Randomized controlled evaluation of an early intervention to prevent post-rape psychopathology

Development of a brief bedside tool to screen women sexual assault survivors for risk of persistent posttraumatic stress six months after sexual assault

This study aims to develop and validate a brief bedside tool to screen women survivors presenting for emergency care following sexual assault for risk of persistent elevated posttraumatic stress symptoms (PTSS) six months after assault. Participants were 547 cisgender women sexual assault survivors who presented to one of 13 sexual assault nurse examiner (SANE) programs for medical care within 72 h of a sexual assault and completed surveys one week and six months after the assault. Data on 222 potential predictors from the SANE visit and the week one survey spanning seven broadly-defined risk factor domains were candidates for inclusion in the screening tool. Elevated PTSS six months after assault were defined as PCL-5 > 38. LASSO logistic regression was applied to 20 randomly selected bootstrapped samples to evaluate variable importance. Logistic regression models comprised of the top 10, 20, and 30 candidate predictors were tested in 10 cross-validation samples drawn from 80% of the sample. The resulting instrument was validated in the remaining 20% of the sample. AUC of the finalized eight-item prediction tool was 0.77 and the Brier Score was 0.19. A raw score of 41 on the screener corresponds to a 70% risk of elevated PTSS at 6 months. Similar performance was observed for elevated PTSS at one year. This brief, eight-item risk stratification tool consists of easy-to-collect information and, if validated, may be useful for clinical trial enrichment and/or patient screening.

Efficacy of EMDR for early intervention after a traumatic event: A systematic review and meta-analysis

BACKGROUND

Eye Movement Desensitization and Reprocessing (EMDR) is a well-established psychological therapy for the treatment of post-traumatic stress disorder, based on the recommendations of clinical practice guidelines. However, these guidelines are not as consistent in recommending EMDR interventions for the early treatment of post-traumatic symptoms. The main objective of this review is to evaluate the effectiveness of EMDR therapy for early intervention after a traumatic event.

METHODS

A systematic search for randomized clinical trials has been carried out in the PUBMED, CINAHL, Psyc-INFO and Cochrane Library search engines. We included individuals exposed to a recent traumatic event (within 3 months of a traumatic incident). Outcomes on PTSD, depression and anxiety in post-treatment, and at follow-up at 3, 6 and 12 months, as well as on safety and tolerability were extracted.

RESULTS

A total of 11 RCTs were found. Studies showed beneficial effects of early EMDR interventions on post-traumatic symptoms at post-treatment and at 3-month follow-up. No differences were found between EMDR and no intervention or another intervention in the remaining analyses.

LIMITATIONS

The main limitations are the low quality of the studies, the small number of studies per outcome assessed, and the small sample sizes.

CONCLUSIONS

There is evidence for the short-term beneficial effect of early EMDR interventions on post-traumatic symptoms. Although it appears to be a safe therapeutic choice, more studies are necessary that include safety data.

Scoping Review: Digital Mental Health Interventions for Children and Adolescents Affected by War

OBJECTIVE

More than 200 million children and adolescents live in countries affected by violent conflict, are likely to have complex mental health needs, and struggle to access traditional mental health services. Digital mental health interventions have the potential to overcome some of the barriers in accessing mental health support. We performed a scoping review to map existing digital mental health interventions relevant for children and adolescents affected by war, to examine the strength of the evidence base, and to inform the development of future interventions.

METHOD

Based on a pre-registered strategy, we systematically searched MEDLINE, Embase, Global Health, APA PsychInfo, and Google Scholar from the creation of each database to September 30, 2022, identifying k = 6,843 studies. Our systematic search was complemented by extensive consultation with experts from the GROW Network.

RESULTS

The systematic search identified 6 relevant studies: 1 study evaluating digital mental health interventions for children and adolescents affected by war, and 5 studies for those affected by disasters. Experts identified 35 interventions of possible relevance. The interventions spanned from universal prevention to specialist-guided treatment. Most interventions directly targeted young people and parents or carers/caregivers and were self-guided. A quarter of the interventions were tested through randomized controlled trials. Because most interventions were not culturally or linguistically adapted to relevant contexts, their implementation potential was unclear.

CONCLUSION

There is very limited evidence for the use of digital mental health interventions for children and adolescents affected by war at present. The review provides a framework to inform the development of new interventions.

DIVERSITY & INCLUSION STATEMENT

We actively worked to promote sex and gender balance in our author group.

STUDY PREREGISTRATION INFORMATION

Digital mental health interventions for children and young people affected by war: a scoping review; https://osf.io/; hrny9.

PTSD in the Year Following Sexual Assault: A Meta-Analysis of Prospective Studies

OBJECTIVE

Sexual assault is associated with higher rates of posttraumatic stress disorder (PTSD) than other traumas, and the course of PTSD may differ by trauma type. However, the course of PTSD after sexual assault has not been summarized. The aim of this meta-analysis was to identify the prevalence and severity of PTSD and changes to the average rate of recovery in the 12 months following sexual assault.

METHOD

Authors searched four databases for prospective studies published before April 2020 and sought relevant unpublished data. Eligible studies assessed PTSD in at least 10 survivors of sexual assault in at least two time points, starting within 3 months postassault. Random effects linear-linear piecewise models were used to identify changes in average recovery rate and produce model-implied estimates of monthly point prevalence and mean symptom severity.

RESULTS

Meta-analysis of 22 unique samples (N = 2,106) indicated that 74.58% (95% confidence interval [CI]: [67.21, 81.29]) and 41.49% (95% CI: [32.36, 50.92]) of individuals met diagnostic criteria for PTSD at the first and 12th month following sexual assault, respectively. PTSD symptom severity was 47.94% (95% CI: [41.27, 54.61]) and 29.91% (95% CI: [23.10, 36.73]) of scales' maximum severity at the first and 12th month following sexual assault, respectively. Most symptom recovery occurred within the first 3 months following sexual assault, after which point the average rate of recovery slowed.

CONCLUSIONS

Findings indicate that PTSD is common and severe following sexual assault, and the first 3 months postassault may be a critical period for natural recovery.

Early intervention using written exposure therapy for PTSD and AUD symptoms following sexual assault: Description of design and methodology

The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common following sexual assault and associated with more severe symptomology and increased likelihood of sexual revictimization. Integrated interventions aimed at reducing PTSD and AUD symptoms following recent sexual assault are needed and should address barriers to care and early treatment termination. The proposed study will test a novel, brief (5 to 7 sessions) intervention that integrates Written Exposure Therapy for PTSD and Cognitive Behavioral Therapy for AUD, and is initiated within the first six weeks post-assault. In Phase 1, qualitative analysis of content gathered during focus groups with treatment providers will be conducted to inform intervention development. In Phase 2, a proof-of-concept pilot study (n = 10) of the intervention, Substance Use Skills Training and Exposure Post-Sexual Assault (STEPS), will be conducted. In Phase 3, a pilot randomized controlled trial (RCT) among 54 recent sexual assault survivors will be implemented using the updated manualized STEPS intervention to evaluate feasibility and preliminary efficacy in reducing PTSD and AUD symptoms. Ecological momentary assessments will be used to assess daily alcohol use, craving, affect, intrusions and avoidance. The effects of STEPS on commonly associated symptoms (e.g., depression, substance use) will be examined. The proposed study has the potential to make a significant public health impact by advancing knowledge on the link between sexual assault and co-occurring PTSD and AUD and informing early intervention efforts for this high-risk population.

Systematic Review: Effectiveness of psychosocial interventions on wellbeing outcomes for adolescent or adult victim/survivors of recent rape or sexual assault

Sexual assault and rape are common forms of sexual violence/abuse. The psychological/health consequences represent significant and ongoing harm. It seems imperative that victim/survivors receive evidence-based support within first response settings. To assess what psychosocial interventions work for victim/survivors of a recent sexual assault. Twenty-seven electronic databases were systematically searched. Narrative data synthesis was used to read across studies. Reporting format follows PRISMA checklist. Ten studies were identifed including range of interventions. The evidence is sparse and scientifically weak, common flaws are reviewed. There is some weak evidence for the impact of video and cognitive behavioural therapy (CBT) based interventions, especially trauma processing. There is a gap in the evidence base on psychosocial interventions for victim/survivors of sexual assault and higher quality research is required.

