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van ’t Wout-Frank M, Arulpragasam AR, Faucher C, Aiken E, Shea MT, Jones RN, Greenberg BD, Philip NS. Virtual Reality and Transcranial Direct Current Stimulation for Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2024; 81:437-446. [PMID: 38446471 PMCID: PMC10918574 DOI: 10.1001/jamapsychiatry.2023.5661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/19/2023] [Indexed: 03/07/2024]
Abstract
Importance Posttraumatic stress disorder (PTSD) is a common psychiatric disorder that is particularly difficult to treat in military veterans. Noninvasive brain stimulation has significant potential as a novel treatment to reduce PTSD symptoms. Objective To test whether active transcranial direct current stimulation (tDCS) plus virtual reality (VR) is superior to sham tDCS plus VR for warzone-related PTSD. Design, Setting, and Participants This double-blind randomized clinical trial was conducted among US military veterans enrolled from April 2018 to May 2023 at a secondary care Department of Veterans Affairs hospital and included 1- and 3-month follow-up visits. Participants included US military veterans with chronic PTSD and warzone-related exposure, recruited via referral and advertisement. Patients in psychiatric treatment had to be on a stable regimen for at least 6 weeks to be eligible for enrollment. Data were analyzed from May to September 2023. Intervention Participants were randomly assigned to receive 2-mA anodal tDCS or sham tDCS targeted to the ventromedial prefrontal cortex, during six 25-minute sessions of standardized warzone VR exposure, delivered over 2 to 3 weeks. Main Outcomes and Measures The co-primary outcomes were self-reported PTSD symptoms, measured via the PTSD checklist for DSM-5 (PCL-5), alongside quality of life. Other outcomes included psychophysiological arousal, clinician-assessed PTSD, depression, and social/occupational function. Results A total of 54 participants (mean [SD] age, 45.7 [10.5] years; 51 [94%] males) were assessed, including 26 in the active tDCS group and 28 in the sham tDCS group. Participants in the active tDCS group reported a superior reduction in self-reported PTSD symptom severity at 1 month (t = -2.27, P = .02; Cohen d = -0.82). There were no significant differences in quality of life between active and sham tDCS groups. Active tDCS significantly accelerated psychophysiological habituation to VR events between sessions compared with sham tDCS (F5,7689.8 = 4.65; P < .001). Adverse effects were consistent with the known safety profile of the corresponding interventions. Conclusions and Relevance These findings suggest that combined tDCS plus VR may be a promising strategy for PTSD reduction and underscore the innovative potential of these combined technologies. Trial Registration ClinicalTrials.gov Identifier: NCT03372460.
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Affiliation(s)
- Mascha van ’t Wout-Frank
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Amanda R. Arulpragasam
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Christiana Faucher
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island
| | - Emily Aiken
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island
| | - M. Tracie Shea
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Benjamin D. Greenberg
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Noah S. Philip
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
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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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Martinez BS, Rowland JA, Shura RD, Magnante AT, Morey RA, Martindale SL. Influence of affective instability on suicidal ideation beyond traumatic brain injury and posttraumatic stress disorder in veterans. J Psychiatr Res 2024; 172:411-419. [PMID: 38458113 DOI: 10.1016/j.jpsychires.2024.02.058] [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: 09/15/2023] [Revised: 02/02/2024] [Accepted: 02/27/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE Mild traumatic brain injury (TBI) is associated with long-term consequences, including greater risk for posttraumatic stress disorder (PTSD) and suicidal ideation. Affective instability is also independently related to PTSD and suicidality, which may explain why some individuals continue to experience chronic psychiatric complaints following mild TBI. The purpose of the present study was to evaluate affective instability as a key factor for PTSD and suicidal ideation among Veterans with and without TBI. METHOD Participants (N = 299 Veterans; 86.96% male) completed the Personality Assessment Inventory (PAI) and structured clinical interviews for TBI and psychiatric diagnoses. Hierarchical linear regression was used to evaluate main and interaction effects. RESULTS There were no significant differences in affective instability (p = 0.140) or suicidal ideation (p = 0.453) between Veterans with or without TBI. Individuals with TBI were more likely to have a PTSD diagnosis (p = 0.001). Analyses evaluating PTSD diagnosis as an outcome indicated a main effect of affective instability (p < 0.001), but not TBI (p = 0.619). Analyses evaluating suicidal ideation as an outcome demonstrated an interaction effect between PTSD and affective instability beyond the effects of TBI (p = 0.034). CONCLUSIONS Severe Affective instability appears to be a key factor in suicidal ideation among Veterans beyond TBI or PTSD history. PTSD was more strongly associated with suicidality at lower and moderate levels of affective instability. At severe levels of affective instability, however, Veterans with and without PTSD experienced suicidal ideation at similar rates. Findings suggests that high levels of affective instability not better explained by other psychiatric conditions confers similar suicidality risk to that of PTSD in a Veteran population.
