1
|
Reeves KD, Shaw J, McAdam R, Lam KHS, Mulvaney SW, Rabago D. A Novel Somatic Treatment for Post-traumatic Stress Disorder: A Case Report of Hydrodissection of the Cervical Plexus Using 5% Dextrose. Cureus 2022; 14:e23909. [PMID: 35411286 PMCID: PMC8988854 DOI: 10.7759/cureus.23909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 11/23/2022] Open
Abstract
Despite years of standard treatments, a Marine veteran and former firefighter, disabled due to severe post-traumatic stress disorder (PTSD), worsened over ten weeks while receiving usual care. Bilateral injection of 10 mL of 5% dextrose in water using a 30-gauge needle just under the sternocleidomastoid muscle was performed at weeks 10, 12, 14, 16, and 18. Clinically important improvements were observed by 18 weeks on a 0-10 anxiety rating scale (57%), the PTSD checklist for civilians (41%), EuroQol overall quality of life scale (40%), and the Hospital Anxiety and Depression Scale (28%). Improvements were stable through 22 weeks. He reported symptomatic benefit on anxiety within 20 minutes of injection, suggesting a neurogenic mechanism, potentially related to a therapeutic effect on the nearby sympathetic trunk/superior sympathetic ganglion. Advantages of this procedure over stellate ganglion blockade include its safety (no lidocaine), bilateral treatment option, simplicity, and comfort.
Collapse
|
2
|
Glavonic E, Mitic M, Adzic M. Hallucinogenic drugs and their potential for treating fear-related disorders: Through the lens of fear extinction. J Neurosci Res 2022; 100:947-969. [PMID: 35165930 DOI: 10.1002/jnr.25017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/17/2021] [Accepted: 01/05/2022] [Indexed: 12/29/2022]
Abstract
Fear-related disorders, mainly phobias and post-traumatic stress disorder, are highly prevalent, debilitating disorders that pose a significant public health problem. They are characterized by aberrant processing of aversive experiences and dysregulated fear extinction, leading to excessive expression of fear and diminished quality of life. The gold standard for treating fear-related disorders is extinction-based exposure therapy (ET), shown to be ineffective for up to 35% of subjects. Moreover, ET combined with traditional pharmacological treatments for fear-related disorders, such as selective serotonin reuptake inhibitors, offers no further advantage to patients. This prompted the search for ways to improve ET outcomes, with current research focused on pharmacological agents that can augment ET by strengthening fear extinction learning. Hallucinogenic drugs promote reprocessing of fear-imbued memories and induce positive mood and openness, relieving anxiety and enabling the necessary emotional engagement during psychotherapeutic interventions. Mechanistically, hallucinogens induce dynamic structural and functional neuroplastic changes across the fear extinction circuitry and temper amygdala's hyperreactivity to threat-related stimuli, effectively mitigating one of the hallmarks of fear-related disorders. This paper provides the first comprehensive review of hallucinogens' potential to alleviate symptoms of fear-related disorders by focusing on their effects on fear extinction and the underlying molecular mechanisms. We overview both preclinical and clinical studies and emphasize the advantages of hallucinogenic drugs over current first-line treatments. We highlight 3,4-methylenedioxymethamphetamine and ketamine as the most effective therapeutics for fear-related disorders and discuss the potential molecular mechanisms responsible for their potency with implications for improving hallucinogen-assisted psychotherapy.
Collapse
Affiliation(s)
- Emilija Glavonic
- Department of Molecular Biology and Endocrinology, "VINČA" Institute of Nuclear Sciences-National Institute of thе Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Milos Mitic
- Department of Molecular Biology and Endocrinology, "VINČA" Institute of Nuclear Sciences-National Institute of thе Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Miroslav Adzic
- Department of Molecular Biology and Endocrinology, "VINČA" Institute of Nuclear Sciences-National Institute of thе Republic of Serbia, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
3
|
Pracht EE, Pracht KC, Langland-Orban B, Kurji N, Salinas A. How does a diagnosis of PTSD add to resource utilization in Florida emergency rooms? INTERNATIONAL JOURNAL OF MENTAL HEALTH 2021. [DOI: 10.1080/00207411.2021.1977573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Etienne E. Pracht
- College of Public Health, University of South Florida, Tampa, FL, USA
| | | | | | - Natasha Kurji
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Abraham Salinas
- College of Public Health, University of South Florida, Tampa, FL, USA
| |
Collapse
|
4
|
Klein AB, Kline AC, Bowling AR, Feeny NC. Bridging the science-practice gap in treatment for posttraumatic stress disorder: Testing strategies to enhance beliefs toward exposure therapy. J Clin Psychol 2021; 77:2765-2780. [PMID: 34273910 DOI: 10.1002/jclp.23221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/27/2021] [Accepted: 06/23/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Exposure therapies (e.g., prolonged exposure [PE]), are first-line interventions for posttraumatic stress disorder but remain underutilized, partially due to providers' negative beliefs about these interventions. We examined two experimental strategies aimed at enhancing beliefs towards PE and subsequent utilization. METHOD Clinicians (N = 155) were randomized to one of three conditions presenting a PE rationale: basic, empirically-based, or emotionally-based description. Participants were rerandomized to write or not write arguments for utilizing PE. Before and after PE rationales and 1-month later, participants completed questions about PE beliefs and utilization. RESULTS Participants reported small yet durable belief change across all rationale conditions, with greatest change following the empirically-based description. Across conditions, belief change was not impacted by writing condition or associated with utilization. CONCLUSION Addressing negative beliefs with empirical information may be a brief, cost-effective strategy to improve clinicians' beliefs toward PE. Complementary strategies that leverage belief modification to increase utilization are needed.
Collapse
Affiliation(s)
- Alexandra B Klein
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Alexander C Kline
- Clinical Psychology, VA San Diego Healthcare System, San Diego, California, USA
| | - Alexandra R Bowling
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Norah C Feeny
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| |
Collapse
|
5
|
Burton MS, Cooper AA, Mello PG, Feeny NC, Zoellner LA. Latent Profiles of Comorbid Depression as Predictors of PTSD Treatment Outcome. Behav Ther 2021; 52:970-981. [PMID: 34134835 PMCID: PMC8543494 DOI: 10.1016/j.beth.2020.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 11/16/2022]
Abstract
Posttraumatic stress disorder (PTSD) frequently co-occurs with major depressive disorder, and empirically supported PTSD treatments consistently improve depression. However, both diagnoses are heterogeneous and specific patterns of symptom overlap may be related to worse treatment outcome. Two hundred individuals with chronic PTSD participated in a doubly randomized preference trial comparing prolonged exposure and sertraline. Latent Profile Analysis was used to identify classes based on PTSD and depression symptoms prior to starting treatment. A three-class model best fit the data, with a high depression and PTSD severity class (distressed), a moderate depression and low PTSD avoidance class (depressive), and a low depression and high PTSD avoidance class (avoidant). The avoidant class showed the lowest rates of major depressive disorder diagnosis and transdiagnostic vulnerabilities to depression. Patients in the distressed class experienced more robust PTSD treatment response, with no differences between prolonged exposure and sertraline. These findings highlight the role of avoidance in nondepressed PTSD presentations while also demonstrating that co-occurring depression is not contraindicated in evidence-based PTSD treatment.
Collapse
|
6
|
Essayli JH, Webster AE, Quaill MA, Zickgraf HF, Lane-Loney SE. Do individuals with eating disorders dislike exposure therapy? Attitudes from children, adults, and parents toward exposure therapy and other treatments for eating disorders. Int J Eat Disord 2021; 54:606-614. [PMID: 33521983 DOI: 10.1002/eat.23468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 12/29/2020] [Accepted: 12/29/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Exposure therapy appears underutilized in the treatment of eating disorders (EDs), perhaps due to clinicians' concerns that patients will dislike exposure therapy. The present study aims to investigate the attitudes of child patients, adult patients, and parents of child patients with EDs toward exposure therapy relative to four other treatments for EDs. METHOD A questionnaire was administered to patients and parents (N = 126) upon admission to a partial hospitalization program for EDs. Participants read vignettes describing five different treatments for EDs, and answered questions assessing attitudes about each treatment. RESULTS At admission, participants reported the most favorable attitudes toward cognitive therapy, and the least favorable attitudes toward psychiatric medication. Exposure therapy generally received similar scores as interpersonal and expressive art therapy, and was perceived as significantly more preferable and effective in the long-term than psychiatric medication. Relative to child and adult patients, parents reported greater preferences for all treatments except medication, and perceived all treatments as more credible except medication and art therapy. Preliminary findings from a subset of participants who also completed the questionnaire at discharge indicated that positive attitudes toward exposure therapy increased over the course of treatment. DISCUSSION Individuals with EDs and their parents may enter treatment with particularly favorable views toward cognitive therapy, and do not appear to have strong attitudes toward exposure therapy one way or the other. Clinicians' concerns that patients with EDs will dislike exposure therapy may be largely unfounded.
Collapse
Affiliation(s)
- Jamal H Essayli
- Penn State College of Medicine, Department of Pediatrics, Hershey, Pennsylvania, USA.,Penn State College of Medicine, Department of Psychiatry and Behavioral Health, Hershey, Pennsylvania, USA
| | - Aiyana E Webster
- Department of Psychology, University of South Florida, Tampa, Florida, USA
| | - Marlana A Quaill
- Morgridge College of Education, Department of Teaching and Learning Sciences, University of Denver, Denver, Colorado, USA
| | - Hana F Zickgraf
- Department of Psychology, University of South Alabama, Mobile, Alabama, USA
| | - Susan E Lane-Loney
- Penn State College of Medicine, Department of Pediatrics, Hershey, Pennsylvania, USA.,Penn State College of Medicine, Department of Psychiatry and Behavioral Health, Hershey, Pennsylvania, USA
| |
Collapse
|
7
|
When Do Posttraumatic Stress and Related Problems Abate During School-Based Group Therapy for Elementary Students? SCHOOL MENTAL HEALTH 2020. [DOI: 10.1007/s12310-020-09377-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
8
|
Etingen B, Grubbs KM, Harik JM. Drivers of Preference for Evidence-Based PTSD Treatment: A Qualitative Assessment. Mil Med 2020; 185:303-310. [DOI: 10.1093/milmed/usz220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 07/02/2019] [Accepted: 06/03/2019] [Indexed: 11/13/2022] Open
Abstract
ABSTRACT
Introduction
Mental health treatment utilization among persons with posttraumatic stress disorder (PTSD) tends to be low but may be improved by aligning treatment with patient preferences. Our objective was to characterize the reasons that drive a person’s selection of a specific evidence-based PTSD treatment.
