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Burback L, Yap S, Purdon SE, Abba-Aji A, O’Shea K, Brémault-Phillips S, Greenshaw AJ, Winkler O. Randomized controlled trial investigating web-based, therapist delivered eye movement desensitization and reprocessing for adults with suicidal ideation. Front Psychiatry 2024; 15:1361086. [PMID: 38435978 PMCID: PMC10904458 DOI: 10.3389/fpsyt.2024.1361086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
Introduction Promising preliminary evidence suggests that EMDR may reduce suicidal ideation (SI) when used to treat Major Depressive Disorder, Posttraumatic Stress Disorder, and trauma symptoms in the context of acute mental health crises. EMDR has never been tested specifically for treating SI, and there is a lack of data regarding the safety and effectiveness of web-based, therapist-delivered EMDR in populations with known SI. The primary objective of this study was to investigate the impact of web-based, therapist-delivered EMDR, targeting experiences associated with suicidal thinking. Secondary objectives included examining the effect of EMDR treatment on symptoms of depression, anxiety, posttraumatic stress, emotional dysregulation, and dissociation, as well as safety and attrition. Methods This randomized control trial (ClinicalTrials.gov ID number: NCT04181047) assigned adult outpatients reporting SI to either a web-based EMDR intervention or a treatment as usual (TAU) group. TAU included primary and mental health services available within the Canadian public health system. Participants in the EMDR group received up to 12 web-based EMDR desensitization sessions, delivered twice weekly during the COVID-19 pandemic (2021-2023). The Health Research Ethics Board at the University of Alberta approved the protocol prior to initiation of data collection for this study (protocol ID number: Pro00090989). Results Forty-two adult outpatients received either EMDR (n=20) or TAU (n=22). Participants reported a high prevalence of early onset and chronic SI, and there was a high rate of psychiatric comorbidity. In the EMDR group, median SI, depression, anxiety, and posttraumatic symptom scale scores decreased from baseline to the four month follow-up. In the TAU group, only the median SI and posttraumatic symptom scale scores decreased from baseline to four month follow up. Although sample size precludes direct comparison, there were numerically fewer adverse events and fewer dropouts in the EMDR group relative to the TAU group. Conclusion Study results provide promising preliminary evidence that web-based EMDR may be a viable delivery approach to address SI. In this complex population, a short treatment course was associated with reductions of SI and other symptoms across multiple diagnostic categories. Further investigation is warranted to verify and extend these results. Clinical Trial Registration https://clinicaltrials.gov/study/NCT04181047?id=NCT04181047&rank=1, identifier NCT04181047.
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Affiliation(s)
- Lisa Burback
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Hospital Edmonton, Edmonton, AB, Canada
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Edmonton, AB, Canada
| | - Sidney Yap
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Scot E. Purdon
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Adam Abba-Aji
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Hospital Edmonton, Edmonton, AB, Canada
| | - Katie O’Shea
- Eye Movement Desensitization and Reprocessing International Association, Austin, TX, United States
| | - Suzette Brémault-Phillips
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Edmonton, AB, Canada
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Andrew J. Greenshaw
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Olga Winkler
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Hospital Edmonton, Edmonton, AB, Canada
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Edmonton, AB, Canada
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Lang AJ, Hamblen JL, Holtzheimer P, Kelly U, Norman SB, Riggs D, Schnurr PP, Wiechers I. A clinician's guide to the 2023 VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder. J Trauma Stress 2024; 37:19-34. [PMID: 38184799 DOI: 10.1002/jts.23013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 01/08/2024]
Abstract
A clinical practice guideline (CPG) is a rigorously established set of recommendations based on currently available evidence about the efficacy, safety, acceptability, and feasibility of interventions to assist with clinical decision-making. The 2023 Department of Veterans Affairs /Department of Defense Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder is described herein. The CPG recommendations are accompanied by a clinical algorithm, which incorporates principles of evidence-based practice, shared decision-making, and functional and contextual assessments of goals and outcomes. An overview of the CPG recommendations is combined with a discussion of questions that clinicians and patients may face in implementing the CPG and suggestions for how to effectively work with the CPG.
