SYMPTOM BENCHMARKS OF IMPROVED QUALITY OF LIFE IN PTSD

Effectiveness of Narrative Exposure Therapy for Treatment of PTSD Following Childhood Trauma: A Single-Case Series Design

BACKGROUND

Narrative exposure therapy (NET) has shown promising outcomes for treating posttraumatic stress disorder (PTSD) in refugees and veterans. Its effectiveness in patients with PTSD following childhood trauma is, however, still unknown.

AIMS

We investigated whether NET is an effective treatment for patients with PTSD following childhood trauma.

METHOD

We studied treatment outcomes of nine adult patients in an outpatient setting. An AB single-case series design was used with a baseline of 4 weeks prior to treatment. Participants filled in weekly online questionnaires to assess their PTSD symptoms (using the Posttraumatic Diagnostic Scale [PDS]) and their experienced quality of life (using the Manchester Short Assessment of Quality of Life [MANSA]). Data were analysed visually and using a mixed-effect model.

RESULTS

Results revealed no significant reduction of PTSD symptoms during NET treatment, nor an increase in quality of life, as compared to baseline.

CONCLUSIONS

The results of our study do not underscore the effectiveness of NET treatment for patients with PTSD following childhood trauma. Further research is needed to study the effectiveness of NET in this population.

Co-occurring Chronic Pain and PTSD Among US Military Veterans: Prevalence, Correlates, and Functioning

BACKGROUND

The prevalence of co-occurring chronic pain and posttraumatic stress disorder (PTSD) has yet to be established in a nationally representative sample of US veterans, and little is known about the individual contributing roles of these disorders to the psychiatric and functional burden of this comorbidity.

OBJECTIVE

To determine the prevalence of chronic pain, PTSD, and co-occurring chronic pain and PTSD, and psychiatric comorbidities and psychosocial functioning in these groups.

DESIGN

Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of US veterans.

PARTICIPANTS

Veterans (n=4069) were classified into four groups: control (i.e., no PTSD or chronic pain), chronic pain only, PTSD only, and co-occurring chronic pain and PTSD.

MAIN MEASURES

A probable PTSD diagnosis was established using the PTSD Checklist for DSM-5, and a chronic pain diagnosis using a self-report item that queried health care professional diagnoses. Psychiatric and functional status were assessed using the Patient Health Questionnaire-4, Alcohol Use Disorders Identification Test, Screen of Drug Use, Suicide Behaviors Questionnaire-Revised, Short Form Health Survey-8, Brief Inventory of Psychosocial Functioning, and Medical Outcomes Study Cognitive Functioning Scale.

KEY RESULTS

A total of 3.8% of veterans reported both probable PTSD and a diagnosis of chronic pain. Relative to veterans with chronic pain alone, those with co-occurring chronic pain and probable PTSD were more likely to screen positive for psychiatric disorders (odds ratios [ORs]=2.59-9.88) and scored lower on measures of psychosocial functioning (Cohen's ds=0.38-1.43). Relative to veterans with probable PTSD only, those with co-occurring chronic pain and probable PTSD were more likely to have attempted suicide (OR=4.79; 95%CI, 1.81-12.69).

CONCLUSIONS

Results underscore the importance of whole health care that considers a broad range of health and functional domains in the assessment and treatment of co-occurring chronic pain and PTSD in veterans.

Moving beyond symptom reduction: A meta-analysis on the effect of exposure therapy for PTSD on quality of life

OBJECTIVES

Quality of life (QOL) is a multidimensional construct including emotional well-being, life satisfaction, and physical health. Individuals with posttraumatic stress disorder (PTSD) consistently report low QOL, highlighting the importance of assessing the effectiveness of first-line PTSD treatments (e.g., exposure-based therapies) on QOL. This meta-analysis examined the efficacy of exposure therapy for PTSD on QOL compared to control conditions (e.g., waitlist, medication, treatment-as-usual) at posttreatment and follow-up (ranging from 1 month to 2 years).

METHODS

Building on a previous meta-analysis of exposure-based therapy for PTSD, we searched PsycINFO and Medline in December 2021, July 2022, and March 2023 to include randomized controlled trials of exposure-based treatments for adult PTSD assessing QOL. We screened 295 abstracts for initial eligibility; 20 articles met inclusion criteria and were included (N = 2729 participants). Risk of bias was evaluated using the Cochrane Risk of Bias tool 2.0.

RESULTS

At posttreatment, exposure-based therapies showed a medium effect on QOL relative to control conditions (k = 25, g = 0.67). This effect was not observed at follow-up for the small subset of studies with follow-up data (k = 8, g = 0.16). At posttreatment, effect size varied significantly as a function of the control condition (p < .0001). There were no differences in QOL effects across exposure therapies at posttreatment or follow-up (p = .09).

CONCLUSION

Exposure therapy was associated with greater improvement in QOL compared to control conditions at posttreatment. Exposure was not superior to control conditions at follow-up, and the longer-term impact of exposure on QOL is unclear. The implications of these findings are discussed, along with the need for more PTSD treatment studies to examine QOL outcomes at posttreatment and follow-up.

Design of a randomized clinical trial of brief couple therapy for PTSD augmented with intranasal oxytocin

BACKGROUND

Leveraging military veterans' intimate relationships during treatment has the potential to concurrently improve posttraumatic stress disorder (PTSD) symptoms and relationship quality. Cognitive-Behavioral Conjoint Therapy (CBCT) and an 8-session Brief Cognitive-Behavioral Conjoint Therapy (bCBCT) are manualized treatments designed to simultaneously improve PTSD and relationship functioning for couples in which one partner has PTSD. Although efficacious in improving PTSD, the effects of CBCT on relationship satisfaction are small, especially among veterans. Intranasal oxytocin, which targets mechanisms of PTSD and relationship quality, may enhance the efficacy of bCBCT.

METHOD/DESIGN

The purpose of this 4-year clinical trial is to compare the outcomes of bCBCT augmented with intranasal oxytocin versus bCBCT plus placebo. We will also explore potential mechanisms of action: self-reported communication skills, empathy, and trust. We will recruit 120 dyads (i.e., veteran with PTSD and their intimate partner) from the VA San Diego Healthcare System. Veterans will be administered 40 international units of oxytocin (n = 60) or placebo (n = 60) 30 min before each of 8 bCBCT sessions delivered via telehealth. Clinical and functioning outcomes will be assessed at five timepoints (baseline, mid-treatment, post-treatment, and 3- and 6-month follow-up).

CONCLUSION

Study findings will reveal the efficacy of oxytocin-assisted brief couple therapy for PTSD, which could serve as highly scalable option for couples coping with PTSD, as well as provide preliminary evidence of interpersonal mechanisms of change.

CLINICALTRIALS

govIdentifier:NCT06194851.

Impact of primary care posttraumatic stress disorder (PC-PTSD) on fertility problem of Iranian women with infertility during the COVID-19 pandemic

BACKGROUND

Infertility continued to be a major stressor among women with infertility during COVID-19pandemic. This study aimed to evaluate the impact of primary care posttraumatic stress disorder (PC-PTSD) on fertility problem of Iranian women with infertility during COVID-19 pandemic.

METHOD

In this cross-sectional study, 386 women with infertility completed the questionnaires of PC-PTSD-5 and Fertility Problem Inventory (FPI) at an infertility center between 2020 and 2022.

