Posttraumatic stress disorder and quality of life: Extension of findings to veterans of the wars in Iraq and Afghanistan

Understanding sexual dysfunction in french military service member with PTSD: findings from a descriptive study

BACKGROUND

Sexual dysfunction is a serious and frequently underrecognized consequence of Post-Traumatic Stress Disorder (PTSD), with profound implications on quality of life. This study aimed to characterize sexual dysfunction observed in French military personnel suffering from PTSD.

RESULTS

This retrospective study included 32 male French military personnel diagnosed with PTSD who participated in a sexual dysfunction screening program at a French National Military Hospital between October 2023 and August 2024. The mean age of participants was 40 years. The Post-Traumatic Stress Disorder Checklist Scale version DSM-5 (PCL-5) and the International Index of Erectile Function version 5 (IIEF-5) were used to assess PTSD and sexual dysfunction severity. Seventy-two percent (n = 23) reported at least one sexual dysfunction, with sexual desire dysfunction being the most common sexual health issue. Approximately 70% perceived the impact of sexual dysfunction on quality of life as high or very high. Significant correlations were found between PCL-5 and IIEF-5 scores, suggesting that the severity of PTSD symptoms impacts sexual health, specifically concerning cluster B (re-experiencing symptoms) and cluster D (negative thoughts and/or feelings) symptoms. Psychiatric symptoms were the primary risk factor, followed by psychotropic treatment and personal factors.

CONCLUSION

This study highlights the high prevalence of sexual dysfunction among French military personnel with PTSD. The diversity of the clinical presentations and risk factors emphasize the need for comprehensive sexual health assessments in PTSD management. Personalized care strategies targeting both psychiatric and sexual health issues are essential for improving outcomes in this population.

Social support and quality of life in oncology patients with post-traumatic stress disorder: a cross-sectional study

BACKGROUND

The potential mediating role of social support in the connection between post-traumatic stress disorder (PTSD) and quality of life among patients with cancer has not been explored in the currently available literature.

AIMS

This study aimed to explore the mediating role of social support in the relationship between PTSD and quality of life among oncology patients.

METHODS

A cross-sectional study was conducted among 343 cancer patients across three tertiary hospitals in Oman. Data were collected using validated, self-administered questionnaires. Mediation analysis was performed using the Sobel test.

FINDINGS

The average patient age was 47.3 years (SD 13.5) and 247 (72%) were female. Patients with PTSD had a lower perceived social support (mean 66.0; SD 10.8) and a poorer quality of life than those without PTSD. Social support played a mediating role in the relationship between PTSD and quality of life (P<0.01).

CONCLUSION

Social support has emerged as a crucial mediator that potentially buffers the adverse effects of PTSD. Integrating educational programmes, healthcare provider training and technology-enabled support systems such as online support groups can help build a stronger social support framework. Policymakers and healthcare organisations should prioritise social support initiatives to enhance the wellbeing of patients with PTSD and cancer.

Trauma and well-being in terrorism survivors in Spain

Long after terrorist attacks, victims may experience both trauma-related symptoms and levels of psychological well-being. This paper aimed to examine: (1) the relationship between overall PTSD and well-being; and (2) the associations among different PTSD symptom clusters, well-being, and daily functioning in 87 adult victims of jihadist and nationalist separatist terrorism in Madrid and Andalusia. The Posttraumatic Stress Questionnaire and the Psychological Well-being Questionnaire were administered. The findings revealed a significant negative correlation between PTSD symptoms and well-being. Among the PTSD symptoms, intrusions were the most prevalent, while alterations in mood and cognition, as well as alterations in arousal and reactivity were the most distressing. These latter symptoms also showed the strongest correlations with well-being and daily functioning. Multivariate analyses indicated that symptoms related to mood/cognition and arousal/reactivity uniquely predicted variance in well-being. This study highlights how different PTSD symptom clusters are related to well-being, suggesting important implications for targeted interventions.

Self-compassion, mindfulness, and emotion regulation predict multiple dimensions of quality of life in US post-9/11 veterans

PURPOSE

Quality of life (QoL), defined by satisfaction, capacity for activities, and functional role performance, is an outcome of interest for both medical and psychological interventions. Among US veterans, QoL is lower than the general population and is associated with mortality and suicide. Third-wave psychosocial interventions (e.g., Acceptance and Commitment Therapy) emphasize QoL as the primary outcome of interest, and specific third-wave intervention targets (e.g., self-compassion, mindfulness, emotion regulation) may contribute to the satisfaction, capacity, and functional domains of QoL of veterans. To evaluate the longitudinal associations of self-compassion, mindfulness, and emotional regulation with three domains of QoL (psychosocial satisfaction, psychosocial capacity, and psychosocial relationship functioning) in US veterans.

METHODS

351 US combat-deployed veterans self-reported measures of QoL, self-compassion, mindfulness, and emotional regulation at four timepoints across 24 months. Bayesian multivariate multilevel models were fit to the QoL outcomes.

RESULTS

Results indicated that all three domains of QoL remained relatively stable over the course of the study period. Increased psychosocial satisfaction and psychosocial capacity were both associated with increased mindfulness and emotion regulation, whereas self-compassion was only related to greater psychosocial capacity for male veterans. Increased functional role performances in romantic and family relationships were associated with increased emotion regulation, with romantic relationship functioning also being associated with increased mindfulness and family relationship functioning with increased self-compassion.

CONCLUSION

These results suggest that mechanisms of third-wave interventions have an impact on QoL among US veterans and that veteran QoL may be improved by broader integration of mindfulness and emotion regulation-based interventions.

"It made me feel more alive": A qualitative analysis of quality of life improvements following completion of trauma-focused therapy for posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is associated with poor quality of life. Although randomized clinical trial data show improvements in quality of life following trauma-focused therapies (TFTs), including prolonged exposure therapy (PE) and cognitive processing therapy (CPT), less is known about how these improvements are experienced from the trauma survivor's perspective. A national sample of 60 veterans who recently completed TFT as part of routine care at U.S. Department of Veterans Affairs facilities participated in semistructured qualitative interviews during which the impact of treatment on quality of life was explored. Following a mixed deductive/inductive approach, six interrelated themes describing changes in quality of life emerged: full participation in social activities, greater emotional intimacy in relationships, improvements in parenting, expanded engagement in hobbies and community, increased occupational commitment and confidence, and more joy in life. The data highlight the positive impact of treatment on quality of life and provide depth to quantitative findings demonstrating improvements in quality of life following TFT.

Moral injury and quality of life among military veterans

INTRODUCTION

Moral injury concerns transgressive harms and the outcomes that such experiences may cause. A gap in the literature surrounding moral injury, and an outcome that may be important to include in the mounting evidence toward the need for the formal clinical acknowledgement of moral injury, has to do with the relationship between moral injury and quality of life. No studies have examined this relationship in US military veterans-a population that is disproportionately exposed to potentially morally injurious events.

METHODS

A nationwide cross-sectional survey was conducted yielding 1495 military veterans. Participants were asked questions about moral injury and quality of life, among other things. Multivariable linear regression was used to characterise the adjusted relationship between moral injury and quality of life.

RESULTS

Moral injury (mean=40.1 out of 98) and quality-of-life (mean=69.5 out of 100) scores were calculated for the sample. Moral injury was inversely associated with quality of life in an adjusted model, indicating that worsening moral injury was associated with decreased quality of life (adjusted unstandardised beta coefficient (b)=-0.3, p<0.001). Results showed that age moderated said relationship, such that ageing veterans experienced an increasingly worse quality of life with increasingly severe moral injury (b=-0.1, p=0.003).

CONCLUSIONS

Results of the study showed that moral injury was inversely associated with quality of life and that this relationship rapidly worsens with age. More work is needed to more precisely understand this relationship and to determine the best strategies for intervention.

Neural activity during working memory predicts clinical response to computerized executive function training prior to cognitive processing therapy

BACKGROUND

Executive dysfunction, including working memory deficits, is prominent in posttraumatic stress disorder (PTSD) and can impede treatment effectiveness. Intervention approaches that target executive dysfunction alongside standard PTSD treatments could boost clinical response. The current study reports secondary analyses from a randomized controlled trial testing combined PTSD treatment with a computerized training program to improve executive dysfunction. We assessed if pre-treatment neurocognitive substrates of executive functioning predicted clinical response to this novel intervention.

METHODS

Treatment-seeking veterans with PTSD (N = 60) completed a working memory task during functional magnetic resonance imaging prior to being randomized to six weeks of computerized executive function training (five 30-minute sessions each week) plus twelve 50-minute sessions of cognitive processing therapy (CEFT + CPT) or placebo training plus CPT (PT + CPT). Using linear mixed effects models, we examined the extent to which the neurocognitive substrates of executive functioning predicted PTSD treatment response.

RESULTS

Results indicated that veterans with greater activation of working memory regions (e.g. lateral prefrontal and cingulate cortex) had better PTSD symptom improvement trajectories in CEFT + CPT v. PT + CPT. Those with less neural activation during working memory showed similar trajectories of PTSD symptom change regardless of treatment condition.