Materials and Methods
Data were collected using an online survey of adults who screened positive for PTSD. Participants viewed descriptions of five evidence-based PTSD treatments (cognitive processing therapy, prolonged exposure, eye movement desensitization and reprocessing, stress inoculation training, antidepressant medication) and identified their most preferred treatment. Participants then explained why they selected their top choice. These free-text responses (n = 249) were analyzed using thematic coding and constant comparative methods.
Results
Identified themes included (1) perceived effectiveness, (2) perceived suitability, (3) requirements of participation, (4) familiarity with the modality, (5) perception of the option as ‘better than alternatives,’ (6) perception of the option as ‘not harmful,’ (7) accessibility, and (8) delivery format. Differences in themes were also examined by treatment modality.
Conclusions
By highlighting which pieces of information may be most important to detail when presenting different treatment options, these results can help guide treatment planning conversations, as well as the development of shared decision-making tools.
Collapse
Affiliation(s)
- Bella Etingen
- Research Health Scientist, Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development Service, US Department of Veterans Affairs, Hines VA Hospital, 5000 South 5th Avenue, Hines, IL, 60141
| | - Kathleen M Grubbs
- Clinical Psychologist, San Diego VA Health Care System, Department of Veterans Affairs, 3350 La Jolla Village Dr., San Diego, California, 92161
- Assistant Professor, Department of Psychiatry, University of California at San Diego, 9500 Gilman Dr., La Jolla, CA 92093
| | - Juliette M Harik
- Clinical Psychologist, National Center for PTSD (NCPTSD), VA Medical Center (116D), 215 North Main St., White River Junction, VT 05009
- Assistant Professor, Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Rd., Hanover, NH 03755
| |
Collapse
|
9
|
van den Berk Clark C, Moore R, Secrest S, Tuerk P, Norman S, Myers U, Lustman PJ, Schneider FD, Barnes J, Gallamore R, Ovais M, Plurad JA, Scherrer JF. Factors Associated With Receipt of Cognitive-Behavioral Therapy or Prolonged Exposure Therapy Among Individuals With PTSD. Psychiatr Serv 2019; 70:703-713. [PMID: 31010409 PMCID: PMC6702958 DOI: 10.1176/appi.ps.201800408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of this study was to systematically review variables associated with initiation of trauma-centered cognitive-behavioral therapy (TC-CBT) among individuals with posttraumatic stress disorder (PTSD). METHODS PubMed, PsycINFO, Web of Science, Published International Literature on Traumatic Stress (PILOTS), and Scopus were searched in a systematic manner up to 2018, and 26 relevant studies were recovered and analyzed. RESULTS The average weighted initiation rate was 6% in larger hospital systems with a high rate of trauma and 28% in outpatient mental health settings (range 4%-83%). Older age (odds ratio [OR]=1.56, 95% confidence interval [CI]=0.51-1.61), female gender (OR=1.18, 95% CI=1.08-1.27), black or other racial-ethnic minority group (OR=1.16, 95% CI=1.03-1.28), Veterans Affairs PTSD service connection status (OR=2.30, 95% CI=2.18-2.42), mental health referral (OR=2.28, 95% CI=1.05-3.50), greater staff exposure to TC-CBT (OR=2.30, 95% CI=2.09-2.52), adaptability of TC-CBT to staff workflow (OR=4.66, 95% CI=1.60-7.72), greater PTSD severity (OR=1.46, 95% CI=1.13-1.78), and comorbid depression (OR=1.21, 95% CI=1.14-1.29) increased the likelihood of TC-CBT initiation, whereas delayed treatment reduced the likelihood of TC-CBT initiation (OR=0.93, 95% CI=0.92-0.95). Qualitative studies showed that mental health beliefs (stigma and lack of readiness), provider organizational factors (low availability, privacy issues), and patient lack of time (logistics) were perceived as barriers to initiation by patients and providers. CONCLUSIONS TC-CBT initiation increased among patients who were older and female. Initiation was also higher among providers who had more exposure to TC-CBT in their work environment and when TC-CBT fit into their existing workflow.
Collapse
Affiliation(s)
- Carissa van den Berk Clark
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Rachel Moore
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Scott Secrest
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Peter Tuerk
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Sonya Norman
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Ursula Myers
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Patrick J Lustman
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - F David Schneider
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Jacqueline Barnes
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Randy Gallamore
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Muhammad Ovais
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - James Alex Plurad
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| | - Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis (Clark, Moore, Secrest, Barnes, Gallamore, Ovais, Plurad, Scherrer); Research and Development Program, Veterans Affairs St. Louis Health Care System, St. Louis (Clark); Research Service, Harry S. Truman Veteran's Hospital, Columbia, Missouri (Scherrer); Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston and PTSD Clinical Team, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina (Tuerk); PTSD Consultation Program, National Center of PTSD, White River Junction, Vermont, and Department of Psychiatry, University of California, San Diego (Norman); U.S. Department of Veterans Affairs, Washington, D.C. (Myers); Department of Psychiatry, Washington University School of Medicine, St. Louis (Lustman); Department of Family and Community Medicine, University of Texas Southwestern, Dallas (Schneider)
| |
Collapse
|
10
|
Zoellner LA, Roy-Byrne PP, Mavissakalian M, Feeny NC. Doubly Randomized Preference Trial of Prolonged Exposure Versus Sertraline for Treatment of PTSD. Am J Psychiatry 2019; 176:287-296. [PMID: 30336702 DOI: 10.1176/appi.ajp.2018.17090995] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The authors examined the effect of patient treatment preference on the differential effectiveness of prolonged exposure and sertraline for the treatment of posttraumatic stress disorder (PTSD). METHOD In a doubly randomized preference trial, 200 patients with PTSD viewed standardized treatment rationales prior to randomization. Patients were first randomized to choice of treatment or no choice. Those assigned to no choice were then randomized to prolonged exposure or sertraline. Acute treatment was 10 weeks, with 24-month follow-up. Interviewer-rated PTSD symptom severity was the main outcome measure, and depression, anxiety, and functioning were assessed as additional outcomes. RESULTS Patients preferred prolonged exposure over sertraline (number needed to benefit [NNTB]=4.5). Using intent-to-treat analyses (N=200), both prolonged exposure and sertraline showed large gains that were maintained over 24 months. Although no differential effect was observed on interviewer-rated PTSD severity, there was a significant benefit of prolonged exposure over sertraline on interview-rated loss of PTSD diagnosis (NNTB=7.0), responder status (NNTB=5.7), and self-reported PTSD, depression, and anxiety symptoms and functioning (effect sizes, 0.35-0.44). Patients who received their preferred treatment were more likely to be adherent, lose their PTSD diagnosis (NNTB=3.4), achieve responder status (NNTB=3.4), and have lower self-reported PTSD, depression, and anxiety symptoms (effect sizes, 0.40-0.72). CONCLUSIONS Prolonged exposure and sertraline confer significant benefits for PTSD, with some evidence of an advantage for prolonged exposure. Giving patients with PTSD their preferred treatment also confers important benefits, including enhancing adherence.
Collapse
Affiliation(s)
- Lori A Zoellner
- From the Department of Psychology and the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle; and the Department of Psychiatry and the Department of Psychology, Case Western Reserve University, Cleveland
| | - Peter P Roy-Byrne
- From the Department of Psychology and the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle; and the Department of Psychiatry and the Department of Psychology, Case Western Reserve University, Cleveland
| | - Matig Mavissakalian
- From the Department of Psychology and the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle; and the Department of Psychiatry and the Department of Psychology, Case Western Reserve University, Cleveland
| | - Norah C Feeny
- From the Department of Psychology and the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle; and the Department of Psychiatry and the Department of Psychology, Case Western Reserve University, Cleveland
| |
Collapse
|
11
|
Morland LA, Wells SY, Glassman LH, Grubbs KM, Mackintosh MA, Golshan S, Sohn MJ, Thorp SR, Savage UC, Acierno RE. What Do Veterans Want? Understanding Veterans’ Preferences for PTSD Treatment Delivery. Mil Med 2019; 184:686-692. [DOI: 10.1093/milmed/usz035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/26/2018] [Accepted: 02/13/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Home-based delivery of psychotherapy may offer a viable alternative to traditional office-based treatment for post-traumatic stress disorder (PTSD) by overcoming several barriers to care. Little is known about patient perceptions of home-based mental health treatment modalities. This study assessed veterans’ preferences for treatment delivery modalities and how demographic variables and trauma type impact these preferences.
Materials and Methods
Veterans with PTSD (N = 180) participating in a randomized clinical trial completed a clinician-administered PTSD assessment and were asked to identify their modality preference for receiving prolonged exposure: home-based telehealth (HBT), office-based telehealth (OBT), or in-home-in-person (IHIP). Ultimately, modality assignment was randomized, and veterans were not guaranteed their preferred modality. Descriptive statistics were used to examine first choice preference. Chi-square tests determined whether there were significant differences among first choice preferences; additional tests examined if age, sex, and military sexual trauma (MST) history were associated with preferences.
