1
|
Porter KE, Stein MB, Grau PP, Kim HM, Powell C, Hoge CW, Venners MR, Smith ER, Martis B, Simon NM, Liberzon I, Rauch SAM. Impact of PTSD treatment on postconcussive symptoms in veterans: A comparison of sertraline, prolonged exposure, and their combination. J Psychiatr Res 2024; 173:64-70. [PMID: 38503135 DOI: 10.1016/j.jpsychires.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/29/2024] [Accepted: 03/07/2024] [Indexed: 03/21/2024]
Abstract
Many Veterans who served in Iraq and Afghanistan struggle with posttraumatic stress disorder (PTSD) and the effects of traumatic brain injuries (TBI). Some people with a history of TBI report a constellation of somatic, cognitive, and emotional complaints that are often referred to as postconcussive symptoms (PCS). Research suggests these symptoms may not be specific to TBI. This study examined the impact of PTSD treatment on PCS in combat Veterans seeking treatment for PTSD. As part of a larger randomized control trial, 198 Operation Iraqi Freedom, Operation Enduring Freedom, Operation New Dawn (OIF/OEF/OND) Veterans with PTSD received Prolonged Exposure Therapy, sertraline, or the combination. Potential deployment related TBI, PCS, PTSD and depression symptoms were assessed throughout treatment. Linear mixed models were used to predict PCS change over time across the full sample and treatment arms, and the association of change in PTSD and depression symptoms on PCS was also examined. Patterns of change for the full sample and the subsample of those who reported a head injury were examined. Results showed that PCS decreased with treatment. There were no significant differences across treatments. No significant differences were found in the pattern of symptom change based on TBI screening status. Shifts in PCS were predicted by change PTSD and depression. Results suggest that PCS reduced with PTSD treatment in this population and are related to shift in depression and PTSD severity, further supporting that reported PCS symptoms may be better understood as non-specific symptoms.
Collapse
Affiliation(s)
- Katherine E Porter
- Mental Health Service Line, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA; Mental Health Service Care VA San Diego Healthcare System, San Diego, CA, USA
| | - Peter P Grau
- Mental Health Service Line, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA; VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Ann Arbor, MI, USA
| | - H Myra Kim
- University of Michigan, Consulting for Statistics, Computing and Analytics Research, Ann Arbor, MI, USA
| | - Corey Powell
- University of Michigan, Consulting for Statistics, Computing and Analytics Research, Ann Arbor, MI, USA
| | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Margaret R Venners
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo, Park, CA, USA; Research Service Line, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Erin R Smith
- Mental Health Service Line, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Brian Martis
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA; Mental Health Service Care VA San Diego Healthcare System, San Diego, CA, USA
| | - Naomi M Simon
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, USA
| | - Israel Liberzon
- Department of Psychiatry & Behavioral Science, Texas A&M Health, Bryan, TX, USA
| | - Sheila A M Rauch
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, USA; Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, USA; Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
2
|
Rauch SA, Venners MR, Ragin C, Ruhe G, Lamp K, Burton M, Pomerantz A, Bernardy N, Schnurr PP, Hamblen JL, Possemato K, Sripada R, Wray LO, Dollar K, Wade M, Astin MC, Cigrang JA. Treatment of posttraumatic stress disorder with prolonged exposure for primary care (PE-PC): Effectiveness and patient and therapist factors related to symptom change and retention. Psychol Serv 2023; 20:745-755. [PMID: 37326566 PMCID: PMC10721715 DOI: 10.1037/ser0000783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Prolonged exposure (PE) is a first-line treatment for posttraumatic stress disorder (PTSD) available in specialty mental health. PE for primary care (PE-PC) is a brief version of PE adapted for primary care mental health integration, composed of four-eight, 30-min sessions. Using retrospective data of PE-PC training cases from 155 Veterans Health Administration (VHA) providers in 99 VHA clinics who participated in a 4- to 6-month PE-PC training and consultation program, we examined patients' PTSD and depression severity across sessions via mixed effects multilevel linear modeling. Additionally, hierarchical logistic regression analysis was conducted to assess predictors of treatment dropout. Among 737 veterans, medium-to-large reductions in PTSD (intent-to-treat, Cohen's d = 0.63; completers, Cohen's d = 0.79) and small-to-medium reductions in depression (intent-to-treat, Cohen's d = 0.40; completers, Cohen's d = 0.51) were observed. The modal number of PE-PC sessions was five (SD = 1.98). Providers previously trained in both PE and cognitive processing therapy (CPT) were more likely than providers who were not trained in either PE or CPT to have veterans complete PE-PC (OR = 1.54). Veterans with military sexual trauma were less likely to complete PE-PC than veterans with combat trauma (OR = 0.42). Asian American and Pacific Islander veterans were more likely than White veterans to complete treatment (OR = 2.93). Older veterans were more likely than younger veterans to complete treatment (OR = 1.11). (PsycInfo Database Record (c) 2023 APA, all rights reserved).
