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Chambliss T, Hsu JL, Chen ML. Post-traumatic Stress Disorder in Veterans: A Concept Analysis. Behav Sci (Basel) 2024; 14:485. [PMID: 38920817 PMCID: PMC11200391 DOI: 10.3390/bs14060485] [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: 02/27/2024] [Revised: 05/06/2024] [Accepted: 05/31/2024] [Indexed: 06/27/2024] Open
Abstract
Post-traumatic stress disorder (PTSD) occurs when an individual experiences a traumatic event that exceeds the limits of psychological endurance. Many veterans experience PTSD. PTSD can negatively impact veterans' quality of life, functioning, life satisfaction, and overall well-being. It is important to analyze the concept of PTSD in the veteran population. This concept analysis aimed to investigate the defining attributes, a model case, antecedents, consequences, and empirical referents related to the concept of PTSD among veterans. Walker and Avant's method was used to guide this concept analysis of PTSD. The results showed that three attributes were determined from the analysis: intrusive memories of traumatic events, feelings of isolation and estrangement, and negative cognitions. PTSD is conceptualized as a collection of symptoms that arise from highly traumatic experiences. The military environment predisposes veterans to traumatic events that should be identified or acknowledged. A better understanding of the concept of PTSD can facilitate the development of effective interventions for the veteran population and enhance their mental health.
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Affiliation(s)
- Tormechi Chambliss
- School of Nursing, Byrdine F. Lewis College of Nursing and Health Professions, Georgia State University, Atlanta, GA 30303, USA;
| | - Jung-Lung Hsu
- Department of Neurology, New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei City 236, Taiwan;
| | - Mei-Lan Chen
- School of Nursing, Byrdine F. Lewis College of Nursing and Health Professions, Georgia State University, Atlanta, GA 30303, USA;
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Monson CM, Pukay-Martin ND, Wagner AC, Crenshaw AO, Blount TH, Schobitz RP, Dondanville KA, Young-McCaughan S, Mintz J, Riggs DS, Brundige A, Hembree EA, Litz BT, Roache JD, Yarvis JS, Peterson AL. Cognitive-behavioural conjoint therapy versus prolonged exposure for PTSD in military service members and veterans: results and lessons from a randomized controlled trial. Eur J Psychotraumatol 2024; 15:2330305. [PMID: 38590124 PMCID: PMC11005874 DOI: 10.1080/20008066.2024.2330305] [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: 12/08/2023] [Accepted: 03/03/2024] [Indexed: 04/10/2024] Open
Abstract
Military personnel and veterans are at heightened risk for exposure to traumatic events and posttraumatic stress disorder (PTSD), as well as intimate relationship problems associated with PTSD. The purpose of this study was to evaluate the relative efficacy of CBCT and PE in improving intimate relationship functioning in active duty military personnel or veterans and their intimate partners; both conditions were hypothesized to significantly improve PTSD. Method: In this study, 32 military service members or veterans with PTSD and their intimate partners were randomized to receive either Cognitive-Behavioral Conjoint Therapy for PTSD (n = 15; CBCT; [Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for posttraumatic stress disorder: Harnessing the healing power of relationships. Guilford]), a trauma-focused couple therapy, or Prolonged Exposure (n = 17; PE; [Foa, E. B., Hembree, E. A., Dancu, C. V., Peterson, A. L., Cigrang, J. A., & Riggs, D. S. (2008). Prolonged exposure treatment for combat-related stress disorders - provider's treatment manual [unpublished]. Department of Psychiatry, University of Pennsylvania]), a front-line evidence-based individual treatment for PTSD. There were significant challenges with recruitment and a significant difference in dropout from treatment for the two therapies (65% for PE; 27% for CBCT). Treatment dropout was differentially related to pre-treatment relationship functioning; those with below average relationship functioning had higher dropout in PE compared with CBCT, whereas those with above average relationship functioning did not show differential dropout. In general, CBCT led to relational improvements, but this was not consistently found in PE. Clinician- and self-reported PTSD symptoms improved with both treatments. This study is the first to test a couple or family therapy against a well-established, front-line recommended treatment for PTSD, with expected superiority of CBCT over PE on relationship outcomes. Lessons learned in trial design, including considerations of equipoise, and the effects of differential dropout on trial analyses are discussed. This trial provides further support for the efficacy of CBCT in the treatment of PTSD and enhancement of intimate relationships.
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Affiliation(s)
- Candice M. Monson
- Department of Psychology, Toronto Metropolitan University, Toronto, Canada
| | | | - Anne C. Wagner
- Department of Psychology, Toronto Metropolitan University, Toronto, Canada
- Remedy, Toronto, Canada
| | | | - Tabatha H. Blount
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Richard P. Schobitz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Katherine A. Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Population Health Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - David S. Riggs
- Hérbert School of Medicine, Uniformed Services University of the Health Sciences, and Center for Deployment Psychology, Bethesda, MD, USA
| | - Antoinette Brundige
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | | | - Brett T. Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - John D. Roache
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Jeffrey S. Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, TX, USA
| | - Alan L. Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX, USA
| | - for the STRONG STAR Consortium
- Department of Psychology, Toronto Metropolitan University, Toronto, Canada
- Cincinnati VA Medical Center, Cincinnati, OH, USA
- Remedy, Toronto, Canada
- Kennesaw State University, Kennesaw, GA, USA
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Hérbert School of Medicine, Uniformed Services University of the Health Sciences, and Center for Deployment Psychology, Bethesda, MD, USA
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, TX, USA
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX, USA
- Department of Population Health Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Shepherd-Banigan M, Shapiro A, Stechuchak KM, Glynn S, Calhoun P, Ackland PE, Bokhour B, Edelman D, Falkovic M, Weidenbacher HJ, Eldridge MR, Lanford T, Swinkels C, Dedert E, Wells S, Ruffin R, Van Houtven CH. Feasibility of a family-involved intervention to increase engagement in evidenced-based psychotherapies for posttraumatic stress disorder: A pilot study. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2024:2024-44916-001. [PMID: 38236230 PMCID: PMC11255124 DOI: 10.1037/tra0001623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To assess the feasibility of a family-involved intervention, family support in mental health recovery (FAMILIAR), for veterans with posttraumatic stress disorder (PTSD) seeking psychotherapy at a single Veterans Administration Health System. METHOD This mixed-methods study reports qualitative and quantitative findings from a single-group pilot of 24 veterans and their support partners (SPs) about experiences with the intervention and interviews with eight VA mental health clinicians and leaders and the study interventionist to explore intervention feasibility. Findings across data sources were merged within domains of Bowen and colleagues' pilot study feasibility framework. RESULTS Out of 24 dyads, 16 veterans and 15 associated SPs completed the intervention. Participants viewed the intervention to be valuable and feasible. Veterans and SPs reported that they enrolled in the study to develop a shared understanding of PTSD and treatment. While participants identified few logistical barriers, finding a time for conjoint sessions could be a challenge. Veterans, SPs, and providers discussed benefits of the intervention, including that it facilitated conversation between the veteran and SP about PTSD and mental health care and helped to prepare the dyad for treatment. Providers noted potential challenges integrating family-involved interventions into clinical workflow in VA and suggested the need for additional training and standardized procedures for family-centered care. CONCLUSIONS Our study identified potential implementation facilitators (e.g., standard operating procedures about session documentation, confidentiality, and family ethics) and challenges (e.g., clinical workflow integration) that require further study to bring FAMILIAR into routine clinical care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120, Durham, NC 27708
- Veterans Affairs Mid-Atlantic Region Mental Illness Research, Education, and Clinical Center, Durham, NC 27705
| | - Abigail Shapiro
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | | | - Shirley Glynn
- West Los Angeles VA Medical Center, 11301 Wilshire Boulevard, Los Angeles, CA 90073-1003
- David Geffen School of Medicine, UCLA, Geffen Hall, 885 Tiverton Drive Los Angeles, CA 90095
| | - Patrick Calhoun
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Veterans Affairs Mid-Atlantic Region Mental Illness Research, Education, and Clinical Center, Durham, NC 27705
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC, 27701
| | - Princess E. Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417
- Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455
| | - Barbara Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, 200 Springs Road, Bedford, MA 01730-11
- UMass Chan Medical School, Population and Quantitative Health Sciences, 55 Lake Avenue North Worcester, MA 01655
| | - David Edelman
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701
| | - Margaret Falkovic
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701
| | | | | | - Tiera Lanford
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Cindy Swinkels
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Veterans Affairs Mid-Atlantic Region Mental Illness Research, Education, and Clinical Center, Durham, NC 27705
| | - Eric Dedert
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Veterans Affairs Mid-Atlantic Region Mental Illness Research, Education, and Clinical Center, Durham, NC 27705
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC, 27701
| | - Stephanie Wells
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Veterans Affairs Mid-Atlantic Region Mental Illness Research, Education, and Clinical Center, Durham, NC 27705
| | - Rachel Ruffin
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Courtney H. Van Houtven
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120, Durham, NC 27708
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Polizzi CP, Sistad RE, Livingston NA, Brief D, Litwack S, Roy M, Solhan M, Rosenbloom D, Keane TM. Alcohol-Related Problems As Moderators of PTSD Symptom Change During Use of a Web-Based Intervention for Hazardous Drinking and PTSD. J Stud Alcohol Drugs 2024; 85:51-61. [PMID: 37796630 PMCID: PMC10846604 DOI: 10.15288/jsad.23-00094] [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: 03/17/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE Alcohol-related problems (e.g., physical, interpersonal, intrapersonal, impulse control, social responsibility) can have an impact on posttraumatic stress disorder (PTSD) symptoms during treatment. Evidence-based online self-help tools exist to target alcohol use and related problems and co-occurring PTSD symptoms. It is unknown to what degree individuals with varying alcohol-related problems respond differently to web-based interventions for hazardous alcohol use and PTSD. The current study evaluated specific alcohol-related problems as potential moderators of PTSD symptom changes during the VetChange online intervention while controlling for average daily alcohol use, gender, race, and age. METHOD We conducted a secondary analysis of a randomized controlled trial that included 600 post-9/11 veterans (518 men and 82 women). Mixed-effects regression models of alcohol-related problems on PTSD severity scores over time were performed separately in an initial intervention group (IIG; n = 404) and a delayed intervention group (DIG; n = 196) that was used as a comparison condition. RESULTS Interpersonal problems emerged as a moderator of PTSD symptom changes in IIG such that veterans endorsing greater interpersonal problems demonstrated larger reductions in PTSD symptoms throughout VetChange. There were no significant moderation effects in DIG. Non-White veterans reported significantly higher PTSD symptoms during VetChange. Post hoc analyses indicated that veterans with higher interpersonal problems were more likely to engage in online intervention content focused on identifying high-risk drinking situations and coping with symptoms. CONCLUSIONS Findings imply that veterans reporting alcohol-related interpersonal problems may benefit the most from, and be more motivated to use, online interventions for hazardous alcohol use and PTSD symptoms.
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Affiliation(s)
- Craig P. Polizzi
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Rebecca E. Sistad
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- U.S. Department of Veteran Affairs, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Nicholas A. Livingston
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- National Center for PTSD, Behavioral Science Division, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Deborah Brief
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Scott Litwack
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Monica Roy
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Marika Solhan
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- U.S. Department of Veterans Affairs, Boston Vet Center, Boston, Massachusetts
| | - David Rosenbloom
- Boston University School of Public Health, Boston, Massachusetts
| | - Terence M. Keane
- U.S. Department of Veteran Affairs, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- National Center for PTSD, Behavioral Science Division, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
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Reuman L, Thompson-Hollands J. Family accommodation in PTSD: Proposed considerations and distinctions from the established transdiagnostic literature. CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2023; 30:453-464. [PMID: 38390036 PMCID: PMC10881198 DOI: 10.1111/cpsp.12375] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/07/2020] [Indexed: 11/29/2022]
Abstract
Accommodation is widely documented and studied among internalizing disorders; however, the conceptualization and study of accommodation in the context of posttraumatic stress disorder (PTSD) is relatively nascent. PTSD entails many diagnostic criteria-including exposure to a distinct Criterion A event, emotional numbing, and anger-that may uniquely influence accommodation and merit special consideration. Our aim was to review the impact of accommodation in PTSD, compare and contrast accommodation in PTSD to other disorders with a strong empirical evidence base regarding accommodation, and highlight considerations unique to PTSD and associated implications for accommodation. We conclude by providing considerations for future research and practice.