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Affiliation(s)
- Brandy S Martinez
- Durham Veteran Affairs (VA) Health Care System, Durham, NC, USA; VA (VISN 6) Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA; Duke-UNC Brain Imaging and Analysis Center, Duke University, Durham, NC, USA.
| | - Jared A Rowland
- VA (VISN 6) Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA; Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA; Department of Neurobiology & Anatomy, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Robert D Shura
- VA (VISN 6) Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA; Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA; Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Anna T Magnante
- VA (VISN 6) Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA; Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA; Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Rajendra A Morey
- Durham Veteran Affairs (VA) Health Care System, Durham, NC, USA; VA (VISN 6) Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA; Duke-UNC Brain Imaging and Analysis Center, Duke University, Durham, NC, USA
| | - Sarah L Martindale
- VA (VISN 6) Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA; Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA; Department of Physiology & Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Contractor AA, Blumenthal H, Rosenfield D, Shea MT, Taylor DJ, Fentem A, Vingren JL. Study protocol and rationale for a pilot randomized clinical trial comparing processing of positive memories technique with supportive counseling for PTSD. Contemp Clin Trials 2024; 138:107455. [PMID: 38253251 DOI: 10.1016/j.cct.2024.107455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/29/2023] [Accepted: 01/19/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Research indicates that positive memories have a role in posttraumatic stress disorder's (PTSD) symptomatology and treatment. Following treatment development guidelines, a novel PTSD intervention - Processing of Positive Memories Technique (PPMT) - was developed and subsequently examined for its effects and feasibility in pilot studies. Extending this research, the proposed pilot randomized clinical trial with PPMT and Supportive Counseling (SC) arms will examine PPMT's effects on PTSD severity and biomarkers of stress systems' dysregulation (awakening salivary alpha amylase [sAA] and cortisol concentrations); examine mechanistic targets (affect) underlying PPMT's effects; and refine PPMT. We hypothesize that the PPMT arm will report greater decreases in PTSD severity and greater decreases in awakening sAA/cortisol ratio compared to the SC arm; and that improved affect (more positive affect and less negative affect) will mediate associations between intervention arm and changes in PTSD severity. METHODS We will recruit 70 individuals aged 18-65 years with PTSD. They will be randomized to 5 weekly therapy sessions of PPMT or SC, and will be assessed at baseline, weekly during treatment, 1-week post-treatment, and 3-months post-treatment. Primary outcomes are past-week PTSD severity, past-week positive and negative affect levels, and feedback data on PPMT's feasibility, format, and content. The secondary outcome is the awakening sAA/cortisol ratio. Statistical analyses include mixed-effect models and within-subjects cross-lag longitudinal mediation analyses. CONCLUSION Study results will advance knowledge of trauma interventions by examining effects and feasibility of a novel PTSD intervention, and by elucidating potential mechanisms underlying PPMT's effects. Clinical Trials #: NCT05523453.
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Affiliation(s)
- Ateka A Contractor
- Department of Psychology, University of North Texas, Terrill Hall, Denton, TX, 76201, United States of America.
| | - Heidemarie Blumenthal
- Department of Psychology, University of North Texas, Terrill Hall, Denton, TX, 76201, United States of America
| | - David Rosenfield
- Department of Psychology, Southern Methodist University, Expressway Tower, Dallas, TX, 75275, United States of America
| | - M Tracie Shea
- Box G-BH, Brown University, Providence, RI 02912, United States of America
| | - Daniel J Taylor
- Department of Psychology, University of Arizona, 1503 W University Blvd, Tuscon, AZ 85721, United States of America
| | - Andrea Fentem
- Department of Psychology, University of North Texas, Terrill Hall, Denton, TX, 76201, United States of America
| | - Jakob L Vingren
- Department of Kinesiology, Health Promotion and Recreation, University of North Texas, Denton TX 76203, United States of America
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Mathersul DC, Zeitzer JM, Schulz-Heik RJ, Avery TJ, Bayley PJ. Emotion regulation and heart rate variability may identify the optimal posttraumatic stress disorder treatment: analyses from a randomized controlled trial. Front Psychiatry 2024; 15:1331569. [PMID: 38389985 PMCID: PMC10881770 DOI: 10.3389/fpsyt.2024.1331569] [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: 11/01/2023] [Accepted: 01/10/2024] [Indexed: 02/24/2024] Open
Abstract
Introduction High variability in response and retention rates for posttraumatic stress disorder (PTSD) treatment highlights the need to identify "personalized" or "precision" medicine factors that can inform optimal intervention selection before an individual commences treatment. In secondary analyses from a non-inferiority randomized controlled trial, behavioral and physiological emotion regulation were examined as non-specific predictors (that identify which individuals are more likely to respond to treatment, regardless of treatment type) and treatment moderators (that identify which treatment works best for whom) of PTSD outcome. Methods There were 85 US Veterans with clinically significant PTSD symptoms randomized to 6 weeks of either cognitive processing therapy (CPT; n = 44) or a breathing-based yoga practice (Sudarshan kriya yoga; SKY; n = 41). Baseline self-reported emotion regulation (Difficulties in Emotion Regulation Scale) and heart rate variability (HRV) were assessed prior to treatment, and self-reported PTSD symptoms were assessed at baseline, end-of-treatment, 1-month follow-up, and 1-year follow-up. Results Greater baseline deficit in self-reported emotional awareness (similar to alexithymia) predicted better overall PTSD improvement in both the short- and long-term, following either CPT or SKY. High self-reported levels of emotional response non-acceptance were associated with better PTSD treatment response with CPT than with SKY. However, all significant HRV indices were stronger moderators than all self-reported emotion regulation scales, both in the short- and long-term. Veterans with lower baseline HRV had better PTSD treatment response with SKY, whereas Veterans with higher or average-to-high baseline HRV had better PTSD treatment response with CPT. Conclusions To our knowledge, this is the first study to examine both self-reported emotion regulation and HRV, within the same study, as both non-specific predictors and moderators of PTSD treatment outcome. Veterans with poorer autonomic regulation prior to treatment had better PTSD outcome with a yoga-based intervention, whereas those with better autonomic regulation did better with a trauma-focused psychological therapy. Findings show potential for the use of HRV in clinical practice to personalize PTSD treatment. Clinical trial registration ClinicalTrials.gov identifier, NCT02366403.
