VT USA
- Geisel School of Medicine at Dartmouth, Hanover, NH USA
| | - Danna L. Cook
- Ralph H. Johnson VAMC, Charleston, SC USA
- Department of Nursing, Medical University of South Carolina, 99 Jonathan Lucas St., MSC 160, Charleston, SC 29425 USA
| | - Anouk L. Grubaugh
- Ralph H. Johnson VAMC, Charleston, SC USA
- Department of Nursing, Medical University of South Carolina, 99 Jonathan Lucas St., MSC 160, Charleston, SC 29425 USA
| | - Brian E. Lozano
- Ralph H. Johnson VAMC, Charleston, SC USA
- Department of Nursing, Medical University of South Carolina, 99 Jonathan Lucas St., MSC 160, Charleston, SC 29425 USA
| | - Peter W. Tuerk
- Ralph H. Johnson VAMC, Charleston, SC USA
- Department of Nursing, Medical University of South Carolina, 99 Jonathan Lucas St., MSC 160, Charleston, SC 29425 USA
| | - Kenneth J. Ruggiero
- Ralph H. Johnson VAMC, Charleston, SC USA
- Department of Nursing, Medical University of South Carolina, 99 Jonathan Lucas St., MSC 160, Charleston, SC 29425 USA
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O'Neil PM, Miller-Kovach K, Tuerk PW, Becker LE, Wadden TA, Fujioka K, Hollander PL, Kushner RF, Timothy Garvey W, Rubino DM, Malcolm RJ, Weiss D, Raum WJ, Salyer JL, Hermayer KL, Rost SL, Veliko JL, Sora ND. Randomized controlled trial of a nationally available weight control program tailored for adults with type 2 diabetes. Obesity (Silver Spring) 2016; 24:2269-2277. [PMID: 27804264 DOI: 10.1002/oby.21616] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [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] [Received: 03/18/2016] [Revised: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Modest weight loss from clinical interventions improves glycemic control in type 2 diabetes (T2DM). Data are sparse on the effects of weight loss via commercial weight loss programs. This study examined the effects on glycemic control and weight loss of the standard Weight Watchers program, combined with telephone and email consultations with a certified diabetes educator (WW), compared with standard diabetes nutrition counseling and education (standard care, SC). METHODS In a 12-month randomized controlled trial at 16 U.S. research centers, 563 adults with T2DM (HbA1c 7-11%; BMI 27-50 kg/m2 ) were assigned to either the commercially available WW program (regular community meetings, online tools), plus telephone and email counseling from a certified diabetes educator, or to SC (initial in-person diabetes nutrition counseling/education, with follow-up informational materials). RESULTS Follow-up rate was 86%. Twelve-month HbA1c changes for WW and SC were -0.32 and +0.16, respectively; 24% of WW versus 14% of SC achieved HbA1c <7.0% (P = 0.004). Weight losses were -4.0% for WW and -1.9% for SC (Ps < 0.001). 26% of WW versus 12% of SC reduced diabetes medications (P < 0.001). WW participants had greater reductions in waist circumference (P < 0.001) and C-reactive protein (P = 0.02) but did not differ on other cardiovascular risk factors. CONCLUSIONS Widely available commercial weight loss programs with community and online components, combined with scalable complementary diabetes education, may represent accessible and effective components of management plans for adults with overweight/obesity and T2DM.
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Affiliation(s)
- Patrick M O'Neil
- Department of Psychiatry and Behavioral Sciences, Weight Management Center, Medical University of South Carolina, Charleston, South Carolina, USA.
