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Fonzo GA, Goodkind MS, Oathes DJ, Zaiko YV, Harvey M, Peng KK, Weiss ME, Thompson AL, Zack SE, Lindley SE, Arnow BA, Jo B, Rothbaum BO, Etkin A. Amygdala and Insula Connectivity Changes Following Psychotherapy for Posttraumatic Stress Disorder: A Randomized Clinical Trial. Biol Psychiatry 2021; 89:857-867. [PMID: 33516458 PMCID: PMC8052256 DOI: 10.1016/j.biopsych.2020.11.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [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: 05/21/2020] [Revised: 11/06/2020] [Accepted: 11/23/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Exposure-based psychotherapy is a first-line treatment for posttraumatic stress disorder (PTSD), but its mechanisms are poorly understood. Functional brain connectivity is a promising metric for identifying treatment mechanisms and biosignatures of therapeutic response. To this end, we assessed amygdala and insula treatment-related connectivity changes and their relationship to PTSD symptom improvements. METHODS Individuals with a primary PTSD diagnosis (N = 66) participated in a randomized clinical trial of prolonged exposure therapy (n = 36) versus treatment waiting list (n = 30). Task-free functional magnetic resonance imaging was completed prior to randomization and 1 month following cessation of treatment/waiting list. Whole-brain blood oxygenation level-dependent responses were acquired. Intrinsic connectivity was assessed by subregion in the amygdala and insula, limbic structures key to the disorder pathophysiology. Dynamic causal modeling assessed evidence for effective connectivity changes in select nodes informed by intrinsic connectivity findings. RESULTS The amygdala and insula displayed widespread patterns of primarily subregion-uniform intrinsic connectivity change, including increased connectivity between the amygdala and insula; increased connectivity of both regions with the ventral prefrontal cortex and frontopolar and sensory cortices; and decreased connectivity of both regions with the left frontoparietal nodes of the executive control network. Larger decreases in amygdala-frontal connectivity and insula-parietal connectivity were associated with larger PTSD symptom reductions. Dynamic causal modeling evidence suggested that treatment decreased left frontal inhibition of the left amygdala, and larger decreases were associated with larger symptom reductions. CONCLUSIONS PTSD psychotherapy adaptively attenuates functional interactions between frontoparietal and limbic brain circuitry at rest, which may reflect a potential mechanism or biosignature of recovery.
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Affiliation(s)
- Gregory A. Fonzo
- Department of Psychiatry, The University of Texas at Austin Dell Medical School
| | | | - Desmond J. Oathes
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Yevgeniya V. Zaiko
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Wu Tsai Neurosciences Institute, Stanford University, Stanford CA, USA,Veterans Affairs Palo Alto Healthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - Meredith Harvey
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Wu Tsai Neurosciences Institute, Stanford University, Stanford CA, USA,Veterans Affairs Palo Alto Healthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - Kathy K. Peng
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Wu Tsai Neurosciences Institute, Stanford University, Stanford CA, USA,Veterans Affairs Palo Alto Healthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - M. Elizabeth Weiss
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Wu Tsai Neurosciences Institute, Stanford University, Stanford CA, USA,Veterans Affairs Palo Alto Healthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - Allison L. Thompson
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sanno E. Zack
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven E. Lindley
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Veterans Affairs Palo Alto Healthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - Bruce A. Arnow
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Booil Jo
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Barbara O. Rothbaum
- Trauma and Anxiety Recovery Program, Department of Psychiatry, Emory University School of Medicine, Atlanta, GA, USA
| | - Amit Etkin
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California; Wu Tsai Neurosciences Institute, Stanford University, Stanford, California; Alto Neuroscience, Los Altos, California.
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Etkin A, Maron-Katz A, Wu W, Fonzo GA, Huemer J, Vértes PE, Patenaude B, Richiardi J, Goodkind MS, Keller CJ, Ramos-Cejudo J, Zaiko YV, Peng KK, Shpigel E, Longwell P, Toll RT, Thompson A, Zack S, Gonzalez B, Edelstein R, Chen J, Akingbade I, Weiss E, Hart R, Mann S, Durkin K, Baete SH, Boada FE, Genfi A, Autea J, Newman J, Oathes DJ, Lindley SE, Abu-Amara D, Arnow BA, Crossley N, Hallmayer J, Fossati S, Rothbaum BO, Marmar CR, Bullmore ET, O'Hara R. Using fMRI connectivity to define a treatment-resistant form of post-traumatic stress disorder. Sci Transl Med 2020; 11:11/486/eaal3236. [PMID: 30944165 DOI: 10.1126/scitranslmed.aal3236] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 02/01/2018] [Accepted: 11/07/2018] [Indexed: 12/14/2022]
Abstract
A mechanistic understanding of the pathology of psychiatric disorders has been hampered by extensive heterogeneity in biology, symptoms, and behavior within diagnostic categories that are defined subjectively. We investigated whether leveraging individual differences in information-processing impairments in patients with post-traumatic stress disorder (PTSD) could reveal phenotypes within the disorder. We found that a subgroup of patients with PTSD from two independent cohorts displayed both aberrant functional connectivity within the ventral attention network (VAN) as revealed by functional magnetic resonance imaging (fMRI) neuroimaging and impaired verbal memory on a word list learning task. This combined phenotype was not associated with differences in symptoms or comorbidities, but nonetheless could be used to predict a poor response to psychotherapy, the best-validated treatment for PTSD. Using concurrent focal noninvasive transcranial magnetic stimulation and electroencephalography, we then identified alterations in neural signal flow in the VAN that were evoked by direct stimulation of that network. These alterations were associated with individual differences in functional fMRI connectivity within the VAN. Our findings define specific neurobiological mechanisms in a subgroup of patients with PTSD that could contribute to the poor response to psychotherapy.
