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Kitaj M, Goff DC. Why Do Veterans Not Respond as Well as Civilians to Trauma-Focused Therapies for PTSD? Harv Rev Psychiatry 2024; 32:160-163. [PMID: 38990904 DOI: 10.1097/hrp.0000000000000400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
ABSTRACT This column first reviews evidence that veterans have poorer response to trauma-focused therapies for PTSD compared to civilians. We then consider several explanations for this trend, starting with gender as a possible confounding variable. We also examine other hypotheses, including the effects of the military acculturation process, the unique influences of military traumas, such as combat and military sexual traumas, and the roles of traumatic brain injuries (TBIs) and moral injury. Future research, we conclude, must determine whether gender explains the differences in trauma-focused therapy response. If so, then the underlying reasons must be further explored. If not, then we must determine the unique characteristics of the veteran population that make it more resistant to treatment. Mining these elements will help us adapt our trauma-focused therapies to better help this population and close the response-rate gap.
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Affiliation(s)
- Max Kitaj
- From Department of Psychiatry, NYU Grossman School of Medicine (Drs. Kitaj and Goff)
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Kline AC, Otis N, Panza KE, McCabe CT, Glassman L, Campbell JS, Walter KH. PTSD, depression, and treatment outcomes: A latent profile analysis among active duty personnel in a residential PTSD program. J Psychiatr Res 2024; 173:71-79. [PMID: 38508035 DOI: 10.1016/j.jpsychires.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/05/2024] [Accepted: 03/07/2024] [Indexed: 03/22/2024]
Abstract
Depression frequently co-occurs with posttraumatic stress disorder (PTSD), including among active duty service members. However, symptom heterogeneity of this comorbidity is complex and its association with treatment outcomes is poorly understood, particularly among active duty service members in residential treatment. This study used latent profile analysis (LPA) to identify symptom-based subgroups of PTSD and depression among 282 male service members in a 10-week, residential PTSD treatment program with evidence-based PTSD psychotherapies and adjunctive interventions. The PTSD Checklist-Military Version and Patient Health Questionnaire-8 were completed by service members at pre- and posttreatment and weekly during treatment. Multilevel models compared subgroups on PTSD and depression symptom change across treatment. LPA indicated four subgroups provided optimal fit: Depressive (high depression severity, low PTSD avoidance; n = 33, 11.7%), Avoidant (high PTSD avoidance, moderate depression severity; n = 89, 31.6%), Moderate (moderate PTSD and depression severity; n = 27, 9.6%), and Distressed (high PTSD and depression severity; n = 133, 47.2%). Treatment response differed across classes for both PTSD and depression outcomes (time × LPA class interaction ps < 0.001). In PTSD models, post-hoc comparisons indicated the Moderate class was associated with less PTSD symptom improvement relative to the other classes (ps < 0.006). In depression models, symptom reduction was greatest for the Distressed and Depressive subgroups relative to the other two classes (ps < 0.009). Study results provide an initial model for two prevalent, impairing disorders among service members and show how these symptom-based subgroups may differentially respond to residential PTSD treatment.
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Affiliation(s)
- Alexander C Kline
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA; Leidos, Inc., San Diego, CA, USA
| | - Nicholas Otis
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA; Leidos, Inc., San Diego, CA, USA
| | - Kaitlyn E Panza
- VA San Diego Healthcare System, San Diego, CA, USA; University of California, San Diego, San Diego, CA, USA
| | - Cameron T McCabe
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA
| | - Lisa Glassman
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA; Leidos, Inc., San Diego, CA, USA
| | | | - Kristen H Walter
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA.
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Chen JA, Shofer J, Barnes ML, Livingston WS, Upham M, Simpson TL. Military Sexual Trauma As a Risk Factor for Treatment Non-Response from an Online, Self-Management Posttraumatic Stress Disorder Treatment for Women Veterans. JOURNAL OF INTERPERSONAL VIOLENCE 2024; 39:2214-2237. [PMID: 38073465 DOI: 10.1177/08862605231216722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Women veterans are exposed to high rates of trauma, including military sexual trauma (MST), and face unique barriers to posttraumatic stress disorder (PTSD) treatment. Telehealth interventions that are tailored to women veterans' unique lived experiences may improve treatment engagement and outcomes. It is important to ascertain how beneficial new telehealth interventions are in the context of different patient characteristics and trauma types, particularly for lower-intensity telehealth interventions (e.g., web-based programs or apps). This secondary analysis of a randomized clinical trial conducted in a sample of 102 women veterans examines predictors of treatment response to a self-management, telehealth intervention for PTSD: Delivery of Self Training and Education for Stressful Situations-Women Veterans (DESTRESS-WV). In the trial, women veterans with PTSD received either an online cognitive behavioral intervention with phone coaching, or phone monitoring alone. We examined associations between baseline patient characteristics (demographics, trauma types, and clinical symptoms) and treatment outcome at post-treatment, 3 months, and 6 months, focusing on the association between treatment outcome and MST. Our primary outcomes were changes in PTSD (PTSD Symptom Checklist, Version 5, PCL-5) and depression (8-item Patient Health Questionnaire, PHQ-8) in the full sample, adjusting for treatment condition. Women veterans who identified MST as the primary trauma for which they were seeking PTSD treatment experienced a nearly nine-point lesser improvement on the PCL-5 than those seeking PTSD treatment for other trauma types (e.g., childhood abuse, combat trauma; p = .0073). Similar patterns were found for depression symptoms. To our knowledge, this is the first study to examine the association between trauma type and treatment outcomes within the context of a self-management, telehealth treatment for PTSD. While the study was not powered to examine differential treatment response for patient subgroups, our exploratory findings suggest that gaps remain in providing effective PTSD care for women veterans who experienced MST.Trial registration: The trial and analysis plan were preregistered in ClinicalTrials.gov (Identifier: NCT02917447).
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Affiliation(s)
- Jessica A Chen
- VA Puget Sound Healthcare System, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | - Jane Shofer
- VA Puget Sound Healthcare System, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | | | - Whitney S Livingston
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Jamaica Plain, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | - Tracy L Simpson
- VA Puget Sound Healthcare System, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment & Education, VA Puget Sound Healthcare System, Seattle, WA, USA
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van den End A, Beekman ATF, Dekker J, Thomaes K. Self-rated personality disorder symptoms do not predict treatment outcome for posttraumatic stress disorder in routine clinical care. Clin Psychol Psychother 2023; 30:1338-1348. [PMID: 37985013 DOI: 10.1002/cpp.2933] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To test the hypothesis that self-rated personality disorder (PD) symptoms are a significant and clinically relevant predictor of treatment outcomes in a naturalistic treatment setting specialized in trauma-focused treatment using a single-group pretest-posttest design. METHOD Treatment-seeking patients reporting clinical levels of posttraumatic stress disorder (PTSD) symptoms filled out questionnaires at intake and after treatment. The primary outcome was change in PTSD severity after treatment, measured by the PTSD Checklist for DSM-5 (PCL-5). PD symptoms were measured with the Structured Clinical Interview for DSM-5 Screening Personality Questionnaire (SCID-5-SPQ). Secondary outcomes were general mental health problems, treatment response, number of sessions and dropout. RESULTS N = 1174 patients (59% female, baseline PCL-5 score M [SD] = 53.0 [10.8]) were included for the primary analysis. Regression analysis revealed that PD symptoms explained 0.4% of variance in PTSD symptom change (p = .066). After controlling for baseline PTSD symptoms, PD symptoms explained 0.0% of variance (p = .311). The fully adjusted model including baseline PTSD symptom severity, age, gender, cumulative exposure to potentially traumatic experiences, PD symptoms, and number of sessions together explained 5% of the observed variance in PTSD symptom change. Baseline PTSD severity was the only significant predictor and negatively predicted outcome. Sensitivity analyses with imputed data from N = 2694 cases yielded comparable results. Finally, secondary analyses showed that PD symptoms did not predict significant or clinically relevant changes in treatment response status, general mental health problems, dropout rates or number of sessions. CONCLUSION The findings provide no evidence that self-rated PD symptoms predict treatment outcomes for patients suffering from clinical levels of PTSD symptoms in a naturalistic treatment setting specializing in trauma-focused treatment. Self-report screening for these symptoms to inform clinicians about expected effects of PTSD treatment is not supported by the evidence.
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Affiliation(s)
- Arne van den End
- Department of Psychiatry, Amsterdam University Medical Center, Location Vrije Universiteit Medical Center, Amsterdam, The Netherlands
- Sinai Center, Amstelveen, The Netherlands
| | - Aartjan T F Beekman
- Department of Psychiatry, Amsterdam University Medical Center, Location Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Jack Dekker
- Department of Research, Arkin Mental Health Care, Amsterdam, The Netherlands
- Faculty of Behavioral and Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| | - Kathleen Thomaes
- Department of Psychiatry, Amsterdam University Medical Center, Location Vrije Universiteit Medical Center, Amsterdam, The Netherlands
- Sinai Center, Amstelveen, The Netherlands
- Department of Research, Arkin Mental Health Care, Amsterdam, The Netherlands
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Cardona ND, Ametaj AA, Cassiello-Robbins C, Tirpak JW, Olesnycky O, Sauer-Zavala S, Farchione TJ, Barlow DH. Outcomes of People of Color in an Efficacy Trial of Cognitive-Behavioral Treatments for Anxiety, Depression, and Related Disorders: Preliminary Evidence. J Nerv Ment Dis 2023; 211:711-720. [PMID: 37432031 PMCID: PMC10524474 DOI: 10.1097/nmd.0000000000001692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
ABSTRACT Although evidence-based psychological treatments such as cognitive behavioral therapy (CBT) have strong empirical support for reducing anxiety and depression symptoms, CBT outcome research often does not report race and ethnicity variables, or assess how well CBT works for people from historically excluded racial and ethnic groups. This study presents post hoc analyses comparing treatment retention and symptom outcomes for participants of color ( n = 43) and White participants ( n = 136) from a randomized controlled efficacy trial of CBT. χ 2 tests and one-way ANCOVA showed no observable differences between the two samples on attrition or on clinician-rated measures of anxiety and depression at posttreatment and follow-up. Moderate to large within-group effect sizes on anxiety and depression were found for Black, Latinx, and Asian American participants at almost all time points. These preliminary findings suggest that CBT for anxiety and comorbid depression may be efficacious for Black, Asian American, and Latinx individuals.
