Maximizing follow-up in longitudinal studies of traumatized populations

Avoidant Parent-Child Communication About COVID-19: A Longitudinal Investigation of Associations with Youth Adjustment Across the First 6 Months of the Pandemic

In the aftermath of discrete disasters, how families discuss the event has been linked with child well-being. There is less understanding, however, of how family communication affects adjustment to a protracted and ongoing public health crisis such as the COVID-19 pandemic. The present research leveraged a large longitudinal sample of families (N = 1884) across the United States and Canada to investigate factors that predicted family communication styles (active versus avoidant communication) about the COVID-19 pandemic and examined the longitudinal sequelae of mental health outcomes for youth associated with different family communication styles. Parents of youth between 5 to 17 years old completed surveys about their own mental health, their child's mental health, and family communication about the COVID-19 pandemic at two time points 6 months apart. Overall, findings indicated that poorer parental mental health was related to greater use of avoidant communication, and avoidant communication styles were associated with poorer youth mental health over time. Findings suggest potential perils of avoidant family communication about ongoing threats and can help identify families at risk of negative mental health outcomes.

Exploring Different Incentive Structures Among US Adults Who Use e-Cigarettes to Optimize Retention in Longitudinal Web-Based Surveys: Case Study

BACKGROUND

Longitudinal cohort studies are critical for understanding the evolution of health-influencing behaviors, such as e-cigarette use, over time. Optimizing follow-up rates in longitudinal studies is necessary for ensuring high-quality data with sufficient power for analyses. However, achieving high rates of follow-up in web-based longitudinal studies can be challenging, even when monetary incentives are provided.

OBJECTIVE

This study compares participant progress through a survey and demographics for 2 incentive structures (conditional and hybrid unconditional-conditional) among US adults using e-cigarettes to understand the optimal incentive structure.

METHODS

The data used in this study are from a web-based longitudinal cohort study (wave 4; July to September 2022) of US adults (aged 21 years or older) who use e-cigarettes ≥5 days per week. Participants (N=1804) invited to the follow-up survey (median completion time=16 minutes) were randomly assigned into 1 of 2 incentive structure groups (n=902 each): (1) conditional (US $30 gift code upon survey completion) and (2) hybrid unconditional-conditional (US $15 gift code prior to survey completion and US $15 gift code upon survey completion). Chi-square tests assessed group differences in participant progress through 5 sequential stages of the survey (started survey, completed screener, deemed eligible, completed survey, and deemed valid) and demographics.

RESULTS

Of the 902 participants invited to the follow-up survey in each group, a higher proportion of those in the conditional (662/902, 73.4%) than the hybrid (565/902, 62.6%) group started the survey (P<.001). Of those who started the survey, 643 (97.1%) participants in the conditional group and 548 (97%) participants in the hybrid group completed the screener (P=.89), which was used each wave to ensure participants remained eligible. Of those who completed the screener, 555 (86.3%) participants in the conditional group and 446 (81.4%) participants in the hybrid group were deemed eligible for the survey (P=.02). Of those eligible, 514 (92.6%) participants from the conditional group and 401 (89.9%) participants from the hybrid group completed the survey and were deemed valid after data review (P=.14). Overall, more valid completions were yielded from the conditional (514/902, 57%) than the hybrid group (401/902, 44.5%; P<.001). Among those who validly completed the survey, no significant differences were found by group for gender, income, race, ethnicity, region, e-cigarette use frequency, past 30-day cigarette use, or number of waves previously completed.

CONCLUSIONS

Providing a US $30 gift code upon survey completion yielded higher rates of survey starts and completions than providing a US $15 gift code both before and after survey completion. These 2 methods yielded participants with similar demographics, suggesting that one approach is not superior in obtaining a balanced sample. Based on this case study, future web-based surveys examining US adults using e-cigarettes could consider providing the full incentive upon completion of the survey.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/38732.

Adaptation in Young Military Recruits: Protocol for the Advancing Research on Mechanisms of Resilience (ARMOR) Prospective Longitudinal Study

BACKGROUND

Military services provide a unique opportunity for studying resilience, a dynamic process of successful adaptation (ie, doing well in terms of functioning and symptoms) in response to significant adversity. Despite the tremendous interest in positive adaptation among military service members, little is known about the processes underlying their resilience. Understanding the neurobiological, cognitive, and social mechanisms underlying adaptive functioning following military stressor exposure is essential for enhancing the resilience of military service members.

OBJECTIVE

The primary objective of the Advancing Research on Mechanisms of Resilience (ARMOR) longitudinal study is to characterize the trajectories of positive adaptation among young military recruits in response to basic combat training (BCT), a well-defined, uniform, and 10-week period of intense stress (aim 1), and identify promotive and protective processes contributing to individual variations in resilience (aim 2). The secondary objective is to investigate the pathways by which neurobehavioral markers of self-regulation assessed using electroencephalography and magnetic resonance imaging contribute to adaptive trajectories (aim 3).

METHODS

ARMOR is an ongoing, prospective longitudinal cohort study of young military recruits who recently joined the National Guard but have not yet shipped out for BCT. Participants (N=1201) are assessed at 5 time points over the initial >2 years of military service beginning before BCT (baseline) and followed up at 2 weeks and 6, 12, and 18 months after BCT. Participants complete web-based questionnaires assessing vulnerability and protective factors, mental health, and socioemotional functioning at each time point and a battery of neurocognitive tests at time 0. A subset of participants also complete structured diagnostic interviews and additional self-report measures and perform neurobehavioral tasks before and after BCT during electroencephalography sessions and before BCT only during magnetic resonance imaging sessions.

RESULTS

This UG3/UH3 project was initially funded in August 2017, with the UG3 pilot work completed at the end of 2018. The UH3 phase of the project was funded in March 2019. Study enrollment for the UH3 phase began on April 14, 2019, and ended on October 16, 2021. A total of 1201 participants are enrolled in the study. Follow-up data collection for the UH3 phase is ongoing and projected to continue through February 2024. We will disseminate the findings through conferences, webinars, open access publications, and communications with participants and stakeholders.

CONCLUSIONS

The ARMOR study provides a rich data set to identify the predictors and mechanisms of resilient and nonresilient outcomes in the context of military stressors, which are intended to empirically inform the development of prevention and intervention strategies to enhance the resilience of military trainees and potentially other young people facing significant life challenges.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51235.