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Affiliation(s)
- Lillian Reuman
- VA Boston Healthcare System, National Center for PTSD, Boston, MA, USA
- School of Medicine, Boston University, Boston, MA, USA
| | - Johanna Thompson-Hollands
- VA Boston Healthcare System, National Center for PTSD, Boston, MA, USA
- School of Medicine, Boston University, Boston, MA, USA
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Dodge J, Sullivan K, Grau PP, Chen C, Sripada R, Pfeiffer PN. Retention in Individual Trauma-Focused Treatment Following Family-Based Treatment Among US Veterans. JAMA Netw Open 2023; 6:e2349098. [PMID: 38127345 PMCID: PMC10739069 DOI: 10.1001/jamanetworkopen.2023.49098] [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: 09/07/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023] Open
Abstract
Importance Despite the availability of several empirically supported trauma-focused interventions, retention in posttraumatic stress disorder (PTSD) psychotherapy is poor. Preliminary efficacy data shows that brief, family-based interventions may improve treatment retention in a veteran's individual PTSD treatment, although whether this occurs in routine clinical practice is not established. Objective To characterize receipt of family therapy among veterans diagnosed with PTSD and evaluate whether participation in family therapy is associated with an increased likelihood of completing individual trauma-focused treatment. Design, Setting, and Participants This retrospective cohort study used the Veterans Health Administration (VHA) Informatics and Computing Infrastructure to extract electronic health record data of participants. All participants were US veterans diagnosed with PTSD between October 1, 2015, and December 31, 2019, who attended at least 1 individual trauma-focused treatment session. Statistical analysis was performed from May to August 2023. Exposures Receipt of any family psychotherapy and subtype of family-based psychotherapy. Main Outcomes and Measures Minimally adequate individual trauma-focused treatment completion (ie, 8 or more sessions of trauma-focused treatment in a 6-month period). Results Among a total of 1 516 887 US veterans with VHA patient data included in the study, 58 653 (3.9%) received any family therapy; 334 645 (23.5%) were Black, 1 006 168 (70.5%) were White, and 86 176 (6.0%) were other race; 1 322 592 (87.2%) were male; 1 201 902 (79.9%) lived in urban areas; and the mean (SD) age at first individual psychotherapy appointment was 52.7 (15.9) years. Among the 58 653 veterans (3.9%) who received any family therapy, 36 913 (62.9%) received undefined family therapy only, 15 528 (26.5%) received trauma-informed cognitive-behavioral conjoint therapy (CBCT) only, 5210 (8.9%) received integrative behavioral couples therapy (IBCT) only, and 282 (0.5%) received behavioral family therapy (BFT) only. Compared with receiving no family therapy, the odds of completing individual PTSD treatment were 7% higher for veterans who also received CBCT (OR, 1.07 [95% CI, 1.01-1.13]) and 68% higher for veterans received undefined family therapy (OR, 1.68 [95% CI, 1.63-1.74]). However, compared with receiving no family therapy care, veterans had 26% lower odds of completing individual PTSD treatment if they were also receiving IBCT (OR, 0.74 [95% CI, 0.66-0.82]). Conclusions and Relevance In this cohort study of US veterans, family-based psychotherapies were found to differ substantially in their associations with individual PTSD psychotherapy retention. These findings highlight potential benefits of concurrently providing family-based therapy with individual PTSD treatment but also the need for careful clinical attention to the balance between family-based therapies and individual PTSD treatment.
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Affiliation(s)
- Jessica Dodge
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
| | | | - Peter P. Grau
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Charity Chen
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
| | - Rebecca Sripada
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Paul N. Pfeiffer
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
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Shepherd-Banigan M, Shapiro A, Sheahan KL, Ackland PE, Meis LA, Thompson-Hollands J, Edelman D, Calhoun PS, Weidenbacher H, Van Houtven CH. Mental health therapy for veterans with PTSD as a family affair: A qualitative inquiry into how family support and social norms influence veteran engagement in care. Psychol Serv 2023; 20:839-848. [PMID: 36780280 PMCID: PMC10423295 DOI: 10.1037/ser0000742] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Social support is important for posttraumatic stress disorder (PTSD) recovery and emerging literature indicate that social support could increase engagement in PTSD therapy. However, there is a need to understand how and why family involvement can increase treatment engagement to inform strategies used in clinical practice. This study explores how individuals with PTSD and family members of individuals with PTSD experience therapy and how social interactions help or hinder therapy engagement. We interviewed 18 U.S. military veterans who had been referred for psychotherapy for PTSD in the Veterans Health Administration and 13 family members and used rapid content analysis to identify themes. We found that engaging in therapy was a family-level decision that participants expected to improve family life. Veterans were motivated to seek treatment to protect their relationships with loved ones. Family members generally encouraged veterans to seek treatment. Specifically, family members who viewed PTSD as a treatable illness versus a static aspect of the veteran's personality expressed positive attitudes about the effectiveness of therapy for reducing symptoms. Veterans whose social networks included individuals with prior military or trauma-related experiences reported that their loved ones possessed more understanding of PTSD and described positive subjective norms around therapy. Family members are often embedded in the therapy process because PTSD has a profound impact on the family. Positive subjective norms for therapy are created by family encouragement and may influence veteran perceptions about the value of treatment. Family members should be engaged early in mental health therapy and to the extent desired by the patient and family member. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120 Durham, NC 27708, USA
| | - Abigail Shapiro
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Kate L. Sheahan
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Princess E. Ackland
- Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Laura A. Meis
- Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Johanna Thompson-Hollands
- Behavioral Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130
- Boston University School of Medicine, Department of Psychiatry, 720 Harrison Ave, Boston, MA 02118
| | - David Edelman
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701, USA
| | - Patrick S. Calhoun
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 W Main St, Durham, NC, 27701, USA
| | | | - Courtney H. Van Houtven
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120 Durham, NC 27708, USA
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8
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Reuman L, Thompson-Hollands J. Women veterans' attitudes toward family involvement in PTSD treatment: A mixed-methods examination. Psychol Serv 2023; 20:770-779. [PMID: 36048088 PMCID: PMC10288350 DOI: 10.1037/ser0000707] [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: 11/08/2022]
Abstract
Family member (FM) involvement in treatment for posttraumatic stress disorder (PTSD) has the potential to enhance veterans' sense of support and connection and reduce treatment dropout. Little is known, however, about women veterans' preferences, concerns, and goals regarding FM involvement in PTSD treatment. The study employed a mixed-methods approach consisting of surveys (n = 143) and interviews (n = 10) with women veterans seeking treatment for PTSD in a Veterans Affairs medical center. Married and partnered women veterans, and women veterans who identified as gay/lesbian, were more likely to be open to FM involvement. Results revealed a range of preferences and goals regarding FM involvement. Women veterans expressed a preference for joint sessions at the midpoint or near the end of treatment. Veterans' goals for FM involvement included enhancing the relationship with their FM and providing the FM with a basic understanding of PTSD. Conclusions, limitations, and future directions are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
| | - Johanna Thompson-Hollands
- National Center for PTSD at VA Boston Healthcare System, Boston, MA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA
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Holder N, Holliday R, Ranney RM, Bernhard PA, Vogt D, Hoffmire CA, Blosnich JR, Schneiderman AI, Maguen S. Relationship of social determinants of health with symptom severity among Veterans and non-Veterans with probable posttraumatic stress disorder or depression. Soc Psychiatry Psychiatr Epidemiol 2023; 58:1523-1534. [PMID: 37173595 DOI: 10.1007/s00127-023-02478-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 03/30/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE Social determinants of health (SDoH) refer to the conditions in the environments in which people live that affect health outcomes and risks. SDoH may provide proximal, actionable targets for interventions. This study examined how SDoH are associated with posttraumatic stress disorder (PTSD) and depression symptoms among Veterans and non-Veterans with probable PTSD or depression. METHODS Four multiple regressions were conducted. Two multiple regressions with Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Two multiple regressions with non-Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Independent variables included demographic characteristics, adverse experiences (in childhood and adulthood), and SDoH (discrimination, education, employment, economic instability, homelessness, justice involvement, and social support). Correlates that were statistically significant (p < 0.05) and clinically meaningful (rpart >|0.10|) were interpreted. RESULTS For Veterans, lower social support (rpart = - 0.14) and unemployment (rpart = 0.12) were associated with greater PTSD symptoms. Among non-Veterans, greater economic instability (rpart = 0.19) was associated with greater PTSD symptoms. In the depression models, lower social support (rpart = - 0.23) and greater economic instability (rpart = 0.12) were associated with greater depression for Veterans, while only lower social support was associated with greater depression for non-Veterans (rpart = - 0.14). CONCLUSION Among Veterans and non-Veterans with probable PTSD or depression, SDoH were associated with PTSD and depression symptoms, particularly social support, economic instability, and employment. Beyond direct treatment of mental health symptoms, addressing social support and economic factors such as instability and employment in the context of PTSD and depression are potential intervention targets that would benefit from future research.
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Affiliation(s)
- Nicholas Holder
- San Francisco Veterans Affairs Health Care System, 4150 Clement Street (116-P), San Francisco, CA, 94121, USA.
- University of California San Francisco, San Francisco, USA.
| | - Ryan Holliday
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Aurora, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Rachel M Ranney
- San Francisco Veterans Affairs Health Care System, 4150 Clement Street (116-P), San Francisco, CA, 94121, USA
- University of California San Francisco, San Francisco, USA
- Sierra Pacific Mental Illness Research, Education and Clinical Center, San Francisco, USA
| | - Paul A Bernhard
- Health Outcomes Military Exposures Epidemiology Program, Patient Care Services, U.S. Department of Veterans Affairs, Washington, D.C., USA
| | - Dawne Vogt
- Women's Health Sciences Division of the National Center for Posttraumatic Stress Disorder, VA Boston Healthcare System, Boston, USA
- Boston University School of Medicine, Boston, USA
| | - Claire A Hoffmire
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Aurora, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, USA
| | - Aaron I Schneiderman
- Health Outcomes Military Exposures Epidemiology Program, Patient Care Services, U.S. Department of Veterans Affairs, Washington, D.C., USA
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System, 4150 Clement Street (116-P), San Francisco, CA, 94121, USA
- University of California San Francisco, San Francisco, USA
- Sierra Pacific Mental Illness Research, Education and Clinical Center, San Francisco, USA
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10
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Wells SY, Morland LA, Hurst S, Jackson GL, Kehle-Forbes SM, Jaime K, Aarons GA. Veterans' reasons for dropping out of prolonged exposure therapy across three delivery modalities: A qualitative examination. Psychol Serv 2023; 20:483-495. [PMID: 36326662 PMCID: PMC10154431 DOI: 10.1037/ser0000714] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Premature dropout from posttraumatic stress disorder treatment (PTSD) hinders treatment response. Studies have primarily used quantitative methodology to identify factors that contribute to Veterans' premature dropout, which has yielded mixed results. Qualitative methods provide rich data and generate additional hypotheses about why Veterans discontinue PTSD treatment. This study aimed to understand Veterans' reasons for dropping out of prolonged exposure therapy (PE) and to examine if there are differences in reasons for dropout between three delivery modalities: in-home, in-person (IHIP), office-based telehealth (OBT), or home-based telehealth (HBT). Twenty-two Veterans who dropped out of PE from a parent randomized clinical trial participated in individual qualitative interviews about potential contextual and individual factors related to discontinuation. Team-based coding was used to conduct open and focused coding. Themes were generated that described factors that influenced Veterans' dropout from PE and constant comparison was used to explore differences in reasons between the three modalities. Most Veterans had multiple reasons for dropping out and reasons were similar across delivery modalities with few differences. Practical barriers (e.g., scheduling difficulties), attitudes toward mental health providers and therapy (e.g., stigma), psychological and physical health factors (e.g., perceived worsening of symptoms, pain), and the therapeutic context (e.g., disliking aspects of PE) contributed to Veterans' decisions to drop out from PE. Veterans in OBT reported more types of practical barriers than Veterans in HBT and IHIP. These findings can help generate hypotheses about interventions that may promote engagement and future studies should continue to study how to reduce dropout. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
| | | | - Samantha Hurst
- Department of Family Medicine & Public Health, University of California, San Diego
| | - George L Jackson
- Durham Veterans Affairs Medical Center, Center of Innovation to Accelerate Discovery and Practice Transformation
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11
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Lewis C, Bailey L, Ariti C, Kitchiner NJ, Roberts NP, Simon N, Bisson JI. Social support as a predictor of outcomes of cognitive behavioral therapy with a trauma focus delivered face-to-face and via guided internet-based self-help. J Trauma Stress 2023; 36:511-523. [PMID: 37277907 DOI: 10.1002/jts.22947] [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: 08/03/2022] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 06/07/2023]
Abstract
There is mounting evidence that cognitive behavioral therapy with a trauma focus (CBT-TF) delivered via guided internet-based self-help is noninferior to CBT-TF delivered face-to-face for individuals with posttraumatic stress disorder (PTSD) of mild-to-moderate severity. The availability of multiple evidence-based treatment options creates a need to determine predictors of outcome to enable clinicians to make informed treatment recommendations. We examined perceived social support as a predictor of treatment adherence and response among 196 adults with PTSD enrolled in a multicenter pragmatic randomized controlled noninferiority trial. Perceived social support was measured using the Multidimensional Scale of Perceived Social Support and PTSD was assessed using the Clinician-Administered PTSD Scale for DSM-5. Linear regression was used to explore the associations between different dimensions of perceived social support (i.e., from friends, family, and significant others) and posttraumatic stress symptoms (PTSS) at baseline. Linear and logistic regression were used to determine whether these dimensions of support predicted treatment adherence or response for either treatment modality. Lower baseline perceived social support from family was associated with higher levels of PTSS, B = -0.24, 95% CI [-0.39, -0.08], p = .003, but the same did not apply to social support from friends or significant others. We did not find evidence that any dimension of social support predicted treatment adherence or response for either treatment. This work does not indicate that social support is a factor that can help predict the suitability of psychological therapy for PTSD delivered via guided internet-based self-help versus face-to-face.