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Affiliation(s)
- Amit Etkin
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA. .,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA.,Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Adi Maron-Katz
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA.,Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Wei Wu
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA.,Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,School of Automation Science and Engineering, South China University of Technology, Guangzhou, Guangdong 510640, China
| | - Gregory A Fonzo
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA.,Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Julia Huemer
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA
| | - Petra E Vértes
- Department of Psychiatry, Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge CB2 0SZ, UK.,School of Mathematical Sciences, Queen Mary University of London, London E1 4NS, UK.,The Alan Turing Institute, London NW1 2DB, UK
| | - Brian Patenaude
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA.,Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Jonas Richiardi
- Department of Medical Radiology, Lausanne University Hospital, Lausanne, Switzerland.,Advanced Clinical Imaging Technology, Siemens Healthcare AG, Lausanne, Switzerland
| | - Madeleine S Goodkind
- New Mexico Veterans Affairs Healthcare System, Albuquerque, NM 87108, USA.,Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM 87131, USA
| | - Corey J Keller
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA.,Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Jaime Ramos-Cejudo
- Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,Department of Psychiatry, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Yevgeniya V Zaiko
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA
| | - Kathy K Peng
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA
| | - Emmanuel Shpigel
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA.,Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Parker Longwell
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA.,Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Russ T Toll
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA.,Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Allison Thompson
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA
| | - Sanno Zack
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA
| | - Bryan Gonzalez
- Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,Department of Psychiatry, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Raleigh Edelstein
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA.,Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Jingyun Chen
- Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,Department of Psychiatry, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Irene Akingbade
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA.,Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Elizabeth Weiss
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA
| | - Roland Hart
- Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,Department of Psychiatry, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Silas Mann
- Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,Department of Psychiatry, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Kathleen Durkin
- Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,Department of Psychiatry, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Steven H Baete
- Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,New Mexico Veterans Affairs Healthcare System, Albuquerque, NM 87108, USA.,Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM 87131, USA
| | - Fernando E Boada
- Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,Center for Advanced Imaging Innovation and Research (CAI2R), NYU School of Medicine, New York, NY 10016, USA.,Center for Biomedical Imaging, Department of Radiology, NYU School of Medicine, New York, NY 10016, USA
| | - Afia Genfi
- Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,Department of Psychiatry, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Jillian Autea
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA.,Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Jennifer Newman
- Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,Department of Psychiatry, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Desmond J Oathes
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Steven E Lindley
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA
| | - Duna Abu-Amara
- Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,Department of Psychiatry, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Bruce A Arnow
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA
| | - Nicolas Crossley
- Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, 6513677 Santiago, Chile.,Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
| | - Joachim Hallmayer
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Wu Tsai Neurosciences Institute at Stanford, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA
| | - Silvia Fossati
- Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,Department of Psychiatry, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Barbara O Rothbaum
- Trauma and Anxiety Recovery Program, Department of Psychiatry, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Charles R Marmar
- Steven and Alexandra Cohen Veterans Center for Post-traumatic Stress and Traumatic Brain Injury, New York University Langone School of Medicine, New York, NY 10016, USA.,Department of Psychiatry, New York University Langone School of Medicine, New York, NY 10016, USA
| | - Edward T Bullmore
- Department of Psychiatry, Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge CB2 0SZ, UK.,Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge CB21 5EF, UK.,ImmunoPsychiatry, Alternative Discovery and Development, GlaxoSmithKline, Stevenage SG1 2NY, UK
| | - Ruth O'Hara
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94304, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94394, USA
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Azevedo KJ, Ramirez JC, Kumar A, LeFevre A, Factor A, Hailu E, Lindley SE, Jain S. Rethinking Violence Prevention in Rural and Underserved Communities: How Veteran Peer Support Groups Help Participants Deal with Sequelae from Violent Traumatic Experiences. J Rural Health 2020; 36:266-273. [DOI: 10.1111/jrh.12362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 01/18/2019] [Accepted: 01/28/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Kathryn J. Azevedo
- VA Palo Alto Health Care System Palo Alto California
- National Center for PTSD at the VA Palo Alto Health Care System Menlo Park California
- Center for Innovation to Implementation (Ci2i) Menlo Park California
| | - Jeremy C. Ramirez
- VA Palo Alto Health Care System Palo Alto California
- Center for Innovation to Implementation (Ci2i) Menlo Park California
| | - Anusha Kumar
- VA Palo Alto Health Care System Palo Alto California
- School of MedicineStanford University Palo Alto California
| | - Ann LeFevre
- VA Palo Alto Health Care System Palo Alto California
| | - Adam Factor
- VA Palo Alto Health Care System Palo Alto California
- Center for Innovation to Implementation (Ci2i) Menlo Park California
| | - Elon Hailu
- VA Palo Alto Health Care System Palo Alto California
- Center for Innovation to Implementation (Ci2i) Menlo Park California
| | - Steven E. Lindley
- VA Palo Alto Health Care System Palo Alto California
- Department of Psychiatry and Behavioral SciencesStanford University Palo Alto California
| | - Shaili Jain
- VA Palo Alto Health Care System Palo Alto California
- Department of Psychiatry and Behavioral SciencesStanford University Palo Alto California
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Kumar A, Azevedo KJ, Factor A, Hailu E, Ramirez J, Lindley SE, Jain S. Peer support in an outpatient program for veterans with posttraumatic stress disorder: Translating participant experiences into a recovery model. Psychol Serv 2018; 16:415-424. [PMID: 30407050 DOI: 10.1037/ser0000269] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Veterans returning from recent conflicts present with increased rates of posttraumatic stress disorder (PTSD), and veterans from prior service eras continue to seek trauma-based services. Peer support for veterans with PTSD has the potential to resolve ongoing challenges in access and engagement in mental health care. Assessing the value of peer support services requires a thorough understanding of the expected role and the empirical mechanisms of peer support participation in PTSD recovery. To better understand these mechanisms, this study interviewed 29 veteran participants from an established peer support program (PSP), located in the Central Valley of the Veterans Affairs (VA) Palo Alto Health Care System (VAPAHCS) in Northern California. A domain analysis of narrative transcripts generated 34 codes through a grounded theory method. Codes were organized into the following thematic categories: the perceived role of the PSP, supportive experiences of the PSP, global gains from the PSP, and limitations to PSP and further mental health engagement. These results were synthesized into a theoretical model that identifies improved functioning and reduced distress as the expected outcomes of PSP-mediated recovery and illustrates the continuum from in-group experiences to these outcomes. Our results suggest that PSP-mediated recovery is defined as acceptance of PTSD into daily life and identity, rather than resolution of symptoms. This conceptualization has implications for peer support provider training, PSP integration into health care settings, and future outcome analyses on the effectiveness of PSPs. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
| | | | - Adam Factor
- Veterans Affairs Palo Alto Health Care System
| | - Elon Hailu
- Veterans Affairs Palo Alto Health Care System
| | | | - Steven E Lindley
- Department of Psychiatry and Behavioral Sciences, Stanford University
| | - Shaili Jain
- Department of Psychiatry and Behavioral Sciences, Stanford University
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Zimmerman L, Lounsbury DW, Rosen CS, Kimerling R, Trafton JA, Lindley SE. Participatory System Dynamics Modeling: Increasing Stakeholder Engagement and Precision to Improve Implementation Planning in Systems. Adm Policy Ment Health 2018; 43:834-849. [PMID: 27480546 DOI: 10.1007/s10488-016-0754-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Implementation planning typically incorporates stakeholder input. Quality improvement efforts provide data-based feedback regarding progress. Participatory system dynamics modeling (PSD) triangulates stakeholder expertise, data and simulation of implementation plans prior to attempting change. Frontline staff in one VA outpatient mental health system used PSD to examine policy and procedural "mechanisms" they believe underlie local capacity to implement evidence-based psychotherapies (EBPs) for PTSD and depression. We piloted the PSD process, simulating implementation plans to improve EBP reach. Findings indicate PSD is a feasible, useful strategy for building stakeholder consensus, and may save time and effort as compared to trial-and-error EBP implementation planning.