RESULTS

The mean of fertility problems was 145.20 (± 32.31). In terms of FPI subscales, the means were as follows: Sexual concern 21.80 (± 7.58), social concern 26.53 (± 8.94), relationship concern 26.02 (± 9.18), need for parenthood concern 40.88 (± 8.98), and rejection of childfree lifestyle 29.96 (± 7.69). The highest mean of FPI subscales was related to the need for parenthood concern in women with infertility. The strongest correlation was found between the subscales of sexual concern and social concern followed by sexual concern and relationship concern. The variables of PC-PTSD were a predictor of fertility problems (β = 0.203, P < .0001). Additionally, the variables of PC-PTSDwere a predictor of sexual concern (β = 0.248, P < .0001), social concern (β = 0.237, P < .0001), relationship concern (β = 0.143, P < .020), and need for parenthood concern (β = 0.101, P < .010). After adjusting for demographic characteristics, there was a significant relationship between FPI with job (β=-0.118, P < .031), education (β=-0.130, P < .023), living place (β = 0.115, P < .035), smoking (β = 0.113, P < .036), relationship with husband (β = 0.118, P < .027), and PC-PTSD symptom (β = 0.158, P < .0001). In addition, the multivariate linear regression showed a significant association between sexual concern and education (β=-0.152, P < .008), smoking (β = 0.129, P < .018), PC-PTSD symptom (β = 0.207, P < .0001); social concern and job (β=-0.119, P < .033), PC-PTSD symptom (β = 0.205, P < .0001); relationship concern and education (β=-0.121, P < .033), living place (β = 0.183, P < .001), relationship with husband (β = 0.219, P < .0001); and rejection of childfree lifestyle and job (β=-0.154, P < .007).

CONCLUSION

Systematic PTSD screening during COVID-19 pandemic by healthcare providers can be uniquely used to identify, evaluate, and treat trauma-related health conditions in infertility settings, which can link women with infertility to mental health services. This can be novel and useful for future policymakers and practitioners in the infertility field.

Dropout in a clinical trial for comorbid PTSD and MDD among US service members: Are pretreatment characteristics predictive?

OBJECTIVE

Despite effective treatment options for posttraumatic stress disorder (PTSD), many patients do not complete therapy. This includes U.S. active duty service members, yet factors linked to attendance in this population remain understudied and dropout remains difficult to predict. Additionally, most studies have not examined samples with PTSD and co-occurring major depressive disorder (MDD) despite high rates of comorbidity.

METHOD

The current study explored predictors of dropout among service members with comorbid PTSD and MDD (N = 94) randomized to cognitive processing therapy enhanced with behavioral activation (BA + CPT) or CPT as part of a clinical trial.

RESULTS

Using the Fournier approach, only two predictors were associated with lower dropout risk among over 20 examined: shorter duration between pretreatment assessment and Session 1 (p = .041) and past 3-month PTSD treatment engagement (p = .036).

CONCLUSION

Results suggest the possible utility of early momentum in starting therapy and leveraging recent treatment to improve attendance. However, this study also highlights the possible limitations of commonly assessed pretreatment factors in predicting attendance and current challenges in measuring dropout risk. Strategies to improve prediction, such as shifting focus to assess modifiable factors and processes more proximal to dropout during treatment, may be needed.Trial registration: ClinicalTrials.gov identifier: NCT02874131.

Post-traumatic stress disorder symptom remission and cognition in a large cohort of civilian women

BACKGROUND

Post-traumatic stress disorder (PTSD) is associated with cognitive impairments. It is unclear whether problems persist after PTSD symptoms remit.

METHODS

Data came from 12 270 trauma-exposed women in the Nurses' Health Study II. Trauma and PTSD symptoms were assessed using validated scales to determine PTSD status as of 2008 (trauma/no PTSD, remitted PTSD, unresolved PTSD) and symptom severity (lifetime and past-month). Starting in 2014, cognitive function was assessed using the Cogstate Brief Battery every 6 or 12 months for up to 24 months. PTSD associations with baseline cognition and longitudinal cognitive changes were estimated by covariate-adjusted linear regression and linear mixed-effects models, respectively.

RESULTS

Compared to women with trauma/no PTSD, women with remitted PTSD symptoms had a similar cognitive function at baseline, while women with unresolved PTSD symptoms had worse psychomotor speed/attention and learning/working memory. In women with unresolved PTSD symptoms, past-month PTSD symptom severity was inversely associated with baseline cognition. Over follow-up, both women with remitted and unresolved PTSD symptoms in 2008, especially those with high levels of symptoms, had a faster decline in learning/working memory than women with trauma/no PTSD. In women with remitted PTSD symptoms, higher lifetime PTSD symptom severity was associated with a faster decline in learning/working memory. Results were robust to the adjustment for sociodemographic, biobehavioral, and health factors and were partially attenuated when adjusted for depression.

CONCLUSION

Unresolved but not remitted PTSD was associated with worse cognitive function assessed six years later. Accelerated cognitive decline was observed among women with either unresolved or remitted PTSD symptoms.

Benchmarking secondary outcomes to posttraumatic stress disorder symptom change in response to cognitive processing and written exposure therapy for posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) has high comorbidity with other psychiatric conditions, including depression, generalized anxiety, and suicidality. Evidence-based treatments (EBTs) for PTSD are effective at reducing PTSD symptoms. However, evidence on the impact of PTSD EBTs on comorbid conditions is mixed and often uses pre-post analyses, which disregards PTSD symptom response. This study replicated and extended prior work on benchmarking quality of life to PTSD symptom response to a broader range of secondary outcomes using a research-based metric of clinically meaningful PTSD symptom change. Ninety-five active duty military members seeking treatment for PTSD participated in a randomized noninferiority trial examining two cognitive behavioral therapies for PTSD: Written Exposure Therapy and Cognitive Processing Therapy. Participants completed clinician-administered and self-rating assessments at baseline and 10 weeks post-first treatment session and were classified as PTSD treatment responders or nonresponders. Data were analyzed using generalized linear mixed effects models with repeated measures with fixed effects of time and PTSD symptom response category. PTSD treatment responders experienced significant improvements in secondary outcomes; nonresponders demonstrated statistically significant, but not clinically meaningful, comorbid symptom change. Our findings provide evidence that successfully treating PTSD symptoms may also positively impact psychiatric comorbidity.

A randomized clinical trial comparing Interpersonal Psychotherapy with Prolonged Exposure for the treatment of PTSD in veterans

Trauma-focused therapies are recommended as first-line treatments for posttraumatic stress disorder (PTSD), but many veterans do not complete or sufficiently respond to these treatments. Interpersonal Therapy (IPT) is a non-trauma focused approach that directly addresses the interpersonal and social impairments associated with PTSD. This two-site randomized controlled equivalence trial compared IPT with Prolonged Exposure (PE) in improving PTSD symptoms and interpersonal functioning in 109 veterans with PTSD. Secondary outcomes included functioning and quality of life. We hypothesized that IPT would be statistically equivalent to PE in reducing PTSD symptoms, and superior to PE in improving interpersonal functioning and secondary outcomes of work and social adjustment and quality of life. PTSD symptom severity decreased significantly in both treatments from pre- to post-treatment. Although IPT improved as much as PE and treatments did not differ significantly, the 95 % confidence interval for the difference between the groups did not fall completely within the margin of equivalence. IPT was not superior to PE in improvement in interpersonal functioning or on secondary outcomes. Findings from multi-level linear mixed models using longitudinal data (posttreatment, three and six month follow up) for the primary outcomes of PTSD and interpersonal functioning were consistent with the post-treatment analyses. Although statistically inconclusive in terms of equivalence, the comparable reduction in PTSD symptoms slightly favoring IPT suggests that IPT is an acceptable alternative to gold-standard trauma-focused treatments for veterans with PTSD.

Design and methods of a randomized controlled trial evaluating the effects of the PE Coach mobile application on prolonged exposure among veterans with PTSD

BACKGROUND

Little is known about the impact of mobile applications (apps) designed to support patients progressing through an evidence-based psychotherapy. Prolonged exposure (PE) is an efficacious treatment for posttraumatic stress disorder (PTSD) and PE Coach is a treatment companion app that may increase patient engagement with the active components of PE, thereby supporting recovery.

