Decreases in Suicide Cognitions After Cognitive Processing Therapy Among Veterans With Posttraumatic Stress Disorder Due to Military Sexual Trauma: A Preliminary Examination

Psychosocial interventions for survivors of rape and sexual assault experienced during adulthood

BACKGROUND

Exposure to rape, sexual assault and sexual abuse has lifelong impacts for mental health and well-being. Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitisation and Reprocessing (EMDR) are among the most common interventions offered to survivors to alleviate post-traumatic stress disorder (PTSD) and other psychological impacts. Beyond such trauma-focused cognitive and behavioural approaches, there is a range of low-intensity interventions along with new and emerging non-exposure based approaches (trauma-sensitive yoga, Reconsolidation of Traumatic Memories and Lifespan Integration). This review presents a timely assessment of international evidence on any type of psychosocial intervention offered to individuals who experienced rape, sexual assault or sexual abuse as adults.

OBJECTIVES

To assess the effects of psychosocial interventions on mental health and well-being for survivors of rape, sexual assault or sexual abuse experienced during adulthood.

SEARCH METHODS

In January 2022, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also checked reference lists of included studies, contacted authors and experts, and ran forward citation searches.

SELECTION CRITERIA

Any study that allocated individuals or clusters of individuals by a random or quasi-random method to a psychosocial intervention that promoted recovery and healing following exposure to rape, sexual assault or sexual abuse in those aged 18 years and above compared with no or minimal intervention, usual care, wait-list, pharmacological only or active comparison(s). We classified psychosocial interventions according to Cochrane Common Mental Disorders Group's psychological therapies list.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 36 studies (1991 to 2021) with 3992 participants randomly assigned to 60 experimental groups (3014; 76%) and 23 inactive comparator conditions (978, 24%). The experimental groups consisted of: 32 Cognitive Behavioural Therapy (CBT); 10 behavioural interventions; three integrative therapies; three humanist; five other psychologically oriented interventions; and seven other psychosocial interventions. Delivery involved 1 to 20 (median 11) sessions of traditional face-to-face (41) or other individual formats (four); groups (nine); or involved computer-only interaction (six). Most studies were conducted in the USA (n = 26); two were from South Africa; two from the Democratic Republic of the Congo; with single studies from Australia, Canada, the Netherlands, Spain, Sweden and the UK. Five studies did not disclose a funding source, and all disclosed sources were public funding. Participants were invited from a range of settings: from the community, through the media, from universities and in places where people might seek help for their mental health (e.g. war veterans), in the aftermath of sexual trauma (sexual assault centres and emergency departments) or for problems that accompany the experience of sexual violence (e.g. sexual health/primary care clinics). Participants randomised were 99% women (3965 participants) with just 27 men. Half were Black, African or African-American (1889 participants); 40% White/Caucasian (1530 participants); and 10% represented a range of other ethnic backgrounds (396 participants). The weighted mean age was 35.9 years (standard deviation (SD) 9.6). Eighty-two per cent had experienced rape or sexual assault in adulthood (3260/3992). Twenty-two studies (61%) required fulfilling a measured PTSD diagnostic threshold for inclusion; however, 94% of participants (2239/2370) were reported as having clinically relevant PTSD symptoms at entry. The comparison of psychosocial interventions with inactive controls detected that there may be a beneficial effect at post-treatment favouring psychosocial interventions in reducing PTSD (standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.22 to -0.44; 16 studies, 1130 participants; low-certainty evidence; large effect size based on Cohen's D); and depression (SMD -0.82, 95% CI -1.17 to -0.48; 12 studies, 901 participants; low-certainty evidence; large effect size). Psychosocial interventions, however, may not increase the risk of dropout from treatment compared to controls, with a risk ratio of 0.85 (95% CI 0.51 to 1.44; 5 studies, 242 participants; low-certainty evidence). Seven of the 23 studies (with 801 participants) comparing a psychosocial intervention to an inactive control reported on adverse events, with 21 events indicated. Psychosocial interventions may not increase the risk of adverse events compared to controls, with a risk ratio of 1.92 (95% CI 0.30 to 12.41; 6 studies; 622 participants; very low-certainty evidence). We conducted an assessment of risk of bias using the RoB 2 tool on a total of 49 reported results. A high risk of bias affected 43% of PTSD results; 59% for depression symptoms; 40% for treatment dropout; and one-third for adverse events. The greatest sources of bias were problems with randomisation and missing outcome data. Heterogeneity was also high, ranging from I2 = 30% (adverse events) to I2 = 87% (PTSD).