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Affiliation(s)
- Danielle C Mathersul
- School of Psychology, Murdoch University, Murdoch, WA, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Health Futures Institute, Murdoch University, Murdoch, WA, Australia
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - Jamie M Zeitzer
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
- Mental Illness Research, Education and Clinical Center (MIRECC), Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - R Jay Schulz-Heik
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - Timothy J Avery
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - Peter J Bayley
- War Related Illness and Injury Study Center (WRIISC), Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
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van der Kolk BA, Wang JB, Yehuda R, Bedrosian L, Coker AR, Harrison C, Mithoefer M, Yazar-Klosinki B, Emerson A, Doblin R. Effects of MDMA-assisted therapy for PTSD on self-experience. PLoS One 2024; 19:e0295926. [PMID: 38198456 PMCID: PMC10781106 DOI: 10.1371/journal.pone.0295926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 11/28/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION There is a resurgence of interest in the therapeutic potential of psychedelic substances such as 3,4-methylenedioxymethamphetamine (MDMA). Primary findings from our randomized, double-blind, placebo-controlled, multi-site Phase 3 clinical trial of participants with severe PTSD (NCT03537014) showed that MDMA-assisted therapy induced significant attenuation in the Clinician-Administered PTSD Scale for DSM-5 compared to Therapy with placebo. Deficits in emotional coping skills and altered self-capacities constitute major obstacles to successful completion of available treatments. The current analysis evaluated the differential effects of MDMA-assisted therapy and Therapy with placebo on 3 transdiagnostic outcome measures and explored the contribution of changes in self-experience to improvement in PTSD scores. METHODS Participants were randomized to receive manualized therapy with either MDMA or placebo during 3 experimental sessions in combination with 3 preparation and 9 integration therapy visits. Symptoms were measured at baseline and 2 months after the last experimental session using the 20-item Toronto Alexithymia Scale (TAS-20), the 26-item Self Compassion Scale (SCS), and the 63-item Inventory of Altered Self-Capacities (IASC). RESULTS 90 participants were randomized and dosed (MDMA-assisted therapy, n = 46; Therapy with placebo, n = 44); 84.4% (76/90) had histories of developmental trauma, and 87.8% (79/90) had suffered multiple traumas. MDMA-assisted therapy facilitated statistically significant greater improvement on the TAS-20, the SCS, and most IASC factors of interpersonal conflicts; idealization disillusionment; abandonment concerns; identity impairment; self-awareness; susceptibility to influence; affect dysregulation; affect instability; affect skill deficit; tension reduction activities; the only exception was identity diffusion. CONCLUSION Compared with Therapy with placebo, MDMA-assisted therapy had significant positive effects on transdiagnostic mental processes of self-experience which are often associated with poor treatment outcome. This provides a possible window into understanding the psychological capacities facilitated by psychedelic agents that may result in significant improvements in PTSD symptomatology.
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Affiliation(s)
| | - Julie B. Wang
- MAPS Public Benefit Corporation (MAPS PBC), San Jose, CA, United States of America
| | - Rachel Yehuda
- James J. Peters Veterans Affairs Medical Center, Bronx, NY, United States of America
- Center for Psychedelic Psychotherapy and Trauma Research, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Leah Bedrosian
- MAPS Public Benefit Corporation (MAPS PBC), San Jose, CA, United States of America
| | - Allison R. Coker
- University of California, San Francisco, San Francisco, CA, United States of America
- Multidisciplinary Association for Psychedelic Studies (MAPS), San Jose, CA, United States of America
| | - Charlotte Harrison
- MAPS Public Benefit Corporation (MAPS PBC), San Jose, CA, United States of America
| | - Michael Mithoefer
- MAPS Public Benefit Corporation (MAPS PBC), San Jose, CA, United States of America
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States of America
| | - Berra Yazar-Klosinki
- MAPS Public Benefit Corporation (MAPS PBC), San Jose, CA, United States of America
| | - Amy Emerson
- MAPS Public Benefit Corporation (MAPS PBC), San Jose, CA, United States of America
| | - Rick Doblin
- Multidisciplinary Association for Psychedelic Studies (MAPS), San Jose, CA, United States of America
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Hardeberg Bach M, Ahrens C, Olff M, Armour C, Krogh SS, Hansen M. EHealth for Sexual Assault: A Systematic Scoping Review. TRAUMA, VIOLENCE & ABUSE 2024; 25:102-116. [PMID: 36632639 DOI: 10.1177/15248380221143355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Providing efficient psychosocial support for survivors of sexual assault is of critical societal importance. Around the globe, technology-based solutions (eHealth) are increasingly being used to accomplish this task, especially following COVID-19. Despite increased importance and reliance on eHealth for sexual assault, minimal efforts have been made to systematically synthesize research in this area. The present study therefore sought to synthesize what is known about eHealth targeting sexual assault survivors' psychosocial needs using a systematic scoping review methodology. To this end, five databases (CINAHL, Embase, PsycINFO, MEDLINE, and Scopus) were systematically searched for studies published from 2010 onwards using terms such as "sexual assault", "eHealth", "digital health", "telehealth", and variations thereof. Of the 6,491 records screened for eligibility, 85 studies were included in the review. We included empirical studies from all countries pertaining to eHealth for sexual assault for survivors 13 years or older. Many innovative eHealth applications for sexual assault exist today, and the included studies suggested that survivors generally experience eHealth positively and seem to benefit from it. Nevertheless, much more clinical and empirical work is needed to ensure accessible and effective solutions for all.
