Gender differences in receipt of telehealth versus in person behavioral therapy, medication for opioid use disorder (MOUD), and 90-day MOUD retention during the pandemic: A retrospective veteran cohort study

BACKGROUND

COVID-19 significantly negatively impacted access to care among patients with opioid use disorder (OUD). The Veterans Health Administration (VHA) enacted policies to expand telehealth and medication for OUD (MOUD) during the public health emergency, which offset risk of treatment disruption. In this study, we evaluated gender differences in utilization of behavioral therapy in person and via telehealth, MOUD utilization, and achieving 90-day MOUD retention pre-post pandemic onset, given known gender differences in treatment utilization between men and women. Secondarily, we examined MOUD receipt and retention as a function of in-person vs. telehealth behavioral therapy received over time.

METHODS

Using VHA's nationwide electronic health record data, we compared outcomes between men and women veterans, pre- to post-pandemic onset (January 2019-February 2020 vs. March 2020-April 2021). Primary outcomes included receipt of behavioral therapy (in person or telehealth), number of appointments attended, any MOUD, and whether patients achieved 90-day MOUD retention post-induction.

RESULTS

Veterans with OUD were less likely to receive behavioral therapy post-pandemic onset, which was driven by marked decreases in in-person care; these effects were strongest among women. The odds of receiving MOUD also decreased pre- to post-pandemic onset, particularly among men. Receipt of or achieving 90-day MOUD retention was differentially related to receipt of behavioral therapy via in person vs. telehealth; telehealth was more strongly associated with these utilization indicators post-pandemic onset-an effect that was more pronounced for men.

CONCLUSION

The likelihood of receiving behavioral therapy and MOUD were lower during COVID-19 and varied by gender, with men being less likely to receive MOUD over time and women being less likely to receive in-person behavioral therapy. Behavioral therapy received via telehealth was generally associated with improved MOUD utilization compared to in-person behavioral therapy, but this was less true for women than for men regarding utilization of or achieving 90-day MOUD retention. In addition to the need for further telehealth expansion for veterans with OUD, more research should explore how to better engage men in MOUD treatment and improve adherence to MOUD among women engaged in behavioral therapy.

The impact of COVID-19 and rapid policy exemptions expanding on access to medication for opioid use disorder (MOUD): A nationwide Veterans Health Administration cohort study

BACKGROUND

In March 2020, Veterans Health Administration (VHA) enacted policies to expand treatment for Veterans with opioid use disorder (OUD) during COVID-19. In this study, we evaluate whether COVID-19 and subsequent OUD treatment policies impacted receipt of therapy/counseling and medication for OUD (MOUD).

METHODS

Using VHA's nationwide electronic health record data, we compared outcomes between a comparison cohort derived using data from prior to COVID-19 (October 2017-December 2019) and a pandemic-exposed cohort (January 2019-March 2021). Primary outcomes included receipt of therapy/counseling or any MOUD (any/none); secondary outcomes included the number of therapy/counseling sessions attended, and the average percentage of days covered (PDC) by, and months prescribed, each MOUD in a year.

RESULTS

Veterans were less likely to receive therapy/counseling over time, especially post-pandemic onset, and despite substantial increases in teletherapy. The likelihood of receiving buprenorphine, methadone, and naltrexone was reduced post-pandemic onset. PDC on MOUD generally decreased over time, especially methadone PDC post-pandemic onset, whereas buprenorphine PDC was less impacted during COVID-19. The number of months prescribed methadone and buprenorphine represented relative improvements compared to prior years. We observed important disparities across Veteran demographics.

CONCLUSION

Receipt of treatment was negatively impacted during the pandemic. However, there was some evidence that coverage on methadone and buprenorphine may have improved among some veterans who received them. These medication effects are consistent with expected COVID-19 treatment disruptions, while improvements regarding access to therapy/counseling via telehealth, as well as coverage on MOUD during the pandemic, are consistent with the aims of MOUD policy exemptions.

The Relationship between Positive Memory Phenomenology and Alcohol Use among Trauma-Exposed Individuals

BACKGROUND

Evidence links positive memory characteristics and hazardous alcohol use (HAU). Relevant to the current study, evidence also indicates that trauma-exposed individuals, especially those with posttraumatic stress disorder (PTSD) symptoms, report difficulties retrieving/accessing positive memories and report HAU.

OBJECTIVE

Considering this literature, we uniquely examined if and which positive memory characteristics were associated with HAU, and the potential mediating role of PTSD symptom severity in the examined relations.

METHODS

A sample of 126 trauma-exposed community participants seeking mental health treatment (Mage=34.97 years) completed measures of HAU (Alcohol Use Disorders Identification Test), positive memory characteristics (Memory Experiences Questionnaire-Short Form [MEQ-SF]), and PTSD severity (PTSD Checklist for DSM-5). We conducted 8 hierarchical multiple regressions; Step 1 examined effects of gender and Step 2 added a single MEQ-SF dimension (specificity, valence, emotional intensity, sensory details, vividness, accessibility, coherence, sharing).

