1
|
Gausemel Å, Filkuková P. Virtual realities, real recoveries: exploring the efficacy of 3MDR therapy for treatment-resistant PTSD. Front Psychol 2024; 15:1291961. [PMID: 38813557 PMCID: PMC11135474 DOI: 10.3389/fpsyg.2024.1291961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 04/16/2024] [Indexed: 05/31/2024] Open
Abstract
Exposure-based therapies have shown promise in treating post-traumatic stress disorder (PTSD), but challenges exist in maintaining patient engagement and finding appropriate stimuli for graded exposure. Virtual reality (VR) technology has been used to enhance exposure therapy, but current software lacks customization and some patients remain treatment-resistant. A novel approach called multimodular motion-assisted memory desensitization and reconsolidation (3MDR) has the potential to solve some of the current limitations of VR-assisted exposure therapy. This study examines the efficacy of 3MDR treatment for individuals with treatment-resistant PTSD through a systematic review of relevant literature and clinical studies. Preliminary findings indicate promise for 3MDR in reducing PTSD symptoms, including emotional regulation and moral injury. However, further research with larger samples and controlled studies is needed to understand underlying mechanisms and validate these results. Moreover, this study highlights the importance of health-economic evaluations to assess costs and resource utilization associated with implementing 3MDR treatment in clinical services.
Collapse
Affiliation(s)
- Åsmund Gausemel
- Department of Psychology, Inland Norway University of Applied Sciences, Lillehammer, Norway
| | - Petra Filkuková
- Department of Psychology, Inland Norway University of Applied Sciences, Lillehammer, Norway
- Department of High Performance Computing, Simula Research Laboratory, Oslo, Norway
| |
Collapse
|
2
|
Burback L, Yap S, Purdon SE, Abba-Aji A, O’Shea K, Brémault-Phillips S, Greenshaw AJ, Winkler O. Randomized controlled trial investigating web-based, therapist delivered eye movement desensitization and reprocessing for adults with suicidal ideation. Front Psychiatry 2024; 15:1361086. [PMID: 38435978 PMCID: PMC10904458 DOI: 10.3389/fpsyt.2024.1361086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
Introduction Promising preliminary evidence suggests that EMDR may reduce suicidal ideation (SI) when used to treat Major Depressive Disorder, Posttraumatic Stress Disorder, and trauma symptoms in the context of acute mental health crises. EMDR has never been tested specifically for treating SI, and there is a lack of data regarding the safety and effectiveness of web-based, therapist-delivered EMDR in populations with known SI. The primary objective of this study was to investigate the impact of web-based, therapist-delivered EMDR, targeting experiences associated with suicidal thinking. Secondary objectives included examining the effect of EMDR treatment on symptoms of depression, anxiety, posttraumatic stress, emotional dysregulation, and dissociation, as well as safety and attrition. Methods This randomized control trial (ClinicalTrials.gov ID number: NCT04181047) assigned adult outpatients reporting SI to either a web-based EMDR intervention or a treatment as usual (TAU) group. TAU included primary and mental health services available within the Canadian public health system. Participants in the EMDR group received up to 12 web-based EMDR desensitization sessions, delivered twice weekly during the COVID-19 pandemic (2021-2023). The Health Research Ethics Board at the University of Alberta approved the protocol prior to initiation of data collection for this study (protocol ID number: Pro00090989). Results Forty-two adult outpatients received either EMDR (n=20) or TAU (n=22). Participants reported a high prevalence of early onset and chronic SI, and there was a high rate of psychiatric comorbidity. In the EMDR group, median SI, depression, anxiety, and posttraumatic symptom scale scores decreased from baseline to the four month follow-up. In the TAU group, only the median SI and posttraumatic symptom scale scores decreased from baseline to four month follow up. Although sample size precludes direct comparison, there were numerically fewer adverse events and fewer dropouts in the EMDR group relative to the TAU group. Conclusion Study results provide promising preliminary evidence that web-based EMDR may be a viable delivery approach to address SI. In this complex population, a short treatment course was associated with reductions of SI and other symptoms across multiple diagnostic categories. Further investigation is warranted to verify and extend these results. Clinical Trial Registration https://clinicaltrials.gov/study/NCT04181047?id=NCT04181047&rank=1, identifier NCT04181047.
Collapse
Affiliation(s)
- Lisa Burback
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Hospital Edmonton, Edmonton, AB, Canada
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Edmonton, AB, Canada
| | - Sidney Yap
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Scot E. Purdon
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Adam Abba-Aji
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Hospital Edmonton, Edmonton, AB, Canada
| | - Katie O’Shea
- Eye Movement Desensitization and Reprocessing International Association, Austin, TX, United States
| | - Suzette Brémault-Phillips
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Edmonton, AB, Canada
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Andrew J. Greenshaw
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Olga Winkler
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Hospital Edmonton, Edmonton, AB, Canada
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Edmonton, AB, Canada
| |
Collapse
|
3
|
Andersen NJ, Schwartzman D, Martinez C, Cormier G, Drapeau M. Virtual reality interventions for the treatment of anxiety disorders: A scoping review. J Behav Ther Exp Psychiatry 2023; 81:101851. [PMID: 36947972 DOI: 10.1016/j.jbtep.2023.101851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 11/13/2022] [Accepted: 02/21/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND & Objectives: Virtual Reality (VR) refers to an artificial, immersive three-dimensional environment with interactive sensory stimuli. VR is typically incorporated into the psychotherapeutic process as a means of providing exposure therapy. The objectives of this scoping review were to synthesize the most up-to-date evidence on the outcomes, acceptability, and side effects of VR interventions for treating anxiety disorders in adults. METHODS This scoping review is grounded in the methodological framework of Arksey and O'Malley (2005). The databases searched were PubMed, EMBASE, Web of Science, PsycINFO, and ProQuest Dissertations and Theses. RESULTS The search process identified 112 unique citations. 52 (46%) of the eligible articles examined participants with specific phobias, 25 (22%) with PTSD, 21 (19%) with social anxiety disorder, 12 (10%) with panic disorder with or without agoraphobia, and 3 (3%) with generalized anxiety disorder. VR interventions often led to statistically significant and meaningful reductions in symptoms for people with anxiety disorders. Additionally, they were acceptable to clients and associated with minimal side effects for all types of anxiety disorders, except for Combat-Related PTSD in Vietnam veterans. LIMITATIONS Limitations included the fact that the studies in this review were of varying quality, and that articles in languages other than English and French were excluded. CONCLUSION VR interventions appeared to be a viable alternative to conventional exposure therapy. Future research should include more male participants and have a stronger emphasis on acceptability and side effects. Increased traction for VR interventions for generalized anxiety disorder and panic disorder is also important.
Collapse
Affiliation(s)
- Nicole J Andersen
- Department of Counselling Psychology, McGill University, Montréal, Québec, Canada
| | - Deborah Schwartzman
- Department of Counselling Psychology, McGill University, Montréal, Québec, Canada
| | - Carolina Martinez
- Department of Counselling Psychology, McGill University, Montréal, Québec, Canada
| | - Gina Cormier
- Department of Counselling Psychology, McGill University, Montréal, Québec, Canada
| | - Martin Drapeau
- Department of Counselling Psychology, McGill University, Montréal, Québec, Canada; Department of Psychiatry, McGill University, Montréal, Québec, Canada.
| |
Collapse
|
4
|
Hoekstra M, van Veelen N, van Leeuwen J, Nijdam MJ, Vermetten E. 3MDR treatment in an adolescent with PTSD: a case report. Eur J Psychotraumatol 2023; 14:2272487. [PMID: 37902263 PMCID: PMC10763824 DOI: 10.1080/20008066.2023.2272487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 05/29/2023] [Indexed: 10/31/2023] Open
Abstract
Background: As Posttraumatic stress disorder (PTSD) in adolescents significantly impacts their well-being, effective treatment is of great importance. Little is known, however, about the novel, multi-modal virtual reality supported, exposure-based psychotherapeutic interventions such as 3MDR in this population.Objective: To describe the 3MDR treatment of an adolescent with PTSD who did not respond to previous exposure-based PTSD interventions.Method: A 14-year-old girl diagnosed with PTSD received six sessions of 3MDR embedded in family therapy.Result: The patient tolerated the 3MDR intervention very well. Personalized music and self-selected pictures appeared to be a good fit, contributing to enhanced engagement in and adherence to the therapy. She no longer met criteria for PTSD post-intervention, and at 18 months follow-up.Conclusion: This case report suggests that 3MDR has potential as a trauma treatment for adolescents with treatment-resistant PTSD.
