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Brooks E, Spokas M, Goldschmidt D. Exclusion of Suicidal Participants From Randomized Controlled Trials for Posttraumatic Stress Disorder: A Meta-Analysis. J Trauma Stress 2021; 34:1209-1218. [PMID: 33089539 DOI: 10.1002/jts.22610] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 07/26/2020] [Accepted: 08/09/2020] [Indexed: 11/10/2022]
Abstract
There has been a lack of consensus regarding whether to include or exclude participants with suicidal ideation (SI) from posttraumatic stress disorder (PTSD) psychotherapy clinical trials and, until recently, how best to report adverse events related to suicide risk. Without consistent reporting or evaluation of SI as an outcome, clinical practice guidelines are limited in their ability to recommend interventions for this common co-occurrence. In the present meta-analysis, we compared randomized controlled trials (RCTs) of PTSD psychotherapies, based on their suicide exclusion criteria. The databases PILOTS, PsycINFO, and PubMed were searched for RCTs of psychotherapy that lasted more than 4 weeks and included adults who met the diagnostic criteria for PTSD. Included studies (N = 48) were coded by two independent reviewers. A random-effects model was used to calculate the pooled effect sizes for trials that excluded (n = 31) and did not exclude SI (n = 17). A test statistic for the significance of effect revealed that the difference between these two groups' effect sizes was not significant, z = 0.96, p = .341. This suggests that the effects observed in clinical trials are not significantly impacted by SI-related exclusion criteria.
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Affiliation(s)
- Emily Brooks
- Department of Psychology, La Salle University, Philadelphia, Pennsylvania, USA
| | - Megan Spokas
- Department of Psychology, La Salle University, Philadelphia, Pennsylvania, USA
| | - Deborah Goldschmidt
- Department of Psychology, La Salle University, Philadelphia, Pennsylvania, USA
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Zeifman RJ, Landy MSH, Liebman RE, Fitzpatrick S, Monson CM. Optimizing treatment for comorbid borderline personality disorder and posttraumatic stress disorder: A systematic review of psychotherapeutic approaches and treatment efficacy. Clin Psychol Rev 2021; 86:102030. [PMID: 33894491 DOI: 10.1016/j.cpr.2021.102030] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/08/2021] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
Comorbid borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) is a severe and complicated clinical presentation characterized by especially high rates of suicide, healthcare utilization, and psychosocial impairment. Although guidelines exist for treating each of these disorders alone, there remains limited guidance on the optimal treatment in cases where BPD and PTSD co-occur. Therefore, this systematic review synthesizes the existing research on the treatment of BPD-PTSD with the aim of optimizing treatment for this population. First, the prevalence and clinical severity of comorbid BPD-PTSD is reviewed. Next, we describe the results of our systematic review, which identified 21 articles that examined treatment outcomes in the context of BPD-PTSD or subclinical BPD-PTSD. Based on our results, we describe existing psychotherapeutic approaches, including BPD-specific treatments, trauma-focused and non-trauma-focused treatments for PTSD, and stage-based treatments for BPD-PTSD. We also summarize BPD-PTSD treatment outcomes, including whether each disorder interferes with treatment and recovery of the other. Results related to treatment safety and concerns regarding conducting trauma-focused treatment for BPD-PTSD are addressed. We end by highlighting important gaps in the literature and provide recommendations for further research.
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Affiliation(s)
| | - Meredith S H Landy
- Department of Psychology, Ryerson University, Toronto, Canada; Mind Beacon Health Inc., Toronto, Canada
| | - Rachel E Liebman
- Department of Psychology, Ryerson University, Toronto, Canada; Department of Psychology, York University, Toronto, Canada
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3
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Harned MS, Ritschel LA, Schmidt SC. Effects of Workshop Training in the Dialectical Behavior Therapy Prolonged Exposure Protocol on Clinician Beliefs, Adoption, and Perceived Clinical Outcomes. J Trauma Stress 2021; 34:427-439. [PMID: 33200443 DOI: 10.1002/jts.22622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/19/2020] [Accepted: 10/08/2020] [Indexed: 11/10/2022]
Abstract
Although extensive efforts have been made to train clinicians in evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), relatively few PTSD patients are considered appropriate for and therefore receive these treatments. The dialectical behavior therapy prolonged exposure (DBT PE) protocol was developed to expand the reach of EBPs for PTSD to suicidal patients with severe comorbidities, but methods of training clinicians to deliver this treatment have not been evaluated. We examined the impact of DBT PE workshops on clinician beliefs, adoption, and perceived patient outcomes. Clinicians (N = 266) attended 2- or 4-day workshops and completed surveys at pretraining, posttraining, and 3- and 6-month follow-ups. From pretraining to 6-month follow-up, there were significant improvements in clinician concerns regarding worsening, perceived treatment credibility, and self-efficacy that did not differ by workshop length, R2 s = .20-.45. At 6-months posttraining, 53.5% of clinicians (38.8% 2-day, 66.3% 4-day) reported using DBT PE with 241 patients. Higher posttraining ratings of self-efficacy and perceived treatment credibility predicted later DBT PE use, R2 = .28. Among adopting clinicians, 81.3% reported that, on average, their patients' PTSD improved and 66.7% reported that patients were much to very much improved on average. Most clinicians reported that their patients' comorbid problems did not worsen during DBT PE and if worsening occurred, it typically involved temporary increases in distress. Workshops may be an effective method of changing clinician beliefs and promoting the use of DBT PE in a manner that clinicians experience as effective and safe for their patients.
