Barriers to delivering trauma-focused interventions for people with psychosis and post-traumatic stress disorder: A qualitative study of health care professionals' views

Assessing Emergency Department Staff Knowledge, Competency, and Implementation of Pre- and Post-Trauma-Informed Care Training

INTRODUCTION

Trauma-informed care has been posited as a framework for creating ideal and safe environments for patients to participate in treatment. However, there are limited studies that demonstrate the impact of a focused trauma-informed care training on ED staff. We implemented a 4-hour trauma-informed care training in a general emergency department. We aimed to measure changes in knowledge, opinions, self-rated competency, barriers, and recent practices before and after implementing trauma-informed care training. We hypothesized that the training would result in significant self-reported improvement in all domains.

METHODS

We performed a pre/post interventional study with the intervention being a trauma-informed care training adapted for ED clinical care staff. A validated, publicly available survey tool (Center for Pediatric Stress Trauma-Informed Care [TIC] Provider Survey) was used to assess knowledge, opinions, competency, and utilization of and perceived barriers to trauma-informed care. Pre- and post-training surveys were collected. Responses were stratified by role. Continuous variables were compared using analysis of variance; categorical variables compared using Pearson's chi-square.

RESULTS

Participants demonstrated a high level of perceived knowledge and opinions of trauma-informed care before and after training. We observed significant increases in self-reported competence for all ED staff, some increase in utilization of trauma-informed care in recent practice, and significant decreases in perceived barriers to providing trauma-informed care.

DISCUSSION

Trauma-informed care training is an effective means to improving ED staff self-perceived competence and practice of trauma-informed care even among those with high self-perceived knowledge and opinions of trauma-informed care before the training. Future study should explore the patient-level impact of trauma-informed care training, as well as how to continue to reduce barriers to system-wide implementation of trauma-informed care practices.

Prevalence and factors associated with polypharmacy in military and veteran populations: A systematic review and meta-analysis

BACKGROUND

Polypharmacy poses a growing concern in military and veteran populations due to complex health needs arising from service-related injuries and mental health conditions. This systematic review and meta-analysis aims to synthesize existing literature on polypharmacy prevalence, focusing on both general and psychotropic medications in military and veteran populations, and to identify contributing factors.

METHODS

The study protocol adhered to PRISMA guidelines and was registered on PROSPERO. A comprehensive search across PubMed, Embase, Scopus, and Web of Science yielded 19 eligible studies. Two independent reviewers conducted study selection, data extraction, and quality assessment using standardized tools. The primary outcome was prevalence of polypharmacy and secondary outcomes included factors associated with increased polypharmacy risk.

RESULTS

Pooled estimates revealed a high prevalence of psychotropic polypharmacy (36 %, 95 % CI: 23-49 %) and general polypharmacy (49 %, 95 % CI: -26-72 %) among active-duty military personnel and veterans. Heterogeneity was substantial (I2 = 100 %). Subgroup analyses in studies on psychotropic polypharmacy revealed that veterans with PTSD had a higher prevalence of polypharmacy (48 %) than those without PTSD (22 %). No significant differences were found in general and psychotropic polypharmacy prevalence based on medication threshold, mean age, and geographical location. Despite heterogeneity and bias, the study indicates generally high-quality research.

CONCLUSION

The findings emphasize the critical importance of tailored medication management strategies for military and veteran personnel, considering mental health diagnosis like PTSD. Future research should prioritize longitudinal studies to discern long-term implications and develop targeted interventions for optimizing medication use in military and veteran populations.