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Affiliation(s)
- Catrin Lewis
- National Centre for Mental Health, Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Leah Bailey
- National Centre for Mental Health, Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Cono Ariti
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Neil J Kitchiner
- National Centre for Mental Health, Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff University, Cardiff, United Kingdom
- Psychology and Psychological Therapies Directorate, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Neil P Roberts
- National Centre for Mental Health, Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff University, Cardiff, United Kingdom
- Psychology and Psychological Therapies Directorate, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Natalie Simon
- National Centre for Mental Health, Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff University, Cardiff, United Kingdom
- Psychology and Psychological Therapies Directorate, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Jonathan I Bisson
- National Centre for Mental Health, Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff University, Cardiff, United Kingdom
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12
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Shepherd-Banigan M, Shapiro A, Stechuchak KM, Sheahan KL, Ackland PE, Smith VA, Bokhour BG, Glynn SM, Calhoun PS, Edelman D, Weidenbacher HJ, Eldridge MR, Van Houtven CH. Exploring the importance of predisposing, enabling, and need factors for promoting Veteran engagement in mental health therapy for post-traumatic stress: a multiple methods study. BMC Psychiatry 2023; 23:372. [PMID: 37237261 DOI: 10.1186/s12888-023-04840-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
PURPOSE This study explored Veteran and family member perspectives on factors that drive post-traumatic stress disorder (PTSD) therapy engagement within constructs of the Andersen model of behavioral health service utilization. Despite efforts by the Department of Veterans Affairs (VA) to increase mental health care access, the proportion of Veterans with PTSD who engage in PTSD therapy remains low. Support for therapy from family members and friends could improve Veteran therapy use. METHODS We applied a multiple methods approach using data from VA administrative data and semi-structured individual interviews with Veterans and their support partners who applied to the VA Caregiver Support Program. We integrated findings from a machine learning analysis of quantitative data with findings from a qualitative analysis of the semi-structured interviews. RESULTS In quantitative models, Veteran medical need for health care use most influenced treatment initiation and retention. However, qualitative data suggested mental health symptoms combined with positive Veteran and support partner treatment attitudes motivated treatment engagement. Veterans indicated their motivation to seek treatment increased when family members perceived treatment to be of high value. Veterans who experienced poor continuity of VA care, group, and virtual treatment modalities expressed less care satisfaction. Prior marital therapy use emerged as a potentially new facilitator of PTSD treatment engagement that warrants more exploration. CONCLUSIONS Our multiple methods findings represent Veteran and support partner perspectives and show that amid Veteran and organizational barriers to care, attitudes and support of family members and friends still matter. Family-oriented services and intervention could be a gateway to increase Veteran PTSD therapy engagement.
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, Box 90120, 100 Fuqua Drive, Durham, NC, 27708, USA
| | - Abigail Shapiro
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA.
| | | | - Kate L Sheahan
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
| | - Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Valerie A Smith
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, 200 Springs Road (152), Bedford, MA, 01730, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, The Albert Sherman Center, Worcester, MA, 01605, USA
| | - Shirley M Glynn
- UCLA Semel Institute of Neuroscience and Human Behavior, VA Greater Los Angeles Healthcare System at West Los Angeles, B151 11301 Whiltshire Boulevard, Los Angeles, CA, 90073, USA
| | - Patrick S Calhoun
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC, 27701, USA
| | - David Edelman
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701, USA
| | | | | | - Courtney H Van Houtven
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, Box 90120, 100 Fuqua Drive, Durham, NC, 27708, USA
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13
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Meis LA, Polusny MA, Kehle-Forbes SM, Erbes CR, O’Dougherty M, Erickson EPG, Orazem R, Burmeister L, Spoont M. Making sense of poor adherence in PTSD treatment from the perspectives of veterans and their therapists. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2023; 15:715-725. [PMID: 35324228 PMCID: PMC10948176 DOI: 10.1037/tra0001199] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Dropout rates from trauma-focused PTSD treatments (TFTs) in VA clinics are particularly high. We conducted in-depth qualitative interviews with 29 veterans and their therapists to better understand this phenomenon. METHOD Participants were part of a multisite, mixed-methods study of TFT adherence in VA clinics. Veterans were eligible for interviews if they exhibited poor TFT adherence and screened positive for PTSD in follow-up surveys. Interviews were analyzed using qualitative dyadic analysis approaches. RESULTS Therapists relied on stereotypes of poor adherence to understand veterans' experiences and were missing information critical to helping veterans succeed. Veterans misunderstood aspects of the therapy and struggled in ways they inadequately expressed to therapists. Therapist attempts at course corrections were poorly matched to veterans' needs. Many dyads reported difficulties in their therapeutic relationships. Veterans reported invalidating experiences that were not prominent in therapists' interviews. CONCLUSIONS Future work is needed to test hypotheses generated and find effective ways to help veterans fully engage in TFTs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Laura A. Meis
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
- University of Minnesota Medical School, Department of Medicine, 420 Delaware Street SE, MMC 194, Suite 14-110 Phillips-Wangensteen Building, Minneapolis, Minnesota 55455
| | - Melissa A. Polusny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
- University of Minnesota Medical School, Department of Psychiatry, 420 Delaware Street SE, MMC 194, Suite 14-110 Phillips-Wangensteen Building, Minneapolis, Minnesota 55455
| | - Shannon M. Kehle-Forbes
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
- University of Minnesota Medical School, Department of Medicine, 420 Delaware Street SE, MMC 194, Suite 14-110 Phillips-Wangensteen Building, Minneapolis, Minnesota 55455
- Women’s Division, National Center for PTSD, Boston, MA
| | - Christopher R. Erbes
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
- University of Minnesota Medical School, Department of Psychiatry, 420 Delaware Street SE, MMC 194, Suite 14-110 Phillips-Wangensteen Building, Minneapolis, Minnesota 55455
| | - Maureen O’Dougherty
- Metropolitan State University, Department of Social Science, Saint John’s Hall, 700 7th Street E, St. Paul, Minnesota 55106
| | - Emily P. G. Erickson
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
| | - Robert Orazem
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
| | - Lori Burmeister
- School of Social and Behavioral Sciences, Arizona State University, Tempe, AZ, 85012
| | - Michele Spoont
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive (152), Minneapolis, MN 55417
- University of Minnesota Medical School, Department of Medicine, 420 Delaware Street SE, MMC 194, Suite 14-110 Phillips-Wangensteen Building, Minneapolis, Minnesota 55455
- University of Minnesota Medical School, Department of Psychiatry, 420 Delaware Street SE, MMC 194, Suite 14-110 Phillips-Wangensteen Building, Minneapolis, Minnesota 55455
- Pacific Islands Division, National Center for PTSD, Honolulu, Hawaii
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14
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Thompson-Hollands J. Introduction to the special section on social relationships and posttraumatic stress disorder treatment: Harnessing the power of significant relationships. J Trauma Stress 2023. [PMID: 36853594 DOI: 10.1002/jts.22922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 01/25/2023] [Indexed: 03/01/2023]
Abstract
This article introduces the special section in the Journal of Traumatic Stress focused on social relationships and their connection to treatment among individuals with posttraumatic stress disorder (PTSD). Interpersonal relationships have the potential to influence treatment-seeking, retention, and outcomes. For individuals with PTSD, social relationships have long been understood to be intimately and bidirectionally tied to symptom levels. In light of somewhat modest rates of treatment response to current first-line interventions for PTSD, there is growing interest in engaging these relationships, as well as relationship-relevant beliefs and behaviors, to enhance PTSD treatment. This introductory article frames the rationale for examining these social factors to better understand and improve treatments and provides an overview of the collection of articles contained herein.
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Affiliation(s)
- Johanna Thompson-Hollands
- National Center for PTSD, Behavioral Science Division, at VA Boston Healthcare System, Boston, MA.,Boston University Chobanian & Avedisian School of Medicine, Boston, MA
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15
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Howard KP, Spoont MR, Polusny MA, Eftekhari A, Rosen CS, Meis LA. The role of symptom accommodation in trauma-focused treatment engagement and response. J Trauma Stress 2023. [PMID: 36782380 DOI: 10.1002/jts.22912] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 12/02/2022] [Accepted: 12/07/2022] [Indexed: 02/15/2023]
Abstract
Although trauma-focused treatments (TFTs) are generally effective, not all patients improve. Symptom accommodation (i.e., altering one's behavior in response to another's symptoms) by loved ones may be particularly relevant to TFT treatment response and engagement. We examined the role of symptom accommodation by support persons (SPs) in veterans' PTSD treatment response, including the mediating role of treatment engagement and the moderating role of relationship strain. Veterans engaging in prolonged exposure or cognitive processing therapy and a loved one (N = 172 dyads) were sampled at two time points approximately four months apart. Measures of treatment engagement (i.e., highest session completed from the treatment protocol and homework completion) were obtained from hospital records. We found that relationship strain moderated the effect of symptom accommodation on treatment response, ∆R2 = .02. Specifically, Time 1 (T1) accommodation predicted poorer treatment response (i.e., Time 2 [T2] PTSD symptom severity, controlling for T1 symptoms) among veterans who reported below-average relationship strain only. Additionally, symptom accommodation was indirectly related to treatment response such that T1 accommodation predicted higher T2 PTSD symptom severity specifically through reduced homework completion, β = .01. The findings suggest that attending to accommodating behaviors of veterans' supportive partners may be an important way to boost both engagement in and response to TFTs for PTSD.
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Affiliation(s)
- Kristen P Howard
- Milwaukee VA Medical Center, Milwaukee, Wisconsin, USA.,Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michele R Spoont
- National Center for PTSD Pacific Islands Division, Honolulu, Hawaii, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA.,Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA.,Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Melissa A Polusny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA.,Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Afsoon Eftekhari
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Palo Alto, California, USA.,VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Craig S Rosen
- National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Palo Alto, California, USA.,VA Palo Alto Health Care System, Palo Alto, California, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Laura A Meis
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA.,Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA.,National Center for PTSD Women's Health Sciences Division, Boston, Massachusetts, USA
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16
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Campbell SB, Caska Wallace CM. Development of a brief support and education intervention for loved ones of veterans with posttraumatic stress disorder. J Trauma Stress 2023. [PMID: 36756986 DOI: 10.1002/jts.22914] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/28/2022] [Accepted: 11/21/2022] [Indexed: 02/10/2023]
Abstract
Clinical practice guidelines for managing posttraumatic stress disorder (PTSD) encourage incorporating loved ones into treatment, and supportive relationships can increase engagement in mental health care for veterans with PTSD. This study describes the iterative refinement, feasibility/acceptability testing, and national dissemination of a brief support and psychoeducation intervention for loved ones of veterans with PTSD. Loved ones (n = 181; range:1-11 per group) attended and qualitatively rated "PTSD 101 for Family and Friends: A Support and Education Workshop." Open-ended questions were used to gather data on suggestions for improvement and descriptions of helpful content, and the workshop was refined following participant and operational partner feedback using a quality improvement framework. Rating quantitative items on a 1-5 scale, participants found the overall quality (M = 4.76) and relevance (M = 4.82) to be excellent, noting they learned substantial new information (M = 4.45). Sense of support (M = 4.95), intentions to use the material (M = 4.87), PTSD self-efficacy (M = 4.41), and understanding of PTSD (M = 4.76) were rated favorably. Common themes among helpful elements were a sense of shared experience and optimism and increased knowledge of treatments/resources. Suggestions for improvement referenced logistics. Following continual stakeholder feedback and refinement, the workshop represents a novel method for providing loved ones with empirically supported psychoeducation, coping skills, and community. It is being disseminated by the Family Services Section of the Veterans Health Administration Office of Mental Health and Suicide Prevention.