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Affiliation(s)
- Lindsey Zimmerman
- National Center for PTSD, Dissemination and Training Division, Veteran Affairs Palo Alto Health Care System, 795 Willow Rd. Bldg. 334 (NC-PTSD), Menlo Park, CA, 94025, USA. .,University of Washington School of Medicine, Seattle, WA, USA.
| | - David W Lounsbury
- Department of Epidemiology and Population Health, Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Craig S Rosen
- National Center for PTSD, Dissemination and Training Division, Veteran Affairs Palo Alto Health Care System, 795 Willow Rd. Bldg. 334 (NC-PTSD), Menlo Park, CA, 94025, USA.,Stanford University School of Medicine, Palo Alto, CA, USA
| | - Rachel Kimerling
- National Center for PTSD, Dissemination and Training Division, Veteran Affairs Palo Alto Health Care System, 795 Willow Rd. Bldg. 334 (NC-PTSD), Menlo Park, CA, 94025, USA
| | - Jodie A Trafton
- Stanford University School of Medicine, Palo Alto, CA, USA.,Program Evaluation Resource Center, Center for Innovation to Implementation, Veteran Affairs Palo Alto Health Care System, Menlo Park, CA, USA
| | - Steven E Lindley
- Stanford University School of Medicine, Palo Alto, CA, USA.,Veteran Affairs Palo Alto Health Care System, Menlo Park, CA, USA
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Fonzo GA, Goodkind MS, Oathes DJ, Zaiko YV, Harvey M, Peng KK, Weiss ME, Thompson AL, Zack SE, Lindley SE, Arnow BA, Jo B, Gross JJ, Rothbaum BO, Etkin A. PTSD Psychotherapy Outcome Predicted by Brain Activation During Emotional Reactivity and Regulation. Am J Psychiatry 2017; 174:1163-1174. [PMID: 28715908 PMCID: PMC5711543 DOI: 10.1176/appi.ajp.2017.16091072] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [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] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Exposure therapy is an effective treatment for posttraumatic stress disorder (PTSD), but many patients do not respond. Brain functions governing treatment outcome are not well characterized. The authors examined brain systems relevant to emotional reactivity and regulation, constructs that are thought to be central to PTSD and exposure therapy effects, to identify the functional traits of individuals most likely to benefit from treatment. METHOD Individuals with PTSD underwent functional MRI (fMRI) while completing three tasks assessing emotional reactivity and regulation. Participants were then randomly assigned to immediate prolonged exposure treatment (N=36) or a waiting list condition (N=30). A random subset of the prolonged exposure group (N=17) underwent single-pulse transcranial magnetic stimulation (TMS) concurrent with fMRI to examine whether predictive activation patterns reflect causal influence within circuits. Linear mixed-effects modeling in line with the intent-to-treat principle was used to examine how baseline brain function moderated the effect of treatment on PTSD symptoms. RESULTS At baseline, individuals with larger treatment-related symptom reductions (compared with the waiting list condition) demonstrated 1) greater dorsal prefrontal activation and 2) less left amygdala activation, both during emotion reactivity; 3) better inhibition of the left amygdala induced by single TMS pulses to the right dorsolateral prefrontal cortex; and 4) greater ventromedial prefrontal/ventral striatal activation during emotional conflict regulation. Reappraisal-related activation was not a significant moderator of the treatment effect. CONCLUSIONS Capacity to benefit from prolonged exposure in PTSD is gated by the degree to which prefrontal resources are spontaneously engaged when superficially processing threat and adaptively mitigating emotional interference, but not when deliberately reducing negative emotionality.
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Affiliation(s)
- Gregory A. Fonzo
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Stanford Neurosciences Institute, Stanford University, Stanford CA, USA,Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA
| | | | - Desmond J. Oathes
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Yevgeniya V. Zaiko
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Stanford Neurosciences Institute, Stanford University, Stanford CA, USA,Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA
| | - Meredith Harvey
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA
| | - Kathy K. Peng
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA
| | - M. Elizabeth Weiss
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA
| | - Allison L. Thompson
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sanno E. Zack
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven E. Lindley
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA
| | - Bruce A. Arnow
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Booil Jo
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - James J. Gross
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Barbara O. Rothbaum
- Trauma and Anxiety Recovery Program, Department of Psychiatry, Emory University School of Medicine, Atlanta, GA, USA
| | - Amit Etkin
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Stanford Neurosciences Institute, Stanford University, Stanford CA, USA,Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA
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Fonzo GA, Goodkind MS, Oathes DJ, Zaiko YV, Harvey M, Peng KK, Weiss ME, Thompson AL, Zack SE, Mills-Finnerty CE, Rosenberg BM, Edelstein R, Wright RN, Kole CA, Lindley SE, Arnow BA, Jo B, Gross JJ, Rothbaum BO, Etkin A. Selective Effects of Psychotherapy on Frontopolar Cortical Function in PTSD. Am J Psychiatry 2017; 174:1175-1184. [PMID: 28715907 PMCID: PMC5711612 DOI: 10.1176/appi.ajp.2017.16091073] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [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] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Exposure therapy is an effective treatment for posttraumatic stress disorder (PTSD), but a comprehensive, emotion-focused perspective on how psychotherapy affects brain function is lacking. The authors assessed changes in brain function after prolonged exposure therapy across three emotional reactivity and regulation paradigms. METHOD Individuals with PTSD underwent functional MRI (fMRI) at rest and while completing three tasks assessing emotional reactivity and regulation. Individuals were then randomly assigned to immediate prolonged exposure treatment (N=36) or a waiting list condition (N=30) and underwent a second scan approximately 4 weeks after the last treatment session or a comparable waiting period, respectively. RESULTS Treatment-specific changes were observed only during cognitive reappraisal of negative images. Psychotherapy increased lateral frontopolar cortex activity and connectivity with the ventromedial prefrontal cortex/ventral striatum. Greater increases in frontopolar activation were associated with improvement in hyperarousal symptoms and psychological well-being. The frontopolar cortex also displayed a greater variety of temporal resting-state signal pattern changes after treatment. Concurrent transcranial magnetic stimulation and fMRI in healthy participants demonstrated that the lateral frontopolar cortex exerts downstream influence on the ventromedial prefrontal cortex/ventral striatum. CONCLUSIONS Changes in frontopolar function during deliberate regulation of negative affect is one key mechanism of adaptive psychotherapeutic change in PTSD. Given that frontopolar connectivity with ventromedial regions during emotion regulation is enhanced by psychotherapy and that the frontopolar cortex exerts downstream influence on ventromedial regions in healthy individuals, these findings inform a novel conceptualization of how psychotherapy works, and they identify a promising target for stimulation-based therapeutics.