Qualitative focus group study of interprofessional healthcare providers to inform the development of a virtual psychoeducational training program for the treatment of childhood interpersonal trauma

The shortage of adequately trained healthcare providers (HCPs) able to treat adults who have experienced childhood interpersonal trauma (CIT) is a pressing concern. This study explored HCPs' training needs for a trauma-focused psychoeducational group intervention and the potential barriers and facilitators to accessing such training. Three 1-hour focus group sessions were conducted with HCPs (n = 17) from two urban and one rural community healthcare organization serving diverse populations in Ontario, Canada, including under-housed people, women struggling with mental health and addiction, and LGBTQ+ populations. On average, participants had 2.4 years in their current role and 18.1 years of mental health field experience. Thematic analysis revealed key findings: a strong clinical need for trauma services, accessible training programs, and broadly applicable interventions relevant for diverse populations. Notably, participants emphasized the clinical advantages and increased accessibility of a virtual training programs focused on psychoeducational treatment interventions, particularly within community-based healthcare settings. This study highlights the potential of a virtual psychoeducational training programs for HCPs to address this critical gap in healthcare provision for individual with CIT. It also underscores the need to move beyond training program development and focus on implementation and sustainability of interventions in clinical practice.

Pharmacotherapy for sleep disturbances in post-traumatic stress disorder (PTSD): A network meta-analysis

BACKGROUND

Sleep disturbances are an important symptom dimension of post-traumatic-stress-disorder (PTSD). There is no meta-analytic evidence examining the effects of all types of pharmacotherapy on sleep outcomes among patients with PTSD.

METHODS

Medline/Embase/PsychInfo/CENTRAL/clinicaltrials.gov/ICTRP, reference lists of published reviews and all included studies were searched for Randomised Controlled Trials (RCTs) examining any pharmacotherapy vs. placebo or any other drug among patients with PTSD.

PRIMARY OUTCOMES

total sleep time, nightmares, sleep quality.

SECONDARY OUTCOMES

sleep onset latency, number of nocturnal awakenings, time spent awake following sleep onset, dropouts due to sleep-related adverse-effects, insomnia/somnolence/vivid-dreams as adverse-effects. Pairwise and network meta-analyses were performed.

RESULTS

99 RCTs with 10,481 participants were included. Prazosin may be the most effective treatment for insomnia (SMD = -0.88, 95%CI = [-1.22;-0.54], nightmares (SMD = -0.44, 95%CI = [-0.84;-0.04]) and poor sleep quality (SMD = -0.55, 95%CI = [-1.01;-0.10]). Evidence is scarce and indicates lack of efficacy for SSRIs, Mirtazapine, z-drugs and benzodiazepines, which are widely used in daily practice. Risperidone and Quetiapine carry a high risk of causing somnolence without having a clear therapeutic benefit. Hydroxyzine, Trazodone, Nabilone, Paroxetine and MDMA-assisted psychotherapy may be promising options, but more research is needed.

CONCLUSIONS

Underpowered individual comparisons and very-low to moderate confidence in effect estimates hinder the generalisability of the results. More RCTs, specifically reporting on sleep-related outcomes, are urgently needed.

Two people making sense of a story: narrative exposure therapy as a trauma intervention in early intervention in psychosis

Background: Narrative exposure therapy (NET) is a recommended intervention for people with multiple trauma histories; however, research is lacking into its use with people experiencing psychosis, many of whom report multiple trauma histories.Objective: This study aimed to explore experiences of NET in early intervention in psychosis (EIP) services.Method: Eight clinicians and four experts with lived experience (experts by experience) of psychosis and multiple trauma were interviewed on a single occasion using two versions (clinician and expert by experience) of a semi-structured interview schedule. Data was analysed using thematic analysis.Results: Five overarching themes were generated, relating to fear and avoidance of memories, importance of trust, organizing memories and making new meaning, reconnecting with emotions, and considerations when delivering NET in EIP.Conclusions: Directly addressing the impact of multiple trauma in people experiencing first episode psychosis is frightening and emotive, but helps to address painful memories and organize them into a personal narrative. Increases in distress and anomalous experiences were carefully considered by clinicians, but typically outweighed by the benefits of NET. Challenges were comparable to those described in non-psychosis research. Implications for clinical practice and future research are outlined.