Collapse
Affiliation(s)
- Mariëlle Hoekstra
- ARQ Centrum’ 45, Oegstgeest, the Netherlands
- Mental Health Caribbean, Bonaire, the Netherlands
| | - Nancy van Veelen
- Department Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Mirjam J. Nijdam
- ARQ Centrum’ 45, Oegstgeest, the Netherlands
- Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Eric Vermetten
- Department Psychiatry, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
5
|
Hannigan B, van Deursen R, Barawi K, Kitchiner N, Bisson JI. Factors associated with the outcomes of a novel virtual reality therapy for military veterans with PTSD: Theory development using a mixed methods analysis. PLoS One 2023; 18:e0285763. [PMID: 37228076 DOI: 10.1371/journal.pone.0285763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 05/01/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Multi-modular motion-assisted memory desensitization and reconsolidation therapy (3MDR) is a new psychological intervention for people with post-traumatic stress disorder (PTSD). 3MDR is immersive, delivered in a virtual reality environment, and emphasises engagement, recollection and reprocessing. OBJECTIVE Through a theory-driven examination of data relating to 10 out of 42 UK military veterans taking part in a trial of 3MDR, the principal objective was to explore the complex interrelationships between people, interventions and context and to investigate how factors within these domains interacted in specific outcome typologies. METHOD Quantitative and qualitative data relating to 10 trial participants were derived from: researcher-assessed and self-report clinical measures; interviews; physiological recordings; words describing thoughts and feelings during therapy; and subjective unit of distress scores. Using a convergent mixed methods approach, data were tabulated using a person, intervention and context model. Participant summaries were grouped into outcome typologies, followed by an analysis of data convergence and divergence within each and an interpretation of identified patterns. RESULTS Three outcome response typologies were identified: dramatic improvement, moderate improvement and minimal improvement. Within the person domain, factors associated with outcomes included walking capacity, commitment and ability to complete therapy, and levels of subjective distress. Within the intervention domain, factors associated with outcomes related to image selection and use, therapeutic alliance and orientations towards the tailoring of sessions. Within the context domain, factors associated with outcomes included reactions to the therapy environment. The patterning of secondary outcomes broadly corresponded with primary outcomes within each typology. Alongside patterned data differentiating aspects of the person, intervention and context domains, within the three response typologies data also existed where no obvious patterning was detected. CONCLUSIONS The model developed here may have novel value in evaluating a range of personalised interventions, but further work is needed before confident assertions can be made of who is likely to benefit from 3MDR specifically.
Collapse
Affiliation(s)
- Ben Hannigan
- School of Healthcare Sciences, Cardiff University, Cardiff, United Kingdom
| | - Robert van Deursen
- School of Healthcare Sciences, Cardiff University, Cardiff, United Kingdom
| | - Kali Barawi
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Neil Kitchiner
- School of Medicine, Cardiff University, Cardiff, United Kingdom
- Veterans' NHS Wales, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | | |
Collapse
|
6
|
Smith-MacDonald L, Jones C, Brown MRG, Dunleavy RS, VanderLaan A, Kaneva Z, Hamilton T, Burback L, Vermetten E, Brémault-Phillips S. Moving Forward from Moral Injury: A Mixed Methods Study Investigating the Use of 3MDR for Treatment-Resistant PTSD. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5415. [PMID: 37048029 PMCID: PMC10094650 DOI: 10.3390/ijerph20075415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/05/2023] [Accepted: 03/10/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Exposure to trauma and potentially morally injurious events may lead to moral injury (MI). The link between MI and posttraumatic stress disorder (PTSD) may have particularly relevant implications for treatment-resistant PTSD (TR-PTSD). Multi-modal Motion-Assisted Memory Desensitization and Reconsolidation (3MDR), a technology-assisted exposure-based trauma therapy that has been used in the treatment of PTSD, may also be an acceptable modality for patients in the treatment of TR-PTSD and MI. This proof-of-concept study aimed to investigate (1) whether MI co-occurs in military members (MMs) and veterans with TR-PTSD, and (2) the perspectives of MMs and veterans with TR-PTSD utilizing 3MDR for MI. METHODS This study employed a mixed-methods clinical trial. Military Members and veterans participated in this study (N = 11) through self-reported questionnaires, video recordings of treatment sessions, and semi-structured interviews post-session and post-intervention, with longitudinal follow-up to 6 months. RESULTS MI scores correlated with self-reported measures of mental health symptoms related to PTSD. The thematic analysis revealed three emergent themes: (1) Realities of War, (2) Wrestling Scruples, and (3) Moral Sensemaking. CONCLUSION MI was highly correlated with TR-PTSD and themes regarding MI. This result, while preliminary, allows for the postulation that MI may be contributing to the continuation of PTSD symptoms in TR-PTSD, and that 3MDR may be an acceptable modality for addressing these symptoms in MMs and veterans.
Collapse
Affiliation(s)
- Lorraine Smith-MacDonald
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada
- St. Stephen’s College, Edmonton, AB T6G 2J6, Canada
| | - Chelsea Jones
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Alberta Health Services, Edmonton, AB T5J 3E4, Canada
| | - Matthew R. G. Brown
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Department of Computing Science, University of Alberta, Edmonton, AB T6G 2S4, Canada
| | | | - Annelies VanderLaan
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada
| | - Zornitsa Kaneva
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada
| | - Tristin Hamilton
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Alberta Health Services, Edmonton, AB T5J 3E4, Canada
| | - Lisa Burback
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Department of Psychiatry, University of Alberta, Edmonton, AB T6G 2B7, Canada
| | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Centre, Leiden University, 2333 ZA Leiden, The Netherlands
| | - Suzette Brémault-Phillips
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada
| |
Collapse
|
7
|
Nijdam MJ, Vermetten E, McFarlane AC. Toward staging differentiation for posttraumatic stress disorder treatment. Acta Psychiatr Scand 2023; 147:65-80. [PMID: 36367112 PMCID: PMC10100486 DOI: 10.1111/acps.13520] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Several medical and psychiatric disorders have stage-based treatment decision-making methods. However, international treatment guidelines for posttraumatic stress disorder (PTSD) fail to give specific treatment recommendations based on chronicity or stage of the disorder. There is convincing evidence of a finite range of PTSD symptom trajectories, implying that different phenotypes of the disorder can be distinguished, which are highly relevant for a staging typology of PTSD. METHODS State-of-the-art review building on prior work on staging models in other disorders as a mapping tool to identify and synthesize toward PTSD. RESULTS We propose a four-stage model of PTSD ranging from stage 0: trauma-exposed asymptomatic but at risk to stage 4: severe unremitting illness of increasing chronicity. We favor a symptom description in various chronological characteristics based on neurobiological markers, information processing systems, stress reactivity, and consciousness dimensions. We also advocate for a separate phenomenology of treatment resistance since this can yield treatment recommendations. CONCLUSION A staging perspective in the field of PTSD is highly needed. This can facilitate the selection of interventions that are proportionate to patients' current needs and risk of illness progression and can also contribute to an efficient framework to organize biomarker data and guide service delivery. Therefore, we propose that a neurobiologically driven trajectory-based typology of PTSD can help deduct several treatment recommendations leading to a more personalized and refined grid to strategize, plan and evaluate treatment interventions.