RESULTS

In Steps 1 (β=.27) and 2 (βs from .27-.28), gender was associated with HAU. In Step 2, positive memory characteristics of specificity (β=.17), sensory details (β=.17), sharing (β=.23), and valence (β=-.19) were associated with greater HAU. PTSD severity mediated relations between sensory details (β=.09, p=.048), emotional intensity (β=.12, p=.011), and sharing (β=.09, p=.036), and the extent of HAU.

CONCLUSIONS AND IMPLICATIONS

Results that specificity, greater sharing, more sensory details, and higher negative valence of positive memories were associated with greater HAU offer potential points of intervention.

Processing of Positive Memories Technique among Clients Reporting Traumatic Experiences: A Case Series

Many current treatments for posttraumatic stress disorder (PTSD) emphasize processing and engaging with trauma memories as the key mechanism of therapeutic change. However, promising emerging research indicates links between PTSD symptoms and positive memories. Processing positive memories, to therapeutically impact health outcomes for trauma-exposed individuals, may have several benefits, including (a) increasing access to positive coping mechanisms via activating positive affect and thoughts; (b) addressing avoidance of positive affect and thoughts; and (c) honing skills that will aid in the eventual processing of trauma memories. The present article demonstrates the utility and effects of a novel Processing of Positive Memories Technique (PPMT) with three clients who reported a history of traumatic experiences. We outline the procedures of a 5-session PPMT, that incorporates symptom assessment, detailed imaginal experiencing of positive memories, and processing of associated positive values, affect, strengths, and thoughts. We utilize longitudinal assessment data to demonstrate the clinical benefits of PPMT, such as less PTSD severity, improved mood (e.g., less negative affect), and greater self-esteem. Finally, we discuss treatment considerations based on unique client factors and treatment modalities (i.e., in-person vs. video telehealth).

Critical considerations for the positive memory-posttraumatic stress disorder model

Posttraumatic stress disorder (PTSD) includes changes in processes such as encoding and retrieval for both traumatic and positive memories. However, most work has predominantly focused on traumatic memories. Thus, Contractor and colleagues proposed a Positive Memory-PTSD model, which highlighted potential benefits associated with and mechanisms underlying positive memory retrieval/processing among individuals reporting PTSD symptoms. To enhance research on and clinical impacts of this model, the current review provides critical considerations for the Positive Memory-PTSD model. Drawing from emerging research and clinical observations, we (i) clarify that the model addresses specific versus overgeneral positive memories; (ii) underscore the importance of considering the heterogeneity in, and transitionary nature of, affect processes following positive memory retrieval; and (iii) highlight the rationale for considering trauma type/count and co-occurring conditions, as potential moderators of relations between positive memory processing and PTSD. Hereby, we provide an updated Positive Memory-PTSD model and implications for positive memory interventions drawing from this model.

A pilot study examining roles of cognitions and affect between positive memory processing and posttraumatic stress disorder symptom severity

Objective: Posttraumatic stress disorder (PTSD) symptoms may impact cognitive processes underlying encoding and retrieval of positive memories. Contractor and colleagues thus proposed a Positive Memory-PTSD model outlining hypothesized pathways (e.g., improved cognitions and affect) linking active processing of positive memories and PTSD symptoms. In the current study, we empirically explored direct and indirect pathways of the Positive Memory-PTSD model including relations between presence/types of processing memory methodology, posttrauma maladaptive cognitions, positive/negative affect, and PTSD symptom severity. Methods: We randomly assigned 65 students reporting trauma histories to time-matched narrating (identifying and sharing details of elicited positive memories), writing (identifying and writing details of elicited positive memories), or control conditions. Participants completed self-report measures (T0) and repeated their assigned task condition and self-report measures 6-8 days later (T1). Results: Half-longitudinal models demonstrated direct associations of (1) being in the narrating versus other conditions with decreases in posttrauma maladaptive cognitions and negative affect, and increases in positive affect; and (2) increases in posttrauma maladaptive cognitions and negative affect with greater PTSD symptom severity. Although, when controlling for posttrauma maladaptive cognitions and negative/positive affect, being in the narrating versus other conditions was associated with decreases in PTSD symptom severity, these constructs did not explain examined relations. Conclusions: Results suggest beneficial impacts of narrating positive memories on PTSD symptom severity (accounting for cognitions/affect) and improved cognitions/affect, and a need to examine moderating variables (e.g., emotion regulation) in the Positive Memory-PTSD model. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Prolonged Exposure Therapy in the Time of COVID-19: Modifying PTSD Treatment for a Military Sexual Trauma Survivor Who Contracted COVID-19 Mid-Treatment

Prolonged exposure (PE) therapy is a gold-standard treatment for posttraumatic stress disorder (PTSD) that can be effectively delivered via telehealth modalities. The following case report describes a course of PE delivered to a veteran seeking PTSD treatment for military sexual trauma (MST), who contracted COVID-19 mid-treatment. Considerations for selecting PE as a treatment modality; modifications made due to the COVID-19 pandemic and transition to telehealth more broadly, and following the veteran contracting COVID-19 more specifically; strategies to increase treatment engagement; and assessment of progress over time, are discussed. In particular, treatment considerations during a global pandemic are explored at the patient-, provider-, and systems level, to inform treatment delivery for other providers during this ongoing pandemic. Although there were numerous technological, environmental, and pandemic-related difficulties, the veteran described here persisted through a course of PE and experienced clinically significant reductions in symptoms of PTSD and a great degree of functional recovery.