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Affiliation(s)
- Nicole D Cardona
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
| | - Amantia A Ametaj
- Department of Epidemiology, Harvard Chan School of Public Health, Boston, Massachusetts
| | | | | | - Olenka Olesnycky
- Department of Psychology, Hofstra University, Hempstead, New York
| | | | - Todd J Farchione
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
| | - David H Barlow
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
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Godfrey LB, Cloitre M, Elwy AR, Fortuna LR, Fuchs C, Valentine SE. Study protocol for a hybrid 1 effectiveness-implementation trial of Brief Skills Training in Affective and Interpersonal Regulation (Brief STAIR) and web-administered STAIR (webSTAIR) for posttraumatic stress disorder in integrated primary care. Contemp Clin Trials 2023; 131:107241. [PMID: 37244367 PMCID: PMC10527289 DOI: 10.1016/j.cct.2023.107241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/06/2023] [Accepted: 05/22/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) disproportionally affects low-income, racial and ethnic minoritized communities, where prevalence is high, yet access to evidence-based treatments (EBTs) is low. As such, there is a need to identify effective, feasible, and scalable interventions for PTSD. Stepped care approaches that include brief, low-intensity treatments are one approach to improving access yet have not been developed for adults with PTSD. Our study aims to test the effectiveness of a step one PTSD treatment in primary care while gathering information on implementation to maximize sustainability in the setting. METHODS This study will be conducted in integrated primary care in the largest safety net hospital in New England using a hybrid type 1 effectiveness-implementation design. Eligible trial participants are adult primary care patients who meet full or subthreshold criteria for PTSD. Interventions include Brief clinician-administered Skills Training in Affective and Interpersonal Regulation (Brief STAIR) versus web-administered STAIR (webSTAIR) during a 15-week active treatment period. Participants complete assessments at baseline (pre-treatment), 15 weeks (post-treatment), and 9 months (follow-up) post-randomization. We will assess feasibility and acceptability post-trial using surveys and interviews with patients, study therapists, and other key informants, and will assess the preliminary effectiveness of interventions in terms of PTSD symptom change and functioning. CONCLUSION This study will provide evidence for the feasibility, acceptability, and preliminary effectiveness of brief, low-intensity interventions in safety net integrated primary care, with the aim of including these interventions in a future stepped care approach to PTSD treatment. CLINICAL TRIAL NUMBER NCT04937504.
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Affiliation(s)
- Laura B Godfrey
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
| | - Marylène Cloitre
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; National Center for PTSD, Dissemination and Training Division at VA Palo Alto Health Care, Palo Alto, CA, USA
| | - A Rani Elwy
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA; Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Lisa R Fortuna
- Department of Psychiatry and Behavioral Sciences at University of California, San Francisco, San Francisco, CA, USA
| | - Cara Fuchs
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sarah E Valentine
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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Makale MT, Abbasi S, Nybo C, Keifer J, Christman L, Fairchild JK, Yesavage J, Blum K, Gold MS, Baron D, Cadet JL, Elman I, Dennen CA, Murphy KT. Personalized repetitive transcranial magnetic stimulation (prtms®) for post-traumatic stress disorder (ptsd) in military combat veterans. Heliyon 2023; 9:e18943. [PMID: 37609394 PMCID: PMC10440537 DOI: 10.1016/j.heliyon.2023.e18943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/24/2023] Open
Abstract
Emerging data suggest that post-traumatic stress disorder (PTSD) arises from disrupted brain default mode network (DMN) activity manifested by dysregulated encephalogram (EEG) alpha oscillations. Hence, we pursued the treatment of combat veterans with PTSD (n = 185) using an expanded form of repetitive transcranial magnetic stimulation (rTMS) termed personalized-rTMS (PrTMS). In this treatment methodology spectral EEG based guidance is used to iteratively optimize symptom resolution via (1) stimulation of multiple motor sensory and frontal cortical sites at reduced power, and (2) adjustments of cortical treatment loci and stimulus frequency during treatment progression based on a proprietary frequency algorithm (PeakLogic, Inc. San Diego) identifying stimulation frequency in the DMN elements of the alpha oscillatory band. Following 4 - 6 weeks of PrTMS® therapy in addition to routine PTSD therapy, veterans exhibited significant clinical improvement accompanied by increased cortical alpha center frequency and alpha oscillatory synchronization. Full resolution of PTSD symptoms was attained in over 50% of patients. These data support DMN involvement in PTSD pathophysiology and suggest a role in therapeutic outcomes. Prospective, sham controlled PrTMS® trials may be warranted to validate our clinical findings and to examine the contribution of DMN targeting for novel preventive, diagnostic, and therapeutic strategies tailored to the unique needs of individual patients with both combat and non-combat PTSD.
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Affiliation(s)
- Milan T. Makale
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, 92093, USA
| | - Shaghayegh Abbasi
- Department of Electrical Engineering, University of Portland, Portland, OR, 97203, USA
| | - Chad Nybo
- CrossTx Inc., Bozeman, MT, 59715, USA
| | | | | | - J. Kaci Fairchild
- Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, 94305, USA
- Sierra Pacific Mental Illness Research, Education, and Clinical Center, VA Medical Center, Palo Alto, CA, 94304, USA
| | - Jerome Yesavage
- Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, 94305, USA
| | - Kenneth Blum
- Division of Addiction Research & Education, Center for Sports, Exercise & Global Mental Health, Western University Health Sciences, Pomona, USA
- Department of Clinical Psychology and Addiction, Institute of Psychology, Faculty of Education and Psychology, Eötvös Loránd University, Hungary
- Department of Psychiatry, Wright University, Boonshoft School of Medicine, Dayton, OH, USA
- Department of Molecular Biology and Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Mark S. Gold
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - David Baron
- Division of Addiction Research & Education, Center for Sports, Exercise & Global Mental Health, Western University Health Sciences, Pomona, USA
| | - Jean Lud Cadet
- Molecular Neuropsychiatry Research Branch, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD, USA
| | - Igor Elman
- Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA
| | - Catherine A. Dennen
- Department of Family Medicine, Jefferson Health Northeast, Philadelphia, PA, USA
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Maguen S, Batten A, Hubbard A, Holder N, Burkman K, Cottonham D, Purcell N, Mehlman H, Shiner B. Advancing health equity by understanding race disparities and other factors associated with PTSD symptom improvement following evidence-based psychotherapy. J Anxiety Disord 2023; 98:102747. [PMID: 37515867 DOI: 10.1016/j.janxdis.2023.102747] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 07/31/2023]
Abstract
Several studies found that Black veterans demonstrate less posttraumatic stress disorder (PTSD) symptom improvement than White veterans following PTSD evidence-based psychotherapies (EBPs). We aimed to understand this disparity among veterans receiving EBPs by modeling race with demographic, clinical, and service utilization factors. Using electronic health records, we employed a cohort study of Iraq and Afghanistan War Veterans who initiated PTSD EBP treatment and completed > 2 PTSD symptom measures (N = 21,751). Using hierarchical Bayesian logistic regressions, we modeled the probability of PTSD symptom improvement. Black race was associated with less PTSD improvement (mean posterior odds ratio [MPOR] = 0.92; 95 % plausibility interval [PI] = 0.84, 1.0), as was group therapy (MPOR = 0.67; 95 % PI = 0.62, 0.73). Factors associated with greatest improvement included prolonged exposure (MPOR = 1.35; 95 % PI = 1.25, 1.45) and treatment density (MPOR = 1.40; 95 % PI = 1.36, 1.45). On average, Black veterans evidenced PTSD EBP improvement disparities. Clinical and utilization did not fully account for these disparities, although disproportionate representation of Black veterans in group CPT may explain some of these differences. Understanding experiences such as race-based trauma and chronic racism and discrimination is critical to provide Black veterans with the most effective PTSD care.
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Affiliation(s)
- Shira Maguen
- San Francisco VA Health Care System, San Francisco, CA, USA; University of California - San Francisco, San Francisco, CA, USA.
| | - Adam Batten
- San Francisco VA Health Care System, San Francisco, CA, USA; University of California - San Francisco, San Francisco, CA, USA
| | - Asale Hubbard
- San Francisco VA Health Care System, San Francisco, CA, USA; University of California - San Francisco, San Francisco, CA, USA
| | - Nicholas Holder
- San Francisco VA Health Care System, San Francisco, CA, USA; University of California - San Francisco, San Francisco, CA, USA
| | - Kristine Burkman
- San Francisco VA Health Care System, San Francisco, CA, USA; University of California - San Francisco, San Francisco, CA, USA
| | - Danielle Cottonham
- San Francisco VA Health Care System, San Francisco, CA, USA; University of California - San Francisco, San Francisco, CA, USA
| | - Natalie Purcell
- San Francisco VA Health Care System, San Francisco, CA, USA; University of California - San Francisco, San Francisco, CA, USA
| | - Haley Mehlman
- San Francisco VA Health Care System, San Francisco, CA, USA; University of California - San Francisco, San Francisco, CA, USA
| | - Brian Shiner
- White River Junction Veterans Affairs Medical Center, White River Junction, VT, USA; Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Sippel LM, Gross GM, Spiller TR, Duek O, Smith N, Hoff R, Harpaz-Rotem I. Comparative effectiveness of evidence-based psychotherapies for PTSD delivered in VA residential PTSD treatment. Psychol Med 2023:1-8. [PMID: 36971021 DOI: 10.1017/s0033291723000375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are first-line treatments for posttraumatic stress disorder (PTSD). There have been few direct comparisons of CPT and PE intended to determine their comparative effectiveness, none of which have examined outcomes among military veterans receiving these treatments in a residential setting such as the Department of Veterans Affairs (VA) residential rehabilitation treatment programs (RRTPs). Such work is essential given that these veterans are among the most complex and severely symptomatic patients with PTSD treated in VA. In this study we compared changes in PTSD and depressive symptoms across admission, discharge, four months and 12 months following discharge among veterans who received CPT or PE within VA RRTPs. METHODS Using linear mixed models conducted on program evaluation data derived from the electronic medical record and follow-up surveys, we compared self-reported PTSD and depressive symptom outcomes among 1130 veterans with PTSD who were treated with individual CPT (n = 832, 73.5%) or PE (n = 297, 26.5%) in VA PTSD RRTPs in fiscal years 2018-2020. RESULTS PTSD and depressive symptom severity did not significantly differ at any time points. The CPT and PE groups both showed large-sized reductions in PTSD (CPT d = 1.41, PE d = 1.51) and depression (CPT d = 1.01, PE d = 1.09) from baseline to 12-month follow-up. CONCLUSIONS Outcomes for PE and CPT do not differ among a highly complex population of veterans with severe PTSD and several comorbid conditions that can make it difficult to engage in treatment.