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Affiliation(s)
- Sarah B Campbell
- VA Puget Sound Health Care System, Seattle, Washington, USA.,Department of Psychiatry and Behavioral Sciences University of Washington School of Medicine, Seattle, Washington, USA
| | - Catherine M Caska Wallace
- VA Puget Sound Health Care System, Seattle, Washington, USA.,Coatesville VA Health Care System, Coatesville, Pennsylvania, USA
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17
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Mavragani A, Wielgosz J, Hallenbeck HW, Chang A, Rosen C, Owen J, Kuhn E. The PTSD Family Coach App in Veteran Family Members: Pilot Randomized Controlled Trial. JMIR Form Res 2023; 7:e42053. [PMID: 36602852 PMCID: PMC9893731 DOI: 10.2196/42053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/10/2022] [Accepted: 11/03/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) among US military veterans can adversely impact their concerned significant others (CSOs; eg, family members and romantic partners). Mobile apps can be tailored to support CSO mental health through psychoeducation, coping skills, and stress monitoring. OBJECTIVE This study assessed the feasibility, acceptability, and potential efficacy of PTSD Family Coach 1.0, a free, publicly available app that includes psychoeducation, stress management tools, self-assessments, and features for connecting to alternative supports, compared with a psychoeducation-only version of the app for cohabitating CSOs of veterans with PTSD. METHODS A total of 200 participants with an average age of 39 (SD 8.44) years, primarily female (193/200, 97%), and White (160/200, 80%) were randomized to self-guided use of either PTSD Family Coach 1.0 (n=104) or a psychoeducation-only app (n=96) for 4 weeks. Caregiver burden, stress, depression, anxiety, beliefs about treatment, CSO self-efficacy, and relationship functioning assessed using measures of dyadic adjustment, social constraints, and communication danger signs were administered via a web survey at baseline and after treatment. User satisfaction and app helpfulness were assessed after treatment. Data were analyzed using linear mixed methods. RESULTS Overall, 50.5% (101/200) of randomized participants used their allocated app. Participants found PTSD Family Coach 1.0 somewhat satisfying (mean 4.88, SD 1.11) and moderately helpful (mean 2.99, SD 0.97) to use. Linear mixed effects models revealed no significant differences in outcomes by condition for caregiver burden (P=.45; Cohen d=0.1, 95% CI -0.2 to 0.4), stress (P=.64; Cohen d=0.1, 95% CI -0.4 to 0.6), depression (P=.93; Cohen d= 0.0, 95% CI -0.3 to 0.3), anxiety (P=.55; Cohen d=-0.1, 95% CI -0.4 to 0.2), beliefs about treatment (P=.71; Cohen d=0.1, 95% CI -0.2 to 0.3), partner self-efficacy (P=.59; Cohen d=-0.1, 95% CI -0.4 to 0.2), dyadic adjustment (P=.08; Cohen d=-0.2, 95% CI -0.5 to 0.0), social constraints (P=.05; Cohen d=0.3, 95% CI 0.0-0.6), or communication danger signs (P=.90; Cohen d=-0.0, 95% CI -0.3 to 0.3). Post hoc analyses collapsing across conditions revealed a significant between-group effect on stress for app users versus nonusers (β=-3.62; t281=-2.27; P=.02). CONCLUSIONS Approximately half of the randomized participants never used their allocated app, and participants in the PTSD Family Coach 1.0 condition only opened the app approximately 4 times over 4 weeks, suggesting limitations to this app version's feasibility. PTSD Family Coach 1.0 users reported moderately favorable impressions of the app, suggesting preliminary acceptability. Regarding efficacy, no significant difference was found between PTSD Family Coach 1.0 users and psychoeducation app users across any outcome of interest. Post hoc analyses suggested that app use regardless of treatment condition was associated with reduced stress. Further research that improves app feasibility and establishes efficacy in targeting the domains most relevant to CSOs is warranted. TRIAL REGISTRATION ClinicalTrials.gov NCT02486705; https://clinicaltrials.gov/ct2/show/NCT02486705.
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Affiliation(s)
| | - Joseph Wielgosz
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, United States.,National Center for PTSD, Veteran Affairs Palo Alto Healthcare System, Palo Alto, CA, United States
| | - Haijing Wu Hallenbeck
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, United States.,National Center for PTSD, Veteran Affairs Palo Alto Healthcare System, Palo Alto, CA, United States
| | - Andrew Chang
- National Center for PTSD, Veteran Affairs Palo Alto Healthcare System, Palo Alto, CA, United States
| | - Craig Rosen
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, United States.,National Center for PTSD, Veteran Affairs Palo Alto Healthcare System, Palo Alto, CA, United States
| | - Jason Owen
- National Center for PTSD, Veteran Affairs Palo Alto Healthcare System, Palo Alto, CA, United States
| | - Eric Kuhn
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, United States.,National Center for PTSD, Veteran Affairs Palo Alto Healthcare System, Palo Alto, CA, United States
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18
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Shepherd-Banigan M, Wells SY, Falkovic M, Ackland PE, Swinkels C, Dedert E, Ruffin R, Van Houtven CH, Calhoun PS, Edelman D, Weidenbacher HJ, Shapiro A, Glynn S. Adapting a family-involved intervention to increase initiation and completion of evidenced-based psychotherapy for posttraumatic stress disorder. SSM - MENTAL HEALTH 2022; 2:100114. [PMID: 35979411 PMCID: PMC9376943 DOI: 10.1016/j.ssmmh.2022.100114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) is disabling condition among United States Veterans. Training programs for evidenced-based therapies have been rolled out nationally in the Veterans Health Administration (VHA), but provider adoption of these treatments is limited and rates of Veteran dropout are high. Increasing support for mental health therapy within the Veteran's social network would improve treatment engagement. We discuss the adaptation of Recovery-Oriented Decisions for Relatives' Support (REORDER)-a family-based intervention for individuals with serious mental illness- to create Family Support in Mental Health Recovery (FAMILIAR), an intervention that seeks to strengthen support partners' abilities to help Veterans engage in therapy. Our goal was to apply modifications to meet the needs of Veterans with PTSD and their support partners. We used input from Veterans, support partners, clinicians and VA system leaders to inform the modifications. Then, a multi-disciplinary intervention development team met to determine which modifications would be applied and how. We used the domains from the Framework for Adaptations and Modification (FRAME) to systematically track and describe modifications. Adaptations made to REORDER included changes in content, structure, and delivery format. The resulting intervention, FAMILIAR, was a 3-4 session intervention beginning prior to EBP initiation and continuing through sessions 3, 4 or 5 of the EBP. Sessions were designed for maximum flexibility and could be offered either in-person or virtually, and sessions involve interactions between the interventionist with the Veteran and support partner alone and together. We learned the importance of including diverse stakeholder perspectives to develop a comprehensive understanding of the needs of the target population and the health system. While feasibility and effectiveness testing is needed, we applied a proactive adaptation approach that we anticipate will make FAMILIAR successful in addressing patient, clinical, and system considerations of a family approach to increase Veteran engagement in PTSD treatment.
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120 Durham, NC 27708, USA
| | | | - Margaret Falkovic
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
| | - Princess E. Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Cindy Swinkels
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Eric Dedert
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC, 27701, USA
| | - Rachel Ruffin
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Courtney H. Van Houtven
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120 Durham, NC 27708, USA
| | - Patrick S. Calhoun
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC, 27701, USA
| | - David Edelman
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701, USA
| | | | - Abigail Shapiro
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Shirley Glynn
- Semel Institute of Neuroscience and Human Behavior, Greater LA VA Health Care System/UCLA, B151 11301 Whiltshire Boulevard, Los Angeles, CA, 90073 USA
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19
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Social Factors Predict Treatment Engagement in Veterans with PTSD or SUD. J Behav Health Serv Res 2022; 50:286-300. [PMID: 36456866 DOI: 10.1007/s11414-022-09823-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 12/03/2022]
Abstract
Veterans with PTSD and SUDs often fail to initiate, or prematurely discontinue, mental health treatment in Veteran Affairs Medical Centers (VAMC). While much is known about clinical characteristics and demographic factors impacting treatment engagement in this population, less is known about the role of social factors. This retrospective study examines primary care-based screening assessment and specialty mental healthcare appointment data in a VAMC, to test whether social factors predict treatment initiation and appointment attendance. Findings reveal veterans were more likely to initiate treatment when (a) those with SUDs (n = 235) reported more frequent negative exchanges with others and (b) those with PTSD (n = 2107) reported more perceived support or being partnered. Those with PTSD who were partnered had higher appointment attendance rates. Findings suggest social factors are relevant to treatment initiation among veterans with PTSD and SUDs and that close others may be helpful in facilitating referrals.
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20
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Thompson-Hollands J, Rando AA, Stoycos SA, Meis LA, Iverson KM. Family Involvement in PTSD Treatment: Perspectives from a Nationwide Sample of Veterans Health Administration Clinicians. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2022; 49:1019-1030. [PMID: 35930084 PMCID: PMC9362012 DOI: 10.1007/s10488-022-01214-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 01/25/2023]
Abstract
Social support is bidirectionally linked to symptoms of posttraumatic stress disorder (PTSD). Evidence suggests that family involvement in veterans' mental health treatment is desired by both veterans and family members, and that such involvement has the potential to improve treatment outcomes. However, rates of family involvement are low in the Veterans Health Administration (VHA). We sought to understand VHA clinicians' perspectives on family involvement in PTSD treatment by conducting qualitative interviews with 31 providers at 10 VHA facilities across the U.S. The i-PARIHS framework was used to guide the interviews and analysis, and several major themes were identified. All clinicians reported that they at least occasionally offered family-inclusive sessions, and they frequently referenced both the influence of family behaviors or attitudes on veterans' functioning, and also how veterans' symptoms could cause tremendous disruption in the family. Clinicians' past experience with supervised family- or couple-based work strongly influenced their current comfort with family-inclusive sessions. Multiple potential avenues exist to support increased family involvement in PTSD treatment in VHA.
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Affiliation(s)
- Johanna Thompson-Hollands
- Behavioral Science Division of the National Center for PTSD at VA Boston Healthcare System, Boston, MA, USA.
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA.
| | | | - Sarah A Stoycos
- Behavioral Science Division of the National Center for PTSD at VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Laura A Meis
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Katherine M Iverson
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
- Women's Health Sciences Division of the National Center for PTSD at VA Boston Healthcare System, Boston, MA, USA
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21
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Harper KL, Thompson-Hollands J, Keane TM, Marx BP. Family-Involved Mental Health Care Among OEF/OIF Veterans With and Without PTSD Using VHA Administrative Records. Behav Ther 2022; 53:819-827. [PMID: 35987541 DOI: 10.1016/j.beth.2022.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 01/04/2022] [Accepted: 01/12/2022] [Indexed: 11/02/2022]
Abstract
Prior research indicates that veterans are interested in including family members in health care and that family-inclusive mental health treatment can improve treatment outcomes. Consequently, the Veterans Health Administration's (VHA) directive requires providers to offer family-inclusive mental health services to veterans. However, the extent to which veterans engage in family-inclusive mental health services at the VHA remains unclear. Using data from a longitudinal registry of male and female veterans with and without posttraumatic stress disorder, we examined the extent to which veterans included family members in their mental health care and predictors of engagement in family-involved therapy visits using VHA administrative records over a 5-year time span. Of the 1,329 veterans who received mental health care during the study, 8.4% received a family therapy visit-the number of visits per veteran ranged from 1 to 34. Results from logistic regressions indicate that relative to White veterans, Black veterans were 61.0% less likely to receive a family-involved therapy visit. Married veterans or veterans living with a partner, and veterans with poor romantic relationship functioning, were more likely to receive a family-involved therapy visit. These findings indicate that only a small percentage of veterans received a family therapy visit across 5 years. Efforts to understand barriers to family-involved therapy visits and strategies to increase engagement in family-involved visits may improve clinical outcomes and promote patient-centered care.