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Affiliation(s)
- Ariel J Lang
- VA San Diego Center of Excellence for Stress and Mental Health (CESAMH), San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, California, USA
| | - Jessica L Hamblen
- National Center for PTSD, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Paul Holtzheimer
- National Center for PTSD, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Ursula Kelly
- VA Atlanta Healthcare System, Decatur, Georgia, USA
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Sonya B Norman
- VA San Diego Center of Excellence for Stress and Mental Health (CESAMH), San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
- National Center for PTSD, White River Junction, Vermont, USA
| | - David Riggs
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Paula P Schnurr
- National Center for PTSD, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Ilse Wiechers
- Veterans Health Administration Office of Mental Health and Suicide Prevention, Washington, DC, USA
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, California, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
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Büscher R, Sander LB, Nuding M, Baumeister H, Teismann T. Blending Video Therapy and Digital Self-Help for Individuals With Suicidal Ideation: Intervention Design and a Qualitative Study Within the Development Process. JMIR Form Res 2023; 7:e49043. [PMID: 37733414 PMCID: PMC10557000 DOI: 10.2196/49043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Digital formats have the potential to enhance accessibility to care for individuals with suicidal ideation. However, digital self-help interventions have faced limitations, including small effect sizes in reducing suicidal ideation, low adherence, and safety concerns. OBJECTIVE Therefore, we aimed to develop a remote blended cognitive behavioral therapy intervention that specifically targets suicidal ideation by blending video therapy with web-based self-help modules. The objective of this paper is to describe the collaborative development process and the resulting intervention and treatment rationale. METHODS First, we compiled intervention components from established treatment manuals designed for people with suicidal ideation or behavior, resulting in the development of 11 drafts of web-based modules. Second, we conducted a qualitative study, involving 5 licensed psychotherapists and 3 lay counselors specialized in individuals with suicidal ideation who reviewed these module drafts. Data were collected using the think-aloud method and semistructured interviews, and a qualitative content analysis was performed. The 4 a priori main categories of interest were blended care for individuals with suicidal ideation, contents of web-based modules, usability of modules, and layout. Subcategories emerged inductively from the interview transcripts. Finally, informed by previous treatment manuals and qualitative findings, we developed the remote blended treatment program. RESULTS The participants suggested that therapists should thoroughly prepare the web-based therapy with patients to tailor the therapy to each individual's needs. Participants emphasized that the web-based modules should explain concepts in a simple manner, convey empathy and validation, and include reminders for the safety plan. In addition, participants highlighted the need for a simple navigation and layout. Taking these recommendations into account, we developed a fully remote blended cognitive behavioral therapy intervention comprising 12 video therapy sessions and up to 31 web-based modules. The treatment involves collaboratively developing a personalized treatment plan to address individual suicidal drivers. CONCLUSIONS This remote treatment takes advantage of the high accessibility of digital formats while incorporating full sessions with a therapist. In a subsequent pilot trial, we will seek input from individuals with lived experience and therapists to test the feasibility of the treatment.
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Affiliation(s)
- Rebekka Büscher
- Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lasse B Sander
- Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mattis Nuding
- Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Ulm University, Ulm, Germany
| | - Tobias Teismann
- Mental Health Research and Treatment Center, Ruhr University Bochum, Bochum, Germany
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Ellis É, Wieling E, Tate A. Complex Posttraumatic Stress Disorder Links Trauma Exposure and Suicidal Behaviors Among Sexual Minority Populations: A New Target in Suicide Prevention? JOURNAL OF HOMOSEXUALITY 2023:1-19. [PMID: 37466931 DOI: 10.1080/00918369.2023.2233654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Exposure to potentially traumatic events and posttraumatic stress are known risk factors for suicidal thoughts and behaviors (STB). Research suggests that sexual minorities are disproportionately exposed to traumatic events and experience greater STB than their heterosexual peers, although few studies have explored connections between these parallel disparities. Further, existing literature may implicate complex posttraumatic stress disorder (CPTSD) as a potential mechanism in the trauma-suicide connection among sexual minorities. This study uses a sample from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III; n = 1351) to test structural equation models for associations between trauma exposure, heterosexist discrimination, and CPTSD with suicide attempt status. We found CPTSD mediated associations between exposure to traumatic events and presence of a lifetime suicide attempt among sexual minority male and female samples. Discrimination demonstrated a synergistic effect on the association between trauma exposure and CPTSD, but, among males, CPTSD did not fully explain associations between discrimination and suicide attempts. Our findings suggest that CPTSD should be considered an important mechanism in the trauma-suicide connection for sexual minorities and may be a potentially important target for suicide prevention and that interventions should address the influence of discrimination on traumatic stress in this high-risk population.