Collapse
Affiliation(s)
- Sheila A.M. Rauch
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
- Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
- Emory University School of Medicine, Atlanta, GA, 30029
| | - Margaret R. Venners
- National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA, 94025
| | - Carly Ragin
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
| | - Gretchen Ruhe
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
| | - Kristen Lamp
- Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
| | - Mark Burton
- Emory University School of Medicine, Atlanta, GA, 30029
| | - Andrew Pomerantz
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington DC
| | - Nancy Bernardy
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, VT, 05009
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, 03755
| | - Paula P. Schnurr
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, VT, 05009
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, 03755
| | - Jessica L. Hamblen
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, VT, 05009
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, 03755
| | - Kyle Possemato
- VA Center for Integrated Healthcare, VA Medical Center, Syracuse, NY 13204
- Department of Psychology, Syracuse University, Syracuse, NY, 13244
| | - Rebecca Sripada
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, 48105
| | - Laura O. Wray
- VA Center for Integrated Healthcare, VA Medical Center, Syracuse, NY 13204
- Department of Psychology, Syracuse University, Syracuse, NY, 13244
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY
| | - Katherine Dollar
- VA Center for Integrated Healthcare, VA Medical Center, Syracuse, NY 13204
- Department of Psychology, Syracuse University, Syracuse, NY, 13244
| | - Michael Wade
- VA Center for Integrated Healthcare, VA Medical Center, Syracuse, NY 13204
| | - Millie C. Astin
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
- Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, 30033
| | - Jeffrey A. Cigrang
- School of Professional Psychology, Wright State University, Dayton, OH, 45402
| |
Collapse
|
3
|
Rauch SA, Kim HM, Venners MR, Porter K, Norman SB, Simon NM, Rothbaum BO, Tuerk PW, Acierno R, Bui E, Powell C, Smith ER, Goetter E, McSweeney L. Change in posttraumatic stress disorder-related thoughts during treatment: Do thoughts drive change when pills are involved? J Trauma Stress 2022; 35:496-507. [PMID: 34973039 PMCID: PMC9446312 DOI: 10.1002/jts.22762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/16/2021] [Accepted: 08/28/2021] [Indexed: 11/09/2022]
Abstract
Posttraumatic negative thoughts about one's self and the world are related to posttraumatic stress disorder (PTSD) symptom severity and change in cognitive behavioral treatment (CBT), but little is known about this association when CBT is delivered with medication. The current study presents a planned comparison of changes in negative posttraumatic thoughts during (a) prolonged exposure (PE) plus pill placebo (PE+PLB), (b) sertraline plus enhanced medication management (SERT+EMM), and (c) PE plus sertraline (PE+SERT) as part of a randomized clinical trial in a sample of 176 veterans. Lagged regression modeling revealed that change in posttraumatic negative thoughts was associated with PTSD symptom change in the conditions in which participants received sertraline, ds = 0.14-0.25, ps = 0.04-.001). However, contrary to previous research, the models that started with symptom change were also statistically significant, d = 0.23, p < .001, for the lagged effect of symptoms on negative thoughts about self in the SERT+EMM condition, indicating a bidirectional association between such thoughts and PTSD symptoms. In the PE+PLB condition, no significant association between posttraumatic thoughts and PTSD symptoms emerged in either direction. These results suggest that the previously demonstrated role of change in posttraumatic thoughts leading to PTSD symptom reduction in PE may be altered when combined with pill administration, either active or placebo.