A secondary analysis of a brief video intervention on suicidal ideation among recent rape victims

Although rape has been linked to risk for suicidal ideation and attempts, there are scant data on the efficacy of brief interventions to reduce suicidality among recent rape victims. This secondary analysis of a randomized controlled trial investigated whether a video intervention delivered in the emergency department (ED), cortisol measured at the ED, and prior rape history predicted postrape suicidal ideation independently or in combination with the other predictors. Participants were 235 women aged 15-71 years who presented to the ED for a sexual assault medical forensic examination and were randomly assigned to either receive a video intervention that addressed avoidance and promoted healthy coping strategies or standard care prior to the examination. Participants also provided a blood sample for cortisol and completed at least one of three follow-ups at 6 weeks, 3 months, or 6 months postrape. The intervention conferred protection against suicidal ideation among women with elevated cortisol and a prior rape; however, it did not reduce risk for women without a prior rape, particularly those with elevated cortisol. It may be important to consider the influence of prior rape and neuroendocrine reactivity in developing treatments to address suicidal ideation among rape victims. More specifically, there appears to be value in screening victims for prior rape and administering this brief intervention to reduce suicidal ideation; however, other avenues should be explored for victims without a prior rape history. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Longitudinal Examination of Interpersonal Violence Exposure, Concern for Loved Ones During a Disaster, and Web-Based Intervention Effects on Posttraumatic Stress Disorder Among Adolescent Victims of the Spring 2011 Tornadoes

Natural disasters are common and devastating, and can affect the mental health of adolescents. It is also common for adolescents to have histories of interpersonal violence (IPV). The current study was a secondary data analysis of a larger randomized clinical trial and examined the moderating effect of IPV history and concern for loved ones during a disaster on treatment condition effects on posttraumatic stress disorder (PTSD) symptoms over time among disaster-exposed adolescents. Participants (n = 979) were recruited postdisaster to participate in a randomized clinical trial examining the efficacy of a web-based intervention, Bounce Back Now (BBN), on mental health symptoms at 4 and 12 months postintervention. It was found that adolescents with an IPV history and who had caregivers that were concerned for loved ones during a disaster had more PTSD symptoms at baseline than those without such histories. Furthermore, caregiver concern for loved ones during a disaster moderated the effect of BBN on PTSD symptoms over time. Specifically, the BBN condition was most effective for adolescents who had caregivers who were concerned for loved ones during the disaster in reductions of PTSD symptoms over time. The current study provides further evidence for the use of technology-based interventions for individuals as a means to address mental health symptoms after a traumatic event, especially among those with more severe traumatic experiences.

Resilience in the age of COVID-19

Resilience is broadly defined as the ability to bounce back from adversity or trauma. Recent advances in resilience research have shifted away from merely describing individual characteristics towards focusing on the complex interactions between individuals and their dynamic personal, community and cultural contexts. It is clear that resilience involves both neurobiological and cultural processes. Neurobiological contributions include genes, epigenetics, stress-response systems, the immune system and neural circuitry. Culture helps to elucidate collective systems of belief and accepted positive adaptations. Importantly, resilience can also be affected by evidence-based interventions and deliberate practice on the part of the individual. This review seeks to understand resilience as a complex and active process that is shaped by neurobiological profiles, developmental experiences, cultural and temporal contexts, and practical training. It uses the COVID-19 pandemic as a case example to better understand individual and group responses to tragedy. We suggest practical recommendations to help populations around the world cope and recover from the global threat of COVID-19.

Early intervention with eye movement desensitization and reprocessing (EMDR) therapy to reduce the severity of post-traumatic stress symptoms in recent rape victims: a randomized controlled trial

BACKGROUND

About 40% of rape victims develop post-traumatic stress disorder (PTSD) within three months after the assault. Considering the high personal and societal impact of PTSD, there is an urgent need for early (i.e. within three months after the incident) interventions to reduce post-traumatic stress in victims of rape.

OBJECTIVE

To assess the effectiveness of early intervention with eye movement desensitization and reprocessing (EMDR) therapy to reduce symptoms of post-traumatic stress, feelings of guilt and shame, sexual dysfunction, and other psychological dysfunction (i.e. general psychopathology, anxiety, depression, and dissociative symptoms) in victims of rape.

METHOD

This randomized controlled trial included 57 victims of rape, who were randomly allocated to either two sessions of EMDR therapy or treatment as usual ('watchful waiting') between 14 and 28 days post-rape. Psychological symptoms were assessed at pre-treatment, post-treatment, and 8 and 12 weeks post-rape. Linear mixed models and ANCOVAs were used to analyse differences between conditions over time.

RESULTS

Within-group effect sizes of the EMDR condition (d = 0.89 to 1.57) and control condition (d = 0.79 to 1.54) were large, indicating that both conditions were effective. However, EMDR therapy was not found to be more effective than watchful waiting in reducing post-traumatic stress symptoms, general psychopathology, depression, sexual dysfunction, and feelings of guilt and shame. Although EMDR therapy was found to be more effective than watchful waiting in reducing anxiety and dissociative symptoms in the post-treatment assessment, this effect disappeared over time.

CONCLUSIONS

The findings do not support the notion that early intervention with EMDR therapy in victims of rape is more effective than watchful waiting for the reduction of psychological symptoms, including symptoms of post-traumatic stress. Further research on the effectiveness of early interventions, including watchful waiting, for this specific target group is needed.

Informing Human Trafficking Clinical Care Through Two Systematic Reviews on Sexual Assault and Intimate Partner Violence

BACKGROUND

There is a lack of evidence on the clinical management of patients who have suffered human trafficking. Synthesizing the evidence from similar patient populations may provide valuable insight. This review summarizes findings on therapeutic interventions for survivors of sexual assault and intimate partner violence (IPV).

METHOD

We conducted two systematic reviews using the MEDLINE database. We included only randomized controlled trials of therapies with primary outcomes related to health for survivors of sexual assault and IPV. For the sexual assault review, there were 78 abstracts identified, 16 full-text articles reviewed, and 10 studies included. For the IPV review, there were 261 abstracts identified, 24 full-text articles reviewed, and 17 studies included. Analysis compared study size, intervention type, patient population, primary health outcomes, and treatment effect.

RESULTS

Although our search included physical and mental health outcomes, almost all the studies meeting inclusion and exclusion criteria focused on mental health. The interventions for sexual assault included spiritually focused group therapy, interference control training, image rehearsal therapy, sexual revictimization prevention, educational videos, cognitive behavioral therapy, and exposure therapy. The interventions in the IPV review included group social support therapy, exposure therapy, empowerment sessions, physician counseling, stress management programs, forgiveness therapy, motivational interviewing, and interpersonal psychotherapy.

CONCLUSIONS

Insights from these reviews included the importance of culturally specific group therapy, the central role of survivor empowerment, and the overwhelming focus on mental health. These key features provide guidance for the development of interventions to improve the health of human trafficking survivors.

Secondary prevention for posttraumatic stress and related symptoms among women whohave experienced a recent sexual assault: A systematic review and meta-analysis

BACKGROUND

Women who have experienced a recent sexual assault (SA) are at high risk for posttraumatic stress disorder (PTSD) and related conditions, with approximately half of women experiencing SA meeting criteria for PTSD. There are no guidelines for the prevention of PTSD and other common mental health disorders after SA. Thus, the purpose of this systematic review and meta-analysis is to synthesize research on secondary preventions for PTSD after SA, determine efficacy whether any intervention seems promising, and ascertain when, how, and to whom interventions should be delivered.

METHODS

After searching electronic databases for secondary preventions for PTSD and related conditions among women who have experienced a recent SA, 17 studies were reviewed, their quality was rated on the clinical trial assessment measure, and 10 studies were meta-analyzed (7 were excluded, as they were not randomized controlled trials or due to the absence of heterogeneity).