AUTHORS' CONCLUSIONS

Our review suggests that survivors of rape, sexual violence and sexual abuse during adulthood may experience a large reduction in post-treatment PTSD symptoms and depressive symptoms after experiencing a psychosocial intervention, relative to comparison groups. Psychosocial interventions do not seem to increase dropout from treatment or adverse events/effects compared to controls. However, the number of dropouts and study attrition were generally high, potentially missing harms of exposure to interventions and/or research participation. Also, the differential effects of specific intervention types needs further investigation. We conclude that a range of behavioural and CBT-based interventions may improve the mental health of survivors of rape, sexual assault and sexual abuse in the short term. Therefore, the needs and preferences of individuals must be considered in selecting suitable approaches to therapy and support. The primary outcome in this review focused on the post-treatment period and the question about whether benefits are sustained over time persists. However, attaining such evidence from studies that lack an active comparison may be impractical and even unethical. Thus, we suggest that studies undertake head-to-head comparisons of different intervention types; in particular, of novel, emerging therapies, with one-year plus follow-up periods. Additionally, researchers should focus on the therapeutic benefits and costs for subpopulations such as male survivors and those living with complex PTSD.

Comparison of mental health outcomes of augmenting medications for patients with posttraumatic stress disorder: A national veterans affairs study

RATIONALE

Posttraumatic stress disorder (PTSD) is highly prevalent among veterans. Many veterans with PTSD respond well to serotonin reuptake inhibitors (SRIs). Nonresponders may be prescribed augmenting medications, which are not as well-studied in PTSD.

AIMS AND OBJECTIVES

We used Veterans Health Administration electronic records to compare mental health outcomes (PTSD symptoms and rates of mental health hospitalizations and psychiatric emergency room visits) in patients with PTSD who were prescribed four different groups of augmenting medications (atypical antipsychotics, mirtazapine, prazosin or tricyclic antidepressants) in addition to SRIs-from the year before to the year after the start of the augmenting medication.

METHOD

We included data from 169,982 patients with a diagnosis of PTSD (excluding patients with comorbid bipolar or psychotic disorders) seen in Veterans Affairs care from 2007 to 2015 who were taking an SRI and filled a new prescription for one of the four augmenting medications for at least 60 days.

RESULTS

Patients evidenced minimal (<2%) reduction in PTSD symptoms and a larger reduction in psychiatric hospitalizations and psychiatric emergency room visits after receiving augmenting medications; this effect was largely similar across the four medication groups. Initiating augmenting medications was preceded by increases in PTSD symptoms, psychiatric hospitalizations and psychiatric emergency room visits. After initiating an augmenting medication, PTSD symptoms/hospitalizations/emergency room visits returned to baseline levels (before the start of the augmenting medication), but generally did not improve beyond baseline.

CONCLUSION

Importantly, these effects could be explained by regression to the mean, additional interventions or confounding. These findings should be further explored with placebo controlled randomized clinical trials.

Impact of residential PTSD treatment on suicide risk in veterans

INTRODUCTION

In 2019, 17 veterans died by suicide every day. Various suicide prevention treatments have emerged, yet limited research has explored the impact of Post Traumatic Stress Disorder (PTSD) treatment on suicidal ideation and behaviors.

METHODS

This study examines the impact of Cognitive Processing Therapy (CPT) on suicidal ideation among veterans in three residential PTSD programs (women's, men's, and PTSD/Traumatic Brain Injury). Interview and self-report data were collected from veterans (n = 446) throughout treatment.