Unprecedented need and recommendations for harnessing data to guide future policy and practice for opioid use disorder treatment following COVID-19

The COVID-19 pandemic struck in the midst of an ongoing opioid epidemic. To offset disruption to life-saving treatment for opioid use disorder (OUD), several federal agencies granted exemptions to existing federal regulations. This included loosening restrictions on medications for OUD (MOUD), including methadone and buprenorphine. In this commentary, we briefly review policy and practice guidelines for treating OUD prior to the onset of the COVID-19 pandemic. We then outline specific MOUD treatment policy and practice exemptions that went into effect in February and March 2020, and discuss the ways in which these unprecedented changes have dramatically changed MOUD treatment. Given the unprecedented nature of these changes, and unknown outcomes to date, we advocate for a data-driven approach to guide future policy and practice recommendations regarding MOUD. We outline several critical clinical, research, and policy questions that can inform MOUD treatment in a post-COVID-19 era.

Do positive memory characteristics relate to reckless behaviours? an exploratory study in a treatment-seeking traumatised sample

Reckless and self-destructive behaviours (RSDBs), common among traumatised individuals, are associated with negative health consequences. Gaining a stronger understanding of factors associated with an increased likelihood of RSDBs among traumatised individuals offers potential new avenues for research and treatment. Mounting evidence indicates relations between traumatic experiences and deficits/disturbances in characteristics of positive memories; however, relations between RSDBs and positive memory characteristics has been understudied. Using hierarchical multiple regression, we examined relations between positive memory characteristics (Memory Experiences Questionnaire-Short Form; MEQ-SF) and RSDBs, controlling for PTSD and depression severity, among a sample of treatment-seeking trauma-exposed individuals (N = 77; Mage = 33.96; 57.10% female). Results indicated that MEQ-SF subscales of Accessibility, Coherence, Emotional Intensity, and Sensory Details were significantly associated with engagement in RSDBs, above and beyond PTSD and depressive severity. Those who easily accessed emotionally evocative positive memories tended to engage in elevated RSDBs; those with less coherence and fewer sensory details in their positive memories were also more likely to engage in RSDBs. Theories related to emotion dysregulation and cognitive deficits may explain these obtained relations.

Caring for patients with posttraumatic stress and substance use disorders during the COVID-19 pandemic

Although COVID-19 is a physical illness, it has had large impacts on mental health. For many individuals, social distancing has led to social isolation; individuals with posttraumatic stress disorder and substance use disorders are at a particular risk for negative outcomes due to the global pandemic. Here, we discuss the impacts we have noticed and procedures we have implemented to care for this population during the pandemic. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Effects of processing positive memories on posttrauma mental health: A preliminary study in a non-clinical student sample

BACKGROUND AND OBJECTIVES

Although trauma research and therapy primarily focus on traumatic memories, recent evidence indicates positive memory processes play a role in the etiology/maintenance of posttraumatic stress disorder (PTSD) symptom severity. We examined the effects of a novel positive memory processing technique on PTSD symptom severity, depression symptom severity, affect, posttrauma cognitions, and self-esteem.

METHODS

Sixty-five trauma-exposed participants were randomly assigned to one of three conditions (narrating/processing vs. writing/processing two specific positive memories, or a time-matched control) and completed self-report measures pre- and post-task (T0). About one week later, participants repeated their assigned task condition and completed self-report measures pre- and post-task (T1). We conducted mixed ANOVAs to examine the impact of the technique on study variables over time.

RESULTS

The narrating condition had significant decreases in PTSD symptom severity, posttrauma cognitions, and negative affect from T0 pre-task to T1 post-task; and significant increases in positive affect from T0 pre-to-post-task and from T1 pre-to-post-task. The writing condition had significant increases in positive affect from T0 pre-to-post-task, but a significant decrease from T0 post-task to T1 post-task; and significant decreases in negative affect from T0 pre-to-post-task with an increase from T0 post-task to T1 post-task.

LIMITATIONS

Use of self-report measures, non-clinical convenience sample with less gender/ethnic/racial diversity, small sample size, methodological differences in time frames for measures, and no examination of follow-up effects.

CONCLUSIONS

Narrating and processing specific positive memories had a beneficial impact on PTSD symptom severity, posttrauma maladaptive cognitions, and affect; such results provide an impetus to examine positive memory interventions in trauma clinical work.

The associations between deployment experiences, PTSD, and alcohol use among male and female veterans

OVERVIEW

Alcohol use is common following traumatic military deployment experiences. What is less clear is why, and for whom, particular deployment experiences lead to alcohol use.

METHOD

The current study explored associations between deployment stressors (Warfare, Military Sexual Trauma, and Concerns about Life and Family Disruptions-"Life Disruptions"), PTSD (PCL-5), and alcohol use (CAGE) post-deployment, stratified by gender among 2344 male and female veterans (1137 men; Mage = 35). Conditional process analyses examined the indirect effect of traumatic deployment experiences on alcohol use, via PTSD symptom severity, with Life Disruptions as a moderator.