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Affiliation(s)
- Gregory A. Fonzo
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA, Alto HeaStanford Neurosciences Institute, Stanford University, Stanford CA, USA,Veterans Affairs Palolthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA,Correspondence To: Amit Etkin, M.D., Ph.D., 401 Quarry Road, MC 5797, Stanford, CA 94305; 650-725-5736;
| | - Madeleine S. Goodkind
- New Mexico Veterans Affairs Healthcare System, Albuquerque, NM, USA,Correspondence To: Amit Etkin, M.D., Ph.D., 401 Quarry Road, MC 5797, Stanford, CA 94305; 650-725-5736;
| | - Desmond J. Oathes
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Yevgeniya V. Zaiko
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA, Alto HeaStanford Neurosciences Institute, Stanford University, Stanford CA, USA,Veterans Affairs Palolthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - Meredith Harvey
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Veterans Affairs Palolthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - Kathy K. Peng
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Veterans Affairs Palolthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - M. Elizabeth Weiss
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Veterans Affairs Palolthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - Allison L. Thompson
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sanno E. Zack
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Colleen E. Mills-Finnerty
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA, Alto HeaStanford Neurosciences Institute, Stanford University, Stanford CA, USA,Veterans Affairs Palolthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - Benjamin M. Rosenberg
- Center for Neuromodulation in Depression and Stress, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Raleigh Edelstein
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA, Alto HeaStanford Neurosciences Institute, Stanford University, Stanford CA, USA,Veterans Affairs Palolthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - Rachael N. Wright
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA, Alto HeaStanford Neurosciences Institute, Stanford University, Stanford CA, USA,Veterans Affairs Palolthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - Carena A. Kole
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA, Alto HeaStanford Neurosciences Institute, Stanford University, Stanford CA, USA,Veterans Affairs Palolthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - Steven E. Lindley
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Veterans Affairs Palolthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
| | - Bruce A. Arnow
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Booil Jo
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - James J. Gross
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Barbara O. Rothbaum
- Department of Psychiatry, Emory University School of Medicine, Atlanta, GA, USA
| | - Amit Etkin
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA, Alto HeaStanford Neurosciences Institute, Stanford University, Stanford CA, USA,Veterans Affairs Palolthcare System, and the Sierra Pacific Mental Illness, Research, Education, and Clinical Center (MIRECC), Palo Alto, CA
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8
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Rosen CS, Azevedo KJ, Tiet QQ, Greene CJ, Wood AE, Calhoun P, Bowe T, Capehart BP, Crawford EF, Greenbaum MA, Harris AHS, Hertzberg M, Lindley SE, Smith BN, Schnurr PP. An RCT of Effects of Telephone Care Management on Treatment Adherence and Clinical Outcomes Among Veterans With PTSD. Psychiatr Serv 2017; 68:151-158. [PMID: 27745535 DOI: 10.1176/appi.ps.201600069] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 11/30/2022]
Abstract
OBJECTIVE This study assessed whether adding telephone care management to usual outpatient mental health care improved treatment attendance, medication compliance, and clinical outcomes of veterans with posttraumatic stress disorder (PTSD). METHODS In a multisite randomized controlled trial, 358 veterans were assigned to either usual outpatient mental health treatment (N=165) or usual care plus twice-a-month telephone care management (TCM) and support in the first three months of treatment (N=193). Treatment utilization and medication refills were determined from U.S. Department of Veterans Affairs administrative data. PTSD, depression, quality of life, aggressive behavior, and substance use were assessed with self-report questionnaires at intake, four months, and 12 months. RESULTS Telephone care managers reached 95% of TCM participants (N=182), completing an average 5.1 of 6.0 planned telephone calls. During the three-month intervention period, TCM participants completed 43% more mental health visits (M±SD=5.9±6.8) than did those in usual care (4.1±4.2) (incident rate ratio=1.36, χ2=6.56, df=1, p<.01). Treatment visits in the nine-month follow-up period and medication refills did not differ by condition. Only 9% of participants were scheduled to receive evidence-based psychotherapy. Slopes of improvement in PTSD, depression, alcohol misuse, drug problems, aggressive behavior, and quality of life did not differ by condition or treatment attendance. CONCLUSIONS TCM improved PTSD patients' treatment attendance but not their outcomes. TCM can enhance treatment engagement, but outcomes depend on the effectiveness of the treatments that patients receive.
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Affiliation(s)
- Craig S Rosen
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Kathryn J Azevedo
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Quyen Q Tiet
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Carolyn J Greene
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Amanda E Wood
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Patrick Calhoun
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Thomas Bowe
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Bruce P Capehart
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Eric F Crawford
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Mark A Greenbaum
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Alex H S Harris
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Michael Hertzberg
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Steven E Lindley
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Brandy N Smith
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Paula P Schnurr
- Dr. Rosen, Dr. Azevedo, Dr. Tiet, and Ms. Smith are with the National Center for PTSD Dissemination and Training Division, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California (e-mail: ). Dr. Rosen and Dr. Tiet are also with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, where Dr. Lindley is affiliated. Dr. Lindley is also with the VA Palo Alto Health Care System, Menlo Park. Dr. Azevedo is also with the Center for Innovation to Implementation, Health Services Research and Development Service, VA Palo Alto Health Care System, Menlo Park, where Dr. Bowe and Dr. Harris are affiliated. Dr. Harris is also with the Department of Surgery, Stanford University School of Medicine, Stanford. Dr. Greene is with the VA Office of Mental Health Services, Menlo Park. Dr. Wood is with Mental Health Services American Lake Division, VA Puget Sound Health Care System, Tacoma, Washington. Dr. Calhoun is with the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC). Dr. Capehart and Dr. Hertzberg are with the Department of Psychiatry, Durham VA Medical Center, Durham, North Carolina. Dr. Calhoun, Dr. Capehart, and Dr. Hertzberg are also with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham. Dr. Crawford, formerly with the Clinical Core, Mid-Atlantic Region MIRECC, Durham, is now with the Sheridan VA Medical Center, Sheridan, Wyoming. Mr. Greenbaum is with the VA Sierra-Pacific MIRECC, Menlo Park. Dr. Schnurr is with the National Center for PTSD Executive Division, White River Junction VA Medical Center, White River Junction, Vermont, and the Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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Landes SJ, Carlson EB, Ruzek JI, Wang D, Hugo E, DeGaetano N, Chambers JG, Lindley SE. Provider-Driven Development of a Measurement Feedback System to Enhance Measurement-Based Care in VA Mental Health. Cognitive and Behavioral Practice 2015. [DOI: 10.1016/j.cbpra.2014.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Jain S, Nazarian D, Weitlauf JC, Lindley SE. Overview of Bioethical Issues in Contemporary PTSD Treatment and Research: Considering Priorities for Future Empirical Ethics Investigation. ACTA ACUST UNITED AC 2011. [DOI: 10.1080/21507716.2011.629640] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Parker KJ, Buckmaster CL, Lindley SE, Schatzberg AF, Lyons DM. Hypothalamic-pituitary-adrenal axis physiology and cognitive control of behavior in stress inoculated monkeys. Int J Behav Dev 2011; 36. [PMID: 24353360 DOI: 10.1177/0165025411406864] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Monkeys exposed to stress inoculation protocols early in life subsequently exhibit diminished neurobiological responses to moderate psychological stressors and enhanced cognitive control of behavior during juvenile development compared to non-inoculated monkeys. The present experiments extended these findings and revealed that stress inoculated monkeys: (a) mount neurobiological responses equivalent to non-inoculated monkeys when the stressor is of sufficient intensity, and (b) continue to exhibit enhanced cognitive control as young adults compared to non-inoculated monkeys. These results suggest that stress inoculation protocols alter the appraisal of and response to moderate stressors as less threatening and permanently enhance cognitive control, at least through early adulthood. These data therefore support the notion that the stress inoculation phenotype reflects stress resilience rather than stress pathology.
