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Gros DF, Pavlacic JM, Argyriou E, Acierno R, Hernandez-Tejada MA. Differential relations between breathing retraining, in vivo exposure, and imaginal exposure homework completion and treatment outcomes in veterans receiving prolonged exposure for PTSD. J Clin Psychol 2024; 80:1259-1270. [PMID: 38367254 DOI: 10.1002/jclp.23662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/08/2024] [Accepted: 02/04/2024] [Indexed: 02/19/2024]
Abstract
OBJECTIVES Limited research exists that outlines the predictive relevance of the treatment components of prolonged exposure (PE) for post-traumatic stress disorder (PTSD) on PTSD and depression symptom outcomes. The goal of the present study was to investigate relations between participant completion of breathing retraining, in vivo exposure, and imaginal exposure exercises and symptom outcomes. METHODS A total of 58 participants completed a trial of PE as part of a larger trial on peer involvement and treatment adherence. Diagnostic and self-report measures were completed throughout treatment. Participants also recorded weekly completion of breathing retraining, in vivo exposure, and imaginal exposure exercises. Pearson correlations and hierarchical regression analyses were used to investigate relations between average weekly treatment component completion and treatment outcomes, controlling for relevant variables. RESULTS Although breathing retraining and in vivo exposures were associated with PTSD outcomes in the correlational findings, use of breathing retraining, in vivo exposures, and imaginal exposures were not reliably associated with PTSD symptom outcomes when controlling for other variables in the regression analysis. However, when investigating changes in comorbid symptoms of depression, greater use of breathing retraining was associated with decreased symptoms of depression at posttreatment. CONCLUSIONS Present findings demonstrate the differential relations between participation in various PE treatment components and posttreatment symptom outcomes. The importance of breathing retraining in addressing comorbid depressive symptoms is discussed, with emphasis on potentially increasing relaxation and positive activities more broadly to encourage further treatment benefits.
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Affiliation(s)
- Daniel F Gros
- Mental Health Service, Ralph H. Johnson VA Healthcare System, Charleston, South Carolina, USA
- Department of Psychology & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jeffrey M Pavlacic
- Mental Health Service, Ralph H. Johnson VA Healthcare System, Charleston, South Carolina, USA
- Department of Psychology & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Evangelia Argyriou
- Mental Health Service, Ralph H. Johnson VA Healthcare System, Charleston, South Carolina, USA
- Department of Psychology & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ron Acierno
- Mental Health Service, Ralph H. Johnson VA Healthcare System, Charleston, South Carolina, USA
- Louis A. Faillace, MD Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Melba A Hernandez-Tejada
- Louis A. Faillace, MD Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, Texas, USA
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McGeary CA, Morland LA, Resick PA, Straud CL, Moring JC, Sohn MJ, Mackintosh MA, Young-McCaughan S, Acierno R, Rauch SAM, Mintz J, McGeary DD, Wells SY, Grubbs K, Nabity PS, McMahon CJ, Litz BT, Velligan DI, Macdonald A, Mata-Galan E, Holliday SL, Dillon KH, Roache JD, Peterson AL. Impact and efficiency of treatment across two PTSD clinical trials comparing in-person and telehealth service delivery formats. Psychol Serv 2024; 21:73-81. [PMID: 37347913 DOI: 10.1037/ser0000774] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
The intent of this study is to examine treatment impact and efficiency observed when cognitive behavioral treatments for posttraumatic stress disorder (PTSD) are delivered in-person or using telehealth. This study pooled data from 268 veterans enrolled in two PTSD clinical trials. In both trials, treatment was delivered using in-home telehealth (telehealth arm), in-home in-person (in-home arm), and in-office care, where patients traveled to the Department of Veterans Affairs for either office-based telehealth or office-based in-person care (office arm). Average age was 44 (SD = 12.57); 80.9% were males. The PTSD Checklist for DSM-5 (PCL-5) was used to assess symptom severity. Treatment impact was measured by (a) the proportion of participants who completed at least eight treatment sessions and (b) the proportion with a reliable change of ≥ 10 points on the PCL-5. Treatment efficiency was measured by the number of days required to reach the end point. The proportion of participants who attended at least eight sessions and achieved reliable change on the PCL-5 differed across treatment formats (ps < .05). Participants in the in-home (75.4%) format were most likely to attend at least eight treatment sessions, followed by those in the telehealth (58.3%) and office (44.0%) formats, the latter of which required patients to travel. Participants in the in-home (68.3%, p < .001) format were also more likely to achieve reliable change, followed by those in the telehealth (50.9%) and office (44.2%) formats. There were no significant differences in the amount of time to complete at least eight sessions. Delivery of therapy in-home results in a significantly greater likelihood of achieving both an adequate dose of therapy and a reliable decrease in PTSD symptoms compared to telehealth and office formats. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Cindy A McGeary
- Department of Psychiatry and Behavioral Sciences, Joe and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio
| | | | - Patricia A Resick
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Casey L Straud
- Department of Psychiatry and Behavioral Sciences, Joe and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio
| | - John C Moring
- Department of Psychiatry and Behavioral Sciences, Joe and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio
| | - Min Ji Sohn
- Pacific Islands Division, National Center for PTSD
| | | | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, Joe and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio
| | - Ron Acierno
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston
| | | | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, Joe and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio
| | - Donald D McGeary
- Department of Psychiatry and Behavioral Sciences, Joe and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio
| | - Stephanie Y Wells
- VISN-6 Mid-Atlantic Mental Illness Research Education Clinical, Centers of Excellence
| | | | - Paul S Nabity
- Department of Psychiatry and Behavioral Sciences, Joe and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio
| | - Chelsea J McMahon
- Department of Psychiatry and Behavioral Sciences, Joe and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio
| | - Brett T Litz
- Department of Psychiatry, Boston University School of Medicine
| | - Dawn I Velligan
- Department of Psychiatry and Behavioral Sciences, Joe and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio
| | | | | | | | - Kirsten H Dillon
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - John D Roache
- Department of Psychiatry and Behavioral Sciences, Joe and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, Joe and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio
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Rauch SA, Kim HM, Acierno R, Ragin C, Wangelin B, Blitch K, Muzzy W, Hart S, Zivin K. Improving function through primary care treatment of posttraumatic stress disorder study outcomes: A randomized controlled trial of prolonged exposure for primary care in veterans. Fam Syst Health 2023; 41:502-513. [PMID: 37650808 PMCID: PMC10840599 DOI: 10.1037/fsh0000823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Despite high cost and wide prevalence of posttraumatic stress disorder (PTSD) in veteran populations, and Veterans Health Administration (VA)-wide mental health provider training in evidence-based treatments for PTSD, most veterans with PTSD do not receive best practices interventions. This may be because virtually all evidence-based PTSD treatment is offered through specialty clinics, which require multiple steps and referrals to access. One solution is to offer PTSD treatment in VA primary care settings, which are often the first and only contact point for veterans. METHOD The present study, Improving Function Through Primary Care Treatment of PTSD (IMPACT), used a randomized controlled design to compare an adaptation of prolonged exposure for PTSD to primary care (PE-PC) versus best practices Primary Care Mental Health Integration (PCMHI) clinic treatment as usual (TAU) in terms of both functioning and psychological symptoms in 120 veterans recruited between April 2019 and September 2021. RESULTS Participants were mostly males (81.7%) with a mean age of 43.6 years (SD = 12.8), and more than half were non-White veterans (50.8%). Both conditions evinced significant improvement over baseline across functioning, PTSD, and depression measures, with no differences observed between groups. As observed in prior studies, PTSD symptoms continued to improve over time in both conditions, as measured by structured clinical interview. DISCUSSION Both PE-PC and best-practices TAU are effective in improving function and reducing PTSD severity and depression severity. Although we did not observe differences between the two treatments, note that this study site and two PCMHI clinics employ primarily cognitive behavioral therapies (e.g., exposure and behavioral activation). (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Sheila A.M. Rauch
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033
- Emory University School of Medicine, 12 Executive Park, 3 Floor, Atlanta, GA, 30029
| | - H. Myra Kim
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105
- University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI, 48109
| | - Ron Acierno
- Ralph H. Johnson VA Health Care System, 109 Bee Street, Charleston, SC, 29401
- University of Texas Health Science Center at Houston, Faillace Department of Psychiatry, Behavioral and Biomedical Sciences Building (BBSB), 1941 East Road, Houston, Texas 77054
| | - Carly Ragin
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033
| | - Bethany Wangelin
- Ralph H. Johnson VA Health Care System, 109 Bee Street, Charleston, SC, 29401
- Medical University of South Carolina, Department of Psychiatry & Behavioral Sciences, 67 President Street, Charleston, SC 29425
| | - Kimberly Blitch
- Ralph H. Johnson VA Health Care System, 109 Bee Street, Charleston, SC, 29401
- Medical University of South Carolina, Department of Psychiatry & Behavioral Sciences, 67 President Street, Charleston, SC 29425
| | - Wendy Muzzy
- Ralph H. Johnson VA Health Care System, 109 Bee Street, Charleston, SC, 29401
- Medical University of South Carolina, Department of Psychiatry & Behavioral Sciences, 67 President Street, Charleston, SC 29425
| | - Stephanie Hart
- Ralph H. Johnson VA Health Care System, 109 Bee Street, Charleston, SC, 29401
- Medical University of South Carolina, Department of Psychiatry & Behavioral Sciences, 67 President Street, Charleston, SC 29425
| | - Kara Zivin
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105
- University of Michigan, Department of Psychiatry, 2800 Plymouth Road, Ann Arbor, MI 48109
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Brown DG, Jarnecke AM, Saraiya TC, Santa-Ana E, Acierno R, Reese M, Adams R, Harley W, Back SE. Clinician perspectives on technology-enhanced in vivo exposures during prolonged exposure therapy for PTSD. J Clin Psychol 2023; 79:2947-2958. [PMID: 37702428 PMCID: PMC10840959 DOI: 10.1002/jclp.23591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVE To investigate clinicians' perceptions regarding the use of mobile technology tools during prolonged exposure (PE) therapy to allow for monitoring and enhancing in-vivo exposures (IVEs). METHODS Clinicians with training in PE therapy (N = 32; average of 9 years of practice) completed surveys asking about their perspectives on the utility of virtually attending IVEs with patients while simultaneously having access to real-time subjective and physiological data (i.e., heart rate, galvanic skin conductance) to guide exposure exercises and assure optimal stimulus engagement. RESULTS Findings showed clinicians to have a favorable view of applying technology devices and systems to enhance IVEs of PE therapy. Most clinicians (93.8%) believed that real-time monitoring of IVEs-particularly monitoring patients' subjective distress and completion of and duration of time in the IVE-would be useful and significantly enhance PE therapy. CONCLUSION The positive perceptions toward integrating technology into IVEs in this study have important implications for the development and implementation of technology-enhanced PE therapy. A mobile technology system that incorporates real-time indicators of engagement (i.e., both subjective and physiological) during IVEs and allows clinicians to review recordings of, or virtually accompany, patients during IVEs has the potential to innovate and transform PE and other exposure-based treatments. Clinicians also believed that technology-enhanced IVEs may help reduce early termination from PE.
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Affiliation(s)
- Delisa G. Brown
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Amber M. Jarnecke
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Tanya C. Saraiya
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Elizabeth Santa-Ana
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
- Ralph H. Johnson VA Medical Center, Charleston, SC
| | - Ron Acierno
- Ralph H. Johnson VA Medical Center, Charleston, SC
- Louis A. Faillace Department of Psychiatry, University of Texas Health Science Center at Houston, Houston, TX
| | | | - Robert Adams
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
- Zeriscope, Inc., Charleston, SC
| | | | - Sudie E. Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
- Ralph H. Johnson VA Medical Center, Charleston, SC
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Hernandez-Tejada MA, Cherry KE, Rauch SAM, Acierno R, Fries GR, Muzzy W, Teng EJ, Wangelin B, Ahn H. Management of Chronic Pain and PTSD in Veterans With tDCS+Prolonged Exposure: A Pilot Study. Mil Med 2023; 188:3316-3321. [PMID: 35808998 DOI: 10.1093/milmed/usac200] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/13/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Chronic pain and posttraumatic stress disorder (PTSD) are prevalent comorbid conditions, particularly in Veterans; however, there are few integrated treatments for chronic pain and PTSD. Instead, interventions are typically implemented separately and may involve addictive opioids. Although there are highly effective, non-pharmacological treatments for PTSD, they are plagued by high dropout, which may be exacerbated by comorbid pain, as these PTSD treatments typically require increased activity. Importantly, a noninvasive pain treatment, tDCS (transcranial direct current stimulation) shows indications of effectiveness and may be integrated with psychological treatments, even when delivered via telehealth. This study examines the feasibility and initial efficacy of integrating home telehealth tDCS with prolonged exposure (PE), an evidence-based PTSD treatment. MATERIALS AND METHODS Thirty-nine Veterans were contacted, 31 consented to evaluation, 21 were enrolled, and 16 completed treatment and provided pre- and post-treatment data at one of two Veterans Affairs Medical Centers. Transcranial direct current stimulation sessions corresponded with PE exposure assignments, as there is theoretical reason to believe that tDCS may potentiate extinction learning featured in PE. RESULTS Patients evinced significant improvement in both pain interference and PTSD symptoms and a trend toward improvement in depression symptoms. However, a significant change in pain intensity was not observed, likely because of the small sample size. DISCUSSION The findings provide initial support for the feasibility of an entirely home-based, integrated treatment for comorbid PTSD and pain.