Collapse
Affiliation(s)
- Mirjam J Nijdam
- Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,ARQ National Psychotrauma Center, Diemen, The Netherlands
| | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexander C McFarlane
- Discipline of Psychiatry, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
8
|
Wiebe A, Kannen K, Selaskowski B, Mehren A, Thöne AK, Pramme L, Blumenthal N, Li M, Asché L, Jonas S, Bey K, Schulze M, Steffens M, Pensel MC, Guth M, Rohlfsen F, Ekhlas M, Lügering H, Fileccia H, Pakos J, Lux S, Philipsen A, Braun N. Virtual reality in the diagnostic and therapy for mental disorders: A systematic review. Clin Psychol Rev 2022; 98:102213. [PMID: 36356351 DOI: 10.1016/j.cpr.2022.102213] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 08/21/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders. OBJECTIVE To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders. DATA SOURCE Systematic literature searches via PubMed (last literature update: 9th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders. ELIGIBILITY CRITERIA To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology. STUDY EVALUATION For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria. RESULTS Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder. CONCLUSION While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application. REVIEW REGISTRATION PROSPERO register CRD42020188436. FUNDING The review was funded by budgets from the University of Bonn. No third party funding was involved.
Collapse
Affiliation(s)
- Annika Wiebe
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Kyra Kannen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Benjamin Selaskowski
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Aylin Mehren
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Ann-Kathrin Thöne
- School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lisa Pramme
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Nike Blumenthal
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Mengtong Li
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Laura Asché
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Stephan Jonas
- Institute for Digital Medicine, University Hospital Bonn, Bonn, Germany
| | - Katharina Bey
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Marcel Schulze
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Maria Steffens
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Max Christian Pensel
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Matthias Guth
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Felicia Rohlfsen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Mogda Ekhlas
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Helena Lügering
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Helena Fileccia
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Julian Pakos
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Silke Lux
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Niclas Braun
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany.
| |
Collapse
|
9
|
Jones C, Smith-MacDonald L, Brown MRG, Pike A, Vermetten E, Brémault-Phillips S. Quantitative changes in mental health measures with 3MDR treatment for Canadian military members and veterans. Brain Behav 2022; 12:e2694. [PMID: 35849703 PMCID: PMC9392526 DOI: 10.1002/brb3.2694] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/05/2022] [Accepted: 06/23/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Military members and veterans are at elevated risk of treatment-resistant posttraumatic stress disorder (TR-PTSD) due to higher rates of exposure to potentially traumatic events during the course of duty. Knowledge of TR-PTSD is limited, and specific protocols or evidence-based TR-PTSD therapies are lacking. Multimodal motion-assisted memory desensitization and reconsolidation (3MDR) therapy is an emerging intervention for combat-related TR-PTSD. The purpose of this study was to preliminarily assess the effectiveness of 3MDR in addressing TR-PTSD in Canadian military members and veterans. METHODS This study is a longitudinal mixed-methods clinical trial. English-speaking military members and veterans aged 18-60 with TR-PTSD were recruited to participate. The intervention consisted of six sessions of 3MDR therapy. Quantitative data were collected pretreatment, posttreatment, and longitudinally at 1, 3, and 6 months after completion of 3MDR. RESULTS Results from the first 11 participants to complete the 3MDR protocol exhibited statistically significant improvement (surviving multiple comparison correction) in clinically administered and self-reported scores for PTSD (CAPS-5 and PCL-5), moral injury (MISS-M-SF), depression (PHQ-9), anxiety (GAD-7), emotional regulation (DERS-18), and resilience (CD-RS-25). CONCLUSION The preliminary and exploratory results from this clinical trial support the growing body of literature illustrating 3MDR as an effective treatment for military-related TR-PTSD. These results are notable given participants' previous lack of success with frontline psychotherapeutic and pharmacological interventions. Given that there are currently very limited treatment options for TR-PTSD, 3MDR could prove to be a valuable treatment option for military members and veterans with TR-PTSD.
Collapse
Affiliation(s)
- Chelsea Jones
- Leiden University Medical Centre, Leiden University, Leiden, the Netherlands.,Alberta Health Services, Edmonton, Ottawa, Canada.,Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Lorraine Smith-MacDonald
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | | | - Ashley Pike
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Eric Vermetten
- Leiden University Medical Centre, Leiden University, Leiden, the Netherlands.,ARQ National Psychotrauma Center, Diemen, the Netherlands.,Military Mental Health Service, Dutch Ministry of Defence, Utrecht, the Netherlands
| | - Suzette Brémault-Phillips
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| |
Collapse
|
10
|
Jones C, Smith-MacDonald L, Brown MRG, VanDehy J, Grunnet-Jepsen R, Ordek VP, Kruger S, Ayres Gerhart A, van Veelen N, Nijdam MJ, Burback L, Cao B, Roy MJ, Sessoms P, Vermetten E, Brémault-Phillips S. The Redesign and Validation of Multimodal Motion-Assisted Memory Desensitization and Reconsolidation Hardware and Software: Mixed Methods, Modified Delphi-Based Validation Study. JMIR Hum Factors 2022; 9:e33682. [PMID: 35819834 PMCID: PMC9328788 DOI: 10.2196/33682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 05/06/2022] [Accepted: 05/14/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In recent years, the delivery of evidence-based therapies targeting posttraumatic stress disorder (PTSD) has been the focus of the Departments of Defense in countries such as Canada, the Netherlands, and the United States. More than 66% of military members continue to experience symptoms of PTSD that significantly impact their daily functioning and quality of life after completing evidence-based treatments. Innovative, engaging, and effective treatments for PTSD are needed. Multimodal motion-assisted memory desensitization and reconsolidation (3MDR) is an exposure-based, virtual reality-supported therapy used to treat military members and veterans with treatment-resistant PTSD. Given the demonstrated efficacy of 3MDR in recently published randomized control trials, there is both an interest in and a need to adapt the intervention to other populations affected by trauma and to improve accessibility to the treatment. OBJECTIVE We aimed to further innovate, develop, and validate new and existing hardware and software components of 3MDR to enhance its mobility, accessibility, feasibility, and applicability to other populations affected by trauma, including public safety personnel (PSP), via international collaboration. METHODS This study used a modified Delphi expert consultation method and mixed methods quasi-experimental validation with the purpose of software validation among PSP (first responders, health care providers) participants (N=35). A team of international experts from the Netherlands, the United States, and Canada met on the web on a weekly basis since September 2020 to discuss the adoption of 3MDR in real-world contexts, hardware and software development, and software validation. The evolution of 3MDR hardware and software was undertaken followed by a mixed methods software validation study with triangulation of results to inform the further development of 3MDR. RESULTS This study resulted in the identification, description, and evolution of hardware and software components and the development of new 3MDR software. Within the software validation, PSP participants widely acknowledged that the newly developed 3MDR software would be applicable and feasible for PSP affected by trauma within their professions. The key themes that emerged from the thematic analysis among the PSP included the desire for occupationally tailored environments, individually tailored immersion, and the applicability of 3MDR beyond military populations. CONCLUSIONS Within the modified Delphi consultation and software validation study, support for 3MDR as an intervention was communicated. PSP participants perceived that 3MDR was relevant for populations affected by trauma beyond military members and veterans. The resulting hardware and software evolution addressed the recommendations and themes that arose from PSP participants. 3MDR is a novel, structured, exposure-based, virtual reality-supported therapy that is currently used to treat military members and veterans with PTSD. Going forward, it is necessary to innovate and adapt 3MDR, as well as other trauma interventions, to increase effectiveness, accessibility, cost-effectiveness, and efficacy among other populations affected by trauma.