METHODS

This paper describes a randomized clinical trial that will evaluate PE delivered with and without PE Coach at post-treatment, and 1-month and 4-months post-treatment. Veterans with PTSD (N = 124) will be randomized (1:1) to conditions and complete up to 15 treatment sessions based on a priori defined termination criteria. We hypothesize that compared to PE without PE Coach, PE with the app will result in greater improvements in PTSD-related social and occupational functioning (primary outcome is the PTSD-Related Functioning Inventory), quality of life, and greater reductions in functional impairment, neurobehavioral symptoms, depression, and suicidal ideation (Aim 1). We also hypothesize that including PE Coach will reduce assessor-masked PTSD symptom severity, relative to PE without the app, as assessed by the revised Clinician-Administered PTSD Scale for DSM-5 (Aim 2). We hypothesize that PE Coach will facilitate increased treatment adherence, as measured by completion of PE homework (Aim 3). We will explore the impact of PE Coach on treatment engagement, as measured by reduced treatment dropout.

CONCLUSION

Data on the outcomes of PE Coach can inform dissemination efforts and help evaluate the return on investment to guide future mental health app development.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.govNCT04959695.

Benchmarking quality of life to posttraumatic stress disorder symptom changes in cognitive processing therapy

Although there is ample evidence that PTSD is effectively treated by first-line therapies such as Cognitive Processing Therapy (CPT), it is less clear to what degree these treatments improve quality of life (QOL), a common presenting concern of treatment-seeking individuals (Rosen et al., 2013). Only two studies, both conducted in military veteran samples, have examined the magnitude of PTSD symptom change needed in order to achieve corresponding changes in QOL during treatment. The current study aimed to replicate and extend these two previous studies by benchmarking multi-faceted QOL in a civilian sample of primarily female interpersonal violence survivors (N = 115) treated with CPT. We grouped participants into categories of increasingly greater PTSD symptom change: no response, response, loss of diagnosis, and remission. Outcomes were clinically meaningful change and good endpoint across five measures of QOL. Some QOL measures showed clinically meaningful change and/or good endpoint after a response to treatment or loss of diagnosis, but only remission from PTSD was associated with both clinically meaningful change and a good endpoint across all QOL indicators. These findings add to the emerging literature showing that treating PTSD to remission may maximize the likelihood of improvements in quality of life.

Treatment efficacy of tDCS and predictors of treatment response in patients with post-traumatic stress disorder

BACKGROUND

Although transcranial direct stimulation (tDCS) has been proposed as an alternative treatment option for various psychiatric disorders, there is inconsistent information regarding the treatment effects of tDCS for patients with post-traumatic stress disorder (PTSD). This study aimed to investigate the tDCS efficacy and identify predictors of treatment response to tDCS in patients with PTSD.

METHOD

Fifty-one patients received 10 sessions of tDCS involving the position of the anode over the F3 area and cathode over the F4 as a condition of 2.0 mA and 20 min duration. Digit span test and 10 questionnaires (Clinician-Administered PTSD Scale (CAPS), Cognitive Emotion Regulation Questionnaire (CERQ), Multidimensional Experiential Avoidance Questionnaire (MEAQ), etc.) were used to measure tDCS effects on PTSD symptoms and identify predictors of response to tDCS.

RESULTS

1) 50.9 % of patients had a significant reduction in the frequency and severity of PTSD symptoms, 2) PTSD-related symptoms such as depression, anxiety, rumination, and quality of life were significantly improved, 3) baseline scores on rumination and digit span test significantly predicted treatment response to tDCS.

LIMITATIONS

This study was open design without a sham control group. Also, the patients' medications were not controlled.

CONCLUSION

This study highlighted the efficacy of frontal tDCS for the treatment of patients with PTSD and identified rumination and digit span as favorable predictive factors for the outcomes of tDCS.

Who improves in trauma-focused treatment: A cluster analysis of treatment response in VA patients undergoing PE and CPT

BACKGROUND

Although most veterans with posttraumatic stress disorder (PTSD) benefit from evidence-based treatments, questions persist concerning the profiles of those at risk for poor outcomes. To help address these gaps, this study analyzed a large clinical cohort of veterans receiving prolonged exposure (PE) or cognitive processing therapy (CPT).

METHODS

Cluster analysis using Ward's method with Euclidian distances identified clinically meaningful subgroups of veterans in a national cohort (n = 20,848) using variables maintained in the electronic medical record. The clusters were then compared via one-way analysis of variance and Tukey's HSD on indicators of treatment progress including PTSD symptom change, clinical recovery, clinically significant change, remission, and treatment completion.

RESULTS

Effect size differences on clinical outcome measures for PE and CPT were negligible. Less than half of veterans achieved at least a 15-point reduction in PCL-5 score and half completed treatment. We identified 10 distinct clusters. Higher rates of PTSD service-connected disability were linked to poorer outcomes across multiple clusters, especially when combined with Post-Vietnam service era. Non-White race was also linked with poorer clinical outcomes. Factors associated with better outcomes included a greater proportion of female veterans, especially when combined with recent service era, and longer PTSD diagnosis duration.

CONCLUSIONS

This study suggests the need to improve PTSD treatment outcomes for non-White and male veterans, examine treatment response in Post-Vietnam era veterans, and consider ways in which the service connection process could hinder treatment response. The results from this study also indicate the benefits of integrating elements of clinical complexity into an analytic approach.

An evidence-based approach to psychopharmacology for posttraumatic stress disorder (PTSD) - 2022 update

Algorithms for posttraumatic stress disorder were published by this team in 1999 and 2011. Developments since then warrant revision. New studies and review articles from January 2011 to November 2021 were identified via PubMed and analyzed for evidence supporting changes. Following consideration of variations required by special patient populations, treatment of sleep impairments remains as the first recommended step. Nightmares and non-nightmare disturbed awakenings are best addressed with the anti-adrenergic agent prazosin, with doxazosin and clonidine as alternatives. First choices for difficulty initiating sleep include hydroxyzine and trazodone. If significant non-sleep PTSD symptoms remain, an SSRI should be tried, followed by a second SSRI or venlafaxine as a third step. Second generation antipsychotics can be considered, particularly for SSRI augmentation when PTSD-associated psychotic symptoms are present, with the caveat that positive evidence is limited and side effects are considerable. Anti-adrenergic agents can also be considered for general PTSD symptoms if not already tried, though evidence for daytime use lags that available for sleep. Regarding other pharmacological and procedural options, e.g., transcranial magnetic stimulation, cannabinoids, ketamine, psychedelics, and stellate ganglion block, evidence does not yet support firm inclusion in the algorithm. An interactive version of this work can be found at www.psychopharm.mobi.

Exposure therapy for PTSD in military populations: A systematic review and meta-analysis of randomized clinical trials

Military populations are disproportionally affected by posttraumatic stress disorder (PTSD) and may experience less benefit from first line psychotherapies for PTSD relative to civilians. We examined the efficacy of exposure therapy among Veterans and active duty military personnel across various control conditions and tested potential treatment-related, demographic, and clinical moderators. Randomized controlled trials of exposure-based therapies for PTSD in military populations were identified from a recent meta-analysis and through PsycINFO and Medline. Nineteen studies met inclusion criteria and were included in the meta-analysis (total N = 2905). Exposure therapy had medium to large effects compared to waitlist and treatment as usual, a small effect compared to non-trauma-focused therapy, and no effect relative to other trauma-focused therapy. The overall effect was similar at post-treatment and follow up. The effect size for exposure was larger in studies with younger participants, more women, fewer participants with comorbid major depression, and fewer participants taking psychiatric medication. Effect sizes were not impacted by treatment length or type, participant race or ethnicity, comorbid substance use, Veteran versus active duty status, or study risk of bias. Findings document the variable efficacy of exposure therapy in military populations across comparator types and point to several potentially important moderators of outcome that should be examined in future research.