Collapse
Affiliation(s)
- Sheila A.M. Rauch
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033,Emory University School of Medicine, 12 Executive Park, 3 Floor, Atlanta, GA, 30029
| | - H. Myra Kim
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105,University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI, 48109
| | | | - Katherine Porter
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105,University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI, 48109
| | - Sonya B. Norman
- National Center for PTSD, 215 N. Main Street, White River Junction, VT 05009,VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Drive, MC116B, San Diego, CA 92161,University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92037
| | - Naomi M. Simon
- Massachusetts General Hospital, Department of Psychiatry, One Bowdoin Square, 6th Floor, Boston, MA 02114,New York University Medical School, Department of Psychiatry, One Park Avenue 8 Floor, New York NY 10016
| | - Barbara O. Rothbaum
- Emory University School of Medicine, 12 Executive Park, 3 Floor, Atlanta, GA, 30029
| | - Peter W. Tuerk
- University of Virginia, Department of Human Services, 417 Emmet St. South, PO Box 400270, Charlottesville, VA 22903
| | - Ron Acierno
- Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC, 29401,Medical University of South Carolina, College of Nursing, Jonathan Lucas Street, Charleston, SC 29425
| | - Eric Bui
- Massachusetts General Hospital, Department of Psychiatry, One Bowdoin Square, 6th Floor, Boston, MA 02114,University of Caen Normandy & Caen University Hospital, avenue de la Côte de Nacre, 14000 Caen, France
| | - Corey Powell
- University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI, 48109
| | - Erin R. Smith
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105,University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI, 48109
| | - Elizabeth Goetter
- Massachusetts General Hospital, Department of Psychiatry, One Bowdoin Square, 6th Floor, Boston, MA 02114,Harvard Medical School, Department of Psychiatry, 25 Shattuck Street, Boston, MA 02115
| | - Lauren McSweeney
- Emory University School of Medicine, 12 Executive Park, 3 Floor, Atlanta, GA, 30029
| |
Collapse
|
4
|
Rauch SAM, Kim HM, Lederman S, Sullivan G, Acierno R, Tuerk PW, Simon NM, Venners MR, Norman SB, Allard CB, Porter KE, Martis B, Bui E, Baker AW. Predictors of Response to Prolonged Exposure, Sertraline, and Their Combination for the Treatment of Military PTSD. J Clin Psychiatry 2021; 82. [PMID: 34133087 DOI: 10.4088/jcp.20m13752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: The current study is an analysis of predictors of posttraumatic stress disorder (PTSD) treatment response in a clinical trial comparing (1) prolonged exposure plus placebo (PE + PLB), (2) PE + sertraline (PE + SERT), and (3) sertraline + enhanced medication management (SERT + EMM) with predictors including time since trauma (TST), self-report of pain, alcohol use, baseline symptoms, and demographics. Methods: Participants (N = 196) were veterans with combat-related PTSD (DSM-IV-TR) of at least 3 months' duration recruited between 2012 and 2016 from 4 sites in the 24-week PROlonGed ExpoSure and Sertraline (PROGrESS) clinical trial (assessments at weeks 0 [intake], 6, 12, 24, 36, and 52). Results: Across treatment conditions, (1) longer TST was predictive of greater week 24 PTSD symptom improvement (β = 1.72, P = .01) after adjusting for baseline, (2) higher baseline pain severity was predictive of smaller symptom improvement (β = -2.96, P = .003), and (3) Hispanic patients showed greater improvement than non-Hispanic patients (β = 12.33, P = .03). No other baseline characteristics, including alcohol consumption, were significantly predictive of week 24 improvement. Comparison of TST by treatment condition revealed a significant relationship only in those randomized to the PE + SERT condition (β = 2.53, P = .03). Longitudinal analyses showed similar results. Conclusions: The finding that longer TST shows larger symptom reductions is promising for PTSD patients who might not seek help for years following trauma. Higher baseline pain severity robustly predicted attenuated and slower response to all treatment conditions, suggesting a common neuropathologic substrate. Finally, in the current study, alcohol use did not impede the effectiveness of pharmacotherapy for PTSD. Trial Registration: ClinicalTrials.gov identifier: NCT01524133.