CONCLUSIONS

Greater activity of frontal regions implicated in working memory may serve as a biomarker of response to a novel treatment in veterans with PTSD. Individuals with greater regional responsiveness benefited more from treatment that targeted cognitive dysfunction than treatment that did not include active cognitive training. Clinically, findings could inform our understanding of treatment mechanisms and may contribute to better personalization of treatment.

The Mediating Role of Posttraumatic Stress Symptoms in the Relationship between Adult Attachment and Quality of Life

There is evidence that anxiety and avoidance toward close relationships (i.e., insecure attachment orientations), as well as posttraumatic stress symptoms (PTSSs), are linked to a poor quality of life. The current study aimed to investigate the potential mediating effects of PTSSs on the associations between insecure attachment orientations and domains of quality of life. A convenience sample of 497 adults (375 females, 75.5%), ranging in age between 18 and 65 years old (M = 32.48, SD = 13.26), was recruited. Participants were administered self-report instruments assessing attachment anxiety and avoidance, PTSSs, and domains of quality of life, including physical health, psychological status, social relationships, and environment. A series of mediation analyses were performed to test the mediating role of PTSSs in the relationships between attachment orientations and domains of quality of life. Results showed that attachment anxiety was related to decreased levels of quality of life in all domains, and that their associations were mediated by PTSSs. Also, attachment avoidance was related to a worse quality of psychological status and social relationships, and PTSSs were a significant mediating variable in these associations. Prevention programs and clinical interventions focused on promoting effective strategies for managing distress might be critical in reducing the impact of distressing events on the quality of life of individuals with insecure attachment.

Effect of Interactive Media-Based Music and Art Therapies on Reduction in PTSD Symptoms in Children and Adult Victims of Abduction

The aim of this study was to examine the impact of music and art therapies in reducing symptoms of PTSD among children and adults with abduction experiences in Nigeria. The study was a quasi-experiment with a pre-test, post-test and follow-up assessment design. The participants were divided into control (n = 107), music therapy (n = 108) and art therapy (n = 108) groups. The result of the ANCOVA analysis revealed no significant interactive effect of family happiness on the relationship between the interventions and reduction in PTSD symptoms, F(1,295)0.037 p = 0.848). However, there was a significant main effect of the treatment condition and PTSD scores of the participants at Times 1, 2, and 3, respectively F(1,295). 1640.756, p = 0.001). The degree of the relationship was assessed using partial eta squared, which yielded (ηp2= 0.848). It was also found that music therapy was more effective in reducing PTSD symptoms in children, while art therapy was more effective in reducing PTSD in adults. The result of this study could be useful for psychologists and mental health experts who may be interested in designing and implementing interventions targeting children and adults with PTSD symptoms. The result also has implications for control mastery theory by showing that music and art therapies could be useful in helping adults and children gain control of their minds after exposure to traumatic events.

Unveiling temporal dynamics of PTSD and its functional impairments: A longitudinal study in UK healthcare workers

PTSD has been associated with negative long-term consequences, including social and occupational impairments. Yet, a nuanced understanding of the interplay between PTSD symptoms and distinct domains of impairments on a short-term basis (weeks/ months) at the within-person level remains underexplored. In a large sample (nwave 1 = 1096, nwave 7 = 304) of UK healthcare workers assessed across seven assessment waves during the COVID-19 pandemic (spaced 6 weeks apart), we employed exploratory graphical vector autoregression models (GVAR) models to discern within-person temporal (across time) and contemporaneous (within same time window) dynamics between PTSD symptoms and functional impairment domains. The contemporaneous network highlighted strong co-occurrences between different symptoms and impairments. The temporal network revealed a mutually reinforcing cycle between intrusion and avoidance symptoms. Intrusion symptoms showed the highest out-strength (i.e., most predictive symptom), predicting avoidance symptoms, elevated sense of current threat, and various functional impairments. Avoidance symptoms, elevated after increased levels of intrusions, predicted work impairments that in turn were associated with difficulties in fulfilling other obligations. Our findings underscore the dynamics between perceived threat and intrusions, and the role intrusions may play in predicting a cascade of adverse effects. Targeted interventions aimed at mitigating intrusions may disrupt this negative cycle.

Massed written exposure therapy delivered to veterans with posttraumatic stress symptoms on an acute inpatient mental health unit

Written exposure therapy (WET) is a brief, manualized trauma-focused treatment typically delivered in five individual weekly sessions. Given the brevity and effectiveness of WET, researchers have begun to focus on its delivery in a massed format. However, only one case study examining massed delivery has been published to date. As such, the objective of the current study was to examine the acceptability, feasibility, and preliminary effectiveness of massed WET among veterans with a trauma- and stressor-related disorder receiving care on an acute inpatient mental health unit. Veterans (N = 26) were assessed prior to, immediately after, and 1 month following massed WET. Most veterans found massed WET to be useful and acceptable. Recruitment and retention rates suggested that the treatment was feasible. Notably, the results revealed statistically significant reductions in overall posttraumatic stress symptoms, ηp 2 = .81, p < .001; depressive symptoms, ηp 2 = .71, p < .001; and functional impairment, ηp 2 = .42, p = .002. These findings add to a growing body of literature highlighting the preliminary effectiveness of WET across various settings, populations, and delivery formats. Limitations include the small sample size and uncontrolled design.

Comparing the effect of prolonged exposure therapy (PET) and metacognitive therapy (MCT) on the quality of life among veterans with PTSD

Veterans' quality of life (QoL) can be drastically affected by posttraumatic stress disorder (PTSD). We compared prolonged exposure therapy (PET) with metacognitive therapy (MCT) in their effects on quality of life (QoL) among veterans with post-traumatic stress disorder (PTSD). Overall, 57 veterans with PTSD were randomly assigned to three groups MCT (N = 17), PET (N = 17), and Control (N = 23). The 36-item short-form survey (SF-36) was used to evaluate QoL pretest, posttest, and after a 3-month follow-up. The MCT was based on the practice of detached mindfulness, controlling rumination/anxiety, and challenging negative beliefs about symptoms. The PET was based on in-vivo and imaginal exposure to trauma-related events, and discontinuation of avoidance-oriented coping strategies. Both MCT and PET groups significantly improved QoL at posttest and follow-up, compared with the control group (P < .001); however, the MCT and PET groups showed no significant difference at posttest (P = .644) or follow-up (P = .646). Our results support the efficacy of PET as the standard for PTSD treatment, while also signifying the effectiveness of MCT at increasing the QoL in war-related PTSD at a 3-month follow-up.

Tonic immobility triggered by COVID-19-related trauma is associated with long-term PTSD symptoms

During the COVID-19 pandemic healthcare workers were repeatedly exposed to traumatic experiences. Facing life-threatening events and repeated exposure to traumatic duty-related situations may cause posttraumatic stress disorder (PTSD). While tonic immobility has been considered a key vulnerability factor for PTSD, little is known about this relationship in the long term. In this study, we aimed to determine whether peritraumatic tonic immobility triggered by COVID-19-related trauma predicts PTSD symptom severity six to twelve months later. We conducted an online longitudinal survey using the PTSD Checklist for the DSM-5 (PCL-5) and the Tonic Immobility Scale to assess PTSD symptoms and the tonic immobility response, respectively. Multivariate regression models revealed a significant association between tonic immobility and PTSD symptoms. Each one-unit increase in the tonic immobility score was associated with a 1.5 % increase in the average PTSD symptom score six to twelve months after the traumatic event that triggered the tonic immobility. Furthermore, participants who showed significant or extreme levels of tonic immobility were 3.5 times or 7.3 times more likely to have a probable PTSD diagnosis, respectively. Hence, peritraumatic tonic immobility seems to have a lasting deleterious effect on mental health. Psychological treatment for health care professionals is urgent, and psychoeducation about the involuntary, biological nature of tonic immobility is essential to reduce suffering.

Social Support and Social Stress Among Suicidal Inpatients at Military Treatment Facilities: A Multidimensional Investigation

ABSTRACT

The associations between social support and stress with internalizing symptoms (depressive symptoms and hopelessness) and hazardous drinking were tested in an inpatient sample of suicidal military personnel. Baseline data from a randomized clinical trial were analyzed. Different sources of support and stressors in the social context of military personnel were differentially linked to internalizing symptoms and hazardous drinking. In the full sample ( n = 192), family and nonfamily support were both inversely associated with internalizing symptoms but not hazardous drinking. Family stress was positively associated with internalizing symptoms. In a subsample of service members who had a history of deployment ( n = 98), postdeployment social support was protective against internalizing symptoms, whereas deployment harassment was associated with increased odds of hazardous drinking. Results underscore the need for assessment of various dimensions of social support and stress to guide case formulation and optimize strategies to support patients' mental well-being and adaptive coping.