RESULTS

More severe Warfare and military sexual trauma (MST) were associated with greater PTSD symptom severity, which was associated with higher problematic alcohol use. PTSD symptom severity accounted for the associations between trauma type (i.e., MST or Warfare) and alcohol use. Among women, but not men, Life Disruptions moderated the associations between trauma type (i.e., MST, Warfare) and PTSD symptom severity, such that elevated Life Disruptions amplified the associations between trauma type and PTSD symptom severity. Moderated mediation was significant for MST among women, indicating that the strength of the indirect effect (MST ➔ PTSD ➔ problematic alcohol use) was moderated by Life Disruptions; problematic alcohol use was highest for women with greater PTSD symptom severity following exposure to more severe Life Disruptions and MST (Est. = 0.0007, SE = 0.0001, CI = 0.0002 to 0.0013).

CONCLUSIONS

Taken together, alcohol use following potentially traumatic deployment experiences can be understood by considering PTSD symptom severity, gender, and Life Disruptions.

Relation of positive memory recall count and accessibility with post-trauma mental health

Positive memory encoding and retrieval deficits have an empirical relation with several post-trauma outcomes. Drawing from the Contractor et al. model, we examined relations between positive memory characteristics and post-trauma mental health indicators. A trauma-exposed community sample of 203 participants (Mage = 35.40 years; 61.10% female) was recruited via Amazon's Mechanical Turk. Participants completed measures of posttraumatic stress disorder (PTSD; PTSD Checklist for DSM-5), depression (Patient Health Questionnaire-9), posttraumatic cognitions (Posttraumatic Cognitions Inventory), affect (Positive and Negative Affect Schedule), count/number of recalled specific positive memories (Autobiographical Memory Test) and accessibility of a specific positive memory (i.e., subjective ease of recalling details of a memory; Memory Experiences Questionnaire-Short Form). Linear regression results indicated that PTSD intrusion severity, PTSD negative alterations in cognitions and mood (NACM) severity, PTSD alterations in arousal and reactivity (AAR) severity, self-blame, and positive affect significantly and negatively predicted the count of specific positive memories. Further, PTSD NACM severity, PTSD AAR severity, negative cognitions about the self, and negative affect significantly and negatively predicted accessibility of a specific positive memory. Thus, count/accessibility of specific positive memories was associated with several post-trauma mental health indicators; this highlights the relevance and potential impact of integrating positive memories into trauma treatment.

Posttraumatic stress disorder and positive memories: Clinical considerations

Encoding and retrieval difficulties, and avoidance of both traumatic and positive memories, are associated with posttraumatic stress disorder (PTSD) symptoms. However, most PTSD research and clinical work has solely examined the role of traumatic memories in the maintenance/resolution of PTSD symptoms. This review provides a comprehensive discussion of the literature on positive memories and PTSD. First, we review theories and evidence on the relations between trauma, PTSD, and memory processes (particularly positive memories). Next, we propose a conceptual model that integrates evidence from experimental and positive/memory-based intervention research and highlights hypothesized mechanisms underlying the potential effectiveness of targeting positive memories in PTSD interventions. Specifically, we discuss how targeting positive memories could (1) increase positive affect and reduce negative affect, (2) correct negative cognitions, (3) increase specificity of retrieving autobiographical memories, and (4) be effectively integrated/sequenced with and enhance the effects of trauma-focused interventions. Lastly, we suggest clinical research avenues for investigating the relations between positive memories and PTSD, to possibly alter the current PTSD intervention paradigm focused only on traumatic memories. Overall, our proposed model drawing from experimental and intervention research, and outlining potential effects of targeting positive memories to reduce PTSD severity, needs further empirical investigation.

An Examination of the Impact of Childhood Emotional Abuse and Gender on Cannabis Use Trajectories among Community Youth

Cannabis is the most frequently used illicit substance among youth, with rates of cannabis use escalating across adolescence. One potential factor predicting cannabis use among youth is childhood emotional abuse (CEA), which has been associated with substance use behaviors more broadly. Although CEA may be associated with increased cannabis use in general, it is likely that sex may have an impact on these relations, given that girls are more likely to use substances following abuse experiences than boys. The purpose of the current study as to examine longitudinal relations between CEA and gender on cannabis use during adolescence. The current study included a sample of 206 9th grade community youth (120 boys; Mage = 14.10, 55% European-American) followed annually through the 12th grade. CEA was assessed with the Childhood Trauma Questionnaire and cannabis use was assessed with the Youth Risk Behavior Survey. A latent growth model was utilized to examine cannabis use trajectories from grades 9-12. Within our initial model, elevated baseline use was associated with male gender and more severe CEA. Significant predictors of increases in cannabis use over time included elevated baseline alcohol use and the interaction between gender and CEA, such that girls with the most severe CEA had the greatest increases in cannabis use over time. These results suggest the importance of addressing CEA among adolescent girls. Given that cannabis use during adolescence is associated with a host of negative outcomes, targeted efforts to reduce use, through prevention and intervention efforts, is critical.