| | | | - Peter W Tuerk
- Department of Psychiatry and Behavioral Sciences, Weight Management Center, Medical University of South Carolina, Charleston, South Carolina, USA
- Mental Health Service, Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Lynne E Becker
- Department of Psychiatry and Behavioral Sciences, Weight Management Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Thomas A Wadden
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ken Fujioka
- Scripps Clinical Research, La Jolla, California, USA
| | | | - Robert F Kushner
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - W Timothy Garvey
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Birmingham VA Medical Center, Birmingham, Alabama, USA
| | - Domenica M Rubino
- Washington Center for Weight Management & Research, Arlington, Virginia, USA
| | - Robert J Malcolm
- Department of Psychiatry and Behavioral Sciences, Weight Management Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Daniel Weiss
- Your Diabetes Endocrine Nutrition Group, Mentor, Ohio, USA
| | | | - Jonny L Salyer
- Lovelace Scientific Resources, Albuquerque, New Mexico, USA
| | - Kathie L Hermayer
- Division of Endocrinology, Diabetes & Medical Genetics, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Jan L Veliko
- Weight Watchers International, New York, New York, USA
| | - Nicoleta D Sora
- Division of Endocrinology, Diabetes & Medical Genetics, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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Cox KS, Mouilso ER, Venners MR, Defever ME, Duvivier L, Rauch SAM, Strom TQ, Joiner TE, Tuerk PW. Reducing suicidal ideation through evidence-based treatment for posttraumatic stress disorder. J Psychiatr Res 2016; 80:59-63. [PMID: 27295122 DOI: 10.1016/j.jpsychires.2016.05.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [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: 12/28/2015] [Revised: 05/09/2016] [Accepted: 05/23/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Suicide is a major public health concern in military and civilian contexts. Veteran populations are at increased risk for suicide, especially veterans with mental health disorders such as Posttraumatic Stress Disorder (PTSD). Suicidal ideation (SI) is a primary risk factor for suicide. METHODS We investigated changes in SI in a multi-site sample of treatment seeking veterans from three separate Veterans Health Administration (VA) medical centers (n = 289) who received Prolonged Exposure (PE) therapy, an evidence-based treatment (EBT) for PTSD. SI and PTSD symptoms were assessed, using self-report instruments, throughout routine clinical care. RESULTS Both PTSD and SI symptoms reduced over the course of treatment (d-type effect sizes of 1.47 and 0.27, respectively). While SI was associated with PTSD symptoms at all time points, appropriately specified, time lagged models indicated that changes in PTSD symptoms were predictive of future declines in SI, while the converse was not true. CONCLUSIONS Results indicate that treating PTSD symptoms with an EBT for PTSD can be an effective way to reduce SI, at least partially, and for some patients. These data are significant in light of the resources and programming devoted to addressing SI in the VA relative to available empirical evidence regarding the effectiveness of developed strategies. The findings demonstrate the importance of facilitating EBT referrals for specific disorders as a component of broad-based suicide outreach and preventions strategies.
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Affiliation(s)
- Keith S Cox
- Department of Psychology, University of North Carolina Asheville, One University Heights, Asheville, NC, 28803, United States.
| | - Emily R Mouilso
- Psychology Department, University of Georgia, 125 Baldwin St., Athens, GA, 30602, United States
| | - Margaret R Venners
- VA Ann Arbor Health Care System, 2215 Fuller Rd, Ann Arbor, MI, 48105, United States; Department of Psychiatry, University of Michigan Medical School, 4250 Plymouth Rd, Ann Arbor, 48109, United States
| | - Mahrie E Defever
- VA Ann Arbor Health Care System, 2215 Fuller Rd, Ann Arbor, MI, 48105, United States; Department of Psychiatry, University of Michigan Medical School, 4250 Plymouth Rd, Ann Arbor, 48109, United States
| | - Leticia Duvivier
- Evidence-Based Practice Institute, 3303 S Irving St, Seattle, WA, 98144, United States
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Dr. NE #200, Atlanta, GA, 30329, United States
| | - Thad Q Strom
- Minneapolis VA Health Care System, 1 Veterans Dr., Minneapolis, MN, 55417, United States; Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, 55454, United States
| | - Thomas E Joiner
- Department of Psychology, Florida State University, 1107 W. Call St., Tallahassee, FL, 32304, United States
| | - Peter W Tuerk
- Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC, 29401, United States; Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President St., MSC 861, Charleston, SC, 29425, United States
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Clapp JD, Kemp JJ, Cox KS, Tuerk PW. PATTERNS OF CHANGE IN RESPONSE TO PROLONGED EXPOSURE: IMPLICATIONS FOR TREATMENT OUTCOME. Depress Anxiety 2016; 33:807-15. [PMID: 27321062 DOI: 10.1002/da.22534] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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: 09/01/2015] [Revised: 06/03/2016] [Accepted: 06/03/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Assessment of response to Prolonged Exposure (PE) suggests some patients may experience discontinuous change involving sudden symptom reductions and/or temporary exacerbations. The current study looked to (1) isolate profiles of PE response among treatment-seeking veterans and (2) identify factors associated with unique patterns of change. METHODS Archival records were examined for veterans receiving PE through a specialty Veterans Affairs Medical Center (VAMC) clinic (N = 109). Latent profile analysis was used to extract response trajectories defined by change in weekly PTSD Checklist (PCL) scores. Associations with provider status (staff vs. intern), setting (in-person vs. telehealth), initial severity (PTSD; depression), and eventual treatment gains were examined. RESULTS Three profiles were observed. Rapid Responders (18.3%) evidenced sharp reductions at Week 2 and again between Weeks 5 and 6. Linear Responders (40.4%) demonstrated gradual reductions throughout the 10-week assessment window. Delayed Responder (41.3%) scores were relatively stable over the evaluation period although final session outcomes indicated reliable change (PCLΔ > 10) in 40% of patients. Profiles were similar with respect to provider status, treatment setting, and initial symptom severity. Rapid Responders evidenced lower final session scores relative to Linear (g = 1.13) and Delayed (g = 1.85) groups, with Linear Responders reporting lower end scores than Delayed Responders (g = 1.02). CONCLUSIONS Anticipating patterns of recovery and their association with therapeutic outcome is of immense clinical value. Sudden gains emerged as a strong predictor of enhanced response. Data also suggest potential benefits of extending standard intervention for patients who fail to demonstrate an immediate response to PE.