Reminiscence and Digital Storytelling to Improve the Social and Emotional Well-Being of Older Adults With Alzheimer's Disease and Related Dementias: Protocol for a Mixed Methods Study Design and a Randomized Controlled Trial

BACKGROUND

Increasing attention is being given to the growing concerns about social isolation, loneliness, and compromised emotional well-being experienced by young adults and older individuals affected by Alzheimer disease and related dementias (ADRD). Studies suggest that reminiscence strategies combined with an intergenerational approach may yield significant social and mental health benefits for participants. Experts also recommended the production of a digital life story book as part of reminiscence. Reminiscence is typically implemented by trained professionals (eg, social workers and nurses); however, there has been growing interest in using trained volunteers owing to staffing shortages and the costs associated with reminiscence programs.

OBJECTIVE

The proposed study will develop and test how reminiscence offered by trained young adult volunteers using a digital storytelling platform may help older adults with ADRD to improve their social and emotional well-being.

METHODS

The proposed project will conduct a randomized controlled trial to assess the effects of the intervention. The older and young adult participants will be randomly assigned to the intervention (reminiscence based) or control groups and then be randomly matched within each group. Data will be collected at baseline before the intervention, in the middle of the intervention, at end of the intervention, and at 3 months after the intervention. An explanatory sequential mixed methods design will be used to take advantage of the strengths of both quantitative and qualitative methods. The quantitative data from surveys will be entered into SPSS and analyzed using covariate-adjusted linear mixed models for repeated measures to compare the intervention and control groups over time on the major outcomes of participants. Conventional content analysis of qualitative interviews will be conducted using data analysis software.

RESULTS

The project was modified to a telephone-based intervention owing to the COVID-19 pandemic. Data collection started in 2020 and ended in 2022. In total, 103 dyads were matched at the beginning of the intervention. Of the 103 dyads, 90 (87.4%) dyads completed the midtest survey and 64 (62.1%) dyads completed the whole intervention and the posttest survey. Although we are still cleaning and finalizing data analyses, the preliminary results from both quantitative and qualitative data showed promising results of this intergenerational reminiscence approach that benefits both the older adults who have cognitive impairments and the young adult participants.

CONCLUSIONS

Intergenerational reminiscence provided by young adult college student offers promising benefits for both the younger and older generations. Future studies may consider scaling up this pilot into a trackable, replicable model that includes more participants with diverse background (eg, public vs private college students and older adults from other agencies) to test the effectiveness of this intervention for older adults with ADRD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05984732; https://classic.clinicaltrials.gov/ct2/show/NCT05984732.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49752.

Functional connectivity of amygdala subnuclei in PTSD: a narrative review

While the amygdala is often implicated in the neurobiology of posttraumatic stress disorder (PTSD), the pattern of results remains mixed. One reason for this may be the heterogeneity of amygdala subnuclei and their functional connections. This review used PRISMA guidelines to synthesize research exploring the functional connectivity of three primary amygdala subnuclei, basolateral (BLA), centromedial (CMA), and superficial nuclei (SFA), in PTSD (N = 331) relative to trauma-exposed (N = 155) and non-trauma-exposed controls (N = 210). Although studies were limited (N = 11), preliminary evidence suggests that in PTSD compared to trauma-exposed controls, the BLA shows greater connectivity with the dorsal anterior cingulate, an area involved in salience detection. In PTSD compared to non-trauma-exposed controls, the BLA shows greater connectivity with the middle frontal gyrus, an area involved in attention. No other connections were replicated across studies. A secondary aim of this review was to outline the limitations of this field to better shape future research. Importantly, the results from this review indicate the need to consider potential mediators of amygdala subnuclei connectivity, such as trauma type and sex, when conducting such studies. They also highlight the need to be aware of the limited inferences we can make with such small samples that investigate small subcortical structures on low field strength magnetic resonance imaging scanners. Collectively, this review demonstrates the importance of exploring the differential connectivity of amygdala subnuclei to understand the pathophysiology of PTSD and stresses the need for future research to harness the strength of ultra-high field imaging to gain a more sensitive picture of the neural connectivity underlying PTSD.

Advancing Research on Mechanisms of Resilience (ARMOR) Prospective Longitudinal Study of Adaptation in Young Military Recruits: Protocol and rationale for methods and measures

Background

Military service provides a unique opportunity for studying resilience, a dynamic process of successful adaptation (i.e., doing well in terms of functioning and symptoms) in response to significant adversity. Despite tremendous interest in positive adaptation among military service members, little is known about the processes underlying their resilience. Understanding neurobiological, cognitive, and social mechanisms underlying adaptive functioning following military stressor exposure is essential to enhance the resilience of military service members.

Objectives

The primary objective of the Advancing Research on Mechanisms of Resilience (ARMOR) longitudinal study is to characterize trajectories of positive adaptation among young military recruits in response to Basic Combat Training (BCT), a well-defined, uniform, 10-week period of intense stress (Aim 1) and identify promotive and protective processes contributing to individual variations in resilience (Aim 2). The secondary objective is to investigate pathways by which neurobehavioral markers of self-regulation assessed by electroencephalography (EEG) and magnetic resonance imaging (MRI) contribute to adaptive trajectories (Aim 3).

Methods

ARMOR is an ongoing, prospective longitudinal cohort study of young military recruits who recently joined the National Guard but have not yet shipped for BCT. Participants (N=1,201) are assessed at five timepoints over the initial 2+ years of military service beginning before BCT (baseline) and followed up at 2 weeks, 6, 12, and 18 months post-BCT. At each time point, participants complete online questionnaires assessing vulnerability and protective factors, mental health and social-emotional functioning, and, at Time 0 only, a battery of neurocognitive tests. A subset of participants also complete structured diagnostic interviews, additional self-report measures, and perform neurobehavioral tasks before and after BCT during EEG sessions, and, at pre-BCT only, during MRI sessions.

Results

Study enrollment began April 14, 2019 and ended in October 16, 2021. A total of 1,201 participants are enrolled in the study (68.9% male; mean age = 18.9, SD = 3.0). Follow-up data-collection is ongoing and projected to continue through March 2024. We will disseminate findings through conferences, webinars, open access publications, and communications with participants and stakeholders.