Collapse
Affiliation(s)
- Chelsea Jones
- Leiden University Medical Center, Leiden University, Leiden, Netherlands.,Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Alberta Health Services, Edmonton, AB, Canada
| | - Lorraine Smith-MacDonald
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Matthew R G Brown
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jacob VanDehy
- Department of Warfighter Performance, Naval Health Research Center, San Diego, CA, United States.,Leidos Inc, San Diego, CA, United States
| | - Rasmus Grunnet-Jepsen
- Department of Warfighter Performance, Naval Health Research Center, San Diego, CA, United States.,Leidos Inc, San Diego, CA, United States
| | - Vrajeshri P Ordek
- Department of Warfighter Performance, Naval Health Research Center, San Diego, CA, United States.,Leidos Inc, San Diego, CA, United States
| | - Sarah Kruger
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Anne Ayres Gerhart
- Department of Warfighter Performance, Naval Health Research Center, San Diego, CA, United States
| | - Nancy van Veelen
- Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Mirjam J Nijdam
- ARQ National Psychotrauma Center, Diemen, Netherlands.,Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Lisa Burback
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Alberta Health Services, Edmonton, AB, Canada.,Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Bo Cao
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Michael J Roy
- Department of Medicine and Center for Neuroscience and Regenerative Medicine, Uniformed Services University, Bethesda, MD, United States
| | - Pinata Sessoms
- Department of Warfighter Performance, Naval Health Research Center, San Diego, CA, United States
| | - Eric Vermetten
- Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Suzette Brémault-Phillips
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
11
|
Voth M, Chisholm S, Sollid H, Jones C, Smith-MacDonald L, Brémault-Phillips S. Efficacy, Effectiveness, and Quality of Resilience-Building Mobile Health Apps for Military, Veteran, and Public Safety Personnel Populations: Scoping Literature Review and App Evaluation. JMIR Mhealth Uhealth 2022; 10:e26453. [PMID: 35044307 PMCID: PMC8811698 DOI: 10.2196/26453] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 10/09/2021] [Accepted: 11/19/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Military members (MMs) and public safety personnel (PSP) are vulnerable to occupational stress injuries because of their job demands. When MMs and PSP transition out of these professions, they may continue to experience mental health challenges. The development and implementation of resilience-building mobile health (mHealth) apps as an emergent mental health intervention platform has allowed for targeted, cost-effective, and easily accessible treatment when in-person therapy may be limited or unavailable. However, current mHealth app development is not regulated, and often lacks both clear evidence-based research and the input of health care professionals. OBJECTIVE This study aims to evaluate the evidence-based quality, efficacy, and effectiveness of resilience-building mobile apps targeted toward the MMs, PSP, and veteran populations via a scoping literature review of the current evidence base regarding resilience apps for these populations and an evaluation of free resilience apps designed for use among these populations. METHODS The studies were selected using a comprehensive search of MEDLINE, CINAHL Plus, PsycINFO, SocINDEX, Academic Search Complete, Embase, and Google and were guided by PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). A narrative synthesis of the resulting papers was performed. The Alberta Rating Index for Apps was used to conduct a review of each of the identified apps. The inclusion criteria consisted of apps that were free to download in either the Google Play Store or the Apple App Store; updated within the last 3 years; available in English and in Canada; and intended for use by MMs, veterans, and PSP. RESULTS In total, 22 apps met the inclusion criteria for evaluation. The resilience strategies offered by most apps included psychoeducation, mindfulness, cognitive behavioral therapy, and acceptance and commitment therapy. Overall, 50% (11/22) of apps had been tested in randomized controlled trials, 7 (32%) apps had been evaluated using other research methods, and 5 (23%) apps had not been studied. Using the Alberta Rating Index for Apps, the app scores ranged from 37 to 56 out of 72, with higher rated apps demonstrating increased usability and security features. CONCLUSIONS The mHealth apps reviewed are well-suited to providing resilience strategies for MMs, PSP, and veterans. They offer easy accessibility to evidence-based tools while working to encourage the use of emotional and professional support with safety in mind. Although not intended to function as a substitute for professional services, research has demonstrated that mHealth apps have the potential to foster a significant reduction in symptom severity for posttraumatic stress disorder, depression, anxiety, and other mental health conditions. In clinical practice, apps can be used to supplement treatment and provide clients with population-specific confidential tools to increase engagement in the treatment process.
Collapse
Affiliation(s)
- Melissa Voth
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Occupational Therapy, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Shannon Chisholm
- Department of Occupational Therapy, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Hannah Sollid
- Department of Occupational Therapy, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Chelsea Jones
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
- Leiden University Medical Centre, Leiden University, Leiden, Netherlands
- Operational Stress Injury Clinic, Alberta Health Services, Edmonton, AB, Canada
| | - Lorraine Smith-MacDonald
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Occupational Therapy, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Suzette Brémault-Phillips
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Occupational Therapy, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
12
|
Jones C, Smith-MacDonald L, Van Veelen N, VanderLaan A, Kaneva Z, Dunleavy RS, Hamilton T, Vermetten E, Bremault-Phillips S. Therapist and operator experiences utilizing multi-modal motion-assisted Memory Desensitization and Reconsolidation (3MDR) for treatment of combat related posttraumatic stress disorder amongst military and veteran populations. Eur J Psychotraumatol 2022; 13:2062996. [PMID: 35599979 PMCID: PMC9116239 DOI: 10.1080/20008198.2022.2062996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND As provisions of mental healthcare services to military and veteran populations increases the risk to service providers developing secondary traumatic stress (STS), efforts are needed to examine the impact of delivering novel interventions which may include 3MDR. As a virtual-reality supported intervention, 3MDR exposes the patient, therapist and operator to graphic and sensory stimuli (i.e. narratives, imagery, smells, and music) in the course of the intervention. 3MDR is actively being researched at multiple sites internationally within military and veteran populations. It is, therefore, crucial to ensure the safety and wellbeing of 3MDR therapists and operators who are exposed to potentially distressing sensory stimuli. OBJECTIVE The purpose of this study is to qualitatively examine the impact and experiences of STS amongst therapists and operators in delivering 3MDR. For this study, impact will be defined as therapists or operators experiencing perceived STS as a result of delivering 3MDR. METHODS This exploratory qualitative study recruited 3MDR therapists and operators (N = 18) from Canada, the Netherlands, the United Kingdom, and the United States who had previously delivered 3MDR therapy. Telephone or video-conferencing interviews were used to gather data that was subsequently transcribed and thematically analyzed. RESULTS Four themes emerged among the therapists (n = 13) and operators (n = 5): (1) personal cost and benefits of 3MDR, (2) professional paradox of a 3MDR therapist, (3) perceived effect of 3MDR on patients, and (4) recommendations for future 3MDR use. CONCLUSIONS STS was not noted to be a significant challenge for 3MDR therapists and operators. Future research may investigate optimal means of providing training and ongoing support for 3MDR therapists and operators. HIGHLIGHTS Secondary Traumatic Stress was not noted to be a significant challenge for 3MDR therapists and operatorsFuture research may investigate optimal means of providing training and ongoing support for 3MDR therapists and operators.