Collapse
Affiliation(s)
- Sheila A M Rauch
- Mental Health Service Line, VA Atlanta Healthcare System, Decatur, Georgia.,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia.,Corresponding author: Sheila A. M. Rauch, PhD, Emory University School of Medicine, 12 Executive Park, 3rd Floor, Atlanta, GA 30329
| | - H Myra Kim
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, Michigan
| | | | | | - Ron Acierno
- Mental Health Service Line, Ralph H. Johnson VA Medical Center, Charleston, South Carolina.,Department of Psychiatry & Behavioral Sciences, McGovern Medical School, University of Texas Health Sciences, Houston, Texas
| | - Peter W Tuerk
- Department of Human Services, University of Virginia, Charlottesville, Virginia
| | - Naomi M Simon
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Margaret R Venners
- National Center for PTSD, VA Palo Alto Medical Center, Menlo Park, California.,Research Service Line, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Sonya B Norman
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont.,Department of Psychiatry, University of California, San Diego, School of Medicine, La Jolla, California.,VA Center of Excellence for Stress and Mental Health, San Diego, California
| | - Carolyn B Allard
- PhD Program, California School of Professional Psychology, Alliant International University, San Diego, California.,Research Service, VA San Diego Healthcare System, San Diego, California
| | - Katherine E Porter
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Mental Health Service Line, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Brian Martis
- Mental Health Care Line, VA San Diego Healthcare System, San Diego, California
| | - Eric Bui
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, University of Caen Normandy & Caen University Hospital, Caen, France
| | - Amanda W Baker
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
5
|
Tripp JC, Norman SB, Kim HM, Venners MR, Martis B, Simon NM, Stein MB, Allard CB, Rauch SAM. Residual symptoms of PTSD following Sertraline plus enhanced medication management, Sertraline plus PE, and PE plus placebo. Psychiatry Res 2020; 291:113279. [PMID: 32763541 DOI: 10.1016/j.psychres.2020.113279] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 01/29/2023]
Abstract
Although prolonged exposure (PE) and SSRI antidepressants are effective in treating posttraumatic stress disorder (PTSD), previous studies have shown that some symptoms tend to persist. The current study compared sertraline hydrochloride plus enhanced medication management (EMM), PE plus placebo, or PE plus sertraline hydrochloride in the likelihood of each individual PTSD symptom persisting in veterans with a PTSD diagnosis. We compared the likelihood of individual PTSD symptoms persisting in those with versus without a PTSD diagnosis at posttreatment. We found no significant differences across conditions in which symptoms were likely to persist posttreatment. Among those without a PTSD diagnosis at posttreatment, sleeping difficulties (63.0%), hypervigilance (47.3%), and nightmares (45.0%) were most likely to persist. Findings indicate no consistent differences in residual symptoms between PE and medications, and shared decision making with patients is encouraged in selecting treatments. Gold standard treatments (e.g., CBT-I) may be warranted for residual symptoms like insomnia.
Collapse
Affiliation(s)
- Jessica C Tripp
- VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA 92161, USA; University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92037, USA
| | - Sonya B Norman
- VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA 92161, USA; University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92037, USA; National Center for PTSD, 215 N. Main St., White River Junction, VT 05009, USA; VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr., MC116B, San Diego, CA 92161, USA.