"Will it work for me?" Developing patient-friendly graphical displays of posttraumatic stress disorder treatment effectiveness

The goal of this study was to create simple visual displays to help patients understand the benefits of evidence-based treatment for posttraumatic stress disorder (PTSD). We reviewed randomized trials of the most effective individual, trauma-focused psychotherapies and first-line antidepressants for adults with PTSD. The analytic sample included 65 treatment arms from 41 trials. We used binomial logistic regression to estimate the proportion of participants who lost their PTSD diagnosis at posttreatment and created a sample icon array to display these estimates. We provide a range of estimates (0-100) based on varying the percentage of the sample with a military affiliation. The percentage of participants who no longer met the diagnostic criteria for PTSD among civilian populations was 64.3% for trauma-focused treatment, 56.9% for SSRI/SNRI, and 16.7% for waitlist/minimal attention. For military populations, the proportions of participants who no longer met the diagnostic criteria were 44.2%, 36.7%, and 8.1%, respectively. We present icon arrays for 0%, 7%, 50%, and 100% military affiliation displaying 100 icons, a portion of which were shaded to indicate the number of participants that no longer met the PTSD criteria following treatment. After evidence-based treatment, between one third and two thirds of participants no longer met the PTSD criteria. Providers can use the icon array developed in this study with patients to facilitate communication regarding PTSD treatment effectiveness.

Gender Differences in Diagnostic Remission of Posttraumatic Stress Disorder (PTSD): Proportions and Correlates of Remission in a Nationally Representative U.S. Sample

This study examines differences in a nationally representative sample, in proportions of men and women with lifetime diagnoses of Posttraumatic Stress Disorder (PTSD) who achieved diagnostic remission and gender-specific correlates. Data from the 2012-13 National Epidemiologic Survey on Alcohol and Related Conditions-III included 1,997 adults with a lifetime PTSD diagnosis (70.8% female and 29.2% male). Of these 25.3% of women and 24.3% of men experienced remission (ns). Women who remitted were older than other women, more likely to be retired, and less likely to report disability, past homelessness, suicide attempts, criminal history, violent behavior, or parental histories of drug problems or suicide. Men who remitted were less likely than other men to be separated/divorced, disabled, incarcerated after age 15, and reported fewer violent behaviors. Remission was significantly more strongly associated among women than men with greater age, emergency room visits, trauma and less with schizotypal personality. Although women were twice as likely to be diagnosed with PTSD, there were no significant gender differences in the proportions who experienced remission. Remission was associated with diverse sociodemographic and clinical disadvantages among both men and women but only four were statistically significantly different between genders.

Social Functioning in Individuals With Post-Traumatic Stress Disorder: A Systematic Review

Post-traumatic stress disorder (PTSD) can lead to multiple deleterious outcomes and has negative, sometimes debilitating, impacts on general functioning of those affected. This systematic review of 26 articles evaluates the existing literature on social functioning outcomes used in PTSD research, the association between PTSD and social functioning, and the impact of interventions for PTSD on social functioning. A review of 26 articles using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for systematic reviews showed that PTSD was associated with significant impairment in global social functioning. This review also reveals the need for both standardized definitions and better assessment methods to operationalize social functioning and improve our ability to compare findings across studies. The literature also suggests that some evidence-based treatments for PTSD improve social functioning despite not explicitly targeting social functioning in the treatment. The findings of this review suggest that there are ample opportunities for improving both research and interventions to improve global social functioning in PTSD.

Post-traumatic stress disorder among victims of great march of return in the Gaza Strip, Palestine: A need for policy intervention

This study aimed to assess the level of Post-Traumatic Stress Disorder (PSTD) and to examine the relationship between exposure to war stress and posttraumatic symptoms among people who were injured during the Great March of Return (GMR) in the Gaza Strip, Palestine. A sample of 264 adults who were injured during participation in the events of GMR completed the Impact Event Scale-Revised (IES-R). IES-R has three sub-scales; intrusion, avoidance, and hyper-arousal. Only 27.3% of the participants had two or more injuries and 38.4% of participants reported having disability due to their injuries. The results showed that 95.4% of the participants had severe posttraumatic symptoms. Total score of IES-R ranged between 29 and 88 (mean = 61.28). The most frequent symptoms of trauma subscales was "Intrusion" (mean = 2.90), followed by "Avoidance" (mean = 2.73), and then "Hyper-arousal" (mean = 2.70). Level of PTSD was affected by working status, need for hospitalization, need for a referral for treatment outside the Gaza Strip, disability and severity of injury. Such high level of PSTD will have negative consequences on participants' physical and mental status. Therefore, a need for special counseling programs is required to help them to survive with least consequences of PTSD on their wellbeing.

Indirect Associations Between Posttraumatic Stress Symptoms and Other Psychiatric Symptoms, Alcohol Use, and Well-being via Psychological Flexibility Among Police Officers

Police officers experience a high number of potentially traumatic events (PTEs) often associated with elevated posttraumatic stress symptoms (PTSS). In addition, PTSS are related to co-occurring psychiatric symptoms (e.g., anxiety, depression), alcohol misuse, and low perceived well-being. Yet, behavioral processes that may account for the associations between PTSS and unfavorable outcomes remain unspecified. Psychological flexibility, or one's response to private experiences (e.g., PTE-related memories) with an open, aware, and active approach, may be one such process. The present study aimed to evaluate psychological flexibility as both a mediator and moderator of PTSS and commonly co-occurring psychiatric symptoms, alcohol use, and general well-being, using cross-sectional data provided by a sample of police officers (N = 459) recruited from three regionally distributed U.S. police agencies. Structural equation modeling indicated a well-fitting model wherein psychological flexibility indirectly accounted for associations among PTSS and endogenous outcomes, χ² (107, N = 457) = 225.33, p < .001, CFI = .99, TLI = .98, RMSEA = .05, 90% CI [.04, .06], SRMR = .03. Psychological flexibility also moderated associations between PTSS and psychiatric symptoms, B = 1.58 (SE = 0.22), p < .001; and well-being, B = -3.84 (SE = 0.46), p < .001. Although additional research is needed, these preliminary results suggest psychological flexibility may be a behavioral process that accounts for negative outcomes associated with PTSS and a productive intervention target in the context of PTSS and generalized distress. Further research regarding the role of psychological flexibility in PTSS-related outcomes for police officers appears warranted.

Psychosocial functioning in integrated treatment of co-occurring posttraumatic stress disorder and alcohol use disorder

Co-occurring posttraumatic stress disorder and alcohol use disorder (PTSD/AUD) is associated with poorer psychosocial functioning than either disorder alone; however, it is unclear if psychosocial functioning improves in treatment for PTSD/AUD. This study examined if psychosocial functioning improved in integrated treatments for PTSD/AUD, and if changes in PTSD severity and percentage heavy drinking days (PHDD) during treatment were associated with functioning outcomes. 119 veterans with PTSD/AUD randomized to receive either Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure or Seeking Safety completed measures of functioning (Medical Outcomes Survey SF-36), PTSD (Clinician Administered PTSD Scale for DSM-5), and alcohol use (Timeline Follow-Back) at baseline, posttreatment, 3- and 6-month follow-ups. Our findings suggest that psychosocial functioning improved to a statistically significant degree with no significant differences between conditions. Reductions in PTSD severity during treatment were associated with psychosocial functioning improvements, whereas reductions in PHDD were associated with improvement in role impairment at posttreatment. Although psychosocial functioning improves to a statistically significant degree in interventions designed to treat PTSD/AUD, these improvements do not represent clinically meaningful improvements in patients' abilities to navigate important roles. Findings underscore the need to study how to best treat psychosocial functioning impairment in PTSD/AUD.

Defining post-traumatic stress disorder recovery in veterans: Benchmarking symptom change against functioning indicators

Improved metrics of Post-traumatic stress disorder (PTSD) treatment response that extend beyond a focus on symptom reduction to incorporate meaningful, patient-centred indicators of functioning are needed in veteran populations. The aim of this study was to extend previous research by investigating whether indicators of functioning can successfully distinguish against symptom response categories derived from the Post-Traumatic Stress Disorder Checklist (PCL-5) pre- and post- PTSD treatment. Participants were 472 veterans receiving hospital-based treatment for PTSD. In addition to the PCL-5, measures included quality of life, social relationships, physical health and psychological distress. Four mutually exclusive, progressive response categories were used to define treatment response including: No Response, Response, Response and Below Threshold, and Remission. PTSD symptom reductions were associated with corresponding improvements in broader indicators of functioning. However, it was only when the magnitude of symptom reduction placed the individual in the 'Response and Below Threshold' category that improvement on functioning measures achieved levels indicative of a good end state. Traditional metrics of treatment 'response' in PTSD treatment do not necessarily indicate recovery on important functioning indicators. Only when an individual both responds to treatment and drops below threshold for probable disorder are they likely to report having meaningful levels of functioning.

