Interventions to treat posttraumatic stress disorder in partnership with primary care: A review of feasibility and large randomized controlled studies

OBJECTIVE

Evidence-based therapies for posttraumatic stress disorder are underutilized and at times unavailable in specialty settings. We reviewed the literature on interventions to treat PTSD within primary care to make recommendations on their effectiveness as treatment modalities or ways to improve engagement in specialty care.

METHOD

We searched PubMed, PsychInfo, CINHAL, and Cochrane Reviews databases using search terms related to PTSD and primary care. We excluded clinical guidelines and studies of screening only or subthreshold PTSD.

RESULTS

524 articles were identified. Twenty-one papers on 15 interventions met review criteria. Seven interventions focus on individual therapies studied via small feasibility studies to prepare for full-scale intervention research. Eight describe treatment programs in primary care based on collaborative care that included medication management, tracking outcomes, referral services, and for some psychotherapy (versus psychotherapy referral). Ten interventions were feasibility studies which precludes meaningful comparison of effect sizes. Of the four RCTs of treatment programs, only two including some psychotherapy found improvements in PTSD symptoms.

CONCLUSION

More research is needed to adapt treatment for PTSD to primary care. Collaborative care may be a promising framework for improving the reach of PTSD treatments when psychotherapy is offered within the collaborative care team.

Engagement With a Trauma Recovery Internet Intervention Explained With the Health Action Process Approach (HAPA): Longitudinal Study

BACKGROUND

There has been a growing trend in the delivery of mental health treatment via technology (ie, electronic health, eHealth). However, engagement with eHealth interventions is a concern, and theoretically based research in this area is sparse. Factors that influence engagement are poorly understood, especially in trauma survivors with symptoms of posttraumatic stress.

OBJECTIVE

The aim of this study was to examine engagement with a trauma recovery eHealth intervention using the Health Action Process Approach theoretical model. Outcome expectancy, perceived need, pretreatment self-efficacy, and trauma symptoms influence the formation of intentions (motivational phase), followed by planning, which mediates the translation of intentions into engagement (volitional phase). We hypothesized the mediational effect of planning would be moderated by level of treatment self-efficacy.

METHODS

Trauma survivors from around the United States used the eHealth intervention for 2 weeks. We collected baseline demographic, social cognitive predictors, and distress symptoms and measured engagement subjectively and objectively throughout the intervention.

RESULTS

The motivational phase model explained 48% of the variance, and outcome expectations (beta=.36), perceived need (beta=.32), pretreatment self-efficacy (beta=.13), and trauma symptoms (beta=.21) were significant predictors of intention (N=440). In the volitional phase, results of the moderated mediation model indicated for low levels of treatment self-efficacy, planning mediated the effects of intention on levels of engagement (B=0.89, 95% CI 0.143-2.605; N=115).

CONCLUSIONS

Though many factors can affect engagement, these results offer a theoretical framework for understanding engagement with an eHealth intervention. This study highlighted the importance of perceived need, outcome expectations, self-efficacy, and baseline distress symptoms in the formation of intentions to use the intervention. For those low in treatment self-efficacy, planning may play an important role in the translation of intentions into engagement. Results of this study may help bring some clarification to the question of what makes eHealth interventions work.

Crisis interventions in online psychological counseling

INTRODUCTION

The world's population is often assailed by crises of various orders. Disasters caused by nature and by humans themselves also impact on people's mental health. Psychological crises, such as suicide attempts, represent a growing problem in mental health. When faced with such scenarios, specific strategies of crisis intervention are both appropriate and necessary.

OBJECTIVE

To conduct a systematic review of the literature dealing with online psychological crisis intervention, describing and discussing their operational design, specific characteristics and applications.

METHOD

A systematic review of literature indexed on the PubMed, PsycINFO, and SciELO databases identified by searches conducted from January to June of 2014.