| | - H Myra Kim
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, 915 E. Washington Street, Ann Arbor, MI 48109, USA
| | - Margaret R Venners
- National Center for PTSD, Dissemination & Training Division, 795 Willow Road, Menlo Park, CA 94025, USA
| | - Brian Martis
- VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA 92161, USA; University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92037, USA
| | - Naomi M Simon
- Department of Psychiatry, Massachusetts General Hospital, One Bowdoin Square, Boston, MA, USA; Department of Psychiatry, New York University Grossman School of Medicine, One Park Avenue 8(th) Floor, New York, NY 10016, USA
| | - Murray B Stein
- VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA 92161, USA; University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92037, USA
| | - Carolyn B Allard
- VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA 92161, USA; Alliant International University, 10455 Pomerado Road, San Diego, CA, USA
| | - Sheila A M Rauch
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, 1670 Clairmont Rd., GA 30030, USA; Emory University School of Medicine, 12 Executive Park, 3(rd) Floor, Atlanta, GA 30329, USA
| | | |
Collapse
|
6
|
Goetter EM, Hoeppner SS, Khan AJ, Charney ME, Wieman S, Venners MR, Avallone KM, Rauch SAM, Simon NM. Combat-Related Posttraumatic Stress Disorder and Comorbid Major Depression in U.S. Veterans: The Role of Deployment Cycle Adversity and Social Support. J Trauma Stress 2020; 33:276-284. [PMID: 32216142 PMCID: PMC7995446 DOI: 10.1002/jts.22496] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/23/2019] [Accepted: 10/12/2019] [Indexed: 12/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- Elizabeth M. Goetter
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Susanne S. Hoeppner
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Amanda J. Khan
- San Francisco VA Medical Center, San Francisco, California, USA,Department of Psychology, Suffolk University, Boston, Massachusetts, USA
| | - Meredith E. Charney
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Sarah Wieman
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Psychology, Suffolk University, Boston, Massachusetts, USA
| | | | | | - Sheila A. M. Rauch
- VA Atlanta Healthcare System, Atlanta, Georgia, USA,Department of Psychiatry, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Naomi M. Simon
- Department of Psychiatry, New York University School of Medicine, New York, New York, USA,NYU Langone Health, New York, New York, USA
| |
Collapse
|
7
|
Rauch SAM, Kim HM, Powell C, Tuerk PW, Simon NM, Acierno R, Allard CB, Norman SB, Venners MR, Rothbaum BO, Stein MB, Porter K, Martis B, King AP, Liberzon I, Phan KL, Hoge CW. Efficacy of Prolonged Exposure Therapy, Sertraline Hydrochloride, and Their Combination Among Combat Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2019; 76:117-126. [PMID: 30516797 PMCID: PMC6439753 DOI: 10.1001/jamapsychiatry.2018.3412] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/08/2018] [Indexed: 12/30/2022]
Abstract
Importance Meta-analyses of treatments for posttraumatic stress disorder (PTSD) suggest that trauma-focused psychotherapies produce greater benefits than antidepressant medications alone. Objective To determine the relative efficacy of prolonged exposure therapy plus placebo, prolonged exposure therapy plus sertraline hydrochloride, and sertraline plus enhanced medication management in the treatment of PTSD. Design, Setting, and Participants The Prolonged Exposure and Sertraline Trial was a randomized, multisite, 24-week clinical trial conducted at the Veterans Affairs Ann Arbor Healthcare System, Veterans Affairs San Diego Healthcare System, Ralph H. Johnson Veterans Affairs Medical Center, and Massachusetts General Hospital Home Base Veterans Program between January 26, 2012, and May 9, 2016. Participants and clinicians were blinded to pill condition, and outcome evaluators were blinded to assignment. Participants completed assessments at weeks 0 (intake), 6, 12, 24, and 52 (follow-up). Participants (N = 223) were service members or veterans of the Iraq and/or Afghanistan wars with combat-related PTSD and significant impairment (Clinician-Administered PTSD Scale score, ≥50) of at least 3 months' duration. Analyses were on an intent-to-treat basis. Intervention Participants completed up to thirteen 90-minute sessions of prolonged exposure therapy by week 24. Sertraline dosage was titrated during a 10-week period and continued until week 24; medication management was manualized. Main Outcomes and Measures The primary outcome was symptom severity of PTSD in the past month as assessed by the Clinician-Administered PTSD Scale score at week 24. Results Of 223 randomized participants, 149 completed the study at 24 weeks, and 207 (180 men and 27 women; mean [SD] age, 34.5 [8.3 years]) were included in the intent-to-treat analysis. Modified intent-to-treat analysis using a mixed model of repeated measures showed that PTSD symptoms decreased significantly during the 24 weeks (sertraline plus enhanced medication management, 33.8 points; prolonged exposure therapy plus sertraline, 32.7 points; and prolonged exposure therapy plus placebo, 29.4 points; β,-9.39; 95% CI, -11.62 to -7.16; P < .001); however, slopes did not differ by treatment group (prolonged exposure therapy plus placebo group, -9.39; sertraline plus enhanced medication management group, -10.37; and prolonged exposure therapy plus sertraline group, -9.99; P = .81). Conclusions and Relevance No difference in change in PTSD symptoms or symptom severity at 24 weeks was found between sertraline plus enhanced medication management, prolonged exposure therapy plus placebo, and prolonged exposure therapy plus sertraline. Trial Registration ClinicalTrials.gov Identifier: NCT01524133.