RESULTS

Results suggested a small-to-moderate effect of prevention on reducing PTSD and related symptoms. There was no moderating effect of medication versus psychosocial interventions, timing, treatment modality, or targeted versus universal prevention. Half of the studies were of high quality.

CONCLUSION

Cognitive-behavioral secondary preventions for PTSD appear to be safe and effective among women who have experienced a recent SA. Future research should identify best practices and mechanisms of treatment, and once identified, it should move toward implementation science.

Early Psychological Intervention After Rape: A Feasibility Study

Rape is the most common trauma leading to post-traumatic stress disorder (PTSD) among women, with a conditioned prevalence of up to 50%. PTSD is considered to be a lethal condition associated with increased risk of suicide, drug- and alcohol dependence, neurological- and vascular problems, as well as sick leave. Given the scope of this problem, novel and swiftly delivered interventions for this large vulnerable population are clearly warranted. One previous trial conducted in the United States (N = 137) showed that an adapted brief version of prolonged exposure (PE) to the fearful memory of the event and situations, provided in the immediate aftermath after trauma (<72 h after a traumatic event), was effective in reducing early PTSD symptoms in rape victims. The aims of the present study were to adapt the brief PE protocol to a Swedish context and investigate its feasibility and delivery in 10 executive patients recruited at the Emergency Clinic for Rape Victims in Stockholm. Ten participants were provided with three sessions of early PE with overall successful results in terms of session attendance, home-work compliance, and also symptom reduction of PTSD and depressive symptoms. However, only a fraction of the screened patients at the Emergency Clinic (5.2%) were eligible to be included in the study, where the majority (40%) were excluded due to the time criteria of 72 h. In this article, we will present detailed results of the intervention and elaborate on how to increase feasibility of preventive interventions for rape victims. In the current form, providing PE with the strict time criteria was not feasible in the clinical setting that constitutes the Emergency Department for rape.

Psychological therapies for women who experience intimate partner violence

BACKGROUND

Intimate partner violence (IPV) against women is prevalent and strongly associated with mental health problems. Women experiencing IPV attend health services frequently for mental health problems. The World Health Organization recommends that women who have experienced IPV and have a mental health diagnosis should receive evidence-based mental health treatments. However, it is not known if psychological therapies work for women in the context of IPV and whether they cause harm.

OBJECTIVES

To assess the effectiveness of psychological therapies for women who experience IPV on the primary outcomes of depression, self-efficacy and an indicator of harm (dropouts) at six- to 12-months' follow-up, and on secondary outcomes of other mental health symptoms, anxiety, quality of life, re-exposure to IPV, safety planning and behaviours, use of healthcare and IPV services, and social support.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, and three other databases, to the end of October 2019. We also searched international trials registries to identify unpublished or ongoing trials and handsearched selected journals, reference lists of included trials and grey literature.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and cross-over trials of psychological therapies with women aged 16 years and older who self-reported recent or lifetime experience of IPV. We included trials if women also experienced co-existing mental health diagnoses or substance abuse issues, or both. Psychological therapies included a wide range of interventions that targeted cognition, motivation and behaviour compared with usual care, no treatment, delayed or minimal interventions. We classified psychological therapies according to Cochrane Common Mental Disorders's psychological therapies list.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and undertook 'Risk of Bias' assessment. Treatment effects were compared between experimental and comparator interventions at short-term (up to six months post-baseline), medium-term (six to under 12 months, primary outcome time point), and long-term follow-up (12 months and above). We used standardised mean difference (SMD) for continuous and odds ratio (OR) for dichotomous outcomes, and used random-effects meta-analysis, due to high heterogeneity across trials.

MAIN RESULTS

We included 33 psychological trials involving 5517 women randomly assigned to experimental (2798 women, 51%) and comparator interventions (2719 women, 49%). Psychological therapies included 11 integrative therapies, nine humanistic therapies, six cognitive behavioural therapy, four third-wave cognitive behavioural therapies and three other psychologically-orientated interventions. There were no trials classified as psychodynamic therapies. Most trials were from high-income countries (19 in USA, three in Iran, two each in Australia and Greece, and one trial each in China, India, Kenya, Nigeria, Pakistan, Spain and UK), among women recruited from healthcare, community, shelter or refuge settings, or a combination of any or all of these. Psychological therapies were mostly delivered face-to-face (28 trials), but varied by length of treatment (two to 50 sessions) and staff delivering therapies (social workers, nurses, psychologists, community health workers, family doctors, researchers). The average sample size was 82 women (14 to 479), aged 37 years on average, and 66% were unemployed. Half of the women were married or living with a partner and just over half of the participants had experienced IPV in the last 12 months (17 trials), 6% in the past two years (two trials) and 42% during their lifetime (14 trials). Whilst 20 trials (61%) described reliable low-risk random-sampling strategies, only 12 trials (36%) described reliable procedures to conceal the allocation of participant status. While 19 trials measured women's depression, only four trials measured depression as a continuous outcome at medium-term follow-up. These showed a probable beneficial effect of psychological therapies in reducing depression (SMD -0.24, 95% CI -0.47 to -0.01; four trials, 600 women; moderate-certainty evidence). However, for self-efficacy, there may be no evidence of a difference between groups (SMD -0.12, 95% CI -0.33 to 0.09; one trial with medium-term follow-up data, 346 women; low-certainty evidence). Further, there may be no difference between the number of women who dropped out from the experimental or comparator intervention groups, an indicator of no harm (OR 1.04, 95% CI 0.75 to 1.44; five trials with medium-term follow-up data, 840 women; low-certainty evidence). Although no trials reported adverse events from psychological therapies or participation in the trial, only one trial measured harm outcomes using a validated scale. For secondary outcomes, trials measured anxiety only at short-term follow-up, showing that psychological therapies may reduce anxiety symptoms (SMD -0.96, 95% CI -1.29 to -0.63; four trials, 158 women; low-certainty evidence). However, within medium-term follow-up, low-certainty evidence revealed that there may be no evidence between groups for the outcomes safety planning (SMD 0.04, 95% CI -0.18 to 0.25; one trial, 337 women), post-traumatic stress disorder (SMD -0.24, 95% CI -0.54 to 0.06; four trials, 484 women) or re-exposure to any form of IPV (SMD 0.03, 95% CI -0.14 to 0.2; two trials, 547 women).

AUTHORS' CONCLUSIONS

There is evidence that for women who experience IPV, psychological therapies probably reduce depression and may reduce anxiety. However, we are uncertain whether psychological therapies improve other outcomes (self-efficacy, post-traumatic stress disorder, re-exposure to IPV, safety planning) and there are limited data on harm. Thus, while psychological therapies probably improve emotional health, it is unclear if women's ongoing needs for safety, support and holistic healing from complex trauma are addressed by this approach. There is a need for more interventions focused on trauma approaches and more rigorous trials (with consistent outcomes at similar follow-up time points), as we were unable to synthesise much of the research.

The identification and treatment of mental health and substance misuse problems in sexual assault services: A systematic review

BACKGROUND

Specialist sexual assault services, which collect forensic evidence and offer holistic healthcare to people following sexual assault, have been established internationally. In England, these services are called sexual assault referral centres (SARCs). Mental health and substance misuse problems are common among SARC attendees, but little is known about how SARCs should address these needs. This review aims to seek and synthesise evidence regarding approaches to identification and support for mental health and substance misuse problems in SARCs and corresponding services internationally; empirical evidence regarding effective service models; and stakeholders' views and policy recommendations about optimal SARC practice.

METHODS

A systematic review was undertaken. PsycINFO, MEDLINE, IBSS and CINAHL were searched from 1975 to August 2018. A web-based search up to December 2018 was also conducted to identify government and expert guidelines on SARCs. Quality assessment and narrative synthesis were conducted.