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Affiliation(s)
| | | | | | | | | | - Maj Hansen
- University of Southern Denmark, Odense, Denmark
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Rauch SA, Venners MR, Ragin C, Ruhe G, Lamp K, Burton M, Pomerantz A, Bernardy N, Schnurr PP, Hamblen JL, Possemato K, Sripada R, Wray LO, Dollar K, Wade M, Astin MC, Cigrang JA. Treatment of posttraumatic stress disorder with prolonged exposure for primary care (PE-PC): Effectiveness and patient and therapist factors related to symptom change and retention. Psychol Serv 2023; 20:745-755. [PMID: 37326566 PMCID: PMC10721715 DOI: 10.1037/ser0000783] [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] [Indexed: 06/17/2023]
Abstract
Prolonged exposure (PE) is a first-line treatment for posttraumatic stress disorder (PTSD) available in specialty mental health. PE for primary care (PE-PC) is a brief version of PE adapted for primary care mental health integration, composed of four-eight, 30-min sessions. Using retrospective data of PE-PC training cases from 155 Veterans Health Administration (VHA) providers in 99 VHA clinics who participated in a 4- to 6-month PE-PC training and consultation program, we examined patients' PTSD and depression severity across sessions via mixed effects multilevel linear modeling. Additionally, hierarchical logistic regression analysis was conducted to assess predictors of treatment dropout. Among 737 veterans, medium-to-large reductions in PTSD (intent-to-treat, Cohen's d = 0.63; completers, Cohen's d = 0.79) and small-to-medium reductions in depression (intent-to-treat, Cohen's d = 0.40; completers, Cohen's d = 0.51) were observed. The modal number of PE-PC sessions was five (SD = 1.98). Providers previously trained in both PE and cognitive processing therapy (CPT) were more likely than providers who were not trained in either PE or CPT to have veterans complete PE-PC (OR = 1.54). Veterans with military sexual trauma were less likely to complete PE-PC than veterans with combat trauma (OR = 0.42). Asian American and Pacific Islander veterans were more likely than White veterans to complete treatment (OR = 2.93). Older veterans were more likely than younger veterans to complete treatment (OR = 1.11). (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Sheila A.M. Rauch
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
- Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
- Emory University School of Medicine, Atlanta, GA, 30029
| | - Margaret R. Venners
- National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA, 94025
| | - Carly Ragin
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
| | - Gretchen Ruhe
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
| | - Kristen Lamp
- Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
| | - Mark Burton
- Emory University School of Medicine, Atlanta, GA, 30029
| | - Andrew Pomerantz
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington DC
| | - Nancy Bernardy
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, VT, 05009
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, 03755
| | - Paula P. Schnurr
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, VT, 05009
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, 03755
| | - Jessica L. Hamblen
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, VT, 05009
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, 03755
| | - Kyle Possemato
- VA Center for Integrated Healthcare, VA Medical Center, Syracuse, NY 13204
- Department of Psychology, Syracuse University, Syracuse, NY, 13244
| | - Rebecca Sripada
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, 48105
| | - Laura O. Wray
- VA Center for Integrated Healthcare, VA Medical Center, Syracuse, NY 13204
- Department of Psychology, Syracuse University, Syracuse, NY, 13244
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY
| | - Katherine Dollar
- VA Center for Integrated Healthcare, VA Medical Center, Syracuse, NY 13204
- Department of Psychology, Syracuse University, Syracuse, NY, 13244
| | - Michael Wade
- VA Center for Integrated Healthcare, VA Medical Center, Syracuse, NY 13204
| | - Millie C. Astin
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
- Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
| | - Jeffrey A. Cigrang
- School of Professional Psychology, Wright State University, Dayton, OH, 45402
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O'Doherty L, Whelan M, Carter GJ, Brown K, Tarzia L, Hegarty K, Feder G, Brown SJ. Psychosocial interventions for survivors of rape and sexual assault experienced during adulthood. Cochrane Database Syst Rev 2023; 10:CD013456. [PMID: 37795783 PMCID: PMC10552071 DOI: 10.1002/14651858.cd013456.pub2] [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] [Indexed: 10/06/2023]
Abstract
BACKGROUND Exposure to rape, sexual assault and sexual abuse has lifelong impacts for mental health and well-being. Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitisation and Reprocessing (EMDR) are among the most common interventions offered to survivors to alleviate post-traumatic stress disorder (PTSD) and other psychological impacts. Beyond such trauma-focused cognitive and behavioural approaches, there is a range of low-intensity interventions along with new and emerging non-exposure based approaches (trauma-sensitive yoga, Reconsolidation of Traumatic Memories and Lifespan Integration). This review presents a timely assessment of international evidence on any type of psychosocial intervention offered to individuals who experienced rape, sexual assault or sexual abuse as adults. OBJECTIVES To assess the effects of psychosocial interventions on mental health and well-being for survivors of rape, sexual assault or sexual abuse experienced during adulthood. SEARCH METHODS In January 2022, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also checked reference lists of included studies, contacted authors and experts, and ran forward citation searches. SELECTION CRITERIA Any study that allocated individuals or clusters of individuals by a random or quasi-random method to a psychosocial intervention that promoted recovery and healing following exposure to rape, sexual assault or sexual abuse in those aged 18 years and above compared with no or minimal intervention, usual care, wait-list, pharmacological only or active comparison(s). We classified psychosocial interventions according to Cochrane Common Mental Disorders Group's psychological therapies list. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included 36 studies (1991 to 2021) with 3992 participants randomly assigned to 60 experimental groups (3014; 76%) and 23 inactive comparator conditions (978, 24%). The experimental groups consisted of: 32 Cognitive Behavioural Therapy (CBT); 10 behavioural interventions; three integrative therapies; three humanist; five other psychologically oriented interventions; and seven other psychosocial interventions. Delivery involved 1 to 20 (median 11) sessions of traditional face-to-face (41) or other individual formats (four); groups (nine); or involved computer-only interaction (six). Most studies were conducted in the USA (n = 26); two were from South Africa; two from the Democratic Republic of the Congo; with single studies from Australia, Canada, the Netherlands, Spain, Sweden and the UK. Five studies did not disclose a funding source, and all disclosed sources were public funding. Participants were invited from a range of settings: from the community, through the media, from universities and in places where people might seek help for their mental health (e.g. war veterans), in the aftermath of sexual trauma (sexual assault centres and emergency departments) or for problems that accompany the experience of sexual violence (e.g. sexual health/primary care clinics). Participants randomised were 99% women (3965 participants) with just 27 men. Half were Black, African or African-American (1889 participants); 40% White/Caucasian (1530 participants); and 10% represented a range of other ethnic backgrounds (396 participants). The weighted mean age was 35.9 years (standard deviation (SD) 9.6). Eighty-two per cent had experienced rape or sexual assault in adulthood (3260/3992). Twenty-two studies (61%) required fulfilling a measured PTSD diagnostic threshold for inclusion; however, 94% of participants (2239/2370) were reported as having clinically relevant PTSD symptoms at entry. The comparison of psychosocial interventions with inactive controls detected that there may be a beneficial effect at post-treatment favouring psychosocial interventions in reducing PTSD (standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.22 to -0.44; 16 studies, 1130 participants; low-certainty evidence; large effect size based on Cohen's D); and depression (SMD -0.82, 95% CI -1.17 to -0.48; 12 studies, 901 participants; low-certainty evidence; large effect size). Psychosocial interventions, however, may not increase the risk of dropout from treatment compared to controls, with a risk ratio of 0.85 (95% CI 0.51 to 1.44; 5 studies, 242 participants; low-certainty evidence). Seven of the 23 studies (with 801 participants) comparing a psychosocial intervention to an inactive control reported on adverse events, with 21 events indicated. Psychosocial interventions may not increase the risk of adverse events compared to controls, with a risk ratio of 1.92 (95% CI 0.30 to 12.41; 6 studies; 622 participants; very low-certainty evidence). We conducted an assessment of risk of bias using the RoB 2 tool on a total of 49 reported results. A high risk of bias affected 43% of PTSD results; 59% for depression symptoms; 40% for treatment dropout; and one-third for adverse events. The greatest sources of bias were problems with randomisation and missing outcome data. Heterogeneity was also high, ranging from I2 = 30% (adverse events) to I2 = 87% (PTSD). AUTHORS' CONCLUSIONS Our review suggests that survivors of rape, sexual violence and sexual abuse during adulthood may experience a large reduction in post-treatment PTSD symptoms and depressive symptoms after experiencing a psychosocial intervention, relative to comparison groups. Psychosocial interventions do not seem to increase dropout from treatment or adverse events/effects compared to controls. However, the number of dropouts and study attrition were generally high, potentially missing harms of exposure to interventions and/or research participation. Also, the differential effects of specific intervention types needs further investigation. We conclude that a range of behavioural and CBT-based interventions may improve the mental health of survivors of rape, sexual assault and sexual abuse in the short term. Therefore, the needs and preferences of individuals must be considered in selecting suitable approaches to therapy and support. The primary outcome in this review focused on the post-treatment period and the question about whether benefits are sustained over time persists. However, attaining such evidence from studies that lack an active comparison may be impractical and even unethical. Thus, we suggest that studies undertake head-to-head comparisons of different intervention types; in particular, of novel, emerging therapies, with one-year plus follow-up periods. Additionally, researchers should focus on the therapeutic benefits and costs for subpopulations such as male survivors and those living with complex PTSD.
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Affiliation(s)
- Lorna O'Doherty
- Institute for Health and Wellbeing, Coventry University, Coventry, UK
- Department of General Practice, The University of Melbourne, Melbourne, Australia
| | - Maxine Whelan
- Institute for Health and Wellbeing, Coventry University, Coventry, UK
| | - Grace J Carter
- Institute for Health and Wellbeing, Coventry University, Coventry, UK
| | - Katherine Brown
- Department of Psychology and Sports Science, University of Hertfordshire, Hatfield, UK
| | - Laura Tarzia
- Department of General Practice, The University of Melbourne, Melbourne, Australia
- The Royal Women's Hospital, Victoria, Australia
| | - Kelsey Hegarty
- Department of General Practice, The University of Melbourne, Melbourne, Australia
- The Royal Women's Hospital, Victoria, Australia
| | - Gene Feder
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah J Brown
- Faculty of Arts, Business and Law, Law School, USC: University of the Sunshine Coast, Sippy Downs, Australia
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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10
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Graziano RC, Brown WJ, Strasshofer DR, Yetter MA, Berfield JB, Haven SE, Bruce SE. Posttraumatic stress symptoms, posttraumatic growth, and personality factors: A network analysis. J Affect Disord 2023; 338:207-219. [PMID: 37290526 DOI: 10.1016/j.jad.2023.06.011] [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: 12/27/2021] [Revised: 02/13/2023] [Accepted: 06/04/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND After experiencing a traumatic event, two possible outcomes are experiencing positive changes, such as posttraumatic growth (PTG), and/or experiencing distress in the form of posttraumatic stress symptoms (PTSS). These constructs are not mutually exclusive; those who experience PTSS may concurrently or at a later date likewise undergo PTG. Pretrauma factors, such as personality as measured by the Big Five Inventory (BFI), can interact with both PTSS and PTG. METHODS The present study utilized Network theory to examine the interactions between PTSS, PTG, and personality in 1310 participants. Three networks were computed (PTSS, PTSS/BFI, PTSS/PTG/BFI). RESULTS Within the PTSS network, strong negative emotions emerged as the strongest influence on the network. Again, in the PTSS and BFI network, strong negative emotions exerted the strongest overall influence in addition to bridging the PTSS and personality domains. In the network with all variables of interest, the PTG domain of new possibilities was the strongest overall influence on the network. Specific relationships between constructs were identified. LIMITATIONS Limitations of this study include the cross-sectional design and utilization of a sub-threshold PTSD, non-treatment seeking sample. CONCLUSIONS Overall, nuanced relationships between variables of interest were identified, informing personalized treatment and furthers our understanding of both positive and negative responses to trauma. As the primary influence across two networks, the experience of strong negative emotions appears to be central to the subjective experience of PTSD. This may indicate a need to modify present treatments for PTSD, which conceptualize PTSD as a primarily fear-based disorder.