RESULTS

Over 50% of veterans reported current suicidal ideation and a history of suicide attempts prior to treatment. Variables that predicted change in suicidal ideation included prior suicide attempt (β = 0.21, p = 0.022), change in CAPS-5 total score (β = 0.28, p = 0.038), employment status (β = -0.20, p = 0.035) and history of suicide attempt (β = 0.25, p = 0.009). Those without a previous suicide attempt made greater gains in CPT treatment than those with a previous suicide attempt.

CONCLUSION

Following 7 weeks of CPT residential treatment, a decrease in PTSD symptoms was significantly associated with a reduction in suicidal ideation. Implications are that CPT can reduce suicide risk in a variety of Veteran cohorts with differing trauma types.

Factor Structure of the Suicide Cognitions Scale in a National Sample of Female Veterans

OBJECTIVE

The Suicide Cognitions Scale (SCS) may be beneficial for suicide risk assessment. However, research has identified diverging factor structures and focused primarily on samples composed of males. Given limited prior research with female veterans, who have experienced increased rates of suicide, we examined the factor structure of the SCS among a national sample of female veterans.

METHOD

Four-hundred thirty-one female veterans using and not using Veterans Health Administration care participated in an anonymous survey.

RESULTS

Exploratory factor analysis identified a three-factor solution, consistent with some prior research. This factor structure was not replicated in a confirmatory factor analysis.

CONCLUSIONS

Findings did not identify a consistent factor structure for the SCS among a sample of female veterans. Research is warranted to determine if suicide-specific cognitions differ among female veterans and to identify SCS items that should be added or removed to produce a more consistent factor structure among female veterans.HighlightsA consistent factor structure of the SCS among female Veterans was not identifiedSuicide-specific cognitions may differ among female VeteransAddition or removal of SCS items may be warranted in this population.

Addressing co-occurring suicidal thoughts and behaviors and posttraumatic stress disorder in evidence-based psychotherapies for adults: A systematic review

Posttraumatic stress disorder (PTSD) is a well-established risk factor for suicidal thoughts and behaviors. Historically, guidelines for treating PTSD have recommended against the use of trauma-focused therapies for patients who are at high risk for suicide, likely due to concerns about potential suicide-related iatrogenesis, specifically the "triggering" of suicidal behaviors. This systematic review examined evidence of the impact of treatments specifically designed to treat PTSD or suicide on both PTSD- and suicide-related outcomes. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a total of 33 articles met the full inclusion criteria: 23 examining PTSD treatments, four examining suicide-focused treatments, and six examining combined treatments. PTSD and combined treatments reduced both PTSD- and suicide-related outcomes, with most studies focusing on cognitive processing therapy or prolonged exposure. Suicide-focused treatments (e.g., cognitive therapies for suicide prevention) also reduced suicide-related outcomes, but the findings were mixed for their impact on PTSD-related outcomes. Overall, PTSD treatments had the most support, primarily due to a larger number of studies examining their outcomes. This supports current clinical guidelines, which suggest utilizing PTSD treatments for individuals who have PTSD and are at risk for suicide. Suicide-focused and combined treatments also appeared to be promising formats, although additional research is needed. Future research should seek to compare the effectiveness of the approaches to the treatment of PTSD and suicidal thoughts and behaviors concurrently as well as to inform guidelines aimed at supporting decisions about the selection of an appropriate treatment approach.

Stress Disorders and the Risk of Nonfatal Suicide Attempts in the Danish Population

Accurate documentation of the associations between stress disorders and suicide attempts provides important information about a high-risk population and target group for preventative interventions. In this case-cohort study, cases were all individuals born or residing in Denmark who made a nonfatal suicide attempt during 1995-2015 (n = 22,974). The comparison subcohort included a 5% random sample of the Danish population on January 1, 1995 (n = 265,183). Stress disorder diagnoses and suicide attempts were identified using ICD-10 codes from national medical registries. The presence of any stress disorder substantially increased the rate of suicide attempts versus the comparison subcohort, rate per 100,000 person-years (PYs) = 604 vs. 13. We observed associations between each type of stress disorder and suicide attempts, hazard ratios (HRs) = 10.1-37.6, even after adjustment for potential confounders, adjusted HRs = 1.8-8.3, with the strongest associations for adjustment disorder relative to other diagnoses. After adjusting for demographic and health variables, the rate of suicide attempts among individuals with any stress disorder diagnosis was nearly 13 times the suicide attempt rate in the comparison cohort. A bias analysis demonstrated that associations remained robust despite potential differential misclassification of suicide attempts. Study strengths included the use of individual-level data linked across administrative and medical registries in the setting of universal health care and the use of longitudinal analyses capturing data over 20 years. The study demonstrated associations between the full range of stress disorders and suicide attempts, extending research specific to posttraumatic stress disorder.