Results
The study includes 135 male veterans and 45 female veterans from all military branches; respondents were 46.30 years old, on average. Veterans were Caucasian (46%), African-American (28%), Asian-American (9%), American Indian or Alaskan Native (3%), Native Hawaiian or Pacific Islander (3%), and 11% identified as another race. Veterans experienced numerous trauma types (e.g., combat, sexual assault), and 29% had experienced MST. Overall, there was no clear preference for one modality: 42% of veterans preferred HBT, 32% preferred IHIP, and 26% preferred OBT. One-sample binomial tests assuming equal proportions were conducted to compare each pair of treatment options. HBT was significantly preferred over OBT (p = 0.01); there were no significant differences between the other pairs. A multinomial regression found that age group significantly predicted veterans’ preferences for HBT compared to OBT (odds ratio [OR] = 10.02, 95% confidence interval [CI]: 1.63, 61.76). Older veterans were significantly more likely to request HBT compared to OBT. Veteran characteristics did not differentiate those who preferred IHIP to OBT. Because there were fewer women (n = 45), additional multinomial regressions were conducted on each sex separately. There was no age group effect among the male veterans. However, compared to female Veterans in the younger age group, older female Veterans were significantly more likely to request HBT over OBT (OR = 10.66, 95% CI: 1.68, 67.58, p = 0.012). MST history did not predict treatment preferences in any analysis.
Conclusions
Fewer than 50% of the sample preferred one method, and each modality was preferred by at least a quarter of all participants, suggesting that one treatment modality does not fit all. Both home-based care options were desirable, highlighting the value of offering a range of options. The use of home-based care can expand access to care, particularly for rural veterans. The current study includes a diverse group of veterans and increases our understanding of how they would like to receive PTSD treatment. The study used a forced choice preference measure and did not examine the strength of preference, which limits conclusions. Future studies should examine the impact of modality preferences on treatment outcomes and engagement.
Collapse
Affiliation(s)
- Leslie A Morland
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA
- Department of Psychiatry, University of California San Diego, Department of Psychiatry, 9500 Gilman Drive Mc 0603, La Jolla, CA
- National Center for PTSD-Pacific Island Division; 3375 Koapaka Street, Suite I-560, Honolulu, HI
- Veterans Medical Research Foundation, 3350 La Jolla Village Dr # 151a Bldg 13, San Diego, CA
| | - Stephanie Y Wells
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA
- Veterans Medical Research Foundation, 3350 La Jolla Village Dr # 151a Bldg 13, San Diego, CA
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, 6363 Alvarado Court, Suite 103, San Diego, CA
| | - Lisa H Glassman
- Department of Psychiatry, University of California San Diego, Department of Psychiatry, 9500 Gilman Drive Mc 0603, La Jolla, CA
- Center of Excellence for Stress and Mental Health, San Diego VA Healthcare System, 3350 La Jolla Village Drive. San Diego, CA (MC 116A)
| | - Kathleen M Grubbs
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA
- Department of Psychiatry, University of California San Diego, Department of Psychiatry, 9500 Gilman Drive Mc 0603, La Jolla, CA
| | - Margaret-Anne Mackintosh
- National Center for PTSD – Dissemination and Training Division; NCPTSD – 334, 795 Willow Road Menlo Park, CA
| | - Shahrokh Golshan
- Department of Psychiatry, University of California San Diego, Department of Psychiatry, 9500 Gilman Drive Mc 0603, La Jolla, CA
| | - Min Ji Sohn
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA
| | | | - Ulysses C Savage
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA
| | - Ronald E Acierno
- College of Nursing, Medical University of South Carolina, 179 Ashley Ave, Charleston, SC
- Ralph H. Johnson Medical Center, 109 Bee St, Charleston, SC
| |
Collapse
|
12
|
Graham B, Garcia NM, Burton MS, Cooper AA, Roy-Byrne PP, Mavissakalian MR, Feeny NC, Zoellner LA. High expectancy and early response produce optimal effects in sertraline treatment for post-traumatic stress disorder. Br J Psychiatry 2018; 213:704-708. [PMID: 30355364 PMCID: PMC6263783 DOI: 10.1192/bjp.2018.211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Better indicators of prognosis are needed to personalise post-traumatic stress disorder (PTSD) treatments.AimsWe aimed to evaluate early symptom reduction as a predictor of better outcome and examine predictors of early response. METHOD Patients with PTSD (N = 134) received sertraline or prolonged exposure in a randomised trial. Early response was defined as 20% PTSD symptom reduction by session two and good end-state functioning defined as non-clinical levels of PTSD, depression and anxiety. RESULTS Early response rates were similar in prolonged exposure and sertraline (40 and 42%), but in sertraline only, early responders were four times more likely to achieve good end-state functioning at post-treatment (Number Needed to Treat = 1.8, 95% CI 1.28-3.00) and final follow-up (Number Needed to Treat = 3.1, 95% CI 1.68-16.71). Better outcome expectations of sertraline also predicted higher likelihood of early response. CONCLUSIONS Higher expectancy of sertraline coupled with early response may produce a cascade-like effect for optimal conditions for long-term symptom reduction. Therefore, assessing expectations and providing clear treatment rationales may optimise sertraline effects. DECLARATION OF INTEREST None.
Collapse
Affiliation(s)
- Belinda Graham
- Department of Psychology, University of Washington, Seattle, WA,Corresponding author’s current contact details: Belinda Graham, Department of Experimental Psychology, University of Oxford, The Old Rectory, Paradise Square, Oxford OX1 1TW, U.K.,
| | | | - Mark S. Burton
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, OH
| | - Andrew A. Cooper
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, OH
| | - Peter P. Roy-Byrne
- Department of Psychiatry and Behavioral Sciences, Harborview Medical Center, Seattle, WA
| | - Matig R. Mavissakalian
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland OH
| | - Norah C. Feeny
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, OH
| | | |
Collapse
|
13
|
Watkins LE, Sprang KR, Rothbaum BO. Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions. Front Behav Neurosci 2018; 12:258. [PMID: 30450043 PMCID: PMC6224348 DOI: 10.3389/fnbeh.2018.00258] [Citation(s) in RCA: 243] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/15/2018] [Indexed: 12/21/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) is a chronic, often debilitating mental health disorder that may develop after a traumatic life event. Fortunately, effective psychological treatments for PTSD exist. In 2017, the Veterans Health Administration and Department of Defense (VA/DoD) and the American Psychological Association (APA) each published treatment guidelines for PTSD, which are a set of recommendations for providers who treat individuals with PTSD. The purpose of the current review article is to briefly review the methodology used in each set of 2017 guidelines and then discuss the psychological treatments of PTSD for adults that were strongly recommended by both sets of guidelines. Both guidelines strongly recommended use of Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and trauma-focused Cognitive Behavioral Therapy (CBT). Each of these treatments has a large evidence base and is trauma-focused, which means they directly address memories of the traumatic event or thoughts and feelings related to the traumatic event. Finally, we will discuss implications and future directions.
Collapse
Affiliation(s)
- Laura E Watkins
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - Kelsey R Sprang
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - Barbara O Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States
| |
Collapse
|
14
|
Wolitzky-Taylor K, Fenwick K, Lengnick-Hall R, Grossman J, Bearman SK, Arch J, Miranda J, Chung B. A Preliminary Exploration of the Barriers to Delivering (and Receiving) Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings. Community Ment Health J 2018; 54:899-911. [PMID: 29524078 PMCID: PMC6129437 DOI: 10.1007/s10597-018-0252-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 02/22/2018] [Indexed: 11/29/2022]
Abstract
Despite the effectiveness of exposure-based cognitive behavioral therapy (CBT) for anxiety disorders, few individuals in need receive this treatment, particularly in community mental health settings serving low-income adults. The present study took a preliminary step to understand these barriers by conducting a series of key informant interviews and focus groups among patients, providers, clinical administrators, and policy makers. Several themes emerged as barriers to the delivery of exposure-based CBT in these settings, including therapist training and compentency issues, logistical issues, and funding stream issues. Clinical implications and future research that can build from these data are discussed.
Collapse
Affiliation(s)
- Kate Wolitzky-Taylor
- Department of Psychiatry and Biobehavioral Sciences, University of California-Los Angeles, Los Angeles, USA.
| | - Karissa Fenwick
- Department of Social Work, University of Southern California, Los Angeles, USA
| | | | - Jason Grossman
- Department of Psychiatry and Biobehavioral Sciences, University of California-Los Angeles, Los Angeles, USA
| | - Sarah Kate Bearman
- Department of Educational Psychology, University of Texas at Austin, Austin, USA
| | - Joanna Arch
- Department of Psychology and Neuroscience, University of Colorado-Boulder, Boulder, USA
| | - Jeanne Miranda
- Department of Psychiatry and Biobehavioral Sciences, University of California-Los Angeles, Los Angeles, USA
| | - Bowen Chung
- Department of Psychiatry and Biobehavioral Sciences, University of California-Los Angeles, Los Angeles, USA
| |
Collapse
|
15
|
Boykin DM, Orcutt HK. Treatment Use Among College Women Following a Campus Shooting. JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 2018; 28:261-280. [PMID: 31467476 PMCID: PMC6715303 DOI: 10.1080/10926771.2018.1480548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 04/20/2018] [Accepted: 05/21/2018] [Indexed: 06/10/2023]
Abstract
Despite increases in campus shootings, there is limited research on treatment utilization after these tragic events. The present study prospectively examined the prevalence and predictors of treatment use among college women following a campus shooting. Predictors included age, race/ethnicity, education level, severity of exposure to shooting, and post-shooting sequelae (i.e., social support, posttraumatic stress disorder [PTSD] severity, depression severity). Present data were obtained from 516 women on campus at the time of the shooting. They completed electronic and online surveys across three time points - pre-shooting (T1), 1-month post-shooting (T2), and 6-months post-shooting (T3). As expected, few participants (14.4%) sought any treatment. Of note, 77.5% of participants endorsed at least one risk factor for PTSD. Prevalence rates of probable PTSD significantly decreased from 51.8% of the full sample at T2 to 12.9% at T3. Results showed that a significantly higher proportion of participants with probable PTSD at T3 sought treatment than those participants at minimal to no risk for PTSD. Psychotherapy was sought at higher rates than medication or combined treatment across risk groups. No reliable predictors of treatment use were observed for at-risk participants or those with probable PTSD. Research and clinical suggestions for optimizing post-disaster recovery and improving treatment utilization among students following campus shootings are discussed.