Collapse
Affiliation(s)
- Sheila A. M. Rauch
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - H. Myra Kim
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor
| | - Corey Powell
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor
| | - Peter W. Tuerk
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
- Department of Psychiatry, Medical University of South Carolina, Charleston
| | - Naomi M. Simon
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Psychiatry, New York University School of Medicine, New York
| | - Ron Acierno
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
- College of Nursing, Medical University of South Carolina, Charleston
| | - Carolyn B. Allard
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
| | - Sonya B. Norman
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
- Veterans Affairs Center of Excellence for Stress and Mental Health, San Diego, California
| | - Margaret R. Venners
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
| | - Barbara O. Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Murray B. Stein
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
| | - Katherine Porter
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - Brian Martis
- Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California
- School of Medicine, University of California, San Diego, La Jolla
| | - Anthony P. King
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - Israel Liberzon
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - K. Luan Phan
- Department of Psychiatry, University of Illinois at Chicago
- Mental Health Service Line, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
| | - Charles W. Hoge
- Walter Reed Army Institute of Research, Silver Spring, Maryland
| |
Collapse
|
8
|
Norman SB, Haller M, Kim HM, Allard CB, Porter KE, Stein MB, Venners MR, Authier CC, Rauch SAM. Trauma related guilt cognitions partially mediate the relationship between PTSD symptom severity and functioning among returning combat veterans. J Psychiatr Res 2018; 100:56-62. [PMID: 29486403 DOI: 10.1016/j.jpsychires.2018.02.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/23/2018] [Accepted: 02/08/2018] [Indexed: 12/13/2022]
Abstract
Trauma related guilt, a distressing emotion associated with negative cognitions regarding one's actions or inaction during a traumatic event, is common among individuals with posttraumatic stress disorder (PTSD). We hypothesized that trauma related guilt cognitions would partially explain the relationship between PTSD symptom severity and functioning. The sample consisted of 254 combat veterans or active duty military personnel who served in Operation Enduring Freedom, Operation Iraqi Freedom or Operation New Dawn (OEF/OIF/OND) who consented to participate in a larger PTSD treatment study. Results revealed a significant relationship between PTSD severity and guilt cognitions (standardized β = 0.40), as well as PTSD and overall functioning (β = 0.49). Guilt cognitions (β's = 0.13 to 0.32) were significantly associated with nearly all domains of functioning, including overall functioning (β = 0.27), and partially explained the relationship between PTSD and functioning. This study lends support to the addition of guilt as a symptom of PTSD in the DSM-5 as it contributes significantly to functional impairment even when accounting for other symptoms of PTSD, although co-occurring mental health problems may also contribute to functional impairments associated with PTSD. Future studies are needed to investigate whether reductions in traumatic guilt are related to improved functional outcomes in PTSD treatments.