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Affiliation(s)
- Melba A Hernandez-Tejada
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77054, USA
| | - Kathryn E Cherry
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77054, USA
- Department of Psychological Sciences, University of Missouri, St. Louis, St. Louis, MO 63121, USA
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA 30329, USA
- Atlanta VA Healthcare System, Atlanta, GA 30329, USA
| | - Ron Acierno
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77054, USA
- Ralph H. Johnson VA Medical Center, Charleston, SC 29401, USA
| | - Gabriel R Fries
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77054, USA
| | - Wendy Muzzy
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Ellen J Teng
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX 77030, USA
- Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
| | - Bethany Wangelin
- Ralph H. Johnson VA Medical Center, Charleston, SC 29401, USA
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Hyochol Ahn
- Florida State University College of Nursing, Tallahassee, FL 32306-4310, USA
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Sloan DM, Marx BP, Acierno R, Messina M, Muzzy W, Gallagher MW, Litwack S, Sloan C. Written Exposure Therapy vs Prolonged Exposure Therapy in the Treatment of Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2023; 80:1093-1100. [PMID: 37610727 PMCID: PMC10448372 DOI: 10.1001/jamapsychiatry.2023.2810] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [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: 03/31/2023] [Accepted: 05/26/2023] [Indexed: 08/24/2023]
Abstract
Importance Evidence-based treatments for posttraumatic stress disorder (PTSD) exist, but all require 8 to 15 sessions and thus are less likely to be completed than brief treatments. Written exposure therapy (WET) is a brief and efficacious treatment that has not been directly compared with prolonged exposure therapy (PE), a more time-intensive, exposure-based treatment. Objective To determine whether WET is noninferior to PE in treating PTSD among veterans. Design, Setting, and Participants A randomized noninferiority clinical trial was conducted between September 9, 2019, and April 30, 2022. Participants were 178 veterans with PTSD presenting to 1 of 3 Veterans Affairs medical centers. Inclusion criteria consisted of a primary diagnosis of PTSD and stable medication. Exclusion criteria included current psychotherapy for PTSD, high suicide risk, active psychosis, unstable bipolar disorder, and severe cognitive impairment. Independent evaluations were conducted at baseline and 10, 20, and 30 weeks after the first treatment session. Data were analyzed from January 1 to March 31, 2023. Interventions Participants assigned to WET (n = 88) received five to seven 45- to 60-minute sessions. Participants assigned to PE (n = 90) received eight to fifteen 90-minute sessions. The WET sessions included 30 minutes of writing-based imaginal exposure conducted in session, whereas PE sessions included 40 minutes of in-session imaginal exposure and between-session in vivo exposures. Main Outcomes and Measures The primary outcome was change in PTSD symptom severity measured with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from baseline to the 20-week assessment; noninferiority was defined as a less than 10-point difference between the 2 treatment groups. Difference in treatment dropout was also examined. Results Of the 178 participants, 134 (75.3%) were men, and the mean (SD) age was 44.97 (13.66) years. In terms of race, 37 participants (20.8%) were Black, 112 (62.9%) were White, 11 (6.2%) were more than 1 race, and 18 (10.1%) were of other race (including American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander [some participants did not specify their race when selecting the category "other"]); in terms of ethnicity, 19 participants (10.7%) were Hispanic. Changes in PTSD symptom severity from baseline to all subsequent assessments among individuals randomized to WET were noninferior relative to individuals randomized to PE. The largest difference between treatments was observed at 10 weeks and was in favor of WET (mean difference, 2.42 [95% CI, 0.35-1.46] points). Participants were significantly less likely to drop out of WET compared with PE (11 [12.5%] vs 32 [35.6%]; χ2 = 12.91; Cramer V = 0.27). Conclusions and Relevance In this study, WET was noninferior to PE in PTSD symptom change and was associated with significantly less attrition. Findings suggest that WET may transcend previously observed barriers to PTSD treatment for both patients and clinicians. Trial Registration ClinicalTrials.gov Identifier: NCT03962504.
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Affiliation(s)
- Denise M. Sloan
- Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
- Behavioral Science Division, National Center for PTSD, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Brian P. Marx
- Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
- Behavioral Science Division, National Center for PTSD, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Ron Acierno
- Faillace Department of Psychiatry, University of Texas Health Sciences Center Houston, Houston
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina
| | - Michael Messina
- William S. Middleton VA Medical Center, Madison, Wisconsin
- University of Wisconsin-Madison School of Medicine and Public Health, Madison
| | - Wendy Muzzy
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston
| | | | - Scott Litwack
- Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Colleen Sloan
- Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
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Price MS, Christensen H, Urquhart J, Butte S, Acierno R, Little DM. Patient-facing, Semi-automated, solutions to enhance patient participation in measurement-based care practice standards in a tele-mental health specialty clinic for populations at higher risk for self-harm. Int J Med Inform 2023; 177:105155. [PMID: 37467589 DOI: 10.1016/j.ijmedinf.2023.105155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/08/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE Collecting validated surveys that describe symptom severity (measurement based care) during evidence-based psychotherapy is crucial to allow a therapist to tailor the speed and intensity of treatment. COVID clinic closures mandated we create a flexible, remote system to conduct measurement-based care, which was accomplished via RedCap. METHODS RedCap was used to create a semi-automated workflow allowing all clinically-indicated evidence-based surveys (including the PHQ-9) to be delivered via email to patients; with results automatically sent to their provider. Importantly, indications of suicidal ideation were automatically escalated to the provider. RESULTS PHQ-9 completion improved, while provider burden for collecting surveys was greatly reduced; however, depending largely upon initial provider-patient 'training', overall compliance could still be significantly improved. CONCLUSION This workflow gave providers additional information compared to the typical telemedicine environment, and in fact, improved data collection rates over our in-person environment. However, when patients did not complete measures on their own, the burden on providers increased.
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Affiliation(s)
- Matthew S Price
- Trauma and Resilience Center, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston; 1941 East Road, Houston TX 7705, USA.
| | - Hande Christensen
- Trauma and Resilience Center, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston; 1941 East Road, Houston TX 7705, USA.
| | - Joy Urquhart
- Trauma and Resilience Center, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston; 1941 East Road, Houston TX 7705, USA.
| | - Sarly Butte
- Trauma and Resilience Center, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston; 1941 East Road, Houston TX 7705, USA.
| | - Ron Acierno
- Trauma and Resilience Center, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston; 1941 East Road, Houston TX 7705, USA.
| | - Deborah M Little
- Trauma and Resilience Center, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston; 1941 East Road, Houston TX 7705, USA.
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Walsh K, Gilmore AK, Jaffe AE, Frazier P, Ledray L, Acierno R, Ruggiero KJ, Kilpatrick DG, Resnick HS. A preliminary examination of sexual and physical victimization 6 months after recent rape. Arch Womens Ment Health 2023; 26:495-501. [PMID: 37286883 PMCID: PMC10913087 DOI: 10.1007/s00737-023-01335-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 06/01/2023] [Indexed: 06/09/2023]
Abstract
One in four US women will experience a completed or attempted rape in their lifetime, and more than 50% of survivors will experience two or more rapes. Rape and physical violence also co-occur. Multiple experiences of sexual and physical violence are associated with elevated mental and physical health problems. This secondary analysis examined the prevalence and correlates of experiencing sexual or physical violence within 6 months of a sexual assault medical forensic exam (SAMFE). Between May 2009 and December 2013, 233 female rape survivors aged 15 and older were enrolled in a randomized controlled trial during a SAMFE in the emergency department (ED). Demographics, rape characteristics, distress at the ED, and pre-rape history of sexual or physical victimization were assessed. New sexual and physical victimization was assessed 6 months after the SAMFE via telephone interview. Six months after the exam, 21.7% reported a new sexual or physical victimization. Predictors of revictimization during follow-up included sexual or physical victimization prior to the index rape, making less than $10,000 annually, remembering the rape well, life threat during the rape, and higher distress at the ED. In adjusted models, only pre-rape victimization and making less than $10,000 annually were associated with revictimization. Factors assessed at the ED can inform subsequent victimization risk. More research is needed to prevent revictimization among recent rape victims. Policies to provide financial support to recent rape victims and/or targeted prevention for those with pre-rape victimization at the SAMFE could reduce revictimization risk. TRIAL REGISTRATION: NCT01430624.
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Affiliation(s)
- Kate Walsh
- Departments of Psychology and Gender & Women's Studies, University of Wisconsin-Madison, Madison, WI, USA.
| | - Amanda K Gilmore
- Department of Health Policy & Behavioral Sciences, School of Public Health, Georgia State University, Atlanta, GA, USA
- National Center for Sexual Violence Prevention, Mark Chaffin Center for Healthy Development, School of Public Health, Georgia State University, Atlanta, GA, USA
| | - Anna E Jaffe
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Patricia Frazier
- Department of Psychology, University of Minnesota, Minneapolis, MN, USA
| | - Linda Ledray
- SANE SART Resource Service, Minneapolis, MN, USA
| | - Ron Acierno
- Department of Psychiatry, University of Texas Health Science Center, Houston, TX, USA
| | - Kenneth J Ruggiero
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Dean G Kilpatrick
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Heidi S Resnick
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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Teixeira AL, Martins LB, Cordeiro TME, Jose L, Suchting R, Holmes HM, Acierno R, Ahn H. Home-based tDCS for apathy in Alzheimer's disease: a protocol for a randomized double-blinded controlled pilot study. Pilot Feasibility Stud 2023; 9:74. [PMID: 37147739 PMCID: PMC10161588 DOI: 10.1186/s40814-023-01310-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 04/21/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Apathy is among the most common behavioral symptoms in dementia and is consistently associated with negative outcomes in Alzheimer's disease (AD). Despite its prevalence and clinical relevance, available pharmacological and non-pharmacological strategies to treat apathy in AD have been marked, respectively, by potentially severe side effects and/or limited efficacy. Transcranial direct current stimulation (tDCS) is a relatively novel non-pharmacological method of neuromodulation with promising results. Compared to previous tDCS formats, recent technological advances have increased the portability of tDCS, which creates the potential for caregiver-administered, home use. Our study aims to evaluate the feasibility, safety, and efficacy of home-based tDCS for the treatment of apathy in AD. METHODS/DESIGN This is an experimenter- and participant-blinded, randomized, sham-controlled, parallel-group (1:1 for two groups) pilot clinical trial, involving 40 subjects with AD. After a brief training, caregivers will administer tDCS for participants at home under remote televideo supervision by research staff to ensure the use of proper technique. Participants will be assessed at baseline, during treatment (week 2, week 4, and week 6), and 6 weeks post-treatment. Dependent measures will cover cognitive performance, apathy, and other behavioral symptoms. Data about side effects and acceptability will also be collected. DISCUSSION Our study will address apathy, an overlooked clinical problem in AD. Our findings will advance the field of non-pharmacological strategies for neuropsychiatric symptoms, presenting a great potential for clinical translation. TRIAL REGISTRATION ClinicalTrials.gov, NCT04855643.
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Affiliation(s)
- Antonio L Teixeira
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center, 1941 East Road, Houston, TX, 77054, USA.
| | - Laís Bhering Martins
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center, 1941 East Road, Houston, TX, 77054, USA
| | - Thiago Macedo E Cordeiro
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center, 1941 East Road, Houston, TX, 77054, USA
| | - Lijin Jose
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center, 1941 East Road, Houston, TX, 77054, USA
| | - Robert Suchting
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center, 1941 East Road, Houston, TX, 77054, USA
| | - Holly M Holmes
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Ron Acierno
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center, 1941 East Road, Houston, TX, 77054, USA
| | - Hyochol Ahn
- College of Nursing, Florida State University, Tallahassee, FL, USA
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10
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Gros DF, Allan NP, Koscinski B, Keller S, Acierno R. Influence of comorbid social anxiety disorder in PTSD treatment outcomes for Prolonged Exposure in female military sexual trauma survivors with PTSD. J Clin Psychol 2023; 79:1039-1050. [PMID: 36399326 DOI: 10.1002/jclp.23456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/14/2022] [Accepted: 11/01/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) is a common psychiatric disorder that frequently presents alongside other comorbid diagnoses. Although several evidence-based psychotherapies have been well-studied for PTSD, limited research has focused on the influence of diagnostic comorbidity on their outcomes. The present study sought to investigate the influence of comorbid social anxiety disorder on treatment outcomes in patients with PTSD. METHODS One hundred and twelve treatment-seeking female veteran participants with PTSD completed baseline assessments and received 12-15 sessions of Prolonged Exposure. Symptom measures were completed biweekly as well as at immediate posttreatment, 3-month, and 6-month follow-ups. RESULTS Thirty (26.8%) participants seeking PTSD treatment also met diagnostic criteria for social anxiety disorder. Multilevel modeling was used to examine effects of social anxiety disorder diagnosis on post-intervention symptoms and revealed significantly worse outcomes for symptoms of PTSD and depression in participants with comorbid PTSD and social anxiety disorder. CONCLUSION Consistent with previous studies of co-occurring PTSD and depression, present findings suggest that comorbid diagnoses may adversely affect disorder-specific treatment outcomes. As such, the presence of diagnostic comorbidity may merit further consideration and potential adaptions to the traditional, disorder-specific assessment and treatment practices for PTSD.