RESULTS

The searches identified 17 empirical studies about online crisis interventions which were reviewed. Three crisis contexts emerged: 1) disasters, 2) risk/prevention of suicide, and 3) trauma. Eleven different intervention programs were described and the predominant treatment approach was cognitive behavioral therapy. The results showed that research into online psychological crisis intervention has been conducted in several different countries, especially the Netherlands and Australia, and that the users of these tools benefit from them.

CONCLUSION

Online crisis interventions have been developed and researched in many countries around the world. In Brazil, there is still a lack of investment and research in this area.

Distance-delivered interventions for PTSD: A systematic review and meta-analysis

This systematic review and meta-analysis evaluated the efficacy of distance-delivered, guided approaches to treatment (e.g., delivered via telephone, Internet, mail, videoconferencing) for clinical and subclinical posttraumatic stress disorder (PTSD). A comprehensive search yielded 19 randomized controlled trials (1491 participants) to be included. Meta-analyses revealed that distance-delivered interventions led to significant within-group improvements in PTSD symptoms at post-treatment (g=0.81, 95% CI 0.65 to 0.97) and 3-6 month follow-up (g=0.78, 95% CI 0.59 to 0.97). Within-group depression and quality of life outcomes showed similar results, with medium post-treatment and follow-up effects. Compared to a waiting list, distance delivery (specifically, Internet treatments) led to superior PTSD outcomes (g=0.68, 95% CI 0.51 to 0.86). Compared to face-to-face interventions, distance delivery (specifically, videoconferencing treatments) did not result in significantly different PTSD outcomes at post-treatment (g=-0.05, 95% CI -0.31 to 0.20) but led to inferior outcomes at 3-6 month follow-up (g=-0.25, 95% CI -0.44 to -0.07). Distance delivery of PTSD treatment is promising, but research is needed to determine its optimal use.

[Personalized Internet-based treatment services for posttraumatic stress disorder]

Among the most important innovations within the psychotherapeutic care system are the new opportunities in the field of e-mental health. During the past decade, Internet-based and other e-mental health approaches for the treatment of post-traumatic stress disorder and related stress-associated symptoms have been developed in great variety. Solely Internet-based self-help programs are the lowest-threshold approaches in a stepped-care system. By contrast, individualized online psychotherapy and virtual reality programs are at the opposite pole of the spectrum. Approaches in the field of m(obile)-mental health complement these new developments in psychotherapy. The existing evidence supports the clinical efficacy of all the described approaches, although not all have been tested rigorously analog to phase III studies in psychopharmacology. Nonetheless, e-mental health approaches will shape our field more and more in the future.

Internet-delivered eye movement desensitization and reprocessing (iEMDR): an open trial

Recent research indicates internet-delivered cognitive behavioural therapy (iCBT) can reduce symptoms of post traumatic stress disorder (PTSD). This study examined the efficacy of an internet-delivered treatment protocol that combined iCBT and internet-delivered eye movement desensitization and reprocessing (iEMDR), in an uncontrolled trial. Eleven of the 15 participants completed post-treatment questionnaires. Large effect sizes were found from pre-treatment to 3-month follow-up ( d = 1.03 – 1.61) on clinician-assessed and self-reported measures of PTSD, anxiety and distress, with moderate effect sizes ( d = 0.59 – 0.70) found on measures of depression and disability. At post-treatment, 55% of the participants no longer met criteria for PTSD and this was sustained at follow-up. Symptom worsening occurred in 3 of 15 (20%) of the sample from pre- to post-treatment; however, these participants reported overall symptom improvement by follow-up. Future research directions for iEMDR are discussed.