Neural response to trauma-related and trauma-unrelated negative stimuli in remitted and persistent pediatric post-traumatic stress disorder

INTRODUCTION

Most youths who suffer from post-traumatic stress disorder (PTSD) lose their diagnosis in the first 1-2 years. However, there are few studies on this brain mechanism, and the heterogeneity of the findings is partially due to the different stimuli applied and the mixed trauma history. Therefore, the use of trauma-related/unrelated stimuli to study the remittance mechanism of earthquake-induced PTSD could advance our knowledge of PTSD and inspire future treatment.

METHODS

Thirteen youths with PTSD, 18 remitted participants, and 18 control participants underwent functional magnetic resonance imaging (fMRI), while viewing trauma-related pictures, trauma-unrelated negative pictures, and scrambled pictures.

RESULTS

Under trauma-unrelated condition, the neural activity of the left hippocampus in the remitted group was between the two other groups. Under trauma-related condition, the PTSD and the remitted group exhibited higher neural activity in the right middle occipital gyrus than controls. The remitted group showed higher neural activity in the right parahippocampal gyrus and right lingual gyrus under trauma-related condition than trauma-unrelated condition, while no significant difference was found in PTSD group.

CONCLUSION

PTSD status-related group differences are mainly reflected in the left hippocampus under the trauma-unrelated condition, while the hyperactivity in the right middle occipital gyrus under trauma-related condition could be an endophenotype for PTSD.

A Pilot Study of the Efficacy of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Treating Posttraumatic Psychopathology: A Randomized Controlled Trial

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is an intervention that targets common mechanisms that maintain symptoms across multiple disorders. The UP has been shown to be effective across many disorders, including generalized anxiety disorder, major depressive episode (MDE), and panic disorder, that commonly codevelop following trauma exposure. The present study represented the first randomized controlled trial of the UP in the treatment of trauma-related psychopathology, including posttraumatic stress disorder (PTSD), depression, and anxiety symptoms. Adults (N = 43) who developed posttraumatic psychopathology that included PTSD, MDE, or an anxiety disorder after sustaining a severe injury were randomly assigned to receive 10-14 weekly, 60-min sessions of UP (n = 22) or usual care (n = 21). The primary treatment outcome was PTSD symptom severity, with secondary outcomes of depression and anxiety symptom severity and loss of diagnosis for any trauma-related psychiatric disorder. Assessments were conducted at intake, posttreatment, and 6-month follow-up. Posttreatment, participants who received the UP showed significantly larger reductions in PTSD, Hedges' g = 1.27; anxiety, Hedges' g = 1.20; and depression symptom severity, Hedges' g = 1.40, compared to those receiving usual care. These treatment effects were maintained at 6-month follow-up for PTSD, anxiety, and depressive symptom severity. Statistically significant posttreatment loss of PTSD, MDE, and agoraphobia diagnoses was observed for participants who received the UP but not usual care. This study provides preliminary evidence that the UP may be an effective non-trauma-focused treatment for PTSD and other trauma-related psychopathology.

Cannabis in the management of PTSD: a systematic review

Introduction

Existing reviews exploring cannabis effectiveness have numerous limitations including narrow search strategies. We systematically explored cannabis effects on PTSD symptoms, quality of life (QOL), and return to work (RTW). We also investigated harm outcomes such as adverse effects and dropouts due to adverse effects, inefficacy, and all-cause dropout rates.

Methods

Our search in MEDLINE, EMBASE, PsycInfo, CINAHL, Web of Science, CENTRAL, and PubMed databases, yielded 1 eligible RCT and 10 observational studies (n = 4672). Risk of bias (RoB) was assessed with the Cochrane risk of bias tool and ROBINS-I.

Results

Evidence from the included studies was mainly based on non-randomized studies with no comparators. Results from unpooled, high RoB studies showed that cannabis was associated with a reduction in overall PTSD symptoms and improved QOL. Dry mouth, headaches, and psychoactive effects such as agitation and euphoria were the commonly reported adverse effects. In most studies, cannabis was well tolerated, but small proportions of patients experienced a worsening of PTSD symptoms.

Conclusion

Evidence in the current study primarily stems from low quality and high RoB observational studies. Further RCTs investigating cannabis effects on PTSD treatment should be conducted with larger sample sizes and explore a broader range of patient-important outcomes.

Measurement Strategies for Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes

We sought to develop a quality standard for the delivery of psychotherapy for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting psychotherapy as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified psychotherapy receipt during the initial year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users who completed patient-reported outcome measurement as part of routine practice. We added progressively stringent measurement requirements. The most stringent requirement was associated with superior outcomes. Quality of psychotherapy for PTSD in the VA improved over time.

Effect of Prolonged Exposure, intensified Prolonged Exposure and STAIR+Prolonged Exposure in patients with PTSD related to childhood abuse: a randomized controlled trial

Background: It is unclear whether the evidence-based treatments for PTSD are as effective in patients with CA-PTSD. Objective: We aimed to investigate the effectiveness of three variants of prolonged exposure therapy. Method: We recruited adults with CA-PTSD. Participants were randomly assigned to Prolonged Exposure (PE; 16 sessions in 16 weeks), intensified Prolonged Exposure (iPE; 12 sessions in 4 weeks followed by 2 booster sessions) or a phase-based treatment, in which 8 sessions of PE were preceded by 8 sessions of Skills Training in Affective and Interpersonal Regulation (STAIR+PE; 16 sessions in 16 weeks). Assessments took place in week 0 (baseline), week 4, week 8, week 16 (post-treatment) and at a 6-and 12-month follow-up. The primary outcome was clinician-rated PTSD symptom severity. Results: We randomly assigned 149 patients to PE (48), iPE (51) or STAIR+PE (50). All treatments resulted in large improvements in clinician assessed and self-reported PTSD symptoms from baseline to 1-year follow-up (Cohen's d > 1.6), with no significant differences among treatments. iPE led to faster initial symptom reduction than PE for self-report PTSD symptoms (t₁₃₅ = -2.85, p = .005, d = .49) but not clinician-assessed symptoms (t₁₃₅ = -1.65, p = .10) and faster initial symptom reduction than STAIR+PE for self-reported (t₁₃₅ = -4.11, p < .001, d = .71) and clinician-assessed symptoms (t₁₃₅ = -2.77, p = .006, Cohen's d = .48) STAIR+PE did not result in significantly more improvement from baseline to 1-year follow-up on the secondary outcome emotion regulation, interpersonal problems and self-esteem compared to PE and iPE. Dropout rates did not differ significantly between conditions. Conclusions: Variants of exposure therapy are tolerated well and lead to large improvements in patients with CA-PTSD. Intensifying treatment may lead to faster improvement but not to overall better outcomes. The trial is registered at the clinical trial registry, number NCT03194113, https://clinicaltrials.gov/ct2/show/NCT03194113.