Conclusions

Results are expected to elucidate how young military recruits adapt to military stressors during the initial years of military service. Understanding positive adaptation of military recruits in the face of BCT has implications for developing prevention and intervention strategies to enhance resilience of military trainees and potentially other young people facing significant life challenges.

NB housing study protocol: investigating the relationship between subsidized housing, mental health, physical health and healthcare use in New Brunswick, Canada

BACKGROUND

Income and housing are pervasive social determinants of health. Subsidized housing is a prominent affordability mechanism in Canada; however, waitlists are lengthy. Subsidized rents should provide greater access to residual income, which may theoretically improve health outcomes. However, little is known about the health of tenants who wait for and receive subsidized housing. This is especially problematic for New Brunswick, a Canadian province with low population density, whose inhabitants experience income inequality, social exclusion, and challenges with healthcare access.  METHODS: This study will use a longitudinal, prospective matched cohort design. All 4,750 households on New Brunswick's subsidized housing wait list will be approached to participate. The survey measures various demographic, social and health indicators at six-month intervals for up to 18 months as they wait for subsidized housing. Those who receive housing will join an intervention group and receive surveys for an additional 18 months post-move date. With consent, participants will have their data linked to a provincial administrative database of medical records.  DISCUSSION: Knowledge of housing and health is sparse in Canada. This study will provide stakeholders with a wealth of health information on a population that is historically under-researched and underserved.

Quality of Life After Violent Crime: The Impact of Acute Stress Disorder, Posttraumatic Stress Disorder, and Other Consequences

Victims of violent crime (VVC) are at risk of developing acute stress disorder (ASD) and subsequent posttraumatic stress disorder (PTSD). In addition, VVC are more likely to have low social support due to stigmatization and victim-blaming, and PTSD is frequently associated with depression, anxiety, and impaired quality of life (QoL). The present study aimed to determine the impact of ASD, PTSD, depressive symptoms, anxiety symptoms, and perceived social support in relation to four domains of QoL among VVC. Individuals were recruited as part of a longitudinal study assessing the efficacy of a brief cognitive behavioral treatment for ASD. Participants (N = 127) were interviewed and completed self-report measures within 30 days of experiencing a violent crime (T₀ ) and at assessments 2 months (T₁ ) and 6 months (T₂ ) after the event. Depressive symptoms, ASD, and PTSD were found to be associated with lower QoL ratings in all four domains. Anxiety symptoms were found to be associated with lower ratings in the physical health and psychological QoL domains. Perceived social support was found to be associated with higher QoL ratings in all domains. The proportions of QoL variance explained by the combined fixed and random effects combined ranged from 70% to 79%. Future research considerations include an examination of how early interventions for VVC could prevent QoL deterioration by targeting ASD and PTSD development, depressive and anxiety symptoms, and social support.

Wireless Participant Incentives Using Reloadable Bank Cards to Increase Clinical Trial Retention With Abused Women Drinkers: A Natural Experiment

Retaining participants in longitudinal studies is a unique methodological challenge in many areas of investigation, and specifically for researchers aiming to identify effective interventions for women experiencing intimate partner violence (IPV). Individuals in abusive relationships are often transient and have logistical, confidentiality, and safety concerns that limit future contact. A natural experiment occurred during a large randomized clinical trial enrolling women in abusive relationships who were also heavy drinkers, which allowed for the comparison of two incentive methods to promote longitudinal retention: cash payment versus reloadable wireless bank cards. In all, 600 patients were enrolled in the overall trial, which aimed to incentivize participants using a reloadable bank card system to promote the completion of 11 weekly interactive voice response system (IVRS) phone surveys and 3-, 6-, and 12-month follow-up phone or in person interviews. The first 145 participants were paid with cash as a result of logistical delays in setting up the bank card system. At 12 weeks, participants receiving the bank card incentive completed significantly more IVRS phone surveys, odds ratio (OR) = 2.4, 95% confidence interval (CI) = [0.01, 1.69]. There were no significant differences between the two groups related to satisfaction or safety and/or privacy. The bank card system delivered lower administrative burden for tracking payments for study staff. Based on these and other results, our large medical research university is implementing reloadable bank card as the preferred method of participant incentive payments.

Loss of loved ones or home due to a disaster: Effects over time on distress in immigrant ethnic minorities

Exposure to mass trauma may bring about increased sensitivity to new or ongoing stressors. It is unclear whether sensitivity to stress associated with ethnic minority/immigrant status may be affected by severe exposure to mass trauma. We examined whether the loss of loved ones or home due to a disaster is associated with more persistent disaster-related distress in ethnic minorities compared with Dutch natives in the Netherlands. In residents affected by a fireworks disaster ( N = 1029), we assessed disaster-related distress after 3 weeks, 18 months, and 4 years. The effects of loss of loved ones or home and ethnic minority/immigrant status on distress were analyzed using latent growth modeling. After controlling for age, gender, education, employment, and post-disaster stressful life events, the loss of loved ones was associated with more persistent disaster-related distress in ethnic minorities compared with natives at 18 months, and the loss of home was associated with more persistent disaster-related distress in ethnic minorities compared with natives between 18 months and 4 years. Our results suggest that the loss of loved ones may increase sensitivity to stress associated with ethnic minority/immigrant status during the early phase of adaptation to a disaster. Loss of home may lead to further resource loss and thereby increase sensitivity to stress associated with ethnic minority/immigrant status in the long term. Efforts to prevent stress-related psychopathology following mass trauma should specifically target ethnic minority groups, notably refugees and asylum seekers, who often experienced multiple losses of loved ones as well as their homes.

Videoconferencing-Based Treatment of Alcohol Use Disorders: Analyses of Nonparticipation

BACKGROUND

We recently conducted a small randomized controlled trial (RCT) aiming to examine the effectiveness of videoconferencing-based treatment of alcohol use disorders in a real-life setting. The patient and participation rates were lower than anticipated.

OBJECTIVE

The objectives of our study were (1) to examine differences between participants and nonparticipants, and (2) to examine the characteristics of nonparticipants and their reported reasons for not participating.

METHODS

First, we analyzed nonparticipation through a comparative analysis of participants and nonparticipants using data from a clinical database, covering all patients starting treatment at the clinic. Second, on the basis of data from an anonymous questionnaire filled out by nonparticipants, we analyzed barriers to participating and the descriptive sociodemographics of nonparticipants who reported technical barriers versus those who did not.