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Affiliation(s)
- Joshua D Clapp
- Department of Psychology, University of Wyoming, Laramie, Wyoming.
| | - Joshua J Kemp
- Department of Psychology, University of Wyoming, Laramie, Wyoming
| | - Keith S Cox
- Department of Psychology, University of North Carolina Asheville, Asheville, North Carolina
| | - Peter W Tuerk
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina, 29401.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
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Acierno R, Gros DF, Ruggiero KJ, Hernandez-Tejada BMA, Knapp RG, Lejuez CW, Muzzy W, Frueh CB, Egede LE, Tuerk PW. BEHAVIORAL ACTIVATION AND THERAPEUTIC EXPOSURE FOR POSTTRAUMATIC STRESS DISORDER: A NONINFERIORITY TRIAL OF TREATMENT DELIVERED IN PERSON VERSUS HOME-BASED TELEHEALTH. Depress Anxiety 2016; 33:415-23. [PMID: 26864655 DOI: 10.1002/da.22476] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [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: 11/18/2015] [Revised: 01/19/2016] [Accepted: 01/22/2016] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Combat veterans returning to society with impairing mental health conditions such as PTSD and major depression (MD) report significant barriers to care related to aspects of traditional psychotherapy service delivery (e.g., stigma, travel time, and cost). Hence, alternate treatment delivery methods are needed. Home-based telehealth (HBT) is one such option; however, this delivery mode has not been compared to in person, clinic-based care for PTSD in adequately powered trials. The present study was designed to compare relative noninferiority of evidence-based psychotherapies for PTSD and MD, specifically Behavioral Activation and Therapeutic Exposure (BA-TE), when delivered via HBT versus in person, in clinic delivery. METHOD A repeated measures (i.e., baseline, posttreatment, 3-, 6-month follow-up) randomized controlled design powered for noninferiority analyses was used to compare PTSD and MD symptom improvement in response to BA-TE delivered via HBT versus in person, in clinic conditions. Participants were 232 veterans diagnosed with full criteria or predefined subthreshold PTSD. RESULTS PTSD and MD symptom improvement following BA-TE delivered by HBT was comparable to that of BA-TE delivered in person at posttreatment and at 3- and 12-month follow-up. CONCLUSION Evidence-based psychotherapy for PTSD and depression can be safely and effectively delivered via HBT with clinical outcomes paralleling those of clinic-based care delivered in person. HBT, thereby, addresses barriers to care related to both logistics and stigma.
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Affiliation(s)
- Ron Acierno
- Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.,College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel F Gros
- Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Kenneth J Ruggiero
- Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.,College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | - B Melba A Hernandez-Tejada
- Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.,College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | - Rebecca G Knapp
- Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Carl W Lejuez
- Center for Addictions, Personality, and Emotion Research, University of Maryland, College Park, Maryland
| | - Wendy Muzzy
- Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.,College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | | | - Leonard E Egede
- Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Peter W Tuerk
- Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
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Stewart RW, Tuerk PW, Metzger IW, Davidson TM, Young J. A decision-tree approach to the assessment of posttraumatic stress disorder: Engineering empirically rigorous and ecologically valid assessment measures. Psychol Serv 2016; 13:1-9. [PMID: 26654473 PMCID: PMC5312769 DOI: 10.1037/ser0000069] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Structured diagnostic interviews are widely considered to be the optimal method of assessing symptoms of posttraumatic stress; however, few clinicians report using structured assessments to guide clinical practice. One commonly cited impediment to these assessment approaches is the amount of time required for test administration and interpretation. Empirically keyed methods to reduce the administration time of structured assessments may be a viable solution to increase the use of standardized and reliable diagnostic tools. Thus, the present research conducted an initial feasibility study using a sample of treatment-seeking military veterans (N = 1,517) to develop a truncated assessment protocol based on the Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale (CAPS). Decision-tree analysis was utilized to identify a subset of predictor variables among the CAPS items that were most predictive of a diagnosis of PTSD. The algorithm-driven, atheoretical sequence of questions reduced the number of items administered by more than 75% and classified the validation sample at 92% accuracy. These results demonstrated the feasibility of developing a protocol to assess PTSD in a way that imposes little assessment burden while still providing a reliable categorization.