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Affiliation(s)
| | | | - Steven E Lindley
- Stanford University, USA ; Veterans Affairs, Palo Alto Health Care System, USA
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Parker KJ, Rainwater KL, Buckmaster CL, Schatzberg AF, Lindley SE, Lyons DM. Early life stress and novelty seeking behavior in adolescent monkeys. Psychoneuroendocrinology 2007; 32:785-92. [PMID: 17604913 PMCID: PMC2716798 DOI: 10.1016/j.psyneuen.2007.05.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Revised: 05/11/2007] [Accepted: 05/16/2007] [Indexed: 11/15/2022]
Abstract
Recent evidence suggests that early exposure to mild stress promotes the development of novelty seeking behavior. Here we test this hypothesis in squirrel monkeys and investigate whether novelty seeking behavior is associated with differences in cerebrospinal fluid (CSF) levels of the serotonin metabolite 5-hydroxyindoleacetic acid (5HIAA), the dopamine metabolite homovanillic acid (HVA), the norepinephrine metabolite 3-methoxy-4-hydroxyphenylethylene glycol (MHPG), and the neuropeptide corticotrophin-releasing factor (CRF). Monkeys were randomized early in life to either mild intermittent stress (IS) or no stress (NS) conditions, and subsequently presented with opportunities to interact with a familiar or novel object in a test box that was connected to each monkey's home cage. To further minimize the potentially stressful nature of the test situation, monkeys were acclimated to the test procedures prior to study initiation. Post-test plasma levels of cortisol in IS and NS monkeys did not differ significantly from baseline levels measured in undisturbed conditions. During testing, more IS than NS monkeys voluntarily left the home cage, and IS monkeys spent more time in the test box compared to NS monkeys. More IS than NS monkeys engaged in object exploration in the test box, and IS monkeys preferred to interact with the novel vs. familiar object. Novelty seeking was not associated with differences in 5HIAA, HVA, MHPG, or CRF, but correlated with differences in object exploration observed in a different test situation at an earlier age. These trait-like differences in novelty seeking appear to reflect mild early stress-induced adaptations that enhance curiosity and resilience.
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Affiliation(s)
- Karen J Parker
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 1201 Welch Road, MSLS Room P104, Mail Code 5485, Stanford, CA 94305-5485, USA.
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Neylan TC, Lenoci M, Samuelson KW, Metzler TJ, Henn-Haase C, Hierholzer RW, Lindley SE, Otte C, Schoenfeld FB, Yesavage JA, Marmar CR. No improvement of posttraumatic stress disorder symptoms with guanfacine treatment. Am J Psychiatry 2006; 163:2186-8. [PMID: 17151174 DOI: 10.1176/appi.ajp.163.12.2186] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The authors report an 8-week, double-blind, randomized controlled trial of guanfacine versus placebo for posttraumatic stress disorder (PTSD). METHOD Veterans with chronic PTSD who were medication-free or receiving stable pharmacotherapy were randomly assigned to guanfacine (N=29) versus placebo (N=34). RESULTS Guanfacine had no effect on PTSD symptoms, subjective sleep quality, or general mood disturbances. Guanfacine was associated with a number of side effects. CONCLUSIONS These results do not support the use of alpha 2 agonists in veterans with chronic PTSD.
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Affiliation(s)
- Thomas C Neylan
- Department of Psychiatry, University of California, San Francisco, USA.
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Lindley SE, She X, Schatzberg AF. Monoamine oxidase and catechol-o-methyltransferase enzyme activity and gene expression in response to sustained glucocorticoids. Psychoneuroendocrinology 2005; 30:785-90. [PMID: 15919584 DOI: 10.1016/j.psyneuen.2005.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [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: 03/19/2004] [Revised: 03/09/2005] [Accepted: 03/14/2005] [Indexed: 10/25/2022]
Abstract
We previously reported changes in DA neurochemical estimates after sustained corticosterone (CORT) administration or adrenalectomy (ADX) that are consistent with glucocorticoid-induced inhibition of DA metabolism. The present investigation measured monoamine oxidase type A (MAO-A), type B (MAO-B) and catechol-o-methyltransferase (COMT) activity by enzymatic assay and levels of gene expression by real-time quantitative polymerase chain reaction (rt-PCR) in tissues from sham, ADX, or ADX+CORT-replaced Lewis rats. One week of ADX had no significant effect on either enzyme activity or gene expression for any of the three enzymes examined in the medial prefrontal cortex, striatum, or liver. One week of CORT administration (100mg-21 day release pellet) in ADX rats produced statistically significant decreases in MAO-A enzyme activity and MAO-B gene expression in the liver but no significant changes for any of the three enzymes in either activity or gene expression in the medial prefrontal cortex or striatum. The results do not support inhibition of DA metabolism as a mechanism by which glucocorticoids influence DA-mediated behaviors.
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Affiliation(s)
- Steven E Lindley
- Department of Psychiatry, Veterans Affairs Palo Alto Health Care System, CA 94304, USA.
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Lindley SE, Carlson EB, Benoit M. Basal and dexamethasone suppressed salivary cortisol concentrations in a community sample of patients with posttraumatic stress disorder. Biol Psychiatry 2004; 55:940-5. [PMID: 15110738 DOI: 10.1016/j.biopsych.2003.12.021] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2003] [Revised: 11/25/2003] [Accepted: 12/23/2003] [Indexed: 12/19/2022]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) has been associated with lower concentrations of cortisol and enhanced suppression of cortisol by dexamethasone, although discrepancies exist among reports. The objective of the study was to determine the pattern of cortisol responses in patients seeking treatment for PTSD resulting from a variety of traumatic experiences and to test whether cortisol responses are significantly related to childhood trauma, severity of symptoms, or length of time since trauma. METHODS Salivary cortisol was measured at 8 AM, 4 PM, and 10 PM on 2 consecutive days before and after a 10 PM dose of .5 mg dexamethasone in 17 psychotropic medication and substance-free subjects with PTSD and 17 matched control subjects. RESULTS Repeated-measures analysis of variance (ANOVA) of the baseline salivary cortisol concentrations demonstrated a significant effect for group with higher concentrations in the PTSD group but no significant differences in responses to dexamethasone. The presence of childhood abuse did not significantly affect salivary cortisol concentrations, and there was no correlation between predexamethasone cortisol and either the severity of PTSD symptoms or the time since the index trauma. CONCLUSIONS Neither low basal concentrations nor enhanced suppression of cortisol are consistent markers of a PTSD diagnosis.