Associations between residential treatment length, PTSD, and outpatient healthcare utilization among veterans

Premature discontinuation of posttraumatic stress disorder (PTSD) treatment is generally associated with poorer outcomes for veterans with PTSD. What is less clear is whether treatment benefits, as a function of treatment length, persist, as well as predict less future mental health care utilization. We sought to determine whether length of stay (LOS) in residential PTSD treatment predicted discharge PTSD symptom severity and outpatient mental health care utilization. We hypothesized discharge PTSD Checklist (PCL) scores would mediate the relations between LOS in residential treatment and outpatient mental health care utilization. The current study included 740 veterans who received residential PTSD treatment within 5 VA hospitals and completed intake and discharge assessments, including the PTSD Checklist (PCL). Information about LOS in residential treatment and outpatient mental health care utilization was obtained from the National Patient Care Database. We examined the relations between residential LOS, discharge Posttraumatic Stress Disorder Checklist (PCL), and outpatient mental health care utilization. Nonparametric bootstrapping was utilized to test for the significance of the indirect effect. Veterans who stayed in residential treatment longer had lower PCL scores at discharge (est. = -2.50, SE = .51, p < .001), and veterans with lower PCL scores at discharge sought fewer outpatient mental health visits (est. = .31, SE = .14, p = .03). A bias-corrected bootstrap confidence interval for the indirect effect (ab = -.77) based on 10,000 bootstrap samples was entirely below zero (-1.72 to -.05). This indicates discharge PCL mediated the relations between LOS and outpatient mental health care utilization, such that individuals with a longer LOS in residential PTSD treatment had lower PCL scores at discharge and thus utilized less outpatient mental health care. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

A Prospective Examination of the Relations Between Emotional Abuse and Anxiety: Moderation by Distress Tolerance

Anxiety, the most common and impairing psychological problem experienced by youth, is associated with numerous individual and environmental factors. Two such factors include childhood emotional abuse (CEA) and low distress tolerance (DT). The current study aimed to understand how CEA and low DT impacted anxiety symptoms measured annually across 5 years among a community sample of youth. We hypothesized DT would moderate the relationship between CEA and anxiety, such that youth with higher levels of CEA and lower levels of DT would have elevated anxiety over time. Community youth (N = 244) were annually assessed across 5 years using the Revised Child Anxiety and Depression Scale, Childhood Trauma Questionnaire, and Behavioral Indicator of Resiliency to Distress. Higher CEA at baseline was associated with higher anxiety at baseline, higher anxiety at each annual assessment, and with greater overall decreases in anxiety over time. Lower DT was associated with higher anxiety at baseline, but did not predict changes in anxiety over time. Baseline DT significantly moderated the relationship between baseline CEA and anxiety, such that youth with both higher CEA and lower DT had the highest anxiety at each annual assessment. Youth with lower DT and higher CEA scores had the highest level of anxiety symptoms across time.

The developmental trajectory of perceived stress mediates the relations between distress tolerance and internalizing symptoms among youth

The current study examines the relation between distress tolerance, perceived stress, and internalizing symptoms across adolescence. Participants included 331 youth, ages 10 to 14 at the first wave of the study, assessed annually over 5 years. A latent growth curve approach was used to test three research questions, including whether perceived stress would increase across adolescence, whether distress tolerance (as measured by a behavioral task) would predict changes in perceived stress, and whether changes in perceived stress would mediate the relation between distress tolerance and internalizing symptoms. Results suggest that, consistent with previous findings, rates of perceived stress do increase across adolescence. Further, findings indicate that distress intolerance at baseline predicted increases in perceived stress, which in turn drove increases in internalizing symptoms. These findings point to the critical role of distress tolerance in bringing about changes in depression and anxiety symptoms and suggest support for utilizing a negative reinforcement framework to understand the emergence of internalizing symptomology.

PTSD Care Among Veterans With and Without Co-Occurring Substance Use Disorders

OBJECTIVE

This study examined whether a co-occurring substance use disorder contributed to disparities in receipt of Veterans Health Administration (VHA) posttraumatic stress disorder (PTSD) specialty care or psychotherapy.

METHODS

Logistic regression, controlling for sociodemographic characteristics, was used to examine predictors of PTSD care among 424,211 veterans with confirmed PTSD (two or more PTSD diagnosis encounters) who accessed care in a VHA facility between fiscal years 2009 and 2010.

RESULTS

Overall, 16% of veterans had PTSD and a co-occurring substance use disorder diagnosis. In adjusted analyses, veterans with a co-occurring substance use disorder were more likely than veterans with PTSD alone to receive any outpatient PTSD specialty care and complete eight or more sessions of outpatient psychotherapy within 14 weeks, but they were less likely to be treated in inpatient PTSD specialty units.

CONCLUSIONS

Co-occurring substance use disorders did not appear to hinder receipt of outpatient specialty PTSD treatment or of sufficient psychotherapy among VHA-enrolled veterans.

