Testing adaptive interventions to improve PTSD treatment outcomes in Federally Qualified Health Centers: Protocol for a randomized clinical trial

BACKGROUND

Posttraumatic stress disorder (PTSD) disproportionately affects low-income individuals and is untreated in 70% of those affected. One third of low-income Americans are treated in Federally Qualified Health Centers (FQHCs), which do not have the capacity to provide all patients with first-line treatments such as Prolonged Exposure (PE). To address this problem, FQHCs could use low-intensity interventions (e.g., Clinician-Supported PTSD Coach: CS PTSD Coach) and medium-intensity interventions (e.g., PE for Primary Care: PE-PC) to treat PTSD with fewer resources. However, some patients will still require high-intensity treatments (e.g., full-length PE) for sustained clinical benefit. Thus, there is a critical need to develop stepped-care models for PTSD in FQHCs.

METHOD

We are conducting a Sequential, Multiple Assignment, Randomized Trial (SMART) with 430 adults with PTSD in FQHCs. Participants are initially randomized to CS PTSD Coach or PE-PC. After four sessions, early responders step down to lower frequency interaction within their assigned initial treatment strategy. Slow responders are re-randomized to either continue their initial treatment strategy or step up to Full PE for an additional eight weeks. The specific aims are to test the effectiveness of initiating treatment with PE-PC versus CS PTSD Coach in reducing PTSD symptoms and to test the effectiveness of second-stage strategies (continue versus step-up to Full PE) for slow responders.

CONCLUSIONS

This project will provide critical evidence to inform the development of an effective stepped-care model for PTSD. Testing scalable, sustainable sequences of PTSD treatments delivered in low-resource community health centers will improve clinical practice for PTSD.

Feasibility and Acceptability of Prolonged Exposure in Primary Care (PE-PC) for Posttraumatic Stress Disorder in Federally Qualified Health Centers: A Pilot Study

Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder that affects 6% of U.S. adults, yet is treated in only 30% of affected individuals and even fewer low-income individuals. One third of the nation’s low-income individuals are treated in Federally Qualified Health Centers (FQHCs). Most of these facilities lack capacity to provide their patients with first-line, evidence-based treatments for PTSD such as Prolonged Exposure (PE). To address this problem, PE has been adapted for use in a primary care setting and demonstrated efficacy in a brief model for military service members (PE in Primary Care: PE-PC). The effectiveness of this treatment in civilian, low-resource settings such as FQHCs is unknown. This pilot study tested the feasibility and acceptability of PE-PC in 30 Michigan FQHC patients. High rates of therapy participation suggest that the intervention was feasible and acceptable. Semi-structured interview data from 10 patients and 5 FQHC providers indicated that the intervention was helpful and filled a critical need for effective PTSD treatment in the FQHC setting. Interviews also elucidated barriers such as transportation, provider training, and time commitment for patients and providers. These findings set the stage for a full-scale randomized controlled trial to test the effectiveness of PE-PC on PTSD symptoms in this low-resource, high-need setting.

Trial registry ClinicalTrials.gov Identifier: NCT03711266. October 18, 2018.

Combat-Related Posttraumatic Stress Disorder and Comorbid Major Depression in U.S. Veterans: The Role of Deployment Cycle Adversity and Social Support

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) commonly co-occur in combat veterans, and this comorbidity has been associated with higher levels of distress and more social and economic costs compared to one disorder alone. In a secondary analysis of a multisite randomized controlled trial of a sample of veterans with combat-related PTSD, we examined the associations among pre-, peri-, and postdeployment adversity, social support, and clinician-diagnosed comorbid MDD. Participants completed the Deployment Risk and Resilience Inventory and the Beck Depression Inventory-II as well as structured clinical interviews for diagnostic status. Among 223 U.S. veterans of the military operations in Iraq and Afghanistan (86.9% male) with primary combat-related PTSD, 69.5% had current comorbid MDD. After adjustment for sex, a linear regression model indicated that more concerns about family disruptions during deployment, f² = 0.065; more harassment during deployment, f² = 0.020; and lower ratings of postdeployment social support, f² = 0.154, were associated with more severe self-reported depression symptoms. Interventions that enhance social support as well as societal efforts to foster successful postdeployment reintegration are critical for reducing the mental health burden associated with this highly prevalent comorbidity in veterans with combat-related PTSD.