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Affiliation(s)
- Daniel F Gros
- Mental Health Service, Ralph H. Johnson VA Healthcare System, Charleston, South Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nicholas P Allan
- Department of Psychiatry and Behavioral Health, Ohio State University, Columbus, Ohio, USA.,VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System Canandaigua, New York, USA
| | | | - Stephanie Keller
- Mental Health Service, Ralph H. Johnson VA Healthcare System, Charleston, South Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ron Acierno
- Mental Health Service, Ralph H. Johnson VA Healthcare System, Charleston, South Carolina, USA.,Louis Faillace Department of Psychiatry, University of Texas Health Science Center at Houston, Houston, USA
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11
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Bruce MJ, Acierno R. Medical board transparency regarding physician sexual misconduct: Two years post-policy updates. J Trauma Stress 2023; 36:247-250. [PMID: 36443893 DOI: 10.1002/jts.22897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 10/14/2022] [Accepted: 10/16/2022] [Indexed: 11/30/2022]
Abstract
Recent years have seen increased attention to and motivation for addressing sexual violence. Physician sexual misconduct (PSM) represents a significant violation and abuse of power, with consequences for both patients and public trust in medicine. In the United States, the Federation of State Medical Boards released updated policies in 2020 imploring increased transparency and stronger punishments for PSM cases. This brief report presents an assessment of how transparent medical board websites are in disclosing PSM now 2 years after this policy paper. We reviewed the websites for all 50 states and Washington, DC, to examine how easily a consumer could find a list of board orders, profiles of licensees, and PSM case summaries. In total, 24 states provided a list of orders, and 21 states provided case summaries. Many barriers to finding clearly discussed PSM-related information remain, including many outdated licensee profiles. Ideas for continued efforts to document and discuss PSM to help foster evidence-based policy recommendations are presented.
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Affiliation(s)
- Madeline J Bruce
- Faillace Department of Psychiatry, McGovern Medical School at UTHealth Houston, Houston, Texas, USA.,Department of Psychology, Saint Louis University, St. Louis, Missouri, USA
| | - Ron Acierno
- Faillace Department of Psychiatry, McGovern Medical School at UTHealth Houston, Houston, Texas, USA.,Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
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12
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Cox KS, Wiener D, Rauch SAM, Tuerk PW, Wangelin B, Acierno R. Individual symptom reduction and post-treatment severity: Varying levels of symptom amelioration in response to prolonged exposure for post-traumatic stress disorder. Psychol Serv 2023; 20:94-106. [PMID: 34941335 DOI: 10.1037/ser0000579] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Many patients evince significant post-traumatic stress disorder (PTSD) symptoms after a dose of an evidence-based treatment (EBT) for PTSD. Little research systematically addresses if individual PTSD symptoms are more or less resistant to change through an EBT for PTSD or have greater or lesser post-treatment severity levels. Two studies within VA medical centers provided data. Study 1 (n = 81) was drawn from a randomized clinical trial of Prolonged Exposure (PE), an EBT for PTSD. Study 2 (n = 225) was drawn from two PTSD specialty clinics employing PE. Symptoms were assessed pre- and post-treatments via semi-structured clinician interview (Study 1) and patient self-report (Studies 1 and 2). Most individual symptoms reduced about the same amount through the course of treatment except for avoidance, which showed greater reductions. High heterogeneity in post-treatment symptom severity was found with troubled sleep and hypervigilance displaying above average levels, and traumatic amnesia, foreshortened future, and flashbacks displaying below average levels. Method of symptom measurement had a modest impact on results, as semi-structured clinical interview results were moderately more differentiated than self-report measures. Results were generally consistent between an efficacy (i.e., extremely high, potentially artificial methodological control) and effectiveness (i.e., relatively more real world) context. Primary limitation is analysis of single items on semi-structured clinician interview and patient self-report scale when psychometric validation studies did not interpret measures this way. Moreover, DSM-IV criteria for PTSD were assessed. EBT augmentation and new treatment development should focus on further reducing both PTSD symptoms in general and on the specific symptoms of troubled sleep and hypervigilance, which persist to a greater degree. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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13
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Luciano MT, Norman SB, Allard CB, Acierno R, Simon NM, Szuhany KL, Baker AW, Stein MB, Martis B, Tuerk PW, Rauch SAM. The influence of posttraumatic stress disorder treatment on anxiety sensitivity: Impact of prolonged exposure, sertraline, and their combination. J Trauma Stress 2023; 36:157-166. [PMID: 36451271 PMCID: PMC9974893 DOI: 10.1002/jts.22894] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 12/05/2022]
Abstract
Trauma-informed beliefs often decrease during posttraumatic stress disorder (PTSD) treatment. This may also extend to anxiety sensitivity (AS), defined as a fear of anxiety-related sensations and beliefs that anxiety is dangerous and/or intolerable. However, little is known about how AS changes during exposure-based and psychopharmacological PTSD treatments. Further, high AS may be a risk factor for diminished PTSD symptom improvement and increased treatment dropout. To better understand how AS impacts and is impacted by PTSD treatment, we conducted a secondary analysis of a randomized clinical trial with a sample of 223 veterans (87.0% male, 57.5% White) with PTSD from four U.S. sites. Veterans were randomized to receive prolonged exposure (PE) plus placebo (n = 74), sertraline plus enhanced medication management (n = 74), or PE plus sertraline (n = 75). Veterans answered questions about PTSD symptoms and AS at baseline and 6-, 12-, 24-, 36-, and 52-week follow-ups. High baseline AS was related to high levels of PTSD severity at 24 weeks across all conditions, β = .244, p = .013, but did not predict dropout from exposure-based, β = .077, p = .374, or psychopharmacological therapy, β = .009, p = .893. AS also significantly decreased across all three treatment arms, with no between-group differences; these reductions were maintained at the 52-week follow-up. These findings suggest that high AS is a risk factor for attenuated PTSD treatment response but also provide evidence that AS can be improved by both PE and an enhanced psychopharmacological intervention for PTSD.
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Affiliation(s)
- Matthew T Luciano
- San Diego State University Research Foundation, San Diego, California, USA
- VA San Diego Healthcare System, San Diego, California, USA
| | - Sonya B Norman
- VA San Diego Healthcare System, San Diego, California, USA
- National Center for PTSD, White River Junction, Vermont, USA
| | - Carolyn B Allard
- VA San Diego Healthcare System, San Diego, California, USA
- California School of Professional Psychology, Alliant International University, San Diego, California, USA
| | - Ron Acierno
- McGovern Medical School, University of Texas Health Sciences Center, Houston, Texas, USA
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Naomi M Simon
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA
| | - Kristin L Szuhany
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA
| | - Amanda W Baker
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Murray B Stein
- VA San Diego Healthcare System, San Diego, California, USA
- Departmetn of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Brian Martis
- VA San Diego Healthcare System, San Diego, California, USA
- Departmetn of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Peter W Tuerk
- Department of Human Services, University of Virginia, Charlottesville, Virginia, USA
| | - Sheila A M Rauch
- Atlanta VA Healthcare System, Atlanta, Georgia, USA
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
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14
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Saraiya TC, Jarnecke AM, Rothbaum AO, Wangelin B, McTeague LM, Acierno R, Brown DG, Bristol E, Feigl H, Reese M, Cobb AR, Harley B, Adams RJ, Back SE. Technology-enhanced in vivo exposures in Prolonged Exposure for PTSD: A pilot randomized controlled trial. J Psychiatr Res 2022; 156:467-475. [PMID: 36347106 PMCID: PMC9811583 DOI: 10.1016/j.jpsychires.2022.10.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/10/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
In vivo exposures (IVEs) are a key component of exposure-based treatments, during which patients approach fear-provoking, yet safe, situations in "real life." This pilot study assessed the use of a wearable technology (Bio Ware) during IVEs to enhance Prolonged Exposure (PE) therapy for PTSD. Bio Ware provides a clinician dashboard with real-time physiological and subjective data for clinicians to use for virtually guided IVEs. Participants (N = 40) were randomized to a Guided group that received standard PE and virtual, clinician-guided IVEs with the Bio Ware device, or a Non-Guided group that received standard PE and used the Bio Ware device on their own for IVEs. Multilevel linear models with bootstrapping were completed on the intent-to-treat (ITT; N = 39) and per-protocol samples (PP; n = 23), defined as completing at least eight sessions of PE and using the Bio Ware system during ≥ 1 IVEs. In the PP sample, there were significant effects of treatment condition (b = -14.55, SE = 1.47, 95% CI [-17.58, -11.78], p < .001) and time (b = -1.98, SE = 0.25, 95% CI [-2.47, -1.48], p < .001). While both groups showed reductions in PTSD symptoms, the Guided group evidenced significantly greater reductions than the Non-Guided group. These findings demonstrate the feasibility and safety of leveraging Bio Ware for virtual, clinician-guided IVEs during PE therapy for PTSD and suggest that virtual, clinician-guided exposures may enhance treatment outcomes. CLINICAL TRIAL REGISTRATION: NCT04471207.
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Affiliation(s)
- Tanya C. Saraiya
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina,Center of Alcohol & Substance Use Studies, Rutgers University—New Brunswick,Corresponding Author: Tanya C. Saraiya, Ph.D., Center of Alcohol & Substance Use Studies, Rutgers University-New Brunswick, 607 Allison Road, Suite 217-C, Piscataway, NJ 08854.
| | - Amber M. Jarnecke
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina
| | - Alex O. Rothbaum
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina,Department of Research and Outcomes, Skyland Trail
| | - Bethany Wangelin
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina,Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
| | - Lisa M. McTeague
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina,Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
| | - Ron Acierno
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas
| | - Delisa G. Brown
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina
| | - Emily Bristol
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina
| | - Hayley Feigl
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina
| | | | - Adam R. Cobb
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina,Department of Research and Outcomes, Skyland Trail,Department of Psychology, Institute for Mental Health Research, University of Texas-Austin
| | | | - Robert J Adams
- Zeriscope, Inc,Department of Neurology, Medical University of South Carolina
| | - Sudie E. Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina,Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
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15
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Walsh K, Gilmore AK, Barr SC, Frazier P, Ledray L, Acierno R, Ruggiero KJ, Kilpatrick DG, Resnick HS. The Role of Discrimination Experiences in Postrape Adjustment Among Racial and Ethnic Minority Women. J Interpers Violence 2022; 37:NP17325-NP17343. [PMID: 34229508 DOI: 10.1177/08862605211028006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Although recent studies have linked discrimination frequency among Black and Latinx individuals to PTSD symptom severity, to our knowledge, these associations have yet to be examined among a diverse sample of recent rape survivors. The current secondary analysis of existing data examined the role of discrimination experiences in post-traumatic stress disorder (PTSD) symptoms, depression, and alcohol and drug problems among a racially and ethnically diverse sample of recent rape survivors. Participants were 139 Black (48.2%; n = 67), American Indian (18.7%; n = 26), Hispanic (15.1%; n = 21), and mixed race (17.3%; n = 24) girls and women age 15 or older who presented to the emergency department (ED) for a sexual assault forensic medical exam. They were randomly assigned to one of three intervention conditions, and completed a six-month postrape follow-up, including questions about mental health, substance use problems, and discrimination experiences. Regression analyses revealed that Black women experienced discrimination in significantly more situations and with greater frequency compared to American Indian and Hispanic women. Discrimination frequency was positively associated with PTSD and depression symptoms even after controlling for age, education, race, and intervention condition, but was not associated with alcohol or drug problems. Findings highlight the importance of attending to the heterogeneous experiences of discrimination among racial and ethnic minority women. Future work should adapt evidence-based early interventions to be maximally effective at combating both racial and sexual trauma exposures.