The impact of changes in distress tolerance on PTSD symptom severity post-treatment among veterans in residential trauma treatment

Given that rates of PTSD, particularly among military populations, are increasing, it is critical to gain a better understanding of factors associated with treatment response. Low distress tolerance (DT), conceptualized as the perceived or actual inability to tolerate negative emotional states, may impacts veterans' responses to PTSD treatment. Low DT has been associated with more severe PTSD symptoms in clinical and non-clinical samples; however, its impact on PTSD symptomatology across treatment has yet to be assessed. We examined the impact of changes in DT, from intake to discharge, on post-treatment PTSD symptom severity within two samples of veterans recruited from Veterans Affairs residential PTSD treatment facilities in the northwestern and southern United States (Total N=86; 87% male; 46% White, 39% Black, 9% Latino, 6% Other). Veterans completed the Distress Tolerance Scale and PTSD Checklist (PCL) at intake and discharge from residential PTSD treatment. Regression analyses revealed that, within each veteran sample, those with the greatest improvements in DT had the lowest PCL total and subscale scores at discharge after controlling for respective intake PCL scores. This suggests increases in DT across treatment help explain the degree of benefits experienced by veterans following PTSD treatment.

The impact of intolerance of emotional distress and uncertainty on veterans with co-occurring PTSD and substance use disorders

The risk of developing a substance use disorder (SUD) is significantly higher among veterans with posttraumatic stress disorder (PTSD). Veterans with this co-occurrence have poorer outcomes than singly diagnosed veterans, which may be related to two risk factors: intolerance uncertainty (IU) and low tolerance of emotional distress (TED). We hypothesized low TED and high IU would independently and interactively relate to heightened PTSD symptomatology and trauma-cue elicited SUD cravings. A sample of 70 veterans (M age=50; 95% men; 65% Black) with co-occurring PTSD-SUD was recruited. The Posttraumatic Stress Disorder Checklist (PCL), Craving Questionnaire, Distress Tolerance Scale, and Intolerance of Uncertainty Scale were administered. In general, low TED and high IU were significantly correlated with the PCL total and subscale scores. When examined within regression models, low TED was associated with elevated PCL scores and trauma-cue elicited SUD cravings; IU was not. However, there was a significant interaction between IU and TED; veterans with elevated IU and low TED had higher PCL Total, Hyperarousal, and Intrusions scores. This highlights the importance of assessing TED and IU among veterans with co-occurring PTSD-SUD, as these risk factors may not only be prognostic indicators of outcomes, but also treatment targets.

Common Questions About Cognitive Behavior Therapy for Psychiatric Disorders

Cognitive behavior therapy (CBT) is a time-limited, goal-oriented psychotherapy that has been extensively researched and has benefits in a number of psychiatric disorders, including anxiety, depression, posttraumatic stress disorder, attention-deficit/hyperactivity disorder, autism, obsessive-compulsive and tic disorders, personality disorders, eating disorders, and insomnia. CBT uses targeted strategies to help patients adopt more adaptive patterns of thinking and behaving, which leads to positive changes in emotions and decreased functional impairments. Strategies include identifying and challenging problematic thoughts and beliefs, scheduling pleasant activities to increase environmental reinforcement, and extended exposure to unpleasant thoughts, situations, or physiologic sensations to decrease avoidance and arousal associated with anxiety-eliciting stimuli. CBT can be helpful in the treatment of posttraumatic stress disorder by emphasizing safety, trust, control, esteem, and intimacy. Prolonged exposure therapy is a CBT technique that includes a variety of strategies, such as repeated recounting of the trauma and exposure to feared real-world situations. For attention-deficit/hyperactivity disorder, CBT focuses on establishing structures and routines, and clear rules and expectations within the home and classroom. Early intensive behavioral interventions should be initiated in children with autism before three years of age; therapy consists of 12 to 40 hours of intensive treatment per week, for at least one year. In many disorders, CBT can be used alone or in combination with medications. However, CBT requires a significant commitment from patients. Family physicians are well suited to provide collaborative care for patients with psychiatric disorders, in concert with cognitive behavior therapists.

Maternal risk taking on the balloon analogue risk task as a prospective predictor of youth alcohol use escalation

The transition from late childhood through middle adolescence represents a critical developmental period during which there is a rapid increase in the initiation and escalation of alcohol use. Alcohol use is part of a constellation of risk taking behaviors that increase during this developmental transition, which can be explained by environmental and genetic factors. Social learning theory (SLT) implicates observations of parental drinking in the development of alcohol use in youth. Parental risk taking more broadly has not previously been examined as a factor predictive of alcohol use escalation in youth across adolescence. The current study examined the relative contributions of maternal risk taking on the Balloon Analogue Risk Task (BART) and maternal alcohol use in the prediction of alcohol escalation among youth over three years. Participants were a sample of 245 youth (55.0% male, 49.6% Caucasian) who participated annually between grades 8 and 10, drawn from a larger study of adolescent risk taking. Within our sample, maternal risk taking, as measured by the BART, predicted increases in alcohol use. Interestingly, maternal alcohol use and other youth factors were not predictive of escalations in youth alcohol use. Our findings suggest the importance of considering maternal riskiness more broadly, rather than solely focusing on maternal alcohol use when attempting to understand youth alcohol use across adolescence. These findings emphasize the relevance of maternal risk taking as measured by a behavioral task and suggest a general level of riskiness displayed by mothers might encourage youth to behave in a riskier manner themselves.

Early adolescent symptoms of social phobia prospectively predict alcohol use

OBJECTIVE

The current study examined whether social phobia (SP) symptoms in early adolescence prospectively predicted alcohol use through middle adolescence in a community sample of youth.