Internet-delivered eye movement desensitization and reprocessing (iEMDR): an open trial

Recent research indicates internet-delivered cognitive behavioural therapy (iCBT) can reduce symptoms of post traumatic stress disorder (PTSD). This study examined the efficacy of an internet-delivered treatment protocol that combined iCBT and internet-delivered eye movement desensitization and reprocessing (iEMDR), in an uncontrolled trial. Eleven of the 15 participants completed post-treatment questionnaires. Large effect sizes were found from pre-treatment to 3-month follow-up ( d = 1.03 - 1.61) on clinician-assessed and self-reported measures of PTSD, anxiety and distress, with moderate effect sizes ( d = 0.59 - 0.70) found on measures of depression and disability. At post-treatment, 55% of the participants no longer met criteria for PTSD and this was sustained at follow-up. Symptom worsening occurred in 3 of 15 (20%) of the sample from pre- to post-treatment; however, these participants reported overall symptom improvement by follow-up. Future research directions for iEMDR are discussed.

Technological advances in the treatment of trauma: a review of promising practices

Given the availability of empirically supported practices for addressing posttraumatic stress disorder and other forms of trauma-related distress, the development and implementation of new technology to deliver these treatments is exciting. Technological innovations in this literature aim to expand availability of empirically based intervention, increase treatment adherence and acceptability, and overcome barriers commonly encountered with conventional trauma-focused treatment. Much of the current research on these technological developments consists of brief reviews and case studies of the separate therapy modalities. Although this work serves to document the appeal and utility of these innovations, it does not provide comprehensive information about the host of options available. To that end, the three general categories of technological advances in trauma therapy (i.e., videoconferencing, e-Health, virtual reality) are reviewed here, including information regarding their empirical support and suggestions for future research and clinical practice.

Controversy clarified: an updated review of clinical psychology and tele-health

One of the most controversial topics in the field of clinical psychology, online tele-health, or the integration of computers and the internet with therapeutic techniques, remains at the forefront of many debates. Despite potential interest, there are numerous factors that a psychologist must consider before integrating an online tele-health intervention into their own practice. This article outlines literature pertinent to the debate. The article begins with a brief history of the use of non-face-to-face interventions as well as the earliest recorded use of "tele-health" before discussing the modern benefits and risks associated with usage. Considerations for the psychologist as well as the client are detailed; incorporating ethical implications. The authors conclude that the utilization of tele-health interventions is an exponentially expanding field that should continue to be explored. Despite many well-conceived studies, a psychologist should educate themselves in all aspects of the new modes of intervention (e.g., ethical, legal, evidence-based treatments) before attempting to implement them into everyday practice. The article ends with a discussion on the acceptance among psychologists, as well as the outlook for the future.

Characteristics and treatment preferences of people with symptoms of posttraumatic stress disorder: an internet survey

Background

Although Posttraumatic Stress Disorder (PTSD) is a severe and disabling anxiety disorder, relatively few people with this condition access evidence-based care. Barriers to treatment are multiple and complex, but the emerging field of Internet therapy for PTSD may improve access to evidence-based treatment. However, little is known about the characteristics of people with PTSD who seek online treatment, or whether they perceive internet treatment as an acceptable treatment option.

Methodology

An online survey was used to collect information about the demographic and symptom characteristics of individuals with elevated levels of PTSD symptoms, and this was compared to data from corresponding sample from a national survey. Previous treatment experiences, perceived barriers to treatment and treatment preferences for Internet therapy and face-to-face treatment were also compared.

Principal Findings

High levels of PTSD symptoms were reported by survey respondents. Psychological distress and disability was greater than reported by individuals with PTSD from a national survey. Half of the sample reported not having received treatment for PTSD; however, 88% of those who reported receiving treatment stated they received an evidence-based treatment. Primary barriers to treatment included cost, poor awareness of service availability, lack of prior treatment response and not perceiving personal distress as severe enough to warrant treatment. Most survey respondents indicated they were willing to try Internet treatment for PTSD.

Conclusions

The Internet sample was symptomatically severe and multiple barriers existed to treatment. Internet therapy is an acceptable option for the treatment of PTSD in an internet sample.