Treating Veterans at Risk for Suicide: An Examination of the Safety, Tolerability, and Outcomes of Cognitive Processing Therapy

Individuals with posttraumatic stress disorder (PTSD) are at increased risk for suicidal thoughts and behaviors; however, clinicians often report apprehension about recommending trauma-focused therapy to patients with an increased risk of suicide. The present study aimed to evaluate the safety, tolerability, and response to cognitive processing therapy (CPT) among a sample of military veterans with PTSD and increased suicide risk. A secondary aim was to provide a clinically useful definition of high suicide risk. Chart review was used to classify the suicide risk level of 290 veterans who participated in CPT at a Veterans Affairs clinic. Treatment outcomes in veterans with different suicide risk levels were also gathered and compared. Over 50% (n = 155) of the sample demonstrated increased suicide risk, and 1.0% (n = 3) engaged in suicidal behavior after initiating treatment. To date, hospital records show no suicide deaths since 2016 among clinic patients who received CPT. Suicide risk level was not associated with CPT tolerability, and PTSD symptom change was equivalent across groups, ps = .085-.976. Veterans across groups reported clinically significant reductions in PTSD symptoms. The tested suicide risk categorization schemes performed similarly in differentiating the odds of CPT completion and PTSD symptom reduction. These results suggest that veterans with PTSD and an increased risk of suicide, including those with previous suicide attempts and current ideation, can tolerate and benefit from CPT. Additional variables must be considered to truly determine the acute and imminent suicide risk that would deem CPT to be contraindicated.

Military sexual trauma and suicidal ideation in VHA-care-seeking OEF/OIF/OND veterans without mental health diagnosis or treatment

Sexual trauma is a suicide risk factor. While military sexual trauma (MST) is frequently associated with suicidal ideation (SI) in women and men veterans who served in recent conflicts, less is known about MST's relationship to SI in veterans who have no documented mental health concerns. Of the 1.1 million post-9/11 veterans enrolled in the Veterans Healthcare Administration (VHA) we examined 41,658 (12.3% women, 87.7% men) without evidence of mental health diagnosis or treatment and who were screened for MST and SI using the standard VHA clinical reminders between 2008 and 2013. Relative risk estimates were generated using separate models for women and men. MST was reported by 27.9% of women and 2.9% of men; SI by 14.7% and 16.5%, respectively. The adjusted relative risk of MST on SI was 1.65 (95% CI 1.35, 2.00) in women, and 1.49 (95% CI 1.26, 1.75) in men. In this sample of veterans without evidence of mental health diagnosis or treatment, MST was associated with a high risk of SI in both genders. Positive MST screening should prompt SI screening and risk management if indicated, and further study of barriers to mental healthcare among MST survivors at risk for suicide is warranted.

More frequent negative social exchanges are associated with higher suicide ideation and risk in men service members/veterans

INTRODUCTION

Suicide is a leading cause of death in military service members/veterans (SM/Vs). Positive social exchanges (e.g., emotional support) buffer against suicide risk but the influence of negative social exchanges (e.g., unwanted advice) is understudied.

METHOD

The current study explored (1) the contributions of positive and negative social exchanges as simultaneous correlates of suicide ideation and risk, (2) whether positive social exchanges mitigated the association of negative social exchanges and suicide ideation and risk, and (3) if facets of social exchanges were uniquely related to suicide ideation and risk. SM/Vs men (N = 508) completed self-report questionnaires.