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Affiliation(s)
- Kate Walsh
- University of Wisconsin-Madison, WI, USA
| | | | - Simone C Barr
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | | | - Linda Ledray
- SANE SART Resource Service, Minneapolis, MN, USA
| | - Ron Acierno
- University of Texas Health Science Center, Houston, TX, USA
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16
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Rauch SAM, Kim HM, Acierno R, Ragin C, Wangelin B, Blitch K, Muzzy W, Hart S, Zivin K, Cigrang J. Improving function through primary care treatment of PTSD: The IMPACT study protocol. Contemp Clin Trials 2022; 120:106881. [PMID: 35964868 PMCID: PMC9489643 DOI: 10.1016/j.cct.2022.106881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/26/2022] [Accepted: 08/06/2022] [Indexed: 11/17/2022]
Abstract
Despite the availability of effective psychological interventions for PTSD, access to and retention in these interventions remains problematic. Of note, the Veterans Health Administration (VHA) developed and implemented post-deployment health surveys that screen for PTSD in primary care (PC), but effective PC-based, psychological intervention treatment options have yet to be established. To address the literal physical gap between where the patients first present for care (i.e., primary care) and where they must go to receive first-line treatment for PTSD (i.e., specialty mental health), study investigators developed a 4-6 visit Prolonged Exposure for Primary Care (PE-PC) treatment that has shown efficacy in reduction of PTSD. To extend previous work to recovery-based mental health care, the Improving Function Through Primary Care Treatment of PTSD (IMPACT) study examined function as assessed by the World Health Organization Disability Assessment Schedule [WHODAS 2.0; (Axelsson, Lindsäter, Ljótsson, Andersson, & Hedman-Lagerlöf, 2017)]. Veterans presenting in VHA primary care mental health integration (PCMHI) clinics with PTSD or significant subsyndromal PTSD who met minimal inclusion and exclusion criteria were randomly assigned to PE-PC or treatment as usual (TAU). If proven effective in improving function, PE-PC would provide a new access point for high quality PTSD care and allow greater numbers of veterans to access effective PTSD treatment. Trial Registration: http://ClinicalTrials.gov: NCT03581981.
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Affiliation(s)
- Sheila A M Rauch
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA 30033, United States of America; Emory University School of Medicine, 12 Executive Park, 3(rd) Floor, Atlanta, GA 30029, United States of America.
| | - H Myra Kim
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States of America; University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI 48109, United States of America
| | - Ron Acierno
- Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC 29401, United States of America; University of Texas Health Science Center at Houston, Faillace Department of Psychiatry, Behavioral and Biomedical Sciences Building (BBSB), 1941 East Road, Houston, TX 77054, United States of America
| | - Carly Ragin
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA 30033, United States of America
| | - Bethany Wangelin
- Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC 29401, United States of America; Medical University of South Carolina, Department of Psychiatry & Behavioral Sciences, 67 President Street, Charleston, SC 29425, United States of America
| | - Kimberly Blitch
- Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC 29401, United States of America; Medical University of South Carolina, Department of Psychiatry & Behavioral Sciences, 67 President Street, Charleston, SC 29425, United States of America
| | - Wendy Muzzy
- Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC 29401, United States of America; Medical University of South Carolina, Department of Psychiatry & Behavioral Sciences, 67 President Street, Charleston, SC 29425, United States of America
| | - Stephanie Hart
- Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC 29401, United States of America; Medical University of South Carolina, Department of Psychiatry & Behavioral Sciences, 67 President Street, Charleston, SC 29425, United States of America
| | - Kara Zivin
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States of America; University of Michigan, Department of Psychiatry, 2800 Plymouth Road, Ann Arbor, MI 48109, United States of America
| | - Jeffrey Cigrang
- Wright State University, 3640 Colonel Glenn Highway, Dayton, OH 45435, United States of America
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17
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Lopez CM, Gilmore AK, Brown WJ, Hahn CK, Muzzy W, Grubaugh A, Acierno R. Effects of Emotion Dysregulation on Post-treatment Post-traumatic Stress Disorder and Depressive Symptoms Among Women Veterans With Military Sexual Trauma. J Interpers Violence 2022; 37:NP13143-NP13161. [PMID: 33775153 DOI: 10.1177/08862605211005134] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Military sexual trauma (MST), defined as sexual assault or repeated, threatening sexual harassment while in the military, is associated with increased risk of long-term mental and physical health problems, with the most common being symptoms of post-traumatic stress disorder (PTSD) and depression. In addition to PTSD and depression, MST is linked to difficulties in emotion regulation as well as poor treatment engagement. Thus, it is important to examine these correlates, and how they affect postintervention symptom reduction in this vulnerable population. The current study presents secondary data analyses from a randomized clinical trial comparing the efficacy of in-person versus telemedicine delivery of prolonged exposure therapy for female veterans with MST-related PTSD (n = 151). Results of the study found that changes in difficulties with emotion regulation predicted postintervention depressive symptoms but not postintervention PTSD symptoms. Neither postintervention depressive nor PTSD symptoms were affected by treatment dosing (i.e., number of sessions attended) nor treatment condition (i.e., in-person vs. telemedicine). Findings from the current study provide preliminary evidence that decreases in difficulties with emotion regulation during PTSD treatment are associated with decreases in depressive symptom severity.
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Affiliation(s)
| | | | | | | | - Wendy Muzzy
- Medical University of South Carolina, Charleston, SC, USA
| | - Anouk Grubaugh
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Ron Acierno
- University of Texas Health Sciences Center at Houston, TX, USA
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18
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Foa EB, Bredemeier K, Acierno R, Rosenfield D, Muzzy W, Tuerk PW, Zandberg LJ, Hart S, Young-McCaughan S, Peterson AL, McLean CP. The efficacy of 90-min versus 60-min sessions of prolonged exposure for PTSD: A randomized controlled trial in active-duty military personnel. J Consult Clin Psychol 2022; 90:503-512. [PMID: 35771512 DOI: 10.1037/ccp0000739] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Prolonged exposure (PE) therapy is a first-line posttraumatic stress disorder (PTSD) treatment, but the manualized 90-min session format constitutes a barrier to adopting PE in most settings because they use 60-min sessions for scheduling and billing. We examined whether 60-min PE sessions were as effective and efficient as 90-min PE sessions. METHOD In total, 160 active-duty military personnel with PTSD were randomized to 8-15 sessions of 60- or 90-min PE sessions and assessed pre- and posttreatment, and 3- and 6-month posttreatment, using the Clinician Administered PTSD Scale for Diagnostic and Statistical Manual for Mental Disorders, 5th edition [DSM-5] (CAPS-5). Participants were also assessed weekly during treatment using the PTSD Checklist for DSM-5 (PCL-5). A 60-min PE was hypothesized to be noninferior to 90-min PE based on preliminary studies. RESULTS Using intent-to-treat analyses, the 95% CI for the difference between 60- and 90-min PE was less than the noninferiority margin (4.69 for the CAPS-5 and 7.38 for the PCL-5) at all three endpoints, suggesting that the efficacy of 60-min PE was noninferior to that of 90-min PE. Similarly, the rate of improvement per session for 60-min PE was noninferior to the rate for 90-min sessions for the PCL-5. Sensitivity analyses and Bayes factors were consistent with these results. CONCLUSIONS 60-min sessions of PE are noninferior to 90-min sessions with regard to both efficacy and efficiency. Thus, PE can be effectively delivered in shorter sessions, making it easier for behavioral health providers to implement within the military health system and in other mental health systems that use 60-min session appointments. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
- Edna B Foa
- Department of Psychiatry, Perlman School of Medicine, University of Pennsylvania
| | - Keith Bredemeier
- Department of Psychiatry, Perlman School of Medicine, University of Pennsylvania
| | - Ron Acierno
- Faillace Department of Psychiatry, University of Texas Health Sciences Center
| | | | - Wendy Muzzy
- Department of Psychiatry, Medical University of South Carolina
| | - Peter W Tuerk
- Sheila C. Johnson Center for Clinical Services, University of Virginia
| | - Laurie J Zandberg
- Department of Psychiatry, Perlman School of Medicine, University of Pennsylvania
| | - Stephanie Hart
- Department of Psychiatry, Medical University of South Carolina
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | - Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System
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19
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Morland LA, Knopp KC, Khalifian CE, Macdonald A, Grubbs KM, Mackintosh MA, Becker-Cretu JJ, Sautter FJ, Buzzella BA, Wrape ER, Glassman LH, Webster K, Sohn MJ, Glynn SM, Acierno R, Monson CM. A randomized trial of brief couple therapy for PTSD and relationship satisfaction. J Consult Clin Psychol 2022; 90:392-404. [PMID: 35604746 DOI: 10.1037/ccp0000731] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE This three-arm randomized trial tested a brief version of cognitive-behavioral conjoint therapy (bCBCT) delivered in two modalities compared to couples' psychoeducation in a sample of U.S. veterans with posttraumatic stress disorder (PTSD) and their intimate partners. METHOD Couples were randomized to receive (a) in-person, office-based bCBCT (OB-bCBCT), (b) bCBCT delivered via home-based telehealth (HB-bCBCT), or (c) an in-person psychoeducation comparison condition (PTSD family education [OB-PFE]). Primary outcomes were clinician-assessed PTSD severity (Clinician Administered PTSD Scale), self-reported psychosocial functioning (Brief Inventory of Psychosocial Functioning), and relationship satisfaction (Couples Satisfaction Index) at posttreatment and through 6-month follow-up. RESULTS PTSD symptoms significantly decreased by posttreatment with all three treatments, but compared to PFE, PTSD symptoms declined significantly more for veterans in OB-bCBCT (between-group d = 0.59 [0.17, 1.01]) and HB-bCBCT (between-group d = 0.76 [0.33, 1.19]) treatments. There were no significant differences between OB-bCBCT and HB-bCBCT. Psychosocial functioning and relationship satisfaction showed significant small to moderate improvements, with no differences between treatments. All changes were maintained through 6-month follow-up. CONCLUSIONS A briefer, more scalable version of CBCT showed sustained effectiveness relative to an active control for improving PTSD symptoms when delivered in-person or via telehealth. Both bCBCT and couples' psychoeducation improved psychosocial and relational outcomes. These results could have a major impact on PTSD treatment delivery within large systems of care where access to brief, evidence-based PTSD treatments incorporating family members are needed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ron Acierno
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at Houston
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20
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Rauch SA, Kim HM, Venners MR, Porter K, Norman SB, Simon NM, Rothbaum BO, Tuerk PW, Acierno R, Bui E, Powell C, Smith ER, Goetter E, McSweeney L. Change in posttraumatic stress disorder-related thoughts during treatment: Do thoughts drive change when pills are involved? J Trauma Stress 2022; 35:496-507. [PMID: 34973039 PMCID: PMC9446312 DOI: 10.1002/jts.22762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/16/2021] [Accepted: 08/28/2021] [Indexed: 11/09/2022]
Abstract
Posttraumatic negative thoughts about one's self and the world are related to posttraumatic stress disorder (PTSD) symptom severity and change in cognitive behavioral treatment (CBT), but little is known about this association when CBT is delivered with medication. The current study presents a planned comparison of changes in negative posttraumatic thoughts during (a) prolonged exposure (PE) plus pill placebo (PE+PLB), (b) sertraline plus enhanced medication management (SERT+EMM), and (c) PE plus sertraline (PE+SERT) as part of a randomized clinical trial in a sample of 176 veterans. Lagged regression modeling revealed that change in posttraumatic negative thoughts was associated with PTSD symptom change in the conditions in which participants received sertraline, ds = 0.14-0.25, ps = 0.04-.001). However, contrary to previous research, the models that started with symptom change were also statistically significant, d = 0.23, p < .001, for the lagged effect of symptoms on negative thoughts about self in the SERT+EMM condition, indicating a bidirectional association between such thoughts and PTSD symptoms. In the PE+PLB condition, no significant association between posttraumatic thoughts and PTSD symptoms emerged in either direction. These results suggest that the previously demonstrated role of change in posttraumatic thoughts leading to PTSD symptom reduction in PE may be altered when combined with pill administration, either active or placebo.