Collapse
Affiliation(s)
- Chelsea Jones
- Leiden University Medical Centre, Leiden University, Leiden, The Netherlands.,Alberta Health Services, Edmonton, Canada.,Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Lorraine Smith-MacDonald
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Nancy Van Veelen
- Leiden University Medical Centre, Leiden University, Leiden, The Netherlands
| | - Annelies VanderLaan
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Zornitsa Kaneva
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Rachel S Dunleavy
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada.,Department of Psychotherapy & Spirituality (Art Therapy), St. Stephen's College, Edmonton, Canada
| | - Tristin Hamilton
- Alberta Health Services, Edmonton, Canada.,Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Eric Vermetten
- Leiden University Medical Centre, Leiden University, Leiden, The Netherlands.,ARQ National Psychotrauma Center, Diemen, The Netherlands
| | - Suzette Bremault-Phillips
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| |
Collapse
|
13
|
Knaust T, Felnhofer A, Kothgassner OD, Reinke M, Browning M, Höllmer H, Schulz H. Nature videos for PTSD: protocol for a mixed-methods feasibility study. Eur J Psychotraumatol 2022; 13:2101765. [PMID: 35936870 PMCID: PMC9347465 DOI: 10.1080/20008198.2022.2101765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
UNLABELLED Background: Given the prevalence of post-traumatic stress disorder (PTSD), particularly among military personnel, new treatment approaches are needed. One may be virtual relaxation interventions, especially 360-degree nature videos, since studies have demonstrated their relaxation effects for healthy participants. If these relaxation effects can be reproduced in patients with PTSD, they may offer a viable tool to reduce distress and hyperarousal. Objective: This research protocol describes a planned study that will examine the relaxation effects of 360-degree nature videos for patients with PTSD. It will also investigate whether these relaxation effects differ depending on the hardware immersion level (head-mounted display [HMD] vs. PC screen) in comparison to a control condition in which patients only listen to natural sounds and do not view a video. Finally, the effect of each intervention's dose duration (five vs. ten minutes) will be explored. Method: A counterbalanced, randomised, controlled, within-subject experiment will be conducted (sample size N = 36). Only soldiers aged 18 years or older with a primary diagnosis of PTSD will be included. Those with psychosis, substance dependence, a change in psychiatric medication within the last month, suicidal intent, and motion sickness will be excluded. All patients will experience the HMD, PC, and control conditions once for five or ten minutes. Self-reported relaxation measures will be collected before and after, and patients' skin conductance level, heart rate, and heart rate variability will be assessed during each condition. Semi-structured interviews will be conducted to examine the patients' experiences in detail. Conclusions: This feasibility study will provide initial evidence of whether viewing 360-degree nature videos via HMD or PC screen is relaxing for patients with PTSD and whether the effects are greater compared with the control condition. The study will also validate the dose duration and thereby informing a subsequent confirmatory interventional trial. Trial registration: DRKS00020277. HIGHLIGHTS This randomised controlled feasibility study will examine whether 360-degree nature videos are a suitable relaxation intervention for military personnel with post-traumatic stress disorder.
Collapse
Affiliation(s)
- Thiemo Knaust
- Center for Mental Health, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | - Anna Felnhofer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Pulmonology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
| | | | - Max Reinke
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthew Browning
- Virtual Reality and Nature Lab, Department of Parks, Recreation and Tourism Management, Clemson University, Clemson, SC, USA
| | - Helge Höllmer
- Center for Mental Health, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | - Holger Schulz
- Department of Medical Psychology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
14
|
Hamilton T, Burback L, Smith-MacDonald L, Jones C, Brown MRG, Mikolas C, Tang E, O'Toole K, Vergis P, Merino A, Weiman K, Vermetten EHGJM, Brémault-Phillips S. Moving Toward and Through Trauma: Participant Experiences of Multi-Modal Motion-Assisted Memory Desensitization and Reconsolidation (3MDR). Front Psychiatry 2021; 12:779829. [PMID: 35002800 PMCID: PMC8728006 DOI: 10.3389/fpsyt.2021.779829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 11/24/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction: Military members and Veterans are at risk of developing combat-related, treatment-resistant posttraumatic stress disorder (TR-PTSD) and moral injury (MI). Conventional trauma-focused therapies (TFTs) have shown limited success. Novel interventions including Multi-modal Motion-assisted Memory Desensitization and Reconsolidation therapy (3MDR) may prove successful in treating TR-PTSD. Objective: To qualitatively study the experiences of Canadian military members and Veterans with TR-PTSD who received the 3MDR intervention. Methods: This study explored qualitative data from a larger mixed-method waitlist control trial testing the efficacy of 3MDR in military members and veterans. Qualitative data were recorded and collected from 3MDR sessions, session debriefings and follow-up interviews up to 6 months post-intervention; the data were then thematically analyzed. Results: Three themes emerged from the data: (1) the participants' experiences with 3MDR; (2) perceived outcomes of 3MDR; and (3) keys to successful 3MDR treatment. Participants expressed that 3MDR provided an immersive environment, active engagement and empowerment. The role of the therapist as a coach and "fireteam partner" supports the participants' control over their therapy. The multi-modal nature of 3MDR, combining treadmill-walking toward self-selected trauma imagery with components of multiple conventional TFTs, was key to helping participants engage with and attribute new meaning to the memory of the traumatic experience. Discussion: Preliminary thematic analysis of participant experiences of 3MDR indicate that 3MDR has potential as an effective intervention for combat-related TR-PTSD, with significant functional, well-being and relational improvements reported post-intervention. Conclusion: Military members and Veterans are at risk of developing TR-PTSD, with worse outcomes than in civilians. Further research is needed into 3MDR and its use with other trauma-affected populations.
Collapse
Affiliation(s)
- Tristin Hamilton
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Lisa Burback
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Lorraine Smith-MacDonald
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Chelsea Jones
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands
- Edmonton Operational Stress Injury Clinic, Alberta Health Services, Edmonton, AB, Canada
| | - Matthew R. G. Brown
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Department of Computing Science, Faculty of Science, University of Alberta, Edmonton, AB, Canada
| | - Cynthia Mikolas
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Emily Tang
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Kaitlin O'Toole
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Priyanka Vergis
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Anna Merino
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Kyle Weiman
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Eric H. G. J. M. Vermetten
- Edmonton Operational Stress Injury Clinic, Alberta Health Services, Edmonton, AB, Canada
- Department of Psychiatry, ARQ National Psychotrauma Center, Diemen, Netherlands
- Military Mental Health Care, Ministry of Defense, Utrecht, Netherlands
| | - Suzette Brémault-Phillips
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
15
|
Mahon-Daly S, Jeyasingam N. A narrative literature review: the application of video games as therapeutic tools for psychological therapy. Australas Psychiatry 2021; 29:614-616. [PMID: 34157897 DOI: 10.1177/10398562211022751] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Video games (games played by electronically manipulating images produced by a computer programme on a screen) are being developed with a specific focus on treating mental health. This narrative review briefly discusses the history of video games and mental health. It then provides a critical discussion on the application of video games as therapeutic tools, then discusses the notion of 'serious games' (games designed for a primary purpose other than entertainment) and their applicability. CONCLUSIONS Serious games have preliminary evidence to support their use practically in the clinical treatment of mental illness. Future randomised control trials are necessary to further explore their efficacy and potential areas of application.
Collapse
Affiliation(s)
- Sean Mahon-Daly
- Northern Sydney Local Health District, Saint Leonards, NSW, Australia
| | | |
Collapse
|
16
|
Tang E, Jones C, Smith-MacDonald L, Brown MRG, Vermetten EHGJM, Brémault-Phillips S. Decreased Emotional Dysregulation Following Multi-Modal Motion-Assisted Memory Desensitization and Reconsolidation Therapy (3MDR): Identifying Possible Driving Factors in Remediation of Treatment-Resistant PTSD. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:12243. [PMID: 34831999 PMCID: PMC8621264 DOI: 10.3390/ijerph182212243] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 12/23/2022]
Abstract
Multi-modal motion-assisted memory desensitization and reconsolidation therapy (3MDR), an interactive, virtual reality-assisted, exposure-based intervention for PTSD, has shown promising results for treatment-resistant posttraumatic stress disorder (TR-PTSD) among military members (MMs) and veterans in randomized controlled trials (RCT). Previous research has suggested that emotional regulation (ER) and emotional dysregulation (ED) may be factors which are correlated with symptom severity and maintenance of TR-PTSD. This embedded mixed-methods pilot study (n = 9) sought to explore the impact of 3MDR on ER and ED of MMs and veterans. Difficulties in Emotional Regulation Scale (DERS-18) data were collected at baseline, prior to each session, and at one week, one month, and three months postintervention and analyzed. Qualitative data collected from sessions, debriefs, and follow-up interviews were transcribed and descriptively analyzed. Results demonstrated statistically significant decreases in DERS-18 scores from preintervention to postintervention at each timepoint. Qualitatively, participants perceived improvements in ER within specified DERS-18 domains. We describe how 3MDR's unique and novel approach addresses ED through cognitive-motor stimulation, narration, divergent thinking, reappraisal of aversive stimuli, dual-task processing, and reconsolidation of traumatic memories. More studies are needed to better understand the underlying neurobiological mechanisms by which 3MDR addresses ER and PTSD.