RESULTS

We included 107 papers. We found that identification based on clinical judgement, supportive counselling and referral to other services without active follow-up were the most common approaches. Evaluations of interventions for post-rape psychopathology in attendees of sexual assault services provided mixed evidence of moderate quality. Very little evidence was found regarding interventions or support for substance misuse. Stakeholders emphasised the importance of accessibility, flexibility, continuity of care, in-house psychological support, staff trained in mental health as well as specialist support for LGBT groups and people with learning difficulties. Guidelines suggested that SARCs should assess for mental health and substance misuse and provide in-house emotional support, but the extent and nature of support were not clarified. Both stakeholders and guidelines recommended close partnership between sexual assault services and local counselling services.

CONCLUSIONS

This review suggests that there is big variation in the mental health and substance misuse provision both across and within different sexual assault service models. We found no robust evidence about how sexual assault services can achieve good mental health and substance misuse outcomes for service users. Clearer guidance for service planners and commissioners, informed by robust evidence about optimal service organisations and pathways, is required. PROSPERO registration number: CRD42018119706.

Post-sexual assault cigarette smoking: Findings from a randomized clinical trial of a video-based intervention

Sexual assault (SA) is associated with elevated risk for cigarette smoking. The current study tested whether a brief video intervention delivered in the emergency department was effective at reducing smoking following SA. Participants were 233 girls and women (age 15+) who received a SA medical forensic examination (SAMFE) and were randomized to one of three conditions: 1) Prevention of Post-Rape Stress (PPRS), a brief video designed to reduce post-SA psychopathology; 2) Pleasant Imagery and Relaxation Information (PIRI), an active control video involving relaxation training; and 3) treatment as usual (TAU). Among those who participated at baseline, 154 participants completed at least one follow-up at 1.5, 3, and 6 months after the SAMFE. Participants reported the number of days of smoking and the average number of cigarettes smoked per day in the two weeks prior to the sexual assault as well as in the two weeks prior to each follow-up. Two-thirds (68.8%) of participants smoked prior to the SA or during any follow-up. One-fifth of participants who did not smoke prior to the SA smoked at one or more follow-ups. Smoking declined on average over follow-up although TAU was associated with increased initial smoking compared to PPRS; PPRS and PIRI did not differ. SA contributes to increases in smoking and the PPRS, a brief and cost-effective video-based intervention delivered during the SAMFE, can protect against increases in post-SA smoking. Trial registration: NCT01430624.

Acute Stress Symptoms After Forcible and Substance-Involved Rapes

In the early aftermath of a sexual assault, survivors often experience symptoms of distress including reexperiencing, avoidance, and hyperarousal symptoms. However, less is known about associations between rape characteristics and the nature of early reactions. We designed the current study to examine the unique and combined associations between force and substances during rape on acute stress symptoms. Participants were 56 women (ages 18 to 58) who completed a sexual assault medical forensic exam in the emergency department within 120 hours of the rape and then completed a follow-up clinical phone screening within 30 days of the forensic exam. Follow-up assessments included characteristics of the recent rape (force, substances), history of prior sexual assault, demographics, and symptoms of acute stress. Multivariate regression analyses revealed that, after controlling for prior sexual assault, sexual orientation, and race/ethnicity, there were no significant differences on any symptom cluster by rape type. However, this study involved a small, difficult-to-reach sample and, therefore, was only powered to detect large effect sizes. We encourage more research examining potentially unique, early symptom presentations for substance-involved rapes.

Refinement and Pilot Testing of a Brief, Early Intervention for PTSD and Alcohol Use Following Sexual Assault

Experiencing a sexual assault can have long-lasting negative consequences including development of posttraumatic stress disorder (PTSD) and alcohol misuse. Intervention provided in the initial weeks following assault can reduce the development of these chronic problems. This study describes the iterative treatment development process for refining a brief intervention targeting PTSD and alcohol misuse for women with recent sexual assault experiences. Experts, treatment providers, and patients provided feedback on the intervention materials and guided the refinement process. Based on principles of cognitive change, the final intervention consists of one in-person session and four coaching calls targeting beliefs about the assault and about drinking behavior. Initial feasibility and acceptability data are presented for patients enrolled in an open trial (N = 6). The intervention was rated as helpful, not distressing, and interesting by patients and all patients completed the entire treatment protocol. A large decrease in PTSD symptoms pre- to post-intervention was observed. A small effect on decreasing alcohol consequences also emerged, although drinks consumed per week showed a slight increase, not a decrease, over the course of the intervention. Applications of this intervention and next steps for testing efficacy are presented.

A Trauma-Informed Approach to Sexual Violence Research Ethics and Open Science

The practice of ethics in social science research is a reflexive process of self-review to define a profession's collective responsibility in the face of changing norms and expectations. In recent years, we have seen transformative changes in how society thinks about supporting sexual assault survivors, and how the scientific community thinks about our obligations to society. Decades of research on trauma and its impact has raised awareness about the needs of victimized individuals, giving rise to the trauma-informed practice movement, which emphasizes that service providers must center survivors' well-being in all interactions, decisions, and program practices. The field of sexual assault research helped give rise to this movement and provides empirical support for its guiding tenets, and in this article, we explore how to bring these ideas full circle to begin articulating trauma-informed principles for research. A trauma-informed perspective on research challenges scientists to go beyond the requirements of the Belmont Report (1979) and institutional review boards' (IRB) regulations to develop research procedures that fully support survivors' choice, control, and empowerment. Such reflection on participants' rights is particularly important given the open science movement sweeping academia, which calls on scientists to share their data publicly to promote transparency, replication, and new discoveries. Disseminating data could pose significant safety, privacy, and confidentiality risks for victims of sexual assault, so we need to evaluate what open science means within a trauma-informed framework. In this article, we examine three key stages of the research process-participant recruitment, data collection, and dissemination-and consider how trauma-informed principles could help, but also could complicate, research practices. We explore these tensions and offer potential solutions so that research on sexual trauma embodies trauma-informed practice.

Early intervention with eye movement desensitisation and reprocessing (EMDR) therapy to reduce the severity of posttraumatic stress symptoms in recent rape victims: study protocol for a randomised controlled trial

Background: It is estimated that more than 40% of rape victims develops a posttraumatic stress disorder (PTSD), a statistic that is relatively high compared to other types of trauma. PTSD can affect the victims' psychological, sexual, and physical health. Therefore, there is an urgent need for early interventions to prevent the onset of PTSD in this target group. Objective: This randomised controlled trial (RCT) examines the efficacy of early Eye Movement Desensitisation and Reprocessing (EMDR) therapy aimed to reduce the severity of posttraumatic stress symptoms in victims of recent rape. Methods: Subjects (N = 34) are individuals of 16 years and older who present themselves within 7 days post-rape at one of the four participating Sexual Assault Centres in the Netherlands. The intervention consists of two sessions of EMDR therapy between day 14 and 28 post-rape, while the control group receives treatment as usual, consisting of careful monitoring of stress reactions by a case-manager across two contacts during 1-month post-rape. Baseline assessment, posttreatment assessment and follow-up assessments at 8 and 12-weeks post-rape will be used to assess the development of posttraumatic stress symptoms. In addition, the efficacy of the intervention on psychological and sexual functioning will be determined. Linear mixed model analysis will be used to explore the differences within and between the EMDR group and control group at the various time points. Conclusions: The results of this RCT may help the dissemination and application of evidence-based preventative treatments for PTSD after rape.

Prescription Opioid Misuse After a Recent Sexual Assault: A Randomized Clinical Trial of a Video Intervention

BACKGROUND AND OBJECTIVES

Prescription opioid (PO) misuse is increasing and is associated with overdose. Individuals who experienced a recent sexual assault are at risk for increased substance use, yet limited interventions target PO misuse after sexual assault. The current study examined the efficacy of video interventions on PO misuse after sexual assault.

METHODS

Adolescent girls and women (n = 154) were recruited in the context of a sexual assault medical forensic exam in the emergency department. Effects of a prevention of post-rape stress (PPRS) video and a pleasant imagery and relaxation instruction (PIRI) video were compared with treatment as usual (TAU) during a sexual assault medical forensic exam on PO misuse. Participants reported if they had used POs for non-medical purposes since the sexual assault at 1.5 month follow-up.