Collapse
Affiliation(s)
- Derrecka M Boykin
- Department of Psychology, Northern Illinois University, DeKalb, Illinois, USA
| | - Holly K Orcutt
- Department of Psychology, Northern Illinois University, DeKalb, Illinois, USA
| |
Collapse
|
16
|
Bedard-Gilligan M, Garcia N, Zoellner LA, Feeny NC. Alcohol, cannabis, and other drug use: Engagement and outcome in PTSD treatment. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2018; 32:277-288. [PMID: 29595297 PMCID: PMC9377391 DOI: 10.1037/adb0000355] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
The co-occurrence of posttraumatic stress disorder (PTSD) and substance use is related to poorer outcome and increased dropout from trauma-focused treatment. Investigating PTSD and substance use can inform the intervention approaches. Exploring cannabis use in particular is especially important because rates of cannabis use have been increasing with recent legalization trends. A better understanding of how substance use is associated with treatment processes and outcome for individuals with PTSD is needed to enhance care. In this study, both lifetime diagnoses of alcohol and drug use disorders and current alcohol and drug use severity were examined in 200 men and women with chronic PTSD who received either prolonged exposure (PE) or sertraline. No lifetime or current alcohol use variables predicted dropout, adherence, or poorer outcome. However, lifetime diagnosis of both an alcohol and drug disorder (OR = 3.42) and recent cannabis use (OR = 3.38) strongly predicted higher dropout. Recent cannabis use and drug use severity predicted poorer adherence to PE (β = -.22 to -.29) but not to sertraline. Drug use severity (β = -.22) also predicted worse treatment outcome, as did lifetime diagnosis of an alcohol and drug disorder (β = -.48). Overall, patients with drug use improved with treatment but had less treatment retention, adherence, and symptom reduction. Strategies to increase engagement and retention may be indicated for these patients. Individuals who are using cannabis or other drugs may be at higher risk for not completing PTSD treatment, potentially prolonging the cycle of PTSD and substance use. (PsycINFO Database Record
Collapse
Affiliation(s)
| | | | | | - Norah C Feeny
- Department of Psychology, Case Western Reserve University
| |
Collapse
|
17
|
Keefe JR, Wiltsey Stirman S, Cohen ZD, DeRubeis RJ, Smith BN, Resick PA. In rape trauma PTSD, patient characteristics indicate which trauma-focused treatment they are most likely to complete. Depress Anxiety 2018; 35:330-338. [PMID: 29489037 DOI: 10.1002/da.22731] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 01/18/2018] [Accepted: 01/20/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Dropout rates for effective therapies for posttraumatic stress disorder (PTSD) can be high, especially in practice settings. Although clinicians have intuitions regarding what treatment patients may complete, there are few systematic data to drive those judgments. METHODS A multivariable model of dropout risk was constructed with randomized clinical trial data (n = 160) comparing prolonged exposure (PE) and cognitive processing therapy (CPT) for rape-induced PTSD. A two-step bootstrapped variable selection algorithm was applied to identify moderators of dropout as a function of treatment condition. Employing identified moderators in a model, fivefold cross-validation yielded estimates of dropout probability for each patient in each condition. Dropout rates between patients who did and did not receive their model-indicated treatment were compared. RESULTS Despite equivalent dropout rates across treatments, patients assigned to their model-indicated treatment were significantly less likely to drop out relative to patients who did not (relative risk = 0.49 [95% CI: 0.29-0.82]). Moderators included in the model were: childhood physical abuse, current relationship conflict, anger, and being a racial minority, all of which were associated with higher likelihood of dropout in PE than CPT. CONCLUSIONS Individual differences among patients affect the likelihood they will complete a particular treatment, and clinicians can consider these moderators in treatment planning. In the future, treatment selection models could be used to increase the percentage of patients who will receive a full course of treatment, but replication and extension of such models, and consideration of how best to integrate them into routine practice, are needed.
Collapse
Affiliation(s)
- John R Keefe
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
| | - Shannon Wiltsey Stirman
- Psychiatry and Behavioral Sciences, Palo Alto Veterans Affairs Health System, Palo Alto, CA, USA
| | | | - Robert J DeRubeis
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian N Smith
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | | |
Collapse
|
18
|
Effects of treatment, choice, and preference on health-related quality-of-life outcomes in patients with posttraumatic stress disorder (PTSD). Qual Life Res 2018. [DOI: 10.1007/s11136-018-1833-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
19
|
Design of a randomized controlled trial examining the efficacy and biological mechanisms of web-prolonged exposure and present-centered therapy for PTSD among active-duty military personnel and veterans. Contemp Clin Trials 2017; 64:41-48. [PMID: 29128649 DOI: 10.1016/j.cct.2017.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/02/2017] [Accepted: 11/07/2017] [Indexed: 01/06/2023]
Abstract
Improved accessibility of effective and efficient evidence-based treatments (EBTs) for military personnel suffering with posttraumatic stress disorder (PTSD) is an urgent need to meet the growing demand for timely care. In addition, a better understanding of the mechanism of action of behavioral therapy can inform the delivery of care to meet accessibility demands. Effective EBTs for PTSD are available, but logistical and stigma-related barriers to accessing behavioral healthcare can deter military personnel from receiving these treatments. Web-based treatments represent an innovative way to overcome these barriers. The efficacy of previously developed web-based treatments for PTSD appears promising; however, they were not developed based on treatment protocols with strong empirical support for their efficacy. No study to date has examined web-based treatment of PTSD using a well-established evidence-based treatment, nor delineated the biological mechanisms through which a web-based treatment exerts its effects. This paper describes the rationale and methods of a randomized controlled trial comparing the efficacy and potential biological mediators of 10 sessions of a web-version of Prolonged Exposure (PE), "Web-PE," delivered over 8weeks compared to 10 sessions of in-person Present-Centered Therapy (PCT) delivered over 8weeks by a therapist in 120 active duty military personnel and veterans with PTSD.
Collapse
|
20
|
van den Berg DPG, van der Vleugel BM, de Bont PAJM, Thijssen G, de Roos C, de Kleine R, Kraan T, Ising H, de Jongh A, van Minnen A, van der Gaag M. Exposing therapists to trauma-focused treatment in psychosis: effects on credibility, expected burden, and harm expectancies. Eur J Psychotraumatol 2016; 7:31712. [PMID: 27606710 PMCID: PMC5015638 DOI: 10.3402/ejpt.v7.31712] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite robust empirical support for the efficacy of trauma-focused treatments, the dissemination proves difficult, especially in relation to patients with comorbid psychosis. Many therapists endorse negative beliefs about the credibility, burden, and harm of such treatment. OBJECTIVE This feasibility study explores the impact of specialized training on therapists' beliefs about trauma-focused treatment within a randomized controlled trial. METHOD Therapist-rated (n=16) credibility, expected burden, and harm expectancies of trauma-focused treatment were assessed at baseline, post-theoretical training, post-technical training, post-supervised practical training, and at 2-year follow-up. Credibility and burden beliefs of therapists concerning the treatment of every specific patient in the trial were also assessed. RESULTS Over time, therapist-rated credibility of trauma-focused treatment showed a significant increase, whereas therapists' expected burden and harm expectancies decreased significantly. In treating posttraumatic stress disorder (PTSD) in patients with psychotic disorders (n=79), pre-treatment symptom severity was not associated with therapist-rated credibility or expected burden of that specific treatment. Treatment outcome had no influence on patient-specific credibility or burden expectancies of therapists. CONCLUSIONS These findings support the notion that specialized training, including practical training with supervision, has long-term positive effects on therapists' credibility, burden, and harm beliefs concerning trauma-focused treatment.
Collapse
Affiliation(s)
| | | | - Paul A J M de Bont
- Mental Health Organization (MHO) GGZ Oost Brabant Land van Cuijk en Noord Limburg, Boxmeer, The Netherlands
| | - Gwen Thijssen
- Parnassia Psychiatric Institute, Den Haag, The Netherlands
| | | | - Rianne de Kleine
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands.,Centre for Anxiety Disorders Overwaal, MHO Pro Persona, Nijmegen, The Netherlands
| | - Tamar Kraan
- Parnassia Psychiatric Institute, Den Haag, The Netherlands
| | - Helga Ising
- Parnassia Psychiatric Institute, Den Haag, The Netherlands
| | - Ad de Jongh
- Department of Behavioral Sciences, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands.,School of Health Sciences, Salford University, Manchester, United Kingdom
| | - Agnes van Minnen
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands.,Centre for Anxiety Disorders Overwaal, MHO Pro Persona, Nijmegen, The Netherlands
| | - Mark van der Gaag
- Parnassia Psychiatric Institute, Den Haag, The Netherlands.,Department of Clinical Psychology, VU University Amsterdam and EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| |
Collapse
|
21
|
Bergman HE, Kline AC, Feeny NC, Zoellner LA. Examining PTSD treatment choice among individuals with subthreshold PTSD. Behav Res Ther 2015; 73:33-41. [PMID: 26246029 PMCID: PMC4573338 DOI: 10.1016/j.brat.2015.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 06/18/2015] [Accepted: 07/21/2015] [Indexed: 10/23/2022]
Abstract
Subthreshold posttraumatic stress disorder (PTSD) is associated with impairment and has a prevalence rate comparable to full PTSD. Yet, little is known regarding treatment preferences among individuals with subthreshold PTSD, even though they seek trauma-related treatment at a similar rate to those with full PTSD. This study explored subthreshold diagnostic PTSD diagnostic category and treatment preference in undergraduate (N = 439) and trauma-exposed community (N = 203) samples. Participants completed the Posttraumatic Stress Diagnostic Scale (PDS), viewed standardized treatment rationales, and made a hypothetical PTSD treatment choice: prolonged exposure (PE), sertraline, combination treatment, or no treatment. The PDS was used to categorize individuals into four PTSD categories: no trauma exposure, trauma exposure only, subthreshold PTSD, and full PTSD. Within the samples, 8.9% (n = 39) of undergraduates and 16.7% (n = 34) of community members met subthreshold PTSD criteria. The majority of individuals with subthreshold PTSD in each sample reported impairment, 59.0% of undergraduates and 76.5% of community members. Within subthreshold PTSD groups, the most commonly selected treatments were PE (61.5%) for undergraduates and combination treatment (47.1%) for community members. Findings underscore the necessity of further examining subthreshold PTSD, which may hold important clinical implications for treatment processes and outcomes.