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Affiliation(s)
| | - Wilson J Brown
- Psychology Department, Penn State Behrend, Erie, PA, United States of America
| | | | - Marissa A Yetter
- Department of Psychological Sciences, University of Missouri-St. Louis, St. Louis, MO, United States of America
| | - Jillian B Berfield
- Department of Psychological Sciences, University of Missouri-St. Louis, St. Louis, MO, United States of America
| | - Sophie E Haven
- Department of Psychological Sciences, University of Missouri-St. Louis, St. Louis, MO, United States of America
| | - Steven E Bruce
- Department of Psychological Sciences, University of Missouri-St. Louis, St. Louis, MO, United States of America.
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11
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Gros DF, Allan NP, Koscinski B, Keller S, Acierno R. Influence of comorbid social anxiety disorder in PTSD treatment outcomes for Prolonged Exposure in female military sexual trauma survivors with PTSD. J Clin Psychol 2023; 79:1039-1050. [PMID: 36399326 DOI: 10.1002/jclp.23456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/14/2022] [Accepted: 11/01/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) is a common psychiatric disorder that frequently presents alongside other comorbid diagnoses. Although several evidence-based psychotherapies have been well-studied for PTSD, limited research has focused on the influence of diagnostic comorbidity on their outcomes. The present study sought to investigate the influence of comorbid social anxiety disorder on treatment outcomes in patients with PTSD. METHODS One hundred and twelve treatment-seeking female veteran participants with PTSD completed baseline assessments and received 12-15 sessions of Prolonged Exposure. Symptom measures were completed biweekly as well as at immediate posttreatment, 3-month, and 6-month follow-ups. RESULTS Thirty (26.8%) participants seeking PTSD treatment also met diagnostic criteria for social anxiety disorder. Multilevel modeling was used to examine effects of social anxiety disorder diagnosis on post-intervention symptoms and revealed significantly worse outcomes for symptoms of PTSD and depression in participants with comorbid PTSD and social anxiety disorder. CONCLUSION Consistent with previous studies of co-occurring PTSD and depression, present findings suggest that comorbid diagnoses may adversely affect disorder-specific treatment outcomes. As such, the presence of diagnostic comorbidity may merit further consideration and potential adaptions to the traditional, disorder-specific assessment and treatment practices for PTSD.
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Affiliation(s)
- Daniel F Gros
- Mental Health Service, Ralph H. Johnson VA Healthcare System, Charleston, South Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nicholas P Allan
- Department of Psychiatry and Behavioral Health, Ohio State University, Columbus, Ohio, USA.,VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System Canandaigua, New York, USA
| | | | - Stephanie Keller
- Mental Health Service, Ralph H. Johnson VA Healthcare System, Charleston, South Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ron Acierno
- Mental Health Service, Ralph H. Johnson VA Healthcare System, Charleston, South Carolina, USA.,Louis Faillace Department of Psychiatry, University of Texas Health Science Center at Houston, Houston, USA
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12
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Killeen TK, Brewerton TD. Women with PTSD and Substance Use Disorders in a Research Treatment Study: A Comparison of those with and without the Dissociative Subtype of PTSD. J Trauma Dissociation 2023; 24:229-240. [PMID: 36266949 PMCID: PMC9905299 DOI: 10.1080/15299732.2022.2136327] [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] [Received: 12/05/2021] [Revised: 07/14/2022] [Accepted: 08/12/2022] [Indexed: 02/07/2023]
Abstract
Significant differences in clinical features have been reported in women with substance use disorders (SUDs) between those with the dissociative subtype of posttraumatic stress disorder (D-PTSD) compared to those without, namely more severe trauma histories, PTSD symptoms, and general psychopathology. This presentation reports on a group of 88 women with PTSD and SUD taking part in a research treatment study. All women were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and were categorized into those with (n = 23, 26%) and without (n = 65, 74%) D-PTSD. Assessments for SUDs were via the Multi-International Neuropsychiatric Inventory, Seventh Version (MINI-7). Compared to those without D-PTSD, those with D-PTSD had significantly higher CAPS-5 scores (50.5 ± 9.9 v. 39.6 ± 8.8), greater number of PTSD symptoms (16.4 ± 2.6 v. 14.2 ± 2.4), more alcohol use disorder (AUD) (65.2% v. 30.8%), and more non-cocaine stimulant use disorder (34.8% v. 12.3%). No significant differences were found for other SUDs. These women with SUDs and D-PTSD have higher degrees of PTSD severity as well as unique clinical presentations. Future research is needed to explore the significance of these findings for clinical assessment and treatment.