RESULTS

Of 128 consecutive patients starting treatment during the study period, we found no significant differences between participants (n=71) and nonparticipants (n=51) according to sociodemographics, alcohol measures, and composite scores. Of 51 nonparticipants, 43 filled out the questionnaire with reasons for not participating. We derived 2 categories of barriers from the questionnaire: scientific barriers, which were barriers to the scientific study in general (n=6), and technical barriers, which were barriers to using a laptop or videoconferencing specifically (n=27). We found no significant differences in sociodemographics between nonparticipants who reported technical barriers to participating in the study and those who did not note technical barriers. A total of 13 patients elaborated on technical barriers, and 9 patients found videoconferencing impersonal, preferred personal contact, and would rather attend face-to-face treatment at the clinic.

CONCLUSIONS

Patient barriers to participating in the RCT were mainly concerned with the technology. There were no significant differences between participants and nonparticipants, nor between nonparticipants who noted technical barriers to participating and those who did not. If a similar study is to be conducted or the solution is to be upscaled and implemented, attention should be given to the user friendliness of the technical equipment and the recruitment process, preparing the patients by emphasizing the information given to them about the technical equipment and its advantages.

Sexual Orientation, Race, and Trauma as Predictors of Sexual Assault Recovery

Sexual minorities and racial minorities experience greater negative impact following sexual assault. We examined recovery from sexual assault among women who identified as heterosexual and bisexual across racial groups. A community sample of women (N = 905) completed three yearly surveys about sexual victimization, recovery outcomes, race group, and sexual minority status. Bisexual women and Black women reported greater recovery problems. However, Black women improved more quickly on depression symptoms than non-Black women. Finally, repeated adult victimization uniquely undermined survivors' recovery, even when controlling for child sexual abuse. Sexual minority and race status variables and their intersections with revictimization play roles in recovery and should be considered in treatment protocols for sexual assault survivors.

Technological aids for improving longitudinal research on substance use disorders

Background

There is a broad consensus that addictive behaviors tend to be chronic and relapsing. But for field studies of substance users, successfully tracking, locating, and following up with a representative sample of subjects is a challenge.

Methods

The purpose of this paper is to provide a general overview of how current technological aids can support and improve the quality of longitudinal research on substance use disorders. The review is grouped into four domains: (1) tracking and locating, (2) prompting/engaging, (3) incentivizing, and (4) collecting data.

Results & conclusions

Although the technologies described in this review will be modified or replaced over time, our findings suggest that incorporating some or all of these currently available approaches may improve research efficiency, follow-up rates, and data quality.

Examining Minority Attrition Among Women in Longitudinal Trauma Research

Research suggests that racial and ethnic minorities are more likely to attrit from longitudinal trauma studies than non-Hispanic Whites. Yet, little is known about how the loss of minority participants influences longitudinal findings as well as internal and external validity of study findings. Thus, the present study examined the effects of race/ethnicity on attrition in a longitudinal trauma study of women (minority = 223, non-Hispanic White or majority = 459) exposed to a campus shooting. Survival analyses were used to compare the attrition rates of minority participants to majority participants and assess the extent to which race/ethnicity, among other variables, predicted attrition. Minority participants were more likely to attrit than majority participants, hazard ratio (HR) = 0.69, 95% CI [0.48, 0.99], even after adjusting for study variables. A main effect was also found for age, HR = 1.06, 95% CI [1.01, 1.12]. Race/ethnicity did not interact with other study variables to influence attrition. The findings underscored the importance of assessing the effects of attrition on longitudinal findings and external validity.

Can we predict retention in longitudinal studies of substance use? Findings from the Australian Treatment Outcome Study

BACKGROUND

Longitudinal studies are often threatened by difficulties with sample attrition, high rates of which threaten the validity of study findings. The present study examined methodological and participant characteristics associated with sample retention in the Australian Treatment Outcome Study (ATOS) across 3years.

METHOD

Follow-up interviews were conducted at 3-, 12-, 24-, and 36-months post baseline, with follow-up rates of 89%, 81%, 76% and 70%, respectively. Structured interviews measuring past-month drug use, mental health, criminal involvement and demographic characteristics were administered to participants at baseline and each follow-up. Data were analysed using multinomial logistic regression and generalised estimating equations to produce odds ratios with 95% confidence intervals.

RESULTS

Completing all follow-up interviews was associated with being in treatment (OR 3.62), using other opiates at baseline (OR 3.45), more years of schooling (OR 1.20), and having completed the previous interview (OR 35.04). A history of incarceration was independently associated with not completing follow-up interviews (OR 0.47).

CONCLUSION

Retention can largely be predicted at study entry, and is unaffected by changes that occur in the interim. These findings highlight the importance of obtaining and maintaining comprehensive locator information, maintaining strong relationships with treatment agencies, as well as the necessity of patience, perseverance and flexibility.

Maintaining Superior Follow-Up Rates in a Longitudinal Study: Experiences from the College Life Study

Longitudinal studies are often considered to be a gold standard for research, but the operational management of such studies is not often discussed in detail; this paper describes strategies used to track and maintain high levels of participation in a longitudinal study involving annual personal interviews with a cohort of 1,253 undergraduates (first-time, first-year students at time of enrollment) at a large public mid-Atlantic university.

Economic Costs of a Postrelease Intervention for Incarcerated Female Substance Abusers: Recovery Management Checkups for Women Offenders (RMC-WO)

This study estimates the economic costs of Recovery Management Checkups for Women Offenders (RMC-WO), highlighting the unique mix of services and differential costs between two distinct phases of the intervention. Participants were randomly assigned to quarterly outcome monitoring (OM) only (n=242) or OM plus Recovery Management Checkups (OM-plus-RMC) (n=238). The OM-only condition has a total annual economic cost of $76,010, which equates to $81 quarterly per person. The average cost per OM interview completed is $86. OM-plus-RMC generates a total annual economic cost of $126,717, or $137 quarterly per person. The cost per interview completed is $147 and the cost per intervention session completed is $161. RMC-WO has a relatively modest additional cost compared with the average costs of post-release supervision, which can range from $3.42 ($1,250) per day (year) for probationers to $7.47 ($2,750) per day (year) for parolees. The clinical, economic, and policy implications of incorporating RMC-WO into existing corrections and/or community-based treatment settings are discussed.