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Affiliation(s)
- Lauren M Sippel
- Northeast Program Evaluation Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH 03755, USA
- National Center for PTSD, Evaluation Division, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Georgina M Gross
- Northeast Program Evaluation Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- National Center for PTSD, Evaluation Division, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- Department of Psychiatry, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Tobias R Spiller
- Department of Psychiatry, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Or Duek
- Department of Psychiatry, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
- Department of Epidemiology, Biostatistics and Community Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Noelle Smith
- Northeast Program Evaluation Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- Department of Psychiatry, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Rani Hoff
- Northeast Program Evaluation Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- National Center for PTSD, Evaluation Division, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- Department of Psychiatry, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Ilan Harpaz-Rotem
- Northeast Program Evaluation Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- National Center for PTSD, Evaluation Division, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- Department of Psychiatry, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
- Department of Psychology and the Wu Tsai Institute, Yale University, New Haven, CT 06510, USA
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10
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Bryant RA, Dawson KS, Azevedo S, Yadav S, Cahill C, Kenny L, Maccallum F, Tran J, Rawson N, Tockar J, Garber B, Keyan D. Augmenting trauma-focused psychotherapy for post-traumatic stress disorder with brief aerobic exercise in Australia: a randomised clinical trial. Lancet Psychiatry 2023; 10:21-29. [PMID: 36436532 DOI: 10.1016/s2215-0366(22)00368-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although exposure therapy is central in most front-line psychotherapies of post-traumatic stress disorder (PTSD), many patients do not respond to this treatment. We aimed to investigate the effects of brief aerobic exercise on the efficacy of exposure therapy in reducing the severity of PTSD. METHODS We did a single-blind, parallel, randomised controlled trial in Sydney, NSW, Australia. We included adults (aged ≥18 years) with clinician-diagnosed PTSD. We excluded participants aged 70 years or older, with imminent suicidal risk (reporting suicidal plan), presence of psychosis or substance dependence, history of moderate-to-severe traumatic brain injury, or presence of a physical disorder or impairment that might be exacerbated by aerobic exercise (eg, back pain). We randomly assigned participants (1:1) to nine 90-min weekly sessions of exposure therapy for PTSD with 10 min aerobic exercise or to the control group of exposure therapy with 10 min passive stretching. The primary outcome was PTSD severity measured by the clinician-administered PTSD scale 2 (CAPS-2), independently assessed at baseline, 1 week after treatment, and 6 months after treatment (primary outcome timepoint). FINDINGS Between Dec 12, 2012, and July 25, 2018, we enrolled 130 participants with PTSD, with 65 (50%) participants randomly assigned to exposure therapy with exercise and 65 (50%) to exposure therapy with passive stretching, including 79 (61%) women and 51 (39%) men, with a mean age of 39·1 years (SD 14·4; range 18-69). 99 (76%) participants were White, 14 (11%) were Asian, and 17 (13%) were listed as other. At the 6-month follow-up assessment, participants in the exposure therapy with exercise group showed greater reductions in CAPS-2 scores relative to those in the exposure therapy with stretching group (mean difference 12·1 [95% CI 2·4-21·8]; p=0·023), which resulted in a moderate effect size of 0·6 (0·1-1·1). No adverse events associated with the intervention were reported. The trial was prospectively registered on the Australian and New Zealand Clinical Trials Registry, ACTRN12612000185864. INTERPRETATION Brief aerobic exercise has the potential to augment long-term gains of exposure therapy for PTSD, which accords with evidence from studies in animals and humans on the role of exercise in modulating the extinction learning processes. This strategy might offer a simple and affordable means to augment treatment gains for exposure therapy in people with PTSD. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia; Brain Dynamics Centre, Westmead Institute for Medical Research, Sydney, NSW, Australia.
| | - Katie S Dawson
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Suzanna Azevedo
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Srishti Yadav
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Catherine Cahill
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Lucy Kenny
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Fiona Maccallum
- School of Psychology, University of Queensland, Brisbane, QLD, Australia
| | - Jenny Tran
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Natasha Rawson
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Julia Tockar
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Benjamin Garber
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Dharani Keyan
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
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11
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Grau PP, Sripada RK, Pietrzak RH, Ganoczy D, Harpaz-Rotem I. Treatment response trajectories in residential PTSD programs for veterans: A national cohort investigation. J Anxiety Disord 2022; 92:102645. [PMID: 36334317 DOI: 10.1016/j.janxdis.2022.102645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/05/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
Although improving residential PTSD care is a priority for the Department of Veterans Affairs, previous evaluations have been limited by a lack of systematic data collection across more than two timepoints. This study used recently available data to assess symptom trajectories in a large, national sample of veterans who engaged in residential PTSD treatment. Group-based trajectory analysis PROC TRAJ was used to identify PTSD residential treatment response in a national cohort of veterans (n = 10,832) and the subset of veterans (n = 6515) receiving evidence-based psychotherapy (EBP). PTSD symptoms were assessed at intake, discharge, and 4-month follow-up. Predictors of trajectory membership were estimated using multinomial models. For the full cohort, a three-group trajectory model provided the best fit with the following identified groups: "Severe/Stable" (51.8%), "Moderate/Rebound" (40.1%), and "Mild/Rebound" (8.1%). For the EBP sub-cohort, a three-group trajectory model was selected with the following groups: "Severe/Stable" (58.5%), "Moderate/Rebound" (34.1%), and "Mild/Rebound" (7.4%). Across all trajectories, psychological distress, pain severity, substance use, Iraq/Afghanistan combat era, non-White race, and treatment dropout were associated with poorer treatment response. In the EBP sub-cohort, homelessness and unemployment at the time of admission were also associated with poorer treatment outcomes to varying degrees. This study demonstrates that residential treatment for PTSD is associated with heterogeneous treatment trajectories which highlight the need to continue to explore and improve residential PTSD treatment outcomes. Our results underscore the importance of obtaining follow-up data and identifying ways to maintain therapeutic gains following discharge.
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Affiliation(s)
- Peter P Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States; VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States.
| | - Rebecca K Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Robert H Pietrzak
- Veterans Affairs National Center for PTSD, Veteran Affairs Connecticut Healthcare System, West Haven, CT, United States; Yale University, Department of Psychiatry, New Haven, CT, United States
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Ilan Harpaz-Rotem
- Veterans Affairs National Center for PTSD, Veteran Affairs Connecticut Healthcare System, West Haven, CT, United States; Yale University, Department of Psychiatry, New Haven, CT, United States; Veterans Affairs Northeast Program Evaluation Center, West Haven, CT, United States
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12
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Grau PP, Bohnert KM, Ganoczy D, Sripada RK. Who improves in trauma-focused treatment: A cluster analysis of treatment response in VA patients undergoing PE and CPT. J Affect Disord 2022; 318:159-166. [PMID: 36070830 DOI: 10.1016/j.jad.2022.08.126] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/20/2022] [Accepted: 08/28/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although most veterans with posttraumatic stress disorder (PTSD) benefit from evidence-based treatments, questions persist concerning the profiles of those at risk for poor outcomes. To help address these gaps, this study analyzed a large clinical cohort of veterans receiving prolonged exposure (PE) or cognitive processing therapy (CPT). METHODS Cluster analysis using Ward's method with Euclidian distances identified clinically meaningful subgroups of veterans in a national cohort (n = 20,848) using variables maintained in the electronic medical record. The clusters were then compared via one-way analysis of variance and Tukey's HSD on indicators of treatment progress including PTSD symptom change, clinical recovery, clinically significant change, remission, and treatment completion. RESULTS Effect size differences on clinical outcome measures for PE and CPT were negligible. Less than half of veterans achieved at least a 15-point reduction in PCL-5 score and half completed treatment. We identified 10 distinct clusters. Higher rates of PTSD service-connected disability were linked to poorer outcomes across multiple clusters, especially when combined with Post-Vietnam service era. Non-White race was also linked with poorer clinical outcomes. Factors associated with better outcomes included a greater proportion of female veterans, especially when combined with recent service era, and longer PTSD diagnosis duration. CONCLUSIONS This study suggests the need to improve PTSD treatment outcomes for non-White and male veterans, examine treatment response in Post-Vietnam era veterans, and consider ways in which the service connection process could hinder treatment response. The results from this study also indicate the benefits of integrating elements of clinical complexity into an analytic approach.