Sympathetic nerve blocks for posttraumatic stress disorder: an evidentiary review for future clinical trials

Posttraumatic stress disorder (PTSD) is a chronic disorder resulting from exposure to traumatic events. In recent years, sympathetic nerve blocks have gained interest as an emerging treatment modality for PTSD. They have been shown to reduce autonomic dysfunction associated with PTSD symptoms, particularly in refractory and treatment-resistant patients. However, there is limited evidence regarding the technique's effectiveness in PTSD patients. Therefore, this scoping review was designed to update and summarize the current literature on this topic to inform the design of future clinical trials and studies. Our review of 22 studies (mostly case reports and series) included 1,293 PTSD patients who received sympathetic nerve blocks, primarily military service members and veterans, with a median age of 42.2 years. 0.5% Ropivacaine was the preferred anesthetic, and the right sided stellate ganglion block was the most commonly used technique. Relapse of symptoms was reported commonly, resulting in additional nerve block sessions. Most reported side effects were mild and transient. Despite the encouraging results, we remain cautious in interpreting the benefit of the technique due to the lack of sufficient standardized clinical trial data, heterogeneity in reported results, and the potential for bias in reporting. Future studies should focus on evaluating and addressing the technique's effectiveness, safety, tolerability, and indications.

Trauma and Trauma-Informed Care in Early Intervention in Psychosis: State of Implementation and Provider Views on Challenges

OBJECTIVE

Although trauma is increasingly recognized as a major risk factor for psychosis and for its link to treatment outcomes, the landscape of trauma-related practices in specialized early psychosis services in the United States and other countries remains only poorly characterized. Research documenting the perspectives of frontline providers is also lacking. The primary goals of this study were to document the state of trauma-related policy implementation in early intervention in psychosis (EIP) programs and to gather provider perspectives.

METHODS

This was a mixed-methods project involving an international EIP provider survey, followed by in-depth provider interviews. The survey was disseminated in Australia, Canada, Chile, the United Kingdom, and the United States. In total, 164 providers, representing 110 unique sites, completed the survey. Frequencies were calculated for responses to survey items, and open-ended responses were analyzed with a systematic content analysis.

RESULTS

The survey findings suggested low implementation rates for a variety of assessment and support practices related to trauma and trauma-informed care. Coding of open-ended responses revealed numerous concerns and uncertainties among providers regarding the relationship between trauma and psychosis and the state of the EIP field.

CONCLUSIONS

An expansion of research and service development aimed at better meeting the trauma-related needs of young people with psychosis is essential, with implications for EIP outcomes and service user and staff experiences.

Self-stigmatization of high-school students seeking professional psychological help: the chain-mediating effect of perceived social support and optimism

Background

Research has shown that stigmatization of professional psychological help-seeking is an important factor influencing attitudes toward seeking professional psychological help (ATSPPH). However, how perceived social support (PSS) and optimism have a mediating role is not clear.

Objective

Examine the associations between ATSPPH, self-stigmatization of seeking help, PSS, and optimism in a cohort of Chinese high-school students (HSSs).

Methods

An offline survey was conducted in three high schools in Chongqing (China) from 20 February to 20 May 2023. Participants were HSSs recruited through their teachers. A total of 2,159 HSSs completed a survey on demographic information as well as the Self-Stigmatization of Seeking Help (SSOSH) score, ATSPPH, Perceived Social Support Scale (PASS), and Life Orientation Test (LOT). Mediation analyses were conducted using the "Process" macro in SPSS 26.0 to estimate the direct and indirect effects of self-stigmatization of seeking psychological help on ATSPPH.

Results

Self-stigmatization of seeking psychological help was significantly and negatively related to ATSPPH among HSSs. Self-stigmatization of psychological help-seeking influenced ATSPPH through three pathways: (a) separate mediating effect of PSS (effect = -0.029); (b) separate mediating effect of optimism (effect = -0.069); (c) chain-mediating effect of PSS and optimism (effect = -0.017). These data suggested that self-stigmatization of psychological help-seeking could influence ATSPPH directly and indirectly through PSS and optimism.