RESULTS

Roughly 27% endorsed suicide ideation. Between 23.62 and 41.14% reported elevated suicide risk. Adjusted analyses revealed higher negative social exchanges, particularly insensitive behaviors, and lower positive social exchanges were associated with higher suicide ideation and risk. The magnitude of positive and negative social exchanges with suicide ideation or risk was statistically similar. Higher positive social exchanges did not attenuate the association of negative social exchanges and suicide ideation or risk (p > 0.05).

CONCLUSION

Higher negative social exchanges are equally strong correlates of suicide ideation and risk as positive social exchanges. Decreasing insensitive behaviors may reduce suicide ideation and risk in men SM/Vs.

A Factor Analysis of the Suicide Cognitions Scale in Veterans with Military Sexual Trauma-Related Posttraumatic Stress Disorder

The Suicide Cognitions Scale (SCS) assesses suicide-specific cognitions which may drive suicide risk. Nonetheless, prior work has been mixed regarding optimal factor structure. Additionally, this measure has not been validated for use with veterans with military sexual trauma-related posttraumatic stress disorder (MST-related PTSD), a population that is at elevated risk for suicidal self-directed violence (SDV). This study sought to determine the optimal factor structure of the SCS for use with veterans with MST-related PTSD as well as its psychometric properties. An exploratory factor analysis revealed a four-factor structure, including unlovability, unbearability, unsolvability, and negative urgency. The SCS also demonstrated excellent internal consistency and good convergent validity. This study identified a novel factor, negative urgency, which may explain some of the predictive power of the SCS found in previous research. This paper provides initial support for a four-factor structure of the SCS among those with MST-related PTSD. Additional work remains necessary in evaluating the SCS as a tool for detecting risk for future suicidal SDV among veterans with MST-related PTSD.

Interpersonal Violence Throughout the Lifespan: Associations With Suicidal Ideation and Suicide Attempt Among a National Sample of Female Veterans

BACKGROUND

Female veterans experience interpersonal violence (ie, physical and sexual violence) more often than male veterans and nonveteran females. There is limited knowledge of types of interpersonal violence across the lifespan in relation to suicidal ideation and suicide attempt. Prior research has also focused on those accessing the Veterans Health Administration (VHA) care.

OBJECTIVE

This study examined if physical and sexual violence at differing time points (ie, premilitary, during military service) were associated with suicidal ideation and a suicide attempt at subsequent time points. We anticipated that violence would be associated with an increased risk of suicidal ideation and attempt; however, given limited prior research, we were uncertain which types of violence and time points would be associated with risk.

RESEARCH DESIGN

Data from a cross-sectional national survey.

SUBJECTS

A total of 407 female veterans using, formerly using, or who never used VHA care.

MEASURES

Suicidal ideation, suicide attempt, physical violence, and sexual violence were assessed.

RESULTS

Premilitary sexual, but not physical, violence was associated with military suicidal ideation. Both premilitary and military sexual and physical violence were associated with postmilitary suicidal ideation. Premilitary and military sexual, but not physical, violence were associated with a postmilitary suicide attempt. These results were maintained after accounting for VHA use. A significant model for military suicide attempt was not generated.

CONCLUSIONS

Assessment of premilitary and military sexual violence among female veterans is warranted within the context of suicide risk assessment and prevention. Preventing sexual violence among female veterans may be important for preventing suicidal ideation and attempt.

Depression and PTSD-related anhedonia mediate the association of military sexual trauma and suicidal ideation in female service members/veterans

Previous research shows a direct link between military sexual trauma and suicide risk. Little is known about mediators of this association, including posttraumatic stress disorder (PTSD) or depression severity, mental health conditions that are correlated with both suicide risk and military sexual trauma. Moreover, existing studies of military sexual trauma do not distinguish between harassment and assault, resulting in a gap in our knowledge regarding suicide risk as a function of sexual trauma type. We explored whether PTSD symptom clusters and depression mediated the association of military sexual trauma type (none, harassment-only, assault) and suicidal ideation (SI). Female service members/Veterans (n = 1190) completed a demographic inventory, military sexual trauma history and type screening, and PTSD symptom cluster severity, depression severity, and SI measures. Structural equation modeling revealed that the association of military sexual trauma, particularly assault, with SI was mediated by depression severity and PTSD-related anhedonia. Screening for SI among those endorsing a history of military sexual trauma, PTSD-related anhedonia, and depression may help identify those at risk for SI. Therapeutic interventions aimed at reducing PTSD-related anhedonia and depression symptoms may be the most efficient way to mitigate suicide risk in those with histories of assault military sexual trauma.