Collapse
Affiliation(s)
- Hannah E Bergman
- Case Western Reserve University, Department of Psychological Sciences, 10900 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Alexander C Kline
- Case Western Reserve University, Department of Psychological Sciences, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Norah C Feeny
- Case Western Reserve University, Department of Psychological Sciences, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Lori A Zoellner
- University of Washington, Department of Psychology, Box 351525, Seattle, WA 98195, USA
| |
Collapse
|
22
|
Wolitzky-Taylor K, Zimmermann M, Arch JJ, De Guzman E, Lagomasino I. Has evidence-based psychosocial treatment for anxiety disorders permeated usual care in community mental health settings? Behav Res Ther 2015; 72:9-17. [DOI: 10.1016/j.brat.2015.06.010] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/20/2015] [Accepted: 06/22/2015] [Indexed: 11/16/2022]
|
23
|
Prolonged exposure, paroxetine and the combination in the treatment of PTSD following a motor vehicle accident. A randomized clinical trial - The "TRAKT" study. J Behav Ther Exp Psychiatry 2015; 48:17-26. [PMID: 25677254 DOI: 10.1016/j.jbtep.2015.01.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 12/26/2014] [Accepted: 01/14/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Little is known about direct comparisons of the efficacy of trauma-focused psychotherapies and SSRIs. This is the first randomized clinical trial comparing the efficacy of prolonged exposure (PE), paroxetine (Ph) and their combination (Comb) in a sample of adults diagnosed with PTSD following motor vehicle accidents (MVA). METHODS A total of 228 people were randomly assigned to a twelve-week treatment of PE (N = 114), Ph (N = 57) or Comb (N = 57). RESULTS The ITT analyses showed that the remission rate of PTSD was significantly greater after PE (65.5%) compared with Ph (43.3%), whereas Comb (51.2%) did not differ from either. The differences in dropout rates were not significant between treatments (18.4% - PE; 12.2% - Ph; 22.8% - Comb), while the differences in numbers of refusers were significant (3.5% PE <31.6% Comb <47.4% Ph; p < .01). The changes in self-rated PTSD were significant for each treatment and without significant differences between treatments. Differences between clinician and self-rated outcomes can be explained by depressive symptoms influencing self-rating by the PDS. At a 12 month follow-up treatment results were maintained and different trajectories of functioning were identified. LIMITATIONS Larger samples would allow analyses of predictors of treatment response, dropout and refusal. CONCLUSIONS In this, largest to date study comparing PE, paroxetine and combination treatment in PTSD PE was more effective than Ph in achieving remission of PTSD. The additive effect of Comb over any monotherapy was not shown.
Collapse
|
24
|
Foa EB, Gillihan SJ, Bryant RA. Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress: Lessons Learned From Prolonged Exposure Therapy for PTSD. Psychol Sci Public Interest 2015; 14:65-111. [PMID: 25722657 DOI: 10.1177/1529100612468841] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress.
Collapse
Affiliation(s)
- Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Seth J Gillihan
- Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, Australia
| |
Collapse
|
25
|
Veteran satisfaction and treatment preferences in response to a posttraumatic stress disorder specialty clinic orientation group. Behav Res Ther 2015; 69:75-82. [PMID: 25898342 DOI: 10.1016/j.brat.2015.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 03/26/2015] [Accepted: 04/11/2015] [Indexed: 11/22/2022]
Abstract
To maximize accessibility to evidence-based treatments for posttraumatic stress disorder (PTSD), the United States Department of Veterans Affairs (VA) has widely disseminated cognitive processing therapy (CPT) and prolonged exposure (PE) therapy to VA clinicians. However, there is a lack of research on veteran preferences when presented with a range of psychotherapy and medication options. This study uses a mixed-method approach to explore veteran satisfaction with a VA PTSD specialty clinic pre-treatment orientation group, which provides education about available PTSD treatment options. This study also tested differences in treatment preference in response to the group. Participants were 183 US veterans. Most were White, male, and referred to the clinic by a VA provider. Results indicated high satisfaction with the group in providing an overview of services and helping to inform treatment choice. Most preferred psychotherapy plus medications (63.4%) or psychotherapy only (30.1%). Participants endorsed a significantly stronger preference for CPT versus other psychotherapies. PE was significantly preferred over nightmare resolution therapy and present-centered therapy, and both PE and cognitive-behavioral conjoint therapy were preferred over virtual reality exposure therapy. Results suggest that by informing consumers about evidence-based treatments for PTSD, pre-treatment educational approaches may increase consumer demand for these treatment options.
Collapse
|
26
|
Moffitt R, Haynes A, Mohr P. Treatment beliefs and preferences for psychological therapies for weight management. J Clin Psychol 2015; 71:584-96. [PMID: 25787892 DOI: 10.1002/jclp.22157] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Treatment beliefs and preferences for psychological therapies were investigated in 80 overweight individuals trying to manage their weight. METHOD Participants read 4 therapy descriptions: cognitive behavioral therapy (CBT), behavior therapy (BT), cognitive therapy (CT), and acceptance and commitment therapy (ACT). They ranked the treatments in order of preference, explained the reason for their preferred choice, and reported their beliefs about each approach. RESULTS Individual CBT (43.42%) and BT (31.58%), delivered face-to-face or technologically, were the most preferred treatment options, while ACT (17.12%) and CT (7.89%) were the least preferred. The main reasons cited among those who chose CBT and BT were perceived comprehensiveness and the practical nature of the approach, respectively. Treatment beliefs were strongly predicted by psychological need satisfaction as well as perceived ease and effort. CONCLUSIONS Further research should ascertain the stability of treatment beliefs and the efficacy of modifying the treatment context to meet individual needs.
Collapse
|
27
|
Rytwinski NK, Rosoff CB, Feeny NC, Zoellner LA. Are PTSD treatment choices and treatment beliefs related to depression symptoms and depression-relevant treatment rationales? Behav Res Ther 2014; 61:96-104. [PMID: 25151916 DOI: 10.1016/j.brat.2014.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 07/23/2014] [Accepted: 07/23/2014] [Indexed: 10/25/2022]
Abstract
Given high rates of depression and low rates of treatment utilization among individuals with posttraumatic stress disorder (PTSD), we examined how depression symptoms impact PTSD treatment beliefs and preference (prolonged exposure (PE), sertraline, or PE plus sertraline). We also examined whether PTSD treatment rationales tailored to individuals with symptoms of depression impact PTSD treatment preference/beliefs. Undergraduates (N = 439) were given an "imagine self" scenario where they either had symptoms of PTSD or PTSD and depression in the future. Trauma-exposed community members (N = 203) reported their own PTSD and depression symptoms. All participants watched standardized treatment rationales for PE and sertraline that were systematically manipulated to include information on depression or not. Across both samples, depression symptoms were associated with significantly increased odds of selecting combination treatment relative to PE alone. For those in the community sample who received the depression-relevant treatment rationale, higher depression symptoms were associated with significantly greater PE credibility and more positive reactions toward PE. Taken together, depression may be associated with a greater preference for combination treatment. However, treatment providers may be able to improve treatment beliefs about PE by offering a treatment rationale that explains that PE tends to help improve symptoms of PTSD and depression.
Collapse
Affiliation(s)
- Nina K Rytwinski
- Case Western Reserve University, Department of Psychological Sciences, 10900 Euclid Ave., Cleveland, OH 44106, USA
| | - Cari B Rosoff
- Case Western Reserve University, Department of Psychological Sciences, 10900 Euclid Ave., Cleveland, OH 44106, USA
| | - Norah C Feeny
- Case Western Reserve University, Department of Psychological Sciences, 10900 Euclid Ave., Cleveland, OH 44106, USA.
| | - Lori A Zoellner
- University of Washington, Department of Psychology, Box 351525, Seattle, WA 98195, USA
| |
Collapse
|
28
|
Kehle-Forbes SM, Polusny MA, Erbes CR, Gerould H. Acceptability of prolonged exposure therapy among U.S. Iraq war veterans with PTSD symptomology. J Trauma Stress 2014; 27:483-7. [PMID: 25158642 DOI: 10.1002/jts.21935] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Despite efforts to increase the availability of prolonged exposure therapy (PE) within the Department of Veterans Affairs, little is known about the acceptability of PE among veteran populations. We queried a sample of 58 U.S. National Guard Iraq War veterans previously deployed to combat who screened positive for posttraumatic stress disorder (PTSD) as to whether they would prefer PE, treatment with an antidepressant, or no treatment. We also gathered open-ended responses regarding the veterans' reasons for their choice and potential barriers to engaging in that treatment. A majority (53.4%) of veterans who completed the interview said they would choose to participate in PE, 36.2% preferred antidepressant treatment, 8.6% chose no treatment, and 1.8% were unable to choose among the options. Credibility of the treatment rationale and beliefs about the treatment's efficacy were the most frequently given reasons for choosing PE (45.2%); past treatment experience was the most common reason for choosing antidepressant treatment (47.6%). The most commonly cited barrier for those who chose both antidepressant treatment and PE was time to participate (52.4% and 77.4%, respectively). The findings suggest that PE is a credible and acceptable treatment option for veterans with PTSD symptomology.