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Affiliation(s)
- Peter P Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States; VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States.
| | - Kipling M Bohnert
- Department of Epidemiology and Biostatistics, Michigan State University, United States
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Rebecca K Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
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13
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Wiltsey Stirman S, La Bash H, Nelson D, Orazem R, Klein A, Sayer NA. Assessment of modifications to evidence-based psychotherapies using administrative and chart note data from the US department of veterans affairs health care system. Front Public Health 2022; 10:984505. [PMID: 36457312 PMCID: PMC9705357 DOI: 10.3389/fpubh.2022.984505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background The US Department of Veterans Affairs (VA) has over 15 years of experience in delivery of evidence-based psychotherapies (EBPs). This paper describes strategies for using clinical documentation and administrative data to understand adherence and modifications to EBPs for Posttraumatic Stress Disorder (PTSD). Methods This study focused on two EBPs for PTSD, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). The sample included VA therapists from across the US who provided CPT and PE and the patients they treated over a 1-year period. The data sources for this study were templated EBP chart notes and VA administrative data. We used a manual review of note content and administrative data rules to code therapy adherence and modifications in 7,297 EBP sessions for 1,257 patients seen by 182 therapists. Two trained coders rated each therapy note and resolved discrepancies through consensus. To contextualize and explain variation in adherence and modifications, we conducted brief 30-45-min semi-structured interviews with a purposive subsample of these therapists (n = 32). Findings Combining manual chart review and administrative data allowed for identification of 11 types of modifications. Raters disagreed on adherence for 30% of notes. The disagreement stemmed from the presence of therapy modifications that were not clearly documented, necessitating the development of decision rules and strategies for modification coding. Both therapists and patients contributed to the variance in the extent to which different modifications occurred. Therapist interviews demonstrated therapist awareness of modifying the protocols in the ways identified through chart review. Conclusion Healthcare systems can use data collected as part of routine care to understand how and when EBPs are modified but need to develop scalable strategies to document adaptations and modifications to EBPs in routine care.
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Affiliation(s)
- Shannon Wiltsey Stirman
- National Center for PTSD, VA Palo Alto Healthcare System, Menlo Park, CA, United States,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States,*Correspondence: Shannon Wiltsey Stirman
| | - Heidi La Bash
- National Center for PTSD, VA Palo Alto Healthcare System, Menlo Park, CA, United States
| | - David Nelson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States,Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Robert Orazem
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States
| | - Abigail Klein
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States
| | - Nina A. Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States,Department of Medicine and Psychiatry, University of Minnesota, Minneapolis, MN, United States
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14
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Haven SE, Brown WJ, Berfield JB, Bruce SE. Predictors of Attrition and Response in Cognitive Processing Therapy for Interpersonal Trauma Survivors with PTSD. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:NP19759-NP19780. [PMID: 34498510 DOI: 10.1177/08862605211043584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
With the establishment of empirically validated treatments for posttraumatic stress disorder (PTSD), concerns remain regarding the effectiveness of such treatments in real-world clinical settings. Specifically, premature termination and treatment response limit the effectiveness of these interventions. The current study investigated factors potentially related to premature termination and treatment response in Cognitive Processing Therapy with Account (CPT-A). Participants in this study included 42 women (Mage = 30.70 SDage = 9.40) with PTSD from exposure to interpersonal trauma. Demographic characteristics, pre-treatment symptoms of PTSD and depression, and transdiagnostic factors were examined as predictors of attrition and treatment response. Hierarchical regression and logistic regression models were analyzed to test the variance explained and predictive value of these factors. The present study revealed that age was a significant factor related to dropout from CPT-A whereas baseline PTSD symptom severity was significantly related to treatment response. Results of this study suggest the importance of the interrelationships among pre-treatment predictors as well as the consideration of attrition and treatment response as distinct metrics of treatment outcome. Further, these results inform the application of CPT-A for PTSD in survivors of interpersonal trauma, as consideration of the identified predictors of dropout and non-response at intake may contribute to treatment retention and response.
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15
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LoSavio ST, Holder N, Wells SY, Resick PA. Clinician Concerns About Cognitive Processing Therapy: A Review of the Evidence. COGNITIVE AND BEHAVIORAL PRACTICE 2022. [DOI: 10.1016/j.cbpra.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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16
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Sripada RK, Rodriguez JL, Wright TP, Hyland JA, Walters HM, Ganoczy D, Haft SM, Smith ER, Porter KE, Driesenga SA, DeJong TM, Rauch SAM. Feasibility and Acceptability of Group-Facilitated Prolonged Exposure Therapy for PTSD in VA Residential Rehabilitation Treatment Programs. Behav Ther 2022; 53:714-724. [PMID: 35697433 DOI: 10.1016/j.beth.2022.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 11/02/2022]
Abstract
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.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research, Ann Arbor; Veterans Affairs Ann Arbor Health Care System; University of Michigan.
| | | | | | | | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Ann Arbor
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17
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Rodriguez JL, Hale AC, Marston HN, Sage-Germain CE, Wright TP, Driesenga SA, Martin SM, Sripada RK. The Association Between Service Connection and Treatment Outcome in Veterans Undergoing Residential PTSD Treatment. Psychiatr Q 2022; 93:285-296. [PMID: 34532825 DOI: 10.1007/s11126-021-09940-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 11/26/2022]
Abstract
The Department of Veterans Affairs has invested significant time and resources into the treatment of posttraumatic stress disorder (PTSD). Despite concerted efforts, a significant portion of patients do not respond optimally to trauma-focused treatment. One of the factors that has been hypothesized to be associated with treatment response is participation in the Veterans Benefits Administration service-connected disability process. This factor may be particularly relevant in the residential treatment setting, where most participants are engaged in the compensation seeking process. We conducted a retrospective chart review of 105 veterans who completed Cognitive Processing Therapy (CPT) in a residential rehabilitation program. ANCOVAs that adjusted for baseline PTSD severity compared symptom change between those who were and were non-compensation seeking at the time of treatment. Compensation seeking status was associated with significantly less symptom improvement over the course of CPT after adjusting for baseline PTSD severity (F(1, 102) = 4.29, p < .001, η2 = .03). Sensitivity analyses did not detect a similar effect during a prior coping skills phase of treatment. During CPT, clinically significant change was met by 66.7% of non-compensation seeking veterans (M = -15, SD = 14.56) and by 40.1% of the compensation seeking group (M = -7.1, SD = 12.24). Compensation-seeking may be associated with reduced response to trauma-focused treatment in certain settings. Future research is needed to better understand the mechanisms underlying this effect.
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Affiliation(s)
- Jessica L Rodriguez
- Psychology Service, Battle Creek VA Medical Center, 5500 Armstrong Road, Battle Creek, MI, 49037, USA.
| | - Andrew C Hale
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System/Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Holloway N Marston
- Psychology Service, Battle Creek VA Medical Center, 5500 Armstrong Road, Battle Creek, MI, 49037, USA
| | - Chelsea E Sage-Germain
- Psychology Service, Battle Creek VA Medical Center, 5500 Armstrong Road, Battle Creek, MI, 49037, USA
| | - Theodore P Wright
- Psychology Service, Battle Creek VA Medical Center, 5500 Armstrong Road, Battle Creek, MI, 49037, USA
| | - Scott A Driesenga
- Psychology Service, Battle Creek VA Medical Center, 5500 Armstrong Road, Battle Creek, MI, 49037, USA
| | - Shannon M Martin
- Department of Psychology, Converse College, Spartanburg, SC, USA
| | - Rebecca K Sripada
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System/Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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18
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Yun JA, Lee CH. Written Exposure Therapy for Korean Adolescents With PTSD: Four Case Studies. Clin Case Stud 2022. [DOI: 10.1177/15346501221074316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Research shows that cognitive behavioral therapy (CBT) is the most effective approach for treating children and adolescents with post-traumatic stress disorder (PTSD). However, evidence regarding CBT for adolescents with PTSD in Korea is lacking. Written Exposure Therapy (WET), which has the advantages of brevity and tolerability, has important clinical implications as an option for effective treatment of PTSD in the context of the Korean medical system. We aimed to examine the application of WET to adolescents through the cases of four Korean adolescents who underwent WET. The treatment experiences of the four adolescent participants with PTSD are presented, and insights based on their pre- and post-treatment research assessments are discussed. Although evidence is insufficient, our study suggests that WET can be considered a suitable treatment for adolescents who do not have a history of childhood abuse and have a relatively good support system.
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Affiliation(s)
- Ji-ae Yun
- Department of Neuropsychiatry, Daejeon Eulji Medical Center, Daejeon, Republic of Korea
| | - Chang-Hwa Lee
- Department of Neuropsychiatry, Daejeon Eulji Medical Center, Daejeon, Republic of Korea
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19
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Suazo NC, Reyes ME, Contractor AA, Thomas ED, Weiss NH. Exploring the moderating role of gender in the relation between emotional expressivity and posttraumatic stress disorder symptom severity among Black trauma-exposed college students at a historically Black university. J Clin Psychol 2022; 78:343-356. [PMID: 34320220 PMCID: PMC8795200 DOI: 10.1002/jclp.23226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/15/2021] [Accepted: 06/30/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Posttraumatic stress disorder (PTSD) is characterized in part by negative alterations of cognition or mood, including alterations in emotional expressivity, or the extent to which one outwardly displays emotions. Yet, research in this area has relied on predominantly white samples and neglected to consider the potential role of gender, despite there being demonstrated gender differences in both PTSD symptom severity and emotional expressivity, separately. The goal of the current study was to fill a critical gap in the literature by examining the moderating role of gender in the relation between PTSD symptom severity and emotional expressivity in a sample of trauma-exposed Black adults. METHODS Participants were 207 Black individuals enrolled in a historically Black university in the Southern United States (68.6% female; Mage = 22.32 years). RESULTS Findings provided support for the moderating role of gender in the association between PTSD symptom severity and emotional expressivity. Specifically, greater PTSD symptom severity was inversely related to emotional expressivity among trauma-exposed Black males and positively associated with emotional expressivity among trauma-exposed Black females. DISCUSSION These results suggest the potential need for gender-specific assessment and treatment techniques for PTSD symptom severity among trauma-exposed Black college students.