Potentially morally injurious experiences and associated factors among Dutch UN peacekeepers: a latent class analysis

Background: During peacekeeping missions, military personnel may be involved in or exposed to potentially morally injurious experiences (PMIEs), such as an inability to intervene due to a limited mandate. While exposure to such morally transgressive events has been shown to lead to moral injury in combat veterans, research on moral injury in peacekeepers is limited.Objective: We aimed to determine patterns of exposure to PMIEs and associated outcome- and exposure-related factors among Dutch peacekeepers stationed in the former Yugoslavia during the Srebrenica genocide.Method: Self-report data were collected among Dutchbat III veterans (N = 431). We used Latent Class Analysis to identify subgroups of PMIE exposure as assessed by the Moral Injury Scale-Military version. We investigated whether deployment location, posttraumatic stress disorder (PTSD), posttraumatic growth, resilience, and quality of life differentiated between latent classes.Results: The analysis identified a three-class solution: a high exposure class (n = 79), a moderate exposure class (n = 261), and a betrayal and powerlessness-only class (n = 135). More PMIE exposure was associated with deployment location and higher odds of having probable PTSD. PMIE exposure was not associated with posttraumatic growth. Resilience and quality of life were excluded from analyses due to high correlations with PTSD.Conclusions: Peacekeepers may experience varying levels of PMIE exposure, with more exposure being associated with worse outcomes 25 years later. Although no causal relationship may be assumed, the results emphasize the importance of better understanding PMIEs within peacekeeping.

Challenges of living with veterans with post-traumatic stress disorder from the perspective of spouses: a qualitative content analysis study

BACKGROUND AND OBJECTIVE

The needs and characteristics of veterans with post-traumatic stress disorder (PTSD) create significant challenges in family life, particularly for spouses. Identifying the nature of these challenges from the perspective of spouses leads to a more comprehensive and profound understanding of their existing problems and can be used for targeted interventions. Therefore, this research was conducted to explore the challenges of living with veterans suffering from PTSD from the perspective of their spouses.

METHODS

This qualitative study used conventional content analysis to explore Challenges of spouses of veterans with post-traumatic stress disorder. Fifteen spouses of veterans with PTSD from the Veterans Affairs Center in Iran between June 2022 and January 2023, were purposively selected to participate in the study. Semi-structured in-depth interviews were conducted to collect data. The interviews were audio-recorded and transcribed verbatim. The data were analyzed using the method proposed by Graneheim and Lundman content analysis method with the support of MAXQDA 2020 software.

RESULTS

The mean age of the participants was 56.74 ± 6.43 years. Through data analysis, seven main categories and sixteen subcategories were identified. These categories included burnout (sleep disturbances, feelings of exhaustion), apathy towards self-care and caring for the veteran (neglecting self-care, lack of interest in continuing care), depression (feelings of hopelessness and being at the end of the line, decreased self-confidence ( Crushed and ignored (being mistreated, having multiple roles), relationship disturbances (Dissatisfaction with marital relationship,isolation and limited social interactions, disconnection from God), financial burden (heavy costs of care, lack of insurance support), and declining social status (negative attitude of the society, suffering from discrimination and inequality).

CONCLUSION

The consequences of PTSD-related injuries in veterans directly and indirectly affect the overall living conditions of their spouses. These spouses experience emotional detachment and constant rejection, leading to a decrease in their resilience against existing stressors and exposing them to disruptive and challenging issues in individual, family, and social dimensions of life that affect their physical and mental well-being. Therefore, these spouses require empowerment and access to social support in dimensions of educational, caregiving, therapeutic, and supportive. It is recommended that health policymakers pay special attention to designing up-to-date interventions to enhance the health of these spouses in physical, mental, spiritual, and social dimensions.

Daily exposure to combat-related cues and posttraumatic stress symptoms among veterans: Moderating effects of peri- and postdeployment experiences

One of the central symptoms of posttraumatic stress disorder (PTSD) is a heightened reactivity to trauma cues. The current study used experience sampling to investigate the associations between exposure to combat-related cues and PTSD symptoms in 93 U.S. veterans who served in support of recent military operations in Afghanistan and Iraq. We also examined the effects of peri- and postdeployment factors, including exposure to combat, unit support during deployment, and postdeployment social support on PTSD. Participants completed eight brief random surveys daily for 2 weeks using palmtop computers. The results indicated that more daytime exposure to trauma cues was associated with experiencing more PTSD symptoms at the within-person level, B = 3.18. At the between-person level, combat exposure, B = 4.20, was associated with more PTSD symptoms, whereas unit support, B = -0.89, was associated with experiencing fewer symptoms. At the cross-level interaction, unit support, B = -0.80, moderated the association between trauma cue exposure and PTSD symptom count. Contrary to our hypothesis, postdeployment social support, B = -0.59, was not associated with PTSD symptoms. These findings suggest a functional association between exposure to trauma cues and PTSD symptoms among recent-era U.S. veterans and underscore the importance of unit support during deployment.

Associations between Predictors of PTSD and Psychosocial Functioning in Veterans: Results from a Longitudinal Assessment Study

Impairments in psychosocial functioning are common in veterans, especially in those with significant mental health symptoms. Although available treatments are aimed at alleviating these symptoms, impairments in psychosocial functioning do not appear to be fully addressed. To achieve rehabilitation and full societal participation, there is a need to identify longitudinal associations of both symptoms and functional outcomes which can be targeted in treatment. United States veterans (N = 491) of the Iraq and Afghanistan wars were recruited as part of a longitudinal assessment study which examined predictors of postdeployment adjustment. Veterans were assessed at four timepoints over the course of a two-year period. A Bayesian multivariate multilevel model was used to estimate the association of predictors of PTSD (depression, alcohol use, suicidal ideation, and sleep) on psychosocial functioning as encompassed by quality of life (Quality of Life Scale (QLS)) and disability (World Health Organization Disability Assessment Schedule (WHODAS)) scores over time. As female veterans have unique environmental exposures and functional demands, interactions between predictors and gender were included in all models. There was significant overlap between predictors of PTSD and predictors of disability across domains and quality of life. Depressive symptoms and social support emerged as the strongest predictors of psychosocial functioning. Additionally, suicidality and alcohol use emerged as predictors of quality of life, but not disability. As expected, increases in PTSD symptoms predicted increased disability and decreased quality of life. The effect of depressive symptoms on quality of life was more pronounced for male veterans, and the effect of PTSD and alcohol use on quality of life was more pronounced for female veterans. Findings highlight various treatment targets which have the potential to improve symptoms of PTSD and functional outcomes. Findings highlight an opportunity to leverage intervention and prevention efforts focused on decreasing depression and increasing social support to improve trauma symptoms and maximize rehabilitation and functional recovery in veterans.

Pretreatment characteristics associated with symptom reduction during group cognitive processing therapy versus exposure therapy for PTSD: an exploratory study of Veterans

Exposure and cognitive-based therapies are both effective for PTSD, but knowledge of which intervention is best for which patient is lacking. This lack of knowledge is particularly noticeable for group treatments, as no study has examined whether responses to different group therapies are associated with different pretreatment characteristics. Here, we explored whether pretreatment levels of three types of psychological characteristics-PTSD symptom clusters, posttraumatic cognitions, and emotion regulation difficulties-were associated with symptom reduction during group-delivered cognitive versus exposure-based PTSD treatment. Participants were Veterans with PTSD drawn from two previous clinical trials: one of group CPT (GCPT; n = 32) and the other of group-based exposure therapy (GBET; n = 21). Growth curve modeling was used to identify pretreatment variables that predicted weekly PTSD symptom changes during each therapy. Higher posttraumatic cognitions at pretreatment predicted steeper PTSD symptom reduction during GCPT but not GBET. Additionally, symptom reduction during each therapy was associated with different pretreatment emotion regulation difficulties: difficulties with goal-directed behavior for GBET and lack of emotional clarity and limited access to emotion regulation strategies for GCPT. These findings suggest that assigning Veterans to a group PTSD therapy that better matches their pretreatment psychological profile might facilitate a better therapeutic response.

Assessing the association between probable posttraumatic stress disorder symptoms and quality of life among emergency service workers using path analysis

BACKGROUND

Emergency service workers have highly stressful occupations; the stressors encountered can contribute to the development of mental disorders such as depression, anxiety, and posttraumatic stress disorder (PTSD).

OBJECTIVE

The present study used a conceptual model and survey to identify variables influencing the association between probable PTSD and quality of life (QOL) in emergency service workers.

METHOD

PTSD was assessed using the Impact of Event Scale-Revised. QOL was assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey. Path analysis was used to determine whether stress-coping (Brief Coping Orientation to Problems Experienced [Brief COPE] scores), social support (Multidimensional Scale of Perceived Social Support [MSPSS] scores), and resilience (Connor-Davidson Resilience Scale scores) explain the association between probable PTSD and QOL among 220 emergency service workers in Japan.

RESULTS

Impact of Event Scale-Revised scores were significantly positively associated with Brief COPE Active coping scores and significantly negatively associated with MSPSS scores. Brief COPE Active coping and MSPSS scores were significantly positively associated with Connor-Davidson Resilience Scale scores, which were in turn significantly positively associated with Medical Outcomes Study 36-Item Short-Form Health Survey scores.