Determining the median effective dose of prolonged exposure therapy for veterans with posttraumatic stress disorder

Prolonged exposure therapy (PE) is an effective treatment for posttraumatic stress disorder (PTSD). Identifying metrics of treatment response can guide treatment delivery. The median effective dose represents the number of sessions at which there is a 50% probability of clinically meaningful improvement (i.e., 10-point reduction in PTSD checklist). The goal of the current study was to investigate the median effective dose of PE. We identified a cohort of Iraq and Afghanistan war veterans who received psychotherapy for PTSD in the Veterans Health Administration between 2001 and 2017. From this cohort, 10,234 veterans who received PE (as identified using natural language processing) and had ≥2 PTSD symptom measures were included in analyses. To determine how the number of PE sessions and covariates affected clinically meaningful improvement, we utilized a Cox proportional hazards regression, followed by Kaplan-Meier curves to determine the median effective dose. The median effective dose of PE was four sessions. Although some covariates were found to be statistically significant predictors of clinically meaningful improvement (e.g., age, gender, PTSD medications, and depressive disorder comorbidity), these effects were small. Clinicians and patients should consider evaluating treatment response after four sessions to determine preliminary effectiveness of PE.

Does Psychosocial Functioning Improve With Prolonged Exposure in Veterans With PTSD?: Exploring Traditional and Home-Based Telehealth Delivery Methods

The current study explored whether prolonged exposure (PE), delivered in person or via home-based telehealth, had a therapeutic effect on psychosocial functioning in combat Veterans with posttraumatic stress disorder (PTSD). The effects of home-based telehealth on these metrics were also evaluated. In addition, we examined whether race, type of war conflict, and service-connected disability rating moderated the effect of PE on psychosocial functioning and whether PTSD, anxiety, and/or depression mediated the effect of PE on psychosocial functioning. We did not find moderating or mediating effects in our study. Improvements in PTSD, depression, and anxiety were associated with improvements in psychosocial functioning. We did not identify statistically significant differences in scores representing change in overall and each domain of psychosocial functioning between groups. Within-group analysis indicated psychosocial functioning improved in both groups but was mostly not statistically significant. However, some clinically relevant improvement may have occurred. [Journal of Psychosocial Nursing and Mental Health Services, 59(2), 31-40.].

Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review

BACKGROUND

People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people.

OBJECTIVE

To identify candidate psychological and non-pharmacological treatments for future research.

DESIGN

Mixed-methods systematic review.

PARTICIPANTS

Adults aged ≥ 18 years with a history of complex traumatic events.

INTERVENTIONS

Psychological interventions versus control or active control; pharmacological interventions versus placebo.

MAIN OUTCOME MEASURES

Post-traumatic stress disorder symptoms, common mental health problems and attrition.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017.

REVIEW METHODS

Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist.

RESULTS

One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs.

LIMITATIONS

Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented.

CONCLUSIONS

Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder.

FUTURE WORK

Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017055523.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.

Residual symptoms of PTSD following Sertraline plus enhanced medication management, Sertraline plus PE, and PE plus placebo

Although prolonged exposure (PE) and SSRI antidepressants are effective in treating posttraumatic stress disorder (PTSD), previous studies have shown that some symptoms tend to persist. The current study compared sertraline hydrochloride plus enhanced medication management (EMM), PE plus placebo, or PE plus sertraline hydrochloride in the likelihood of each individual PTSD symptom persisting in veterans with a PTSD diagnosis. We compared the likelihood of individual PTSD symptoms persisting in those with versus without a PTSD diagnosis at posttreatment. We found no significant differences across conditions in which symptoms were likely to persist posttreatment. Among those without a PTSD diagnosis at posttreatment, sleeping difficulties (63.0%), hypervigilance (47.3%), and nightmares (45.0%) were most likely to persist. Findings indicate no consistent differences in residual symptoms between PE and medications, and shared decision making with patients is encouraged in selecting treatments. Gold standard treatments (e.g., CBT-I) may be warranted for residual symptoms like insomnia.

Prolonged Exposure and Sertraline Treatments for Posttraumatic Stress Disorder Also Improve Multiple Indicators of Social Functioning

Trauma survivors with posttraumatic stress disorder (PTSD) frequently also suffer from difficulties in social functioning that range across emotional, cognitive, and environmental domains. A detailed evaluation of the differential impacts of effective PTSD treatments on social functioning is needed. Men and women (N = 200) with chronic PTSD received 10 weeks of prolonged exposure (PE) or sertraline in a randomized clinical trial and were followed for 24 months. A secondary data analysis examined changes in social functioning with regard to fear of intimacy; receipt of social support; and distress, avoidance, and negative cognitions in social situations. Effects were examined between treatments over time, controlling for baseline functioning. There were large, durable improvements across all indices. Compared to sertraline, PE was more efficient at reducing fear of intimacy and distress from negative social cognitions by posttreatment, ds = 0.94-1.14. Patients who received sertraline continued to improve over the course of follow-up, ds = 0.54-1.17. The differential speed of therapeutic effects may argue for more direct mechanisms in cognitive behavioral interventions versus cascade effects in serotonin reuptake inhibitors. Notably, both treatments produced substantial social benefits for trauma survivors with social functioning difficulties, and effect sizes were comparable to typical reductions in PTSD, depression, and anxiety.

Exploring Theta Burst Stimulation for Post-traumatic Stress Disorder in Australian Veterans—A Pilot Study

Introduction

Post-traumatic stress disorder (PTSD) is a severe and debilitating condition affecting a significant proportion of the veteran community. A substantial number of veterans with PTSD fail to benefit from trauma-focused psychological therapies or pharmacotherapy or are left with residual symptoms, and therefore, investigation of new and innovative treatment is required. Theta Burst Stimulation (TBS) is a novel form of Repetitive Transcranial Magnetic Stimulation, which has been shown to improve depression symptoms and associated cognitive deficits. The current pilot study aimed to explore the acceptability, safety, and tolerability of intermittent TBS (iTBS) as a treatment for PTSD in Australian veterans.

Materials and Methods

This study employed a case series, repeated-measures design. Eight Australian Defence Force veterans with PTSD received 20 bilateral iTBS treatments (1 session per day, 5 days per week over a 4-week period) and were assessed on a range of mental health and neuropsychological measures, including the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and Hamilton Depression Rating Scale (HAM-D), at pretreatment, post-treatment, and a 3-month follow-up.

Results

Treatment was generally welltolerated, with reported side-effects including mild to moderate site-specific cranial pain and headaches during stimulation, which were relieved with the use of low dose analgesics. No serious side effects or adverse events were reported. Participants exhibited reductions in both PTSD and depression symptom severity (the repeated-measures effect size [dRM] for the CAPS-5 was −1.78, and the HAM-D was −1.16 post-treatment), as well as improvements in working memory and processing speed. Although significance cannot be inferred, these preliminary estimates of effect size indicate change over time.

Conclusions

Bilateral iTBS appears to be welltolerated by Australian veterans. Within this repeated-measures case series, iTBS treatment shows promise in reducing both PTSD and mood symptoms, as well as improving cognitive difficulties associated with these disorders. Large-scale randomized controlled trials of this promising treatment are warranted.

Posttraumatic Stress Disorder in Primary Care: A Study of General Practices in England

Posttraumatic Stress Disorder (PTSD) may be a common issue in primary care in the UK, but there have been no studies of all-cause PTSD in general samples of attenders in this country. The current paper thus explores the extent and distribution of probable PTSD among patients attending general practices in England. Cross-sectional survey data from adult patients (n = 1058) attending 11 general practices in southwest England were analysed. Patients were recruited from waiting rooms and completed anonymous questionnaires, including measures of depression, anxiety and risky alcohol use. Current probable PTSD was measured using the 4-item Primary Care PTSD Scale (PC-PTSD). Results indicated 15.1% of patients that exhibited probable PTSD (PC-PTSD ≥ 3), with higher levels observed in practices from deprived areas. There were 53.8% of patients with probable PTSD that expressed the desire for help with these issues. The analyses suggested that rates were lowest among older adults, and highest among patients who were not in cohabitating relationships or were unemployed. Measures of anxiety and depression were associated with 10-fold and 16-fold increases in risk of probable PTSD, respectively, although there were no discernible associations with risky drinking. Such preliminary findings highlight the need for vigilance for PTSD in routine general practice in the UK, and signal a strong need for additional research and attention in this context.