Associations between substance use, post-traumatic stress disorder and the perpetration of violence: A longitudinal investigation

AIM

Substance use disorder (SUD) and post-traumatic stress disorder (PTSD) commonly co-occur. This is of significant concern, given the increased risk for violence perpetration among individuals with this comorbidity. Limited research, however, has examined relationships between SUD, PTSD and violence among individuals longitudinally. Such an investigation is warranted given that substance use and PTSD symptoms can fluctuate over time. This study therefore aims to examine how changes in substance use and PTSD symptom severity are associated with the perpetration of violent crime over time among individuals with comorbid SUD and PTSD.

METHOD

One-hundred and two men and women who met criteria for SUD and PTSD were interviewed four times over a 9-month period. These interviews included measures of past-month violent crime perpetration, substance use and dependence, PTSD symptom severity, and depression and state anxiety symptoms. Generalised estimating equations (GEE) modelled associations between substance use, PTSD and violence.

RESULTS

Increased substance use, more severe substance dependence and more severe PTSD symptomology were consistently associated with violent crime over time. Multivariate GEE analyses, however, revealed that the PTSD hyperarousal symptoms, specifically, were independently associated with violence over time.

CONCLUSIONS

This longitudinal study found that PTSD hyperarousal symptoms were consistently associated with the perpetration of violent crime, further highlighting the potentiating role of PTSD hyperarousal in relation to violence among individuals with SUD. These findings indicate that interventions addressing hyperarousal symptoms have the potential to reduce the susceptibility for violence among individuals with this common comorbidity.

Posttraumatic stress disorder following traumatic injury at 6 months: associations with alcohol use and depression

BACKGROUND

Posttraumatic stress disorder (PTSD) is progressively recognized as a psychological morbidity in injured patients. Participants in a longitudinal study were identified as PTSD positive or PTSD negative at 6 months following injury. Risky alcohol use, depression, demographic, and injury-related variables were explored.

METHODS

This prospective cohort included patients 18 years or older, admitted to our Level I trauma center. Outcome measures included PTSD Checklist-Civilian Version (PCL-C), Alcohol Use Disorders Identification Test (AUDIT-C), and Patient Health Questionnaire (PHQ-8). Demographic and injury variables were collected.

RESULTS

A total of 211 participants enrolled in the study, and 118 participants completed measures at both baseline and 6 months. Of the participants, 25.4% (n = 30) screened positive for PTSD at 6 months. The entire sample showed a decline in risky alcohol use at 6 months (p = 0.0043). All PTSD-positive participants at 6 months were also positive for depression (p < 0.0001). For the entire sample, there was a 10% increase in depression from baseline to 6 months (p = 0.03). However, for those participants who were PTSD positive at 6 months, there was a 53% increase in depression from baseline (p = 0.0002) as compared with the group at 6 months without PTSD. Statistically significant differences were found between PTSD-positive and PTSD-negative participants regarding age (40.1 [15.9] vs. 50.9 [18.2], p = 0.0047), male (77% vs. 50%, p = 0.0109), penetrating injury (30% vs. 4%, p < 0.0001), PTSD history (17% vs. 4%, p = 0.0246), or other psychiatric condition (63% vs. 19%, p ≤ 0.001).

CONCLUSION

PTSD was not associated with risky alcohol use at 6 months. Surprisingly, risky alcohol use declined in both groups. Incidence of PTSD (25.4%, n = 30) and risky alcohol use (25%, n = 29) were equal at 6 months. Although the American College of Surgeons' Committee on Trauma requires brief screening and intervention for risky alcohol use owing to societal impact, reinjury rates, and cost effectiveness, our study suggests that screening for psychological conditions may be equally important.

LEVEL OF EVIDENCE

Prognostic study, level III.

Psychological First Aid: Rapid proliferation and the search for evidence

Psychological first aid (PFA) has become the flagship early intervention for disaster survivors, with recent adaptations for disaster responders, in the post-9/11 era. PFA is broadly endorsed by expert consensus and integrated into guidelines for mental health and psychosocial support in disasters and extreme events. PFA frameworks are proliferating, with increasing numbers of models developed for delivery by a range of providers for use with an expanding array of target populations. Despite popularity and promotion there remains a dearth of evidence for effectiveness and recent independent reviews of PFA have highlighted this important gap. This commentary juxtaposes the current propagation of PFA against the compelling need to produce evidence for effectiveness and suggests a series of actions to prioritize and expedite real-time, real-event field evaluation of PFA.

The role of stress sensitization in progression of posttraumatic distress following deployment

PURPOSE

Military personnel exposed to combat are at risk for experiencing post-traumatic distress that can progress over time following deployment. We hypothesized that progression of post-traumatic distress may be related to enhanced susceptibility to post-deployment stressors. This study aimed at examining the concept of stress sensitization prospectively in a sample of Dutch military personnel deployed in support of the conflicts in Afghanistan.

METHOD

In a cohort of soldiers (N = 814), symptoms of post-traumatic stress disorder (PTSD) were assessed before deployment as well as 2, 7, 14, and 26 months (N = 433; 53 %) after their return. Data were analyzed using latent growth modeling. Using multiple group analysis, we examined whether high combat stress exposure during deployment moderated the relation between post-deployment stressors and linear change in post-traumatic distress after deployment.

RESULTS

A higher baseline level of post-traumatic distress was associated with more early life stressors (standardized regression coefficient = 0.30, p < 0.001). In addition, a stronger increase in posttraumatic distress during deployment was associated with more deployment stressors (standardized coefficient = 0.21, p < 0.001). A steeper linear increase in posttraumatic distress post-deployment (from 2 to 26 months) was predicted by more post-deployment stressors (standardized coefficient = 0.29, p < 0.001) in high combat stress exposed soldiers, but not in a less combat stress exposed group. The group difference in the predictive effect of post-deployment stressors on progression of post-traumatic distress was significant (χ²(1) = 7.85, p = 0.005).

CONCLUSIONS

Progression of post-traumatic distress following combat exposure may be related to sensitization to the effects of post-deployment stressors during the first year following return from deployment.

Interventions to prevent post-traumatic stress disorder: a systematic review

CONTEXT

Traumatic events are prevalent worldwide; trauma victims seek help in numerous clinical and emergency settings. Using effective interventions to prevent post-traumatic stress disorder (PTSD) is increasingly important. This review assessed the efficacy, comparative effectiveness, and harms of psychological, pharmacologic, and emerging interventions to prevent PTSD.