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Affiliation(s)
- Sheila A.M. Rauch
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033,Emory University School of Medicine, 12 Executive Park, 3 Floor, Atlanta, GA, 30029
| | - H. Myra Kim
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105,University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI, 48109
| | | | - Katherine Porter
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105,University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI, 48109
| | - Sonya B. Norman
- National Center for PTSD, 215 N. Main Street, White River Junction, VT 05009,VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Drive, MC116B, San Diego, CA 92161,University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92037
| | - Naomi M. Simon
- Massachusetts General Hospital, Department of Psychiatry, One Bowdoin Square, 6th Floor, Boston, MA 02114,New York University Medical School, Department of Psychiatry, One Park Avenue 8 Floor, New York NY 10016
| | - Barbara O. Rothbaum
- Emory University School of Medicine, 12 Executive Park, 3 Floor, Atlanta, GA, 30029
| | - Peter W. Tuerk
- University of Virginia, Department of Human Services, 417 Emmet St. South, PO Box 400270, Charlottesville, VA 22903
| | - Ron Acierno
- Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC, 29401,Medical University of South Carolina, College of Nursing, Jonathan Lucas Street, Charleston, SC 29425
| | - Eric Bui
- Massachusetts General Hospital, Department of Psychiatry, One Bowdoin Square, 6th Floor, Boston, MA 02114,University of Caen Normandy & Caen University Hospital, avenue de la Côte de Nacre, 14000 Caen, France
| | - Corey Powell
- University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI, 48109
| | - Erin R. Smith
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105,University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI, 48109
| | - Elizabeth Goetter
- Massachusetts General Hospital, Department of Psychiatry, One Bowdoin Square, 6th Floor, Boston, MA 02114,Harvard Medical School, Department of Psychiatry, 25 Shattuck Street, Boston, MA 02115
| | - Lauren McSweeney
- Emory University School of Medicine, 12 Executive Park, 3 Floor, Atlanta, GA, 30029
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21
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McLean CP, Back SE, Capone C, Morland L, Norman SB, Rauch SAM, Schnurr PP, Teng E, Acierno R. The Impact of COVID-19 on Psychotherapy Participation Among Individuals With Posttraumatic Stress Disorder Enrolled in Treatment Research. J Trauma Stress 2022; 35:308-313. [PMID: 34291832 PMCID: PMC8426668 DOI: 10.1002/jts.22718] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 12/25/2022]
Abstract
The onset of the COVID-19 pandemic disrupted many aspects of daily life and required a rapid and unprecedented shift in psychotherapy delivery from in-person to telemental health. In the present study, we explored the impact of the pandemic on individuals' ability to participate in posttraumatic stress disorder (PTSD) psychotherapy and the association between the impact of COVID-19 impact on health and financial well-being and psychotherapy participation. Participants (N = 161, 63.2% male, Mage = 42.7 years) were United States military veterans (n = 108), active duty military personnel (n = 12), and civilians (n = 6), who were participating in one of nine PTSD treatment trials. The results indicate a predominately negative COVID-19 impact on therapy participation, although some participants (26.1%) found attending therapy sessions through telehealth to be easier than in-person therapy. Most participants (66.7%) reported that completing in vivo exposure homework became harder during the pandemic. Moreover, the impact of the pandemic on PTSD symptom severity and daily stress were each associated with increased difficulty with aspects of therapy participation. The findings highlight the unique challenges to engaging in PTSD treatment during the pandemic as well as a negative impact on daily stress and PTSD severity, both of which were related to treatment engagement difficulties.
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Affiliation(s)
- Carmen P. McLean
- Dissemination and Training Division, National Center for PTSDVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA,Department of Psychiatry and Behavioral Sciences, School of MedicineStanford UniversityStanfordCaliforniaUSA
| | - Sudie E. Back
- Department of Psychiatry and Behavioral SciencesMedical University of South CarolinaCharlestonSouth CarolinaUSA,Ralph H. Johnson Veterans Affairs Medical CenterCharlestonSouth Carolina
| | - Christy Capone
- Providence VA Medical CenterProvidenceRhode IslandUSA,Department of Psychiatry and Human BehaviorCenter for Alcohol and Addiction StudiesBrown UniversityProvidenceRhode IslandUSA
| | - Leslie Morland
- VA San Diego Healthcare SystemSan DiegoCaliforniaUSA,National Center for PTSD Pacific Islands DivisionHonoluluHawaiiUSA,Department of PsychiatryUniversity of California San Diego School of MedicineSan DiegoCaliforniaUSA
| | - Sonya B. Norman
- VA San Diego Healthcare SystemSan DiegoCaliforniaUSA,Department of PsychiatryUniversity of California San Diego School of MedicineSan DiegoCaliforniaUSA,Executive DivisionNational Center for PTSDWhite River JunctionVermontUSA
| | - Sheila A. M. Rauch
- Health Service LineAtlanta VA Medical CenterAtlantaGeorgiaUSA,Department of Psychiatry and Behavioral SciencesEmory University School of MedicineAtlantaGeorgiaUSA
| | - Paula P. Schnurr
- Executive DivisionNational Center for PTSDWhite River JunctionVermontUSA,Geisel School of Medicine at DartmouthHanoverNew HampshireUSA
| | - Ellen Teng
- Department of Psychiatry and Behavioral SciencesBaylor College of MedicineHoustonTexasUSA,Michael E. DeBakey VA Medical CenterHoustonTexasUSA
| | - Ron Acierno
- Louis Faillace Department of PsychiatryMcGovern Medical School at UTHealth HoustonHoustonTexas
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22
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Walsh K, Badour CL, Zuromski KL, Gilmore AK, Kilpatrick DG, Acierno R, Resnick HS. A secondary analysis of a brief video intervention on suicidal ideation among recent rape victims. Psychol Serv 2021; 18:703-708. [PMID: 33661694 PMCID: PMC8417147 DOI: 10.1037/ser0000495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although rape has been linked to risk for suicidal ideation and attempts, there are scant data on the efficacy of brief interventions to reduce suicidality among recent rape victims. This secondary analysis of a randomized controlled trial investigated whether a video intervention delivered in the emergency department (ED), cortisol measured at the ED, and prior rape history predicted postrape suicidal ideation independently or in combination with the other predictors. Participants were 235 women aged 15-71 years who presented to the ED for a sexual assault medical forensic examination and were randomly assigned to either receive a video intervention that addressed avoidance and promoted healthy coping strategies or standard care prior to the examination. Participants also provided a blood sample for cortisol and completed at least one of three follow-ups at 6 weeks, 3 months, or 6 months postrape. The intervention conferred protection against suicidal ideation among women with elevated cortisol and a prior rape; however, it did not reduce risk for women without a prior rape, particularly those with elevated cortisol. It may be important to consider the influence of prior rape and neuroendocrine reactivity in developing treatments to address suicidal ideation among rape victims. More specifically, there appears to be value in screening victims for prior rape and administering this brief intervention to reduce suicidal ideation; however, other avenues should be explored for victims without a prior rape history. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Kate Walsh
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Kelly L. Zuromski
- National Crime Victims Research and Treatment Center, Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Amanda K. Gilmore
- National Crime Victims Research and Treatment Center, Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Dean G. Kilpatrick
- National Crime Victims Research and Treatment Center, Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Ron Acierno
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Heidi S. Resnick
- National Crime Victims Research and Treatment Center, Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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23
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Fina BA, Wright EC, Rauch SAM, Norman SB, Acierno R, Cuccurullo LAJ, Dondanville KA, Moring JC, Brown LA, Foa EB. Conducting Prolonged Exposure for PTSD During the COVID-19 Pandemic: Considerations for Treatment. Cogn Behav Pract 2021; 28:532-542. [PMID: 33100809 PMCID: PMC7567702 DOI: 10.1016/j.cbpra.2020.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/18/2020] [Indexed: 11/11/2022]
Abstract
The unprecedented effects and duration of the COVID-19 crisis are likely to elevate the population's level of anxiety due to psychological stress, economic hardship, and social isolation. This effect may be especially potent for individuals with preexisting mental health conditions, such as posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) therapy is a highly effective treatment for PTSD across trauma-exposed populations, and has been implemented effectively via telehealth. Nevertheless, PE implementation via telehealth may require specific adaptations during the COVID-19 crisis due to public health mandates calling for sheltering in place and physical distancing. This paper discusses strategies for implementing PE for PTSD during the COVID-19 pandemic, which may also be applied to other situations in which physical distancing must be considered.
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Affiliation(s)
- Brooke A Fina
- University of Texas Health Science Center at San Antonio
| | - Edward C Wright
- Home Base: A Red Sox Foundation and Massachusetts General Hospital Program, Massachusetts General Hospital, and Harvard Medical School
| | - Sheila A M Rauch
- Atlanta VA Medical Center and Emory University School of Medicine
| | - Sonya B Norman
- National Center for PTSD, VA San Diego Healthcare System, and University of California, San Diego
| | - Ron Acierno
- University of Texas Health Science Center at Houston and Ralph H. Johnson VA Medical Center
| | | | | | - John C Moring
- University of Texas Health Science Center at San Antonio
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24
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Gilmore AK, Walsh K, Frazier P, Meredith L, Ledray L, Davis J, Acierno R, Ruggiero KJ, Kilpatrick DG, Jaffe AE, Resnick HS. Post-Sexual Assault Mental Health: A Randomized Clinical Trial of a Video-Based Intervention. J Interpers Violence 2021; 36:10614-10637. [PMID: 31709903 PMCID: PMC7232869 DOI: 10.1177/0886260519884674] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The current study assessed the efficacy of a brief video intervention (Prevention of Post-Rape Stress [PPRS]) delivered in the emergency department to recent sexual assault (SA) victims. PPRS was compared to treatment as usual (TAU) and an active control condition (Pleasant Imagery and Relaxation Instruction [PIRI]). Primary outcomes were posttraumatic stress disorder (PTSD) symptoms and perceived present control. Prior SA was examined as a moderator of treatment effects. Women (n = 233; aged 15 years and older; 59.70% identified as a racial or ethnic minority) who received a post-SA medical forensic exam participated in the study (NCT01430624). Participants were randomized to watch the PPRS video (n = 77), the PIRI video (n = 77), or receive TAU (n = 79). Participants completed measures of PTSD symptoms and perceived present control 1.5-, 3-, and 6-months post-SA. An interaction between condition and prior SA was found on PTSD symptom frequency and on perceived present control. Among women with a prior SA, women in the PPRS versus TAU condition reported less frequent PTSD symptoms 6-months post-SA. Those in the PPRS condition had lower perceived present control than those in the TAU condition among those with no prior SA 3-months post-SA. However, at 6-months post-SA, among women with a prior SA, women in the PPRS reported higher perceived present control than those in TAU. These findings partially replicate a prior study in which PPRS was found to be beneficial in mitigating the development of PTSD symptoms, but only for women with a prior SA.
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Affiliation(s)
| | | | | | | | - Linda Ledray
- SANE-SART Resource Service, Minneapolis, MN, USA
| | | | - Ron Acierno
- University of Texas Health Science Center at Houston, Houston, TX, USA
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25
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Acierno R, Jaffe AE, Gilmore AK, Birks A, Denier C, Muzzy W, Lopez CM, Tuerk P, Grubaugh AL. A randomized clinical trial of in-person vs. home-based telemedicine delivery of Prolonged Exposure for PTSD in military sexual trauma survivors. J Anxiety Disord 2021; 83:102461. [PMID: 34391978 DOI: 10.1016/j.janxdis.2021.102461] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 07/27/2021] [Accepted: 07/27/2021] [Indexed: 11/26/2022]
Abstract
Posttraumatic stress disorder (PTSD) is common in women who experienced Military Sexual Trauma (MST). Despite Veterans Affairs Medical Center-wide screening and tailored MST services, substantial barriers to care exist, and about 50 % of those who start evidence-based treatment for PTSD drop out prematurely. Home-based telemedicine (HBT) may reduce logistical and stigma related barriers to mental health care, thereby reducing dropout. The current randomized clinical trial (NCT02417025) for women veterans with MST-related PTSD (N = 136) compared the efficacy of HBT delivery of Prolonged Exposure (PE) to in-person delivery of PE on measures of PTSD and depression, as well as on "PE dose" received. Hypotheses predicted that women in the HBT PE group would complete more sessions, and evince greater PTSD and depression symptom reduction compared to in-person PE. Results revealed that there were no differences in dose received or PTSD symptom reduction between in-person and HBT conditions; however, dose (i.e., more sessions) was related to reduced PTSD symptom severity. Future research should examine other factors associated with high PTSD treatment dropout among MST patients.
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Affiliation(s)
- Ron Acierno
- Faillace Department of Psychiatry, University of Texas Health Science Center at Houston, United States; Ralph H. Johnson VA Medical Center, Charleston, SC, United States.
| | - Anna E Jaffe
- Department of Psychology, University of Nebraska-Lincoln, NE, United States
| | - Amanda K Gilmore
- Department of Psychology, Georgia State University, GA, United States
| | - Anna Birks
- Ralph H. Johnson VA Medical Center, Charleston, SC, United States
| | - Carol Denier
- Ralph H. Johnson VA Medical Center, Charleston, SC, United States
| | - Wendy Muzzy
- Department of Psychiatry, Medical University of South Carolina, United States
| | - Cristina M Lopez
- College of Nursing, Medical University of South Carolina, United States
| | - Peter Tuerk
- School of Education and Human Development, University of Virginia, United States
| | - Anouk L Grubaugh
- Ralph H. Johnson VA Medical Center, Charleston, SC, United States; Department of Psychiatry, Medical University of South Carolina, United States
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26
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Rauch SAM, Kim HM, Lederman S, Sullivan G, Acierno R, Tuerk PW, Simon NM, Venners MR, Norman SB, Allard CB, Porter KE, Martis B, Bui E, Baker AW. Predictors of Response to Prolonged Exposure, Sertraline, and Their Combination for the Treatment of Military PTSD. J Clin Psychiatry 2021; 82. [PMID: 34133087 DOI: 10.4088/jcp.20m13752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: The current study is an analysis of predictors of posttraumatic stress disorder (PTSD) treatment response in a clinical trial comparing (1) prolonged exposure plus placebo (PE + PLB), (2) PE + sertraline (PE + SERT), and (3) sertraline + enhanced medication management (SERT + EMM) with predictors including time since trauma (TST), self-report of pain, alcohol use, baseline symptoms, and demographics. Methods: Participants (N = 196) were veterans with combat-related PTSD (DSM-IV-TR) of at least 3 months' duration recruited between 2012 and 2016 from 4 sites in the 24-week PROlonGed ExpoSure and Sertraline (PROGrESS) clinical trial (assessments at weeks 0 [intake], 6, 12, 24, 36, and 52). Results: Across treatment conditions, (1) longer TST was predictive of greater week 24 PTSD symptom improvement (β = 1.72, P = .01) after adjusting for baseline, (2) higher baseline pain severity was predictive of smaller symptom improvement (β = -2.96, P = .003), and (3) Hispanic patients showed greater improvement than non-Hispanic patients (β = 12.33, P = .03). No other baseline characteristics, including alcohol consumption, were significantly predictive of week 24 improvement. Comparison of TST by treatment condition revealed a significant relationship only in those randomized to the PE + SERT condition (β = 2.53, P = .03). Longitudinal analyses showed similar results. Conclusions: The finding that longer TST shows larger symptom reductions is promising for PTSD patients who might not seek help for years following trauma. Higher baseline pain severity robustly predicted attenuated and slower response to all treatment conditions, suggesting a common neuropathologic substrate. Finally, in the current study, alcohol use did not impede the effectiveness of pharmacotherapy for PTSD. Trial Registration: ClinicalTrials.gov identifier: NCT01524133.