Predicting and Managing Treatment Non-Response in Posttraumatic Stress Disorder

PURPOSE OF REVIEW

This review aims to synthesize existing research regarding the definition of treatment resistance in posttraumatic stress disorder (PTSD), predictors of treatment non-response to first-line interventions, and emerging second-line PTSD treatment options into an accessible resource for the practicing clinician.

RECENT FINDINGS

The concept of treatment resistance in PTSD is currently poorly defined and operationalized. There are no well-established predictors of treatment non-response utilized in routine clinical care, but existing research identifies several potential candidate markers, including male gender, low social support, chronic and early life trauma exposure, comorbid psychiatric disorders, severe PTSD symptoms, and poor physical health. The most promising available treatment options for PTSD patients non-responsive to first-line psychotherapies and antidepressants include transcranial magnetic stimulation and ketamine infusion. Methylenedioxymethamphetamine-assisted psychotherapy also appears promising but is only available in a research context. These options require careful consideration of risks and benefits for a particular patient.

SUMMARY

More research is required to develop a robust, clinically-useful definition of treatment resistance in PTSD; identify reliable, readily assessable, and generalizable predictors of PTSD treatment non-response; and implement measurement and prediction in clinical settings to identify individuals unlikely to respond to first-line treatments and direct them to appropriate second-line treatments.

Measurement Strategies for Evidence-Based Antidepressants for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes

We sought to develop a quality standard for the prescription of antidepressants for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting antidepressants as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified antidepressant initiation during the first year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users, and compared outcomes in a subgroup who completed patient-reported outcome measurement (PROM) as part of routine practice. We added progressively stringent measurement requirements. Prescribing quality for PTSD in the VA was stable over time. Use of PROM was rare in the case of antidepressant treatment, limiting our assessment of outcomes.

Peer support during in vivo exposure homework to reverse attrition from prolonged exposure therapy for posttraumatic stress disorder (PTSD): description of a randomized controlled trial

BACKGROUND

Effective treatments for posttraumatic stress disorder (PTSD) (e.g., prolonged exposure (PE); cognitive processing therapy (CPT)) exist and are widely adopted by the Departments of Veterans Affairs (VA) and Defense (DoD). Unfortunately, dropout from these treatments regularly exceeds 30%. However, in a recent survey of patients who dropped out of PE, approximately half indicated a greater likelihood of completion if a peer who had completed treatment were available to help with the in vivo exposure homework.

METHODS

We will use a between-groups randomized controlled design with repeated assessment at baseline, post treatment, and 3- and 6-month follow-up across measures of PTSD, depression, and functioning with 150 veterans who have indicated that they intend to drop out of treatment. Participants will be randomly assigned to one of two PE + Peer Support conditions: (1) a peer will offer support directly during in vivo exposure homework for 3-4 weeks; vs (2) a peer will call weekly for 3-4 weeks to offer general support and to check in on treatment progress.

DISCUSSION

The present study was designed to test the hypothesis that dropout from exposure-based PTSD treatment may be mitigated by using peers as support agents directly during PE in vivo homework experiences. Specifically, we intend to determine: whether patients who have dropped out of PE and are offered the "in vivo peer" adjunctive component to PE therapy will (1) return and complete treatment and (2) evince reduced PTSD symptomatology, compared to the same PE treatment, but with general peer support more reflective of current VA practices.

TRIAL REGISTRATION

This study protocol is approved and information is available at ClinicalTrials.gov, ID: NCT03485391. Registered on 2 April 2018.

"It leaves me very skeptical" messaging in marketing prolonged exposure and cognitive processing therapy to veterans with PTSD

OBJECTIVE

Direct-to-consumer marketing has the potential to increase demand for specific treatments, but little is known about how to best market evidence-based psychotherapies to veterans with posttraumatic stress disorder (PTSD). The objective of this study was to gain an understanding of marketing messages that may impact veteran demand for prolonged exposure (PE) and cognitive processing therapy (CPT).

METHOD

Veterans (n = 31) with full or subthreshold PTSD participated in semistructured interviews that queried attitudes about PTSD and recovery, current knowledge of PE and CPT, and reactions to existing educational materials. A 2-stage qualitative coding and analytic strategy was used to identify primary themes related to the marketing of PE and CPT.

RESULTS

Veterans viewed the treatments' effectiveness as their primary selling point but questioned the credibility of improvement descriptions that didn't fit with their experiences or beliefs about PTSD. Participants had difficulties distinguishing CPT from non-trauma-focused approaches in which they had previously participated, leading to skepticism about promised treatment effects and decreased interest. Without targeting, women veterans assumed information regarding PTSD treatment options applied only to men.

CONCLUSIONS

Examination of the impact of a direct-to-consumer marketing campaign including these messages on PE and CPT demand is needed. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Using patient-reported outcomes to understand the effectiveness of guideline-concordant care for post-traumatic stress disorder in clinical practice

RATIONALE

Identifying predictors of improvement amongst patients receiving routine treatment for post-traumatic stress disorder (PTSD) could provide information about factors that influence the clinical effectiveness of guideline-concordant care. This study builds on prior work by accounting for delivery of specific evidence-based treatments (EBTs) for PTSD while identifying potential predictors of clinical improvement using patient-reported outcomes measurement.

METHOD

Our sample consisted of 2 643 US Department of Veterans Affairs (VA) outpatients who initiated treatment for PTSD between 2008 and 2013 and received at least four PTSD checklist (PCL) measurements over 12 weeks. We obtained PCL data as well as demographic, diagnostic, and health services use information from the VA corporate data warehouse. We used latent trajectory analysis to identify classes of patients based on PCL scores, then determined demographic, diagnostic, and treatment predictors of membership in each class.

RESULTS

Patients who met our PCL-based inclusion criteria were far more likely than those who did not receive EBTs. We identified two latent trajectories of PTSD symptoms. Patients in the substantial improvement group (25.9%) had a mean decrease in PCL score of 16.24, whereas patients in the modest improvement group improved by a mean of 8.09 points. However, there were few differences between the groups, and our model to predict group membership was only slightly better than chance (area under the curve [AUC] = 0.55). Of the 64 covariates we tested, the only robust individual predictor of improvement was gender, with men having lower odds of being in the substantial improvement group compared with women (odds ratio [OR] 0.76; 95% confidence interval [CI] 0.58-0.96).

CONCLUSION

VA patients with PTSD can realize significant improvement in routine clinical practice. Although available medical records-based variables were generally insufficient to predict improvement trajectory, this study did indicate that men have lower odds of substantial improvement than women.

Evidence-Based Psychotherapy Interventions to Improve Psychosocial Functioning in Veterans With PTSD: An Integrative Review

Posttraumatic stress disorder (PTSD) is a prevalent diagnosis among Veterans and is linked to psychosocial functioning impairment across various domains, including marriage, employment, parenting, family, and education. Veterans are more likely to be divorced, unemployed, and experience difficulties with parenting. Some research has suggested that improvement in PTSD-specific symptoms can also improve psychosocial functioning. An integrative review was conducted to explore the content and effectiveness of evidence-based psychotherapy (EBP) interventions to improve psychosocial functions and investigate conditions for symptom change. The Socio-Interpersonal Framework Model of PTSD was used to synthesize and organize findings. MEDLINE, CINAHL, and PsycINFO databases were searched and seven articles met inclusion criteria. The main results indicate that EBP interventions can improve psychosocial functioning in Veterans with PTSD. Treating Veterans until they no longer meet diagnostic criteria for PTSD may be beneficial to improve psychosocial functioning. The current integrative review revealed that this area is neglected in research. [Journal of Psychosocial Nursing and Mental Health Services, 57(10), 24-33.].

Randomised controlled trial comparing narrative exposure therapy with present-centred therapy for older patients with post-traumatic stress disorder

BACKGROUND

Evidence-based treatment and age-specific services are required to address the needs of trauma-affected older populations. Narrative exposure therapy (NET) may present an appropriate treatment approach for this population since it provides prolonged exposure in a lifespan perspective. As yet, however, no trial on this intervention has been conducted with older adults from Western Europe.AimsExamining the efficacy of NET in a sample of older adults.