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Affiliation(s)
- Steven E Lindley
- Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, Palo Alto Veterans Affairs Health Care System, Menlo Park, California 94025, USA
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Lindley SE, Bengoechea TG, Wong DL, Schatzberg AF. Mesotelencephalic dopamine neurochemical responses to glucocorticoid administration and adrenalectomy in Fischer 344 and Lewis rats. Brain Res 2002; 958:414-22. [PMID: 12470878 DOI: 10.1016/s0006-8993(02)03719-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The effects of alterations in peripheral corticosterone levels on multiple dopamine neurochemical estimates were examined in inbred Fischer and Lewis inbred rat strains. 2x2 ANOVA's (treatment x strain) showed a main effect for treatment (1 week CORT versus placebo) on the concentrations of the dopamine metabolites homovanillic acid and dihydroxyphenylacetic acid in the medial prefrontal cortex, with lower levels after treatment, but no significant treatment versus strain interaction. There was no effect of CORT treatment on DA metabolites in the nucleus accumbens shell or dorsal striatum. DOPA accumulation in any terminal region examined and tyrosine hydroxylase protein content in the ventral tegmental area were also not affected by 1 week of corticosterone in either strain. One week after adrenalectomy, homovanillic acid but not dihydroxyphenylacetic acid concentrations were significantly increased in the medial prefrontal cortex, dorsal striatum, and nucleus accumbens shell in the Lewis but not the Fischer strain, with a significant treatment x strain interaction only in the dorsal striatum. Based on these findings, the effect of adrenalectomy on DOPA accumulation and extracellular DA concentrations was examined in the Lewis strain only. Adrenalectomy produced a decrease in DOPA accumulation in the dorsal striatum with no significant change in the other regions. Adrenalectomy did not alter estimates of extracellular dopamine concentrations determined by in vivo no net flux microdialysis but did significantly increase in vivo dopamine recovery in the dorsal striatum. The findings indicate a pattern of changes in neurochemical measurements consistent with a small magnitude inhibition of basal dopamine metabolism, but not with a change neuronal activity, release or reuptake.
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Affiliation(s)
- Steven E Lindley
- National Center for PTSD, Department of Veterans Affairs, Palo Alto Health Care Systema, PTSD 352/117, 795 Willow Road, Menlo Park, CA 94025, USA.
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Abstract
Recent data suggest that the presence of psychotic symptoms in patients suffering from posttraumatic stress disorder (PTSD) may represent an underrecognized and unique subtype of PTSD. Among combat veterans with PTSD, 30% to 40% report auditory or visual hallucinations and/or delusions. The presence of psychotic symptoms in PTSD is associated with a more severe level of psychopathology, similar to that of chronic schizophrenia. In this review, the differential diagnosis of psychotic symptoms in PTSD is discussed, including possible comorbid schizophrenia, psychotic depression, substance-induced psychosis, and personality disorder. A recent biologic study supporting the existence of a unique subtype of PTSD with psychotic features is also addressed, as are the similarities between PTSD with psychotic features and psychotic depression disorder. Finally, data on the treatment implications of psychotic symptoms in PTSD are presented. The intriguing recent findings on psychotic symptoms in PTSD need further investigation in noncombat-related PTSD populations before findings can be generalized to all individuals with PTSD.
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Affiliation(s)
- S E Lindley
- National Center for PTSD, Palo Alto VA Health Care System, Menlo Park, CA, USA
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Abstract
Multiple neurochemical estimates were used to examine peripheral corticosterone (CORT) effects in dopaminergic terminal regions. Acute CORT administration, which elevated plasma CORT (5 h), slightly decreased dihydroxyphenylacetic acid (DOPAC) to dopamine (DA) ratios in the striatum but not in other regions examined. Two weeks of adrenalectomy (ADX) increased both medial prefrontal cortex DOPAC/DA and homovanillic acid (HVA)/DA and striatal HVA/DA. A reciprocal pattern of changes was observed with CORT replacement in ADX animals. In contrast, CORT replacement in ADX animals did not significantly influence tyrosine hydroxylase content, basal dihydroxyphenylalanine (DOPA) accumulation after NSD 1015 treatment or the decline in DA after alpha-methyl-para-tyrosine, suggesting that neither DA neuronal activity nor release are altered by CORT. Moreover, neither gamma-hydroxybutyric acid lactone-induced increases in DOPA accumulation or stress-induced increases in DA utilization were influenced by CORT replacement, indicating that neither autoreceptor regulation of DA synthesis nor acute stress regulation of DA utilization are changed by CORT. The findings are most consistent with direct inhibition of basal DA metabolism in the medial prefrontal cortex and striatum. The possible physiological and behavioral significance of this inhibition is being further explored.
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Affiliation(s)
- S E Lindley
- Nancy Pritzker Neurobiology Laboratory, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, California 94305-5485, USA
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Lindley SE, Bengoechea TG, Wong DL, Schatzberg AF. Strain differences in mesotelencephalic dopaminergic neuronal regulation between Fischer 344 and Lewis rats. Brain Res 1999; 832:152-8. [PMID: 10375661 DOI: 10.1016/s0006-8993(99)01446-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Differences in the behavioral responses of Lewis and Fischer (F344) inbred rat strains to stress and psychoactive drugs have been related to differences in the expression of various regulatory proteins in regions containing mesolimbic dopamine (DA) neurons. The present study compared basal and stimulated neurochemical estimates of DA utilization and synthesis in mesocortical, mesolimbic and nigrostriatal DA terminal regions of these two strains. In unstressed control animals, the Lewis strain had lower DA concentrations in the dorsal striatum (ST; 80.3% of F344) and lower basal dihydroxyphenylalanine (DOPA) accumulation after m-hydroxybenzylhydrazine (NSD 1015) treatment in the medial prefrontal cortex (mPfx; 75.3% of F344). Similar differences were observed in vehicle-injected animals. No strain differences in basal neurochemistry were apparent in the nucleus accumbens shell (NAs) or core (NAc). In response to restraint stress, dihydroxyphenylacetic acid (DOPAC) to DA ratios in the mPfx, NAs and ST increased in the F344 but not the Lewis strain. However, restraint stress did not significantly increase DOPA accumulation in the F344 strain. This latter finding was not due to a deficit in synthesis capacity, as gamma-hydroxybutyric acid lactone (GBL) increased DOPA accumulation significantly more in F344 than Lewis animals. Finally, haloperidol increased DA utilization similarly in the two strains. Together these findings suggest that the inbred, behaviorally divergent F344 and Lewis rats have selective differences in mesocortical, nigrostriatal and mesolimbic DA neuronal regulation.
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Affiliation(s)
- S E Lindley
- National Center for PTSD, Department of Veterans Affairs, Palo Alto Health Care System Division PTSD 352/117, 795 Willow Road, Menlo Park, CA 94025, USA.
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Lyons DM, Wang OJ, Lindley SE, Levine S, Kalin NH, Schatzberg AF. Separation induced changes in squirrel monkey hypothalamic-pituitary-adrenal physiology resemble aspects of hypercortisolism in humans. Psychoneuroendocrinology 1999; 24:131-42. [PMID: 10101722 DOI: 10.1016/s0306-4530(98)00065-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [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] [Indexed: 11/17/2022]
Abstract
When separated from groups, squirrel monkeys respond with significant increases in plasma cortisol and adrenocorticotropic hormone (ACTH). While cortisol remains elevated above pre-separation levels, significant reductions occur in ACTH. Monkeys that respond with greater increases in cortisol subsequently exhibit greater reductions in ACTH, which suggests that reductions in ACTH are mediated by corticosteroid feedback. Monkeys that respond with greater increases in cortisol also tend to exhibit greater cerebrospinal fluid levels of the dopamine metabolite HVA, but not the norepinephrine metabolite MHPG, or corticotropin-releasing factor (CRF). Attenuation of corticosteroid feedback with metyrapone results in significant increases in circulating ACTH, and in older monkeys increases plasma HVA. Similar findings in humans have been reported in clinical studies of hypercortisolism and major depression.