Collapse
Affiliation(s)
- S B Norman
- National Center for PTSD, 215 N. Main Street, White River Junction, VT 05009, United States; VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Drive, MC116B, San Diego, CA 92161, United States; University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92037, United States.
| | - M Haller
- VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Drive, MC116B, San Diego, CA 92161, United States; University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92037, United States
| | - Hyungjin Myra Kim
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, United States; Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, United States; University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI, 48109, United States
| | - C B Allard
- University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92037, United States; VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA 92161, United States; Solara Mental Health, 1321 Garnet Ave, San Diego, CA 92109, United States
| | - K E Porter
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, United States; University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI, 48109, United States
| | - M B Stein
- University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92037, United States; VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA 92161, United States
| | - M R Venners
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, United States
| | - C C Authier
- University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI, 48109, United States
| | - S A M Rauch
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033, United States; Emory University School of Medicine, 12 Executive Park, 3rd Floor, Atlanta, GA, 30029, United States
| | | |
Collapse
|
9
|
Rauch SA, Simon NM, Kim HM, Acierno R, King AP, Norman SB, Venners MR, Porter K, Phan KL, Tuerk PW, Allard C, Liberzon I, Rothbaum BO, Martis B, Stein MB, Hoge CW. Integrating biological treatment mechanisms into randomized clinical trials: Design of PROGrESS (PROlonGed ExpoSure and Sertraline Trial). Contemp Clin Trials 2018; 64:128-138. [DOI: 10.1016/j.cct.2017.10.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/21/2017] [Accepted: 10/23/2017] [Indexed: 01/07/2023]
|
10
|
Simon NM, O'Day EB, Hellberg SN, Hoeppner SS, Charney ME, Robinaugh DJ, Bui E, Goetter EM, Baker AW, Rogers AH, Nadal-Vicens M, Venners MR, Kim HM, Rauch SAM. The loss of a fellow service member: Complicated grief in post-9/11 service members and veterans with combat-related posttraumatic stress disorder. J Neurosci Res 2017; 96:5-15. [PMID: 28609578 DOI: 10.1002/jnr.24094] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/01/2017] [Accepted: 05/09/2017] [Indexed: 11/10/2022]
Abstract
Bereavement is a potent and highly prevalent stressor among service members and veterans. However, the psychological consequences of bereavement, including complicated grief (CG), have been minimally examined. Loss was assessed in 204 post-9/11, when service members and veterans with combat-related posttraumatic stress disorder (PTSD) took part in a multicenter treatment study. Those who reported the loss of an important person completed the inventory of complicated grief (ICG; n = 160). Over three quarters (79.41%) of the sample reported an important lifetime loss, with close to half (47.06%) reporting the loss of a fellow service member (FSM). The prevalence of CG was 24.75% overall, and nearly one third (31.25%) among the bereaved. CG was more prevalent among veterans who lost a fellow service member (FSM) (41.05%, n = 39) compared to those bereaved who did not (16.92%, n = 11; OR = 3.41, 95% CI: 1.59, 7.36). CG was associated with significantly greater PTSD severity, functional impairment, trauma-related guilt, and lifetime suicide attempts. Complicated grief was prevalent and associated with adverse psychosocial outcomes in veterans and service members with combat-related PTSD. Clinicians working with this population should inquire about bereavement, including loss of a FSM, and screen for CG. Additional research examining CG in this population is needed.