CONCLUSION

Active coping in response to stressful situations is important for maintaining good mental health among emergency service workers. Active coping and social support may strengthen resilience, and resilience may improve QOL. Screening for mental health and QOL should include simultaneous assessment of stress-coping, social support, and resilience. Although the findings of this cross-sectional study are important, it could not confirm a causal relationship between PTSD and QOL.

An examination of relationship satisfaction as a predictor of outcomes of brief couple therapy for posttraumatic stress disorder

The pretreatment quality of intimate relationships can promote or interfere with couple therapy for posttraumatic stress disorder (PTSD) treatment response. We tested whether baseline relationship satisfaction predicted clinical and process outcomes in two dyadic treatments for PTSD. Using data from a randomized trial comparing brief cognitive behavioral conjoint therapy (bCBCT) for PTSD to PTSD family education (PFE) among 137 military veterans and their partners (N = 274, Mage = 42.3 years, 46.7% White, 81.0% male veteran partner), we examined whether baseline relationship satisfaction (Couples Satisfaction Index; CSI-32) predicted change in PTSD symptom severity (Clinician Administered PTSD Scale for DSM-5; CAPS-5), psychosocial functioning (Brief Inventory of Psychosocial Functioning; B-IPF), and relationship satisfaction at posttreatment and 6-month follow-up. We also explored associations with process outcomes (working alliance, treatment satisfaction, dropout). In both treatment conditions, neither partner's baseline CSI-32 score moderated change in veteran CAPS-5 or B-IPF score or any process variable. However, baseline CSI-32 scores moderated both partners' CSI-32 score change during bCBCT and PFE; participants who scored in the distressed range at baseline (n = 123) experienced significant improvements in relationship satisfaction, β = .199, whereas there was no change among those in the nondistressed range at baseline (n = 151), β = .025. Results suggest bCBCT and PFE are effective in improving PTSD symptoms and psychosocial functioning regardless of whether a couple is experiencing clinically significant relationship distress; further, these treatments improve relationship satisfaction for the most distressed individuals.

The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study

STUDY OBJECTIVES

Intranasal administration of esketamine is Food and Drug Administration-approved for treatment-resistant depression. In a recent retrospective case series, we show that it has promise in reducing symptoms of posttraumatic stress disorder (PTSD) as well. Untreated obstructive sleep apnea (OSA) is prevalent among veterans with PTSD and has been shown to interfere with other PTSD treatments. In the current study, we examined whether OSA impacts esketamine's effectiveness in reducing symptoms of PTSD or depression.

METHODS

Participants were 60 veterans with a diagnosis of major depressive disorder and PTSD who received intranasal esketamine treatment at the San Diego Veterans Affairs (VA) Medical Center. We used growth-curve modeling to examine changes in depression and PTSD symptoms following esketamine treatments and, in the subset of individuals screened for OSA (n = 24, all prescribed positive airway pressure therapy), examined the impacts of OSA severity on these trajectories.

RESULTS

We first showed that both PTSD and depressive symptoms significantly decreased over the course of esketamine treatment. In the subset of veterans screened for OSA, individuals with lower OSA severity reported the greatest reduction in PTSD symptoms, while veterans with the most severe OSA reported the least reduction in PTSD symptoms. Depression response was not affected by severity of OSA in this analysis.

CONCLUSIONS

Veterans with PTSD and depression tend to benefit from esketamine treatment, but OSA may interfere with esketamine effectiveness. Comorbid OSA should be assessed for and treated to maximize esketamine's benefits in PTSD.

CITATION

Titone MK, Hunt C, Bismark A, et al. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med. 2023;19(12):2043-2051.

Effects of trauma history on cancer-related screening, diagnosis, and treatment

Trauma has substantial effects on human health and is recognised as a potential barrier to seeking or receiving cancer care. The evidence that exists regarding the effect of trauma on seeking cancer screening, diagnosis, and treatment and the gaps therein can define this emerging research area and guide the development of interventions intended to improve the cancer care continuum for trauma survivors. This Review summarises current literature on the effects of trauma history on screening, diagnosis, and treatment among adult patients at risk for or diagnosed with cancer. We discuss a complex relationship between trauma history and seeking cancer-related services, the nature of which is influenced by the necessity of care, perceived or measured health status, and potential triggers associated with the similarity of cancer care to the original trauma. Collaborative scientific investigations by multidisciplinary teams are needed to generate further clinical evidence and develop mitigation strategies to provide trauma-informed cancer care for this patient population.

Using the multiphase optimization strategy to adapt cognitive processing therapy (CPT MOST): study protocol for a randomized controlled factorial experiment

BACKGROUND

Approximately ten percent of US military veterans suffer from posttraumatic stress disorder (PTSD). Cognitive processing therapy (CPT) is a highly effective, evidence-based, first-line treatment for PTSD that has been widely adopted by the Department of Veterans Affairs (VA). CPT consists of discrete therapeutic components delivered across 12 sessions, but most veterans (up to 70%) never reach completion, and those who discontinue therapy receive only four sessions on average. Unfortunately, veterans who drop out prematurely may never receive the most effective components of CPT. Thus, there is an urgent need to use empirical approaches to identify the most effective components of CPT so CPT can be adapted into a briefer format.

METHODS

The multiphase optimization strategy (MOST) is an innovative, engineering-inspired framework that uses an optimization trial to assess the performance of individual intervention components within a multicomponent intervention such as CPT. Here we use a fractional factorial optimization trial to identify and retain the most effective intervention components to form a refined, abbreviated CPT intervention package. Specifically, we used a 16-condition fractional factorial experiment with 270 veterans (N = 270) at three VA Medical Centers to test the effectiveness of each of the five CPT components and each two-way interaction between components. This factorial design will identify which CPT components contribute meaningfully to a reduction in PTSD symptoms, as measured by PTSD symptom reduction on the Clinician-Administered PTSD Scale for DSM-5, across 6 months of follow-up. It will also identify mediators and moderators of component effectiveness.

DISCUSSION

There is an urgent need to adapt CPT into a briefer format using empirical approaches to identify its most effective components. A brief format of CPT may reduce attrition and improve efficiency, enabling providers to treat more patients with PTSD. The refined intervention package will be evaluated in a future large-scale, fully-powered effectiveness trial. Pending demonstration of effectiveness, the refined intervention can be disseminated through the VA CPT training program.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05220137. Registration date: January 21, 2022.

Aerobic exercise improves sleep in U. S. active duty service members following brief treatment for posttraumatic stress disorder symptoms

Introduction

Physical exercise is a lifestyle intervention that can positively impact aspects of physical and psychological health. There is a growing body of evidence suggesting that physical exercise, sleep, and PTSD are interrelated. This study investigated possible relationships. Three research questions were posed: (1) Did randomization to an aerobic exercise intervention reduce insomnia more than being randomized to an intervention without exercise, (2) Did change in sleep predict change in PTSD symptoms, and (3) Did change in sleep impact the relationship between exercise and PTSD symptom reductions?

Methods

Data were collected from 69 treatment-seeking active duty service members with PTSD symptoms randomized into one of four conditions; two conditions included aerobic exercise, and two conditions did not include exercise. Participants in the exercise groups exercised five times per week keeping their heart rate > 60% of their heart rate reserve for 20-25 min.

Results

At baseline, 58% of participants reported moderate or severe insomnia. PTSD symptom severity decreased following treatment for all groups (p < 0.001). Participants randomized to exercise reported greater reductions in insomnia compared to those in the no exercise group (p = 0.47). However, change in insomnia did not predict change in PTSD symptoms nor did it significantly impact the relationship between exercise and PTSD symptom reductions.

Discussion

Adding exercise to evidence-based treatments for PTSD could reduce sleep disturbance, a characteristic of PTSD not directly addressed with behavioral therapies. A better understanding of exercise as a lifestyle intervention that can reduce PTSD symptoms and insomnia is warranted.

P3a amplitude to trauma-related stimuli reduced after successful trauma-focused PTSD treatment

An elevated P3a amplitude to trauma-related stimuli is strongly associated with posttraumatic stress disorder (PTSD), yet little is known about whether this response to trauma-related stimuli is affected by treatment that decreases PTSD symptoms. As an analysis of secondary outcome measures from a randomized controlled trial, we investigated the latency and amplitude changes of the P3a in responses in a three-condition oddball visual task that included trauma-related (combat scenes) and trauma-unrelated (threatening animals) distractors. Fifty-five U.S. veterans diagnosed with combat-related PTSD were randomized to receive either active or sham repetitive transcranial magnetic stimulation (rTMS). All received cognitive processing therapy, CPT+A, which requires a written account of the index trauma. They were tested before and 6 months after protocol completion. P3a amplitude and response time decreases were driven largely by the changes in the responses to the trauma-related stimuli, and this decrease correlated to the decrease in PTSD symptoms. The amplitude changes were greater in those who received rTMS + CPT than in those who received sham rTMS + CPT, suggesting that rTMS plays beneficial role in reducing arousal and threat bias, which may allow for more effective engagement in trauma-focused PTSD treatment.