EVIDENCE ACQUISITION

The following sources were searched for research on interventions to be included in the review: MEDLINE; Cochrane Library; CINAHL; EMBASE; PILOTS (Published International Literature on Traumatic Stress); International Pharmaceutical Abstracts; PsycINFO; Web of Science; reference lists of published literature; and unpublished literature (January 1, 1980 to July 30, 2012). Two reviewers independently selected studies, extracted data or checked accuracy, assessed study risk of bias, and graded strength of evidence. All data synthesis occurred between January and September 2012.

EVIDENCE SYNTHESIS

Nineteen studies covered various populations, traumas, and interventions. In meta-analyses of three trials (from the same team) for people with acute stress disorder, brief trauma-focused cognitive behavioral therapy was more effective than supportive counseling in reducing the severity of PTSD symptoms (moderate-strength); these two interventions had similar results for incidence of PTSD (low-strength); depression severity (low-strength); and anxiety severity (moderate-strength). PTSD symptom severity after injury decreased more with collaborative care than usual care (single study; low-strength). Debriefing did not reduce incidence or severity of PTSD or psychological symptoms in civilian traumas (low-strength). Evidence about relevant outcomes was unavailable for many interventions or was insufficient owing to methodologic shortcomings.

CONCLUSIONS

Evidence is very limited regarding best practices to treat trauma-exposed individuals. Brief cognitive behavioral therapy may reduce PTSD symptom severity in people with acute stress disorder; collaborative care may help decrease symptom severity post-injury.

Stress sensitization following a disaster: a prospective study

BACKGROUND

According to the stress sensitization hypothesis, prior exposure to extreme stressors may lead to increased responsiveness to subsequent stressors. It is unclear whether disaster exposure is associated with stress sensitization and, if so, whether this effect is lasting or temporary. This study aimed to investigate the occurrence and duration of stress sensitization prospectively following a major disaster.

METHOD

Residents affected by a fireworks disaster (n=1083) participated in surveys 2-3 weeks (T1), 18-20 months (T2) and almost 4 years (T3) after the disaster. Participants reported disaster exposure, including direct exposure, injury and damage to their home at T1, and also stressful life events (SLEs) at T2 and T3. Feelings of anxiety and depression, concentration difficulty, hostility, sleep disturbance, and intrusion and avoidance of disaster-related memories were used as indicators of distress.

RESULTS

Residents whose home was completely destroyed responded with greater distress to SLEs reported 18-20 months following the disaster than residents whose home was less damaged. There were no differences in stress responsiveness almost 4 years after the disaster.

CONCLUSIONS

During the first years after a disaster, stress sensitization may occur in disaster survivors who experienced extreme disaster exposure. Stress sensitization may explain the persistence or progression of distress over time following extreme stressor exposure.

Written exposure as an intervention for PTSD: a randomized clinical trial with motor vehicle accident survivors

The present study examined the efficacy of a brief, written exposure therapy (WET) for posttraumatic stress disorder (PTSD). Participants were 46 adults with a current primary diagnosis of motor vehicle accident-related PTSD. Participants were randomly assigned to either WET or a waitlist (WL) condition. Independent assessments took place at baseline and 6-, 18-, and 30-weeks post baseline (WL condition not assessed at 30 weeks). Participants assigned to WET showed significant reductions in PTSD symptom severity at 6- and 18-week post-baseline, relative to WL participants, with large between-group effect sizes. In addition, significantly fewer WET participants met diagnostic criteria for PTSD at both the 6- and 18-week post-baseline assessments, relative to WL participants. Treatment gains were maintained for the WET participants at the 30-week post baseline assessment. Notably, only 9% of participants dropped out of WET and the WET participants reported a high degree of satisfaction with the treatment. These findings suggest that a brief, written exposure treatment may efficaciously treat PTSD. Future research should examine whether WET is efficacious with other PTSD samples, as well as compare the efficacy of WET with that of evidence-based treatments for PTSD.

Project VALOR: design and methods of a longitudinal registry of post-traumatic stress disorder (PTSD) in combat-exposed veterans in the Afghanistan and Iraqi military theaters of operations

Few studies have investigated the natural history of post-traumatic stress disorder (PTSD). Project VALOR (Veterans' After-discharge Longitudinal Registry) was designed as a longitudinal patient registry assessing the course of combat-related PTSD among 1600 male and female Veterans who served in Operation Enduring Freedom (OEF) in Afghanistan or Operation Iraqi Freedom (OIF). Aims of the study include investigating patterns and predictors of progression or remission of PTSD and treatment utilization. The study design was based on recommendations from the Agency for Healthcare Quality and Research for longitudinal disease registries and used a pre-specified theoretical model to select the measurement domains for data collection and interpretation of forthcoming results. The registry will include 1200 male and female Veterans with a recent diagnosis of PTSD in the Department of Veteran Affairs (VA) electronic medical record and a comparison group of 400 Veterans without a medical record-based PTSD diagnosis, to also allow for case-control analyses. Data are collected from administrative databases, electronic medical records, a self-administered questionnaire, and a semi-structured diagnostic telephone interview. Project VALOR is a unique and timely registry study that will evaluate the clinical course of PTSD, psychosocial correlates, and health outcomes in a carefully selected cohort of returning OEF/OIF Veterans.

Home-based telehealth to deliver evidence-based psychotherapy in veterans with PTSD

Although medical service delivery via home-based telehealth technology (HBT) is gaining wider acceptance in managing chronic illnesses such as diabetes or chronic obstructive pulmonary disease, few studies have tested HBT applications of psychotherapy. Clinicians, administrators, and researchers question whether delivering psychotherapeutic services to patients in their homes via video-conferencing technology compromises patient safety, potency of treatment, or data security. Despite these concerns, HBT service delivery may increase access to evidence-based psychotherapies for veterans with posttraumatic stress disorder (PTSD), who may be less willing or less able to receive weekly treatment at a VA medical center or outpatient clinic due to symptom severity or other similar barriers to care. Indeed, although combat-exposed service members endorse high rates of psychiatric disorders, few appear to initiate mental health services or receive an adequate dose of treatment. Thus, using HBT technologies to administer evidence-based therapies remains uncharted territory in both the clinical and research arenas. This manuscript describes an ongoing four year randomized controlled trial comparing in-person Prolonged Exposure (PE) - a specialized evidence-based psychotherapy for PTSD - and PE delivered via HBT, with a particular focus on the selection, application, and strengths/weaknesses of HBT procedures.