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Affiliation(s)
- Regan W Stewart
- Department of Psychology and Behavioral Sciences, Medical University of South Carolina
| | - Peter W Tuerk
- Department of Psychology and Behavioral Sciences, Medical University of South Carolina
| | - Isha W Metzger
- Department of Psychology and Behavioral Sciences, Medical University of South Carolina
| | - Tatiana M Davidson
- Department of Psychology and Behavioral Sciences, Medical University of South Carolina
| | - John Young
- Department of Psychology, University of Mississippi
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Keller SM, Tuerk PW. Evidence-based psychotherapy (EBP) non-initiation among veterans offered an EBP for posttraumatic stress disorder. Psychol Serv 2015; 13:42-8. [PMID: 26654474 DOI: 10.1037/ser0000064] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Current efforts to disseminate evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) in Veterans Affairs Medical Centers (VAMCs) have made effective treatment options more available throughout the system. Yet many veterans identified as likely to benefit from such services choose not to utilize them. The evidence base regarding factors that contribute to treatment initiation among those offered EBPs is still in its early stages. The present study investigated clinical presentation, patient demographics, and environment of care factors as potential predictors of EBP treatment initiation among veterans offered such care. The sample consisted of 324 veterans (62% Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]; 77% male; age M = 42.95, SD = 12.57 years), who attended an intake evaluation at a VAMC outpatient PTSD Clinical Team, were diagnosed with PTSD, and offered a course of EBP. Overall, 72% of veterans (n = 232) who were offered an EBP initiated such treatment, and 28% of veterans (n = 92) did not initiate treatment. Veterans who initiated treatment were significantly older. Treatment initiation did not significantly differ by ethnicity, gender, or baseline PTSD severity. Significantly more veterans referred from mental health clinics initiated treatment than did veterans referred from primary care. This study examined treatment initiation among veterans who were offered EBP for PTSD. Rates of initiation differed across subgroups of veterans. Clinically, this suggests the need to tailor outreach efforts to younger veterans, OEF/OIF veterans, and veterans referred from primary care, and potentially including programming and education aimed at primary care referrers, to increase help-seeking. (PsycINFO Database Record
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Affiliation(s)
| | - Peter W Tuerk
- Ralph H. Johnson Veterans Affairs Medical Center, Mental Health Service
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36
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Wangelin BC, Tuerk PW. TAKING THE PULSE OF PROLONGED EXPOSURE THERAPY: PHYSIOLOGICAL REACTIVITY TO TRAUMA IMAGERY AS AN OBJECTIVE MEASURE OF TREATMENT RESPONSE. Depress Anxiety 2015; 32:927-34. [PMID: 26522237 DOI: 10.1002/da.22449] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [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: 02/09/2015] [Revised: 09/19/2015] [Accepted: 10/09/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Physiological reactivity to trauma-related cues is a primary symptom of PTSD and can be assessed objectively using script-driven imagery paradigms. However, subjective self-reported symptom measures are the most common outcome indices utilized in PTSD treatment trials and clinic settings. We examined physiological reactivity during a short trauma imagery task as an objective index of response to PTSD treatment, optimized for use in routine clinical care settings. METHODS Participants were 35 male combat veterans receiving prolonged exposure (PE) therapy in a Veterans Affairs outpatient clinic. In addition to traditional subjective self-reported and clinician-rated symptom measures, patients also completed a script-driven imagery task in which heart rate (HR) and skin conductance (SC) were recorded at three assessment points across treatment. We examined changes in subjective symptom measures and objective trauma-specific physiological reactivity over the course of PE, and investigated the association between pretreatment physiological reactivity and treatment response. RESULTS Patients who completed PE showed significantly diminished HR and SC reactivity to trauma imagery across therapy. Additionally, individuals showing greater trauma-specific HR reactivity at pretreatment showed greater reductions in subjectively reported PTSD symptoms at posttreatment. CONCLUSIONS Findings support the utility of physiological reactivity during trauma imagery as an objective outcome measure that has the potential to be incorporated into evidence-based PTSD treatment in routine clinical settings, or prospective studies related to the individualization of care at pretreatment.