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20
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Gross GM, Smith N, Holliday R, Rozek DC, Hoff R, Harpaz-Rotem I. Racial Disparities in Clinical Outcomes of Veterans Affairs Residential PTSD Treatment Between Black and White Veterans. Psychiatr Serv 2022; 73:126-132. [PMID: 34369806 DOI: 10.1176/appi.ps.202000783] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Racial disparities across various domains of health care are a long-standing public health issue that affect a variety of clinical services and health outcomes. Mental health research has shown that prevalence rates of posttraumatic stress disorder (PTSD) are high for Black veterans compared with White veterans, and some studies suggest poorer clinical outcomes for Black veterans with PTSD. The aim of this study was to examine the impact of racial disparities longitudinally in the U.S. Department of Veterans Affairs (VA) residential rehabilitation treatment programs (RRTPs). METHODS Participants included 2,870 veterans treated nationally in VA PTSD RRTPs in fiscal year 2017. Veterans provided demographic data upon admission to the program. Symptoms of PTSD and depression were collected at admission, discharge, and 4-month follow-up. Hierarchical linear modeling was used to examine symptom change throughout and after treatment. RESULTS Black veterans experienced attenuated PTSD symptom reduction during treatment as well as greater depression symptom recurrence 4 months after discharge, relative to White veterans. CONCLUSIONS This study adds to the body of literature that has documented poorer treatment outcomes for Black compared with White veterans with PTSD. Although both Black and White veterans had an overall reduction in symptoms, future research should focus on understanding the causes, mechanisms, and potential solutions to reduce racial disparities in mental health treatment.
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Affiliation(s)
- Georgina M Gross
- U.S. Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Yale University School of Medicine, New Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado (Holliday); University of Colorado Anschutz Medical Campus, Aurora (Holliday); UCF RESTORES, University of Central Florida, Orlando (Rozek)
| | - Noelle Smith
- U.S. Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Yale University School of Medicine, New Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado (Holliday); University of Colorado Anschutz Medical Campus, Aurora (Holliday); UCF RESTORES, University of Central Florida, Orlando (Rozek)
| | - Ryan Holliday
- U.S. Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Yale University School of Medicine, New Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado (Holliday); University of Colorado Anschutz Medical Campus, Aurora (Holliday); UCF RESTORES, University of Central Florida, Orlando (Rozek)
| | - David C Rozek
- U.S. Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Yale University School of Medicine, New Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado (Holliday); University of Colorado Anschutz Medical Campus, Aurora (Holliday); UCF RESTORES, University of Central Florida, Orlando (Rozek)
| | - Rani Hoff
- U.S. Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Yale University School of Medicine, New Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado (Holliday); University of Colorado Anschutz Medical Campus, Aurora (Holliday); UCF RESTORES, University of Central Florida, Orlando (Rozek)
| | - Ilan Harpaz-Rotem
- U.S. Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Yale University School of Medicine, New Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado (Holliday); University of Colorado Anschutz Medical Campus, Aurora (Holliday); UCF RESTORES, University of Central Florida, Orlando (Rozek)
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Abstract
Post-traumatic Stress Disorder is a chronic condition that occurs following a traumatic experience. Information processing models of PTSD focus on integrating situationally triggered sensory-emotional memories with consciously accessible autobiographical memories. Review of the nature of implicit memory supports the view that sensory-emotional memories are implicit in nature. Dissociation was also found to be associated with the development and severity of PTSD, as well as deficits in autobiographical memory. Moreover, disorganized attachment (DA) was associated with greater degrees of dissociation and PTSD, and like the defining neural activation in PTSD, was found to be associated with basal ganglia activity. In addition, subcortical neuroception of safety promotes a neurophysiological substrate supportive of social engagement and inhibition of fear-based responses. Furthermore, activation of representations of co-created imagined scenes of safety and secure attachment are associated with increases in this neurophysiological substrate. Repeated priming of secure attachment imagery was associated with modification of internal working models of DA along with reductions in dissociation and recovery from complex PTSD. In conclusion, it is posited that adequate recovery from extensive trauma experiences requires more than conscious elaboration of traumatic autobiographical memories and that the application of implicit nonconscious memory modification strategies will facilitate more optimal recovery.
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22
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Schwartzkopff L, Gutermann J, Steil R, Müller-Engelmann M. Which Trauma Treatment Suits me? Identification of Patients' Treatment Preferences for Posttraumatic Stress Disorder (PTSD). Front Psychol 2021; 12:694038. [PMID: 34456808 PMCID: PMC8387597 DOI: 10.3389/fpsyg.2021.694038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/20/2021] [Indexed: 11/18/2022] Open
Abstract
Several psychotherapy treatments exist for posttraumatic stress disorder. This study examines the treatment preferences of treatment-seeking traumatized adults in Germany and investigates the reasons for their treatment choices. Preferences for prolonged exposure, cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), psychodynamic psychotherapy and stabilization were assessed via an online survey. Reasons for preferences were analyzed by means of thematic coding by two independent rates. 104 traumatized adults completed the survey. Prolonged exposure and CBT were each preferred by nearly 30%, and EMDR and psychodynamic psychotherapy were preferred by nearly 20%. Stabilization was significantly less preferred than all other options, by only 4%. Significantly higher proportions of patients were disinclined to choose EMDR and stabilization. Patients who preferred psychodynamic psychotherapy were significantly older than those who preferred CBT. Reasons underlying preferences included the perceived treatment mechanisms and treatment efficacy. Traumatized patients vary in their treatment preferences. Preference assessments may help clinicians comprehensively address patients' individual needs and thus improve therapy outcomes.
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Affiliation(s)
- Laura Schwartzkopff
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt, Frankfurt, Germany
| | - Jana Gutermann
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt, Frankfurt, Germany
| | - Regina Steil
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt, Frankfurt, Germany
| | - Meike Müller-Engelmann
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt, Frankfurt, Germany
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23
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Belsher BE, Beech EH, Reddy MK, Smolenski DJ, Rauch SAM, Kelber M, Issa F, Lewis C, Bisson JI. Advances in repetitive transcranial magnetic stimulation for posttraumatic stress disorder: A systematic review. J Psychiatr Res 2021; 138:598-606. [PMID: 33992983 DOI: 10.1016/j.jpsychires.2021.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/01/2021] [Accepted: 05/01/2021] [Indexed: 01/18/2023]
Abstract
Repetitive transcranial magnetic stimulation (rTMS) as a treatment for posttraumatic stress disorder (PTSD) has gained interest over the past two decades. However, it has yet to be recommended in major treatment guidelines. We conducted a systematic review of randomized controlled trials to examine the efficacy of rTMS for PTSD. Thirteen studies with 549 participants were included in this review. We compared the effects of (1) rTMS versus sham, and (2) high-frequency (HF) versus low-frequency (LF) rTMS, on posttreatment PTSD scores and other secondary outcomes. We calculated the standardized mean differences (SMD) to determine the direction of effects, and unstandardized mean differences to estimate the magnitude of efficacy. At post-treatment, rTMS was superior to sham comparison in reducing PTSD (SMD = -1.13, 95% CI: -2.10 to -0.15) and depression severity (SMD = -0.83, 95% CI: -1.30 to -0.36). The quality of evidence, however, was rated very low due to small samples sizes, treatment heterogeneity, inconsistent results, and an imprecise pooled effect. HF rTMS was associated with slightly improved, albeit imprecise, outcomes compared to LF rTMS on PTSD (SMD = -0.19, 95% CI: -1.39 to 1.00) and depression (SMD = -1.09, 95% CI: -1.65 to -0.52) severity. Further research is required to advance the evidence on this treatment.
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Affiliation(s)
- Bradley E Belsher
- Carl T Hayden Veterans Medical Center, 650 E Indian School Rd, Phoenix, AZ, 85012, USA; Uniformed Services University of the Health Sciences, 4310 Jones Bridge Road, Bethesda, MD, 20814, USA.
| | - Erin H Beech
- Psychological Health Center of Excellence, Defense Health Agency, 1335 East West Highway, Silver Spring, MD, 20910, USA
| | - Madhavi K Reddy
- Psychological Health Center of Excellence, Defense Health Agency, 1335 East West Highway, Silver Spring, MD, 20910, USA
| | - Derek J Smolenski
- Psychological Health Center of Excellence, Defense Health Agency, 1335 East West Highway, Silver Spring, MD, 20910, USA
| | - Sheila A M Rauch
- Atlanta VA Healthcare System, 1670 Clairmont Road, Decatur, GA, 300233, USA; Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park, 3rd Floor, Atlanta, GA, 30329, USA
| | - Marija Kelber
- Psychological Health Center of Excellence, Defense Health Agency, 1335 East West Highway, Silver Spring, MD, 20910, USA
| | - Fuad Issa
- Psychological Health Center of Excellence, Defense Health Agency, 1335 East West Highway, Silver Spring, MD, 20910, USA
| | - Catrin Lewis
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Hadyn Ellis Building, Maindy Road, Cardiff, CF24 4HQ, UK
| | - Jonathan I Bisson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Hadyn Ellis Building, Maindy Road, Cardiff, CF24 4HQ, UK
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Hoeboer CM, de Kleine RA, Oprel DAC, Schoorl M, van der Does W, van Minnen A. Does complex PTSD predict or moderate treatment outcomes of three variants of exposure therapy? J Anxiety Disord 2021; 80:102388. [PMID: 33831660 DOI: 10.1016/j.janxdis.2021.102388] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/27/2021] [Accepted: 03/17/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND One reason for the inclusion of Complex Posttraumatic Stress Disorder (CPTSD) in the 11th revision of the International Classification of Diseases (ICD-11) was its suspected relevance for treatment indications. We investigated whether CPTSD predicted and moderated treatment outcomes of Prolonged Exposure (PE), intensified PE (iPE) and Skills Training in Affective and Interpersonal Regulation followed by PE (STAIR + PE). We expected that CPTSD would predict worse treatment outcomes across treatments. Secondly, we expected that CPTSD would lead to better treatment effect in STAIR + PE compared to PE and iPE. METHODS We analyzed 149 patients with childhood-abuse related PTSD from a randomized clinical trial. CPTSD diagnosis and symptom severity were measured with the International Trauma Questionnaire. The main outcome was change in clinician-assessed PTSD symptoms. Assessments took place at baseline, week 4, week 8, week 16 (post-treatment) and at a 6-and 12-month follow-up. Analyses were based on an intention-to-treat sample using mixed effect models. RESULTS More than half (54 %) of the patients met criteria for CPTSD at baseline. CPTSD was related to more severe PTSD symptoms and higher comorbidity at baseline. CPTSD neither predicted nor moderated treatment outcome. LIMITATIONS Inclusion was limited to patients with PTSD related to childhood abuse. Replication is needed in different samples. CONCLUSIONS CPTSD is associated with more severe PTSD and with higher comorbidity. CPTSD did not predict treatment outcome and did not indicate differential treatment outcome of STAIR + PE compared to PE and iPE.