METHOD

Data from an ongoing longitudinal study (N = 277) of mechanisms of HIV-related risk behaviors in youth were used to assess the extent to which SP symptoms in early adolescence (mean [SD] age = 11.00 years [0.81]) would predict alcohol use across five annual assessment waves. Adolescents completed measures of SP symptoms, depressive symptoms, and alcohol use at each wave.

RESULTS

Higher SP symptoms at baseline predicted higher average odds of alcohol consumption during subsequent waves but did not significantly predict an increase in the odds of alcohol use as a function of time. Within a lagged model, SP symptoms measured at a prior assessment point (1 year earlier) predicted greater odds of drinking alcohol at the following assessment point. Importantly, alcohol use did not significantly predict SP symptoms over time. These results suggest that early SP symptoms are an important risk factor for increased odds of subsequent alcohol use.

CONCLUSIONS

The present findings highlight that elevated SP symptoms place adolescents at risk for early alcohol use. Early interventions targeting SP symptoms may be crucial for the prevention of problematic alcohol use in early to mid-adolescence. Implications for prevention and treatment approaches are discussed.

Variation in SLC1A1 is related to combat-related posttraumatic stress disorder

Candidate gene studies have yet to investigate the glutamate system, the primary excitatory neurotransmitter of the HPA-axis related to PTSD risk. We investigated 13 SNPs in the glutamate transporter gene (SLC1A1) in relation to PTSD among combat-exposed veterans. Participants (n=418) completed a diagnostic interview and provided a blood sample for DNA isolation and genotyping. A subset of participants (n=391) had severity and combat exposure data available. In the primary logistic regression gender and rs10739062 were significant predictors of PTSD diagnosis (OR=0.50; OR=1.43). In the linear regression analysis, combat exposure was the only significant predictor (β=0.16) of severity. A computed genetic risk sum score was significant in relation to PTSD diagnosis (OR=1.15) and severity scores (β=0.14) above and beyond the effects of combat exposure. This study provides preliminary support for the relationship of glutamate transporter polymorphisms to PTSD risk and the need for further genetic studies within this system.

The relationship between child abuse and negative outcomes among substance users: psychopathology, health, and comorbidities

BACKGROUND

Adults with substance use disorders (SUDs) report higher rates of child abuse than adults without SUDs. Prior work suggests that this abuse is associated with higher rates of psychosis, posttraumatic stress disorder, physical health problems, alcohol dependence, and cannabis dependence among substance users. Little is known about other problems associated with child abuse experienced by substance users. We hypothesized that among adults with SUDs, child abuse would be associated with elevated rates of all Diagnostic and Statistical Manual (DSM-IV-TR) psychiatric disorders, substance dependencies, and comorbidities assessed.

METHOD

We assessed 280 inpatients in substance use treatment with the Structured Clinical Interview for the DSM-IV-TR, the Diagnostic Instrument for Personality Disorders, and Childhood Trauma Questionnaire (CTQ). We used chi-square and regression analyses to establish whether rates of psychiatric disorders, substance dependencies, and comorbidities differed as a function of child abuse.

RESULTS

Consistent with our hypotheses, higher scores on the CTQ were associated with elevated rates of psychiatric disorders (mood disorders, anxiety disorders, psychotic symptoms, and personality disorders) and substance dependencies (alcohol dependence and cocaine dependence). Moreover, higher rates of all comorbidity patterns (e.g. comorbid alcohol dependence and anxiety) were observed among individuals who reported experiencing child abuse. Across all substance dependencies examined, individuals who had been abused had significantly higher rates of all psychiatric disorders assessed.

CONCLUSIONS

Individuals with substance use disorders who have been abused have particularly elevated rates of psychiatric and substance use disorders as a function of their abuse experiences. These findings have important treatment implications for individuals in residential substance use treatment settings.

The mediating role of depression in the relationship between anxiety sensitivity and alcohol dependence

BACKGROUND

Many studies have reported that Anxiety Sensitivity (AS) is positively associated with alcohol use or other alcohol-related variables. More recent mediator and moderator models have shown promise in elucidating mechanisms within this relationship; the literature to date suggests that the relationship between AS and alcohol is likely mediated by problematic coping motives. However, few studies have considered the effects of depression within the AS-alcohol use relationship, despite a strong body of evidence linking AS to subsequent depression and depression to subsequent alcohol use problems, independently. Therefore, the current study assessed depression as a potential mediator of this relationship.

METHOD

Participants were 418 sequential admissions to a substance abuse treatment facility. A mediation analysis using bootstrapping was utilized in order to estimate indirect effects of AS on alcohol dependence through depression.

RESULTS

Results reveal an indirect effect suggesting that the effects of anxiety sensitivity on alcohol dependence are mediated by symptoms of depression. More specifically, the effects of AS total score and AS somatic sensations on alcohol dependence were mediated by symptoms of depression. Lastly, a dual mediator model demonstrated that both depression and problematic coping uniquely mediate the relationship between AS and alcohol dependence.

CONCLUSIONS

While preliminary in nature, the current study provides evidence supporting the hypothesis that depression is an important factor to consider when examining the relationship between AS and alcohol dependence.