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Affiliation(s)
- Melanie S Harned
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA.,Department of Psychology, University of Washington, Seattle, Washington, USA.,VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Lorie A Ritschel
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Triangle Area Psychology Clinic, Durham, North Carolina, USA
| | - Sara C Schmidt
- Department of Psychology, University of Washington, Seattle, Washington, USA.,VA Puget Sound Health Care System, Seattle, Washington, USA
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Treating Posttraumatic Stress Disorder in the Presence of Acute Suicide Risk in Veterans and Active Duty Service Members: A Call for Research. J Nerv Ment Dis 2019; 207:611-614. [PMID: 31259796 DOI: 10.1097/nmd.0000000000001022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Posttraumatic stress disorder (PTSD) is associated with increased risk for suicide, and clinicians often encounter acute suicide risk during the process of intervening upon PTSD. Although the Department of Veterans Affairs (VA) and the Department of Defense (DoD) have disseminated evidence-based treatments for PTSD, prior clinical trials have used inconsistent definitions and unclear assessment methods of suicide risk. Consequently, translating findings from PTSD treatment research to clinical practice remains challenging. This article describes challenges inherent to the current PTSD interventional research literature related to concurrent acute suicide risk among veterans and active duty service members. We reviewed prior trials and how their assessment methods and nomenclature compare with strategies and definitions mandated within the VA/DoD. Furthermore, we describe methodological recommendations for future research, including consistent use of mandated universal suicide nomenclature, standardization for classifying suicide risk, transparency in reporting assessment means and measures, and examination of current models of PTSD treatment in the context of acute suicide risk.
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Brown LA, McLean CP, Zang Y, Zandberg L, Mintz J, Yarvis JS, Litz BT, Peterson AL, Bryan CJ, Fina B, Petersen J, Dondanville KA, Roache JD, Young-McCaughan S, Foa EB. Does prolonged exposure increase suicide risk? Results from an active duty military sample. Behav Res Ther 2019; 118:87-93. [PMID: 31022593 DOI: 10.1016/j.brat.2019.04.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 12/19/2018] [Accepted: 04/05/2019] [Indexed: 11/30/2022]
Abstract
The efficacy of prolonged exposure (PE) on suicide ideation (SI) as a secondary outcome among individuals with posttraumatic stress disorder (PTSD) is unclear. The purpose of this study was to compare the efficacy of PE in two formats (spaced, S-PE, 10 sessions over 8 weeks, and massed, M-PE, 10 sessions over 2 weeks) to Present Centered Therapy (PCT) and minimal contact control (MCC) on SI exacerbation among patients without suicide intent or plans. Active duty military personnel (n = 335) were randomized to: (1) S-PE vs. PCT and (2) M-PE vs. MCC. All participants completed the Beck Scale for Suicide Ideation and the Beck Depression Inventory (Suicide item) at baseline, posttreatment, and follow-ups. S-PE and PCT had significant and comparable reductions in SI during treatment. M-PE had significantly steeper reductions in SI during treatment compared to MCC. Specifically, more participants in M-PE compared to MCC had reliable improvement versus reliable exacerbation. Reduction in PTSD symptoms was significantly associated with reduction of SI. PE was associated with significant reductions in SI over time that were comparable to PCT and superior to MCC. These findings suggest that both trauma- and non-trauma-focused treatments are associated with reductions in SI, and that trauma-focused treatments improve SI relative to waitlist.
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Affiliation(s)
- Lily A Brown
- Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 600 North, Philadelphia, PA, USA.