Hope, proactive personality, coping styles, and satisfaction with life among veterans during COVID-19

Veterans of the U.S. Armed Forces are an at-risk population given their increased mental health concerns resulting from their military service. However, there has been limited research conducted with this population during the novel coronavirus (COVID-19) pandemic. The purpose of this exploratory study was to examine aspects of positive psychological functioning with 132 U.S. veterans during COVID-19 using Lazarus and Folkman's (1984) transactional model of stress and coping. Specifically, we examined the personal resources of hope and proactive personality, two coping styles, and satisfaction with life. We performed correlation analyses to determine how these constructs related to each other. We also conducted a regression analysis to examine if the two dimensions of hope, proactive personality, adaptive coping, and maladaptive coping predicted veterans' satisfaction with life. Lastly, we utilized a mediation analysis to investigate whether two coping styles mediated the relationships among personal resources and satisfaction with life. Findings from the regression analysis suggested hope pathways and proactive personality were significant predictors of satisfaction with life. Results from the mediation analysis suggested that adaptive and maladaptive coping did not mediate the relationships among personal resources and satisfaction with life.

Exposure to self-reported traumatic events and probable PTSD in a national sample of Poles: Why does Poland's PTSD prevalence differ from other national estimates?

BACKGROUND

There is a lack of studies on trauma exposure and PTSD prevalence in Poland on representative samples. Available data from studies on convenient samples show very high rates of probable PTSD compared with relevant estimates in other countries.

OBJECTIVE

This study aimed to measure the exposure to self-report traumatic events (PTEs) and to estimate the current rate of prevalence of probable posttraumatic stress disorder (PTSD) in accordance with DSM-5 criteria in a population-based sample of Poles. Additionally, the link between PTSD intensity and level of life satisfaction was investigated.

METHOD

A representative sample of 1,598 adult Poles was recruited. Probable PTSD was assessed with the Posttraumatic Diagnostic Scale for DSM-5 (PDS-5) and the Satisfaction with Life Scale (SWLS) was also used.

RESULTS

The findings showed that 60.3% of Poles had experienced at least one PTE and 31.1% of those who had been exposed to trauma reported symptoms of PTSD. At the level of the entire sample, the obtained rate for probable PTSD was 18.8%. The traumatic events with the highest probabilities of PTSD symptoms were child abuse and sexual assault. Levels of life satisfaction were significantly lower in the group of participants with probable PTSD.

CONCLUSIONS

We found that the current prevalence of probable PTSD in Poland is intriguingly high relative to rates reported in comparable representative samples from other countries across the world. Possible mechanisms are discussed, including a lack of social acknowledgement of WWII and other traumas as well as poor access to trauma-focused care. We hope that this research may inspire more studies investigating cross-national differences in PTSD and trauma exposure.

Effect of massed v. standard prolonged exposure therapy on PTSD in military personnel and veterans: a non-inferiority randomised controlled trial

BACKGROUND

A short, effective therapy for posttraumatic stress disorder (PTSD) could decrease barriers to implementation and uptake, reduce dropout, and ameliorate distressing symptoms in military personnel and veterans. This non-inferiority RCT evaluated the efficacy of 2-week massed prolonged exposure (MPE) therapy compared to standard 10-week prolonged exposure (SPE), the current gold standard treatment, in reducing PTSD severity in both active serving and veterans in a real-world health service system.

METHODS

This single-blinded multi-site non-inferiority RCT took place in 12 health clinics across Australia. The primary outcome was PTSD symptom severity measured by the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) at 12 weeks. 138 military personnel and veterans with PTSD were randomised. 71 participants were allocated to SPE, with 63 allocated to MPE.

RESULTS

The intention-to-treat sample included 138 participants, data were analysed for 134 participants (88.1% male, M = 46 years). The difference between the mean MPE and SPE group PTSD scores from baseline to 12 weeks-post therapy was 0.94 [95% confidence interval (CI) -4.19 to +6.07]. The upper endpoint of the 95% CI was below +7, indicating MPE was non-inferior to SPE. Significant rates of loss of PTSD diagnosis were found for both groups (MPE 53.8%, SPE 54.1%). Dropout rates were 4.8% (MPE) and 16.9% (SPE).

CONCLUSIONS

MPE was non-inferior to SPE in significantly reducing symptoms of PTSD. Significant reductions in symptom severity, low dropout rates, and loss of diagnosis indicate MPE is a feasible, accessible, and effective treatment. Findings demonstrate novel methods to deliver gold-standard treatments for PTSD should be routinely considered.

Sleep efficiency predicts improvements in fear extinction and PTSD symptoms during prolonged exposure for veterans with comorbid insomnia

Prolonged exposure (PE) is an evidenced-based psychotherapy for PTSD, but many Veterans fail to achieve a clinically meaningful response. Sleep issues are prevalent in Veterans and may interfere with PE by disrupting the learning and consolidation of fear extinction memories during PE exposures. Here, we examined whether changes in fear extinction across imaginal exposures and PTSD symptoms during PE were predicted by diary-assessed levels of nightly sleep efficiency (SE; i.e., percent of time in bed spent sleeping), which may indirectly index sleep fragmentation and sleep-facilitated memory processes. Participants were Veterans with PTSD and comorbid insomnia (N = 40) participating in a clinical trial of cognitive-behavioral therapy for insomnia plus PE. SE was measured via nightly sleep diaries, fear extinction was operationalized as a reduction in peak distress between weekly imaginal exposures, and PTSD symptoms were assessed bi-weekly. Cross-lagged panel models revealed that higher sleep efficiency during the week predicted lower peak distress at the subsequent imaginal exposure and lower PTSD symptoms at the subsequent assessment, whereas PTSD symptoms and peak distress did not predict subsequent sleep efficiency. Efficient sleep may facilitate fear extinction and PTSD reduction during PE. Targeting sleep efficiency could improve PE effectiveness for Veterans with comorbid insomnia.

Testing adaptive interventions to improve PTSD treatment outcomes in Federally Qualified Health Centers: Protocol for a randomized clinical trial

BACKGROUND

Posttraumatic stress disorder (PTSD) disproportionately affects low-income individuals and is untreated in 70% of those affected. One third of low-income Americans are treated in Federally Qualified Health Centers (FQHCs), which do not have the capacity to provide all patients with first-line treatments such as Prolonged Exposure (PE). To address this problem, FQHCs could use low-intensity interventions (e.g., Clinician-Supported PTSD Coach: CS PTSD Coach) and medium-intensity interventions (e.g., PE for Primary Care: PE-PC) to treat PTSD with fewer resources. However, some patients will still require high-intensity treatments (e.g., full-length PE) for sustained clinical benefit. Thus, there is a critical need to develop stepped-care models for PTSD in FQHCs.

METHOD

We are conducting a Sequential, Multiple Assignment, Randomized Trial (SMART) with 430 adults with PTSD in FQHCs. Participants are initially randomized to CS PTSD Coach or PE-PC. After four sessions, early responders step down to lower frequency interaction within their assigned initial treatment strategy. Slow responders are re-randomized to either continue their initial treatment strategy or step up to Full PE for an additional eight weeks. The specific aims are to test the effectiveness of initiating treatment with PE-PC versus CS PTSD Coach in reducing PTSD symptoms and to test the effectiveness of second-stage strategies (continue versus step-up to Full PE) for slow responders.

CONCLUSIONS

This project will provide critical evidence to inform the development of an effective stepped-care model for PTSD. Testing scalable, sustainable sequences of PTSD treatments delivered in low-resource community health centers will improve clinical practice for PTSD.

Meaning(s) of transition(s) from military to civilian life at the intersection with mental health: implications for clinical settings

The experiences of military personnel moving into civilian life can be varied for the individual, families and communities. This paper aims to shed light on the various meanings of the multiple and "nested" transitions of military personnel to civilian life in the context of attending a mental health service in the UK. This was achieved through secondary analysis of semi-structured interviews with veterans who were engaging with a mental health service in the UK and a further interview with the mental health service lead. A thematic analysis was employed based on a descriptive phenomenological approach. Results indicate that an appropriate support infrastructure needs to be put in place for veterans prior to, during and after the transition to civilian life. The support appropriateness includes themes specific to connectedness to others, support service accessibility, mental health professionals' military culture awareness and mental health stigma. Although the findings suggest that community services need an awareness of veterans' specific needs, many of the themes are similar to those of the general population. Therefore, the need for an integrated healthcare system is essential in the transition of military service personnel to civilian life. Drawing on international evidence as well as the current findings, implications for policy and practice are highlighted throughout.

Influence of comorbid social anxiety disorder in PTSD treatment outcomes for Prolonged Exposure in female military sexual trauma survivors with PTSD

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a common psychiatric disorder that frequently presents alongside other comorbid diagnoses. Although several evidence-based psychotherapies have been well-studied for PTSD, limited research has focused on the influence of diagnostic comorbidity on their outcomes. The present study sought to investigate the influence of comorbid social anxiety disorder on treatment outcomes in patients with PTSD.

METHODS

One hundred and twelve treatment-seeking female veteran participants with PTSD completed baseline assessments and received 12-15 sessions of Prolonged Exposure. Symptom measures were completed biweekly as well as at immediate posttreatment, 3-month, and 6-month follow-ups.