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Affiliation(s)
- Therese K. Killeen
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425
| | - Timothy D. Brewerton
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425
- Timothy D. Brewerton, MD, LLC, Mt. Pleasant, SC 29464
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13
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Hofmann UK, Hildebrand F, Mederake M, Migliorini F. Telemedicine in orthopaedics and trauma surgery during the first year of COVID pandemic: a systematic review. BMC Musculoskelet Disord 2023; 24:101. [PMID: 36750962 PMCID: PMC9903270 DOI: 10.1186/s12891-023-06194-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/24/2023] [Indexed: 02/09/2023] Open
Abstract
PURPOSE Prior to the COVID-19 pandemic, telemedicine in orthopaedics and trauma surgery had mostly developed for joint arthroplasty, fracture management, and general pre- and postoperative care including teleradiology. With the corona-outbreak, telemedicine was applied on a broad scale to prevent assemblage and to guarantee access to medical care protecting critical areas. The purpose of the present study was to give an overview of the spectrum of clinical applications and the efficacy of telemedicine in orthopaedic and trauma surgery as published in times of the COVID-19 pandemic. METHODS All published studies investigating the application of telemedicine related to orthopaedics and trauma during the COVID-19 pandemic were accessed and screened for suitability. The primary outcome of interest was the efficacy of telemedicine in various clinical applications. The secondary outcome of interest was the spectrum of different applications in which telemedicine applications were investigated. RESULTS The literature search resulted in 1047 articles. After the removal of duplicates, 894 articles were screened of which 31 finally met the inclusion criteria. Dimensions that were described by studies in the literature to have positive effects were preoperative patient optimisation, the usefulness of telemedicine to correctly diagnose a condition, conservative treatment, willingness to and feasibility for telemedicine in patients and doctors, and postoperative/post-trauma care improvement. The efficacy of telemedicine applications or interventions thereby strongly varied and seemed to depend on the exact study design and the research question addressed. CONCLUSION Various successful applications of telemedicine have already been reported in orthopaedics and trauma surgery, with a strong increase in scientific output during the COVID-19 years 2020-2021. Whether the advantages of such an approach will lead to a relevant implementation of telemedicine in everyday clinical practice should be monitored after the COVID-19 pandemic.
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Affiliation(s)
- Ulf Krister Hofmann
- grid.412301.50000 0000 8653 1507Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, Aachen, 52074 Germany
| | - Frank Hildebrand
- grid.412301.50000 0000 8653 1507Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, Aachen, 52074 Germany
| | - Moritz Mederake
- grid.10392.390000 0001 2190 1447Department of Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, 72076 Germany
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, Aachen, 52074, Germany.
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14
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Killeen TK, Wen CC, Neelon B, Baker N. Predictors of Treatment Completion among Women Receiving Integrated Treatment for Comorbid Posttraumatic Stress and Substance Use Disorders. Subst Use Misuse 2023; 58:500-511. [PMID: 36705433 DOI: 10.1080/10826084.2023.2170183] [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: 01/28/2023]
Abstract
Background: Retention in treatment for individuals with comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is an area of concern in treatment outcome studies. The current study explores key variables related to retention in a group of women with comorbid PTSD and SUD enrolled in community SUD treatment randomized to eight weekly sessions of a trauma adapted mindfulness-based relapse prevention (TA-MBRP) or an integrated coping skills (ICS) group intervention. Methods: Two unadjusted and adjusted logistic discrete failure time (DFT) models were fit to examine associations between participants and the time (in weeks) to treatment completion status. Key covariates of interest, including time-varying PTSD Symptom Scale-Self Report (PSS) total score, time-varying Five Factors Mindfulness Questionnaire (FFMQ) total score, group assignment, baseline endorsements of substance use and demographics such as age, race and employment status were fit into the model. Results: In the adjusted PSS model, increased levels of PTSD symptom severity (PSS) scores at week 5 and 7 (PSS OR: 1:06: OR 1.13, respectively) were associated with higher odds of non-completion. In the FFMQ model, increased levels of FFMQ scores at week 6 (OR: 0:92) were associated with lower odds of non-completion. In both models, assignment to the ICS control group and unemployment were associated with lower odds of completion and baseline use of cocaine and sedatives were associated with higher odds of completion. Conclusion: Monitoring PTSD symptom severity and measures of mindfulness can inform providers on strategies to enhance retention early in treatment for individuals with comorbid PTSD/SUD.ClinicalTrials.gov # NCT02755103.
