1
|
Chen Y, Markowitz JC, Blanco C, Hershman DL, Zhang JT, Hellerstein DJ. Geographical distance predicts psychiatric treatment retention for Hispanic women with comorbid major depression and breast cancer. Breast Cancer Res Treat 2024; 205:249-256. [PMID: 38376796 DOI: 10.1007/s10549-024-07250-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 01/05/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE Depression is among the most common comorbid psychiatric disorders of patients with breast cancer. Depression decreases patient quality of life and, if untreated, can adversely affect cancer treatment. We sought to identify treatment barriers for women with breast cancer receiving psychotherapy for depression. Findings may help policy makers and researchers determine funding and design of future studies involving this population, especially in communities with high rates of health disparities. METHODS We used data from a randomized trial for women with breast cancer and current DSM-IV non-psychotic unipolar major depressive disorder (MDD). Patients were randomly assigned to 12 weeks of one of three psychotherapies and attrition was assessed by whether subjects completed 12 weekly treatment sessions. We used descriptive analyses and logistic regression to identify treatment barriers. R shiny was used to determine study patient residences. RESULTS Of 134 randomized patients, 84 (62.7%) were Hispanic. Fifty-nine patients (44%) either did not start or dropped out of treatment, 49 (83.1%) of them being Hispanic. Being a Hispanic woman, less educated, and geographically distant from treatment significantly predicted attrition. Single Hispanic mothers had significantly higher attrition risk than married and/or childless women. CONCLUSION Identifying barriers to treatment is important to improve treatment adherence for patients with concurrent diagnoses of breast cancer and MDD, especially for traditionally underserved minorities. Additional support such as affordable tele-medicine, multi-language assistance, financial aid for transportation and child-care, and allocation of more funds to address some identified barriers deserve consideration to improve treatment adherence and outcomes.
Collapse
Affiliation(s)
- Ying Chen
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA.
- Columbia University Irving Medical Center (CUIMC), New York, NY, 10032, USA.
| | - John C Markowitz
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- Columbia University Irving Medical Center (CUIMC), New York, NY, 10032, USA
| | - Carlos Blanco
- Division of Epidemiology, Services and Prevention Research, National Institute on Drug Abuse (NIDA), Gaithersburg, MD, 20892, USA
| | - Dawn L Hershman
- Columbia University Irving Medical Center (CUIMC), New York, NY, 10032, USA
| | - Joy T Zhang
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- University of Virginia, Charlottesville, VA, 22904, USA
| | - David J Hellerstein
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- Columbia University Irving Medical Center (CUIMC), New York, NY, 10032, USA
| |
Collapse
|
2
|
Kline AC, Otis NP, Norman SB, Hunt WM, Walter KH. Dropout in a clinical trial for comorbid PTSD and MDD among US service members: Are pretreatment characteristics predictive? Psychother Res 2024:1-13. [PMID: 38497740 DOI: 10.1080/10503307.2024.2325519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/26/2024] [Indexed: 03/19/2024] Open
Abstract
OBJECTIVE Despite effective treatment options for posttraumatic stress disorder (PTSD), many patients do not complete therapy. This includes U.S. active duty service members, yet factors linked to attendance in this population remain understudied and dropout remains difficult to predict. Additionally, most studies have not examined samples with PTSD and co-occurring major depressive disorder (MDD) despite high rates of comorbidity. METHOD The current study explored predictors of dropout among service members with comorbid PTSD and MDD (N = 94) randomized to cognitive processing therapy enhanced with behavioral activation (BA + CPT) or CPT as part of a clinical trial. RESULTS Using the Fournier approach, only two predictors were associated with lower dropout risk among over 20 examined: shorter duration between pretreatment assessment and Session 1 (p = .041) and past 3-month PTSD treatment engagement (p = .036). CONCLUSION Results suggest the possible utility of early momentum in starting therapy and leveraging recent treatment to improve attendance. However, this study also highlights the possible limitations of commonly assessed pretreatment factors in predicting attendance and current challenges in measuring dropout risk. Strategies to improve prediction, such as shifting focus to assess modifiable factors and processes more proximal to dropout during treatment, may be needed.Trial registration: ClinicalTrials.gov identifier: NCT02874131.