RESULTS

Thirty (26.8%) participants seeking PTSD treatment also met diagnostic criteria for social anxiety disorder. Multilevel modeling was used to examine effects of social anxiety disorder diagnosis on post-intervention symptoms and revealed significantly worse outcomes for symptoms of PTSD and depression in participants with comorbid PTSD and social anxiety disorder.

CONCLUSION

Consistent with previous studies of co-occurring PTSD and depression, present findings suggest that comorbid diagnoses may adversely affect disorder-specific treatment outcomes. As such, the presence of diagnostic comorbidity may merit further consideration and potential adaptions to the traditional, disorder-specific assessment and treatment practices for PTSD.

Introduction to the special section on social relationships and posttraumatic stress disorder treatment: Harnessing the power of significant relationships

This article introduces the special section in the Journal of Traumatic Stress focused on social relationships and their connection to treatment among individuals with posttraumatic stress disorder (PTSD). Interpersonal relationships have the potential to influence treatment-seeking, retention, and outcomes. For individuals with PTSD, social relationships have long been understood to be intimately and bidirectionally tied to symptom levels. In light of somewhat modest rates of treatment response to current first-line interventions for PTSD, there is growing interest in engaging these relationships, as well as relationship-relevant beliefs and behaviors, to enhance PTSD treatment. This introductory article frames the rationale for examining these social factors to better understand and improve treatments and provides an overview of the collection of articles contained herein.

Baseline executive functioning moderates treatment-related changes in quality of life in veterans with posttraumatic stress disorder and comorbid traumatic brain injury

Posttraumatic stress disorder (PTSD) treatment has been associated with improvement in quality of life (QOL); however, little is known about factors that moderate treatment-related changes in QOL, particularly cognitive factors. Executive functioning (EF) is important for success across all aspects of everyday life and predicts better psychological and physical health. EF is important to QOL, but more work is needed to better understand the association between EF and QOL improvements following interventions. We hypothesized that poorer baseline EF would be associated with less improvement in overall life satisfaction and satisfaction with health following PTSD treatment. U.S. veterans who served after the September 11, 2001 terrorist attacks (post 9-11; N = 80) with PTSD and a history of mild-to-moderate traumatic brain injury were randomized to standard cognitive processing therapy (CPT) or CPT combined with cognitive rehabilitation (SMART-CPT). Multilevel modeling was used to examine whether baseline EF performance was associated with changes in QOL scores from pretreatment to follow-up across both groups. Results indicated that poorer baseline performance on EF tests of working memory and inhibition were associated with less treatment-related improvements in general life satisfaction and satisfaction with health, rs = .26-.36. Treatment condition did not moderate any results. Future research should examine whether implementing EF-focused techniques before and/or concurrently with CPT for individuals with poorer baseline working memory and inhibition enhances QOL treatment gains, particularly in terms of general life and health-related satisfaction.

Using interactive television-based art therapy to treat post-traumatic symptoms among survivors of abduction in Nigeria

This study was a quasi-experimental design that was aimed at understanding the impact of interactive television-based art therapy for treating post-traumatic stress disorder (PTSD) symptoms among school children who have experienced abduction. Participants took part in a 12-week art therapy delivered through interactive television. The result showed that art therapy was effective in reducing PTSD symptoms. A follow-up assessment after 6 months showed a steady decline in PTSD symptoms among participants in the treatment group when compared with their counterparts in the non-treatment group. The implications of these results have been discussed and recommendations made.

The PTSD Family Coach App in Veteran Family Members: Pilot Randomized Controlled Trial

BACKGROUND

Posttraumatic stress disorder (PTSD) among US military veterans can adversely impact their concerned significant others (CSOs; eg, family members and romantic partners). Mobile apps can be tailored to support CSO mental health through psychoeducation, coping skills, and stress monitoring.

OBJECTIVE

This study assessed the feasibility, acceptability, and potential efficacy of PTSD Family Coach 1.0, a free, publicly available app that includes psychoeducation, stress management tools, self-assessments, and features for connecting to alternative supports, compared with a psychoeducation-only version of the app for cohabitating CSOs of veterans with PTSD.

METHODS

A total of 200 participants with an average age of 39 (SD 8.44) years, primarily female (193/200, 97%), and White (160/200, 80%) were randomized to self-guided use of either PTSD Family Coach 1.0 (n=104) or a psychoeducation-only app (n=96) for 4 weeks. Caregiver burden, stress, depression, anxiety, beliefs about treatment, CSO self-efficacy, and relationship functioning assessed using measures of dyadic adjustment, social constraints, and communication danger signs were administered via a web survey at baseline and after treatment. User satisfaction and app helpfulness were assessed after treatment. Data were analyzed using linear mixed methods.

RESULTS

Overall, 50.5% (101/200) of randomized participants used their allocated app. Participants found PTSD Family Coach 1.0 somewhat satisfying (mean 4.88, SD 1.11) and moderately helpful (mean 2.99, SD 0.97) to use. Linear mixed effects models revealed no significant differences in outcomes by condition for caregiver burden (P=.45; Cohen d=0.1, 95% CI -0.2 to 0.4), stress (P=.64; Cohen d=0.1, 95% CI -0.4 to 0.6), depression (P=.93; Cohen d= 0.0, 95% CI -0.3 to 0.3), anxiety (P=.55; Cohen d=-0.1, 95% CI -0.4 to 0.2), beliefs about treatment (P=.71; Cohen d=0.1, 95% CI -0.2 to 0.3), partner self-efficacy (P=.59; Cohen d=-0.1, 95% CI -0.4 to 0.2), dyadic adjustment (P=.08; Cohen d=-0.2, 95% CI -0.5 to 0.0), social constraints (P=.05; Cohen d=0.3, 95% CI 0.0-0.6), or communication danger signs (P=.90; Cohen d=-0.0, 95% CI -0.3 to 0.3). Post hoc analyses collapsing across conditions revealed a significant between-group effect on stress for app users versus nonusers (β=-3.62; t₂₈₁=-2.27; P=.02).

CONCLUSIONS

Approximately half of the randomized participants never used their allocated app, and participants in the PTSD Family Coach 1.0 condition only opened the app approximately 4 times over 4 weeks, suggesting limitations to this app version's feasibility. PTSD Family Coach 1.0 users reported moderately favorable impressions of the app, suggesting preliminary acceptability. Regarding efficacy, no significant difference was found between PTSD Family Coach 1.0 users and psychoeducation app users across any outcome of interest. Post hoc analyses suggested that app use regardless of treatment condition was associated with reduced stress. Further research that improves app feasibility and establishes efficacy in targeting the domains most relevant to CSOs is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02486705; https://clinicaltrials.gov/ct2/show/NCT02486705.

A Qualitative Exploration of the Use of Service Dogs in Veterans with Post Traumatic Stress Disorder and Traumatic Brain Injury

Objective

This qualitative research was conducted to add to the body of knowledge that supports the benefits of service dogs (SDs), as a tertiary treatment modality, to veterans with post-traumatic stress disorder (PTSD) and/or traumatic brain injury (TBI).

Methods

This grounded theory research design utilized open-ended, semi-structured interviews with veterans (n = 10) who were using SDs as a treatment modality for PTSD and/or TBI. Transcripts were analyzed using NVivo qualitative software until data saturation was achieved.

Results

Results from the data analysis identified 4 major themes with concurrent subthemes. The most prominent themes were functional status, impact of a SD, recognition of symptoms of PTSD and/or TBI by the SD, and barriers and challenges to the acquisition of a SD. Participants reported that the SD increased socialization and was a positive adjunct to treatment modalities for PTSD and/or TBI.

Conclusions

Our study highlights the benefits of using a SD as a tertiary treatment for PTSD and/or TBI in veterans. Veterans in our study articulated the benefits of using a SD as a tertiary treatment option, and the need to make this a standard treatment option for all veterans who suffer from PTSD and/or TBI.

Analysis of the bidirectional relationships between posttraumatic stress and depression symptoms with physical health functioning in post-9/11 veteran men and women deployed to a war zone

OBJECTIVE

Many war-zone deployed post-9/11 veterans report negative mental health symptoms related to their military service, which can have consequences for physical health symptoms and the impact of physical health on functioning. The current study examined the longitudinal, bidirectional relationships between mental health symptoms and physical health functioning in veteran men and women, allowing for exploration of gender differences.

METHODS

A sample of 1032 post-9/11 veterans (women: n = 554; men: n = 478) who recently returned from a war-zone deployment completed self-report measures of posttraumatic stress disorder (PTSD) symptoms, depression symptoms, and physical health functioning at 3 time points spanning approximately 7 years. Gender-stratified longitudinal cross-lagged panel analyses were used to examine bidirectional relationships.

RESULTS

PTSD symptom severity was negatively associated with physical health functioning across time. For women, associations were reciprocal, such that those reporting poorer physical health functioning reported more severe PTSD symptoms at later time points. Men with greater PTSD symptom severity reported poorer physical health functioning at later time points, but there was no evidence of bidirectionality. Men and women with more severe depression symptoms reported worse later physical health functioning, which further exacerbated depression symptoms across time.