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Affiliation(s)
- Kelly L Harper
- National Center for PTSD at VA Boston Healthcare System.
| | | | | | - Brian P Marx
- National Center for PTSD at VA Boston Healthcare System and Boston University School of Medicine
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22
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Jacoby VM, Straud CL, Bagley JM, Tyler H, Baker SN, Denejkina A, Sippel LM, Kaya R, Rozek DC, Fina BA, Dondanville KA. Evidence-based posttraumatic stress disorder treatment in a community sample: Military-affiliated versus civilian patient outcomes. J Trauma Stress 2022; 35:1072-1086. [PMID: 35201657 DOI: 10.1002/jts.22812] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 12/22/2021] [Accepted: 01/09/2022] [Indexed: 12/31/2022]
Abstract
Posttraumatic stress disorder (PTSD) is a significant mental health issue among military service members and veterans. Although the U.S. Department of Veterans Affairs (VA) provides crucial resources for behavioral health care, many veterans seek mental health services through community clinics. Previous research illustrates that military and veteran patients benefit less from evidence-based treatments (EBTs) for PTSD than civilians. However, most PTSD treatment outcome research on military and veteran populations is conducted in VA or military settings. Little is known about outcomes among military-affiliated patients in community settings. The primary aim of this study was to directly compare civilian versus military-affiliated patient outcomes on PTSD and depression symptoms using the PTSD Checklist for DSM-5 (PCL-5) and the nine-item Patient Health Questionnaire (PHQ-9) in a community setting. Participants (N = 502) included military-affiliated (veteran, Guard/Reservist, active duty) and civilian patients who engaged in cognitive processing therapy (CPT) or prolonged exposure (PE) for PTSD in community clinics. Both groups demonstrated significant reductions on the PCL-5, military-affiliated: d = -0.91, civilian: d = -1.18; and PHQ-9, military-affiliated: d = -0.65, civilian: d = -0.88, following treatment. However, military-affiliated patients demonstrated smaller posttreatment reductions on the PCL-5, Mdiff = 5.75, p = .003, and PHQ-9, Mdiff = 1.71, p = .011, compared to civilians. Results demonstrate that military-affiliated patients benefit from EBTs for PTSD, albeit to a lesser degree than civilians, even in community settings. These findings also highlight the importance of future research on improving EBTs for military personnel with PTSD.
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Affiliation(s)
- Vanessa M Jacoby
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Casey L Straud
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, USA.,Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Jenna M Bagley
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Hannah Tyler
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Shelby N Baker
- UCF RESTORES & Department of Psychology, University of Central Florida, Florida, Orlando, USA
| | - Anna Denejkina
- Graduate Research School, Western Sydney University, South Penrith, Australia
| | - Lauren M Sippel
- National Center for Posttraumatic Stress Disorder, White River Junction, Vermont, USA.,Geisel School of Medicine at Dartmouth, Department of Psychiatry, Hanover, New Hampshire, USA
| | - Robert Kaya
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - David C Rozek
- UCF RESTORES & Department of Psychology, University of Central Florida, Florida, Orlando, USA
| | - Brooke A Fina
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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23
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Kehle-Forbes SM, Ackland PE, Spoont MR, Meis LA, Orazem RJ, Lyon A, Valenstein-Mah HR, Schnurr PP, Zickmund SL, Foa EB, Chard KM, Alpert E, Polusny MA. Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout. Behav Res Ther 2022; 154:104123. [PMID: 35644083 PMCID: PMC9873271 DOI: 10.1016/j.brat.2022.104123] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/04/2022] [Accepted: 05/13/2022] [Indexed: 01/26/2023]
Abstract
Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are first-line treatments for posttraumatic stress disorder (PTSD) and have been disseminated throughout the U.S. Veterans Health Administration. Treatment non-completion is common and lessens clinical effectiveness; however, prior work has failed to identify factors consistently associated with non-completion. Semi-structured interviews were conducted with a national sample of veterans who recently completed (n = 60) or did not complete (n = 66) PE or CPT. Non-completer interviews focused on factors that contributed to veterans' decisions to drop out and efforts undertaken to complete PE/CPT. Completer interviews focused on challenges faced in completing treatment and facilitators of completion. Transcripts were coded using a mixed deductive/inductive approach; constant comparison was used to identify differences between completers and non-completers. Completers and non-completers differed in the extent of treatment-specific therapist support received, therapists' flexibility in treatment delivery, the type of encouragement offered by the care team and social supports, their interpretation of symptom worsening, the perceived impact of treatment on functioning, and the impact of stressors on their treatment engagement. Treatment-specific therapist support, more patient-centered and flexible treatment delivery, leveraging the full care team, and addressing functional concerns are potential targets for PE and CPT engagement interventions.
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Affiliation(s)
- Shannon M. Kehle-Forbes
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA,Women’s Health Sciences Division at VA Boston, National Center for PTSD, 150 S Huntington Ave, Boston, MA, 02130, USA,University of Minnesota, Department of Medicine, 420 Delaware St SE, Minneapolis, MN, 55455, USA,Corresponding author. Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA. (S.M. Kehle-Forbes)
| | - Princess E. Ackland
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA,University of Minnesota, Department of Medicine, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Michele R. Spoont
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA,University of Minnesota, Department of Medicine, 420 Delaware St SE, Minneapolis, MN, 55455, USA,National Center for PTSD, Pacific Islands Division, 459 Patterson Rd, Honolulu, HI, 96819, USA
| | - Laura A. Meis
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA,University of Minnesota, Department of Medicine, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Robert J. Orazem
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Alexandra Lyon
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Helen R. Valenstein-Mah
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Paula P. Schnurr
- National Center for PTSD, Department of Veterans Affairs, 163 Veterans Dr, White River Junction, VT, 05009, USA,Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Rd, Hanover, NH, 03755, USA
| | - Susan L. Zickmund
- Informatics, Decision-Enhancement & Analytic Sciences Center, Salt Lake City VA, 500 S Foothill Blvd, Salt Lake City, UT, 84108, USA
| | - Edna B. Foa
- Department of Psychiatry, University of Pennsylvania, 6th Gateway, 3535 Market St, Philadelphia, PA, 19104, USA
| | - Kathleen M. Chard
- Cincinnati VA Medical Center, 3200 Vine St, Cincinnati, OH, 45220, USA
| | - Elizabeth Alpert
- Women’s Health Sciences Division at VA Boston, National Center for PTSD, 150 S Huntington Ave, Boston, MA, 02130, USA
| | - Melissa A. Polusny
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive, Minneapolis, MN, 55417, USA,University of Minnesota, Department of Psychiatry, 420 Delaware St SE, Minneapolis, MN, 55455, USA
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24
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Holder N, Batten AJ, Shiner B, Li Y, Madden E, Neylan TC, Seal KH, Patterson OV, DuVall SL, Maguen S. Veterans receiving a second course of cognitive processing therapy or prolonged exposure therapy: is it better to switch or stay the same? Cogn Behav Ther 2022; 51:456-469. [PMID: 35475499 DOI: 10.1080/16506073.2022.2058996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) are effective psychotherapies for post-traumatic stress disorder (PTSD). However, these treatments also have high rates of dropout and non-response. Therefore, patients may need a second course of treatment. We compared outcomes for patients who switched between CPT/PE and those who repeated CPT/PE during a second course of treatment. We collected data from Iraq and Afghanistan war veterans (n = 2,958) who received a second course of CPT/PE in the Veterans Health Administration from 2001 to 2017 and had symptom outcomes (PTSD checklist; PCL). We measured the association between treatment sequence and change in PCL score over the second course of treatment using hierarchical Bayesian regression, adjusted for sociodemographic and clinical characteristics. All treatment sequences showed a significant reduction in PCL score over time (β = -4.80; HDI95: -5.74, -3.86). Veterans who switched from CPT to PE had modestly greater PCL reductions during the second course than those who repeated CPT. However, no significant difference in PCL change during the second course was observed between veterans who repeated PE and those who switched from PE to CPT. Veterans participating in a second course of CPT/PE can benefit, and switching treatment may be slightly more beneficial following CPT.
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Affiliation(s)
- Nicholas Holder
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Adam J Batten
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA.,Applied Statistics Unit, AB Evergreen Analytics LLC, Seattle, WA, USA
| | - Brian Shiner
- Mental Health Service, White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Executive Division Hanover, New Hampshire, USA.,Executive Division, National Center for Posttraumatic Stress Disorder, White River Junction, Vermont, USA
| | - Yongmei Li
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Erin Madden
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Thomas C Neylan
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Karen H Seal
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA.,Integrative Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Departments of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Olga V Patterson
- VA Informatics and Computing Infrastructure, Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Scott L DuVall
- VA Informatics and Computing Infrastructure, Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shira Maguen
- Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
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25
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Maglione MA, Chen C, Franco M, Gizaw M, Shahidinia N, Baxi S, Hempel S. Effect of patient characteristics on posttraumatic stress disorder treatment retention among veterans: A systematic review. J Trauma Stress 2022; 35:718-728. [PMID: 34800059 DOI: 10.1002/jts.22757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 08/19/2021] [Accepted: 08/21/2021] [Indexed: 11/08/2022]
Abstract
To identify baseline patient characteristics (i.e., demographic and psychological factors, military background) associated with better posttraumatic stress disorder (PTSD) treatment retention among veterans, we conducted a systematic review. After an electronic database search for studies of PTSD treatment in veterans, two reviewers independently screened the literature for eligibility, abstracted study-level information, and assessed risk of bias. As most studies used multivariate models to assess multiple potential predictors of retention simultaneously, the results were described narratively. The GRADE approach, adapted for prognostic literature, was used to assess the overall quality of evidence (QoE). In total, 19 studies reported in 25 publications met the inclusion criteria (n = 6 good quality, n = 9 fair quality, n = 4 poor quality). Definitions of treatment completion and dropout varied, and some studies lumped different therapy approaches together. Older age and higher treatment expectations were associated with better retention (moderate QoE). In 5 of 6 studies, baseline PTSD severity was not associated with retention, and the remaining study reported an association between better retention and more severe PTSD symptoms; the presence of more co-occurring psychiatric disorders was associated with better retention (moderate QoE). QoE was low or insufficient to support conclusions for any other characteristics due to inconsistent results, imprecision, potential publication bias, possible study population overlap, study limitations, or lack of studies. More research is needed regarding the associations between modifiable factors (e.g., motivation, barriers, expectations) and retention, and consistent definitions of treatment completion and minimally adequate treatment should be adopted throughout the field.
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Affiliation(s)
- Margaret A Maglione
- RAND Corporation, Santa Monica, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | | | | | | | | | - Susanne Hempel
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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26
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Meis LA, Glynn SM, Spoont MR, Kehle-Forbes SM, Nelson D, Isenhart CE, Eftekhari A, Ackland PE, Linden EB, Orazem RJ, Cutting A, Hagel Campbell EM, Astin MC, Porter KE, Smith E, Chuick CD, Lamp KE, Vuper TC, Oakley TA, Khan LB, Keckeisen SK, Polusny MA. Can families help veterans get more from PTSD treatment? A randomized clinical trial examining Prolonged Exposure with and without family involvement. Trials 2022; 23:243. [PMID: 35354481 PMCID: PMC8965544 DOI: 10.1186/s13063-022-06183-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/17/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Posttraumatic stress disorder occurs in as many as one in five combat veterans and is associated with a host of negative, long-term consequences to the individual, their families, and society at large. Trauma-focused treatments, such as Prolonged Exposure, result in clinically significant symptom relief for many. Adherence to these treatments (i.e., session attendance and homework compliance) is vital to ensuring recovery but can be challenging for patients. Engaging families in veterans’ treatment could prove to be an effective strategy for promoting treatment adherence while also addressing long-standing calls for better family inclusion in treatment for posttraumatic stress disorder. This paper describes the methods of a pragmatic randomized controlled trial designed to evaluate if family inclusion in Prolonged Exposure can improve treatment adherence.
Methods
One hundred fifty-six veterans, with clinically significant symptoms of posttraumatic stress disorder, will be randomized to receive either standard Prolonged Exposure or Prolonged Exposure enhanced through family inclusion (Family-Supported Prolonged Exposure) across three different VA facilities. Our primary outcomes are session attendance and homework compliance. Secondary outcomes include posttraumatic stress disorder symptom severity, depression, quality of life, and relationship functioning. The study includes a concurrent process evaluation to identify potential implementation facilitators and barriers to family involvement in Prolonged Exposure within VA.
Discussion
While the importance of family involvement in posttraumatic stress disorder treatment is non-controversial, there is no evidence base supporting best practices on how to integrate families into PE or any other individually focused trauma-focused treatments for posttraumatic stress disorder. This study is an important step in addressing this gap, contributing to the literature for both retention and family involvement in trauma-focused treatments.
Trial registration
ClinicalTrials.govNCT03256227. Registered on August 21, 2017.