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Affiliation(s)
- Chris M Hoeboer
- Leiden University, Department of Clinical Psychology, Leiden, the Netherlands; Parnassiagroep, PsyQ The Hague, the Netherlands.
| | - Rianne A de Kleine
- Leiden University, Department of Clinical Psychology, Leiden, the Netherlands.
| | - Danielle A C Oprel
- Leiden University, Department of Clinical Psychology, Leiden, the Netherlands; Parnassiagroep, PsyQ The Hague, the Netherlands.
| | - Maartje Schoorl
- Leiden University, Department of Clinical Psychology, Leiden, the Netherlands.
| | - Willem van der Does
- Leiden University, Department of Clinical Psychology, Leiden, the Netherlands; Parnassiagroep, PsyQ The Hague, the Netherlands; Leiden University Medical Center, Department of Psychiatry, Leiden, the Netherlands.
| | - Agnes van Minnen
- PSYTREC, Bilthoven, the Netherlands; Radboud University, Behavioural Science Institute, Nijmegen, the Netherlands.
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Smits FM, de Kort GJ, Geuze E. Acceptability of tDCS in treating stress-related mental health disorders: a mixed methods study among military patients and caregivers. BMC Psychiatry 2021; 21:97. [PMID: 33588798 PMCID: PMC7883955 DOI: 10.1186/s12888-021-03086-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 02/01/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Noninvasive brain stimulation techniques like transcranial direct current stimulation (tDCS) offer potential new approaches to treat stress-related mental health disorders. While the acceptability of tDCS as a treatment tool plays a crucial role in its development and implementation, little is known about tDCS acceptability for users in mental healthcare, especially in the context of stress-related disorders. METHODS Using a mixed-methods approach, we investigated tDCS acceptability among 102 active duty and post-active military patients with stress-related symptoms (posttraumatic stress disorder, anxiety and impulsive aggression) who participated in a 5-session tDCS intervention. Quantitative dropout and adverse effects data was collected for all patients involved in the sham-controlled tDCS intervention. We additionally explored perspectives on the acceptability of tDCS treatment via a theory-based semi-structured interview. A subgroup of patients as well as their caregivers were interviewed to include the views of both patients and mental healthcare professionals. RESULTS Quantitative outcomes showed minimal tDCS-related adverse effects (mild itching or burning sensations on the scalp) and high tDCS treatment adherence (dropout rate: 4% for active tDCS, 0% for sham). The qualitative outcomes showed predominantly positive attitudes towards tDCS interventions for stress-related disorders, but only as complementary to psychotherapy. Remarkably, despite the perception that sufficient explanation was provided, patients and caregivers stressed that tDCS treatment comprehension was limited and should improve. Also, the travel associated with frequent on-site tDCS sessions may produce a significant barrier to care for patients with stress-related disorders and active-duty military personnel. CONCLUSIONS Acceptability numbers and perspectives from military patients and caregivers suggest that tDCS is an acceptable complementary tool in the treatment of stress-related disorders. Critically, however, if tDCS is to be used beyond scientific studies, adequately educating users on tDCS working mechanisms is vital to further improve its acceptability. Also, the perceived potential barrier to care due to frequent travel may favor home-based tDCS solutions. TRIAL REGISTRATION The tDCS intervention was part of a sham-controlled trial registered on 05-18-2016 at the Netherlands Trial Register with ID NL5709 .
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Affiliation(s)
- Fenne M. Smits
- grid.462591.dBrain Research & Innovation Centre, Ministry of Defence, Lundlaan 1, 3584 EZ Utrecht, The Netherlands ,grid.7692.a0000000090126352Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Guido J. de Kort
- grid.462591.dBrain Research & Innovation Centre, Ministry of Defence, Lundlaan 1, 3584 EZ Utrecht, The Netherlands
| | - Elbert Geuze
- grid.462591.dBrain Research & Innovation Centre, Ministry of Defence, Lundlaan 1, 3584 EZ Utrecht, The Netherlands ,grid.7692.a0000000090126352Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Youngstedt SD, Kline CE, Reynolds AM, Crowley SK, Burch JB, Khan N, Han S. Bright Light Treatment of Combat-related PTSD: A Randomized Controlled Trial. Mil Med 2021; 187:e435-e444. [PMID: 33511988 DOI: 10.1093/milmed/usab014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/28/2020] [Accepted: 01/11/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Post-traumatic stress disorder (PTSD) is a prevalent consequence of combat with significant associated morbidity. Available treatments for PTSD have had limitations, suggesting a need to explore alternative or adjuvant treatments. Numerous rationales for bright light treatment of PTSD include its benefits for common PTSD comorbidities of depression, anxiety, and circadian misalignment and its relative ease of use with few side effects. The primary aims of this research were to examine the effects of bright light treatment for combat-related PTSD and associated morbidity. MATERIALS AND METHODS A randomized controlled trial was performed in N = 69 veterans with PTSD attributable to combat in Afghanistan and/or Iraq. Following a 1-week baseline, participants were randomized to 4 weeks of daily morning bright light treatment (10,000 lux for 30 min/day) or a control treatment (inactivated negative ion generator). At baseline and at the end of treatment, participants were rated blindly on the Clinician Assessed PTSD Scale (CAPS), the Clinical Global Impressions Scale (CGI), and the Hamilton Depression Scale and rated themselves on the PTSD Checklist-Military (PCL-M). Following baseline and each treatment week, participants completed self-reported scales of state anxiety, depression, and sleep, and sleep and the circadian rhythm of wrist activity were also assessed with wrist actigraphy. RESULTS Compared with the control treatment, bright light elicited significantly greater improvements in the CAPS and CGI-Improvement. The bright light also elicited a significantly greater rate of treatment response (reduction ≥33%) for the CAPS (44.1% vs. 8.6%) and PCL-M (33% vs. 6%), but no participant had remission from PTSD. Changes in depression, anxiety, and sleep did not differ between treatments. Improvement in CAPS was significantly correlated with a phase advance of the circadian rhythm of wrist activity. CONCLUSIONS The most comprehensive study on the topic to date indicated significant short-term efficacy of bright light treatment on the primary variables (CAPS and CGI) with clinical relevance (i.e., treatment response) in veterans with chronic PTSD who did not report extremely high habitual light exposure. No significant effects were found for anxiety, depression, or sleep disturbance. Further research is warranted, particularly exploration of circadian phase-shifting mechanisms of bright light for PTSD.
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Affiliation(s)
- Shawn D Youngstedt
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ 85004, USA.,Phoenix VA Health Care System, Phoenix, AZ 85012, USA
| | - Christopher E Kline
- Department of Health and Human Development, Research Service, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Alexandria M Reynolds
- Department of Psychology, University of Virginia's College at Wise, Wise, VA 24293, USA
| | - Shannon K Crowley
- Department of Exercise Science, Department of Health Promotion, North Carolina Wesleyan College, Rocky Mount, NC 27804, USA
| | - James B Burch
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC 29208, USA
| | - Nidha Khan
- Department of Environmental Health Sciences, University of South Carolina, Columbia, SC 29208, USA
| | - SeungYong Han
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ 85004, USA
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Holder N, Shiner B, Li Y, Madden E, Neylan TC, Seal KH, Lujan C, Patterson OV, DuVall SL, Maguen S. Determining the median effective dose of prolonged exposure therapy for veterans with posttraumatic stress disorder. Behav Res Ther 2020; 135:103756. [PMID: 33157475 DOI: 10.1016/j.brat.2020.103756] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 08/14/2020] [Accepted: 10/16/2020] [Indexed: 10/23/2022]
Abstract
Prolonged exposure therapy (PE) is an effective treatment for posttraumatic stress disorder (PTSD). Identifying metrics of treatment response can guide treatment delivery. The median effective dose represents the number of sessions at which there is a 50% probability of clinically meaningful improvement (i.e., 10-point reduction in PTSD checklist). The goal of the current study was to investigate the median effective dose of PE. We identified a cohort of Iraq and Afghanistan war veterans who received psychotherapy for PTSD in the Veterans Health Administration between 2001 and 2017. From this cohort, 10,234 veterans who received PE (as identified using natural language processing) and had ≥2 PTSD symptom measures were included in analyses. To determine how the number of PE sessions and covariates affected clinically meaningful improvement, we utilized a Cox proportional hazards regression, followed by Kaplan-Meier curves to determine the median effective dose. The median effective dose of PE was four sessions. Although some covariates were found to be statistically significant predictors of clinically meaningful improvement (e.g., age, gender, PTSD medications, and depressive disorder comorbidity), these effects were small. Clinicians and patients should consider evaluating treatment response after four sessions to determine preliminary effectiveness of PE.