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Affiliation(s)
- Sheila A M Rauch
- Mental Health Service Line, VA Atlanta Healthcare System, Decatur, Georgia.,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia.,Corresponding author: Sheila A. M. Rauch, PhD, Emory University School of Medicine, 12 Executive Park, 3rd Floor, Atlanta, GA 30329
| | - H Myra Kim
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, Michigan
| | | | | | - Ron Acierno
- Mental Health Service Line, Ralph H. Johnson VA Medical Center, Charleston, South Carolina.,Department of Psychiatry & Behavioral Sciences, McGovern Medical School, University of Texas Health Sciences, Houston, Texas
| | - Peter W Tuerk
- Department of Human Services, University of Virginia, Charlottesville, Virginia
| | - Naomi M Simon
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Margaret R Venners
- National Center for PTSD, VA Palo Alto Medical Center, Menlo Park, California.,Research Service Line, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Sonya B Norman
- National Center for PTSD, White River Junction VA Medical Center, White River Junction, Vermont.,Department of Psychiatry, University of California, San Diego, School of Medicine, La Jolla, California.,VA Center of Excellence for Stress and Mental Health, San Diego, California
| | - Carolyn B Allard
- PhD Program, California School of Professional Psychology, Alliant International University, San Diego, California.,Research Service, VA San Diego Healthcare System, San Diego, California
| | - Katherine E Porter
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Mental Health Service Line, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Brian Martis
- Mental Health Care Line, VA San Diego Healthcare System, San Diego, California
| | - Eric Bui
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, University of Caen Normandy & Caen University Hospital, Caen, France
| | - Amanda W Baker
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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27
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Acierno R, Kauffman B, Muzzy W, Tejada MH, Lejuez C. Behavioral Activation and Therapeutic Exposure vs. Cognitive Therapy for Grief Among Combat Veterans: A Randomized Clinical Trial of Bereavement Interventions. Am J Hosp Palliat Care 2021; 38:1470-1478. [DOI: 10.1177/1049909121989021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Approximately two-thirds of Operations Enduring Freedom, Iraqi Freedom, and New Veterans reported knowing someone who was killed or seriously injured, lost someone in their immediate unit, or personally saw dead or seriously injured Americans (Hoge et al., 2004; Thomas et al., 2010; Toblin et al., 2012). Thus, it is not surprising that prevalence of Persistent Complex Bereavement Disorder (PCBD) is high in these groups. Importantly, PCBD impact appears to be independent of both Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (Bonnano, 2007), 2 disorders that are also highly prevalent in these groups, thus tailored treatments for grief are indicated. The Department of Veterans Affairs suggests Cognitive Therapy for Grief as a first line psychotherapy, however treatments relatively more focused on behavior change and exposure to grief cues also may be useful for this population. To address this question, the present study used a randomized controlled trial to compare a 7-session program of Behavioral Activation and Therapeutic Exposure for Grief vs. Cognitive Therapy for Grief among 155 OIF/OEF/OND veterans. Both treatments produced significant treatment gains over baseline, and these improvements were maintained over 6-month followup; however no differences were observed between groups. Given equal efficacy, implications for matching treatment to patient characteristics are discussed.
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Affiliation(s)
- Ron Acierno
- Faillace Department of Psychiatry, University of Texas Health Sciences Center Houston, TX, USA
- Department of Veterans Affairs Medical Center, Charleston, SC, USA
| | - Brooke Kauffman
- Faillace Department of Psychiatry, University of Texas Health Sciences Center Houston, TX, USA
- Department of Psychology, University of Houston, TX, USA
| | - Wendy Muzzy
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - Melba Hernandez Tejada
- Faillace Department of Psychiatry, University of Texas Health Sciences Center Houston, TX, USA
| | - Carl Lejuez
- Office of the Provost, University of Connecticut, Storrs, CT, USA
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28
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White CN, Kauffman BY, Acierno R. Factors contributing to veterans' satisfaction with PTSD treatment delivered in person compared to telehealth. J Telemed Telecare 2021:1357633X20987704. [PMID: 33497311 DOI: 10.1177/1357633x20987704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/17/2022]
Abstract
INTRODUCTION Telehealth is an increasingly popular treatment delivery modality for mental healthcare, including evidence-based treatment for complex and intense psychopathologies such as post-traumatic stress disorder (PTSD). Despite the growing telehealth literature, there is a need for more confirmatory research on satisfaction with PTSD telehealth treatment, particularly among veterans, for whom the most rapid and permanent expansion of telehealth services has been implemented through the Department of Veterans Affairs. METHODS The current paper integrates data from two concurrent PTSD treatment outcome studies that compared prolonged exposure therapy delivered both in person and via telehealth for veterans (N = 140). Using two different measures of satisfaction (the Charleston Psychiatric Outpatient Satisfaction Scale-Veteran Affairs Version (CPOSS) and the Service Delivery Perception Questionnaire (SDPQ)), we hypothesized that PTSD improvement would predict satisfaction, but that delivery modality (in person vs telehealth) would not. RESULTS Results only partially supported the hypotheses, in that PTSD symptom improvement was associated with greater satisfaction, and in-person treatment modality was associated with satisfaction as measured by the CPOSS (but not the SDPQ). Subgroup differences by sex were found, such that male veterans, typically with combat-related trauma, were more satisfied with their PTSD treatment compared to female veterans, who were most frequently seen in this study for military sexual trauma. DISCUSSION Altogether, results illustrate a need for additional satisfaction studies with diverse samples and large sample sizes. Future research may benefit from examining satisfaction throughout treatment, identifying predictors of greater PTSD improvement, and further examining demographic subgroups.
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Affiliation(s)
- C Nicole White
- University of Texas Health Science Center at Houston, USA.,University of South Carolina, USA
| | - Brooke Y Kauffman
- University of Texas Health Science Center at Houston, USA.,University of Houston, USA
| | - Ron Acierno
- University of Texas Health Science Center at Houston, USA
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Meinertz N, Liu PJ, Acierno R. Long-Term Effects of Abuse in Later Life Perpetrated by Family Members. Innov Aging 2020. [PMCID: PMC7741568 DOI: 10.1093/geroni/igaa057.1438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Abuse in later life could potentially lead to lower levels of social support, especially when perpetrated by family members who are charged with protecting the older adult in their care. Using both waves of the National Elder Mistreatment longitudinal data (wave one collected in 2008 and wave two in 2015; N=774), long-term effects of abuse (i.e., physical, emotional, sexual, and financial) on levels of social support, physical health, and clinical depressive symptoms for respondents at or above the age of 60 years were analyzed. A multivariate analysis of variance showed that respondents abused at wave one (n=261) by a family member (B=-0.55, p≤0.001), a spouse or ex-partner (B=-0.349, p=0.02), or a non-relative or stranger (B=-0.301, p=0.026) had lower levels of social support eight years later at wave two. Those abused by a family member at wave one also experienced higher levels of depressive symptoms at wave two (B=-0.187, p=0.01). Perpetrator type did not predict general health at wave two. These results emphasize the long-term impact of abuse on the lives of older adults and highlight the importance trusted relationships, such as with family members, have on older adult health and wellbeing.
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Affiliation(s)
| | - Pi-Ju Liu
- Purdue University, West Lafayette, Indiana, United States
| | - Ron Acierno
- UT Health Sciences Houston, Houston, Texas, United States
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Williams JL, Racette EH, Hernandez-Tejada MA, Acierno R. Prevalence of Elder Polyvictimization in the United States: Data From the National Elder Mistreatment Study. J Interpers Violence 2020; 35:4517-4532. [PMID: 29294807 DOI: 10.1177/0886260517715604] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Elder abuse, including emotional, physical, sexual, financial, and neglectful mistreatment is widespread in the United States, with as much as 11% of community-residing older adults experiencing some form of abuse in the past year. Little data exist regarding the prevalence of polyvictimization, or experience of multiple forms of abuse, which may exacerbate negative outcomes over that of any one form of victimization in isolation. This study evaluates the prevalence of elder polyvictimization among a nationally representative sample of community-residing U.S. older adults. Data from the National Elder Mistreatment Study were examined using bivariate and logistic regression analyses. Approximately, 1.7% of older adults experienced past-year polyvictimization, for which risk factors included problems accomplishing activities of daily living (odds ratio [OR] = 2.47), low social support (OR = 1.64), and past experience of traumatic events (OR = 4.81). Elder polyvictimization is a serious problem affecting community-residing older adults with identifiable targets for intervention.
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Affiliation(s)
| | | | | | - Ron Acierno
- Medical University of South Carolina, Charleston, USA
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
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Reich K, Nemeth LS, Mueller M, Sternke LM, Acierno R. Psychosocial functioning in veterans with combat-related PTSD: An evolutionary concept analysis. Nurs Forum 2020; 56:194-201. [PMID: 33125741 DOI: 10.1111/nuf.12519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 10/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Veterans returning from combat have a greater risk for developing posttraumatic stress disorder (PTSD) and greater severity of psychosocial functioning impairment. Previous research has demonstrated the strong association between PTSD and psychosocial functioning impairment. Psychosocial functioning is an ambiguous term often used in literature to discuss PTSD-associated consequences, intervention response, and symptom progression. An evolutionary concept analysis was conducted to clarify understanding of psychological functioning in veterans with combat-related PTSD. Rodgers' method for an evolutionary concept analysis was used to examine the concept of psychosocial functioning. A literature search using the Cumulative Index to Nursing and Allied Health Literature and SCOPUS databases and subsequent screening yielded twenty articles meeting established criteria for analysis. The analysis highlights significant attributes, antecedents, consequences, and implications for future concept development. Psychosocial functioning environment/domain, social support, and engagement in treatment were distinguishing attributes identified. Combat exposure and various PTSD symptoms are related antecedents. Consequences such as decreased intimacy, decreased work function, low parenting satisfaction, and inadequate productivity in educational settings are all components of this concept. The concept of psychosocial functioning is meaningful in the everyday lives of US combat veterans with PTSD and requires special consideration in treatment planning by healthcare providers.
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Affiliation(s)
- Kristina Reich
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA.,Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Lynne S Nemeth
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Martina Mueller
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lisa M Sternke
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA.,Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Ron Acierno
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA.,Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, Trauma and Resilience Center, Huston, Texas, USA
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Reich K, Nemeth LS, Mueller M, Sternke LM, Acierno R. Does Psychosocial Functioning Improve With Prolonged Exposure in Veterans With PTSD?: Exploring Traditional and Home-Based Telehealth Delivery Methods. J Psychosoc Nurs Ment Health Serv 2020; 59:31-40. [PMID: 33095268 DOI: 10.3928/02793695-20201015-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/28/2020] [Indexed: 12/21/2022]
Abstract
The current study explored whether prolonged exposure (PE), delivered in person or via home-based telehealth, had a therapeutic effect on psychosocial functioning in combat Veterans with posttraumatic stress disorder (PTSD). The effects of home-based telehealth on these metrics were also evaluated. In addition, we examined whether race, type of war conflict, and service-connected disability rating moderated the effect of PE on psychosocial functioning and whether PTSD, anxiety, and/or depression mediated the effect of PE on psychosocial functioning. We did not find moderating or mediating effects in our study. Improvements in PTSD, depression, and anxiety were associated with improvements in psychosocial functioning. We did not identify statistically significant differences in scores representing change in overall and each domain of psychosocial functioning between groups. Within-group analysis indicated psychosocial functioning improved in both groups but was mostly not statistically significant. However, some clinically relevant improvement may have occurred. [Journal of Psychosocial Nursing and Mental Health Services, 59(2), 31-40.].