Conclusion

PSS and optimism mediated the relationship between self-stigmatization of seeking help and ATSPPH. Improving the ability of HSSs to perceive social support and cultivating optimism could help improve the self-stigmatization of help-seeking and promote a positive attitude toward professional help-seeking.

Making meaning of trauma in psychosis

Background

Finding new meaning and identity in the aftermath of trauma has been identified as a key process of mental health recovery. However, research indicates that this meaning-making process is compromised in people with psychosis. Considering the high prevalence, yet under-treatment of trauma in people with psychosis, it is urgent to gain insight into how their meaning-making process can be supported.

Aim

To gain insight into how people with psychosis make meaning of trauma and identify barriers and facilitators in their meaning-making process.

Methods

Qualitative inquiry of N = 21 interviews transcripts from the Dutch Psychiatry Storybank. We included interviews of people who (a) lived through multiple psychotic episodes, and (b) spontaneously addressed traumatic experiences in a low-structured interview. Storyline analysis was performed to gain insight into the meaning-making of trauma within their self-stories. Psychosocial conceptualizations of narrative identity were used to inform the analysis. A data-validation session with four experts-by-experience was organized to check and improve the quality of our analysis.

Results

We identified four different story types: (1) Psychiatry as the wrong setting to find meaning; (2) The ongoing struggle to get trauma-therapy; (3) Exposure to trauma as a threat to a stable life, and (4) Disclosure as the key to resolving alienation. Each story type comprises a different plot, meaning of trauma withing the self-story, (lack of) integration and barriers and facilitators in the meaning-making process. Overall, barriers in the meaning-making process were mostly situated within mental healthcare and stigma-related. People felt particularly hindered by pessimistic ideas on their capacity to develop self-insight and cope with distress, resulting in limited treatment options. Their process of adaptive meaning-making often started with supportive, non-judgmental relationships with individuals or communities that offered them the safety to disclose trauma and motivated them to engage in a process of self-inquiry and growth.

Conclusion

The outcomes illuminate the social context of the meaning-making challenges that people with psychosis face and illustrate the devastating influence of stigma. Our outcomes offer guidance to remove barriers to adaptive meaning-making in people with psychosis, and can help clinicians to attune to differences in the meaning-making of trauma.

Trauma measures for use with psychosis populations: A systematic review of psychometric properties using COSMIN

Traumatic events play a key role in the development and course of psychosis. Psychotic symptoms themselves and coercive treatment practices can be inherently traumatic. Hence, reliable and valid methods of assessing trauma and its impact (i.e., Post-Traumatic Stress Disorder (PTSD) symptomology) are essential for use with people with psychosis. Many measures are available to select from, but this is the first review to appraise the psychometric properties of trauma measures to guide decision making regarding instrument use. The review was prospectively registered on Prospero (CRD42022306100). Evaluation of methodological and psychometric quality followed Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidance. Twenty-four articles were eligible, with sixteen trauma measures evaluated. Childhood Trauma Questionnaire- Short Form demonstrated the most robust evidence for assessing experience of trauma. The Trauma and Life Experience (TALE) checklist was the only measure to include specific psychosis and iatrogenic harm items. For PTSD measures, the Symptoms of Trauma Scale and PTSD Symptom Scale- Self Report had the highest quality evidence. Psychometric strengths and weaknesses of various trauma measures are comprehensively evaluated, highlighting future research directions to strengthen the evidence base with emphasis on further evaluation of the TALE, which integrates trauma specific to psychosis.