Collapse
Affiliation(s)
- Emily Tang
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada; (E.T.); (L.S.-M.)
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada; (C.J.); (M.R.G.B.)
- Neuroscience and Mental Health Institute (NMHI), University of Alberta, Edmonton, AB T6G 2E1, Canada
| | - Chelsea Jones
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada; (C.J.); (M.R.G.B.)
- Alberta Health Services, Edmonton, AB T5E 5R8, Canada
- Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Lorraine Smith-MacDonald
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada; (E.T.); (L.S.-M.)
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada; (C.J.); (M.R.G.B.)
| | - Matthew R. G. Brown
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada; (C.J.); (M.R.G.B.)
- Department of Computing Science, University of Alberta, Edmonton, AB T6G 2E8, Canada
| | - Eric H. G. J. M. Vermetten
- Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
- ARQ National Psychotrauma Center, 1112 XE Diemen, The Netherlands
- Military Mental Health, Dutch Ministry of Defense, 3584 EZ Utrecht, The Netherlands
| | - Suzette Brémault-Phillips
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada; (E.T.); (L.S.-M.)
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada; (C.J.); (M.R.G.B.)
- Neuroscience and Mental Health Institute (NMHI), University of Alberta, Edmonton, AB T6G 2E1, Canada
| |
Collapse
|
17
|
Jones C, Miguel Cruz A, Smith-MacDonald L, Brown MRG, Vermetten E, Brémault-Phillips S. Technology Acceptance and Usability of a Virtual Reality Intervention for Military Members and Veterans with Posttraumatic Stress Disorder: A Mixed Methods UTAUT Study (Preprint). JMIR Form Res 2021; 6:e33681. [PMID: 35451971 PMCID: PMC9073607 DOI: 10.2196/33681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/24/2021] [Accepted: 02/25/2022] [Indexed: 11/20/2022] Open
Abstract
Background Military members and veterans exhibit higher rates of injuries and illnesses such as posttraumatic stress disorder (PTSD) because of their increased exposure to combat and other traumatic scenarios. Novel treatments for PTSD are beginning to emerge and increasingly leverage advances in gaming and other technologies, such as virtual reality. Without assessing the degree of technology acceptance and perception of usability to the end users, including the military members, veterans, and their attending therapists and staff, it is difficult to determine whether a technology-based treatment will be used successfully in wider clinical practice. The Unified Theory of Acceptance and Use of Technology model is commonly used to address the technology acceptance and usability of applications in 5 domains. Objective Using the Unified Theory of Acceptance and Use of Technology model, the purpose of this study was to determine the technology acceptance and usability of multimodal motion-assisted memory desensitization and reconsolidation (3MDR) on a virtual reality system in the primary user group (military members and veterans with treatment-resistant PTSD, 3MDR therapists, and virtual reality environment operators). Methods This mixed methods embedded pilot study included military members (n=3) and veterans (n=8) with a diagnosis of combat-related PTSD, as well as their therapists (n=13) and operators (n=5) who completed pre-post questionnaires before and on completion of 6 weekly sessions of 3MDR. A partial least squares structural equation model was used to analyze the questionnaire results. Qualitative data from the interviews were assessed using thematic analysis. Results Effort expectancy, which was the most notable predictor of behavioral intention, increased after a course of 3MDR with the virtual reality system, whereas all other constructs demonstrated no significant change. Participants’ expectations of the technology were met, as demonstrated by the nonsignificant differences in the pre-post scores. The key qualitative themes included feasibility and function, technical support, and tailored immersion. Conclusions 3MDR via a virtual reality environment appears to be a feasible, usable, and accepted technology for delivering 3MDR to military members and veterans who experience PTSD and 3MDR therapists and operators who facilitate their treatment.
Collapse
Affiliation(s)
- Chelsea Jones
- Heroes in Mind, Advocacy and Research Consortum, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
- Leiden University Medical Centre, Leiden, Netherlands
- Edmonton Occupational Stress Injury Clinic, Alberta Health Services, Edmonton, AB, Canada
| | - Antonio Miguel Cruz
- Glenrose Rehabilitation Hospital Research Innovation and Technology, Glenrose Rehabilitation Hospital, Alberta Health Services, Edmonton, AB, Canada
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Lorraine Smith-MacDonald
- Heroes in Mind, Advocacy and Research Consortum, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Matthew R G Brown
- Heroes in Mind, Advocacy and Research Consortum, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Suzette Brémault-Phillips
- Heroes in Mind, Advocacy and Research Consortum, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
18
|
Lehrner A, Hildebrandt T, Bierer LM, Flory JD, Bader HN, Makotkine I, Yehuda R. A randomized, double-blind, placebo-controlled trial of hydrocortisone augmentation of Prolonged Exposure for PTSD in U.S. combat veterans. Behav Res Ther 2021; 144:103924. [PMID: 34298438 DOI: 10.1016/j.brat.2021.103924] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 06/01/2021] [Accepted: 06/29/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Cognitive behavioral therapies such as Prolonged Exposure (PE) are considered first line treatments for posttraumatic stress disorder (PTSD). Nonetheless, many continue to experience significant symptoms following treatment and there is interest in enhancing treatment effectiveness. Glucocorticoid alterations in PTSD are well documented, and these steroids have been shown to enhance extinction learning. METHODS Augmentation of PE with the synthetic glucocorticoid hydrocortisone (HCORT) was tested in a randomized, double-blind, placebo-controlled trial in 60 veterans of wars in Iraq or Afghanistan with PTSD (NCT01525680). Participants ingested 30 mg oral HCORT or placebo 30 min prior to exposure sessions. PRIMARY OUTCOME MEASURE PTSD severity assessed by the CAPS; secondary outcome measures: self reported PTSD symptoms assessed by the PDS and depression assessed by the BDI; all administered at pretreatment, posttreatment, and 3-month follow up. RESULTS Across conditions, there was a robust effect of PE over time. An intent-to-treat analysis showed that HCORT did not measurably improve PTSD symptoms or secondary outcomes. However, exploratory analyses indicated that veterans with mild TBI exposure and current postconcussive symptoms showed a greater reduction in hyperarousal symptoms following PE treatment with HCORT augmentation. Additionally, veterans with higher baseline glucocorticoid sensitivity showed a greater reduction in avoidance symptoms with HCORT augmentation. CONCLUSIONS Treatment matching based on cognitive or biological vulnerabilities might lead to greater efficacy of PE with glucocorticoid augmentation.