RESULTS

Results from a logistic regression analysis indicated that participants with a prior sexual assault were less likely to misuse prescription opioids 1.5 months after the assault in the PIRI condition compared with TAU. There were no main effects for video condition and no interactions for the PPRS condition on PO misuse.

DISCUSSION AND CONCLUSIONS

Providing the PIRI video, or teaching other types of mindfulness or relaxation exercises, may be warranted as a secondary prevention for individuals during the sexual assault medical forensic exam for those with a prior sexual assault history.

SCIENTIFIC SIGNIFICANCE

This research provides an initial examination of the impact of mindfulness skills recently after traumatic event exposure on PO misuse. (Am J Addict 2019;28:376-381).

Understanding Resilience and Preventing and Treating PTSD

Resilience is defined as the dynamic ability to adapt successfully in the face of adversity, trauma, or significant threat. Some of the key early studies of resilience were observational studies in children. They were followed by research in adults, studies testing interventions to promote resilience in different populations, and a recent upsurge of studies on the underlying genomic and neurobiological mechanisms. Neural and molecular studies in preclinical models of resilience are also increasingly identifying active stress adaptations in resilient animals. Knowledge gained from animal and human studies of resilience can be harnessed to develop new preventive interventions to enhance resilience in at-risk populations. Further, treatment interventions focused on enhancing potentially modifiable protective factors that are consistently linked to psychological resilience can enrich currently available treatment interventions for individuals with posttraumatic stress disorder (PTSD). Translating our expanding knowledge of the neurobiology of resilience additionally promises to yield novel therapeutic strategies for treating this disabling condition. This review summarizes the vast field of resilience research spanning genomic, psychosocial, and neurobiological levels, and discusses how findings have led and can lead to new preventive and treatment interventions for PTSD.

Do early interventions prevent PTSD? A systematic review and meta-analysis of the safety and efficacy of early interventions after sexual assault

Objective: To review the safety and efficacy of early interventions after sexual assault in reducing or preventing posttraumatic stress disorder (PTSD). Method: Systematic searches were performed on studies (1980-2018) that examined the efficacy of interventions for PTSD within 3 months after sexual assault. Results: The review identified 7 studies (n = 350) with high risk of bias that investigated 5 interventions. Only two studies reported on safety. Contact with the authors of six studies provided no indications for the occurrence of adverse events. Two studies reported the efficacy using PTSD diagnosis as dependent variable but found no difference between groups. All studies reported on efficacy using PTSD severity as dependent variable. For the meta-analysis, 4 studies (n = 293) were included yielding significantly greater reductions of PTSD severity than standard care at 2 to 12 months follow-up (g = -0.23, 95% CI [-0.46, 0.00]), but not at 1 to 6 weeks post-intervention (g = -0.28, 95% CI [-0.57, 0.02]). The heterogeneity of the interventions precluded further analyses. Discussion: Findings suggest that early interventions can lead to durable effects on PTSD severity after sexual assault. However, due to limited availability of data, it is impossible to draw definite conclusions about safety and efficacy of early interventions, and their potential to prevent PTSD.

Preventing Posttraumatic Stress Related to Sexual Assault Through Early Intervention: A Systematic Review

Sexual assault survivors come into contact with a variety of community responders after assault, and these interactions may play an important role in mitigating distress. Given theoretical understandings of the importance of early experiences in the development of posttraumatic stress (PTS), early contact with formal systems (e.g., health care, criminal justice, social services) and informal responders (e.g., friends, family) might be particularly important in preventing PTS. However, the effectiveness of these early interventions is unclear. Understanding the key elements of early interventions, both formal and informal, that successfully prevent the development of PTS could help to improve community responses to sexual assault and ultimately promote survivor well-being. In this systematic review, we investigate the types of experiences with responders in the early aftermath of assault that are associated with PTS, the duration of effects on PTS, and the role of the timing of these responses in the development of PTS. Findings indicate that responder contact alone is not typically associated with significant differences in PTS, and there is insufficient evidence to indicate that the timing of seeking help is associated with PTS, but the quality of services provided and perceptions of interactions with certain responders appear to be associated with PTS. Although many effects were short-lived, interventions that were perceived positively may be associated with lower PTS up to a year postassault. These findings support the importance of offering best practice interventions that are perceived positively, rather than simply encouraging survivors to seek help.

Mental and sexual health outcomes following sexual assault in adolescents: a prospective cohort study

BACKGROUND

Young people are disproportionately affected by sexual assault, yet longitudinal data are sparse. This paper examines the characteristics of adolescents presenting to sexual assault services and mental and sexual health outcomes after an assault.

METHODS

This was a prospective cohort study in adolescents aged 13-17 years attending the Sexual Assault Referral Centres serving Greater London, UK, over 2 years. Baseline interviews (T0) were done less than 6 weeks after an assault to collect data on sociodemographic and assault characteristics and psychological symptoms, with follow-up interviews (T1) at 4-5 months after the assault. Four psychological symptom questionnaires were used at T0 and T1: The Child Revised Impact of Events Scale, the Short Mood and Feelings Questionnaire, the Screen for Child Anxiety Related Disorders, and the Strengths and Difficulties Questionnaire. The primary outcome was prevalence of any psychiatric disorder at T1, assessed using the Development and Wellbeing Assessment. Secondary outcomes at T1 were pregnancy, sexually transmitted infections, and sexual health screening since the assault.

FINDINGS

Between April 15, 2013, and April 20, 2015, 141 (29%) of 491 eligible young people were recruited to the study (134 females; mean age 15·6 years [SD 1·27]), and 106 (75%) of 141 participants had T1 interviews (99 female). At T0, psychological symptom scores showed that 115 (88%) of 130 females were at risk for depressive disorder, 90 (71%) of 126 were at risk for anxiety disorders, and 116 (91%) of 128 were at risk for post-traumatic stress disorder, with symptoms largely persisting at T1. 68 (80%) of 85 females who had a diagnostic assessment at T1 had a psychiatric disorder, with multiple disorders in 47 (55%) of 85. Anxiety, post-traumatic stress, and major depressive disorders were the commonest diagnoses. Presence of a psychiatric disorder was associated with baseline psychosocial vulnerability (previous social services involvement, mental health service use, self-harm, or sexual abuse), but not assault characteristics. At T1, four (4%) of 105 females had been pregnant since the assault, 14 (12%) of 119 had a sexually transmitted infection diagnosed between T0 and T1, and nine (8%) of 107 reported re-victimisation since the assault.

INTERPRETATION

Vulnerable adolescents have the double disadvantage of being at risk for both sexual assault and associated psychiatric disorders, highlighting the need for comprehensive support after an assault. Feasibility and effectiveness of prevention programmes should be investigated.

FUNDING

National Institute for Health Research Policy Research Programme grant (115/0001).

A Randomized Clinical Trial Examining the Effect of Video-Based Prevention of Alcohol and Marijuana Use Among Recent Sexual Assault Victims

BACKGROUND

This study examined whether a brief video intervention (Prevention of Post-Rape Stress [PPRS]) delivered in the emergency department to recent sexual assault (SA) victims reduced alcohol and marijuana use at 3 points over the course of a 6-month follow-up compared to treatment as usual (TAU) and an active control condition (Pleasant Imagery and Relaxation Instruction [PIRI]). Prior assault history, minority status, and pre-SA substance use also were examined as moderators of intervention efficacy.

METHODS

Women aged 15 and older (N = 154) who participated in a post-SA medical forensic examination were randomly assigned to watch the PPRS video (n = 54) or the PIRI video (n = 48) or receive TAU (n = 52) and completed at least 1 follow-up assessment targeted at 1.5 (T1), 3 (T2), or 6 (T3) months following the examination.