Collapse
Affiliation(s)
- Alexander C Kline
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA
- Leidos, Inc., San Diego, CA, USA
| | - Nicholas P Otis
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA
- Leidos, Inc., San Diego, CA, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
- National Center for PTSD, Executive Division, White River Junction, VT, USA
- VA San Diego Healthcare System, San Diego, CA, USA
| | - W Michael Hunt
- Directorate of Mental Health, Naval Medical Center San Diego, San Diego, CA, USA
| | - Kristen H Walter
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA
| |
Collapse
|
3
|
Bonson A, Murphy D, Aldridge V, Greenberg N, Williamson V. Veterans' experiences of moral injury, treatment and recommendations for future support. BMJ Mil Health 2023:military-2022-002332. [PMID: 37192765 DOI: 10.1136/military-2022-002332] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/01/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION Moral injury (MI) significantly impacts the lives of many UK military veterans however, there is a lack of manualised treatment to address the needs of this population. To develop future treatments that are acceptable and well tolerated, veterans should be consulted on their experiences of existing psychological treatments and suggestions for future treatments. METHODS 10 UK military veterans were interviewed about their experiences of receiving treatment for psychological difficulties after MI, and beliefs about core components of future treatments. Thematic analysis of these interviews were conducted. RESULTS 2 superordinate themes were identified: experiences of previous mental health treatment and perceptions of the proposed treatments. Reflections on cognitive behavioural therapy were mixed, with some describing that it did not ameliorate their guilt or shame. In future treatments, focusing on values, using written letters and including therapy sessions with close companions were considered beneficial. Veterans reported that a strong rapport with therapist was key for MI treatment. CONCLUSION Findings provide a useful account of how current post-trauma treatments may be experienced by patients with MI. Although limited by sample size, the results highlight therapeutic approaches that may be helpful in future and provide important considerations for therapists treating MI.
Collapse
Affiliation(s)
| | - D Murphy
- Research Department, Combat Stress, Leatherhead, UK
- King's Centre for Military Health Research, King's College London, London, UK
| | - V Aldridge
- Research Department, Combat Stress, Leatherhead, UK
| | - N Greenberg
- King's Centre for Military Health Research, King's College London, London, UK
| | - V Williamson
- King's Centre for Military Health Research, King's College London, London, UK
- Department of Experimental Psychology, Ann Watts Building, University of Oxford, Oxford, UK
| |
Collapse
|
4
|
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.
Collapse
|
5
|
Pinto JV, Hunt C, O'Toole B. Advancing PTSD Diagnosis and the Treatment of Trauma in Humanitarian Emergencies via Mobile Health: Protocol for a Proof-of-Concept Non-Randomized Controlled Trial. JMIR Res Protoc 2022; 11:e38223. [PMID: 35596546 PMCID: PMC9244657 DOI: 10.2196/38223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/17/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Decentralized health systems in Low and Middle-Income Countries (LMICs) impacted by humanitarian crises lack resources and a qualified workforce to attend to the overwhelming demand for mental health care in emergencies. Innovative approaches that are safe, cost-effective, and scalable are needed to address the burden of traumatic stress brought by emergencies. High mobile phone ownership rates combined with the precision of neural, cognitive, and biometric measures of trauma and its feasible integration with Artificial Intelligence (AI) makes digital application (app) interventions a promising pathway to promote precision diagnosis and high-impact care. OBJECTIVE The aims of this study are to advance methods for the objective diagnosis and treatment of trauma in emergencies across LMICs by examining (i) neural, cognitive, and biometric markers and (ii) the efficacy of the eResilience App, a neuroscience-informed mobile health mental health app intervention, via changes in clinical symptomatology, cognitive performance, and brain activity. METHODS Trauma-exposed African refugees residing in Australia were selected for this study. A research software version of the eResilience App with advanced monitoring capabilities was designed for the trial. Participants completed the eResilience App at home during a seven-day period. Clinical, cognitive, and electrophysiological data were collected during baseline and post-test to examine biomarkers of trauma and the efficacy of the proposed digital intervention for the treatment of trauma and its potential outcomes including depression, anxiety, physical symptoms, self-harm, substance misuse, and cognitive impairment. In addition, biofeedback, wellbeing, and subjective stress data points were collected via the app during the treatment week, followed by clinical interviews at 1, 3, 6 and 12-months post-intervention. RESULTS Data collection was conducted between 2018 and 2020. A total n=100 participants exposed to war were screened, n= 75 were enrolled and assigned to a trauma-exposed control (n=38) or Posttraumatic Stress Disorder (PTSD) condition (n=37), and n= 70 completed all baseline, treatment, and post-test assessments. A total n=62 of the n=70 who completed the intervention opted to enrol in the 3, 6 and 12-month follow-ups. Data collection is complete, and results are being prepared for publication. If proven efficacious, this proof-of-concept clinical trial will inform fully powered randomized clinical trials in LMICs to further develop AI-powered, app-based diagnostic and prognostic features, and determine the app's cross-cultural efficacy for the treatment of trauma in emergency settings. CONCLUSIONS This protocol provides researchers with a comprehensive background of the study rationale, a detailed guideline for replication studies interested in examining the feasibility and the efficacy of the eResilience App across varied demographics, and a robust framework for investigations of low-cost objective diagnostic markers in mental health interventions. Methodological limitations and suggestions are also provided. CLINICALTRIAL Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616001205426. Universal Trial Number (UTN): U1111-1180-0347.