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Affiliation(s)
- D M Lyons
- Department of Psychiatry and Behavioral Science, Stanford University School of Medicine, CA 94305-5485, USA.
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Faustman WO, Ringo DL, Lindley SE. Cholesterol and violence: is there a connection? Ann Intern Med 1998; 129:669; author reply 669-70. [PMID: 9786820 DOI: 10.7326/0003-4819-129-8-199810150-00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Ebert SN, Lindley SE, Bengoechea TG, Bain D, Wong DL. Adrenergic differentiation potential in PC12 cells: influence of sodium butyrate and dexamethasone. Brain Res Mol Brain Res 1997; 47:24-30. [PMID: 9221898 DOI: 10.1016/s0169-328x(97)00032-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The ability of sodium butyrate and dexamethasone to promote adrenergic differentiation in PC12 cells was examined using the gene encoding the epinephrine biosynthetic enzyme, phenylethanolamine N-methyltransferase (PNMT), as a marker. Sodium butyrate and dexamethasone independently stimulated expression of PNMT mRNA in PC12 cells, and the combined action of these drugs led to synergistic activation of the PNMT gene. Despite the induction of the PNMT gene, epinephrine is not produced in these cells, in part due to the absence of a corresponding induction in PNMT enzymatic activity. Another contributing factor appears to be a reduction in the precursor catecholamines, norepinephrine and dopamine, in the presence of sodium butyrate. Thus, while sodium butyrate and dexamethasone can induce PNMT gene expression, treatment of PC12 cells with these drugs appears insufficient for full acquisition of the adrenergic phenotype.
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Affiliation(s)
- S N Ebert
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, CA 94305-5485, USA
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Horne M, Lindley SE. Divalproex sodium in the treatment of aggressive behavior and dysphoria in patients with organic brain syndromes. J Clin Psychiatry 1995; 56:430-1. [PMID: 7665542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Bohannon JR, Dosser DA, Lindley SE. Using couple data to determine domestic violence rates: an attempt to replicate previous work. Violence Vict 1995; 10:133-141. [PMID: 8599598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Research methodology using only one spouse to report for the couple has been questioned. Szinovacz (1983) reported higher rates of violence when both spouses responded to six items on Straus's Conflict Tactics Scale (CTS). The purpose of this study was to replicate her methodology by using all items measuring severe violence in the latest CTS scale with 94 military couples, to see if couple reports of violence indicated higher rates of violence compared to individual spouses' reports. Results were similar to Szinovacz's findings, and support the advisability of using both spouses to report violence in marriages.
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Affiliation(s)
- J R Bohannon
- Department of Child Development and Family Relations, East Carolina University, USA
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Affiliation(s)
- D L Ringo
- Stanford/VA Mental Health Clinical Research Center, Department of Veterans Affairs Medical Center, Palo Alto, CA 94304
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Goudreau JL, Lindley SE, Lookingland KJ, Moore KE. Evidence that hypothalamic periventricular dopamine neurons innervate the intermediate lobe of the rat pituitary. Neuroendocrinology 1992; 56:100-5. [PMID: 1322505 DOI: 10.1159/000126214] [Citation(s) in RCA: 90] [Impact Index Per Article: 2.8] [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] [Indexed: 12/26/2022]
Abstract
The purpose of the present study was to provide neurochemical and endocrinological evidence that dopamine (DA) neurons terminating in the intermediate lobe of the rat pituitary originate in the periventricular nucleus of the hypothalamus. One week following surgical separation of the periventricular nucleus from the mediobasal hypothalamus, DA and 3,4-dihydroxyphenyl-acetic acid (DOPAC) concentrations in the intermediate lobe were reduced by 50%, and this was accompanied by an increase in plasma alpha-melanocyte-stimulating hormone (alpha-MSH) concentrations. In contrast, this procedure had no effect on concentrations of prolactin in the plasma, or DA or DOPAC in the median eminence, the region of the mediobasal hypothalamus containing terminals of tuberoinfundibular DA neurons. Electrical stimulation of the periventricular nucleus increased the ratio of DOPAC/DA in the intermediate lobe and reduced the concentrations of alpha-MSH in the plasma, whereas in these same animals the DOPAC/DA ratio in the median eminence and concentrations of prolactin in the plasma were unaltered. These results indicate that approximately 50% of all the DA neurons terminating in the intermediate lobe of the rat pituitary originate in or project through the periventricular nucleus of the hypothalamus, and that these DA neurons regulate the secretion of alpha-MSH from intermediate lobe melanotrophs.
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Affiliation(s)
- J L Goudreau
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing 48824
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Abstract
The relative roles of dopaminergic and beta-adrenergic receptors in mediating the stress-induced increase in the secretion of alpha-melanocyte-stimulating hormone (alpha-MSH) from the intermediate lobe of the pituitary were determined in the male rat. Thirty minutes of physical immobilization (restraint stress) increased the circulating concentrations of alpha-MSH and decreased the 3,4-dihydroxyphenylacetic acid/dopamine (DOPAC/DA) ratio in the intermediate lobe of the pituitary, reflecting a decrease in the tuberohypophysial dopaminergic neuronal activity. Pretreatment with the beta-adrenergic antagonist propranolol reduced the stress-induced increase in the circulating levels of alpha-MSH, but had no effect on the basal plasma concentrations of this hormone or the stress-induced decrease in DOPAC/DA in the intermediate lobe. If the dopaminergic tone during stress was maintained by administration of the DA agonist apomorphine, the stress-induced increase in alpha-MSH secretion was prevented. In nonstressed animals the administration of the beta 2-adrenergic agonist metaproterenol increased the plasma levels of alpha-MSH, and the effect of this drug was augmented if the inhibitory dopaminergic tone on alpha-MSH secretion was blocked by the administration of the DA antagonist haloperidol. Severing neurons in the retrochiasmatic region of the hypothalamus blocked the stress-induced decrease in DOPAC/DA in the intermediate lobe and attenuated the stress-induced increase in plasma concentrations of alpha-MSH. Taken together, these results indicate that a decrease in tuberohypophysial dopaminergic neuronal inhibitory tone and an increase in beta-adrenergic stimulation are both necessary for the full expression of the stress-induced increase in secretion of alpha-MSH from melanotrophs in the intermediate lobe of the rat pituitary.