Randomized controlled trial of Internet-delivered cognitive behavioral therapy for posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is a severe and disabling condition and few receive appropriate care. Internet-based treatment of PTSD shows promise in reducing barriers to care and preliminary evidence suggests it is efficacious in treating symptoms of PTSD.

METHODOLOGY

Forty-two individuals with a diagnosis of PTSD confirmed by clinician interview completed a randomized controlled comparison of Internet-based cognitive behavioral therapy (CBT) with a waitlist control condition.

PRINCIPLE FINDINGS

Large pre- to posttreatment effect sizes (ESs) were found for the Treatment group on measures of PTSD symptoms, depression, anxiety, and disability. A small between-group ES was found for PTSD symptoms and moderate between-group ESs were found for depression, anxiety, and disability.

CONCLUSIONS

Results provide preliminary support for Internet-based CBT as an efficacious treatment for individuals with a confirmed primary diagnosis of PTSD.

Web-Based Intervention for Returning Veterans with Symptoms of Posttraumatic Stress Disorder and Risky Alcohol Use

A substantial number of military personnel who have served in Iraq (Operation Iraqi Freedom; OIF) and Afghanistan (Operating Enduring Freedom; OEF) develop symptoms of posttraumatic stress disorder (PTSD) in response to their military experiences and many of these same individuals will drink in a risky or problematic manner following deployment. If left untreated, PTSD symptoms and alcohol problems can become chronic and have a significant, negative impact on the lives of veterans, their families and communities. Further, OIF and OEF service members are often reluctant to seek treatment for mental health symptoms or alcohol problems secondary to stigma. In order to reach this population it is essential that new strategies and venues for delivering evidence-based care are explored. Web-based interventions are uniquely suited to this cohort of veterans in that they have the potential to reach a significant number of veterans who commonly use the Web and who might not otherwise receive care. This article will review the prevalence of PTSD and alcohol problems among OIF and OEF veterans, common barriers they experience with accessing care in traditional mental health settings, and what is known about the effectiveness of Web-based approaches for PTSD and alcohol problems. It also describes the components of a new Web-based intervention, developed by the authors, that uses motivational enhancement and cognitive-behavioral strategies to intervene with returning veterans who report PTSD symptoms and problem drinking. Recommendations for future directions in working with returning veterans with PTSD and alcohol problems will be offered.

Internet-based prevention of posttraumatic stress symptoms in injured trauma patients: design of a randomized controlled trial

BACKGROUND

Injured trauma victims are at risk of developing Posttraumatic Stress Disorder (PTSD) and other post-trauma psychopathology. So far, interventions using cognitive behavioral techniques (CBT) have proven most efficacious in treating early PTSD in highly symptomatic individuals. No early intervention for the prevention of PTSD for all victims has yet proven effective. In the acute psychosocial care for trauma victims, there is a clear need for easily applicable, accessible, cost-efficient early interventions.

OBJECTIVE

To describe the design of a randomized controlled trial (RCT) evaluating the effectiveness of a brief Internet-based early intervention that incorporates CBT techniques with the aim of reducing acute psychological distress and preventing long-term PTSD symptoms in injured trauma victims.

METHOD

In a two armed RCT, 300 injured trauma victims from two Level-1 trauma centers in Amsterdam, the Netherlands, will be assigned to an intervention or a control group. Inclusion criteria are: being 18 years of age or older, having experienced a traumatic event according to the diagnostic criteria of the DSM-IV and understanding the Dutch language. The intervention group will be given access to the intervention's website (www.traumatips.nl), and are specifically requested to login within the first month postinjury. The primary clinical study outcome is PTSD symptom severity. Secondary outcomes include symptoms of depression and anxiety, quality of life, and social support. In addition, a cost-effectiveness analysis of the intervention will be performed. Data are collected at one week post-injury, prior to first login (baseline), and at 1, 3, 6 and 12 months. Analyses will be on an intention-to-treat basis.