The bumpy road of trauma-focused treatment: Posttraumatic stress disorder symptom exacerbation in people with psychosis

Concern for symptom exacerbation and treatment drop-out is an important barrier to the implementation of trauma-focused therapy (TFT), especially in people with a psychotic disorder. This study, which was part of a multicenter randomized controlled trial, investigated posttraumatic stress disorder (PTSD) symptom exacerbation during eye movement desensitization reprocessing (EMDR) therapy and prolonged exposure (PE) in a sample of 99 participants with PTSD and psychosis. Symptom exacerbations during the first four sessions (early exacerbation) and between-session exacerbations over the course of therapy were monitored using the PTSD Symptom Scale-Self Report. Analyses of covariance and chi-square tests were conducted to investigate exacerbation rates and their associations with treatment response and drop-out. Both early exacerbation and between-session exacerbation were relatively common (32.3% and 46.5%, respectively) but were unrelated to poor treatment response or an increased likelihood of treatment drop-out. Both clinicians and patients need to be aware that symptom exacerbation during TFT is common and not related to poor outcomes. Symptom exacerbation can be part of the therapeutic process, should be acknowledged and guided, and should not be a barrier to the implementation of TFT in people with psychosis.

Barriers to delivering trauma-focused interventions for people with psychosis and post-traumatic stress disorder: A qualitative study of health care professionals' views

OBJECTIVES

Trauma-focused interventions have been shown to be effective treatments for post-traumatic stress disorder (PTSD), and clinical guidelines support their use with people with psychosis. Despite this, they are used relatively infrequently in this population. We sought to explore UK health care professionals' perceptions of what impedes or facilitates the use of trauma-focused interventions among people with psychosis and PTSD.

DESIGN

A qualitative study using constructivist grounded theory methodology.

METHODS

We conducted semi-structured interviews with 18 health care professionals working within the commissioning and delivery of clinical services for people with psychosis.

RESULTS

Three inter-related barriers to the use of trauma-focused interventions were conceptualized: coherent understanding; structural support; and safe space.

CONCLUSIONS

Delivery of trauma-focused interventions within routine clinical practice may be supported by attention to the coherent integration of discussion of trauma into the clinical discourse of services; the processes, pathways, and organizational culture that facilitate access to treatment; and training that targets clinician confidence and skills.

"It hurt but it helped": A mixed methods audit of the implementation of trauma- focused cognitive-behavioral therapy for psychosis

BACKGROUND

Emerging evidence supports the safety, acceptability, and efficacy of trauma therapies for people experiencing post-traumatic stress and psychosis, despite common concerns about iatrogenic harm when processing trauma memories for this population. However, to date there have been no mixed-method studies examining whether trauma-focused therapy can be implemented in routine care. This study reports an audit of a post-traumatic stress in psychosis clinic based in an inner-city trust in the U.K. National Health Service.

MATERIALS AND METHODS

People under the care of psychosis community mental health teams with a significant history of past trauma were referred to the clinic by their multidisciplinary clinicians. Referral outcomes were recorded, including the proportion of people for whom trauma-focused cognitive-behavior therapy for psychosis was indicated. Post-traumatic stress symptoms were assessed pre- and post-therapy for clinically significant change on the Post-traumatic Stress Checklist (version 4) and Post-traumatic Stress Checklist (version 5). A subgroup of service users was also interviewed about their experience of therapy, with transcripts analyzed using inductive thematic analysis.

RESULTS

Seventy one service-users were referred to the clinic between 2014 and 2018, of which 51 (71.8%) attended an assessment. Of these, 20 (39.2%) were identified as having clinically significant PTSD symptoms with re-experiencing and were offered trauma-focused cognitive-behavior therapy for psychosis. Sixteen (80%) accepted and completed therapy, with no dropouts, and received a mean of 17.54 sessions (SD = 17.60, range = 12-91). There were no serious adverse events related to therapy. Clinically significant change was observed in 68.8% (n = 11) of the therapy group and post-therapy six people (37.5%) no longer met the threshold for clinically significant PTSD. Six service users completed an interview about their therapy experiences with findings organized within four main themes and associated subthemes: (1) Perseverance, (2) Establishing safety, (3) The challenges of therapy, and (4) Rebuilding one's life after trauma.

CONCLUSION

Trauma-focused cognitive-behavior therapy for psychosis can be safe, acceptable, and effective when implemented in routine care. Lived experience perspectives highlight the emotional demands of therapy and long-term impact of trauma, thus underscoring the necessity of sufficient support and continuity of care both during and after therapy.