| | - Carmen P McLean
- Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 600 North, Philadelphia, PA, USA; (b)National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Rd., Menlo Park, CA, USA
| | - Yinyin Zang
- Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 600 North, Philadelphia, PA, USA
| | - Laurie Zandberg
- Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 600 North, Philadelphia, PA, USA
| | - Jim Mintz
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 8300 Floyd Curl Dr., San Antonio, TX, USA; Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., San Antonio, TX, USA
| | - Jeffrey S Yarvis
- Headquarters, Carl R. Darnall Army Medical Center, 36065 Santa Fe Avenue, Fort Hood, TX, USA
| | - Brett T Litz
- Massachusetts Veterans Epidemiological Research Center, VA Boston Health Care System, 150 S Huntington Ave, Boston, MA, USA; Department of Psychiatry, Boston University School of Medicine, 720 Harrison Ave., Boston, MA, USA; Department of Psychological and Brain Sciences, Boston University, 64 Cummington Mall, Boston, MA, USA
| | - Alan L Peterson
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 8300 Floyd Curl Dr., San Antonio, TX, USA; Research and Development Service, South Texas Veterans Health Care System, 7400 Merton Minter, San Antonio, TX, USA; Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, USA
| | - Craig J Bryan
- National Center for Veterans Studies, 332 S 1400 E, Building 73, Salt Lake City, UT, USA; Department of Psychology, The University of Utah, 1721 Campus Center Drive Saec, 3220 S, Salt Lake City, UT, USA
| | - Brooke Fina
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 8300 Floyd Curl Dr., San Antonio, TX, USA
| | - Julie Petersen
- Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 600 North, Philadelphia, PA, USA
| | - Katherine A Dondanville
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 8300 Floyd Curl Dr., San Antonio, TX, USA
| | - John D Roache
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 8300 Floyd Curl Dr., San Antonio, TX, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, 8300 Floyd Curl Dr., San Antonio, TX, USA
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, 3535 Market St., Suite 600 North, Philadelphia, PA, USA
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Ribeiro SP, LaCroix JM, De Oliveira F, Novak LA, Lee-Tauler SY, Darmour CA, Perera KU, Goldston DB, Weaver J, Soumoff A, Ghahramanlou-Holloway M. The Link between Posttraumatic Stress Disorder and Functionality among United States Military Service Members Psychiatrically Hospitalized Following a Suicide Crisis. Healthcare (Basel) 2018; 6:E95. [PMID: 30087239 PMCID: PMC6164520 DOI: 10.3390/healthcare6030095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 07/18/2018] [Accepted: 07/30/2018] [Indexed: 11/25/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) is one of the most commonly diagnosed psychiatric disorders in the United States and has been linked to suicidal thoughts and behaviors, yet the role of a PTSD diagnosis on functional impairment among suicidal individuals remains unknown. This study examined the association between PTSD status and functional impairment among military psychiatric inpatients admitted for acute suicide risk (N = 166) with a lifetime history of at least one suicide attempt. Measures of functionality included: (1) alcohol use; (2) sleep quality; (3) social problem-solving; and (4) work and social adjustment. Thirty-eight percent of the sample met criteria for PTSD. Women were more likely than men to meet criteria for PTSD (p = 0.007), and participants who met PTSD criteria had significantly more psychiatric diagnoses (p < 0.001). Service members who met PTSD criteria reported more disturbed sleep (p = 0.003) and greater difficulties with work and social adjustment (p = 0.004) than those who did not meet PTSD criteria. However, functionality measures were not significantly associated with PTSD status after controlling for gender and psychiatric comorbidity. Gender and number of psychiatric comorbidities other than PTSD were significant predictors of PTSD in logistic regression models across four functionality measures. Future studies should assess the additive or mediating effect of psychiatric comorbidities in the association between impaired functioning and PTSD. Clinicians are encouraged to assess and address functionality during treatment with suicidal individuals, paying particular attention to individuals with multiple psychiatric diagnoses.
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Affiliation(s)
- Sissi Palma Ribeiro
- Suicide Care, Prevention, and Research Initiative, Department of Medical & Clinical Psychology, Uniformed Services University, Bethesda, MD 20814, USA.
| | - Jessica M LaCroix
- Suicide Care, Prevention, and Research Initiative, Department of Medical & Clinical Psychology, Uniformed Services University, Bethesda, MD 20814, USA.
| | - Fernanda De Oliveira
- Suicide Care, Prevention, and Research Initiative, Department of Medical & Clinical Psychology, Uniformed Services University, Bethesda, MD 20814, USA.
| | - Laura A Novak
- Suicide Care, Prevention, and Research Initiative, Department of Medical & Clinical Psychology, Uniformed Services University, Bethesda, MD 20814, USA.
| | - Su Yeon Lee-Tauler
- Suicide Care, Prevention, and Research Initiative, Department of Medical & Clinical Psychology, Uniformed Services University, Bethesda, MD 20814, USA.
| | - Charles A Darmour
- Suicide Care, Prevention, and Research Initiative, Department of Medical & Clinical Psychology, Uniformed Services University, Bethesda, MD 20814, USA.
| | - Kanchana U Perera
- Suicide Care, Prevention, and Research Initiative, Department of Medical & Clinical Psychology, Uniformed Services University, Bethesda, MD 20814, USA.
| | - David B Goldston
- Department of Psychiatry, Duke University, Durham, NC 27708, USA.
| | - Jennifer Weaver
- Inpatient Psychiatry, Fort Belvoir Community Hospital, VA 22060, USA.
| | - Alyssa Soumoff
- Department of Psychiatry, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.
| | - Marjan Ghahramanlou-Holloway
- Suicide Care, Prevention, and Research Initiative, Department of Medical & Clinical Psychology, Uniformed Services University, Bethesda, MD 20814, USA.
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