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Affiliation(s)
- Émilie Ellis
- College of Public Health, University of Georgia School of Public Health, Athens, Georgia, USA
| | - Elizabeth Wieling
- Human Development and Family Science, University of Georgia Department of Human Development and Family Science, Athens, Georgia, USA
| | - Allan Tate
- College of Public Health, University of Georgia School of Public Health, Athens, Georgia, USA
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Understanding veteran barriers to specialty outpatient PTSD clinical care. J Anxiety Disord 2023; 95:102675. [PMID: 36854224 DOI: 10.1016/j.janxdis.2023.102675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 12/28/2022] [Accepted: 01/26/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Veterans seeking treatment for posttraumatic stress disorder (PTSD) commonly report general and veteran-specific barriers to treatment such as stigma and challenges with navigating the Veterans Health Affairs (VHA) system. This study aimed to characterize barriers endorsed by a national sample of veterans seeking care in VHA PTSD specialty outpatient clinics, as well as to examine the impact of demographics on endorsed barriers. METHODS This study included 17,069 veterans referred to PTSD specialty outpatient clinics in the VHA during Fiscal Year 2019. Barriers to care, demographics, clinical concerns, and PTSD symptom severity (PCL-5) were assessed at intake. RESULTS Veterans (mean age=47.6 years, 83.3% male) endorsed an average of 2.39 barriers. The most commonly endorsed barriers included difficulty interacting with others (37.9%), difficulty being in public (33.8%), work (30.3%), concern for finances (20%), and difficulty getting out of bed (19.5%). A significant minority of veterans (22%) endorsed no barriers. Male sex (23.1%) and White race (23.6%) were associated with a greater likelihood of reporting no barriers. CONCLUSIONS These findings indicate the need for a comprehensive approach to addressing multi-faceted barriers for veterans seeking treatment in PTSD specialty clinics. Findings also highlight the potential importance of tailoring strategies to reduce barriers based on demographic and clinical characteristics such as race, sex, and degree of avoidance. Future research should seek to longitudinally examine the impact of barriers on treatment engagement.
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Akbar R, Arya V, Conroy E, Wilcox HC, Page A. Posttraumatic stress disorder and risk of suicidal behavior: A systematic review and meta-analysis. Suicide Life Threat Behav 2023; 53:163-184. [PMID: 36385705 DOI: 10.1111/sltb.12931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 10/10/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This study conducted a systematic review and meta-analysis of the association between posttraumatic stress disorder (PTSD) and (i) death by suicide, (ii) attempted suicide (AS), and (iii) suicidal ideation (SI). METHODS The systematic review identified seven studies on PTSD and suicide, 33 studies for AS, and 20 studies for SI. A series of stratified meta-analyses were conducted to estimate pooled effects, in addition to meta-regression to investigate sources of heterogeneity. RESULTS A higher relative risk of suicide was evident among those diagnosed with PTSD (RR = 2.09 [95% confidence interval (CI): 1.11-3.94]), with strongest associations among combat veterans (RR = 3.97, 95% CI 2.22-7.10). A lower relative risk of suicide among those with PTSD and co-morbid psychiatric conditions was evident (RR = 0.74, 95% CI 0.63-0.86). A strong association between PTSD and attempted suicide (RR = 4.05, 95% CI 3.14-5.23) and suicidal ideation (RR = 2.91, 95% CI 2.22-3.82) was also found, with a consistently strong association among those with co-morbid psychiatric conditions and non-clinical cohorts. CONCLUSION This review found a strong association between PTSD and death by suicide, attempted suicide, and suicidal ideation, and also suicide among veteran populations. Early identification and treatment of PTSD across both clinical and non-clinical cohorts should be a priority for suicide prevention.