RESULTS

Regression analyses revealed that, relative to TAU, PPRS was associated with less frequent alcohol use at 6 months post-SA among women reporting pre-SA binge drinking and minority women. Relative to TAU, PPRS also was associated with fewer days of marijuana use at T1 among those who did not report pre-SA marijuana use and prior SA. Findings for pre-SA marijuana use were maintained at T3; however, findings for prior SA shifted such that PPRS was associated with fewer days of marijuana use at T3 for women with a prior SA.

CONCLUSIONS

PPRS may be effective at reducing substance use for some recent SA victims, including those with a prior SA history, a prior substance use history, and minority women.

The National Problem of Untested Sexual Assault Kits (SAKs): Scope, Causes, and Future Directions for Research, Policy, and Practice

Victims of sexual assault are often advised to have a medical forensic exam and sexual assault kit (SAK; also termed a "rape kit") to preserve physical evidence (e.g., semen, blood, and/or saliva samples) to aid in the investigation and prosecution of the crime. Law enforcement are tasked with submitting the rape kit to a forensic laboratory for DNA (deoxyribonucleic acid) analysis, which can be instrumental in identifying offenders in previously unsolved crimes, confirming identify in known-offender assaults, discovering serial rapists, and exonerating individuals wrongly accused. However, a growing number of media stories, investigative advocacy projects, and social science studies indicate that police are not routinely submitting SAKs for forensic testing, and instead rape kits are placed in evidence storage, sometimes for decades. This review article examines the growing national problem of untested rape kits by summarizing current research on the number of untested SAKs in the United States and exploring the underlying reasons why police do not submit this evidence for DNA testing. Recommendations for future research that can guide policy and practice are discussed.

An Evidence-Based Review of Early Intervention and Prevention of Posttraumatic Stress Disorder

We present an evidence-based review of post-trauma interventions used to prevent posttraumatic stress disorder (PTSD). Literature search of PubMed from 1988 to March 2016 using keywords "Early Intervention AND Prevention of PTSD" yielded 142 articles, of which 52 intervention studies and 6 meta-analyses were included in our review. Trauma-focused cognitive behavioral therapy and modified prolonged exposure delivered within weeks of a potentially traumatic event for people showing signs of distress have the most evidence in the treatment of acute stress and early PTSD symptoms, and the prevention of PTSD. Even though several pharmacological agents have been tried, only hydrocortisone prior to high-risk surgery, severe traumatic injury, or during acute sepsis has adequate evidence for effectiveness in the reduction of acute stress symptoms and prevention of PTSD. There is an urgent need to determine the best targets for interventions after trauma to accelerate recovery and prevent PTSD.

Interventions to support recovery after domestic and sexual violence in primary care

Experiences of domestic and sexual violence are common in patients attending primary care. Most often they are not identified due to barriers to asking by health practitioners and disclosure by patients. Women are more likely than men to experience such violence and present with mental and physical health symptoms to health practitioners. If identified through screening or case finding as experiencing violence they need to be supported to recover from these traumas. This paper draws on systematic reviews published in 2013-2015 and a further literature search undertaken to identify recent intervention studies relevant to recovery from domestic and sexual violence in primary care. There is limited evidence as to what interventions in primary care assist with recovery from domestic violence; however, they can be categorized into the following areas: first line response and referral, psychological treatments, safety planning and advocacy, including through home visitation and peer support programmes, and parenting and mother-child interventions. Sexual violence interventions usually include trauma informed care and models to support recovery. The most promising results have been from nurse home visiting advocacy programmes, mother-child psychotherapeutic interventions, and specific psychological treatments (Cognitive Behaviour Therapy, Trauma informed Cognitive Behaviour Therapy and, for sexual assault, Exposure and Eye Movement Desensitization and Reprocessing Interventions). Holistic healing models have not been formally tested by randomized controlled trials, but show some promise. Further research into what supports women and their children on their trajectory of recovery from domestic and sexual violence is urgently needed.

Understanding resilience: New approaches for preventing and treating PTSD

All individuals experience stressful life events, and up to 84% of the general population will experience at least one potentially traumatic event. In some cases, acute or chronic stressors lead to the development of posttraumatic stress disorder (PTSD) or other psychopathology; however, the majority of people are resilient to such effects. Resilience is the ability to adapt successfully in the face of stress and adversity. A wealth of research has begun to identify the genetic, epigenetic, neural, and environmental underpinnings of resilience, and has indicated that resilience is mediated by adaptive changes encompassing several environmental factors, neural circuits, numerous neurotransmitters, and molecular pathways. The first part of this review focuses on recent findings regarding the genetic, epigenetic, developmental, psychosocial, and neurochemical factors as well as neural circuits and molecular pathways that underlie the development of resilience. Emerging and exciting areas of research and novel methodological approaches, including genome-wide gene expression studies, immune, endocannabinoid, oxytocin, and glutamatergic systems, are explored to help delineate innovative mechanisms that may contribute to resilience. The second part reviews several interventions and preventative approaches designed to enhance resilience in both developmental and adult populations. Specifically, the review will delineate approaches aimed to bolster resilience in individuals with PTSD. Furthermore, we discuss novel pharmacologic approaches, including the N-methyl-d-aspartate (NMDA) receptor ketamine and neuropeptide Y (NPY), as exciting new prospects for not only the treatment of PTSD but as new targets to enhance resilience. Our growing understanding of resilience and interventions will hopefully lead to the development of new strategies for not just treating PTSD but also screening and early identification of at-risk youth and adults. Taken together, efforts aimed at dissemination and implementation of novel interventions to enhance resilience will have to keep pace with the growth of new preventive and treatment strategies.

A Randomized, Controlled Pilot Study of a Single-Session Psychoeducation Treatment for Urban, Culturally Diverse, Trauma-Exposed Adults

This randomized pilot study aimed to determine whether a single session of psychoeducation improved mental health outcomes, attitudes toward treatment, and service engagement among urban, impoverished, culturally diverse, trauma-exposed adults. Sixty-seven individuals were randomly assigned to a single-session psychoeducation treatment or a delayed treatment comparison control group. The control group was found to be superior to the treatment group at posttest with respect to symptoms of posttraumatic stress disorder, anxiety, and occupational and family disability. At follow-up, all participants had completed the psychoeducation treatment, and a mixed-effects model indicated significant improvements over time in symptoms of posttraumatic stress disorder, anxiety, depression, somatization, and attitudes toward treatment. Ninety-eight percent of the participants reported the psychoeducation was helpful at follow-up. Participants also reported a 19.1% increase in mental health service utilization at follow-up compared with baseline. Implications for treatment and future research are discussed.

Prevention of Trauma and Stressor-Related Disorders: A Review

Posttraumatic stress disorder (PTSD) is a common, frequently chronic, and disabling condition which, along with acute stress disorder (ASD), is categorized as a trauma- and stressor-related disorder by the DSM-5. These disorders are unique in requiring exposure to a severe stressor, which implies that potential sufferers could be identified and helped before developing a disorder. Research on prevention strategies for stress-related disorders has taken a number of avenues, including intervention before and after trauma and the use of both psychosocial and somatic approaches. Despite advances in neurobiological understanding of response to trauma, clinical evidence for preventive interventions remains sparse. This review provides an overview of prevention approaches and summarizes the existing literature on prevention of ASD and PTSD, including clinical and preclinical studies. Given the potential benefits to trauma survivors and society, the development of effective preventive interventions should be given greater priority. Resources should be directed to adequately test promising interventions in clinical trials, and research should be conducted according to translational research principles in which preclinical research informs the design of clinical studies.