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Gilmore AK, Lopez C, Muzzy W, Brown WJ, Grubaugh A, Oesterle DW, Acierno R. Emotion Dysregulation Predicts Dropout from Prolonged Exposure Treatment among Women Veterans with Military Sexual Trauma-Related Posttraumatic Stress Disorder. Womens Health Issues 2020; 30:462-469. [PMID: 32843240 DOI: 10.1016/j.whi.2020.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 03/19/2020] [Accepted: 07/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Military sexual trauma (MST) is notably prevalent among military personnel and can result in mental and physical health problems, including post-traumatic stress disorder (PTSD). Although there are several evidence-based treatments for MST-related PTSD, including prolonged exposure (PE) therapy, it is unclear what factors are associated with premature termination (i.e., dropout) from this treatment. Given the popularity of PE as an evidence-based treatment for PTSD, the examination of variables that influence dropout from PE among women veterans with MST is warranted. Identification of these specific factors may assist clinicians in addressing the unique symptom profiles and potential barriers to treatment access for individual MST survivors. METHODS The current study presents secondary data analyses from an ongoing randomized clinical trial that compared the effectiveness of PE delivered in person to delivery via telemedicine for women veterans with MST-related PTSD (n = 136). RESULTS A total of 50% of participants dropped out from the study (n = 68). Difficulties with emotion regulation at baseline were associated with treatment dropout (odds ratio, 1.03; p < .01), whereas baseline PTSD and demographic factors were not. CONCLUSIONS Findings from the current study indicate that emotion regulation skills deficits contribute to PE dropout and may be an appropriate target to address in future clinical trials for PTSD treatment.
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Affiliation(s)
- Amanda K Gilmore
- Department of Health Policy and Behavioral Sciences and Mark Chaffin Center for Healthy Development, School of Public Health, Georgia State University, Atlanta, Georgia.
| | - Cristina Lopez
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | - Wendy Muzzy
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | - Wilson J Brown
- School of Humanities & Social Sciences, Pennsylvania State University, The Behrend College, Erie, Pennsylvania
| | - Anouk Grubaugh
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina; Military Sciences Division, Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel W Oesterle
- Department of Health Policy and Behavioral Sciences and Mark Chaffin Center for Healthy Development, School of Public Health, Georgia State University, Atlanta, Georgia; Department of Psychological Sciences, College of Health and Human Sciences, Purdue University, West Lafayette, Indiana
| | - Ron Acierno
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina; University of Texas Health Science Center at Houston, Houston, Texas
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Lopez C, Gilmore AK, Moreland A, Danielson CK, Acierno R. Meeting Kids Where They Are At-A Substance Use and Sexual Risk Prevention Program via Telemedicine for African American Girls: Usability and Acceptability Study. J Med Internet Res 2020; 22:e16725. [PMID: 32780022 PMCID: PMC7448181 DOI: 10.2196/16725] [Citation(s) in RCA: 6] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 05/29/2020] [Accepted: 06/03/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Rural African American youth lack access to drug and sexual risk-taking prevention programs available in more urban areas. Recent data indicate that rural youth now use substances at higher rates and at younger ages than their urban peers. OBJECTIVE This study aims to evaluate the initial usability and acceptability of a low-cost, technology-based approach to delivering effective, culturally tailored, integrated substance use disorder (SUD) and HIV risk behavior prevention programs to African American female youth to inform the use of this intervention via telemedicine for rural youth. METHODS Effective SUD prevention strategies and emotion regulation skills were integrated into an existing evidence-based HIV risk reduction program culturally tailored for African American female adolescents-Sisters Informing, Healing, Living, and Empowering (SIHLE)-and delivered to 39 African American female youth via group telehealth. The evaluation of the resulting program, 12-session SIHLEplus, was completed by 27 girls who also completed self-report measures that assessed sexual risk behaviors (eg, number of partners and age of sex initiation), substance use, exposure to traumatic events, and emotion regulation. RESULTS The descriptive and qualitative results of the pilot study demonstrate the initial usability and acceptability of delivering evidence-based prevention successfully via telehealth to help address health disparities in this vulnerable population. CONCLUSIONS Although more research is needed, the findings from this study suggest that SIHLEplus has demonstrated initial usability and acceptability.
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Affiliation(s)
- Cristina Lopez
- Medical University of South Carolina, Charleston, SC, United States
| | | | - Angela Moreland
- Medical University of South Carolina, Charleston, SC, United States
| | | | - Ron Acierno
- University of Texas, Houston, TX, United States
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Wells SY, Morland LA, Wilhite ER, Grubbs KM, Rauch SA, Acierno R, McLean CP. Delivering Prolonged Exposure Therapy via Videoconferencing During the COVID-19 Pandemic: An Overview of the Research and Special Considerations for Providers. J Trauma Stress 2020; 33:380-390. [PMID: 32881116 PMCID: PMC7461321 DOI: 10.1002/jts.22573] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 11/11/2022]
Abstract
Leveraging technology to provide evidence-based therapy for posttraumatic stress disorder (PTSD), such as prolonged exposure (PE), during the COVID-19 pandemic helps ensure continued access to first-line PTSD treatment. Clinical video teleconferencing (CVT) technology can be used to effectively deliver PE while reducing the risk of COVID-19 exposure during the pandemic for both providers and patients. However, provider knowledge, experience, and comfort level with delivering mental health care services, such as PE, via CVT is critical to ensure a smooth, safe, and effective transition to virtual care. Further, some of the limitations associated with the pandemic, including stay-at-home orders and physical distancing, require that providers become adept at applying principles of exposure therapy with more flexibility and creativity, such as when assigning in vivo exposures. The present paper provides the rationale and guidelines for implementing PE via CVT during COVID-19 and includes practical suggestions and clinical recommendations.
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Affiliation(s)
- Stephanie Y. Wells
- Durham VA Health Care SystemDurhamNorth CarolinaUSA,VISN‐6 Mid‐Atlantic MIRECCDurhamNorth CarolinaUSA,Department of PsychiatryDuke UniversityDurhamNorth CarolinaUSA
| | - Leslie A. Morland
- VA San Diego Healthcare SystemSan DiegoCaliforniaUSA,Department of PsychiatryUniversity of California San DiegoSan DiegoCaliforniaUSA,National Center for PTSDPacific Islands DivisionHonoluluHawaiiUSA
| | | | | | - Sheila A.M. Rauch
- VA Atlanta Healthcare SystemAtlantaGeorgiaUSA,Department of Psychiatry Emory University School of MedicineAtlantaGeorgiaUSA
| | - Ron Acierno
- Faillace Department of PsychiatryUniversity of Texas Health Sciences CenterHouston TexasUSA,Ralph H. Johnson VA Medical CenterCharlestonSouth CarolinaUSA
| | - Carmen P. McLean
- National Center for PTSDVA Palo Alto Health Care SystemPalo AltoCaliforniaUSA,Stanford UniversityPalo AltoCaliforniaUSA
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Hernandez-Tejada MA, Muzzy W, Price M, Hamski S, Hart S, Foa E, Acierno R. Peer support during in vivo exposure homework to reverse attrition from prolonged exposure therapy for posttraumatic stress disorder (PTSD): description of a randomized controlled trial. Trials 2020; 21:366. [PMID: 32345329 PMCID: PMC7189578 DOI: 10.1186/s13063-020-04302-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/01/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Effective treatments for posttraumatic stress disorder (PTSD) (e.g., prolonged exposure (PE); cognitive processing therapy (CPT)) exist and are widely adopted by the Departments of Veterans Affairs (VA) and Defense (DoD). Unfortunately, dropout from these treatments regularly exceeds 30%. However, in a recent survey of patients who dropped out of PE, approximately half indicated a greater likelihood of completion if a peer who had completed treatment were available to help with the in vivo exposure homework. METHODS We will use a between-groups randomized controlled design with repeated assessment at baseline, post treatment, and 3- and 6-month follow-up across measures of PTSD, depression, and functioning with 150 veterans who have indicated that they intend to drop out of treatment. Participants will be randomly assigned to one of two PE + Peer Support conditions: (1) a peer will offer support directly during in vivo exposure homework for 3-4 weeks; vs (2) a peer will call weekly for 3-4 weeks to offer general support and to check in on treatment progress. DISCUSSION The present study was designed to test the hypothesis that dropout from exposure-based PTSD treatment may be mitigated by using peers as support agents directly during PE in vivo homework experiences. Specifically, we intend to determine: whether patients who have dropped out of PE and are offered the "in vivo peer" adjunctive component to PE therapy will (1) return and complete treatment and (2) evince reduced PTSD symptomatology, compared to the same PE treatment, but with general peer support more reflective of current VA practices. TRIAL REGISTRATION This study protocol is approved and information is available at ClinicalTrials.gov, ID: NCT03485391. Registered on 2 April 2018.
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Affiliation(s)
- Melba A Hernandez-Tejada
- Department of Psychiatry and Behavioral Sciences, Trauma and Resilience Center, McGovern Medical School at UTHealth, Houston, TX, USA. .,Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
| | - Wendy Muzzy
- Medical University of South Carolina College of Nursing, Charleston, SC, USA
| | - Matthew Price
- Department of Psychiatry and Behavioral Sciences, Trauma and Resilience Center, McGovern Medical School at UTHealth, Houston, TX, USA
| | | | | | - Edna Foa
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ron Acierno
- Department of Psychiatry and Behavioral Sciences, Trauma and Resilience Center, McGovern Medical School at UTHealth, Houston, TX, USA.,Ralph H. Johnson VA Medical Center, Charleston, SC, USA
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Morland LA, Mackintosh MA, Glassman LH, Wells SY, Thorp SR, Rauch SAM, Cunningham PB, Tuerk PW, Grubbs KM, Golshan S, Sohn MJ, Acierno R. Home-based delivery of variable length prolonged exposure therapy: A comparison of clinical efficacy between service modalities. Depress Anxiety 2020; 37:346-355. [PMID: 31872563 DOI: 10.1002/da.22979] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/24/2019] [Accepted: 11/06/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE This study examined clinical and retention outcomes following variable length prolonged exposure (PE) for posttraumatic stress disorder (PTSD) delivered by one of three treatment modalities (i.e., home-based telehealth [HBT], office-based telehealth [OBT], or in-home-in-person [IHIP]). METHOD A randomized clinical trial design was used to compare variable-length PE delivered through HBT, OBT, or IHIP. Treatment duration (i.e., number of sessions) was determined by either achievement of a criterion score on the PTSD Checklist for Diagnostic and Statistical Manual-5 (DSM-5; PTSD Checklist for DSM-5) for two consecutive sessions or completion of 15 sessions. Participants received PE via HBT (n = 58), OBT (n = 59) or IHIP (n = 58). Data were collected between 2012 and 2018, and PTSD was diagnosed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), administered at baseline, posttreatment, and 6 months following treatment completion. The primary clinical outcome was CAPS-5 PTSD severity. Secondary outcomes included self-reported PTSD and depression symptoms, as well as treatment dropout. RESULTS The clinical effectiveness of PE did not differ by treatment modality across any time point; however, there was a significant difference in treatment dropout. Veterans in the HBT (odds ratio [OR] = 2.67; 95% confidence interval [CI] = 1.10, 6.52; p = .031) and OBT (OR = 5.08; 95% CI = 2.10; 12.26; p < .001) conditions were significantly more likely than veterans in IHIP to drop out of treatment. CONCLUSIONS Providers can effectively deliver PE through telehealth and in-home, in-person modalities although the rate of treatment completion was higher in IHIP care.
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Affiliation(s)
- Leslie A Morland
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | | | - Lisa H Glassman
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Stephanie Y Wells
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Steven R Thorp
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Sheila A M Rauch
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Phillippe B Cunningham
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Peter W Tuerk
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Kathleen M Grubbs
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Shahrokh Golshan
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Min Ji Sohn
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
| | - Ron Acierno
- Regional TeleMental Health Program, VA San Diego Healthcare System, San Diego, California
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Hernandez-Tejada MA, Frook G, Steedley M, Watkins J, Acierno R. Demographic-based risk of reporting psychopathology and poor health among mistreated older adults in the national elder mistreatment study wave II. Aging Ment Health 2020; 24:22-26. [PMID: 30450918 DOI: 10.1080/13607863.2018.1509296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 10/27/2022]
Abstract
Objectives: Past year elder mistreatment rate is about 11% of community residing older adults, with significant demographic-based variations in prevalence. However, very little research on demographic variable-based differences in correlates of elder abuse, such as mental health, exist. The National Elder Mistreatment Study 8-year follow-up (NEMS II) specifically investigated the relation between demographic factors and the presence of these correlates (i.e. diagnoses of depression, post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and self-ratings of physical health).Methods: The NEMS II used random digit dial telephone survey methodology to assess demographic variables and reports of depression PTSD, GAD, and poor health, in 774 older adults. RESULTS: a consistent association was observed between demographic factors related to financial status and poor mental and general health ratings.Discussion: A subset of demographic factors associated with increased risk of reporting elder abuse, low income and financial distress, were also associated with increased risk of reporting correlates of elder abuse that included depression, PTSD GAD and poor health.