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Affiliation(s)
- Nicholas Holder
- San Francisco Veterans Affairs Health Care System, United States; Sierra Pacific Mental Illness Research, Education, and Clinical Center, United States; University of California San Francisco School of Medicine, United States.
| | - Brian Shiner
- White River Junction Veterans Affairs Medical Center, United States; Geisel School of Medicine at Dartmouth, United States; National Center for Posttraumatic Stress Disorder, Executive Division, United States
| | - Yongmei Li
- San Francisco Veterans Affairs Health Care System, United States
| | - Erin Madden
- San Francisco Veterans Affairs Health Care System, United States
| | - Thomas C Neylan
- San Francisco Veterans Affairs Health Care System, United States; Sierra Pacific Mental Illness Research, Education, and Clinical Center, United States; University of California San Francisco School of Medicine, United States
| | - Karen H Seal
- San Francisco Veterans Affairs Health Care System, United States; University of California San Francisco School of Medicine, United States
| | - Callan Lujan
- San Francisco Veterans Affairs Health Care System, United States
| | - Olga V Patterson
- Department of Veterans Affairs Salt Lake City Health Care System, United States; University of Utah School of Medicine, United States
| | - Scott L DuVall
- Department of Veterans Affairs Salt Lake City Health Care System, United States; University of Utah School of Medicine, United States
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System, United States; Sierra Pacific Mental Illness Research, Education, and Clinical Center, United States; University of California San Francisco School of Medicine, United States
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How do gender and military sexual trauma impact PTSD symptoms in cognitive processing therapy and prolonged exposure? J Psychiatr Res 2020; 130:89-96. [PMID: 32798774 DOI: 10.1016/j.jpsychires.2020.06.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/12/2020] [Accepted: 06/25/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Effectiveness of evidence-based psychotherapy (EBP) for PTSD can vary based on gender and trauma type, with poorer outcomes for men and sexual traumas. Among veterans receiving EBPs for PTSD, the effects of the interaction between gender and military sexual trauma (MST) on treatment outcome are unclear. This study examined how gender and MST impact PTSD symptoms following cognitive processing therapy (CPT) and prolonged exposure (PE). METHOD We conducted a national, retrospective cohort study of all post 9/11 veterans who had a PTSD diagnosis from 10/2001-9/2017 at VHA facilities and >1 psychotherapy visit. Inclusion criteria included completion of ≥8 CPT/PE sessions and pre- and post-treatment PCL (N = 9711). Mixed-effects linear regression models were conducted, separately by treatment, to examine associations between changes in PTSD symptoms and gender, MST, and their interactions with time. RESULTS For both treatments, there were no significant differences in pre-treatment PCL by gender or MST, and PCL decreased significantly over time. In adjusted models, only the gender by time interaction on pre-to-post-CPT change was significant (p < .001); the decrease in women's PCL was 2.67 points greater, compared to men. CONCLUSIONS Women veterans demonstrated greater reductions in PTSD symptoms from CPT. There were no differences by gender for PE, suggesting men and women veterans benefit similarly. Results suggest outcomes may be impacted by gender socialization when utilizing certain cognitive behavioral techniques. MST, regardless of gender, did not impact PTSD outcomes for either treatment. Both CPT and PE may thus be effective for veterans irrespective of MST history.
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Sheynin J, Duval ER, King AP, Angstadt M, Phan KL, Simon NM, Rauch SAM, Liberzon I. Associations between resting-state functional connectivity and treatment response in a randomized clinical trial for posttraumatic stress disorder. Depress Anxiety 2020; 37:1037-1046. [PMID: 32668087 PMCID: PMC7722156 DOI: 10.1002/da.23075] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/04/2020] [Accepted: 06/13/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Alterations in resting-state functional connectivity (rsFC) have been reported in posttraumatic stress disorder (PTSD). Here, we examined pre- and post-treatment rsFC during a randomized clinical trial to characterize alterations and examine predictors of treatment response. METHODS Sixty-four combat veterans with PTSD were randomly assigned to prolonged exposure (PE) plus placebo, sertraline plus enhanced medication management, or PE plus sertraline. Symptom assessment and resting-state functional magnetic resonance imaging (fMRI) scans occurred before and after treatment. Twenty-nine trauma-exposed combat veterans without PTSD served as a control group at intake. Seed-based and region of interest (ROI)-to-ROI connectivities, as well as an exploratory connectome-based approach were used to analyze rsFC patterns. Based on previously reported findings, analyses focused on Salience Network (SN) and Default-Mode Network (DMN). RESULTS At intake, patients with PTSD showed greater DMN-dorsal attention network (DAN) connectivity (between ventromedial prefrontal cortex and superior parietal lobule; family-wise error corrected p = .011), greater SN-DAN connectivity (between insula and middle frontal gyrus; corrected p = .003), and a negative correlation between re-experiencing symptoms and within-DMN connectivity (between posterior cingulate cortex (PCC) and middle temporal gyrus; corrected p < .001). We also found preliminary evidence for associations between rsFC and treatment response. Specifically, high responders (≥50% PTSD symptom improvement), compared with low responders, had greater SN-DMN segregation (i.e., less pre-treatment amygdala-PCC connectivity; p = .011) and lower pre-treatment global centrality (p = .042). CONCLUSIONS Our findings suggest neural abnormalities in PTSD and may inform future research examining neural biomarkers of PTSD treatment response.
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Affiliation(s)
- Jony Sheynin
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth R. Duval
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Anthony P. King
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Mike Angstadt
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - K. Luan Phan
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA
| | - Naomi M. Simon
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, New York University Medical School, New York, NY, USA
| | - Sheila A. M. Rauch
- Atlanta VA Healthcare System, Decatur, GA, USA
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Israel Liberzon
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Holder N, Shiner B, Li Y, Madden E, Neylan TC, Seal KH, Lujan C, Patterson OV, DuVall SL, Maguen S. Cognitive Processing Therapy for Veterans with Posttraumatic Stress Disorder: What is the Median Effective Dose? J Affect Disord 2020; 273:425-433. [PMID: 32560937 DOI: 10.1016/j.jad.2020.04.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/27/2020] [Accepted: 04/21/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Cognitive Processing Therapy (CPT) has been disseminated in the Veterans Health Administration (VHA) to treat posttraumatic stress disorder (PTSD). Identifying the median effective dose (MED) of CPT, the number of sessions at which the probability of experiencing clinically meaningful improvement (CMI) is 50%, can assist with treatment. METHOD From a cohort of Iraq and Afghanistan war veterans who received PTSD psychotherapy in VHA between 2001-2017, veterans who received CPT with available PTSD symptom outcomes (PTSD Checklist; PCL) were identified using natural language processing (n=26,189). Cox proportional hazards regression was used to examine how number of CPT sessions, together with covariates, influenced CMI (10-point PCL reduction). Kaplan-Meier curves were plotted to determine MED. RESULTS At eight sessions, there was a 50% probability of experiencing CMI. The Cox proportional hazard regression indicated a greater likelihood of CMI in fewer sessions for veterans who received individual-only CPT versus any group CPT (HR:1.31, 95%CI:1.23-1.39). Kaplan-Meier curves indicated a 50% probability of experiencing CMI at seven sessions for veterans who received individual-only CPT versus ten sessions for veterans receiving any group CPT. LIMITATIONS PCL data was not available for all veterans who received CPT or at each potential assessment point. Not all veterans continued in CPT until CMI was observed. CONCLUSIONS The MED of CPT was eight sessions. Fewer sessions were needed to reach MED for veterans who received individual versus group CPT. These results may help those who treat, research, and are recovering from PTSD through accurately anchoring treatment expectations and providing a marker of initial treatment response.
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Affiliation(s)
- Nicholas Holder
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine.
| | - Brian Shiner
- White River Junction Veterans Affairs Medical Center; Geisel School of Medicine at Dartmouth; National Center for Posttraumatic Stress Disorder, Executive Division
| | - Yongmei Li
- San Francisco Veterans Affairs Health Care System
| | - Erin Madden
- San Francisco Veterans Affairs Health Care System
| | - Thomas C Neylan
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine
| | - Karen H Seal
- San Francisco Veterans Affairs Health Care System; University of California San Francisco School of Medicine
| | - Callan Lujan
- San Francisco Veterans Affairs Health Care System
| | - Olga V Patterson
- Department of Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine
| | - Scott L DuVall
- Department of Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine
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Maguen S, Holder N, Li Y, Madden E, Neylan TC, Seal KH, Lujan C, Patterson OV, DuVall SL, Shiner B. Factors associated with PTSD symptom improvement among Iraq and Afghanistan veterans receiving evidenced-based psychotherapy. J Affect Disord 2020; 273:1-7. [PMID: 32421589 DOI: 10.1016/j.jad.2020.04.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/02/2020] [Accepted: 04/24/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite availability of evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), not all veterans who initiate EBPs experience benefit. Better understanding factors associated with clinically significant improvement can help ameliorate care. METHODS A cohort of Iraq and Afghanistan War veterans who initiated an EBP was identified (N = 32,780) with ≥1 post-deployment psychotherapy visit at the Veterans Health Administration from 10/2001-6/2017, a post-deployment PTSD diagnosis, and ≥2 PTSD symptom measures. We used random-effects logistic regression to assess whether patient-level, diagnostic, and treatment factors were associated with achieving symptom improvement. RESULTS Increased odds of PTSD symptom improvement were seen in women (OR = 1.19; 95% CI: 1.09--1.29), those who initiated EBP within a year of engaging in mental healthcare compared with the delayed EBP group (OR = 1.20; 95% CI: 1.14--1.28), those who completed at least 8 EBP sessions in 16 weeks (OR = 1.23; 95% CI:1.11--1.36), those who received PE only (vs. CPT or both; OR = 2.23; 95% CI: 1.86--2.68) or CPT individual therapy only (vs. CPT group or both; OR = 1.34; 95% CI: 1.22--1.48), and those with a drug dependence diagnosis (OR = 1.24; 95% CI: 1.11--1.39). Decreased odds of improvement were seen in Black veterans (OR=0.75; 95% CI: 0.69--0.81) and those with service-connected disability (OR = 0.61; 95% CI: 0.52--0.71). LIMITATIONS Diagnoses were from medical charts and not confirmed with gold standard assessment tools; we only included veterans with at least two PTSD measurements, which may cause bias. CONCLUSION Modifiable factors associated with PTSD improvement (timing, dose, and modality) can be used to improve EBP outcomes.