Psychological Outcomes After a Sexual Assault Video Intervention: A Randomized Trial

Sexual assault survivors are at risk for a number of mental and physical health problems, including posttraumatic stress disorder and anxiety. Unfortunately, few seek physical or mental health services after a sexual assault (Price, Davidson, Ruggiero, Acierno, & Resnick, 2014). Mitigating the impact of sexual assault via early interventions is a growing and important area of research. This study adds to this literature by replicating and expanding previous studies (e.g., Resnick, Acierno, Amstadter, Self-Brown, & Kilpatrick, 2007) examining the efficacy of a brief video-based intervention that provides psychoeducation and modeling of coping strategies to survivors at the time of a sexual assault nurse examination. Female sexual assault survivors receiving forensic examinations were randomized to standard care or to the video intervention condition (N = 164). The participants completed mental health assessments 2 weeks (n = 69) and 2 months (n = 74) after the examination. Analyses of covariance revealed that women in the video condition had significantly fewer anxiety symptoms at the follow-up assessments. In addition, of those participants in the video condition, survivors reporting no previous sexual assault history reported significantly fewer posttraumatic stress symptoms 2 weeks after the examination than those with a prior assault history. Forensic nurses have the unique opportunity to intervene immediately after a sexual assault. This brief video intervention is a cost-effective tool to aid with that process.

Post-traumatic stress disorder--a diagnostic and therapeutic challenge

BACKGROUND

In Germany, the one-month prevalence of post-traumatic stress disorder (PTSD) is in the range of 1% to 3%. Soldiers, persons injured in accidents, and victims of domestic violence increasingly seek medical help for symptoms of emotional stress. Days lost from work and monetary compensation for emotional disturbances are markedly on the rise. The term "PTSD" is commonly used uncritically and imprecisely, with too little regard for the existing diagnostic criteria. It is at risk of turning into a nonspecific collective term for emotional stress of any kind.

METHODS

We selectively reviewed the literature in the PubMed database and pertinent journals, with additional consideration of the recommendations and guidelines of medical societies from Germany and abroad.

RESULTS

The characteristic types of reactions seen in PTSD are nightmares and an intense, repetitive, intrusive "reliving" of the traumatic event(s). Emotional traumatization manifests itself not only as PTSD but also through major effects on other mental and somatic diseases. An early, trauma-focused behavioral therapeutic intervention involving several sessions, generally on an outpatient basis, can prevent the development of PTSD. The most important components of effective treatment are a focus on the particular trauma experienced and confrontation with the patient's memories of the trauma. The best existing evidence is for cognitive therapy, behavioral therapy according to the exposure paradigm of Foa, and eye movement desensitization and reprocessing therapy. The most recent meta-analysis reveals effect strengths of g = 1.14 for all types of psychotherapy and g = 0.42 for all types of pharmacotherapy taken together (with considerable differences among psychotherapeutic methods and among drugs). The efficacy of psychodynamic therapy, systemic therapy, body-oriented therapy, and hypnotherapy has not been adequately documented in randomized controlled trials.

CONCLUSION

PTSD can be precisely diagnosed and effectively treated when the diagnostic criteria and guideline recommendations are taken into account. Referral for trauma-focused psychotherapy should be considered if the acute symptoms persist for several weeks.

Victims' use of professional services in a Dutch sexual assault centre

BACKGROUND

Prior research endorsed the establishment of sexual assault centres in the Netherlands because of the potential benefit for victims' mental recovery. In 2012, the first Dutch sexual assault centre was founded at the University Medical Center Utrecht. The aim of the centre is to provide 24/7 coordinated and integrated services (i.e., medical, forensic, and psychological) in one location.

OBJECTIVE

The purpose of the present study was to describe demographic, background, and assault characteristics of victims seen at the centre within one week post-assault, and their use of post-assault services in order to improve current services.

METHOD

From January 2012 to September 2013, prospective data of 108 patients were collected. To describe the population included, frequency counts and proportions were generated for categorical variables.

RESULTS

The mean age was 21.3 years (SD=9.8). Most victims were female (91.7%). A large proportion of victims reported background characteristics known to increase the risk for post-traumatic stress disorder (PTSD) and revictimisation such as prior sexual abuse (32.4%), pre-existing use of mental health services (45.4%), and not living with both biological parents (61.7%). Most patients (88.9%) consulted the centre within 72 hours post-assault. The uptake of services was high: 82.4% received emergency medical care, 61.7% underwent a forensic-medical exam, 34% reported to the police, and 82.4% utilised psychological services.

CONCLUSION

To prevent revictimisation and PTSD, current psychological services could be improved with immediate trauma-focused treatments. Current forensic services may be improved with the use of standard top to toe forensic-medical examinations for both children and adults.

Predictors of using mental health services after sexual assault

Sexual assault increases the risk for psychopathology. Despite the availability of effective interventions, relatively few victims who need treatment receive care in the months following an assault. Prior work identified several factors associated with utilizing care, including ethnicity, insurance, and posttraumatic stress disorder (PTSD) symptoms. Few studies, however, have examined predictors of treatment utilization prospectively from the time of assault. The present study hypothesized that White racial status, younger age, being partnered, having health insurance, having previously received mental health treatment, and having more PTSD and depression symptoms would predict utilization of care in the 6 months postassault. This was examined in a sample of 266 female sexual assault victims with an average age of 26.2 years, of whom 62.0% were White and 38.0% were African American assessed at 1.5 and 6 months postassault. Available information on utilizing care varied across assessments (1.5 months, n = 214; 3 months, n = 126; 6 months, n = 204). Significant predictors included having previously received mental health treatment (OR = 4.09), 1 day depressive symptoms (OR = 1.06), and having private insurance (OR = 2.24) or Medicaid (OR = 2.19). Alcohol abuse and prior mental health care were associated with a substantial increase in treatment utilization (OR = 4.07). The findings highlight the need to help victims at risk obtain treatment after sexual assault.

Altered hippocampal function before emotional trauma in rats susceptible to PTSD-like behaviors

Posttraumatic stress disorder (PTSD) is an anxiety disorder that occurs after experiencing a traumatic event. Susceptibility to PTSD exists, as only some trauma-exposed individuals develop this condition. Investigating susceptibilities in animal models can contribute to understanding the etiology of the disorder. We previously reported an animal model which allows reliable pre-classification of rats as susceptible (Sus) or resistant (Res) to developing a PTSD-like phenotype after a later trauma. Here we report that Sus, compared to Res, rats have altered hippocampal function, along the septo-temporal axis, prior to experiencing a traumatic event. In Experiment I, Res and Sus rats explored a novel box twice. Using a cellular imaging method for assessing plasticity-related immediate-early gene expression in large neuronal ensembles, Arc/Homer1a catFISH, we show that Sus rats have smaller vCA3 ensembles during the second exploration. This suppressed vCA3 activation in Sus rats was not due to a difference in exploratory behavior, or to a difference in Arc/Homer1a expression in the basolateral amygdala (BLA). BLA is a main source of inputs to vCA3, but both the ensemble size and overlap of BLA ensembles activated during the two explorations was similar to that of Res rats. Additionally, Sus rats had significant 'infidelity' in their dorsal hippocampal representations of the second event: a lower overlap, compared to Res rats, of Arc/Homer1a-expressing ensembles activated during the two explorations (the size of the ensembles were similar to those of Res rats). These differences were revealed only in conditions of relatively low stress, because they were not observed when Sus and Res rats experienced fear conditioning (Experiment II). Combined, the findings show that altered hippocampal function exists before experiencing emotional trauma in susceptible rats and suggest that this is a risk factor for PTSD.

Cortisol at the emergency room rape visit as a predictor of PTSD and depression symptoms over time

BACKGROUND

Dysregulation of the hypothalamic-pituitary-adrenal axis, typically reflected by alterations in cortisol responsivity, has been associated with exposure to traumatic events and the development of stress-related disorders such as posttraumatic stress disorder (PTSD) and depression.

METHODS

Serum cortisol was measured at the time of a post sexual assault medical exam among a sample of 323 female victims of recent sexual assault. Analyses were conducted among 235 participants who provided data regarding history of previous assault as well as PTSD and depression symptoms during at least one of the three follow-ups.

RESULTS

Growth curve models suggested that prior history of assault and serum cortisol were positively associated with the intercept and negatively associated with the slope of PTSD and depression symptoms after controlling for covariates. Prior history of assault and serum cortisol also interacted to predict the intercept and slope of PTSD and depression symptoms such that women with a prior history of assault and lower ER cortisol had higher initial symptoms that decreased at a slower rate relative to women without a prior history and those with higher ER cortisol.