PTSD as a Mediator in the Relationship Between Post-Concussive Symptoms and Pain Among OEF/OIF/OND Veterans

Introduction

Traumatic brain injury (TBI), pain, and post-traumatic stress disorder (PTSD) commonly co-occur in Veteran populations, particularly among Veterans returning from the recent conflicts in Iraq and Afghanistan. Extant research indicates that both TBI and PTSD can negatively impact pain broadly; however, less is known about how these variables impact one another. The current study examines the impact of self-reported post-concussive symptoms on both pain severity and pain interference among Veterans with PTSD who screened positive for a possible TBI, and subsequently, evaluates the potential mediating role of PTSD in these relationships.

Materials and Methods

Participants were 126 combat Veterans that served in Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn who were being evaluated for participation in a multisite treatment outcomes study. As part of an initial evaluation for inclusion in the study, participants completed several self-report measures and interviews, including the Brief Traumatic Brain Injury Screen, Neurobehavioral Symptom Inventory, Brief Pain Inventory, and the Clinician Administered PTSD Scale, which were utilized in these analyses.

Results

For pain severity, greater post-concussive symptoms significantly predicted increased pain severity with a significant indirect effect of post-concussive symptoms on pain severity through PTSD (indirect effect = 0.03; 95% confidence interval = 0.0094-0.0526). Similar results were found for pain interference (indirect effect = 0.03; 95% confidence interval = 0.0075-0.0471).

Conclusions

These findings replicate and extend previous findings regarding the relationship between TBI, pain, and PTSD. Self-reported post-concussive symptoms negatively impact both pain severity and pain interference among Veterans with probable TBI, and PTSD serves as a mediator in these relationships. Clinically, these results highlight the importance of fully assessing for PTSD symptoms in Veterans with a history of TBI presenting with pain. Further, it is possible that providing effective PTSD treatment to reduce PTSD severity may provide some benefit in reducing post-concussive and pain symptoms.

Postconcussive symptoms (PCS) following combat-related traumatic brain injury (TBI) in Veterans with posttraumatic stress disorder (PTSD): Influence of TBI, PTSD, and depression on symptoms measured by the Neurobehavioral Symptom Inventory (NSI)

Mild traumatic brain injury (mTBI) is commonly reported in recent combat Veterans. While the majority resolve, some Veterans develop postconcussive symptoms (PCS). Previous research suggests these symptoms are not specific to head injury and are often associated with psychiatric symptoms. The current study examines the relative contributions of posttraumatic stress, depressive symptoms, and TBI on postconcussive symptoms, and explores whether the relationship remains after controlling for symptom overlap. Two hundred eighteen combat Veterans from Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) provided the data for this study as part of a baseline evaluation for inclusion into larger treatment study for posttraumatic stress disorder (PTSD). Participants completed the Brief Traumatic Brain Injury Screen (BTBIS), Neurobehavioral Symptom Inventory (NSI), PTSD Checklist-Stressor Version (PCL-S), Beck Depression Inventory-II (BDI-II). Significant differences in NSI total score between individuals with and without history of TBI were not found. A series of regression analyses demonstrated that Depression and PTSD were significant predictors of NSI score even after removal of NSI symptoms that overlap with PTSD or depression. TBI status was also a significant predictor of PCS in most models, but its relative contribution was much smaller than that of depression and PTSD. Within PTSD symptoms, hyperarousal cluster was a significant predictor of NSI scores. Findings demonstrate that depression and PTSD are related to PCS beyond similarities in construct. Further, within a primarily PTSD treatment-seeking population, these psychiatric symptoms appear to be a stronger contributor than TBI.