Collapse
Affiliation(s)
- Shannon M Kehle-Forbes
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA; Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | | | | |
Collapse
|
29
|
Spence J, Titov N, Johnston L, Jones MP, Dear BF, Solley K. Internet-based trauma-focused cognitive behavioural therapy for PTSD with and without exposure components: a randomised controlled trial. J Affect Disord 2014; 162:73-80. [PMID: 24767009 DOI: 10.1016/j.jad.2014.03.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Revised: 03/08/2014] [Accepted: 03/08/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Internet-delivered trauma-focused cognitive behavioural therapy is efficacious for PTSD; however, no studies have investigated the roles of individual treatment components or the safety of online treatments. AIMS To compare the efficacy and safety of an online treatment for PTSD comprised of psychoeducation, stress management, cognitive restructuring and exposure components with the equivalent protocol without the exposure components, using a randomised controlled trial design. METHODS Sixty-six individuals were randomised to a non-exposure condition and 59 to the full protocol with exposure components. Treatment duration was 8 weeks and pre-, post-treatment and three-month follow-up outcomes were analysed using a mixed linear modelling approach. RESULTS Both groups achieved improvements in symptoms with no differences between groups on any primary or secondary outcome measures, diagnostic remission rates or adverse events. LIMITATIONS The study included several secondary measures that have not been previously validated and treatments were not time matched in terms of number of lessons. CONCLUSIONS These findings indicate that trauma-focused cognitive behavioural therapy for PTSD with or without exposure components can be safe and efficacious.
Collapse
Affiliation(s)
- Jay Spence
- Macquarie University, Sydney, NSW, Australia.
| | | | | | | | - Blake F Dear
- NHMRC Public Health Fellow, Macquarie University, Sydney, NSW, Australia.
| | - Karen Solley
- Macquarie University, Sydney, NSW, Australia; NHMRC Public Health Fellow, Macquarie University, Sydney, NSW, Australia
| |
Collapse
|
30
|
McLean CP, Foa EB. Prolonged exposure therapy for post-traumatic stress disorder: a review of evidence and dissemination. Expert Rev Neurother 2014; 11:1151-63. [DOI: 10.1586/ern.11.94] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
31
|
de Kleine RA, Hendriks GJ, Smits JAJ, Broekman TG, van Minnen A. Prescriptive variables for d-cycloserine augmentation of exposure therapy for posttraumatic stress disorder. J Psychiatr Res 2014; 48:40-6. [PMID: 24183818 DOI: 10.1016/j.jpsychires.2013.10.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 09/21/2013] [Accepted: 10/10/2013] [Indexed: 11/25/2022]
Abstract
In recent years, several studies have demonstrated efficacy of d-cycloserine (DCS) enhanced exposure therapy across anxiety disorders. In this study we examined person-level variables that predicted response to DCS enhanced exposure therapy in a chronic, mixed trauma PTSD sample. The sample consisted of 67 treatment-seeking individuals, randomly allocated to receive exposure therapy augmented with DCS (50 mg) or identical looking placebo. We examined the following baseline predictors of treatment response: (1) demographic characteristics (age, gender, marital status, and education); (2) clinical characteristics (initial PTSD symptom severity, Axis I comorbidity, depression symptom severity, and antidepressants use); (3) personality characteristics (openness, conscientiousness, extraversion, agreeableness, and neuroticism). Outcome was measured with the PTSD Symptom Scale, Self-Report, which was assessed weekly during treatment. Two prescriptive variables were identified: conscientiousness and extraversion. For high conscientious participants, those who received DCS showed better outcome than those who received placebo. And for low extraversion, DCS showed superior outcome relative to placebo. Education was identified as a prognostic variable, it predicted response across both groups: higher education was related to worse outcome. Our results provide support for the influence of personality traits on DCS augmented exposure outcome and give more insight into possible working mechanisms of this novel treatment strategy. Ultimately, this may contribute to treatment matching strategies in order to improve treatment efficacy of exposure therapy for PTSD.
Collapse
Affiliation(s)
- Rianne A de Kleine
- Radboud University Nijmegen, Behavioural Science Institute, NijCare, The Netherlands; Center for Anxiety Disorders Overwaal, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands.
| | | | | | | | | |
Collapse
|
32
|
Dimidjian S, Goodman SH. Preferences and attitudes toward approaches to depression relapse/recurrence prevention among pregnant women. Behav Res Ther 2013; 54:7-11. [PMID: 24440577 DOI: 10.1016/j.brat.2013.11.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 11/21/2013] [Accepted: 11/26/2013] [Indexed: 11/15/2022]
Abstract
Patient preferences are increasingly recognized as important in clinical research and the delivery of evidence based practice in psychology. Although the prevention of depressive relapse/recurrence among perinatal women is an important public health goal, little is known about pregnant women's preferences and attitudes toward relapse/recurrence prevention interventions. Such information is important given low rates of care seeking among this population, and the potential for a relapse/recurrence prevention to avert negative outcomes among both vulnerable women and their offspring. Pregnant women seeking routine prenatal care in obstetric clinics (n = 200) were surveyed to assess their preferences for and attitudes about psychotherapy and pharmacological approaches to relapse/recurrence prevention. Women preferred psychotherapy (mindfulness based cognitive therapy and interpersonal therapy) more so than pharmacotherapy and reported significantly more favorable perceptions of the psychotherapy as compared to pharmacotherapy approaches to depression relapse/recurrence prevention. Results suggest also that depression history is important to consider in evaluating women's preferences and attitudes. Clinical and research implications of these findings are discussed.
Collapse
Affiliation(s)
- Sona Dimidjian
- University of Colorado Boulder, Department of Psychology and Neuroscience, 345 UCB, Boulder, CO 80309, USA.
| | | |
Collapse
|
33
|
Dissemination and implementation of prolonged exposure therapy for posttraumatic stress disorder. J Anxiety Disord 2013; 27:788-92. [PMID: 23602350 DOI: 10.1016/j.janxdis.2013.03.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 03/13/2013] [Accepted: 03/13/2013] [Indexed: 11/23/2022]
Abstract
Posttraumatic stress disorder (PTSD) is a highly prevalent, often chronic and disabling psychiatric disorder that is associated with significant adverse health and life consequences. Although several evidence-based treatments (EBTs), including Prolonged Exposure therapy (PE), have been found effective and efficacious in reducing PTSD symptomology, the majority of individuals with this disorder receive treatments of unknown efficacy. Thus, it is imperative that EBTs such as PE be made available to PTSD sufferers through widespread dissemination and implementation. We will review some of the efforts to increase the availability of PE and the common barriers to successful dissemination and implementation. We also discuss novel dissemination strategies that are harnessing technology to overcome barriers to dissemination.
Collapse
|
34
|
Arch JJ. Cognitive behavioral therapy and pharmacotherapy for anxiety: treatment preferences and credibility among pregnant and non-pregnant women. Behav Res Ther 2013; 52:53-60. [PMID: 24326075 DOI: 10.1016/j.brat.2013.11.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Revised: 10/16/2013] [Accepted: 11/13/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND Relatively little is known about women's anxiety-related treatment preferences and no studies have examined potential differences between pregnant versus non-pregnant women. Treatment credibility and willingness are particularly important to understand regarding exposure-based cognitive behavioral therapy (CBT) and pharmacotherapy, the leading evidence-based treatments. METHODS A large U.S. sample of pregnant (n = 377) and matched non-pregnant (n = 399) women (total N = 776) rated overall treatment preferences and treatment credibility, concerns, and willingness to have CBT and pharmacotherapy if suffering from anxiety. RESULTS Women preferred anxiety-related treatment that included psychotherapy. Preference for psychotherapy alone was stronger among pregnant (74%) than non-pregnant (47%) women, p < .001. In response to treatment descriptions, both groups rated CBT more favorably than pharmacotherapy on treatment willingness, credibility, and concerns, ps < .001, with the magnitude of this preference significantly greater among pregnant than non-pregnant women, ps < .001. Pregnancy status was unrelated to CBT ratings. Treatment credibility and to a lesser extent total concerns mediated the relationship between pregnancy status and pharmacotherapy willingness. CONCLUSIONS Non-pregnant and especially pregnant women rated exposure-based CBT for anxiety more favorably than pharmacotherapy. Pregnancy status predicted general treatment preferences and pharmacotherapy, but not CBT, ratings.
Collapse
Affiliation(s)
- Joanna J Arch
- Department of Psychology and Neuroscience, University of Colorado, 345 UCB Muenzinger, Boulder, CO 80309-0345, USA.
| |
Collapse
|
35
|
"How will it help me?" Reasons underlying treatment preferences between sertraline and prolonged exposure in posttraumatic stress disorder. J Nerv Ment Dis 2013; 201:691-7. [PMID: 23896851 PMCID: PMC3910902 DOI: 10.1097/nmd.0b013e31829c50a9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Individuals with posttraumatic stress disorder (PTSD) often wait years before seeking treatment. Improving treatment initiation and adherence requires a better understanding of patient beliefs that lead to treatment preferences. Using a treatment-seeking sample (N = 200) with chronic PTSD, qualitative reasons underlying treatment preferences for either prolonged exposure (PE) or sertraline (SER) were examined. Reasons for treatment preference primarily focused on how the treatment was perceived to reduce PTSD symptoms rather than practical ones. The patients were more positive about PE than SER. Individual differences did not reliably predict underlying preference reasons, suggesting that what makes a treatment desirable is not strongly determined by current functioning, treatment, or trauma history. Taken together, this information is critical for treatment providers, arguing for enhancing psychoeducation about how treatment works and acknowledging preexisting biases against pharmacotherapy for PTSD that should be addressed. This knowledge has the potential to optimize and better personalize PTSD patient care.