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Affiliation(s)
- Bethany C Wangelin
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center (VAMC), Charleston, South Carolina.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Peter W Tuerk
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center (VAMC), Charleston, South Carolina.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
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Yuen EK, Gros DF, Price M, Zeigler S, Tuerk PW, Foa EB, Acierno R. Randomized Controlled Trial of Home-Based Telehealth Versus In-Person Prolonged Exposure for Combat-Related PTSD in Veterans: Preliminary Results. J Clin Psychol 2015; 71:500-12. [PMID: 25809565 DOI: 10.1002/jclp.22168] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [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: 11/11/2022]
Abstract
OBJECTIVES Telehealth technology may reduce the effect of treatment barriers and improve participation in treatment for veterans with posttraumatic stress disorder (PTSD). The present study is an ongoing randomized controlled trial comparing the effectiveness of prolonged exposure (PE) delivered via in person or home-based video telehealth modalities. METHOD A total of 52 veterans with combat-related PTSD were randomized to receive 8-12 weeks of PE through either home-based telehealth or standard in-person office-based care. RESULTS Participants evinced significant reductions in symptoms of PTSD, depression, and anxiety from pre- to posttreatment across both conditions. Analyses conducted within a noninferiority framework suggested nonsignificant treatment outcome differences in clinician-reported PTSD and self-reported anxiety between the conditions. Results were inconclusive for self-reported PTSD and depression symptoms. Patient satisfaction ratings did not significantly differ between the two groups. CONCLUSIONS Results suggest that PE can be delivered via home-based telehealth with outcomes and satisfaction ratings comparable to in-person practices for certain symptoms, however additional research is needed. This modality has the potential to address stigma- and geographic-related barriers to treatment, such as travel time and cost.
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Affiliation(s)
| | - Daniel F Gros
- Ralph H. Johnson Veterans Affairs Medical Center.,Medical University of South Carolina
| | | | - Stephanie Zeigler
- Ralph H. Johnson Veterans Affairs Medical Center.,Medical University of South Carolina
| | - Peter W Tuerk
- Ralph H. Johnson Veterans Affairs Medical Center.,Medical University of South Carolina
| | | | - Ron Acierno
- Ralph H. Johnson Veterans Affairs Medical Center.,Medical University of South Carolina
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Rauch SAM, King AP, Abelson J, Tuerk PW, Smith E, Rothbaum BO, Clifton E, Defever A, Liberzon I. Biological and symptom changes in posttraumatic stress disorder treatment: a randomized clinical trial. Depress Anxiety 2015; 32:204-12. [PMID: 25639570 DOI: 10.1002/da.22331] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [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: 07/09/2014] [Revised: 09/30/2014] [Accepted: 10/10/2014] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Understanding cognitive and biological mechanisms of PTSD treatment can help refine treatments and increase rates of response. METHODS Thirty-six veterans with PTSD were randomly assigned to receive Prolonged exposure therapy (PE) or Present-Centered therapy (PCT). We examined symptoms, trauma-related cognitions, and two indices of HPA axis function (cortisol awakening response and cortisol response to a script-driven imagery task). RESULTS Thirty veterans started treatment and 26 completed. PE resulted in significantly more symptom reduction than PCT (P = .008). High treatment responders collapsed across treatments showed nominally higher cortisol levels measured at pretreatment 30 min after trauma script exposure compared to low responders (P = .08). At midtreatment, high treatment responders showed higher cortisol levels throughout the imagery task (Ps = .03-.04). There were no differences between high and low treatment responders at posttreatment. Thoughts of incompetence (F (1.6, 35.8) = 16.8, P = .000) and a dangerous world (F (1.3, 29.9) = 8.2, P = .004) significantly improved over time in high treatment responders but showed no change in low responders. Script-associated cortisol response prior to treatment and reductions in thoughts of incompetence accounted for 83% of the variance in reductions in PTSD severity with PE. CONCLUSIONS Both increased cortisol response to personal trauma script prior to PTSD therapy and reductions in cognitive symptoms of PTSD were significantly and uniquely related to reductions in the core symptoms of PTSD in PE. However, contrary to our hypotheses, cortisol measures were not related to cognitive changes.