The Impact of Child-Related Stressors on the Psychological Functioning of Lower-Income Mothers After Hurricane Katrina

In the present study, the authors examined the role of child-related stressors in the psychological adjustment of lower-income, primarily unmarried and African American, mothers (N = 386). All participants lived in areas affected by Hurricane Katrina, and about a third were also exposed to Hurricane Rita (30.3%, n = 117). Lacking knowledge of a child's safety during the hurricanes was a significant predictor of heightened postdisaster psychological distress and posttraumatic stress, even after controlling for demographic variables, predisaster psychological distress, evacuation timing, and bereavement. From interviews with a subset of the participants (n = 57), we found that mothers consistently put their own needs behind those of their children. The authors recommend policies that promptly reunite mothers with missing children and support lower-income mothers in caring for their children during natural disasters and the aftermath.

Efficacy of telehealth treatments for posttraumatic stress-related symptoms: a meta-analysis

This meta-analysis summarizes the findings of outcome research on the degree to which telehealth treatments reduce posttraumatic stress disorder (PTSD)-related symptoms. In a search of the literature, 13 studies were identified for inclusion in the meta-analysis and were coded for relevant variables. A total of 725 participants were included. Results indicate that telehealth treatments are associated with significant pre- to postreduction in PTSD symptoms (d = 0.99, 95% confidence interval [CI]: 0.87-1.11, p < .001), and result in superior treatment effects relative to a wait-list comparison condition (d = 1.01, 95% CI: 0.76-1.26, p < .001). However, no significant findings were obtained for telehealth intervention relative to a supportive counseling telehealth comparison condition (d = 0.11, 95% CI: - 0.38 to 0.60, p = .67), and telehealth intervention produced an inferior outcome relative to a face-to-face intervention (d = - 0.68, 95% CI: - 0.39 to - 0.98, p < .001). Findings for depression symptom severity outcome were generally consistent with those for PTSD outcome. Telehealth interventions produced a significant within-group effect size (d = 0.98, 95% CI: 0.86 to 1.10, p < .001) and superior effect relative to wait-list comparison condition (d = 0.80, 95% CI: 0.56-1.05, p < .001). Relative to face-to-face interventions, telehealth treatments produced comparable depression outcome effects (d = 0.13, 95% CI: - 0.55 to 0.28, p = .53). Taken together, these findings support the use of telehealth treatments for individuals with PTSD-related symptoms.

The economic costs of quarterly monitoring and recovery management checkups for adults with chronic substance use disorders

Recovery management checkups (RMCs) for clients with substance use disorders reduce the time from relapse to treatment reentry, increase treatment retention, and improve long-term outcomes. The objectives of this article are to calculate and compare the economic costs of providing outcome monitoring (OM) only with those of providing OM + RMC to help understand the feasibility of disseminating this model more widely. We estimate the total and incremental costs of OM and OM + RMC using data from a recently completed randomized controlled trial with adult chronic substance users (N = 446). Adding RMC to OM increased total intervention costs by about 50% per person per year ($707 to $1,283) and quarter ($177 to $321). It cost an average of $834 to identify a person in relapse and $2,699 to identify, link, and retain them in treatment. The increased costs of RMC are modest relative to the substantial societal costs of chronic substance users returning to regular use, crime, and other risk behaviors.

Do parents benefit from the offer of a follow-up appointment after their child's admission to intensive care?: an exploratory randomised controlled trial

OBJECTIVE

The study aim was to evaluate the psychological impact on parents of the provision of a paediatric intensive care follow-up clinic.

DESIGN

Exploratory randomised controlled trial. Families were allocated to intervention (follow-up clinic appointment two months after discharge) or control (no appointment) condition.

SETTING

An eight-bed Paediatric Intensive Care Unit (PICU) in an inner city teaching hospital.

MEASUREMENTS

Parents' baseline stress was assessed using the Parental Stressor Scale: PICU. Post-traumatic stress, anxiety and depression were assessed at five months using the Impact of Event Scale and the Hospital Anxiety and Depression Scale.

RESULTS

Only 18/72 families (25%) in the intervention group chose to attend the clinic. Outcome data were provided by 55/82 parents in the intervention group and 50/72 in the control group. Although no significant differences were found between the groups as a whole, parents with higher baseline stress reported lower rates of post-traumatic stress (n=8/32(25%) vs. n=13/23(57%), p=0.018) and depression (n=6/32(19%) vs. n=12/23(52%), p=0.009) at five months if they had been offered an appointment than if they had not.

CONCLUSIONS

Whilst these results do not justify routine follow-up for all, they suggest that, for the most traumatised parents, rates of long-term distress could be reduced by this intervention.

Challenges to Engaging Black Male Victims of Community Violence in Healthcare Research: Lessons Learned From Two Studies

A dearth of literature exists on barriers to conducting research with Black male victims of community violence, despite the need for evidence-based postinjury interventions. This study used qualitative data from a cross-sectional interview study (n = 16) and a pilot intervention study (n = 11) conducted in Boston, MA to identify challenges and facilitators to conducting research with Black male victims of community violence, particularly with regard to recruitment and maintenance of a study sample. Qualitative methods, including Grounded Theory and ethnography, were used to analyze the data. Challenges included a fear of police involvement, an impression of "snitching" when disclosing personal information, mistrust of research motives, suspicion of the informed consent process, the emotional impact of the trauma itself, and logistical issues. Facilitators to research included monetary incentives and motivation to help oneself and others. Participant recommendations on recruitment methods relating to approach and timing are provided. Findings from this study may assist in the planning of research studies for Black male victims of community violence.

Enhancing clinical trial design of interventions for posttraumatic stress disorder

The 2008 Institute of Medicine review of interventions research for posttraumatic stress disorder (PTSD) concluded that new, well-designed studies are needed to evaluate the efficacy of treatments for PTSD. The Department of Veterans Affairs (VA), the Department of Defense, and the National Institute of Mental Health convened a meeting on research methodology and the VA issued recommendations for design and analysis of randomized controlled clinical trials (RCTs) for PTSD. The rationale that formed the basis for several of the components of the recommendations is discussed here. Fundamental goals of RCT design are described. Strategies in design and analysis that contribute to the goals of an RCT and thereby enhance the likelihood of signal detection are considered.