Collapse
Affiliation(s)
- Amy Lehrner
- Mental Health Patient Care Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Tom Hildebrandt
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Linda M Bierer
- Mental Health Patient Care Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Janine D Flory
- Mental Health Patient Care Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Heather N Bader
- Mental Health Patient Care Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Iouri Makotkine
- Mental Health Patient Care Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel Yehuda
- Mental Health Patient Care Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
19
|
Knaust T, Felnhofer A, Kothgassner OD, Höllmer H, Gorzka RJ, Schulz H. Virtual Trauma Interventions for the Treatment of Post-traumatic Stress Disorders: A Scoping Review. Front Psychol 2020; 11:562506. [PMID: 33281664 PMCID: PMC7691274 DOI: 10.3389/fpsyg.2020.562506] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/30/2020] [Indexed: 12/16/2022] Open
Abstract
Some post-traumatic stress disorder (PTSD) patients do not benefit from imaginal exposure therapy. One possible approach to reach such patients are virtual trauma interventions. Herein, a qualitative scoping review was conducted. Different types of virtual trauma exposure interventions were identified. For each type of virtual trauma exposure interventions it was examined in detail: (1) which in sensu trauma exposure approach serves as therapeutic framework, how it was transferred into virtual reality, and if it was manualized; (2) which hardware and software were used; (3) whether the influence of spatial and social presence on the efficacy of virtual trauma interventions have been measured, and (4) whether the efficacy of virtual trauma interventions for PTSD patients having imagination difficulties was evaluated. These research questions were analyzed qualitatively. Accordingly, an extensive literature search was conducted using the databases Web of Science, PsycINFO, LIVIVO, PTSDpubs, and PubMed for scientific articles published between January 2013 and July 2020. Only studies aimed to reduce PTSD symptoms using virtual trauma interventions were included. The literature search was not limited to a specific study design, treatment/intervention method, or a minimum sample size. Eighteen studies were identified, which reported three different virtual trauma intervention approaches, namely, virtual reality exposure therapy (VRET), multi-modular motion-assisted memory desensitization and reconsolidation (3MDR), and action-centered exposure therapy (ACET). Seven randomized controlled trials (RCTs), two pilot studies, and one case study were focused on VRET; while two RCTs, one pilot study, and three case studies focused on 3MDR, and two case studies on ACET. Regarding the first research question (1), the results show that VRET is based on prolonged exposure, aiming for a virtual re-creation of the patient's traumatic recounting. Several treatment protocols exist for VRET. 3MDR is based on eye movement desensitization and reprocessing, aiming to reduce the patient's avoidance behavior. In 3MDR patients walk toward individualized trauma-related symbolic images in a cave automatic virtual environment (CAVE). One treatment protocol exists for 3MDR. ACET is based on the inhibitory learning theory, aiming for active interactions with a virtual trauma-associated environment to alter the anxiety structure through new secondary inhibitory learning. One treatment protocol exists for ACET. For the second research question (2), the results indicate that all VRET studies used head-mounted displays (HMDs) with a virtual version of the Iraq/Afghanistan or the World Trade Center attacks, while 3MDR studies utilized two different versions of a CAVE with personalized trauma-related images, and the ACET studies used HMDs with virtual street scenarios. For the third research question (3), the results demonstrate that the influence of spatial or social presence on the efficacy of virtual trauma interventions was not examined in any of the included studies. Similarly, for the fourth research question (4), the results show that empirical evidence for the efficacy of virtual trauma interventions on PTSD patients having imagination difficulties was lacking. Therefore, such empirical studies are needed to fill these research gaps.
Collapse
Affiliation(s)
- Thiemo Knaust
- Center for Mental Health, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | - Anna Felnhofer
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Oswald D. Kothgassner
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Helge Höllmer
- Center for Mental Health, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | - Robert-Jacek Gorzka
- Department of Applied Military and Operational Psychology, Military Police Command, Hanover, Germany
| | - Holger Schulz
- Department of Medical Psychology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
20
|
van Gelderen MJ, Nijdam MJ, de Vries F, Meijer OC, Vermetten E. Exposure-related cortisol predicts outcome of psychotherapy in veterans with treatment-resistant posttraumatic stress disorder. J Psychiatr Res 2020; 130:387-393. [PMID: 32889356 DOI: 10.1016/j.jpsychires.2020.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/28/2020] [Accepted: 08/12/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hypothalamic-pituitary-adrenal axis functioning has been related to treatment outcome in posttraumatic stress disorder (PTSD). Previous studies have primarily focused on cortisol levels before and after a course of therapy and findings have not been fully consistent. This study investigated session-related cortisol levels in veterans with treatment-resistant PTSD over the course of a novel motion-assisted virtual reality exposure therapy and aimed to determine whether cortisol levels were related to changes in PTSD symptom severity. METHODS Veterans (N = 22) received six exposure sessions during which salivary cortisol samples were collected pre-session, post-session and in the late afternoon following sessions. PTSD symptom severity was assessed by structured clinical interviews at pre- and post-treatment. Average cortisol levels were compared between responders and non-responders. Linear regression analyses were conducted with PTSD symptom change as criterion variable, average cortisol levels as predictor, and timing of sampling and baseline PTSD symptoms as covariates. RESULTS Responders to treatment tended to have higher average cortisol levels at pre-session (p = 0.064) and post-session (p = 0.050) compared to non-responders. Higher average pre-session and post-session cortisol levels predicted greater PTSD symptom improvement (pre: b = -1.83, p = 0.009; post: b = -3.57, p = 0.004). CONCLUSION This study provides preliminary evidence for session-related cortisol as biomarker of response to exposure-based therapies for PTSD. Higher cortisol levels may have facilitated fear extinction and reconsolidation, and may indicate increased physiological stress activation necessary for appropriate treatment engagement. Further work involving comparable methodology is encouraged to establish session-related cortisol as biomarker and to determine the mechanisms through which it interacts with treatment outcome.
Collapse
Affiliation(s)
- Marieke J van Gelderen
- ARQ Centrum'45, ARQ National Psychotrauma Centre, Nienoord 5, 1112XE, Diemen, the Netherlands; Department of Psychiatry, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
| | - Mirjam J Nijdam
- ARQ Centrum'45, ARQ National Psychotrauma Centre, Nienoord 5, 1112XE, Diemen, the Netherlands; Department of Psychiatry, Amsterdam University Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Friso de Vries
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Onno C Meijer
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Eric Vermetten
- ARQ Centrum'45, ARQ National Psychotrauma Centre, Nienoord 5, 1112XE, Diemen, the Netherlands; Department of Psychiatry, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Military Mental Health-Research, Ministry of Defense, Lundlaan 1, 3584 EZ, Utrecht, the Netherlands
| |
Collapse
|
21
|
van Gelderen MJ, Nijdam MJ, Dubbink GE, Sleijpen M, Vermetten E. Perceived treatment processes and effects of interactive motion-assisted exposure therapy for veterans with treatment-resistant posttraumatic stress disorder: a mixed methods study. Eur J Psychotraumatol 2020; 11:1829400. [PMID: 33244364 PMCID: PMC7678674 DOI: 10.1080/20008198.2020.1829400] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: A novel intervention, Multi-modular motion-assisted memory desensitization and reconsolidation (3MDR), aims to reduce avoidance and improve engagement for patients with posttraumatic stress disorder (PTSD) who did not sufficiently respond to previous treatments. It has been found to effectively reduce PTSD symptoms for veterans with treatment-resistant PTSD. Symptomatic measures alone might not capture all treatment effects, and addition of qualitative outcomes may provide deeper understanding of treatment processes and treatment-induced changes. Objective: To study the perspectives of veterans with treatment-resistant PTSD on 3MDR treatment processes and effects and explore the relation of their experiences to PTSD symptom improvement. Method: A convergent parallel mixed methods design was applied. For the qualitative part, open-ended question interviews were conducted until data saturation was reached (N = 10). Thematic analysis, rooted in grounded theory, was performed. Quantitative data included pre- to posttreatment responder status based on a structured clinical interview for PTSD. Results: Treatment processes endorsed by the veterans were engaging, regulating distress, feeling supported, facing traumatic memories, allowing emotions, associating, and disengaging from trauma. In terms of effects, veterans reported positive changes following 3MDR, including openness, new learning, self-understanding, closure, and reintegration. High comparability across themes was observed for responders and non-responders, except for the themes closure and reintegration, which were reported more often or more in depth by responders. Conclusions: Veterans indicated 3MDR treatment processes that complied with its aims of breaking through avoidance and increasing engagement, thereby facilitating traumatic memory retrieval and processing. However, this did not necessarily translate into PTSD symptom improvement for all veterans. Walking towards trauma-related pictures was highlighted as unique component of 3MDR and connected to specific treatment processes and effects. Positive changes following 3MDR were experienced outside the domain of PTSD symptom improvement, implicating that 3MDR may beneficially impact veterans beyond symptom changes alone.