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Affiliation(s)
- Sheila A M Rauch
- PTSD Clinical Team, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
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Taylor JJ, Neitzke DJ, Khouri G, Borckardt JJ, Acierno R, Tuerk PW, Schmidt M, George MS. A pilot study to investigate the induction and manipulation of learned helplessness in healthy adults. Psychiatry Res 2014; 219:631-7. [PMID: 25023370 PMCID: PMC4186698 DOI: 10.1016/j.psychres.2014.05.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 05/13/2014] [Accepted: 05/22/2014] [Indexed: 10/25/2022]
Abstract
Eliminating the controllability of a noxious stimulus may induce a learned helplessness (LH) that resembles aspects of depression and post-traumatic stress disorder (PTSD). This study examined whether repetitive transcranial magnetic stimulation (rTMS) of the left dorsolateral prefrontal cortex (DLPFC) promotes resilience in an aversive stimulus model of LH. All 55 participants were told that an undisclosed sequence of button presses would terminate an aversive stimulus on their forearm. In truth, only half had control (+C). The other half had no control (-C). All participants received real (R) or sham (S) left DLPFC rTMS during the paradigm (+C/R, -C/S,+C/S,-C/R). We evaluated the cognitive effects of LH using an anagram task. The LH paradigm successfully reduced perceived control in the -C groups. As predicted, the +C/R and +C/S groups tended to give up less quickly and take less time to solve each anagram than did the -C/S group. Superior anagram performance in the -C/R group approached statistical significance. Our preliminary results suggest that manipulating the controllability of an aversive stimulus may induce an LH effect that manifests as impaired anagram performance. Further research is needed to refine this model and determine if DLPFC rTMS mitigates any LH effects.
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Affiliation(s)
| | | | - George Khouri
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Ron Acierno
- Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Peter W Tuerk
- Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | | | - Mark S George
- Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
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Abstract
In this paper, we consider ethical issues related to the treatment of posttraumatic stress disorder (PTSD) in combat zones, via exposure therapy. Exposure-oriented interventions are the most well-researched behavioral treatments for PTSD, and rigorous studies across contexts, populations, and research groups provide robust evidence that exposure therapy for PTSD is effective and can be widely disseminated. Clinical procedures for Prolonged Exposure therapy, a manualized exposure-oriented protocol for PTSD, are reviewed, and we illustrate the potential benefits, as well as the potential difficulties, associated with providing this treatment in combat zones. Several ethical considerations are identified: (1) Assuming successful treatment, is it ethical to send individuals with a known risk of developing PTSD back into combat? (2) If treatment is unsuccessful in theater (perhaps due to the confounding factor of ongoing danger), could that impact treatment effectiveness for soldiers who attempt therapy again post-deployment? (3) If the military finds combat-zone treatment effective and useful in maintaining an efficient work force, will treatment become mandatory for those diagnosed with PTSD? (4) What unintended consequences might be associated with large-scale dissemination of exposure therapy in or near combat, outside of mental health care infrastructures? (5) How would genetic variations known to be associated with PTSD risk influence decisions regarding who receives treatment or returns to combat? We conclude with a review of the personal and societal costs associated with not providing evidence-based PTSD treatments wherever possible.
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Affiliation(s)
- Bethany C Wangelin
- Staff psychologist on the PTSD Clinical Team at the Ralph H. Johnson VA Medical Center in Charleston, SC
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Soltis K, Acierno R, Gros DF, Yoder M, Tuerk PW. Post-traumatic stress disorder: ethical and legal relevance to the criminal justice system. J Law Med Ethics 2014; 42:147-154. [PMID: 25040378 DOI: 10.1111/jlme.12130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Post-Traumatic Stress Disorder is a major public health concern in both civilian and military populations, across race, age, gender, and socio-economic status. While PTSD has been around for centuries by some name or another, its definition and description also continue to evolve. Within the last few years, the American Psychological Association has published the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, which includes some major changes in the diagnostic criteria for PTSD. Recent data on epidemiology, etiological theories, and empirically supported methods of treatment, as well as implications for legal processes and criminal justice system personnel, are discussed.
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Affiliation(s)
- Kathryn Soltis
- Research assistant in the National Crime Victims Research and Treatment Center at the Medical University of South Carolina (MUSC)
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Abstract
Exposure-based therapy is an effective treatment for PTSD, including combat-related PTSD. However, questions remain within PTSD treatment literature and among front-line clinicians about the appropriateness of exposure-based therapies for older adults. The current study examined the effectiveness of Prolonged Exposure (PE) in reducing PTSD and depression symptoms in a sample of 65 Veterans age 60 and older who were diagnosed with PTSD via structured clinical interview. In addition to within-subject repeated measure analyses, the entire intent to treat sample was compared to treatment completers. Within group d-type effect sizes across both groups were large (1.13-1.90) and the retention rate was high (85%). Importantly, no adverse medical or psychiatric events were reported over the course of the study. Results are discussed and limitations, along with future directions, are presented.
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Affiliation(s)
- Matthew S Yoder
- Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC 29401, USA.