Clinical outcomes of traumatized youth in adolescent substance abuse treatment: a longitudinal multisite study

The purpose of this study was to evaluate the effectiveness of outpatient substance abuse treatment for youth with high traumatic stress compared to youth without high traumatic stress in substance abuse treatment centers across the United States. The data for this study were gathered using a longitudinal survey design with purposive sampling from nine drug treatment delivery systems across the United States participating in the cooperative grant Strengthening Communities for Youth (SCY) awarded by SAMHSA's Center for Substance Abuse Treatment (CSAT) between September 2002 and June 2006. Follow-up assessments were conducted with the youth at three,six, and 12 months following intake. Traumatized youth responded to outpatient treatment in a similar pattern when compared to nontraumatized youth, although the traumatized youth had consistently higher scores on substance use frequency and substance problems scales than nontraumatized youth throughout the study. Current empirically validated treatments for adolescent substance abuse do not prepare the practitioner for trauma-informed practice or specifically address trauma-informed recovery. Based on our results, we advocate for the development and integration of trauma-informed practice within substance abuse treatment for adolescents to help them recover from trauma and substance abuse issues.

Are patients after severe injury who drop out of a longitudinal study at high risk of mental disorder?

In longitudinal studies of traumatic stress, it is particularly important to examine the data for any differences between those who drop out and those who continue to participate, because reluctance to participate might reflect symptoms of avoidance frequently seen in posttraumatic stress disorder (PTSD). However, whether those who drop out are at high risk of PTSD remains unclear. Over a 25-month period, 188 consecutive patients with motor vehicle accident (MVA)-related injuries admitted emergently were enrolled and followed for 4 to 6 weeks. Baseline characteristics were compared between subjects who did and did not participate in the follow-up study. At 4 to 6 weeks, 66 (35.1%) of the participants had dropped out. Bivariate analyses revealed that those who dropped out were likely to be men, alcohol drinkers, smokers, and unconscious just after MVA and to have fewer years of education, less severe injuries, less posttraumatic symptoms, and lower cooperativeness as assessed by the Temperament and Character Inventory. Logistic regression analysis revealed that male sex, unconsciousness during MVA, low cooperativeness, and less severe injuries were significant predictors of dropout. The literature says that male sex and unconsciousness just after MVA might be protective factors against MVA-related PTSD, whereas low cooperativeness is a risk factor for general mental problems. To summarize, it is expected that those who drop from the follow-up are unlikely to have MVA-related PTSD, but might have mental problems independent of injury.

Traumatized youth and substance abuse treatment outcomes: a longitudinal study

This longitudinal study examined whether youth with high traumatic stress (HTS) respond differently to outpatient substance abuse treatment compared to youth without HTS at intake, and at 3 and 6 months following intake. Data were analyzed using a mixed-effects two-part model to fit repeated data with zero saturation. Clients in both groups significantly increased their odds of abstinence and full symptom remission of substance problems from baseline to 6 months. Of youth still using substances, the group with HTS reduced substance use significantly more than substance users without HTS. Recommendations for future research are provided.

Children's factual and delusional memories of intensive care

RATIONALE

Delusional memories are significantly associated with post-traumatic stress in adult patients after intensive care.

OBJECTIVES

In this study, we attempted to establish whether this relationship was found in children. We also examined the association between factual memory and distress.

METHODS

One hundred two consecutive children, aged between 7 and 17 years, were interviewed about their pediatric intensive care unit (PICU) experience 3 months after discharge from a PICU. Principal measures were the ICU Memory Tool (a checklist of intensive care memories) and an abbreviated version of the Impact of Event Scale (a screen for post-traumatic stress disorder).

MEASUREMENTS AND MAIN RESULTS

In total, 64 of 102 (63%) children reported at least one factual memory of their admission and 33 of 102 (32%) reported delusional memories, including disturbing hallucinations. Traumatic brain injury was negatively associated with factual memory (odds ratio, 0.23; 95% confidence interval [CI], 0.09-0.58; P = 0.002). Longer duration of opiates/benzodiazepines was associated with delusional memory (odds ratio, 4.98; 95% CI, 1.3-20.0; P = 0.023). Post-traumatic stress scores were higher in children reporting delusional memories (adjusted difference, 3.0; 95% CI, 0.06-5.9; P = 0.045) when illness severity and emergency status were controlled for. Factual memory was not significantly associated with post-traumatic stress.

CONCLUSIONS

This study indicates that delusional memories are reported by almost one-third of children and are associated both with the duration of opiates/benzodiazepines and risk of post-traumatic stress. More research is needed on the presence of delusional memories and associated risk factors in children receiving intensive care treatment.

Development and validation of the GAIN Short Screener (GSS) for internalizing, externalizing and substance use disorders and crime/violence problems among adolescents and adults

The Global Appraisal of Individual Needs (GAIN)1 is a 1-2 hour standardized biopsychosocial that integrates clinical and research assessment for people presenting to substance abuse treatment. The GAIN - Short Screener (GSS) is 3-5 minute screener to quickly identify those who would have a disorder based on the full 60-120 minute GAIN and triage the problem and kind of intervention they are likely to need along four dimensions (internalizing disorders, externalizing disorders, substance disorders, and crime/violence). Data were collected from 6,177 adolescents and 1,805 adults as part of 77 studies in three dozen locations around the United States that used the GAIN. For both adolescents and adults the 20-item total disorder screener (TDScr) and its four 5-item sub-screeners (internalizing disorders, externalizing disorders, substance disorders, and crime/violence) has good internal consistency (alpha of .96 on total screener), is highly correlated (r = .84 to .94) with the 123-item longer scales in the full GAIN. The GSS also does well in terms of its receiver operator characteristics (90% or more under the curve in all analyses) and has clinical decision-making cut points with excellent sensitivity (90% or more) for identifying people with a disorder and excellent specificity (92% or more) for correctly ruling out people who did not have a disorder. The GSS has good potential as an efficient screener for identifying people with co-occurring disorders across multiple systems and routing them to the right services and more detailed assessments.