Collapse
Affiliation(s)
- Janaina Videira Pinto
- Faculty of Medicine and Health, the University of Sydney, 94 Mallett St, Sydney, AU.,Sync Body-Brain Health, Currimundi, AU
| | - Caroline Hunt
- School of Psychology, Faculty of Science, the University of Sydney, Sydney, AU
| | - Brian O'Toole
- Faculty of Medicine and Health, the University of Sydney, 94 Mallett St, Sydney, AU
| |
Collapse
|
6
|
Schnitzer G, Holttum S, Huet V. "My heart on this bit of paper": A grounded theory of the mechanisms of change in art therapy for military veterans. J Affect Disord 2022; 297:327-337. [PMID: 34715166 DOI: 10.1016/j.jad.2021.10.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 10/12/2021] [Accepted: 10/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND A proportion of veterans experience post-traumatic stress disorder (PTSD). Research has shown reduced effectiveness of commonly offered psychotherapies in military personnel. Some research suggested the usefulness of art therapy for veterans with PTSD, but its mechanism of operation has been unclear. The current project aimed to establish participants' perceptions of any impact of group art therapy and some of the perceived mechanisms of change. METHOD In a grounded theory design, single semi-structured interviews were conducted with nine veterans who had received group art therapy, two art therapists, and a veteran's wife. Interviews were transcribed and analysed. FINDINGS Theorised categories included (a) art therapy group as "the family", (b) "the gentle conductor", (c) trust, (d) doing the work, (e) art therapy as "a communication tool", (f) "points of recognition", (g) "making things concrete", and (h) "not a cure". LIMITATIONS Shortcomings included a homogenous sample who all attended art therapy alongside other interventions, reliance on subjective and unmeasured symptom change, and researcher effects related to qualitative methodology. CONCLUSION The developed grounded theory is consistent with existing evidence and neuropsychological theory. Group art therapy may enable some veterans to prepare for verbal-only therapy, by offering a safe space in which to approach non-verbal traumatic and trauma-related contextual material in a controlled way. Artworks may provide a bridge to facilitate communication of experiences within subsequent verbal therapy and with loved-ones. It is suggested to replicate the project at different sites. Elements of the developed theory may be investigated further to establish its transferability.
Collapse
Affiliation(s)
- Gabriel Schnitzer
- Salomons Institute for Applied Psychology, Canterbury Christ Church University, Tunbridge Wells BN2 3EW, United Kingdom.
| | - Sue Holttum
- Salomons Institute for Applied Psychology, Canterbury Christ Church University, Tunbridge Wells BN2 3EW, United Kingdom; British Association of Art Therapists, London, United Kingdom
| | - Val Huet
- British Association of Art Therapists, London, United Kingdom
| |
Collapse
|
7
|
Proença CR, Markowitz JC, Coimbra BM, Cogo-Moreira H, Maciel MR, Mello AF, Mello MF. Interpersonal psychotherapy versus sertraline for women with posttraumatic stress disorder following recent sexual assault: a randomized clinical trial. Eur J Psychotraumatol 2022; 13:2127474. [PMID: 36267873 PMCID: PMC9578463 DOI: 10.1080/20008066.2022.2127474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Sexual assault often triggers posttraumatic stress disorder (PTSD), a potentially chronic severe mental disorder. Most guidelines recommend selective serotonin reuptake inhibitors (SSRIs) and trauma-focused psychotherapies as treatment options. Interpersonal Psychotherapy (IPT), adapted for PTSD (IPT-PTSD), focuses on interpersonal consequences of trauma rather than confronting the trauma itself. Studies have found IPT-PTSD efficaciously reduced PTSD symptoms with limited attrition. No efficacy trials have compared IPT-PTSD and SSRI. We hypothesized IPT would reduce PTSD, anxiety, and depressive symptoms more than sertraline among women with PTSD following a recent sexual assault. Objectives: To compare the efficacy of IPT-PTSD to SSRI sertraline in a 14-week randomized clinical trial for women with PTSD following a recent sexual assault. Methods: Seventy-four women with PTSD who had suffered sexual assault in the last six months were randomly assigned to 14 weeks of IPT-PTSD (n = 39) or sertraline (n = 35). Instruments assessed PTSD, anxiety, and depressive symptoms. This randomized clinical trial was conducted in São Paulo, Brazil, using the Clinician-Administered PTSD Scale-5 (CAPS-5) as the primary outcome measure. Results: Both treatments significantly reduced PTSD, anxiety, and depressive symptoms, without between-group outcome differences. CAPS-5 mean decreased from 42.5 (SD = 9.4) to 27.1 (SD = 15.9) with sertraline and from 42.6 (SD = 9.1) to 29.1 (SD = 15.5) with IPT-PTSD. Attrition was high in both arms (p = .40). Conclusions: This trial showed within-group improvements without differences between IPT-PTSD and sertraline treatment of PTSD. Our findings suggest that non-exposure-based psychotherapies may benefit patients with PTSD, although we did not directly compare these treatments to an exposure therapy. Brazilian Clinical Trials Registry RBR-3z474z.
Collapse
Affiliation(s)
- Cecília R Proença
- Program for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - John C Markowitz
- New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Bruno M Coimbra
- Program for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil.,Department of Psychiatry, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Hugo Cogo-Moreira
- Department of Education, ICT and Learning, Østfold University College, Halden, Norway
| | - Mariana R Maciel
- Program for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Andrea F Mello
- Program for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Marcelo F Mello
- Program for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| |
Collapse
|