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44
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Wangelin BC, Powers MB, Smits JAJ, Tuerk PW. Enhancing exposure therapy for PTSD with yohimbine HCL: protocol for a double-blind, randomized controlled study implementing subjective and objective measures of treatment outcome. Contemp Clin Trials 2013; 36:319-26. [PMID: 23939512 DOI: 10.1016/j.cct.2013.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [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: 04/03/2013] [Revised: 07/30/2013] [Accepted: 08/03/2013] [Indexed: 02/06/2023]
Abstract
Prolonged exposure (PE) therapy is considered a gold standard protocol for the treatment of PTSD, and it is associated with large treatment effect sizes in combat veteran samples. However, considering high rates of PTSD in the present veteran population, ongoing research work is important toward improving treatment efficiency by decreasing time to symptom amelioration and increasing the amount of symptom amelioration. The proposed research aims to enhance exposure therapy outcomes for veterans with PTSD via combination treatment with PE and yohimbine hydrochloride (HCL), an alpha-2 adrenergic receptor antagonist. The proposed investigation entails a randomized, placebo-controlled trial investigating the effect of a single administration of yohimbine HCL (paired with the first session of imaginal exposure) on outcome of PE in 40 veterans with PTSD. An additional goal is to establish a pragmatic method of tracking psychophysiological measures over the course of therapy for incorporation into future clinical psychotherapy trials. Thus, in addition to traditional self- and clinician-reported psychological outcomes, heart rate and skin conductance reactivity will be measured during a standard trauma-specific imagery task before, during, and after PE treatment. We will further investigate whether changes in psychophysiological measures predict changes in patient- and clinician-reported outcome measures.
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Affiliation(s)
- Bethany C Wangelin
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, 109 Bee St., Charleston, SC, United States; Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President St., Charleston, SC 29401, United States.
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45
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Gros DF, Morland LA, Greene CJ, Acierno R, Strachan M, Egede LE, Tuerk PW, Myrick H, Frueh BC. Delivery of Evidence-Based Psychotherapy via Video Telehealth. J Psychopathol Behav Assess 2013. [DOI: 10.1007/s10862-013-9363-4] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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46
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Sripada RK, Rauch SAM, Tuerk PW, Smith E, Defever AM, Mayer RA, Messina M, Venners M. Mild traumatic brain injury and treatment response in prolonged exposure for PTSD. J Trauma Stress 2013; 26:369-75. [PMID: 23696427 DOI: 10.1002/jts.21813] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [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: 12/19/2022]
Abstract
A proportion of U.S. veterans returning from Iraq and Afghanistan have experienced mild traumatic brain injury (mTBI), which is associated with increased risk for developing posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) has proven effectiveness in the treatment of PTSD; however, some clinicians have reservations about using PE with individuals with a history of mTBI. We examined the impact of PE for veterans with PTSD and with or without a history of mTBI in a naturalistic sample of 51 veterans who received PE at a Veterans Health Administration PTSD clinic. We also analyzed previously collected data from a controlled trial of 22 veterans randomly assigned to PE or present centered therapy. For both sets of data, we found that PE reduced symptom levels and we also did not detect an effect for mTBI, suggesting that PE may be helpful for individuals with PTSD and a history of mTBI.
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Affiliation(s)
- Rebecca K Sripada
- VA Ann Arbor Health Care System/University of Michigan Medical School, Ann Arbor, Michigan, USA.
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47
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Tuerk PW, Hall B, Nagae N, McCauley JL, Yoder M, Rauch SA, Acierno R, Dussich J. Forty days after the Great East Japan Earthquake: field research investigating community engagement and traumatic stress screening in a post-disaster community mental health training. Int J Psychiatry Med 2013; 45:159-74. [PMID: 23977819 PMCID: PMC4887095 DOI: 10.2190/pm.45.2.e] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [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: 11/22/2022]
Abstract
The current article describes the results of posttraumatic stress educational outreach and screening offered to 141 citizens of Japan who attended a public-service mental health training regarding post-disaster coping 40 days after a 6.8 Richter Scale earthquake, local and regional deaths, and an ongoing nuclear radiation threat. Attendees were given access to anonymous questionnaires that were integrated into the training as a tool to help enhance mental health literacy and bridge communication gaps. Questionnaires were turned in by a third of those in attendance. Among respondents, multiple exposures to potentially-traumatic events were common. More than a quarter of respondents met criteria for probable PTSD. Physical health and loss of sense of community were related to PTSD symptoms. Associations and diagnosis rates represented in these data are not generalizable to the population as a whole or intended for epidemiological purposes; rather, they are evidence of a potentially useful approach to post-disaster clinical screening, education, and engagement. Results are presented in the context of previous findings in Japan and ecologically-supportive post-disaster field research is discussed.