Collapse
Affiliation(s)
- Naomi M Simon
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, 02114, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, 02114, USA
| | - Emily B O'Day
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Samantha N Hellberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Susanne S Hoeppner
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, 02114, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, 02114, USA
| | - Meredith E Charney
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, 02114, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, 02114, USA
| | - Donald J Robinaugh
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, 02114, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, 02114, USA
| | - Eric Bui
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, 02114, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, 02114, USA
| | - Elizabeth M Goetter
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, 02114, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, 02114, USA
| | - Amanda W Baker
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, 02114, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, 02114, USA
| | - Andrew H Rogers
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Mireya Nadal-Vicens
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, 02114, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, 02114, USA
| | - Margaret R Venners
- VA Ann Arbor Healthcare System, 2215 Fuller Road 116c, Ann Arbor, MI, 48105, USA.,University of Michigan, Department of Psychiatry, 4250 Plymouth Rd., Ann Arbor, MI, 48109
| | - Hyungjin M Kim
- VA Ann Arbor Healthcare System, 2215 Fuller Road 116c, Ann Arbor, MI, 48105, USA
| | - Sheila A M Rauch
- VA Ann Arbor Healthcare System, 2215 Fuller Road 116c, Ann Arbor, MI, 48105, USA.,University of Michigan, Department of Psychiatry, 4250 Plymouth Rd., Ann Arbor, MI, 48109.,Emory University, School of Medicine, 12 Executive Park, 3rd Floor, Atlanta, GA, 30329, USA.,Atlanta VA Medical Center, 1670 Clairmont Road 116c, Atlanta, GA, 30033, USA
| |
Collapse
|
11
|
Cox KS, Mouilso ER, Venners MR, Defever ME, Duvivier L, Rauch SAM, Strom TQ, Joiner TE, Tuerk PW. Reducing suicidal ideation through evidence-based treatment for posttraumatic stress disorder. J Psychiatr Res 2016; 80:59-63. [PMID: 27295122 DOI: 10.1016/j.jpsychires.2016.05.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 05/09/2016] [Accepted: 05/23/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Suicide is a major public health concern in military and civilian contexts. Veteran populations are at increased risk for suicide, especially veterans with mental health disorders such as Posttraumatic Stress Disorder (PTSD). Suicidal ideation (SI) is a primary risk factor for suicide. METHODS We investigated changes in SI in a multi-site sample of treatment seeking veterans from three separate Veterans Health Administration (VA) medical centers (n = 289) who received Prolonged Exposure (PE) therapy, an evidence-based treatment (EBT) for PTSD. SI and PTSD symptoms were assessed, using self-report instruments, throughout routine clinical care. RESULTS Both PTSD and SI symptoms reduced over the course of treatment (d-type effect sizes of 1.47 and 0.27, respectively). While SI was associated with PTSD symptoms at all time points, appropriately specified, time lagged models indicated that changes in PTSD symptoms were predictive of future declines in SI, while the converse was not true. CONCLUSIONS Results indicate that treating PTSD symptoms with an EBT for PTSD can be an effective way to reduce SI, at least partially, and for some patients. These data are significant in light of the resources and programming devoted to addressing SI in the VA relative to available empirical evidence regarding the effectiveness of developed strategies. The findings demonstrate the importance of facilitating EBT referrals for specific disorders as a component of broad-based suicide outreach and preventions strategies.
Collapse
Affiliation(s)
- Keith S Cox
- Department of Psychology, University of North Carolina Asheville, One University Heights, Asheville, NC, 28803, United States.
| | - Emily R Mouilso
- Psychology Department, University of Georgia, 125 Baldwin St., Athens, GA, 30602, United States
| | - Margaret R Venners
- VA Ann Arbor Health Care System, 2215 Fuller Rd, Ann Arbor, MI, 48105, United States; Department of Psychiatry, University of Michigan Medical School, 4250 Plymouth Rd, Ann Arbor, 48109, United States
| | - Mahrie E Defever
- VA Ann Arbor Health Care System, 2215 Fuller Rd, Ann Arbor, MI, 48105, United States; Department of Psychiatry, University of Michigan Medical School, 4250 Plymouth Rd, Ann Arbor, 48109, United States
| | - Leticia Duvivier
- Evidence-Based Practice Institute, 3303 S Irving St, Seattle, WA, 98144, United States
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Dr. NE #200, Atlanta, GA, 30329, United States
| | - Thad Q Strom
- Minneapolis VA Health Care System, 1 Veterans Dr., Minneapolis, MN, 55417, United States; Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, 55454, United States
| | - Thomas E Joiner
- Department of Psychology, Florida State University, 1107 W. Call St., Tallahassee, FL, 32304, United States
| | - Peter W Tuerk
- Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC, 29401, United States; Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President St., MSC 861, Charleston, SC, 29425, United States
| |
Collapse
|