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Affiliation(s)
- Shira Maguen
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine.
| | - Nicholas Holder
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine
| | - Yongmei Li
- San Francisco Veterans Affairs Health Care System
| | - Erin Madden
- San Francisco Veterans Affairs Health Care System
| | - Thomas C Neylan
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine
| | - Karen H Seal
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center
| | - Callan Lujan
- San Francisco Veterans Affairs Health Care System
| | - Olga V Patterson
- Department of Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine
| | - Scott L DuVall
- Department of Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine
| | - Brian Shiner
- White River Junction Veterans Affairs Medical Center; Geisel School of Medicine at Dartmouth; National Center for Posttraumatic Stress Disorder, Executive Division
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Fonzo GA, Federchenco V, Lara A. Predicting and Managing Treatment Non-Response in Posttraumatic Stress Disorder. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2020; 7:70-87. [PMID: 33344106 PMCID: PMC7748158 DOI: 10.1007/s40501-020-00203-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review aims to synthesize existing research regarding the definition of treatment resistance in posttraumatic stress disorder (PTSD), predictors of treatment non-response to first-line interventions, and emerging second-line PTSD treatment options into an accessible resource for the practicing clinician. RECENT FINDINGS The concept of treatment resistance in PTSD is currently poorly defined and operationalized. There are no well-established predictors of treatment non-response utilized in routine clinical care, but existing research identifies several potential candidate markers, including male gender, low social support, chronic and early life trauma exposure, comorbid psychiatric disorders, severe PTSD symptoms, and poor physical health. The most promising available treatment options for PTSD patients non-responsive to first-line psychotherapies and antidepressants include transcranial magnetic stimulation and ketamine infusion. Methylenedioxymethamphetamine-assisted psychotherapy also appears promising but is only available in a research context. These options require careful consideration of risks and benefits for a particular patient. SUMMARY More research is required to develop a robust, clinically-useful definition of treatment resistance in PTSD; identify reliable, readily assessable, and generalizable predictors of PTSD treatment non-response; and implement measurement and prediction in clinical settings to identify individuals unlikely to respond to first-line treatments and direct them to appropriate second-line treatments.
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Affiliation(s)
- Gregory A. Fonzo
- Department of Psychiatry, Dell Medical School, The University of Texas at Austin
| | - Vecheslav Federchenco
- General Psychiatry Residency, Dell Medical School, The University of Texas at Austin
- Equal contributions to authorship
| | - Alba Lara
- General Psychiatry Residency, Dell Medical School, The University of Texas at Austin
- Equal contributions to authorship
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Holliday R, Smith NB, Holder N, Gross GM, Monteith LL, Maguen S, Hoff RA, Harpaz-Rotem I. Comparing the effectiveness of VA residential PTSD treatment for veterans who do and do not report a history of MST: A national investigation. J Psychiatr Res 2020; 122:42-47. [PMID: 31923834 DOI: 10.1016/j.jpsychires.2019.12.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/13/2019] [Accepted: 12/19/2019] [Indexed: 11/15/2022]
Abstract
The Department of Veterans Affairs (VA) has implemented initiatives to promote veterans' recovery from the health sequelae of military sexual trauma (MST), including posttraumatic stress disorder (PTSD). MST can impact emotion regulation, interpersonal functioning, and perceptions of trust and safety, as well as increase risk for psychiatric comorbidity, which may impede PTSD treatment.. VA PTSD Residential Rehabilitation Treatment Programs (RRTPs) may facilitate the therapeutic process by offering increased structure, support, and adjunctive services. Limited research has examined the effect of MST on PTSD RRTP outcomes. Utilizing data from 7918 men and women veterans participating in a VA PTSD RRTP, the impact of the experience of MST on rates of program completion and changes in PTSD symptoms during and after treatment were examined. Rates of program completion were similar between those who did and did not report experiencing MST. Multilevel modeling was utilized to examine the impact of MST on PTSD symptoms after accounting for gender, age, race/ethnicity, and program completion. MST survivors endorsed more severe PTSD symptoms at admission; however, PTSD symptom severity scores were similar to those who did not report experiencing MST by discharge. Additionally, MST survivors had larger initial reductions in PTSD symptoms, followed by a greater recurrence of PTSD symptoms over time, compared to those who did not report experiencing MST. MST survivors appear able to participate in and benefit from PTSD RRTPs. Nonetheless, the increased recurrence of PTSD symptoms following discharge from residential treatment indicates the need for strategies to maintain post-treatment gains among MST survivors.
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Affiliation(s)
- Ryan Holliday
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, USA; University of Colorado Anschutz Medical Campus, USA
| | - Noelle B Smith
- VA Northeast Program Evaluation Center, USA; Yale University School of Medicine, USA.
| | - Nicholas Holder
- San Francisco Veterans Affairs Health Care System, USA; Sierra Pacific Mental Illness Research, Education and Clinical Center, USA; University of California San Francisco, School of Medicine, USA
| | - Georgina M Gross
- VA Northeast Program Evaluation Center, USA; Yale University School of Medicine, USA; VA Connecticut Healthcare System, USA
| | - Lindsey L Monteith
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, USA; University of Colorado Anschutz Medical Campus, USA
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System, USA; Sierra Pacific Mental Illness Research, Education and Clinical Center, USA; University of California San Francisco, School of Medicine, USA
| | - Rani A Hoff
- VA Northeast Program Evaluation Center, USA; Yale University School of Medicine, USA; VA National Center for PTSD, VA Connecticut Healthcare System, USA
| | - Ilan Harpaz-Rotem
- VA Northeast Program Evaluation Center, USA; Yale University School of Medicine, USA; VA National Center for PTSD, VA Connecticut Healthcare System, USA
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Sripada RK, Ready DJ, Ganoczy D, Astin MC, Rauch SAM. When to Change the Treatment Plan: An Analysis of Diminishing Returns in VA Patients Undergoing Prolonged Exposure and Cognitive Processing Therapy. Behav Ther 2020; 51:85-98. [PMID: 32005342 DOI: 10.1016/j.beth.2019.05.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 12/15/2022]
Abstract
Evidence-based treatments for posttraumatic stress disorder (PTSD) often produce significant symptom reduction within eight sessions. However, some patients take longer to respond and a better understanding of predictors of later response can help guide treatment. In the current study, the cohort consisted of all VA patients with a PTSD diagnosis who received at least eight sessions of documented evidence-based treatment within a 6-month period in FY16-FY17 and had at least two PTSD symptom assessments. We examined the proportion of patients who achieved meaningful change (defined as at least 50% reduction in self-reported PTSD symptoms), both within the first eight sessions and subsequently. Fourteen percent of patients achieved meaningful change within eight sessions and 10% subsequently. Symptom change within the first eight sessions was highly predictive of subsequent change. Those who experienced at least 20% symptom reduction by session eight were twice as likely to subsequently achieve meaningful change as compared with all patients who continued treatment. Patients receiving service-connected disability compensation were less likely and White patients more likely to achieve meaningful change. Without some degree of symptom reduction by session eight, patients are unlikely to achieve meaningful change if treatment is not enhanced or changed.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research VA Ann Arbor Health Care System; University of Michigan.
| | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research and Veterans Affairs Ann Arbor Health Care System
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Sippel LM, Watkins LE, Pietrzak RH, Hoff R, Harpaz-Rotem I. Heterogeneity of posttraumatic stress symptomatology and social connectedness in treatment-seeking military veterans: a longitudinal examination. Eur J Psychotraumatol 2019; 10:1646091. [PMID: 31489133 PMCID: PMC6713134 DOI: 10.1080/20008198.2019.1646091] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 11/21/2022] Open
Abstract
Elucidating whether PTSD symptoms predict poorer social connectedness over time (i.e. social erosion) and/or that poor social connectedness contributes to maintenance of PTSD (i.e. social causation) has implications for PTSD treatment and relapse prevention. Most extant research has been cross-sectional and examined overall PTSD symptoms. Evidence of longitudinal associations among heterogeneous PTSD symptom clusters and social connectedness could provide insight into more nuanced targets for intervention. Using data from 1,491 U.S. military veterans in residential treatment for PTSD at 35 Department of Veterans Affairs facilities, we evaluated a two-wave cross-lagged panel model including a five-factor model of PTSD and two aspects of social connectedness. PTSD, quality of connectedness (i.e. degree of distress related to interpersonal conflict), and structural social support (i.e. number of days of contact with supportive loved ones) in the past 30 days were assessed at baseline and 4 months after discharge. The largest effect was greater severity of PTSD dysphoric arousal symptoms (i.e. irritability/anger, poor concentration, and sleep problems) at baseline predicting more conflict-related distress at follow-up (β = 0.43). Post-hoc symptom-level analyses indicated that irritability/anger drove this association. In addition, conflict-related distress predicted greater PTSD symptom severity across all five clusters (β's = 0.10 to 0.14, p's < 0.01). More days of contact predicted lower severity of avoidance and numbing symptoms (β's = -.05 and -.07, p's < 0.01), along with individual symptoms within these clusters, plus flashbacks. Results support both social erosion and social causation models. Engaging loved ones in veterans' treatment and targeting dysphoric arousal symptoms, particularly anger and irritability, may improve long-term PTSD and relationship outcomes, respectively.
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Affiliation(s)
- Lauren M Sippel
- National Center for PTSD Executive Division, White River Junction, VT, USA.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Laura E Watkins
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Robert H Pietrzak
- National Center for PTSD Clinical Neurosciences Division, West Haven, CT, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Rani Hoff
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.,National Center for PTSD Evaluation Division, West Haven, CT, USA
| | - Ilan Harpaz-Rotem
- National Center for PTSD Clinical Neurosciences Division, West Haven, CT, USA.,National Center for PTSD Evaluation Division, West Haven, CT, USA
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