DISCUSSION

The results will provide more insight into the effects of preventive interventions in general, and Internet-based early interventions specifically, on acute stress reactions and PTSD, in an injured population, during the acute phase after trauma. We will discuss possible strengths and limitations.

Bringing Internet-based education and intervention into mental health practice: afterdeployment.org

BACKGROUND

Internet-facilitated interventions may offer numerous advantages in reaching the large numbers of military service men and women exposed to traumatic events. The Internet is now a primary source of health-related information for consumers and research has shown the effectiveness of web-based interventions in addressing a range of mental health problems.

OBJECTIVE

Clinicians can learn how to bring Internet education and intervention into routine care, to help clients better understand mental health issues and learn skills for self-management of problems.

METHOD

The Afterdeployment.org (AD) Internet site can be used by health care professionals serving U.S. military personnel returning from Iraq and Afghanistan, and their families. The site currently addresses 18 key domains of functioning, including post-traumatic stress, sleep, anger, alcohol and drugs, and military sexual trauma. It provides an extensive amount of client and family education that is suitable for immediate use by clients and providers, as well as the kinds of interactive workshop content and self-assessment tools that have been shown to be helpful in other treatment contexts.

RESULTS

AD CAN BE UTILIZED IN CLINICAL PRACTICE IN A VARIETY OF WAYS: as an adjunct to treatment for PTSD, to supplement existing treatments for a range of post-deployment problems, or as the primary focus of treatment for a client.

CONCLUSIONS

AD represents a kind of service that is likely to become increasingly available in coming years and that is important for mental health providers to actively explore as a tool for extending their reach, improving their efficiency, and improving quality of care.

Chronic pain in torture victims

Torture is widely practiced throughout the world. Recent studies indicate that 50% of all countries, including 79% of the G-20 countries, continue to practice systematic torture despite a universal ban. It is well known that torture has numerous physical, psychological, and pain-related sequelae that can inflict a devastating and enduring burden on its victims. Health care professionals, particularly those who specialize in the treatment of chronic pain, have an obligation to better understand the physical and psychological effects of torture. This review highlights the epidemiology, classification, pain sequelae, and clinical treatment guidelines of torture victims. In addition, the role of pharmacologic and psychologic interventions is explored in the context of rehabilitation.

Internet-based interventions for traumatic stress-related mental health problems: a review and suggestion for future research

Exposure to potentially traumatic events is a common occurrence. Most individuals exposed to such an event are resilient or recover rapidly, although some individuals develop psychological problems that warrant treatment. However, a small percentage of individuals seek traditional treatment, thereby calling for novel approaches or methodologies of treatment. The present paper provides a comprehensive and critical review of the extant literature on computerized and internet-based interventions (IBIs) for traumatic stress-related conditions (i.e., panic disorder, posttraumatic stress disorder/complicated grief, depression, comorbid anxiety and depression, alcohol abuse, smoking cessation). Generally, computerized or IBIs for depression and anxiety are yielding effect sizes that are comparable to traditional psychosocial treatment. Interventions aimed at alcohol and smoking cessation generally have lower effect sizes than do IBIs for anxiety and depression. Most interventions reviewed in this paper included common components (e.g., were developed through a cognitive behavioral framework and included psychoeducation, cognitive restructuring, goal setting, exposure). Therefore, it is possible that these shared features may in part account for symptom reduction. Little is known regarding mechanisms of change. Future directions for novel web-based approaches to treatment are provided.