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Affiliation(s)
- Therese K Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Chun-Che Wen
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian Neelon
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nathanial Baker
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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15
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Brown WJ, Saulnier KG, Allan NP, Wojtalik JA, Zampogna AM, Grubaugh AL. Dropout from prolonged exposure among individuals with posttraumatic stress disorder and comorbid severe mental illness. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2022. [DOI: 10.1016/j.jadr.2022.100405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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16
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Levinson DB, Halverson TF, Wilson SM, Fu R. Less dropout from prolonged exposure sessions prescribed at least twice weekly: A meta-analysis and systematic review of randomized controlled trials. J Trauma Stress 2022; 35:1047-1059. [PMID: 35278229 DOI: 10.1002/jts.22822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/06/2022]
Abstract
Trauma-focused psychotherapies, such as prolonged exposure (PE), are strongly recommended to treat posttraumatic stress disorder due to their effects in reducing symptoms. However, such therapies may also suffer from high dropout rates. To investigate how clients might benefit from trauma-focused therapy while minimizing dropout, we conducted a meta-analysis of 1,508 adults from 35 randomized controlled trials (RCTs) of outpatient PE programs to evaluate treatment frequency as a predictor of dropout. When an RCT prescribed PE sessions at least twice weekly compared to less frequently, the dropout rate was significantly lower at 21.0%, 95% CI [13.9%, 30.4%], compared to 34.0%, 95% CI [28.9%, 39.4%], OR = 0.52, 95% CI [0.30, 0.89], p = .018. It was not possible to draw causal conclusions, as only one RCT compared two PE treatment frequencies head-to-head. Nonetheless, the findings remained significant after controlling for study characteristics. These data invite reconsideration of the common practice of weekly psychotherapy in favor of twice-weekly sessions in standard outpatient treatment.
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Affiliation(s)
| | - Tate F Halverson
- Durham VA Health Care System, Durham, North Carolina, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, USA
| | - Sarah M Wilson
- Durham VA Health Care System, Durham, North Carolina, USA
- Division of Behavioral Medicine and Neurosciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rongwei Fu
- School of Public Health, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
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17
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Fitzgerald JM, Timmer-Murillo S, Sheeran C, Begg H, Christoph M, deRoon-Cassini TA, Larson CL. Psychophysiological predictors of change in emotion dysregulation 6 months after traumatic injury. Int J Psychophysiol 2022; 173:29-37. [PMID: 35007667 DOI: 10.1016/j.ijpsycho.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/10/2021] [Accepted: 01/04/2022] [Indexed: 10/19/2022]
Abstract
Emotion dysregulation that occurs after trauma conveys risk for multiple disorders, including posttraumatic stress disorder, depression, and anxiety. Psychophysiological data (e.g., skin conductance level [SCL]) may be a useful biomarker for quantifying emotion dysregulation given that autonomic nervous system (ANS)-mediated arousal may underlie this feature. In this longitudinal study, we tested whether SCL collected following a single-incident traumatic injury could predict changes in emotion dysregulation over 6 months. Sixty-six adults were recruited from the emergency department; SCL was quantified during an active trauma narrative, in which participants re-told their traumatic event to a research staff member, as well as a neutral narrative for a control condition. Change in SCL (ΔSCL) was calculated using a maximum activation - minimum activation difference score. Multilevel linear modeling was used to test ΔSCL as a predictor of emotion dysregulation using the Emotion Dysregulation Scale (EDS) over time (3 timepoints over 6 months). Results showed that greater ΔSCL - indicative of increasing arousal- during both the trauma (p = 0.037) and neutral (p = 0.013) narratives was a significant predictor of greater emotion dysregulation at each subsequent timepoint. Further, we found a ΔSCL by time interaction, such that less ΔSCL during the neutral narrative predicted decreased emotion dysregulation over time (b = -1.26, SE = 0.43, t = -2.91, p = 0.004). Results validate the use of lab-based assessments of arousal to study emotion dysregulation in trauma survivors. That recovery from emotion dysregulation was predicted by less arousal during a neutral event underscores the importance of clinically targeting response to safety in trauma survivors.
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Affiliation(s)
| | - Sydney Timmer-Murillo
- Medical College of Wisconsin, Department of Surgery, Division of Trauma & Acute Care Surgery, Milwaukee, WI, USA
| | - Claire Sheeran
- Marquette University, Department of Psychology, Milwaukee, WI, USA
| | - Hailey Begg
- Marquette University, Department of Psychology, Milwaukee, WI, USA
| | - Morgan Christoph
- Marquette University, Department of Psychology, Milwaukee, WI, USA
| | - Terri A deRoon-Cassini
- Medical College of Wisconsin, Department of Surgery, Division of Trauma & Acute Care Surgery, Milwaukee, WI, USA
| | - Christine L Larson
- University of Wisconsin-Milwaukee, Department of Psychology, Milwaukee, WI, USA
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18
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Contractor AA, Banducci AN, Weiss NH. Critical considerations for the positive memory-posttraumatic stress disorder model. Clin Psychol Psychother 2021; 29:81-91. [PMID: 33870586 DOI: 10.1002/cpp.2599] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 11/05/2022]
Abstract
Posttraumatic stress disorder (PTSD) includes changes in processes such as encoding and retrieval for both traumatic and positive memories. However, most work has predominantly focused on traumatic memories. Thus, Contractor and colleagues proposed a Positive Memory-PTSD model, which highlighted potential benefits associated with and mechanisms underlying positive memory retrieval/processing among individuals reporting PTSD symptoms. To enhance research on and clinical impacts of this model, the current review provides critical considerations for the Positive Memory-PTSD model. Drawing from emerging research and clinical observations, we (i) clarify that the model addresses specific versus overgeneral positive memories; (ii) underscore the importance of considering the heterogeneity in, and transitionary nature of, affect processes following positive memory retrieval; and (iii) highlight the rationale for considering trauma type/count and co-occurring conditions, as potential moderators of relations between positive memory processing and PTSD. Hereby, we provide an updated Positive Memory-PTSD model and implications for positive memory interventions drawing from this model.
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Affiliation(s)
| | - Anne N Banducci
- The National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Nicole H Weiss
- Department of Psychology, University of Rhode Island, Kingston, RI, USA
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