A Case Series of a Behavioral Activation−Enhanced Smoking Cessation Program for Inpatient Substance Users With Elevated Depressive Symptoms

Smoking is the leading preventable cause of death and disease in the world and represents a critical public health problem. Smokers with substance use disorders and depressive symptoms have particular difficulties quitting smoking and represent an underserved population. The current study utilized a novel behavioral activation (BA)−enhanced smoking cessation treatment with three clients in residential substance use treatment who had elevated depressive symptoms. We present detailed descriptions of the treatment they received and the challenges they faced. Our clients, who received five individual BA-enhanced smoking cessation sessions and two follow-up booster sessions, benefited significantly from the BA treatment. Over an 8-week follow-up period, they did not relapse to smoking and experienced significant decreases in depressive symptoms. This suggests BA may be a beneficial treatment strategy for this particularly challenging population.

The impact of childhood abuse on inpatient substance users: specific links with risky sex, aggression, and emotion dysregulation

Adults with substance use disorders (SUDs) report a high prevalence of childhood abuse. Research in the general population suggests specific types of abuse lead to particular negative outcomes; it is not known whether this pattern holds for adults with SUDs. We hypothesized that specific types of abuse would be associated with particular behavioral and emotional outcomes among substance users. That is, childhood sexual abuse would be associated with risky sex behaviors, childhood physical abuse with aggression, and childhood emotional abuse with emotion dysregulation. 280 inpatients (M age=43.3; 69.7% male; 88.4% African American) in substance use treatment completed the Childhood Trauma Questionnaire (CTQ), HIV Risk-Taking Behavior Scale, Addiction Severity Index, Difficulties with Emotion Regulation Scale (DERS), Distress Tolerance Scale (DTS), and Affect Intensity and Dimensions of Affiliation Motivation (AIM). Consistent with our hypotheses, the CTQ sexual abuse subscale uniquely predicted exchanging sex for cocaine and heroin, number of arrests for prostitution, engaging in unprotected sex with a casual partner during the prior year, and experiencing low sexual arousal when sober. The physical abuse subscale uniquely predicted number of arrests for assault and weapons offenses. The emotional abuse subscale uniquely predicted the DERS total score, AIM score, and DTS score. Among substance users, different types of abuse are uniquely associated with specific negative effects. Assessment of specific abuse types among substance users may be informative in treatment planning and relapse prevention.

A Preliminary Examination of the Relationship Between the 5-HTTLPR and Childhood Emotional Abuse on Depressive Symptoms in 10-12-Year-Old Youth

Childhood emotional abuse (CEA) is a pervasive problem associated with negative sequelae such as elevated depressive symptoms. Key stress-related genes, such as the 5-HTTLPR polymorphism, interact with childhood abuse to produce elevated depressive symptoms in older adolescent girls, but not in older adolescent boys. To date, studies have not examined this relationship as a function of CEA specifically or among younger adolescents. To extend prior work, we examined the effects of the 5-HTTLPR and CEA on depressive symptoms among 10-12-year-old youth. Based on previous findings, we expected a main effect of CEA on depressive symptoms among all youth, but only expected an interactive effect between the 5-HTTLPR and CEA on depressive symptoms in girls. In the current study, 222 youth (mean age 11.02 years, 44.1% girls, 51.6% Caucasian, 33.0% African American, 2.7% Latino, and 12.7% other) and their parent(s)/guardian(s) completed the Revised Child Anxiety and Depression Scale and the Emotional Abuse subscale of the Childhood Trauma Questionnaire and provided saliva samples for genotyping the 5-HTTLPR. Results indicate that CEA, but not the 5-HTTLPR, was related to elevated depressive symptoms among boys. Among girls, each copy of the s allele of the 5-HTTLPR was related to increased depressive symptoms, but only for those who had experienced CEA. Our results extend prior findings by specifically examining CEA and by focusing on 10-12-year-old youth. These results, although preliminary, suggest that focusing on the interplay between putative genetic markers and a broader range of environmental events, such as CEA, might allow researchers to determine factors differentially influencing the later emergence of sex differences in depressive symptoms.

Clinical characteristics as a function of referral status among substance users in residential treatment

In the United States, substance users who voluntarily (VO) elect to receive treatment and substance users who are court-mandated (CM) to receive treatment typically obtain care within the same facilities. Little is known about the clinical characteristics that differentiate these individuals. The current study provides rates of specific DSM-IV Axis I and Axis II psychiatric and substance use disorders, comorbidities, childhood trauma, motivation, and other clinical and demographic characteristics as a function of referral status, among individuals in residential substance use treatment (463 participants, M age=43.3; 69.7% male; 88.4% African American). Participants were interviewed and diagnosed using the Structure Clinical Interview for DSM-IV and the Diagnostic Interview for Personality Disorders. Within our sample, VO individuals, as compared to CM individuals had significantly higher rates of psychiatric disorders (68.7% versus 55.2%, respectively), including mood disorders, major depressive disorder, generalized anxiety disorder, and borderline personality disorder. Additionally, they were significantly more likely to have alcohol dependence (43.0% versus 20.8%) and cocaine dependence (66.5% versus 48.9%). Elevated rates of comorbidities and childhood abuse were also observed among VO individuals, while motivation did not differ as a function of referral status. Overall, VO individuals appeared to have more severe problems than their CM counterparts which may suggest that they require more intensive or different types of treatment.