Collapse
|
36
|
Hellmuth JC, Jaquier V, Young-Wolff K, Sullivan TP. Posttraumatic stress disorder symptom clusters, alcohol misuse, and women's use of intimate partner violence. J Trauma Stress 2013; 26:451-8. [PMID: 23868671 PMCID: PMC3981454 DOI: 10.1002/jts.21829] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Exploring how PTSD and alcohol misuse relate to women's use of intimate partner violence (IPV) is vital to develop our understanding of why some women may engage in IPV, which can serve to maximize intervention efforts for women. This study examined the extent to which posttraumatic stress disorder (PTSD) symptom clusters are directly and indirectly related to women's use of IPV through pathways involving alcohol misuse while controlling for severity of women's IPV victimization. The sample was comprised of substance-using, low socioeconomic status community women (N = 143) currently experiencing IPV victimization. The majority of the sample was African American (n = 115, 80.42%). This sample had an average annual household income of $14,368.68 (SD = $12,800.68) and the equivalent of a high school education (11.94 years, SD = 1.32). Path analyses indicated that the strongest statistical relationship emerged between women's use of IPV and women's IPV victimization. PTSD reexperiencing and numbing symptom severity was related to women's use of psychological, minor physical, and severe physical IPV; however, these relationships were indirect through alcohol misuse. Findings lend preliminary support for the application of the self-medication hypothesis to the study of PTSD, alcohol misuse, and IPV among women.
Collapse
Affiliation(s)
- Julianne C. Hellmuth
- Department of Psychiatry; Yale University School of Medicine; New Haven Connecticut USA
| | - Véronique Jaquier
- Department of Psychiatry; Yale University School of Medicine; New Haven Connecticut USA
| | - Kelly Young-Wolff
- Department of Psychiatry; Yale University School of Medicine; New Haven Connecticut USA
| | - Tami P. Sullivan
- Department of Psychiatry; Yale University School of Medicine; New Haven Connecticut USA
| |
Collapse
|
37
|
Rates and Predictors of Referral for Individual Psychotherapy, Group Psychotherapy, and Medications among Iraq and Afghanistan Veterans with PTSD. J Behav Health Serv Res 2013; 41:99-109. [DOI: 10.1007/s11414-013-9352-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
38
|
Harned MS, Tkachuck MA, Youngberg KA. Treatment preference among suicidal and self-injuring women with borderline personality disorder and PTSD. J Clin Psychol 2013; 69:749-61. [PMID: 23444147 PMCID: PMC4075754 DOI: 10.1002/jclp.21943] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES This study examined treatment preferences among suicidal and self-injuring women with borderline personality disorder (BPD) and PTSD. METHOD Women (N = 42, M(age) = 34) with BPD, PTSD and recent intentional self-injury were evaluated upon entry into a psychotherapy outcome study. RESULTS The majority preferred a combined dialectical behavior therapy (DBT) and prolonged exposure (PE) treatment (73.8%), followed by DBT alone (26.2%), and PE alone (0%). Women who preferred the combined treatment were more likely to report a desire to obtain relief from PTSD and to receive specific DBT and PE treatment components as reasons underlying this preference. Few women (21.4%) reported concerns about PE, but those who did were more likely to prefer DBT alone. More severe PTSD re-experiencing symptoms, a childhood index trauma, and less reduction in positive affect after a trauma interview predicted a preference for the combined treatment. CONCLUSIONS These results may help to inform treatment for these complex patients.
Collapse
Affiliation(s)
- Melanie S Harned
- Behavioral Research and Therapy Clinics, University of Washington, Seattle, WA, 98195-5915, USA.
| | | | | |
Collapse
|
39
|
McHugh RK, Whitton SW, Peckham AD, Welge JA, Otto MW. Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry 2013; 74:595-602. [PMID: 23842011 PMCID: PMC4156137 DOI: 10.4088/jcp.12r07757] [Citation(s) in RCA: 468] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 10/31/2012] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Evidence-based practice involves the consideration of efficacy and effectiveness, clinical expertise, and patient preference in treatment selection. However, patient preference for psychiatric treatment has been understudied. The aim of this meta-analytic review was to provide an estimate of the proportion of patients preferring psychological treatment relative to medication for psychiatric disorders. DATA SOURCES A literature search was conducted using PubMed, PsycINFO, and the Cochrane Collaboration library through August 2011 for studies written in English that assessed adult patient preferences for the treatment of psychiatric disorders. The following search terms and subject headings were used in combination: patient preference, consumer preference, therapeutics, psychotherapy, drug therapy, mental disorders, depression, anxiety, insomnia, bipolar disorder, schizophrenia, substance-related disorder, eating disorder, and personality disorder. In addition, the reference sections of identified articles were examined to locate any additional articles not captured by this search. STUDY SELECTION Studies that assessed preferred type of treatment and included at least 1 psychological treatment and 1 pharmacologic treatment were included. Of the 644 articles identified, 34 met criteria for inclusion. DATA EXTRACTION Authors extracted relevant data including the proportion of participants reporting preference for psychological or pharmacologic treatment. RESULTS The proportion of adult patients preferring psychological treatment was 0.75 (95% CI, 0.69-0.80), which was significantly higher than equivalent preference (ie, higher than 0.50; P < .001). Sensitivity analyses suggested that younger patients (P = .05) and women (P < .01) were significantly more likely to choose psychological treatment. A preference for psychological treatment was consistently evident in both treatment-seeking and unselected (ie, non-treatment-seeking) samples (P < .001 for both) but was somewhat stronger for unselected samples. CONCLUSIONS Aggregation of patient preferences across diverse settings yielded a significant 3-fold preference for psychological treatment. Given evidence for enhanced outcomes among those receiving their preferred psychiatric treatment and the trends for decreasing utilization of psychotherapy, strategies to maximize the linkage of patients to preferred care are needed.
Collapse
Affiliation(s)
- R Kathryn McHugh
- McLean Hospital, Proctor House 3 MS 222, 115 Mill St, Belmont, MA 02478, USA.
| | | | | | | | | |
Collapse
|
40
|
Rytwinski NK, Scur MD, Feeny NC, Youngstrom EA. The co-occurrence of major depressive disorder among individuals with posttraumatic stress disorder: a meta-analysis. J Trauma Stress 2013; 26:299-309. [PMID: 23696449 DOI: 10.1002/jts.21814] [Citation(s) in RCA: 411] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Although co-occurring posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) is associated with greater distress, impairment, and health care utilization than PTSD alone, the magnitude of this problem is uncertain. This meta-analysis aimed to estimate the mean prevalence of current MDD co-occurrence among individuals with PTSD and examine potential moderating variables (U.S. nationality, gender, trauma type, military service, referral type) that may influence the rate of PTSD and MDD co-occurrence. Meta-analytic findings (k = 57 studies; N = 6,670 participants) revealed that 52%, 95% confidence interval [48, 56], of individuals with current PTSD had co-occurring MDD. When outliers were removed, military samples and interpersonal traumas demonstrated higher rates of MDD among individuals with PTSD than civilian samples and natural disasters, respectively. U.S. nationality, gender, and referral type did not significantly account for differences in co-occurrence rates. This high co-occurrence rate accentuates the importance of routinely assessing MDD among individuals with PTSD and continuing research into the association between these disorders.
Collapse
Affiliation(s)
- Nina K Rytwinski
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, OH 44106, USA.
| | | | | | | |
Collapse
|
41
|
Empirically Supported Treatments and Efficacy Trials: What Steps Do We Still Need to Take? JOURNAL OF CONTEMPORARY PSYCHOTHERAPY 2013. [DOI: 10.1007/s10879-013-9236-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
42
|
Oʼbrien PG, Fleming L. Recognizing anxiety disorders. Nurse Pract 2012; 37:35-42. [PMID: 23014178 DOI: 10.1097/01.npr.0000419299.87440.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The majority of patients with anxiety disorders present in primary care settings, and many are undiagnosed or undertreated-each disorder has defining characteristics. Anxiety disorders are debilitating, and proper treatment can improve quality of life. Preferred treatments are cognitive-behavior therapy and pharmacotherapy with selective serotonin reuptake inhibitors.
Collapse
|
43
|
Schneier FR, Neria Y, Pavlicova M, Hembree E, Suh EJ, Amsel L, Marshall MRD. Combined prolonged exposure therapy and paroxetine for PTSD related to the World Trade Center attack: a randomized controlled trial. Am J Psychiatry 2012; 169:80-8. [PMID: 21908494 PMCID: PMC3606709 DOI: 10.1176/appi.ajp.2011.11020321] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Selective serotonin reuptake inhibitors (SSRIs) are often recommended in combination with established cognitive-behavioral therapies (CBTs) for posttraumatic stress disorder (PTSD), but combined initial treatment of PTSD has not been studied under controlled conditions. There are also few studies of either SSRIs or CBT in treating PTSD related to terrorism. The authors compared prolonged exposure therapy (a CBT) plus paroxetine (an SSRI) with prolonged exposure plus placebo in the treatment of terrorism-related PTSD. METHOD Adult survivors of the World Trade Center attack of September 11, 2001, with PTSD were randomly assigned to 10 weeks of treatment with prolonged exposure (10 sessions) plus paroxetine (N=19) or prolonged exposure plus placebo (N=18). After week 10, patients discontinued prolonged exposure and were offered 12 additional weeks of continued randomized treatment. RESULTS Patients treated with prolonged exposure plus paroxetine experienced significantly greater improvement in PTSD symptoms (incidence rate ratio=0.50, 95% CI=0.30-0.85) and remission status (odds ratio=12.6, 95% CI=1.23-129) during 10 weeks of combined treatment than patients treated with prolonged exposure plus placebo. Response rate and quality of life were also significantly more improved with combined treatment. The subset of patients who continued randomized treatment for 12 additional weeks showed no group differences. CONCLUSIONS Initial treatment with paroxetine plus prolonged exposure was more efficacious than prolonged exposure plus placebo for PTSD related to the World Trade Center attack. Combined treatment medication and prolonged exposure therapy deserves further study in larger samples with diverse forms of PTSD and over longer follow-up periods.