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Affiliation(s)
- Rahat Akbar
- Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
| | - Vikas Arya
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Elizabeth Conroy
- Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
| | - Holly C Wilcox
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Andrew Page
- Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
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Schwartz RM, Shaam P, Williams MS, McCann-Pineo M, Ryniker L, Debnath S, Zanos TP. Understanding Mental Health Needs and Gathering Feedback on Transcutaneous Auricular Vagus Nerve Stimulation as a Potential PTSD Treatment among 9/11 Responders Living with PTSD Symptoms 20 Years Later: A Qualitative Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084847. [PMID: 35457714 PMCID: PMC9029393 DOI: 10.3390/ijerph19084847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/05/2022] [Accepted: 04/14/2022] [Indexed: 02/01/2023]
Abstract
Posttraumatic stress disorder (PTSD) remains one of the most prevalent diagnoses of World Trade Center (WTC) 9/11 responders. Transcutaneous auricular vagus nerve stimulation (taVNS) is a potential treatment for PTSD, as it can downregulate activity in the brain, which is known to be related to stress responses and hyperarousal. To understand barriers and facilitators to engagement in mental health care and the feasibility and acceptability of using the taVNS device as a treatment for PTSD symptoms, a focus group was conducted among patients from the Queens WTC Health Program who had elevated symptoms of PTSD. The focus group discussion was recorded, transcribed, and analyzed. Three themes and subthemes emerged: (1) the continued prevalence of mental health difficulties and systematic challenges to accessing care; (2) positive reception toward the taVNS device as a potential treatment option, including a discussion of how to increase usability; and (3) feedback on increasing the feasibility and acceptance of the research methodology associated with testing the device in a pilot clinical trial. The findings highlight the need for additional treatment options to reduce PTSD symptoms in this population and provide key formative phase input for the pilot clinical trial of taVNS.
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Affiliation(s)
- Rebecca M. Schwartz
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, Great Neck, NY 11021, USA; (R.M.S.); (M.M.-P.); (L.R.)
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; (M.S.W.); (T.P.Z.)
- Center for Traumatic Stress, Resilience and Recovery, Northwell Health, 175 Community Drive, Great Neck, NY 11021, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra University, Hempstead, NY 11549, USA
| | - Pooja Shaam
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, Great Neck, NY 11021, USA; (R.M.S.); (M.M.-P.); (L.R.)
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; (M.S.W.); (T.P.Z.)
- Center for Traumatic Stress, Resilience and Recovery, Northwell Health, 175 Community Drive, Great Neck, NY 11021, USA
- Correspondence:
| | - Myia S. Williams
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; (M.S.W.); (T.P.Z.)
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra University, Hempstead, NY 11549, USA
- Department of Medicine, Northwell Health, 600 Community Drive, Manhasset, NY 11030, USA
| | - Molly McCann-Pineo
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, Great Neck, NY 11021, USA; (R.M.S.); (M.M.-P.); (L.R.)
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; (M.S.W.); (T.P.Z.)
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra University, Hempstead, NY 11549, USA
| | - Laura Ryniker
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, Great Neck, NY 11021, USA; (R.M.S.); (M.M.-P.); (L.R.)
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; (M.S.W.); (T.P.Z.)
- Center for Traumatic Stress, Resilience and Recovery, Northwell Health, 175 Community Drive, Great Neck, NY 11021, USA
| | - Shubham Debnath
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA;
| | - Theodoros P. Zanos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; (M.S.W.); (T.P.Z.)
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra University, Hempstead, NY 11549, USA
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA;
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Vianez A, Marques A, Simões de Almeida R. Virtual Reality Exposure Therapy for Armed Forces Veterans with Post-Traumatic Stress Disorder: A Systematic Review and Focus Group. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19010464. [PMID: 35010723 PMCID: PMC8744859 DOI: 10.3390/ijerph19010464] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/27/2021] [Accepted: 12/29/2021] [Indexed: 11/16/2022]
Abstract
Virtual reality exposure therapy (VRET) is an emerging treatment for people diagnosed with Post-Traumatic Stress Disorder (PTSD) due to the limited accessibility of psychotherapies. This research aims to determine the guidelines for developing a Virtual Reality–War Scenario program for Armed Forces veterans with PTSD and encompasses two studies: Study 1, a systematic electronic database review; Study 2, a focus group of twenty-two Portuguese Armed Forces veterans. Results showed a positive impact of VRET on PTSD; however, there were no group differences in most of the studies. Further, according to veterans, new VRET programs should be combined with the traditional therapy and must consider as requirements the sense of presence, dynamic scenarios, realistic feeling, and multisensorial experience. Regardless, these findings suggest VRET as a co-creation process, which requires more controlled, personalized, and in-depth research on its clinical applicability.
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Affiliation(s)
- Ana Vianez
- Psychosocial Rehabilitation Laboratory, Center for Rehabilitation Research, School of Health, Polytechnic Institute of Porto, 4200-072 Porto, Portugal;
| | - António Marques
- Psychosocial Rehabilitation Laboratory, Center for Rehabilitation Research, School of Health, Polytechnic Institute of Porto, 4200-072 Porto, Portugal;
- Correspondence:
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