Meaning in life following deployment sexual trauma: Prediction of posttraumatic stress symptoms, depressive symptoms, and suicidal ideation

Deployment sexual trauma (DST; i.e., sexual harassment or assault during deployment in the military) is associated with physical and mental health consequences, including posttraumatic stress disorder (PTSD), depression, and suicidal ideation (SI). Less attention has been placed on factors that may offer protection from deleterious mental health outcomes following DST. Global meaning in life (i.e., purpose, beliefs, goals, and subjective feelings) has been shown to be a protective factor against PTSD, depression, and SI following combat trauma; however, the extent to which meaning in life may affect outcomes following DST has not been investigated. Cross-sectional associations and Hayes mediation models were examined using baseline interview data from the Survey of Experiences of Returning Veterans sample (SERV; 850 recently returned veterans, 352 women). DST was associated with post-deployment posttraumatic stress symptoms (PTSS), depressive symptoms, and SI severity, and with decreased sense of meaning in life. Further, meaning in life was a significant mediator between DST and each of the three outcomes, even after controlling for demographic variables and combat experiences. The mediation models did not differ by gender. Findings suggest meaning in life may be an important clinical factor, both for the identification of risk and as a point of intervention.

Timing of evidence-based psychotherapy for posttraumatic stress disorder initiation among Iraq and Afghanistan war veterans in the Veterans Health Administration

OBJECTIVE

Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) were widely disseminated to treat posttraumatic stress disorder (PTSD) in the Veterans Health Administration (VHA). However, few Iraq and Afghanistan war veterans (Operation Enduring Freedom [OEF], Operation Iraqi Freedom [OIF], Operation New Dawn [OND]) diagnosed with PTSD have received CPT/PE and many initiate CPT/PE after substantial delay. Veterans who do not initiate CPT/PE or initiate CPT/PE after delay may have poorer treatment outcomes. This study aimed to identify predictors of CPT/PE initiation and timing.

METHODS

Participants included OEF/OIF/OND veterans diagnosed with PTSD who received psychotherapy between 2001 and 2017 in the VHA (n = 265,566). Logistic regression analysis was utilized to predict initiating CPT/PE (vs. no CPT/PE). Multinomial logistic regression analysis was utilized to predict not initiating or initiating delayed CPT/PE versus "early CPT/PE" (< 1 year after first mental health visit). Analyzed predictors included demographic, military, and clinical complexity variables (e.g., comorbidities, reported military sexual trauma [MST] history).

RESULTS

Seventy-Seven percent of veterans did not initiate CPT/PE, with 7.4% initiating early and 15.4% initiating delayed CPT/PE. Reported MST history (odds ratio [OR] = 1.45, 95% CI [1.39, 1.51]) and history of suicidal ideation/attempt (OR = 1.42, 95% CI [1.38, 1.46]) were strong predictors of CPT/PE initiation versus no CPT/PE. Comorbid pain (relative risk ratio [RRR] = 1.35, 95% CI [1.30, 1.42]) and depressive disorders (RRR = 1.37, 95% CI [1.32, 1.43]) were associated with increased likelihood of delayed versus early CPT/PE.

CONCLUSIONS

Most veterans in our study did not initiate CPT/PE. Generally, clinical complexity variables increased likelihood of initiating CPT/PE and initiating CPT/PE more than 1 year after first mental health visit. Additional research is needed to understand whether CPT/PE delay results from receipt of alternative intervention due to clinical complexity variables. (PsycINFO Database Record (c) 2020 APA, all rights reserved).