Sleep disturbances as predictors of prolonged exposure therapy effectiveness among veterans with PTSD

Sleep disturbances (SD) are pronounced in Veterans with posttraumatic stress disorder (PTSD). In clinical trials, SD have been shown to limit the effectiveness of evidence-based treatments for non-PTSD disorders. The purpose of this study was to investigate the relationships between pretreatment SD and the effectiveness of Prolonged Exposure (PE) therapy for Veterans with PTSD. Twenty-one Veterans completed the Pittsburgh Sleep Quality Index (PSQI) and the Clinician Administered PTSD Scale upon presenting to a PTSD specialty clinic. Veterans completed the PTSD Symptom Checklist-Civilian (PCL-C) at the initiation of PE and biweekly thereafter for the duration of treatment (96 total assessments). Correlations and hierarchical linear modeling were utilized to examine the potential impact of baseline sleep variables on the slope and magnitude of treatment outcomes. Higher PSQI total scores, and higher sleep latency and sleep medication use subscale scores were associated with higher PCL-C scores at baseline. Veterans evidenced significant reductions in PTSD symptoms during the course of the treatment study. Total PSQI scores and composites were not associated with reduced effectiveness of PE treatment or the slope of PTSD symptom changes. Sleep disturbances do not preclude Veterans from benefits derived from engagement in this gold standard PTSD intervention.

The Role of Distress Tolerance in the Use of Specific Emotion Regulation Strategies

The present study evaluated the role of distress tolerance (DT), defined as the ability to tolerate negative emotional states, in the use of four specific emotion regulation strategies (suppression, avoidance, rumination, and reappraisal). Undergraduate psychology students ( N = 431, 71.7% female; Mage = 19.80 years, SD = 3.71) completed self-report measures online for course credit. It was hypothesized that, after controlling for the effects of anxiety sensitivity and negative affectivity, DT would be negatively associated with suppression, avoidance, and rumination, and positively associated with reappraisal. Consistent with prediction, low DT significantly predicted greater use of suppression, avoidance, and rumination. However, contrary to prediction, DT did not significantly predict reappraisal. These results suggest that individuals who are unable to withstand negative emotions are more likely to use maladaptive regulation strategies.

Evaluating the role of anxiety sensitivity in barriers to cessation and reasons for quitting among smokers with asthma

The aim of the present study was to examine the unique predictive ability of anxiety sensitivity (AS) in terms of perceived barriers to cessation and smoking cessation motives among daily smokers with asthma (n = 125, 54% male, Mage = 37.7 years, SD = 12.1). As hypothesized, after controlling for the effects of race, asthma control, negative affect, and smoking rate, AS significantly predicted greater barriers to cessation, and reasons for quitting related to health concerns and self-control. Contrary to hypotheses, AS did not significantly predict external reasons for quitting. These findings suggest that smokers with asthma who are fearful of physiological arousal may be a particularly 'at-risk' population for smoking cessation difficulties due, in part, to greater perceived barriers to cessation. Interventions focused on enhancing intrinsic motivation for quitting and reducing AS may be most effective for this population.

Anxiety sensitivity as a mediator of the association between asthma and smoking

OBJECTIVE

Despite its negative effects, smoking is more common among individuals with asthma compared to those without. Anxiety sensitivity (fear of arousal-related sensations) is associated with both smoking and asthma; however, no research, to date, has examined the interplay between these three factors. Thus, the purpose of the current study was to evaluate the mediating role of anxiety sensitivity in the association between asthma diagnosis and smoking status.

METHODS

The current study was a secondary analysis of data from three existing datasets of non-smokers and smokers with and without asthma (n = 433; 56.3% female, M(age) = 34.01 years, SD = 13.9). Participants provided information on their asthma diagnosis status and smoking status and completed self-report measures.

RESULTS

As hypothesized, after controlling for gender, race and age, there was a significant indirect effect of asthma diagnosis on smoking status through anxiety sensitivity (95% CI = 0.07-0.48).

CONCLUSIONS

These results indicate that the association between asthma diagnosis and smoking status appears to be driven, in part, by anxiety sensitivity and suggest that anxiety sensitivity may serve as an important target for prevention and intervention efforts for smokers with asthma.

Distress tolerance and perceived barriers to smoking cessation

BACKGROUND

The present study examined the role of emotional distress tolerance (DT) in predicting barriers to smoking cessation and number of quit attempts.

METHODS

The sample consisted of regular daily smokers (N = 126; 37 females; M age = 36.51, SD = 13.05) who completed self-report measures on affect and smoking.