METHOD

Out-patients with post-traumatic stress disorder (PTSD), aged 55 years and over, were randomly assigned to either 11 sessions of NET (n = 18) or 11 sessions of present-centred therapy (PCT) (n = 15) and assessed on the Clinician-Administered PTSD Scale (CAPS) pre-treatment, post-treatment and at follow-up. Total scores as well as symptom scores (re-experience, avoidance and hyperarousal) were evaluated.

RESULTS

Using a piecewise mixed-effects growth model, at post-treatment a medium between-treatment effect size for CAPS total score (Cohen's d = 0.44) was found, favouring PCT. At follow-up, however, the between-treatment differences were non-significant. Drop-out rates were low (NET 6.7%, PCT 14.3%) and no participant dropped out of the study because of increased distress.

CONCLUSIONS

Both NET and PCT appear to be safe and efficacious treatments with older adults: PCT is non-intrusive and NET allows for imaginal exposure in a lifespan perspective. By selectively providing these approaches in clinical practice, patient matching can be optimised.Declaration of interestNone.

Post-traumatic stress disorder in living donors after pediatric liver transplantation: A cross-sectional investigation study

Liver transplantation can lead to post-traumatic stress disorder (PTSD) in recipients, but the risk factors associated with PTSD in living donors are unknown. To investigate this progression in pediatric living donors, a cross-sectional investigation was carried out.All participants completed 2 questionnaires: a PTSD self-rating scale (PTSD-SS) and a validated Chinese version of the Medical Outcomes Study Short Form-36 (SF-36). Clinical and demographic data were collected from medical records and self-report questionnaires. Univariate analysis was conducted to identify statistical differences.The prevalence of full PTSD (all symptom clusters) and partial PTSD (2 out of 3 symptom clusters) was 12.1% and 31.1%, respectively. Those with an educational status of elementary school (P = .001), who were donors to their children (P = .008), who were in the first 6 months after transplant (P < .001), or were involved in transplants where the recipients had severe complications (P = .02) were more likely to have higher PTSD-SS scores than other groups. The non-PTSD group had a higher health-related quality-of-life score compared with the full and partial PTSD groups in the domains of physical function, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. In addition, the occurrence of PTSD was related to a poorer quality of life.The occurrence of PTSD was common in living donors after pediatric liver transplantation. Those with a lower educational status, who were donors to their children, were in the first 6 months after transplant, or were involved in transplants where the recipients had severe complications were most likely to experience PTSD. Post-traumatic stress symptom severity was significantly associated with a poorer quality of life after transplant.

An initial review of residual symptoms after empirically supported trauma-focused cognitive behavioral psychological treatment

OBJECTIVE

Although residual symptoms remain following clinical treatment for posttraumatic stress disorder (PTSD), little is known about the characteristics of these residual symptoms. We aimed to determine the type, severity, and frequency of symptoms that remain after trauma-focused psychotherapy.

METHODS

We conducted a systematic review of 51 randomized controlled trials of empirically supported psychosocial interventions for PTSD (68 total treatment arms). Outcomes included: 1) PTSD symptoms and 2) conditions commonly comorbid with PTSD: depression, anxiety, and quality of life impairment.

RESULTS

In general, the results revealed that participants who completed PTSD treatment continued to report residual PTSD symptoms: 31% reported clinical symptom levels, and 59% reported subthreshold levels at posttreatment, particularly within the hyperarousal cluster. Residual symptoms also emerged for depression (19% clinical), anxiety (55% clinical), and quality of life (36% clinical). Few differences emerged across treatment types, but differential patterns were revealed for sample/trauma types.

CONCLUSIONS

Results suggest a need for focused research attention to and clinical assessment of individual residual symptoms following empirically supported treatment for PTSD to determine whether further treatment sessions are warranted.

Residual symptoms following prolonged exposure and present-centered therapy for PTSD in female veterans and soldiers

BACKGROUND

Despite the effectiveness of evidence-based treatments for posttraumatic stress disorder (PTSD), some symptoms, such as sleep disturbance, can be difficult to treat regardless of treatment type.

METHODS

We examined residual PTSD symptoms in 235 female veterans and soldiers who were randomized to receive 10 weekly sessions of either Prolonged Exposure (PE) or Present-Centered Therapy (PCT). PTSD symptoms were assessed using the Clinician-Administered PTSD Scale. Analyses examined the effects of PE and the effects of clinically significant improvement (loss of diagnosis, operationalized as meaningful symptom reduction and no longer meeting diagnostic criteria).

RESULTS

Both treatments resulted in reductions in PTSD symptoms. PE had lower conditional probabilities than PCT of retaining intrusive memories, avoidance of people/places, detachment/estrangement, and restricted range of affect. Loss of diagnosis had lower conditional probabilities of almost all symptoms, although hyperarousal symptoms-especially irritability/anger (60.7%) and sleep difficulties (50.9%)-were the most likely to remain.

CONCLUSIONS

Results are consistent with previous findings on sleep difficulties being difficult to treat, but also show that hyperarousal symptoms overall may not be resolved even after substantial improvement. Additional strategies may be needed to treat the full range of PTSD symptoms in some patients.

Treatment of military-related post-traumatic stress disorder: challenges, innovations, and the way forward

Post-traumatic stress disorder (PTSD) is one of the common mental disorders in military and veteran populations. Considerable research and clinical opinion has been focused on understanding the relationship between PTSD and military service and the implications for prevention, treatment, and management. This paper examines factors associated with the development of PTSD in this population, considers issues relating to engagement in treatment, and discusses the empirical support for best practice evidence-based treatment. The paper goes on to explore the challenges in those areas, with particular reference to treatment engagement and barriers to care, as well as treatment non-response. The final section addresses innovative solutions to these challenges through improvements in agreed terminology and definitions, strategies to increase engagement, early identification approaches, understanding predictors of treatment outcome, and innovations in treatment. Treatment innovations include enhancing existing treatments, emerging non-trauma-focused interventions, novel pharmacotherapy, personalized medicine approaches, advancing functional outcomes, family intervention and support, and attention to physical health.

Health-economic benefits of treating trauma in psychosis

Background: Co-occurrence of posttraumatic stress disorder (PTSD) in psychosis (estimated as 12%) raises personal suffering and societal costs. Health-economic studies on PTSD treatments in patients with a diagnosis of a psychotic disorder have not yet been conducted, but are needed for guideline development and implementation. This study aims to analyse the cost-effectiveness of guideline PTSD therapies in patients with a psychotic disorder. Methods: This health-economic evaluation alongside a randomized controlled trial included 155 patients with a psychotic disorder in care as usual (CAU), with comorbid PTSD. Participants received eye movement desensitization and reprocessing (EMDR) (n = 55), prolonged exposure (PE) (n = 53) or waiting list (WL) (n = 47) with masked assessments at baseline (T0) and at the two-month (post-treatment, T2) and six-month follow-up (T6). Costs were calculated using the TiC-P interview for assessing healthcare consumption and productivity losses. Incremental cost-effectiveness ratios and economic acceptability were calculated for quality-adjusted life years (EQ-5D-3L-based QALYs) and PTSD 'Loss of diagnosis' (LoD, CAPS). Results: Compared to WL, costs were lower in EMDR (-€1410) and PE (-€501) per patient per six months. In addition, EMDR (robust SE 0.024, t = 2.14, p = .035) and PE (robust SE 0.024, t = 2.14, p = .035) yielded a 0.052 and 0.051 incremental QALY gain, respectively, as well as 26% greater probability for LoD following EMDR (robust SE = 0.096, z = 2.66, p = .008) and 22% following PE (robust SE 0.098, z = 2.28, p = .023). Acceptability curves indicate high probabilities of PTSD treatments being the better economic choice. Sensitivity analyses corroborated these outcomes. Conclusion: Adding PTSD treatment to CAU for individuals with psychosis and PTSD seem to yield better health and less PTSD at lower costs, which argues for implementation.