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27
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Knobloch LK, Owens JL, Gobin RL. Spiritual care for combat trauma: A qualitative evaluation of REBOOT Combat Recovery. MILITARY PSYCHOLOGY 2021. [DOI: 10.1080/08995605.2021.1962183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Leanne K. Knobloch
- Department of Communication, University of Illinois, Urbana-Champaign, Illinois, USA
| | | | - Robyn L. Gobin
- Department of Kinesiology and Community Health, University of Illinois, Urbana-Champaign, Illinois, USA
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28
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Thompson-Hollands J, Lee DJ, Sloan DM. The Use of a Brief Family Intervention to Reduce Dropout Among Veterans in Individual Trauma-Focused Treatment: A Randomized Controlled Trial. J Trauma Stress 2021; 34:829-839. [PMID: 33891718 PMCID: PMC8555692 DOI: 10.1002/jts.22680] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/16/2021] [Accepted: 03/14/2021] [Indexed: 01/09/2023]
Abstract
Dropout from trauma-focused treatment for posttraumatic stress disorder (PTSD) represents a daunting challenge for the field, particularly among military and veteran samples. Family involvement may help to increase the effectiveness of PTSD treatment while also improving retention. We tested a two-session brief family intervention (BFI) protocol delivered as an adjunct to individual trauma-focused treatment among a sample of 20 veteran-family member dyads (N = 40). Willingness to participate in the family-inclusive protocol was high, with over 85% of veterans and family members who were screened agreeing to take part. All enrolled veterans were beginning a course of either cognitive processing therapy (CPT) or prolonged exposure (PE), delivered in outpatient Veterans Affairs clinics. Family members were randomized to either receive or not receive the BFI from study clinicians. In the BFI condition, 20.0% of veterans dropped out of CPT/PE before the 16-week study end; the remainder were either still attending on-protocol sessions or had completed the full protocol. In the control condition, 40.0% of veterans dropped out of CPT/PE before the end of the study. Observed significant, large-magnitude decreases in PTSD symptoms over time did not differ by condition, ESsg range = -1.12 to -2.04. Accommodation did not significantly decrease over time in either condition, ESsg range = 0.18 to -0.98. The BFI represents a promising option for veterans, family members, and clinicians who are seeking a brief, feasible, narrowly focused method for incorporating families into veterans' individual trauma-focused therapy and potentially reducing the rate of dropout.
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Affiliation(s)
- Johanna Thompson-Hollands
- National Center for PTSD at VA Boston Healthcare System, Behavioral Science Division, Boston, Massachusetts, United States
- Department of Psychiatry, Boston University School of Medicine, Boston University, Boston, Massachusetts, United States
| | - Daniel J Lee
- National Center for PTSD at VA Boston Healthcare System, Behavioral Science Division, Boston, Massachusetts, United States
- Department of Psychiatry, Boston University School of Medicine, Boston University, Boston, Massachusetts, United States
| | - Denise M Sloan
- National Center for PTSD at VA Boston Healthcare System, Behavioral Science Division, Boston, Massachusetts, United States
- Department of Psychiatry, Boston University School of Medicine, Boston University, Boston, Massachusetts, United States
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29
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Allen E, Renshaw K, Fredman SJ, Le Y, Rhoades G, Markman H, Litz B. Associations Between Service Members' Posttraumatic Stress Disorder Symptoms and Partner Accommodation Over Time. J Trauma Stress 2021; 34:596-606. [PMID: 33372361 DOI: 10.1002/jts.22645] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/24/2020] [Accepted: 11/29/2020] [Indexed: 11/10/2022]
Abstract
When service members manifest symptoms of posttraumatic stress disorder (PTSD), intimate partners may engage in behaviors to accommodate their partners' experiences (e.g., helping service members avoid situations that could make them uncomfortable, not expressing own thoughts and feelings to minimize PTSD-related conflict), which may inadvertently serve to maintain or increase PTSD symptoms over time. In a sample of 274 male service member/female civilian couples, we evaluated hypothesized bidirectional pathways between self-reported service member PTSD symptoms and partner accommodation, assessed four times over an approximately 18-month period. A random-intercept cross-lagged panel model disaggregating between and within effects revealed that, on average, couples in which the service member had higher levels of total PTSD symptoms also scored higher in partner accommodation, between-couple correlation, r = .40. In addition, at time points when service members' PTSD symptoms were higher relative to their own average symptom level, their partners' level of accommodation was also higher than their personal average, within-couple correlation r = .22. Longitudinally, service member PTSD symptom scores higher than their personal average predicted subsequent increases in partner accommodation, β = .19, but not vice versa, β = .03. Overall, the findings indicate both stable and time-specific significant associations between service member PTSD symptoms and partner accommodation and suggest that higher levels of PTSD symptoms are a significant driver of later increases in partner accommodation. These findings add further support for treating PTSD in an interpersonal context to address the disorder and concomitant relational processes that can adversely impact individual and relational well-being.
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Affiliation(s)
- Elizabeth Allen
- Department of Psychology, University of Colorado Denver, Denver, Colorado, USA
| | - Keith Renshaw
- Department of Psychology, George Mason University, Fairfax, Virginia, USA
| | - Steffany J Fredman
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Yunying Le
- Department of Psychology, University of Miami, Miami, Florida, USA
| | - Galena Rhoades
- Department of Psychology, University of Denver, Denver, Colorado, USA
| | - Howard Markman
- Department of Psychology, University of Denver, Denver, Colorado, USA
| | - Brett Litz
- Departments of Psychiatry and Psychological and Brain Sciences, VA Boston Healthcare System and Boston University, Boston, Massachusetts, USA
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30
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Reuman L, Thompson-Hollands J, Abramowitz JS. Better Together: A Review and Recommendations to Optimize Research on Family Involvement in CBT for Anxiety and Related Disorders. Behav Ther 2021; 52:594-606. [PMID: 33990236 PMCID: PMC8124087 DOI: 10.1016/j.beth.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 07/25/2020] [Accepted: 07/29/2020] [Indexed: 11/20/2022]
Abstract
Anxiety and related disorders (ARDs) occur in an interpersonal context. Individuals with ARDs respond well to individual cognitive behavioral therapy (CBT); however, there is room for improvement. As such, family members may be included to "enhance" treatment outcomes, yet findings from studies examining family involvement in CBT for ARDs are equivocal. The present paper (a) identifies methodological considerations for explaining inconsistent outcomes among CBT for ARDs with family involvement, and (b) reviews factors that affect outcomes of CBT for ARDs with family involvement including levels of involvement in treatment (e.g., number, duration, and spacing of sessions) and characteristics of who is involved in treatment (e.g., family member cognitions and cultural factors). Limitations of the literature and recommendations for future research are discussed. Researchers should focus on conducting studies that can test not whether but for whom and how family involvement can contribute to improved outcomes above and beyond individual CBT for ARDs.
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Affiliation(s)
- Lillian Reuman
- University of North Carolina at Chapel Hill; Boston University School of Medicine; National Center for PTSD at VA Boston Healthcare System.
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31
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Thompson-Hollands J, Burmeister LB, Rosen CS, O’Dougherty M, Erickson EPG, Meis LA. Veterans with poor PTSD treatment adherence: Exploring their loved ones' experience of PTSD and understanding of PTSD treatment. Psychol Serv 2021; 18:216-226. [PMID: 31436444 PMCID: PMC7035146 DOI: 10.1037/ser0000389] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Trauma-focused psychotherapies such as cognitive processing therapy (CPT) and prolonged exposure (PE) are some of the most effective treatments available for posttraumatic stress disorder (PTSD). These treatments have been widely disseminated and promoted throughout the VA Health care System. However, adherence to and completion of these protocols among veterans is often poor, resulting in diminished impact. "Support persons" (SPs) such as relatives and close friends may provide a source of emotional or practical support in treatment, but little is known about how SPs are involved in or exposed to treatment principles and activities. The primary goal of the current research was to examine the experience of SPs of veterans who had poor adherence to treatment. We were interested in SPs' knowledge about the treatment, their level of involvement in treatment activities or sessions, and their potential interest in more participation or education. Qualitative analyses were used to examine data collected from interviews with 19 SPs of veterans who had an unsuccessful course of CPT or PE. Results indicated generally very low levels of knowledge and treatment participation. However, among most SPs there was substantial interest in the possibility of more treatment involvement, particularly in order to receive guidance from the clinician about how to respond to the veteran's symptoms. We suggest that it is possible and desirable to incorporate loved ones more formally into such protocols. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Johanna Thompson-Hollands
- National Center for PTSD, Behavioral Science Division
- VA Boston Healthcare System
- Boston University School of Medicine, Department of Psychiatry
| | | | - Craig S. Rosen
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care
| | | | | | - Laura A. Meis
- Minneapolis VA Health Care System, Center for Care Delivery & Outcomes Research
- University of Minnesota, Medical School, Department of Medicine
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32
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Rationale, design, and methods of a two-site randomized controlled trial: Comparative effectiveness of two treatments for posttraumatic stress disorder in veterans. Contemp Clin Trials 2021; 105:106408. [PMID: 33872802 DOI: 10.1016/j.cct.2021.106408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/09/2021] [Accepted: 04/14/2021] [Indexed: 11/23/2022]
Abstract
PTSD is associated with serious problems in interpersonal functioning, including higher rates of marital conflict and divorce, disrupted relationships with family and friends, estrangement from others and social isolation. Cognitive behavioral and trauma focused treatments are effective for treating PTSD symptoms, but a substantial proportion of individuals, particularly veterans, with PTSD, do not engage, complete, or fully respond to these treatments, and the effects of these treatments on interpersonal functioning are unknown. There is a critical need for alternative treatments with established efficacy, and for treatments that directly address problems in relationship functioning. Interpersonal Psychotherapy for PTSD (IPT-PTSD) is a promising candidate for such a treatment. This paper describes the rationale, design, and methods of the first randomized controlled equivalence trial comparing IPT-PTSD with a first-line gold standard treatment for PTSD (Prolonged Exposure; PE) in the treatment of PTSD in veterans. Both treatments include up to 12 weekly individual sessions. Assessments were conducted at baseline, following sessions four and eight, end of treatment, and 3 and 6 months post-treatment. Primary hypotheses are that IPT-PTSD will be statistically equivalent to PE in reducing the severity of PTSD symptoms, and superior to PE in improving interpersonal functioning. Secondary hypotheses propose that IPT will be superior to PE in improving overall social adjustment and quality of life, and in reducing suicidal ideation. Findings from this study have the potential to improve treatment options for veterans struggling with PTSD and interpersonal problems.
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33
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Meis LA, Noorbaloochi S, Hagel Campbell EM, Erickson EPG, Velasquez TL, Leverty DM, Thompson K, Erbes C. A Theory of Planned Behavior Scale for Adherence to Trauma-Focused Posttraumatic Stress Disorder Treatments. J Trauma Stress 2021; 34:440-453. [PMID: 33200475 DOI: 10.1002/jts.22620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/25/2020] [Accepted: 09/16/2020] [Indexed: 11/10/2022]
Abstract
Evidence-based psychotherapies for posttraumatic stress disorder (PTSD), such as cognitive processing therapy and prolonged exposure (CPT/PE), greatly reduce suffering for veterans, but many veterans fail to complete treatment. Developing a theory-based understanding of adherence is necessary to inform interventions to improve treatment retention. We developed and tested a series of scales applying the theory of planned behavior (TPB) to CPT/PE adherence. The scales were administered in mailed surveys as part of a larger mixed-methods study of veteran adherence to PE/CPT. Surveys were sent to 379 veterans who were initiating CPT/PE across four U.S. Veterans Affairs (VA) hospitals and 207 of their loved ones. Subsequent session attendance and homework compliance were coded via a review of electronic medical records. We examined item-level characteristics, factor structure, and the convergent and discriminant validity of the resultant scales. The findings support four subscales: two related to attitudes (i.e., Treatment Makes Sense and Treatment Fits Needs), one related to perceived behavioral control over participation (i.e., Participation Control), and one related to perceived family attitudes about CPT/PE participation (i.e., Subjective Norms). Scale validity was supported through significant associations with theoretically relevant constructs, including intentions to persist in CPT/PE, rs = .19-.38; treatment completion, rs = .21-.25; practical treatment barriers, rs = -.19 to -.24; and therapeutic alliance, rs = .39-.57.
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Affiliation(s)
- Laura A Meis
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Siamak Noorbaloochi
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Emily M Hagel Campbell
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Emily P G Erickson
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Tina L Velasquez
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - David M Leverty
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Katie Thompson
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Christopher Erbes
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA.,Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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34
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Banducci AN. Prolonged Exposure Therapy in the Time of COVID-19: Modifying PTSD Treatment for a Military Sexual Trauma Survivor Who Contracted COVID-19 Mid-Treatment. Clin Case Stud 2021. [DOI: 10.1177/1534650121993547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Prolonged exposure (PE) therapy is a gold-standard treatment for posttraumatic stress disorder (PTSD) that can be effectively delivered via telehealth modalities. The following case report describes a course of PE delivered to a veteran seeking PTSD treatment for military sexual trauma (MST), who contracted COVID-19 mid-treatment. Considerations for selecting PE as a treatment modality; modifications made due to the COVID-19 pandemic and transition to telehealth more broadly, and following the veteran contracting COVID-19 more specifically; strategies to increase treatment engagement; and assessment of progress over time, are discussed. In particular, treatment considerations during a global pandemic are explored at the patient-, provider-, and systems level, to inform treatment delivery for other providers during this ongoing pandemic. Although there were numerous technological, environmental, and pandemic-related difficulties, the veteran described here persisted through a course of PE and experienced clinically significant reductions in symptoms of PTSD and a great degree of functional recovery.