CONCLUSIONS

Findings showed that individual differences in mental health symptoms both set the stage for and were impacted by physical health functioning in post-9/11 veterans. Although additional research is needed, the current study suggests that healthcare approaches that consider the whole person, such as through integration of mental and physical health treatments, may be particularly relevant for post-9/11 veterans.

A qualitative study of equine-assisted therapy for Israeli military and police veterans with PTSD-impact on self-regulation, bonding and hope

Equine-assisted therapy (EAT) is an increasingly popular form of treatment for people suffering from post-traumatic stress disorder (PTSD) who, for one reason or another, find psychotherapy and other traditional treatment approaches unsuitable or unhelpful. However, the concomitant growth of research in the field is yet to engage with key factors relating to EAT; specifically, there are few studies considering the phenomenological perspective of patients, and the embodied knowledge deriving from the lived experience of PTSD patients who participated in EAT-based intervention programmes. Based on a qualitative-phenomenological study, interviews were conducted with 12 PTSD patients who had completed an EAT-based intervention programme. From these, three main themes characterising the meanings they gave to participation in an EAT-based treatment programme were identified: the ability to relax (self-regulation); establishing a relationship (bonding) and transformation and hope for the future. The findings of this study point to a process whereby participation in an EAT-based treatment programme facilitates the ability to cope with PTSD symptoms in a way that bridges the patient's emotional, social and spiritual-existential dimensions. The findings suggest that EAT can contribute to the healing process of veterans suffering from PTSD.

Community-Based Recreational Therapy for Veterans with Behavioral Health Disorders: Impacts on Quality of Life, Participation, and Happiness

Identifying evidenced-based interventions that improve health outcomes for Veterans with behavioral health disorders is a national priority. Thus, this study examined the outcomes of a community-based recreational therapy (RT) program focused on health promotion for Veterans with behavioral health disorders. Fifty-five Veterans with disabilities completed pretest and posttest questionnaires that assessed Quality of Life (QOL), Participation, and Happiness. Significant improvements were found in Overall QOL, Environmental QOL, Psychological QOL, QOL Rated, Satisfaction with Health, Participation, and Happiness. Younger age and female gender were significantly associated with improved Overall QOL. Factors significantly associated with improved Environmental QOL included younger age and non-Caucasian race. Older age was significantly associated with improved Participation. Female gender was positively associated with improved Happiness, while being divorced/separated was negatively associated with Happiness. These results have important implications for the use and expansion of community-based RT health promotion programs for Veterans with behavioral health disorders.

The impact of depression and post-traumatic stress symptoms on physical health perceptions and functional impairment among sexual minority men living with HIV with histories of trauma

Mental health symptoms may compromise health-related quality of life (HRQOL), including among men who have sex with men (MSM) living with HIV, who experience high rates of trauma and other stressors. This study sought to examine the relative contributions of post-traumatic stress disorder (PTSD) symptoms, depression symptoms, and biological indices of HIV disease status on HRQOL in this population. Participants were 79 MSM with HIV (49% White; 35% Black; 8% Hispanic/Latinx) with trauma histories (52% met current PTSD diagnostic criteria). HRQOL outcomes were general perceptions of health (0-100 visual analog scale) and functional disability (WHODAS 2.0). Dominance analysis was applied to examine the relative share of variance in these outcomes accounted for by PTSD symptom severity, depression symptom severity, viral suppression status, and CD4 count. Depression symptom severity accounted for 70% and 92% of variance in perceived health, respectively, across models (p's < 0.05). Both PTSD symptom severity (45%) and depression symptom severity (43%) scores also accounted for significant variance in functional disability (p's < 0.05). Medical indices of HIV disease progression did not explain significant variance in HRQOL in any model. A trauma-informed approach may aid clinicians in interpreting reports of health and physical functioning in MSM with HIV.

Feasibility and Acceptability of Prolonged Exposure in Primary Care (PE-PC) for Posttraumatic Stress Disorder in Federally Qualified Health Centers: A Pilot Study

Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder that affects 6% of U.S. adults, yet is treated in only 30% of affected individuals and even fewer low-income individuals. One third of the nation's low-income individuals are treated in Federally Qualified Health Centers (FQHCs). Most of these facilities lack capacity to provide their patients with first-line, evidence-based treatments for PTSD such as Prolonged Exposure (PE). To address this problem, PE has been adapted for use in a primary care setting and demonstrated efficacy in a brief model for military service members (PE in Primary Care: PE-PC). The effectiveness of this treatment in civilian, low-resource settings such as FQHCs is unknown. This pilot study tested the feasibility and acceptability of PE-PC in 30 Michigan FQHC patients. High rates of therapy participation suggest that the intervention was feasible and acceptable. Semi-structured interview data from 10 patients and 5 FQHC providers indicated that the intervention was helpful and filled a critical need for effective PTSD treatment in the FQHC setting. Interviews also elucidated barriers such as transportation, provider training, and time commitment for patients and providers. These findings set the stage for a full-scale randomized controlled trial to test the effectiveness of PE-PC on PTSD symptoms in this low-resource, high-need setting.Trial registry ClinicalTrials.gov Identifier: NCT03711266. October 18, 2018.

Post-traumatic stress disorder and depression are uniquely associated with disability and life dissatisfaction in post-9/11 veterans

Veterans who served in post-9/11 conflicts and experience deployment trauma sequelae frequently endorse disability and dissatisfaction with life. Although correlated, disability and life dissatisfaction represent distinct constructs with separate implications for quality of life. We examined associations between deployment trauma sequelae, disability and life dissatisfaction in 288 post-9/11 Veterans. Participants completed assessments of psychiatric, somatic and social functioning. Self-reports evaluating disability and life dissatisfaction were used to group participants based on established criteria (i.e., Disability and Dissatisfaction, Disability Only, Dissatisfaction Only, or No Disability or Dissatisfaction). Multinomial logistic regressions revealed that greater post-traumatic stress disorder (PTSD) and depressive symptom severity were independently associated with increased odds of being in the Disability and Dissatisfaction group, the Disability Only group and the Dissatisfaction Only group, relative to the No Disability or Dissatisfaction group. Number of prior mild traumatic brain injuries (mTBI) was not associated with disability or dissatisfaction after accounting for other trauma sequelae. Social support attenuated the relationship between depression and membership in the Disability and Dissatisfaction group. Participants who reported greater dissatisfaction than disability endorsed greater depression and mTBI frequency. Overall, PTSD and depression convey a heightened risk of both disability and life dissatisfaction, while social support may be protective.

The mediating effect of symptoms of posttraumatic stress disorder and depression on the relationship between personality traits and quality of life in emergency service workers

BACKGROUND

Emergency service workers are often exposed to fatalities during accidents or disasters. Therefore, they may be more prone to experiencing posttraumatic stress disorder (PTSD) and depression. It has been shown that these comorbid disorders are related to personality traits and quality of life (QOL).

METHODS

We hypothesized that mental disorders, such as symptoms of PTSD and depression, mediate the relationship between personality traits, as measured on the 10-Item Personality Inventory (TIPI), and QOL, as measured on the MOS 36-item Short-Form Health Survey (SF-36).

RESULTS

Participants were aged 23-61 years. Questionnaires were sent to 373 participants, 220 of whom returned responses. A direct effect was found between two subscales of the TIPI (Extraversion and Emotional stability) and mental component summary scores of the SF-36 (Extraversion: β = 0.154, p < .001; Emotional stability: β = 0.179, p < .001), which indicated partial mediation. A significant indirect effect was revealed between two personality traits and mental health summary scores (Extraversion: β = 0.058, p < .001; Emotional stability: β = 0.087, p < .001). We also found a direct effect of extraversion scores of the TIPI on role/social component summary scores of the SF-36 (β = 0.084, p < .05). However, none of the 95% confidential intervals was significant, which indicated full mediation, and the indirect effect was significant (β = 0.023, p < .01). Sensitivity analysis indicated that a direct effect between extraversion scores of the TIPI and role/social component summary scores of the SF-36 was significant, which indicated partial mediation.

CONCLUSIONS

The findings of direct and indirect effects highlight the importance of identifying effective methods for protecting individuals from developing symptoms of PTSD and depression; moreover, they may help improve QOL. The capacity of dealing with incidents among emergency service workers may vary depending on their personality traits. Therefore, the screening of mental health states that includes a personality trait inventory may be valuable.