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Affiliation(s)
- S E Lindley
- Department of Pharmacology/Toxicology, Michigan State University, East Lansing
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Lindley SE, Lookingland KJ, Moore KE. Activation of tuberoinfundibular but not tuberohypophysial dopaminergic neurons following intracerebroventricular administration of alpha-melanocyte-stimulating hormone. Neuroendocrinology 1990; 51:394-9. [PMID: 2161087 DOI: 10.1159/000125381] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [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] [Indexed: 12/30/2022]
Abstract
The effect of alpha-melanocyte-stimulating hormone (alpha MSH) on the activity of different central dopaminergic neurons in the male rat was determined by measuring the concentration of 3,4-dihydroxyphenylacetic acid (DOPAC) and the accumulation of 3,4-dihydroxyphenylalanine (DOPA) following the administration of a decarboxylase inhibitor in brain regions that contain terminals of nigrostriatal (striatum), mesolimbic (nucleus accumbens), tuberoinfundibular (median eminence) and tuberohypophysial (neural and intermediate lobe of the pituitary) dopaminergic neurons. Intracerebroventricular (i.c.v.) administration of alpha MSH caused a prompt (within 30 min) increase in the concentration of DOPAC and the accumulation of DOPA in the median eminence, but was without effect in the other brain regions. The alpha MSH-induced increase in tuberoinfundibular dopaminergic neuronal activity was temporally related to a decrease in circulating concentrations of prolactin. Twelve hours after the i.c.v. administration of prolactin DOPA accumulation increased in the median eminence but not in the neural or intermediate lobes of the pituitary. DOPA accumulation was not altered in any brain region 12 h after the i.c.v. administration of alpha MSH. These results suggest that alpha MSH acts acutely to selectively activate tuberoinfundibular dopaminergic neurons and thereby cause the secretion of prolactin from the anterior pituitary to decrease.
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Affiliation(s)
- S E Lindley
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing
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Lindley SE, Gunnet JW, Lookingland KJ, Moore KE. 3,4-Dihydroxyphenylacetic acid concentrations in the intermediate lobe and neural lobe of the posterior pituitary gland as an index of tuberohypophysial dopaminergic neuronal activity. Brain Res 1990; 506:133-8. [PMID: 2302550 DOI: 10.1016/0006-8993(90)91209-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Tuberohypophysial dopamine (DA) neurons terminate in the intermediate and neural lobes of the posterior pituitary. The objective of this study was to determine if concentrations of 3,4-dihydroxyphenylacetic acid (DOPAC), a major metabolite of DA in these regions, reflect the activity of tuberohypophysial DA neurons. The concentrations of DOPAC and DA in the intermediate lobe were approximately twice those in the neural lobe, so that the ratios of DOPAC/DA were similar between lobes. The administration of a monoamine oxidase inhibitor pargyline produced a rapid decline (by 5 min) of DOPAC concentrations in both the intermediate and neural lobes. The administration of nomifensine, an inhibitor of DA uptake at the nerve terminal, produced a modest 33% decline in DOPAC concentrations in the intermediate lobe, but was without effect in the neural lobe. Activation of tuberohypophysial DA neurons by electrical stimulation of the pituitary stalk increased both the rate of DA synthesis (accumulation of dihydroxyphenylalanine (DOPA) after administration of the decarboxylase inhibitor NSD 1015) and the concentrations of DOPAC in the intermediate and neural lobes. Administration of the DA antagonist haloperidol increased, and the DA agonist apomorphine decreased both the rate of DOPA accumulation and DOPAC concentrations in the intermediate lobe but not the neural lobe. The results of the present study demonstrate that: (1) elimination of DOPAC from the intermediate lobe and neural lobe is rapid and alterations in DOPAC concentrations reflect dynamic changes in metabolism of DA; (2) DA which is released and recaptured is a minor contributor to DOPAC concentrations; and (3) alterations in the activity of tuberohypophysial DA neurons are accompanied by corresponding changes in DOPAC concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S E Lindley
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing 48824
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Lindley SE, Gunnet JW, Lookingland KJ, Moore KE. Effects of alterations in the activity of tuberohypophysial dopaminergic neurons on the secretion of alpha-melanocyte stimulating hormone. Proc Soc Exp Biol Med 1988; 188:282-6. [PMID: 2839845 DOI: 10.3181/00379727-188-42735] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Administration of gamma-butyrolactone (GBL), an anesthetic which reduces dopaminergic neuronal activity, decreased the concentration of the dopamine (DA) metabolite 3,4-dihydroxyphenylacetic acid (DOPAC) in the intermediate lobe of the pituitary gland, and increased alpha-melanocyte stimulating hormone (alpha MSH) concentrations in the serum of male rats. Bilateral electrical stimulation of the rostral arcuate nucleus, which contains perikarya of tuberohypophysial DA neurons, increased DOPAC concentrations in the intermediate lobe and decreased alpha MSH concentrations in the serum of GBL-anesthetized rats. Administration of the DA antagonist haloperidol prevented the decline in serum alpha MSH levels following arcuate nucleus stimulation, but had no effect on serum alpha MSH concentrations in sham-stimulated GBL-treated rats. These results indicate that GBL-induced decreases or stimulation-induced increases in the activity of tuberohypophysial DA neurons are accompanied by corresponding changes in the metabolism of DA in the intermediate lobe of the rat pituitary gland, and by reciprocal changes in the secretion of alpha MSH.
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Affiliation(s)
- S E Lindley
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing 48824
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Gunnet JW, Lookingland KJ, Lindley SE, Moore KE. Effect of electrical stimulation of the arcuate nucleus on neurochemical estimates of tuberoinfundibular and tuberohypophysial dopaminergic neuronal activities. Brain Res 1987; 424:371-8. [PMID: 3119157 DOI: 10.1016/0006-8993(87)91482-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The activity of nigrostriatal dopaminergic neurons has been estimated biochemically by measuring the rates of dopamine (DA) synthesis (accumulation of dihydroxyphenylalanine (DOPA) after NSD 1015) and turnover (decline of DA concentrations after alpha-methyltyrosine) in the striatum. It has been assumed that the activities of tuberoinfundibular dopaminergic (TIDA) and tuberohypophysial dopaminergic (THDA) neurons can also be estimated by making the same measurements in the terminals of these neurons in the median eminence and the posterior pituitary, respectively. In the present study, this assumption was tested directly by measuring the rates of DA synthesis and turnover in the median eminence and posterior pituitary following electrical stimulation of TIDS and THDA cell bodies in the arcuate nucleus. Electrical stimulation of the arcuate nucleus increased the rate of DOPA accumulation and the alpha-methyltyrosine-induced decline of DA concentrations in the median eminence and in the neural and intermediate lobes of the posterior pituitary. gamma-Butyrolactone (GBL), an anesthetic that selectively inhibits DA impulse flow, reduced the rates of DA synthesis and turnover in the median eminence. GBL also increased prolactin secretion which is tonically inhibited by DA released from TIDA neurons. Serum prolactin levels were significantly decreased by arcuate nucleus stimulation in GBL-anesthetized rats. These results indicate that the rates of DA synthesis and turnover within the median eminence and posterior pituitary reflect the activities of TIDA and THDA neurons, respectively.
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Affiliation(s)
- J W Gunnet
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing 48824
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