Collapse
Affiliation(s)
- Marieke J van Gelderen
- ARQ Centrum'45, ARQ National Psychotrauma Centre, Diemen, The Netherlands.,Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| | - Mirjam J Nijdam
- ARQ Centrum'45, ARQ National Psychotrauma Centre, Diemen, The Netherlands.,Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - G Elsemieke Dubbink
- Department of Clinical Psychology, University of Utrecht, Utrecht, The Netherlands
| | - Marieke Sleijpen
- ARQ Centrum'45, ARQ National Psychotrauma Centre, Diemen, The Netherlands.,Department of Clinical Psychology, University of Utrecht, Utrecht, The Netherlands
| | - Eric Vermetten
- ARQ Centrum'45, ARQ National Psychotrauma Centre, Diemen, The Netherlands.,Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands.,Military Mental Health-Research, Ministry of Defense, Utrecht, The Netherlands
| |
Collapse
|
22
|
Jones C, Smith-MacDonald L, Miguel-Cruz A, Pike A, van Gelderen M, Lentz L, Shiu MY, Tang E, Sawalha J, Greenshaw A, Rhind SG, Fang X, Norbash A, Jetly R, Vermetten E, Brémault-Phillips S. Virtual Reality-Based Treatment for Military Members and Veterans With Combat-Related Posttraumatic Stress Disorder: Protocol for a Multimodular Motion-Assisted Memory Desensitization and Reconsolidation Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e20620. [PMID: 33118957 PMCID: PMC7661230 DOI: 10.2196/20620] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 12/12/2022] Open
Abstract
Background Military members are at elevated risk of operational stress injuries, including posttraumatic stress disorder (PTSD) and moral injury. Although psychotherapy can reduce symptoms, some military members may experience treatment-resistant PTSD. Multimodular motion-assisted memory desensitization and reconsolidation (3MDR) has been introduced as a virtual reality (VR) intervention for military members with PTSD related to military service. The 3MDR intervention incorporates exposure therapy, psychotherapy, eye movement desensitization and reconsolidation, VR, supportive counselling, and treadmill walking. Objective The objective of this study is to investigate whether 3MDR reduces PTSD symptoms among military members with combat-related treatment-resistant PTSD (TR-PTSD); examine the technology acceptance and usability of the Computer Assisted Rehabilitation ENvironment (CAREN) and 3MDR interventions by Canadian Armed Forces service members (CAF-SMs), veterans, 3MDR clinicians, and operators; and evaluate the impact on clinicians and operators of delivering 3MDR. Methods This is a mixed-methods waitlist controlled crossover design randomized controlled trial. Participants include both CAF-SMs and veterans (N=40) aged 18-60 years with combat-related TR-PTSD (unsuccessful experience of at least 2 evidence-based trauma treatments). Participants will also include clinicians and operators (N=12) who have been trained in 3MDR and subsequently utilized this intervention with patients. CAF-SMs and veterans will receive 6 weekly 90-minute 3MDR sessions. Quantitative and qualitative data will be collected at baseline and at 1, 3, and 6 months postintervention. Quantitative data collection will include multiomic biomarkers (ie, blood and salivary proteomic and genomic profiles of neuroendocrine, immune-inflammatory mediators, and microRNA), eye tracking, electroencephalography, and physiological data. Data from outcome measures will capture self-reported symptoms of PTSD, moral injury, resilience, and technology acceptance and usability. Qualitative data will be collected from audiovisual recordings of 3MDR sessions and semistructured interviews. Data analysis will include univariate and multivariate approaches, and thematic analysis of treatment sessions and interviews. Machine learning analysis will be included to develop models for the prediction of diagnosis, symptom severity, and treatment outcomes. Results This study commenced in April 2019 and is planned to conclude in April 2021. Study results will guide the further evolution and utilization of 3MDR for military members with TR-PTSD and will have utility in treating other trauma-affected populations. Conclusions The goal of this study is to utilize qualitative and quantitative primary and secondary outcomes to provide evidence for the effectiveness and feasibility of 3MDR for treating CAF-SMs and veterans with combat-related TR-PTSD. The results will inform a full-scale clinical trial and stimulate development and adaptation of the protocol to mobile VR apps in supervised clinical settings. This study will add to knowledge of the clinical effectiveness of 3MDR, and provide the first comprehensive analysis of biomarkers, technology acceptance and usability, moral injury, resilience, and the experience of clinicians and operators delivering 3MDR. Trial Registration ISRCTN Registry 11264368; http://www.isrctn.com/ISRCTN11264368. International Registered Report Identifier (IRRID) DERR1-10.2196/20620
Collapse
Affiliation(s)
- Chelsea Jones
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Lorraine Smith-MacDonald
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Antonio Miguel-Cruz
- Department of Occupational Therapy, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada.,Glenrose Rehabilitation Hospital Research Innovation and Technology (GRRIT), Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Ashley Pike
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Marieke van Gelderen
- ARQ Centrum'45, Diemen, Netherlands.,Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands
| | - Liana Lentz
- School of Health Studies, Western University, London, ON, Canada
| | - Maria Y Shiu
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada
| | - Emily Tang
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Jeffrey Sawalha
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Andrew Greenshaw
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Shawn G Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada
| | - Xin Fang
- Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Adrian Norbash
- Canadian Forces Health Services, Department of National Defense, Edmonton, AB, Canada
| | - Rakesh Jetly
- Department of Mental Health, Canadian Forces Health Services, Department of National Defense, Ottawa, ON, Canada
| | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands.,Military Mental Health Research, Ministry of Defense, Utrecht, Netherlands.,ARQ National Psychotrauma Centre, Deimen, Netherlands
| | - Suzette Brémault-Phillips
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada.,Department of Occupational Therapy, Faculty of Rehabilitation, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
23
|
Bisson JI, van Deursen R, Hannigan B, Kitchiner N, Barawi K, Jones K, Pickles T, Skipper J, Young C, Abbott LR, van Gelderen M, Nijdam MJ, Vermetten E. Randomized controlled trial of multi-modular motion-assisted memory desensitization and reconsolidation (3MDR) for male military veterans with treatment-resistant post-traumatic stress disorder. Acta Psychiatr Scand 2020; 142:141-151. [PMID: 32495381 DOI: 10.1111/acps.13200] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To explore the potential efficacy of multi-modular motion-assisted memory desensitization and reprocessing (3MDR) in British military veterans with treatment-resistant service-related PTSD. METHODS Exploratory single-blind, randomized, parallel arm, cross-over controlled trial with nested process evaluation to assess fidelity, adherence and factors that influence outcome. RESULTS A total of 42 participants (all male) were randomized with 83% retention at 12 weeks and 86% at 26 weeks. The difference in mean Clinician-Administered PTSD Scale for DSM-5 scores between the immediate and delayed 3MDR arms was -9.38 (95% CI -17.33 to -1.44, P = 0.021) at 12 weeks and -3.59 (-14.39 to 7.20, P = 0.513) at 26 weeks when both groups had received 3MDR. The likely effect size of 3MDR was found to be 0.65. Improvements were maintained at 26-week follow-up. 3MDR was found to be acceptable to most, but not all, participants. Several factors that may impact efficacy and acceptability of 3MDR were identified. CONCLUSION 3MDR is a promising new intervention for treatment-resistant PTSD with emerging evidence of effect.
Collapse
Affiliation(s)
- J I Bisson
- School of Medicine, Cardiff University, Cardiff, UK
| | - R van Deursen
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - B Hannigan
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - N Kitchiner
- Veterans' NHS Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - K Barawi
- School of Medicine, Cardiff University, Cardiff, UK
| | - K Jones
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - T Pickles
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - J Skipper
- School of Medicine, Cardiff University, Cardiff, UK
| | - C Young
- Cardiff and Vale University Health Board, Cardiff, UK
| | - L R Abbott
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - M van Gelderen
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| | - M J Nijdam
- ARQ Centrum'45, ARQ National Psychotrauma Centre, Diemen, The Netherlands.,Department of Psychiatry, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - E Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|