CONCLUSIONS

Prior history of assault was associated with diminished acute cortisol responsivity at the emergency room visit. Prior assault history and cortisol both independently and interactively predicted PTSD and depression symptoms at first follow-up and over the course a 6-month follow-up.

Uptake to HIV post-exposure prophylaxis in Haiti: opportunities to align sexual violence, HIV PEP and mental health

Sexual violence is a public health problem in Haiti, potentially augmenting HIV transmission. Reports from L'Hôpital de l'Université d'État d'Haiti (HUEH) suggest severe underutilization of antiretroviral post-exposure prophylaxis (ARV-PEP) among rape survivors. Cross-sectional design using mixed methods. Informational interviews were conducted with HUEH personnel to learn about post-rape service offerings. HUEH surveillance data were used to estimate the sexual assault reporting rate/100,000 and to examine the proportion of survivors receiving ARV-PEP within 72 hr, stratified by age (<18 years, ≥18 years). Informational interviews revealed that survivors were navigated through two hospital algorithms to receive post-rape care; however, <5% of victims sought mental health services. Surveillance data show that 2193 sexual assault survivors (adult and pediatric) reported a rape to HUEH personnel between 2004 through first quarter of 2010. Annual estimates suggest a twofold increase comparing cases in 2004 versus 2009. Between 2008 and 2009, uptake to ARV-PEP within 72 hr was lower for pediatric (38.4%; N = 131/341) compared with adult survivors (60.1%; N = 83/138) (χ(2)  = 18.8, P < 0.001). The prioritization of funding and comprehensive interventions that align sexual violence, HIV, and mental health is crucial to support the timely uptake to ARV-PEP.

Early intervention may prevent the development of posttraumatic stress disorder: a randomized pilot civilian study with modified prolonged exposure

BACKGROUND

Posttraumatic stress disorder (PTSD) is a major public health concern with long-term sequelae. There are no accepted interventions delivered in the immediate aftermath of trauma. This study tested an early intervention aimed at modifying the memory to prevent the development of PTSD before memory consolidation.

METHODS

Patients (n = 137) were randomly assigned to receive three sessions of an early intervention beginning in the emergency department compared with an assessment only control group. Posttraumatic stress reactions (PTSR) were assessed at 4 and 12 weeks postinjury and depression at baseline and week 4. The intervention consisted of modified prolonged exposure including imaginal exposure to the trauma memory, processing of traumatic material, and in vivo and imaginal exposure homework.

RESULTS

Patients were assessed an average of 11.79 hours posttrauma. Intervention participants reported significantly lower PTSR than the assessment group at 4 weeks postinjury, p < .01, and at 12 weeks postinjury, p < .05, and significantly lower depressive symptoms at week 4 than the assessment group, p < .05. In a subgroup analysis, the intervention was the most effective at reducing PTSD in rape victims at week 4 (p = .004) and week 12 (p = .05).

CONCLUSIONS

These findings suggest that the modified prolonged exposure intervention initiated within hours of the trauma in the emergency department is successful at reducing PTSR and depression symptoms 1 and 3 months after trauma exposure and is safe and feasible. This is the first behavioral intervention delivered immediately posttrauma that has been shown to be effective at reducing PTSR.

Early interventions for PTSD: a review

The high prevalence of trauma exposure and subsequent negative consequences for both survivors and society as a whole emphasize the need for secondary prevention of posttraumatic stress disorder. However, clinicians and relief workers remain limited in their ability to intervene effectively in the aftermath of trauma and alleviate traumatic stress reactions that can lead to chronic PTSD. The scientific literature on early intervention for PTSD is reviewed, including early studies on psychological debriefing, pharmacological, and psychosocial interventions aimed at preventing chronic PTSD. Studies on fear extinction and memory consolidation are discussed in relation to PTSD prevention and the potential importance of immediate versus delayed intervention approaches and genetic predictors are briefly reviewed. Preliminary results from a modified prolonged exposure intervention applied within hours of trauma exposure in an emergency room setting are discussed, along with considerations related to intervention reach and overall population impact. Suggestions for future research are included. Prevention of PTSD, although currently not yet a reality, remains an exciting and hopeful possibility with current research approaches translating work from the laboratory to the clinic.

The influence of emergency contraception on post-traumatic stress symptoms following sexual assault

Conservative estimates indicate that 18-25% of women in the United States will be exposed to some form of sexual assault in their lifetime. A great number of these women will develop post-traumatic stress disorder (PTSD). The current study explores the relationship between emergency contraception (EC) administration and subsequent post-traumatic stress symptoms in female sexual assault (SA) survivors. In a study population of 111 participants, post-traumatic stress symptoms were assessed approximately six months after the SA. Women who were already taking hormonal contraception (HC) at the time of the SA and those who declined EC were compared to women who took either Ogestrel or Plan B following the SA. While the administration of traditional HC and both types of EC were associated with fewer intrusive symptoms, women who took Ogestrel reported significantly lower post-traumatic stress total symptom levels than did those who took Plan B or those who declined EC. The results suggest that the manipulation of sex hormone levels with HC and EC in the immediate aftermath of trauma may influence subsequent post-traumatic stress symptoms. The current results may be useful in guiding the choice of EC.

Trajectories of PTSD symptoms following sexual assault: is resilience the modal outcome?

Theoretical frameworks positing qualitatively distinct trajectories of posttrauma outcome have received initial empirical support, but have not been investigated in cases of severe interpersonal trauma. To address this limitation, we conducted latent class growth analysis with longitudinal data collected from 119 female sexual assault survivors at 1-, 2-, 3-, and 4-months postassault. Participants' mean age was 33 years; 63% were White. We hypothesized that given the severity of exposure associated with sexual assault, resilience would not be the modal course of adaptation. Four distinct PTSD growth trajectories, representing unique latent classes of participants, best fit the data: a high chronic trajectory, a moderate chronic trajectory, a moderate recovery trajectory, and a marked recovery trajectory. Contrary to previous studies and recent theoretical models, resilience and resistance trajectories were not observed, as high levels of distress were evident in nearly all participants at 1-month postassault. These results suggest that theoretical models of posttrauma response positing resilience as the modal outcome may not generalize to cases of sexual assault.

Alcohol use disorder history moderates the relationship between avoidance coping and posttraumatic stress symptoms

Avoidance coping (AVC) is common in individuals with posttraumatic stress disorder (PTSD) and in individuals with alcohol use disorder (AUD). Given that PTSD and AUD commonly co-occur, AVC may represent a risk factor for the development of comorbid posttraumatic stress and alcohol use. In this study, the relationship between AVC and PTSD symptoms (PTSS) was examined in individuals with versus without AUDs. Motor vehicle accident (MVA) victims were assessed 6 weeks postaccident for AUD history (i.e. diagnoses of current or past alcohol abuse or dependence) and AVC. PTSS were assessed 6 weeks and 6 months post-MVA. All analyses were conducted on the full sample of MVA victims as well as on the subset of participants who were legally intoxicated (blood alcohol concentration ≥ 0.08) during the accident. It was hypothesized that the relationship between AVC and PTSS would be stronger in those individuals with an AUD history and especially strong in the subset of individuals who were legally intoxicated during the MVA. Results were largely supportive of this hypothesis, even after controlling for in-hospital PTSS, gender, and current major depression. Early assessment of AUD history and avoidance coping may aid in detecting those at elevated risk for PTSD, and intervening to reduce AVC soon after trauma may help buffer the development of PTSD + AUD comorbidity.

The mental health focus in rape crisis services: tensions and recommendations

In the evolution of rape crisis services, tensions persist between rape crisis service programs and mental health professionals. Changes within these programs and professions have brought the embedded concerns to the surface, but they remain unexamined and unresolved. Recent research on rape trauma and survivors' mental health needs has added to tensions by calling for description and evaluation of rape crisis services and timely psychological treatment for survivors. This article offers a new perspective by discussing the tensions in an open but balanced way so as to promote discussion and solutions. Recommendations and action steps are offered for promoting constructive dialogue and change to improve direct services for survivors.