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Affiliation(s)
- Peter W. Tuerk
- Mental Health Service Line, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Brian Hall
- Department of Mental Health; Johns Hopkins Bloomberg School of Public Health
| | - Nobukazu Nagae
- Faculty of Humanities, Fukuoka University, Fukuoka, Japan
| | - Jenna L. McCauley
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Matthew Yoder
- Mental Health Service Line, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Sheila A.M. Rauch
- VA Ann Arbor Healthcare System, Ann Arbor MI,University of Michigan Medical School, Department of Psychiatry, Ann Arbor, MI
| | - Ron Acierno
- Mental Health Service Line, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - John Dussich
- Tokiwa International Victimology Institute, Tokiwa University, Mito, Japan
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48
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Tuerk PW, Wangelin B, Rauch SAM, Dismuke CE, Yoder M, Myrick H, Eftekhari A, Acierno R. Health service utilization before and after evidence-based treatment for PTSD. Psychol Serv 2012; 10:401-9. [PMID: 23148769 DOI: 10.1037/a0030549] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Posttraumatic stress disorder (PTSD) is associated with functional impairment, co-occurring diagnoses, and increased health care utilization. Associated high demand for health care services is an important contributor to the large public-health cost of PTSD. Treatments incorporating exposure therapy are efficacious in ameliorating or eliminating PTSD symptoms. Accordingly, the Veterans Health Administration has made significant investments toward nationwide dissemination of a manualized exposure therapy protocol, prolonged exposure (PE). PE is effective with veterans; however, the relationship between PE and mental health service utilization is unknown. The current study investigates PE as it relates to actual tracked mental health service utilization in an urban VA medical center. A sample of 60 veterans with a diagnosis of PTSD was used to examine mental health service utilization in the 12-months prior to and 12-months after being offered PE. Hierarchical Linear Models and traditional repeated-measures ANOVA were used to estimate R²- and d-type effect sizes for service utilization. Associated estimated cost saving are reported. PE was associated with large reductions in symptoms and diagnosis remission. Treatment was also associated with statistically significant, large reductions in mental health service utilization for veterans who completed treatment. Findings suggest that expanding access to PE can increase access to mental health services in general by decreasing ongoing demand for specialty care clinical services.
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Affiliation(s)
- Peter W Tuerk
- Mental Health Service Line, Ralph H. Johnson Department of Veterans Affairs Medical Center
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49
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Turner TH, Horner MD, VanKirk KK, Myrick H, Tuerk PW. A Pilot Trial of Neuropsychological Evaluations Conducted via Telemedicine in the Veterans Health Administration. Telemed J E Health 2012; 18:662-7. [DOI: 10.1089/tmj.2011.0272] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Travis H. Turner
- Mental Health Service Line, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
- Division of Neurology, Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina
| | - Michael D. Horner
- Mental Health Service Line, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Kathryn K. VanKirk
- Mental Health Service Line, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Hugh Myrick
- Mental Health Service Line, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Peter W. Tuerk
- Mental Health Service Line, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
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50
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Yoder M, Tuerk PW, Price M, Grubaugh AL, Strachan M, Myrick H, Acierno R. Prolonged exposure therapy for combat-related posttraumatic stress disorder: comparing outcomes for veterans of different wars. Psychol Serv 2012; 9:16-25. [PMID: 22449084 DOI: 10.1037/a0026279] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [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
There is significant support for exposure therapy as an effective treatment for posttraumatic stress disorder (PTSD) across a variety of populations, including veterans; however, there is little empirical information regarding how veterans of different war theaters respond to exposure therapy. Accordingly, questions remain regarding therapy effectiveness for treatment of PTSD for veterans of different eras. Such questions have important implications for the dissemination of evidence based treatments, treatment development, and policy. The current study compared treatment outcomes across 112 veterans of the Vietnam War, the first Persian Gulf War, and the wars in Afghanistan and Iraq. All subjects were diagnosed with PTSD and enrolled in prolonged exposure (PE) treatment. Veterans from all three groups showed significant improvement in PTSD symptoms, with veterans from Vietnam and Afghanistan/Iraq responding similarly to treatment. Persian Gulf veterans did not respond to treatment at the same rate or to the same degree as veterans from the other two eras. Questions and issues regarding the effectiveness of evidence based treatment for veterans from different eras are discussed.
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Affiliation(s)
- Matthew Yoder
- Mental Health Service, Ralph H. Johnson VA Medical Center
| | - Peter W Tuerk
- Mental Health Service, Ralph H. Johnson VA Medical Center
| | - Matthew Price
- Mental Health Service, Ralph H. Johnson VA Medical Center
| | | | | | - Hugh Myrick
- Mental Health Service, Ralph H. Johnson VA Medical Center
| | - Ron Acierno
- Mental Health Service, Ralph H. Johnson VA Medical Center
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