Feasibility and Acceptability of Group-Facilitated Prolonged Exposure Therapy for PTSD in VA Residential Rehabilitation Treatment Programs

Prolonged Exposure therapy (PE) is a first-line treatment for posttraumatic stress disorder (PTSD); however, few VA patients receive this treatment. One of the barriers to PE receipt is that it is only available in an individual (one-on-one) format, whereas many VA mental health clinics provide the majority of their psychotherapy services in group format. In particular, PTSD residential rehabilitation treatment programs (RRTPs) offer most programming in group format. Consequently, strategies are needed to improve the scalability of PE by adapting it to fit the delivery setting. The current study was designed to pilot test a group-facilitated format of PE in RRTPs. Thirty-nine Veterans who were engaged in care in the PTSD RRTP at a Midwestern VA were recruited to participate in a Group-facilitated PE protocol. Participants engaged in twelve 90-minute sessions of Group PE over the course of 6 weeks, plus six 60-minute individual sessions for imaginal exposure. Group treatment followed the PE model and consisted of psychoeducation, treatment rationale, and in vivo exposure to reduce trauma-related avoidance and thereby improve PTSD symptoms. PTSD symptoms were measured via the PTSD Checklist for DSM-5 (PCL-5) and depression symptoms were measured via the Patient Health Questionnaire (PHQ-9) at baseline, endpoint (6 weeks), and at 2-month follow-up. Thirty-nine individuals initiated Group-facilitated PE and 34 completed treatment. The average number of group sessions attended was 11 out of 12. Acceptability ratings were high. Mean change (improvement) in the intent-to-treat sample at 2-month follow-up was 20.0 points on the PCL-5 (CI 18.1, 21.9; Cohen's d = 1.1) and 4.8 points on the PHQ-9 (CI 4.1, 5.5, d = .8). These results suggest that adapted evidence-based interventions for PTSD can improve treatment access and efficiency for the RRTP setting. A group-based approach has the potential to improve the scalability of PTSD treatment by reducing required resources. A fully powered trial is now needed to test the effectiveness of Group-facilitated PE in the RRTP setting.

Effect of patient characteristics on posttraumatic stress disorder treatment retention among veterans: A systematic review

To identify baseline patient characteristics (i.e., demographic and psychological factors, military background) associated with better posttraumatic stress disorder (PTSD) treatment retention among veterans, we conducted a systematic review. After an electronic database search for studies of PTSD treatment in veterans, two reviewers independently screened the literature for eligibility, abstracted study-level information, and assessed risk of bias. As most studies used multivariate models to assess multiple potential predictors of retention simultaneously, the results were described narratively. The GRADE approach, adapted for prognostic literature, was used to assess the overall quality of evidence (QoE). In total, 19 studies reported in 25 publications met the inclusion criteria (n = 6 good quality, n = 9 fair quality, n = 4 poor quality). Definitions of treatment completion and dropout varied, and some studies lumped different therapy approaches together. Older age and higher treatment expectations were associated with better retention (moderate QoE). In 5 of 6 studies, baseline PTSD severity was not associated with retention, and the remaining study reported an association between better retention and more severe PTSD symptoms; the presence of more co-occurring psychiatric disorders was associated with better retention (moderate QoE). QoE was low or insufficient to support conclusions for any other characteristics due to inconsistent results, imprecision, potential publication bias, possible study population overlap, study limitations, or lack of studies. More research is needed regarding the associations between modifiable factors (e.g., motivation, barriers, expectations) and retention, and consistent definitions of treatment completion and minimally adequate treatment should be adopted throughout the field.

PTSD Coach Version 3.1: A Closer Look at the Reach, Use, and Potential Impact of This Updated Mobile Health App in the General Public

BACKGROUND

With widespread smartphone ownership, mobile health apps (mHealth) can expand access to evidence-based interventions for mental health conditions, including posttraumatic stress disorder (PTSD). Research to evaluate new features and capabilities in these apps is critical but lags behind app development. The initial release of PTSD Coach, a free self-management app developed by the US Departments of Veterans Affairs and Defense, was found to have a positive public health impact. However, major stakeholder-driven updates to the app have yet to be evaluated.

OBJECTIVE

We aimed to characterize the reach, use, and potential impact of PTSD Coach Version 3.1 in the general public. As part of characterizing use, we investigated the use of specific app features, which extended previous work on PTSD Coach.

METHODS

We examined the naturalistic use of PTSD Coach during a 1-year observation period between April 20, 2020, and April 19, 2021, using anonymous in-app event data to generate summary metrics for users.

RESULTS

During the observation period, PTSD Coach was broadly disseminated to the public, reaching approximately 150,000 total users and 20,000 users per month. On average, users used the app 3 times across 3 separate days for 18 minutes in total, with steep drop-offs in use over time; a subset of users, however, demonstrated high or sustained engagement. More than half of users (79,099/128,691, 61.46%) accessed one or more main content areas of the app (ie, Manage Symptoms, Track Progress, Learn, or Get Support). Among content areas, features under Manage Symptoms (including coping tools) were accessed most frequently, by over 40% of users (53,314/128,691, 41.43% to 56,971/128,691, 44.27%, depending on the feature). Users who provided initial distress ratings (56,971/128,691, 44.27%) reported relatively high momentary distress (mean 6.03, SD 2.52, on a scale of 0-10), and the use of a coping tool modestly improved momentary distress (mean -1.38, SD 1.70). Among users who completed at least one PTSD Checklist for DSM-5 (PCL-5) assessment (17,589/128,691, 13.67%), PTSD symptoms were largely above the clinical threshold (mean 49.80, SD 16.36). Among users who completed at least two PCL-5 assessments (4989/128,691, 3.88%), PTSD symptoms decreased from the first to last assessment (mean -4.35, SD 15.29), with approximately one-third (1585/4989, 31.77%) of these users experiencing clinically significant improvements.

CONCLUSIONS

PTSD Coach continues to fulfill its mission as a public health resource. Version 3.1 compares favorably with version 1 on most metrics related to reach, use, and potential impact. Although benefits appear modest on an individual basis, the app provides these benefits to a large population. For mHealth apps to reach their full potential in supporting trauma recovery, future research should aim to understand the utility of individual app features and identify strategies to maximize overall effectiveness and engagement.

Auditory N2 Correlates of Treatment Response in Posttraumatic Stress Disorder

Emotional processing and cognitive control are implicated as being dysfunctional in posttraumatic stress disorder (PTSD) and targeted in cognitive processing therapy (CPT), a trauma-focused treatment for PTSD. The N2 event-related potential has been interpreted in the context of emotional processing and cognitive control. In this analysis of secondary outcome measures from a randomized controlled trial, we investigated the latency and amplitude changes of the N2 in responses to task-relevant target tones and task-irrelevant distractor sounds (e.g., a trauma-related gunshot and a trauma-unrelated lion's roar) and the associations between these responses and PTSD symptom changes. United States military veterans (N = 60) diagnosed with combat-related PTSD were randomized to either active or sham repetitive transcranial magnetic stimulation (rTMS) and received a CPT intervention that included a written trauma account element (CPT+A). Participants were tested before and 6 months after protocol completion. Reduction in N2 amplitude to the gunshot stimulus was correlated with reductions in reexperiencing, |r| = .445, and hyperarousal measures, |r| = .364. In addition, in both groups, the latency of the N2 event-related potential to the distractors became longer with treatment and the N2 latency to the task-relevant stimulus became shorter, η_p ²  = .064, both of which are consistent with improved cognitive control. There were no between-group differences in N2 amplitude and latency. Normalized N2 latencies, reduced N2 amplitude to threatening distractors, and the correlation between N2 amplitude reduction and PTSD symptom reduction reflect improved cognitive control, consistent with the CPT+A objective of addressing patients' abilities to respond more appropriately to trauma triggers.

A Scoping Review on the Prevalence and Determinants of Post-Traumatic Stress Disorder among Military Personnel and Firefighters: Implications for Public Policy and Practice

INTRODUCTION

Firefighters and military personnel are public safety personnel who protect the safety of individuals and their properties. They are usually exposed to traumatic events leaving them at risk of developing mental health conditions such as post-traumatic stress disorder (PTSD). Increasing concern is being raised regarding the mental health impacts, specifically PTSD, among military personnel and firefighters.

OBJECTIVE

There is an increased exposure of firefighters and military personnel to traumatic events and the attendant risk of developing post-traumatic stress disorder. It is crucial to ascertain the level of PTSD amongst this cohort and determinants to formulate policies and practices that mitigate the risk and protect public safety personnel. This scoping review sought to determine the prevalence of PTSD among this cohort globally and to explore determinants of this mental health condition.

METHODS

A literature search in databases including MEDLINE, CINAHL, PubMed, PsycINFO, and EMBASE was conducted electronically from May 2021 to 31 July 2021. Two reviewers independently assessed full-text articles according to the predefined inclusion criteria and screening process undertaken to identify studies for the review. Articles were screened with a third reviewer, resolving conflicts where necessary and further assessing them for eligibility. During article selection, the PRISMA checklist was adopted, and with the Covidence software, a total of 32 articles were selected for the final examination. For the eligible studies, data extraction was conducted, information was collated and summarized, and the findings were reported. Original qualitative and quantitative data on the prevalence and predictors of PTSD among veterans, military, and firefighters were reported.

RESULTS

The prevalence of PTSD was 57% for firefighters and 37.8% for military personnel. Demographic factors, job factors, social support, injuries, physical and psychological factors, and individual traits were the main predictors of PTSD in this cohort.

CONCLUSION

This information is vital for developing and implementing prevention and intervention strategies for PTSD in military personnel and firefighters. Recognizing and addressing factors that predict PTSD will help to improve mental wellbeing and increase productivity. More peer-reviewed studies are needed on the prevalence of PTSD amongst these cohorts.