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Affiliation(s)
- Anne N. Banducci
- The National Center for PTSD at the VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
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35
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Wells SY, Morland LA, Wilhite ER, Grubbs KM, Rauch SA, Acierno R, McLean CP. Delivering Prolonged Exposure Therapy via Videoconferencing During the COVID-19 Pandemic: An Overview of the Research and Special Considerations for Providers. J Trauma Stress 2020; 33:380-390. [PMID: 32881116 PMCID: PMC7461321 DOI: 10.1002/jts.22573] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 11/11/2022]
Abstract
Leveraging technology to provide evidence-based therapy for posttraumatic stress disorder (PTSD), such as prolonged exposure (PE), during the COVID-19 pandemic helps ensure continued access to first-line PTSD treatment. Clinical video teleconferencing (CVT) technology can be used to effectively deliver PE while reducing the risk of COVID-19 exposure during the pandemic for both providers and patients. However, provider knowledge, experience, and comfort level with delivering mental health care services, such as PE, via CVT is critical to ensure a smooth, safe, and effective transition to virtual care. Further, some of the limitations associated with the pandemic, including stay-at-home orders and physical distancing, require that providers become adept at applying principles of exposure therapy with more flexibility and creativity, such as when assigning in vivo exposures. The present paper provides the rationale and guidelines for implementing PE via CVT during COVID-19 and includes practical suggestions and clinical recommendations.
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Affiliation(s)
- Stephanie Y. Wells
- Durham VA Health Care SystemDurhamNorth CarolinaUSA,VISN‐6 Mid‐Atlantic MIRECCDurhamNorth CarolinaUSA,Department of PsychiatryDuke UniversityDurhamNorth CarolinaUSA
| | - Leslie A. Morland
- VA San Diego Healthcare SystemSan DiegoCaliforniaUSA,Department of PsychiatryUniversity of California San DiegoSan DiegoCaliforniaUSA,National Center for PTSDPacific Islands DivisionHonoluluHawaiiUSA
| | | | | | - Sheila A.M. Rauch
- VA Atlanta Healthcare SystemAtlantaGeorgiaUSA,Department of Psychiatry Emory University School of MedicineAtlantaGeorgiaUSA
| | - Ron Acierno
- Faillace Department of PsychiatryUniversity of Texas Health Sciences CenterHouston TexasUSA,Ralph H. Johnson VA Medical CenterCharlestonSouth CarolinaUSA
| | - Carmen P. McLean
- National Center for PTSDVA Palo Alto Health Care SystemPalo AltoCaliforniaUSA,Stanford UniversityPalo AltoCaliforniaUSA
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36
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Campbell SB, Erbes C, Grubbs K, Fortney J. Social Support Moderates the Association Between Posttraumatic Stress Disorder Treatment Duration and Treatment Outcomes in Telemedicine-Based Treatment Among Rural Veterans. J Trauma Stress 2020; 33:391-400. [PMID: 32521100 DOI: 10.1002/jts.22542] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 04/28/2020] [Accepted: 04/30/2020] [Indexed: 01/18/2023]
Abstract
For patients participating in trauma-focused psychotherapies for posttraumatic stress disorder (PTSD), such as cognitive processing therapy (CPT), pretreatment characteristics may moderate treatment effectiveness. For instance, preexisting supportive relationships may encourage skill utilization or provide contrasts to maladaptive cognitive biases highlighted in trauma-focused treatments for PTSD. Such pretreatment characteristics are important to study in rural individuals, who may experience barriers to initiating and completing treatment. The aim of this study was to examine whether pretreatment social support, measured using the Medical Outcomes Study Social Support Survey, would moderate the association between CPT duration (i.e., number of sessions attended) and change in PTSD symptoms, using data from a pragmatic randomized controlled trial of a telemedicine-based collaborative care intervention for rural veterans (N = 225). Social support moderated the association between CPT duration and PTSD symptom change, B = -0.016, SE = -.006; 95% CI [-0.028, -0.005], such that increased duration was associated with more PTSD symptom change only at average or higher levels of support. This effect was found for overall and emotional support but not tangible support. Additionally, on average, among participants who attended eight or more CPT sessions, only those at or above 1 standard deviation above the mean social support score demonstrated a reliable change in PTSD symptoms. The results indicate that the link between CPT treatment duration and treatment outcomes may be stronger for veterans with higher levels of pretreatment social support.
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Affiliation(s)
- Sarah B Campbell
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA.,Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Christopher Erbes
- Minneapolis VA Health Care System, Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota, USA.,Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathleen Grubbs
- VA San Diego Health Care System, San Diego, California, USA.,Department of Psychiatry, University of California-San Diego, La Jolla, California, USA
| | - John Fortney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA.,Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
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37
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Bidirectional Relationships Between Posttraumatic Stress Disorder and Social Functioning During Cognitive Processing Therapy. Behav Ther 2020; 51:447-460. [PMID: 32402260 PMCID: PMC7232057 DOI: 10.1016/j.beth.2019.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/29/2019] [Accepted: 08/02/2019] [Indexed: 11/24/2022]
Abstract
This study investigated temporal relationships between posttraumatic stress symptoms and two indicators of social functioning during cognitive processing therapy. Participants were 176 patients (51.5% female, M age = 39.46 [SD = 11.51], 89.1% White, 42.6% active duty military/veteran) who participated in at least two assessment time points during a trial of cognitive processing therapy. Posttraumatic stress disorder (PTSD) symptoms (PTSD Checklist for DSM-IV) and interpersonal relationship and social role functioning problems (Outcome Questionnaire-45) were assessed prior to each of 12 sessions. Multivariate multilevel lagged analyses indicated that interpersonal relationship problems predicted subsequent PTSD symptoms (b = .22, SE = 0.09, cr = 2.53, p = .01, pr = .46) and vice versa (b = .05, SE = 0.02, cr = 2.11, p = .04, pr = .16); and social role functioning problems predicted subsequent PTSD symptoms (b = .21, SE = 0.10, cr = 2.18, p = .03, pr = .16) and vice versa (b = .06, SE = 0.02, cr = 3.08, p < .001, pr = .23). Military status moderated the cross-lag from social role functioning problems to PTSD symptoms (b = -.35, t = -2.00, p = .045, pr = .16). Results suggest a robust association between PTSD symptoms and social functioning during cognitive processing therapy with a reciprocal relationship between PTSD symptoms and social functioning over time. Additionally, higher social role functioning problems for patients with military status indicate smaller reductions in PTSD symptoms from session to session.
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38
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Hoppen TH, Morina N. Is high-quality of trials associated with lower treatment efficacy? A meta-analysis on the association between study quality and effect sizes of psychological interventions for pediatric PTSD. Clin Psychol Rev 2020; 78:101855. [PMID: 32361507 DOI: 10.1016/j.cpr.2020.101855] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/23/2020] [Accepted: 04/23/2020] [Indexed: 12/29/2022]
Abstract
This meta-analysis aimed at providing an up-to-date estimate on the efficacy of psychological interventions for pediatric PTSD and to analyze the association between treatment efficacy and study quality. We systematically searched PsycINFO, Medline and recent meta-analyses for randomized controlled trials (RCTs). RCTs were eligible if a) they included at least 10 participants per group, b) compared a psychological intervention to a control condition or another psychological intervention and c) mean age was below 19 years. Study quality was assessed independently by both authors on the basis of eight quality criteria. We explored the potential associations between study quality and effect sizes in three ways. Firstly, we compared effect-sizes of high-quality vs. lower-quality studies. Secondly, we analyzed study quality as a continuous predictor of effect sizes. And thirdly, we examined the relationship between the eight individual quality criteria and effect sizes. A total of 46 eligible RCTs were included in the meta-analysis. Psychological interventions produced a large effect size when compared to waitlist (g = 1.07, k = 23, NNT = 1.81) and a medium effect size when compared to active control conditions (g = 0.60, k = 15, NNT = 3.03) at post-treatment. Overall, study quality was moderate. Comparisons of high-quality trials (k = 16) with lower-quality trials (k = 30) produced only non-significant findings in main-analyses as well as moderator sub-analyses. Study quality as a continuous variable was also not found to be related to effect sizes in any of the main analyses, nor was any of the eight individual quality criteria. The summary of the available literature strongly suggests that psychological interventions are effective in treating PTSD in children and adolescents. No significant associations between study quality and treatment efficacy were observed.
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Affiliation(s)
- Thole H Hoppen
- University of Münster, Institute of Psychology, Fliednerstr. 21, 48149 Münster, Germany.
| | - Nexhmedin Morina
- University of Münster, Institute of Psychology, Fliednerstr. 21, 48149 Münster, Germany.
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39
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Maguen S, Holder N, Madden E, Li Y, Seal KH, Neylan TC, Lujan C, Patterson OV, DuVall SL, Shiner B. Evidence-based psychotherapy trends among posttraumatic stress disorder patients in a national healthcare system, 2001-2014. Depress Anxiety 2020; 37:356-364. [PMID: 31850650 DOI: 10.1002/da.22983] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 11/11/2019] [Accepted: 11/19/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Although evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) were implemented starting in 2005 in the veterans health administration (VHA), the largest national healthcare system in the U.S., the rate of initiation (uptake) and prevalence of these treatments in each calendar year have not been determined. We aimed to elucidate two metrics of EBP utilization, uptake and prevalence, following implementation. METHODS Cohort study of Iraq and Afghanistan veterans in VHA (N = 181,620) with a PTSD diagnosis and ≥1 psychotherapy-coded outpatient visit from 2001 to 2014. Using natural language processing techniques, annual and cumulative uptake and prevalence rates from 2001 to 2014 were calculated for each of the two EBPs for PTSD, cognitive processing therapy (CPT) and prolonged exposure (PE) therapy. RESULTS Annual uptake of CPT increased during most years, reaching a maximum of 11.1%. Annual uptake of PE showed little change until 2008 and then increased, reaching a maximum of 4.4%. The annual prevalence of CPT increased throughout the study, reaching a maximum of 14.6%. The annual prevalence of PE increased to a maximum of 5.0% in 2010, but then flattened and declined. Annual uptake of minimally adequate CPT increased a to maximum of 5% in 2014. Annual uptake of minimally adequate PE increased to a maximum of 1.2% in 2010. The cumulative prevalence of CPT was 19.9% and cumulative prevalence for PE was 7.5%. CONCLUSIONS Access to EBPs for PTSD modestly increased for Iraq and Afghanistan veterans after nationwide implementation efforts. Further expanding the reach to veterans is critical, given low rates of minimally adequate EBPs for PTSD.
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Affiliation(s)
- Shira Maguen
- Mental Health Service, San Francisco VA Health Care System, San Francisco, California.,Department of Psychiatry, University of California, San Francisco, California
| | - Nicholas Holder
- Mental Health Service, San Francisco VA Health Care System, San Francisco, California.,Department of Psychiatry, University of California, San Francisco, California
| | - Erin Madden
- Mental Health Service, San Francisco VA Health Care System, San Francisco, California
| | - Yongmei Li
- Mental Health Service, San Francisco VA Health Care System, San Francisco, California
| | - Karen H Seal
- Integrative Health Service, San Francisco VA Health Care System, San Francisco, California.,Departments of Medicine and Psychiatry, University of California, San Francisco, California
| | - Thomas C Neylan
- Mental Health Service, San Francisco VA Health Care System, San Francisco, California.,Department of Psychiatry, University of California, San Francisco, California
| | - Callan Lujan
- Mental Health Service, San Francisco VA Health Care System, San Francisco, California
| | - Olga V Patterson
- Informatics and Computing, VA Salt Lake City Health Care System, Salt Lake City, Utah.,Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Scott L DuVall
- Informatics and Computing, VA Salt Lake City Health Care System, Salt Lake City, Utah.,Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Brian Shiner
- Mental Health Service, White River Junction VA Medical Center, and National Center for Posttraumatic Stress Disorder, Executive Division, White River Junction, Vermont.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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40
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Bourassa KJ, Smolenski DJ, Edwards-Stewart A, Campbell SB, Reger GM, Norr AM. The impact of prolonged exposure therapy on social support and PTSD symptoms. J Affect Disord 2020; 260:410-417. [PMID: 31539674 PMCID: PMC7570950 DOI: 10.1016/j.jad.2019.09.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 09/05/2019] [Accepted: 09/08/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) results in high costs to society, particularly among military personnel. Much is known about PTSD treatments-such as exposure therapies-and their outcomes, but less is known about how treatment might impact social support and PTSD symptoms over the course of treatment. METHODS In the current study, soldiers with PTSD (N = 162) were randomized to complete prolonged exposure therapy (either with or without virtual reality) or a waitlist control condition. We examined the impact of treatment on perceived social support as a secondary treatment outcome, as well as the associations between social support and PTSD symptoms over time. RESULTS Exposure therapy increased perceived social support at the end of treatment compared to waitlist control, β = 0.43, 95% CI [0.13, 0.73]. Multigroup structural equation modeling using a cross-lagged panel design provided evidence that perceived social support was an antecedent of PTSD symptom improvement for participants engaging in treatment, but not for participants in the waitlist control. Treatment effects on change in PTSD symptoms was mediated by change in perceived social support (B = 1.10, 95% CI [0.20, 3.05]). LIMITATIONS The results should be considered in light of limitations, including the characteristics of the sample of active duty soldiers, the measurement of social support, and missingess over the course of the study. CONCLUSIONS These results suggest that increased perceived social support is a secondary outcome of exposure therapy and may be one pathway through which treatment reduces PTSD symptoms.