RESULTS

After controlling for daily smoking rate and anxiety sensitivity, emotional DT significantly predicted internal barriers to cessation (6.9% unique variance) but not external or addiction-related barriers to cessation. Inconsistent with prediction, emotional DT did not significantly predict number of quit attempts.

CONCLUSIONS

These results suggest that individuals who are low in emotional DT believe that quitting smoking will be difficult because it takes away an important affect regulation strategy, and there may be utility in targeting emotional DT in smoking cessation interventions.

The role of mindfulness skills in terms of distress tolerance: a pilot test among adult daily smokers

BACKGROUND AND OBJECTIVES

Low distress tolerance is associated with difficulties quitting smoking. Mindfulness is associated with improved cessation outcomes and may be one method by which to increase distress tolerance. The purpose of the current study was to examine the relationship between mindfulness skills and distress tolerance among regular smokers.

METHODS

Daily smokers (n=125; Mage=37.5, 70% male) completed self-report measures assessing smoking and emotions.

RESULTS

After controlling for age, gender, and nicotine dependence, and education the mindfulness skills of acting with awareness and accepting without judgment significantly predicted distress tolerance.

DISCUSSION AND CONCLUSIONS

For smokers, being able to pay attention to present moment vents and accept negative events without judgment is associated with a greater ability to withstand such events.

SCIENTIFIC SIGNIFICANCE

These findings suggest that mindfulness-based approaches to smoking cessation may be effective because of improvements in distress tolerance. However, future prospective and laboratory-based studies are needed to better understand the mindfulness-distress tolerance link among smokers.

Asthma and aerobic exercise: a review of the empirical literature

OBJECTIVE

The purpose of the present article was to provide a comprehensive review of the empirical literature on the association between asthma and aerobic exercise among adults.

METHODS

A literature search was conducted utilizing electronic search engines (i.e., PsycINFO and PubMed) using the following keyword algorithms: asthma AND (exercise OR physical activity).

RESULTS

These searches resulted in approximately 5665 citations. Only results that were directly relevant were included in the present review.

CONCLUSIONS

Overall, empirical evidence suggests that (1) individuals with asthma are less likely to engage in physical activity than those without asthma, (2) individuals with asthma are not biased in their subjective reporting of symptoms during aerobic exercise, (3) physical inactivity among individuals with asthma is associated with negative health consequences and increased asthma-related difficulties, and (4) regular aerobic exercise improves asthma symptom management, lung function, and mental health.

Asthma and its relation to smoking behavior and cessation motives among adult daily smokers

Despite the negative effects of smoking on lung functioning and overall health, smoking is more prevalent among individuals with asthma compared to those without asthma. The purpose of this study was to examine the predictive ability of asthma diagnosis in terms of smoking behavior and reasons for quitting. Participants were 251 regular daily smokers: 125 smokers with self-reported, physician-diagnosed asthma and 126 smokers without asthma. Asthma diagnosis significantly predicted age of regular smoking onset, number of quit attempts, and reasons for quitting related to self-control suggesting that smokers with asthma may have more difficulty quitting and unique reasons for quitting.

Anxiety sensitivity, asthma control, and quality of life in adults with asthma

OBJECTIVE

The aim of this study was to examine the role of anxiety sensitivity (AS) in terms of asthma control and asthma-related quality of life in a sample of adults with a physician-verified diagnosis of asthma.

METHODS

Self-report measures assessing psychological and asthma symptoms were mailed to 368 asthma patients from a community allergy and asthma office who had been seen for a physician follow-up visit between 1 January 2009 and 1 January 2010. Participants in the current study were 127 asthma patients (74% female; M(age) = 43.4 years, SD = 12.3) who completed and returned the self-report measures.

RESULTS

The results indicated that, after controlling for gender, age, negative affect, and number of comorbid medical problems, the physical concerns factor of AS (AS-Physical Concerns) significantly predicted asthma control and all domains of asthma-related quality of life (symptoms, activity limitations, emotional functioning, and environmental stimuli).

CONCLUSIONS

These findings replicate and extend previous research and indicate that the fear of physical sensations negatively affects both asthma control and quality of life. These findings also suggest that targeting the AS-Physical Concerns may be a novel way to improve asthma control and quality of life.