Collapse
|
44
|
van Minnen A, Harned MS, Zoellner L, Mills K. Examining potential contraindications for prolonged exposure therapy for PTSD. Eur J Psychotraumatol 2012; 3:EJPT-3-18805. [PMID: 22893847 PMCID: PMC3406222 DOI: 10.3402/ejpt.v3i0.18805] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 06/28/2012] [Accepted: 07/04/2012] [Indexed: 11/14/2022] Open
Abstract
Although prolonged exposure (PE) has received the most empirical support of any treatment for post-traumatic stress disorder (PTSD), clinicians are often hesitant to use PE due to beliefs that it is contraindicated for many patients with PTSD. This is especially true for PTSD patients with comorbid problems. Because PTSD has high rates of comorbidity, it is important to consider whether PE is indeed contraindicated for patients with various comorbid problems. Therefore, in this study, we examine the evidence for or against the use of PE with patients with problems that often co-occur with PTSD, including dissociation, borderline personality disorder, psychosis, suicidal behavior and non-suicidal self-injury, substance use disorders, and major depression. It is concluded that PE can be safely and effectively used with patients with these comorbidities, and is often associated with a decrease in PTSD as well as the comorbid problem. In cases with severe comorbidity, however, it is recommended to treat PTSD with PE while providing integrated or concurrent treatment to monitor and address the comorbid problems.
Collapse
Affiliation(s)
- Agnes van Minnen
- Behavioural Science Institute, Radboud University Nijmegen, NijCare, the Netherlands
| | | | | | | |
Collapse
|
45
|
Echiverri AM, Jaeger JJ, Chen JA, Moore SA, Zoellner LA. "Dwelling in the Past": The Role of Rumination in the Treatment of Posttraumatic Stress Disorder. COGNITIVE AND BEHAVIORAL PRACTICE 2011; 18:338-349. [PMID: 22190846 DOI: 10.1016/j.cbpra.2010.05.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Prolonged exposure, a cognitive behavioral therapy including both in vivo and imaginal exposure to the traumatic memory, is one of several empirically supported treatments for chronic posttraumatic stress disorder (PTSD). In this article, we provide a case illustration in which this well-validated treatment did not yield expected clinical gains for a client with PTSD and co-occurring major depression. After providing an overview of the literature, theory, and treatment protocol, we discuss the clinical cascade effect that underlying ruminative processes had on the treatment of this case. Specifically, we highlight how ruminative processes, focusing on trying to understand why the traumatic event happened and why the client was still suffering, resulted in profound emotional distress in session and in a lack of an "optimal dose" of exposure during treatment.
Collapse
|
46
|
Abstract
Cognitive behavioral therapy (CBT) and pharmacotherapy are each efficacious for generalized anxiety disorder (GAD). It is not known, however, whether GAD partial and nonresponders to one treatment modality benefit from the other. This study explored acceptability and efficacy of escitalopram for persons with persistent GAD symptoms after a course of CBT. Twenty-four patients with GAD were treated with CBT and 15 completed at least 12 sessions. Eight completers continued to have clinically significant symptoms and were offered 12 weeks of treatment with escitalopram, and 7 started escitalopram treatment. During CBT, patients evidenced significant improvement in GAD, depression, and quality of life. During escitalopram treatment, patients evidenced trends toward further improvement in GAD, depression, and quality of life. Escitalopram phase completers had initially reported low-to-moderate preferences for medication treatment. Escitalopram may benefit GAD patients with clinically significant symptoms after CBT and merits further study under controlled conditions in a larger sample.
Collapse
|
47
|
Roy-Byrne P, Craske MG, Sullivan G, Rose RD, Edlund MJ, Lang AJ, Bystritsky A, Welch SS, Chavira DA, Golinelli D, Campbell-Sills L, Sherbourne CD, Stein MB. Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial. JAMA 2010; 303:1921-8. [PMID: 20483968 PMCID: PMC2928714 DOI: 10.1001/jama.2010.608] [Citation(s) in RCA: 292] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Improving the quality of mental health care requires moving clinical interventions from controlled research settings into real-world practice settings. Although such advances have been made for depression, little work has been performed for anxiety disorders. OBJECTIVE To determine whether a flexible treatment-delivery model for multiple primary care anxiety disorders (panic, generalized anxiety, social anxiety, and posttraumatic stress disorders) would be better than usual care (UC). DESIGN, SETTING, AND PATIENTS A randomized controlled effectiveness trial of Coordinated Anxiety Learning and Management (CALM) compared with UC in 17 primary care clinics in 4 US cities. Between June 2006 and April 2008, 1004 patients with anxiety disorders (with or without major depression), aged 18 to 75 years, English- or Spanish-speaking, were enrolled and subsequently received treatment for 3 to 12 months. Blinded follow-up assessments at 6, 12, and 18 months after baseline were completed in October 2009. INTERVENTION CALM allowed choice of cognitive behavioral therapy (CBT), medication, or both; included real-time Web-based outcomes monitoring to optimize treatment decisions; and a computer-assisted program to optimize delivery of CBT by nonexpert care managers who also assisted primary care clinicians in promoting adherence and optimizing medications. MAIN OUTCOME MEASURES Twelve-item Brief Symptom Inventory (BSI-12) anxiety and somatic symptoms score. Secondary outcomes included proportion of responders (> or = 50% reduction from pretreatment BSI-12 score) and remitters (total BSI-12 score < 6). RESULTS A significantly greater improvement for CALM vs UC in global anxiety symptoms was found (BSI-12 group mean differences of -2.49 [95% confidence interval {CI}, -3.59 to -1.40], -2.63 [95% CI, -3.73 to -1.54], and -1.63 [95% CI, -2.73 to -0.53] at 6, 12, and 18 months, respectively). At 12 months, response and remission rates (CALM vs UC) were 63.66% (95% CI, 58.95%-68.37%) vs 44.68% (95% CI, 39.76%-49.59%), and 51.49% (95% CI, 46.60%-56.38%) vs 33.28% (95% CI, 28.62%-37.93%), with a number needed to treat of 5.27 (95% CI, 4.18-7.13) for response and 5.50 (95% CI, 4.32-7.55) for remission. CONCLUSION For patients with anxiety disorders treated in primary care clinics, CALM compared with UC resulted in greater improvement in anxiety symptoms, depression symptoms, functional disability, and quality of care during 18 months of follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00347269.
Collapse
Affiliation(s)
- Peter Roy-Byrne
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine and Harborview Center for Healthcare Improvement for Addictions, Mental Illness, and Medically Vulnerable Populations, Seattle, Washington 98104, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Doane LS, Feeny NC, Zoellner LA. A preliminary investigation of sudden gains in exposure therapy for PTSD. Behav Res Ther 2010; 48:555-60. [PMID: 20304385 DOI: 10.1016/j.brat.2010.02.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Revised: 02/11/2010] [Accepted: 02/12/2010] [Indexed: 11/24/2022]
Abstract
The purpose of the current study was to examine sudden gains in those receiving treatment for PTSD and whether these rapid changes were related to overall symptom reduction in a small sample of female assault survivors with PTSD undergoing prolonged exposure (PE) therapy. Sudden gains were found to occur in 52% of the sample. Among those who experienced a sudden gain, the average magnitude (12.4 points) accounted for 61% of overall symptom reduction. Importantly, treatment outcome was better for those who experienced sudden gains than those who did not. The experience of a sudden gain may result in patients becoming more fully engaged with treatment, and recognition of them may result in identifying potential process-related predictors of treatment response.
Collapse
Affiliation(s)
- Lisa Stines Doane
- Case Western Reserve University, Department of Psychology, 10900 Euclid Ave., Cleveland, OH 44145, USA.
| | | | | |
Collapse
|
49
|
What you believe is what you want: modeling PTSD-related treatment preferences for sertraline or prolonged exposure. J Behav Ther Exp Psychiatry 2009; 40:455-67. [PMID: 19577224 PMCID: PMC3241616 DOI: 10.1016/j.jbtep.2009.06.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Revised: 05/13/2009] [Accepted: 06/01/2009] [Indexed: 11/23/2022]
Abstract
Despite the known efficacy of various psychotherapies and pharmacotherapies for posttraumatic stress disorder (PTSD), we know little about what factors predict treatment preference. In the present study, we first developed exploratory path models of treatment preference for a psychotherapy or pharmacotherapy (n=273) and then conducted confirmatory analyses of these models in a second sample (n=324) and in a third generalization sample of trauma-exposed women (n=105). We examined demographic and psychopathology factors and treatment-related beliefs (i.e., credibility and personal reactions). Across all samples, treatment-related beliefs were the strongest predictors of treatment preference. Further, severity of depression directly reduced the likelihood of choosing psychotherapy, and severity of PTSD directly increased the likelihood of choosing pharmacotherapy. These results underscore the importance of better understanding individual's beliefs regarding treatments. With a clearer understanding of these factors, we may be able to reduce barriers to treatment and increase access to effective treatments for those with trauma-related symptoms.
Collapse
|
50
|
Angelo FN, Miller HE, Zoellner LA, Feeny NC. "I need to talk about it": a qualitative analysis of trauma-exposed women's reasons for treatment choice. Behav Ther 2008; 39:13-21. [PMID: 18328866 PMCID: PMC2638172 DOI: 10.1016/j.beth.2007.02.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 02/09/2007] [Accepted: 02/22/2007] [Indexed: 11/29/2022]
Abstract
A significant proportion of individuals suffering from posttraumatic stress disorder do not seek or receive effective treatment. Understanding the reasons why an individual chooses to seek treatment or prefers one treatment to another is a critical step to improve treatment seeking. To begin to understand these reasons, we conducted a qualitative analysis of the reasons women gave for choosing a cognitive-behavioral treatment, prolonged exposure (PE), or a pharmacological treatment, sertraline (SER). A community sample of women with trauma histories were asked to view standardized rationales, to choose among PE, SER, or no treatment, and to give 5 reasons for their choice. Women indicated that they were more likely to prefer the psychotherapy to the medication. Across reasons given, the most commonly cited reason for treatment preference highlighted why or how the treatment worked (e.g., I need to talk about it); and this reason emerged as the strongest predictor of preference for PE. Understanding this role of perceived treatment mechanism may aid clinicians and public health policy officials to identify and address help-seeking barriers regarding treatment.
Collapse
|