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Affiliation(s)
- K. J. Bourassa
- VA Puget Sound Healthcare System,University of Arizona, Department of Psychology,Duke University Medical Center, Center for the Study of Aging and Human Development
| | - D. J. Smolenski
- Defense Health Agency, Psychological Health Center of Excellence
| | | | - S. B. Campbell
- VA Puget Sound Healthcare System,University of Washington School of Medicine
| | - G. M. Reger
- VA Puget Sound Healthcare System,University of Washington School of Medicine
| | - A. M. Norr
- University of Washington School of Medicine,VISN 20 Northwest Network Mental Illness Research, Education and Clinical Center (MIRECC)
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41
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Holmes SC, Johnson CM, Suvak MK, Sijercic I, Monson CM, Wiltsey Stirman S. Examining patterns of dose response for clients who do and do not complete cognitive processing therapy. J Anxiety Disord 2019; 68:102120. [PMID: 31585686 PMCID: PMC10408992 DOI: 10.1016/j.janxdis.2019.102120] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/30/2019] [Accepted: 08/02/2019] [Indexed: 12/11/2022]
Abstract
Trauma-focused therapies, including Cognitive Processing Therapy (CPT; Resick et al., 2016), are effective at reducing clients' PTSD symptoms. A limitation to these treatments, however, is client completion of them. The current study examined temporal patterns of treatment non-completion and the relationships among non-completion, PTSD, and overall mental health functioning outcomes, among clients in a randomized controlled CPT implementation trial. Two models of symptom change were tested: 1) dose-effect model (i.e., clients uniformly improve with additional sessions at a negatively accelerating rate); and 2) the good-enough level model (i.e., clients remain in therapy until they have achieved sufficient improvement, thus clients who attend fewer sessions improve at quicker rates). Results indicated that 42% of clients did not complete treatment, with most discontinuing between sessions two and five. Data did not fit the dose-effect or good-enough level model. Rather, clients who improved at a greater rate in their PTSD symptoms and overall mental health functioning attended more sessions. The average client had the best outcomes when they completed all 12 sessions. Identifying clients who may be at risk for discontinuing treatment, and making a concerted effort toward retaining them, is imperative to reduce non-completion rates and ultimately improve client outcomes.
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Affiliation(s)
- Samantha C Holmes
- Yale School of Medicine, Department of Psychiatry, United States; University of Akron, Department of Psychology, United States
| | - Clara M Johnson
- National Center for PTSD, Dissemination and Training Division, United States
| | | | - Iris Sijercic
- Ryerson University, Department of Psychology, Canada
| | | | - Shannon Wiltsey Stirman
- National Center for PTSD, Dissemination and Training Division, United States; Stanford University, Department of Psychiatry and Behavioral Sciences, United States.
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42
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Holliday R, Holder N, Wiblin J, Surís A. Validation of the Timberlawn Couple and Family Evaluation Scales-Self-Report in Veterans with PTSD. Fed Pract 2019; 36:S14-S21. [PMID: 31772494 PMCID: PMC6876426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
A modified version of the the Timberlawn Couple and Family Evaluation Scales was validated to assess intimate partner relationship functioning among veterans who suffer from PTSD.
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Affiliation(s)
- Ryan Holliday
- is a Clinical Research Psychologist at the Rocky Mountain Regional VA Medical Center, Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention in Aurora, Colorado and Assistant Professor in the Department of Psychiatry at the University of Colorado Anschutz Medical Campus. is an Advanced Research Postdoctoral Fellow at the San Francisco Veterans Affairs Health Care System, Sierra Pacific MIRECC, and in the Department of Psychiatry at the University of California, San Francisco School of Medicine. is a VA Advanced Fellow in Women's Health at the VA Los Angeles HSR&D CSHIIP (Center for the Study of Healthcare Innovation, Implementation, & Policy) in California. is a Clinical Professor in the Department of Psychiatry at the University of Texas Southwestern Medical Center in Dallas, Texas
| | - Nicholas Holder
- is a Clinical Research Psychologist at the Rocky Mountain Regional VA Medical Center, Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention in Aurora, Colorado and Assistant Professor in the Department of Psychiatry at the University of Colorado Anschutz Medical Campus. is an Advanced Research Postdoctoral Fellow at the San Francisco Veterans Affairs Health Care System, Sierra Pacific MIRECC, and in the Department of Psychiatry at the University of California, San Francisco School of Medicine. is a VA Advanced Fellow in Women's Health at the VA Los Angeles HSR&D CSHIIP (Center for the Study of Healthcare Innovation, Implementation, & Policy) in California. is a Clinical Professor in the Department of Psychiatry at the University of Texas Southwestern Medical Center in Dallas, Texas
| | - Jessica Wiblin
- is a Clinical Research Psychologist at the Rocky Mountain Regional VA Medical Center, Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention in Aurora, Colorado and Assistant Professor in the Department of Psychiatry at the University of Colorado Anschutz Medical Campus. is an Advanced Research Postdoctoral Fellow at the San Francisco Veterans Affairs Health Care System, Sierra Pacific MIRECC, and in the Department of Psychiatry at the University of California, San Francisco School of Medicine. is a VA Advanced Fellow in Women's Health at the VA Los Angeles HSR&D CSHIIP (Center for the Study of Healthcare Innovation, Implementation, & Policy) in California. is a Clinical Professor in the Department of Psychiatry at the University of Texas Southwestern Medical Center in Dallas, Texas
| | - Alina Surís
- is a Clinical Research Psychologist at the Rocky Mountain Regional VA Medical Center, Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention in Aurora, Colorado and Assistant Professor in the Department of Psychiatry at the University of Colorado Anschutz Medical Campus. is an Advanced Research Postdoctoral Fellow at the San Francisco Veterans Affairs Health Care System, Sierra Pacific MIRECC, and in the Department of Psychiatry at the University of California, San Francisco School of Medicine. is a VA Advanced Fellow in Women's Health at the VA Los Angeles HSR&D CSHIIP (Center for the Study of Healthcare Innovation, Implementation, & Policy) in California. is a Clinical Professor in the Department of Psychiatry at the University of Texas Southwestern Medical Center in Dallas, Texas
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43
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Sippel LM, Watkins LE, Pietrzak RH, Hoff R, Harpaz-Rotem I. Heterogeneity of posttraumatic stress symptomatology and social connectedness in treatment-seeking military veterans: a longitudinal examination. Eur J Psychotraumatol 2019; 10:1646091. [PMID: 31489133 PMCID: PMC6713134 DOI: 10.1080/20008198.2019.1646091] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 11/21/2022] Open
Abstract
Elucidating whether PTSD symptoms predict poorer social connectedness over time (i.e. social erosion) and/or that poor social connectedness contributes to maintenance of PTSD (i.e. social causation) has implications for PTSD treatment and relapse prevention. Most extant research has been cross-sectional and examined overall PTSD symptoms. Evidence of longitudinal associations among heterogeneous PTSD symptom clusters and social connectedness could provide insight into more nuanced targets for intervention. Using data from 1,491 U.S. military veterans in residential treatment for PTSD at 35 Department of Veterans Affairs facilities, we evaluated a two-wave cross-lagged panel model including a five-factor model of PTSD and two aspects of social connectedness. PTSD, quality of connectedness (i.e. degree of distress related to interpersonal conflict), and structural social support (i.e. number of days of contact with supportive loved ones) in the past 30 days were assessed at baseline and 4 months after discharge. The largest effect was greater severity of PTSD dysphoric arousal symptoms (i.e. irritability/anger, poor concentration, and sleep problems) at baseline predicting more conflict-related distress at follow-up (β = 0.43). Post-hoc symptom-level analyses indicated that irritability/anger drove this association. In addition, conflict-related distress predicted greater PTSD symptom severity across all five clusters (β's = 0.10 to 0.14, p's < 0.01). More days of contact predicted lower severity of avoidance and numbing symptoms (β's = -.05 and -.07, p's < 0.01), along with individual symptoms within these clusters, plus flashbacks. Results support both social erosion and social causation models. Engaging loved ones in veterans' treatment and targeting dysphoric arousal symptoms, particularly anger and irritability, may improve long-term PTSD and relationship outcomes, respectively.
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Affiliation(s)
- Lauren M Sippel
- National Center for PTSD Executive Division, White River Junction, VT, USA.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Laura E Watkins
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Robert H Pietrzak
- National Center for PTSD Clinical Neurosciences Division, West Haven, CT, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Rani Hoff
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.,National Center for PTSD Evaluation Division, West Haven, CT, USA
| | - Ilan Harpaz-Rotem
- National Center for PTSD Clinical Neurosciences Division, West Haven, CT, USA.,National Center for PTSD Evaluation Division, West Haven, CT, USA
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Saraiya T, Fareri D, López-Castro T, Hien D, Fertuck E, Melara R. The social cognitive appraisal of trustworthiness in individuals with dimensional levels of post-traumatic stress symptoms: a translational study. Eur J Psychotraumatol 2019; 10:1697582. [PMID: 31839901 PMCID: PMC6896450 DOI: 10.1080/20008198.2019.1697582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/24/2019] [Accepted: 10/09/2019] [Indexed: 01/09/2023] Open
Abstract
Background: Misappraisals in evaluating the trustworthiness of others may be one mechanism contributing to the interpersonal difficulties individuals with posttraumatic stress disorder (PTSD) face. Objective: This study used a translational experimental design to examine the behavioural and neural correlates underlying the appraisal of facial stimuli morphed on dimensions of trustworthiness across three groups: individuals with high posttraumatic stress symptoms (HPTS), low posttraumatic stress symptoms (LPTS), and healthy controls (HC). Methods: Participants (N = 70) rated how trustworthy to untrustworthy they perceived three facial morphs (trustworthy, neutral, and untrustworthy) while undergoing electroencephalography (EEG). Results: Behavioural results showed that the HPTS group rated the untrustworthy morph as more untrustworthy than the HC group (β = 0.20, SE = .07, 95% CI [0.06, 0.33], z = 2.88, p = .004). The HPTS group also showed no variation in response time across morphs ( X 2 (2) = 0.92, p = 0.63), while the LPTS and HC groups did ( X 2 (2) = 9.60, p = .008; X 2 (2) = 23.62, p < .001). EEG data revealed significant group by morph interactions at the N170 latency and the Vertex Positive Potential (VPP): the HPTS and LPTS identified the untrustworthy morph faster than the HCs, but diverged to the degree to which they encoded each facial morph. Conclusions: Taken together our results suggest that HPTS individuals demonstrate an early attentional avoidance of faces morphed on dimensions of trustworthiness. This early, preconscious, avoidance may be one mechanism contributing to the miscalculations individuals with PTSD make in interpersonal situations.
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Affiliation(s)
- Tanya Saraiya
- Derner School of Psychology, Adelphi University, Garden City, NY, USA.,Psychology Department, The City College of New York, CUNY, New York, NY, USA
| | - Dominic Fareri
- Derner School of Psychology, Adelphi University, Garden City, NY, USA
| | - Teresa López-Castro
- Psychology Department, The City College of New York, CUNY, New York, NY, USA
| | - Denise Hien
- Center of Alcohol Studies, Graduate School of Applied and Professional Psychology, Rutgers University, Piscataway, NJ, USA
| | - Eric Fertuck
- Psychology Department, The City College of New York, CUNY, New York, NY, USA
| | - Robert Melara
- Psychology Department, The City College of New York, CUNY, New York, NY, USA
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