Cognitive-behavioral psychology: implications for disaster and terrorism response

Given the personal and societal costs associated with acute impairment and enduring post-traumatic stress disorder (PTSD), the mental health response to disasters is an integral component of disaster response planning. The purpose of this paper is to explore the compatibility between cognitive-behavioral psychology and the disaster mental health model, and explicate how cognitive-behavioral perspectives and intervention methods can enhance the effectiveness of disaster mental health services. It is argued that cognitive-behavioral methods, if matched to the contexts of the disaster and the needs of individuals, will improve efforts to prevent the development of PTSD and other trauma-related problems in survivors of disaster or terrorist events. First, the similarities between models of care underlying both disaster mental health services and cognitive-behavioral therapies are described. Second, examples of prior cognitive-behavioral therapy-informed work with persons exposed to disaster and terrorism are provided, potential cognitive-behavioral therapy applications to disaster and terrorism are explored, and implications of cognitive-behavioral therapy for common challenges in disaster mental health is discussed. Finally, steps that can be taken to integrate cognitive-behavioral therapy into disaster mental health are outlined. The aim is to prompt disaster mental health agencies and workers to consider using cognitive-behavioral therapy to improve services and training, and to motivate cognitive-behavioral researchers and practitioners to develop and support disaster mental health response.

Internet interventions for traumatic stress: a review and theoretically based example

Trauma recovery Web sites are proliferating with limited supportive evidence for effectiveness. In this article, the authors review the current very early studies on trauma recovery Web sites highlighting the different approaches, the empirical support provided, and the critical development issues facing this exciting frontier. An example site based on social cognitive theory is also reviewed.

Therapist-assisted, Internet-based treatment for panic disorder: can general practitioners achieve comparable patient outcomes to psychologists?

Background

Mental illness is an escalating concern worldwide. The management of disorders such as anxiety and depression largely falls to family doctors or general practitioners (GPs). However, GPs are often too time constrained and may lack the necessary training to adequately manage the needs of such patients. Evidence-based Internet interventions represent a potentially valuable resource to reduce the burden of care and the cost of managing mental health disorders within primary care settings and, at the same time, improve patient outcomes.

Objective

The present study sought to extend the efficacy of a therapist-assisted Internet treatment program for panic disorder, Panic Online, by determining whether comparable outcomes could be achieved and maintained when Panic Online was supported by either GPs or psychologists.

Methods

Via a natural groups design, 96 people with a primary diagnosis of panic disorder (with or without agoraphobia) completed the Panic Online program over 12 weeks with the therapeutic assistance of their GP (n = 53), who had received specialist training in cognitive behavioral therapy, or a clinical psychologist (n = 43). Participants completed a clinical diagnostic telephone interview, conducted by a psychologist, and a set of online questionnaires to assess panic-related symptoms at three time periods (pretreatment, posttreatment, and 6 month follow-up).

Results

Both treatments led to clinically significant improvements on measures of panic and panic-related symptomatology from pretreatment to posttreatment. Both groups were shown to significantly improve over time. Improvements for both groups were maintained at follow-up; however, the groups did differ significantly on two quality of life domains: physical (F_1,82 = 9.13, P = .00) and environmental (F_1,82 = 4.41, P = .04). The attrition rate was significantly higher among those being treated by their GP (χ²₁ = 4.40, P = .02, N = 96).

Conclusions

This study provides evidence that Internet-based interventions are an effective adjunct to existing mental health care systems. Consequently, this may facilitate and enhance the delivery of evidence-based mental health treatments to increasingly large segments of the population via primary care systems and through suitably trained health professionals.

Directions for the International Society for Research on Internet Interventions (ISRII)

In 2004, the International Society for Research on Internet Interventions (ISRII) was formed to encourage eHealth researchers to collaborate in their efforts to further the science behind developing, testing, and disseminating Web-based treatment programs. The group held its second meeting (April 2006) to clarify the Society's direction and identify key issues that need addressing in the field. These issues are identified and examined in the current paper. Given the success of using the Internet to treat a range of medical and mental health problems, and the growing need for better dissemination of health care, Internet interventions will almost certainly play a prominent role in global health. ISRII plans to provide the necessary venue to ensure the science driving this field is strong, enabling researchers to conduct the highest quality research and permitting meaningful conclusions from completed studies.