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Affiliation(s)
- Melba A Hernandez-Tejada
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA.,Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Gabrielle Frook
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Mara Steedley
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Jordan Watkins
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Ron Acierno
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA.,Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
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Walsh K, Gilmore AK, Schumacher JA, Coffey SF, Frazier PA, Ledray L, Acierno R, Ruggiero KJ, Kilpatrick DG, Resnick HS. Post-sexual assault cigarette smoking: Findings from a randomized clinical trial of a video-based intervention. Addict Behav 2020; 100:106121. [PMID: 31622944 DOI: 10.1016/j.addbeh.2019.106121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/23/2019] [Accepted: 09/04/2019] [Indexed: 10/26/2022]
Abstract
Sexual assault (SA) is associated with elevated risk for cigarette smoking. The current study tested whether a brief video intervention delivered in the emergency department was effective at reducing smoking following SA. Participants were 233 girls and women (age 15+) who received a SA medical forensic examination (SAMFE) and were randomized to one of three conditions: 1) Prevention of Post-Rape Stress (PPRS), a brief video designed to reduce post-SA psychopathology; 2) Pleasant Imagery and Relaxation Information (PIRI), an active control video involving relaxation training; and 3) treatment as usual (TAU). Among those who participated at baseline, 154 participants completed at least one follow-up at 1.5, 3, and 6 months after the SAMFE. Participants reported the number of days of smoking and the average number of cigarettes smoked per day in the two weeks prior to the sexual assault as well as in the two weeks prior to each follow-up. Two-thirds (68.8%) of participants smoked prior to the SA or during any follow-up. One-fifth of participants who did not smoke prior to the SA smoked at one or more follow-ups. Smoking declined on average over follow-up although TAU was associated with increased initial smoking compared to PPRS; PPRS and PIRI did not differ. SA contributes to increases in smoking and the PPRS, a brief and cost-effective video-based intervention delivered during the SAMFE, can protect against increases in post-SA smoking. Trial registration: NCT01430624.
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40
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Simon NM, Hoeppner SS, Lubin RE, Robinaugh DJ, Malgaroli M, Norman SB, Acierno R, Goetter EM, Hellberg SN, Charney ME, Bui E, Baker AW, Smith E, Kim HM, Rauch SA. Understanding the impact of complicated grief on combat related posttraumatic stress disorder, guilt, suicide, and functional impairment in a clinical trial of post-9/11 service members and veterans. Depress Anxiety 2020; 37:63-72. [PMID: 31916660 PMCID: PMC7433022 DOI: 10.1002/da.22911] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 04/18/2019] [Accepted: 04/22/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Complicated grief (CG) is a bereavement-specific syndrome distinct from but commonly comorbid with posttraumatic stress disorder (PTSD). While bereavement is common among military personnel (Simon et al., 2018), there is little research on the impact of CG comorbidity on PTSD treatment outcomes. METHODS To evaluate the impact of comorbid CG on PTSD treatment outcomes we analyzed data from a randomized trial comparing prolonged exposure, sertraline, and their combination in veterans with a primary diagnosis of combat-related PTSD (n = 194). Assessment of PTSD, trauma-related guilt, functional impairment, and suicidal ideation and behavior occurred at baseline and weeks 6, 12, and 24 during the 24-week trial. RESULTS CG was associated with lower PTSD treatment response (odds ratio (OR) = 0.29, 95% confidence interval (CI) [0.12, 0.69], p = 0.005) and remission (OR = 0.28, 95% CI [0.11, 0.71], p = 0.007). Those with CG had greater severity of PTSD (p = 0.005) and trauma-related guilt (<0.001) at baseline and endpoint. In addition, those with CG were more likely to experience suicidal ideation during the study (CG: 35%, 14/40 vs. no CG 15%, 20/130; OR = 3.01, 95% CI [1.29, 7.02], p = 0.011). CONCLUSIONS Comorbid CG is associated with elevated PTSD severity and independently associated with poorer endpoint treatment outcomes in veterans with combat-related PTSD, suggesting that screening and additional intervention for CG may be needed.
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Affiliation(s)
- Naomi M. Simon
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, New York University School of Medicine, New York, NY
| | - Susanne S. Hoeppner
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Rebecca E. Lubin
- Department of Psychiatry, New York University School of Medicine, New York, NY
| | - Donald J. Robinaugh
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Matteo Malgaroli
- Department of Psychiatry, New York University School of Medicine, New York, NY
| | - Sonya B. Norman
- National Center for PTSD, White River Junction, VT,Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, CA,School of Medicine, University of California, San Diego, La Jolla,Veterans Affairs Center of Excellence for Stress and Mental Health, San Diego, CA
| | - Ron Acierno
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC,College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Elizabeth M. Goetter
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | | | - Meredith E. Charney
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Eric Bui
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Amanda W. Baker
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Erin Smith
- VA Ann Arbor Healthcare System, Ann Arbor, MI,Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - H. Myra Kim
- VA Ann Arbor Healthcare System, Ann Arbor, MI,Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, MI
| | - Sheila A.M. Rauch
- Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, GA,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
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Acierno R, Muzzy W. RESILIENCE THROUGH CONNECTION: SOCIAL SUPPORT AND ELDER ABUSE, DISASTER, BEREAVEMENT, AND COMBAT. Innov Aging 2019. [PMCID: PMC6840441 DOI: 10.1093/geroni/igz038.1581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Elder abuse prevalence among community residing adults is 10%, but this prevalence is cut by more than half among those who report high levels of social connection. Relatedly, elder abuse outcomes are significant, producing increased prevalence of anxiety and depressive disorders, the prevalences of which are, again, halved when one experiences abuse in the context of high social support. Similarly, mental health effects of natural disaster on older adults are virtually eliminated in the presence of high social support. Moreover, treatment for anxiety and depressive disorders is improved when high social support is present. We will present findings from five of our major studies in the aforementioned areas that underscore this point.
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Affiliation(s)
- Ron Acierno
- Medical University of South Carolina, Charleston, South Carolina, United States
| | - Wendy Muzzy
- Medical University of South Carolina, Charleston, South Carolina, United States
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Hernandez-Tejada M, Acierno R, Anetzberger G, Loew D, Muzzy W. THE NATIONAL ELDER MISTREATMENT STUDY 8 YEARS LATER: VICTIM MENTAL HEALTH OUTCOMES AND PROTECTIVE FACTORS. Innov Aging 2019. [PMCID: PMC6840381 DOI: 10.1093/geroni/igz038.1773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The purpose of this study was to conduct an 8-year follow-up of the National Elder Mistreatment Study (NEMS) and specify risk ratios for negative outcomes of elder abuse, including DSM-5 defined depression, generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and poor self-reported health. Methodology: Attempts were made to re-contact, via Computer Assisted Telephone Interview, all 752 NEMS participants who reported mistreatment since age 60 at Wave I, as well as a randomly selected sample of non-mistreated NEMS participants Results: 183 NEMS Wave I elder abuse victims and 591 non-victims provided data. In bivariate analyses, elder mistreatment 8 years earlier increased risk of negative outcomes by 200-700%. However, multivariate analyses revealed that Current (Wave II) social support was highly protective against most negative outcomes (excepting PTSD), and even appeared to nullify effects of mistreatment on GAD and poor self-reported health. Conclusions: Outcomes of elder mistreatment have not been studied prospectively in a national sample. The NEMS 8-year follow-up findings indicate a strong relationship between elder mistreatment at Wave I and negative emotional and physical health 8 years later. Fortunately, current (Wave II) social support appears to be both consistently and powerfully protective against most negative outcomes.
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Affiliation(s)
| | - Ron Acierno
- Medical University of South Carolina, Charleston, South Carolina, United States
| | | | | | - Wendy Muzzy
- Medical University of South Carolina, Charleston, South Carolina, United States
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43
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Hernandez-Tejada M, Acierno R, Watkins J, Frook G, Muzzy W, Anetzberger G, Steedley M. NATIONAL ELDER MISTREATMENT STUDY WAVE II: MENTAL HEALTH CORRELATES OF FINANCIAL MISTREATMENT. Innov Aging 2019. [PMCID: PMC6846483 DOI: 10.1093/geroni/igz038.692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: Whereas prevalence of elder financial mistreatment has received increased attention over the past decade, health and mental health correlates are rarely studied. Thus, the potential relevance of financial abuse to mental health and perceived health is relatively unknown, and the objective of this article is to illustrate this relationship. Method: The second wave of the National Elder Mistreatment Study used random digit dialing telephone survey methodology to assess both recent financial mistreatment and its potential mental health correlates (i.e., diagnoses of depression, post-traumatic stress disorder [PTSD], generalized anxiety disorder [GAD], and self-ratings of physical health) in 774 older adults. Results: The study indicated that past-year Wave II financial mistreatment was associated with significantly increased likelihood of depression, PTSD, GAD, and poor self-rated health; and financial mistreatment perpetrated by family members was associated with particularly increased risk of depression. Discussion: Assessment of mental health is relevant and important in cases of financial abuse.
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Affiliation(s)
| | - Ron Acierno
- Medical University of South Carolina, Charleston, South Carolina, United States
| | - Jordan Watkins
- Medical University of South Carolina, Charleston, South Carolina, United States
| | - Gabrielle Frook
- Medical University of South Carolina, Charleston, South Carolina, United States
| | - Wendy Muzzy
- Medical University of South Carolina, Charleston, South Carolina, United States
| | | | - Mara Steedley
- Medical University of South Carolina, Charleston, South Carolina, United States
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44
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Burnes D, Acierno R, Hernandez-Tejada M. FACILITATORS AND BARRIERS FOR ELDER ABUSE VICTIMS SEEKING HELP: FINDINGS FROM THE NATIONAL ELDER MISTREATMENT STUDY. Innov Aging 2019. [PMCID: PMC6840103 DOI: 10.1093/geroni/igz038.1774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Understanding help-seeking among victims of elder abuse is a critical challenge in the field. The vast majority of elder abuse victims remain hidden from formal support/protective response systems, such as adult protective services, legal/justice, law enforcement, or other agencies responsible for addressing this issue in the community. Guided by the Behavioral Model of Health Services Use, this study examined factors that facilitate or impede formal help-seeking among victims of elder emotional, physical and sexual abuse, represented by a call for help in the form of a report to police or other authorities. Data came from a national, population-based elder abuse study in the U.S. with a representative sample (n=304) of victims reporting abuse in the past year. Gold-standard measurement strategies were used to assess each elder abuse subtype. Multivariable logistic regression was conducted to identify help-seeking facilitators/barriers. Help-seeking through reporting to police or other authorities occurred among only 15.4% of elder abuse victims nationwide. Help-seeking was predicted by factors attached to the victim (abuse type, poly-victimization), perpetrator (prior police trouble, social network size), and victim-perpetrator relationship (victim dependence on perpetrator). This study highlights the extremely hidden nature of elder abuse in our society, as well as the need to develop strategies that incorporate victim, perpetrator, and victim-perpetrator relationship factors to promote greater help-seeking among victims.
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Affiliation(s)
| | - Ron Acierno
- Medical University of South Carolina, Charleston, South Carolina, United States
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45
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Gros DF, Lancaster CL, Teves JB, Libet J, Acierno R. Relations between post-deployment divorce/separation and deployment and post-deployment stressors, social support, and symptomatology in Veterans with combat-related PTSD symptoms. Journal of Military, Veteran and Family Health 2019. [DOI: 10.3138/jmvfh.2018-0015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction: Post-traumatic stress disorder (PTSD) is a highly prevalent diagnosis in combat Veterans. In addition to reduced quality of life in various domains of functioning, PTSD also is associated with poorer relationships and social support, including marital dissatisfaction and divorce. Although post-deployment divorce/separation was noted as problematic in past conflicts, little is known about divorce/separation following modern conflicts, such as Operations Enduring/Iraqi Freedom (OEF/OIF). The present study investigated the relations between post-deployment divorce/separation and post-deployment stressors, social support, and psychiatric symptomatology in OEF/OIF Veterans seeking treatment for PTSD. Methods: We recruited 98 United States (US) male Veterans from OEF/OIF to participate in the study. Marital status of once-married was required for participation. All participants completed consent documentation and a series of diagnostic interviews and self-report measures. Participants were separated into two groups based on their post-deployment marital status (still married vs. divorced/separated). Results: One-third of the sample indicated they divorced/separated following OEF/OIF. Participants that endorsed a post-deployment divorce/separation demonstrated heightened stress during and after deployment as well as significantly less social support compared to participants who remained married. Discussion: The rates of divorce/separation reported in the sample were comparable to samples of the general American population, despite the elevated risk factors in the Veteran sample (e.g., psychiatric diagnosis). Also, Veterans reporting post-deployment divorce/separation endorsed heightened stress and poorer social support, two factors associated with poorer treatment outcome for PTSD. Together, these findings highlight potential factors associated with post-deployment divorce/separation in OEF/OIF Veterans with PTSD.
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Affiliation(s)
- Daniel F. Gros
- Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Jenna B. Teves
- Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Julian Libet
- Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ron Acierno
- Mental Health Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
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López CM, Lancaster CL, Wilkerson A, Gros DF, Ruggiero KJ, Acierno R. Residual Insomnia and Nightmares Postintervention Symptom Reduction Among Veterans Receiving Treatment for Comorbid PTSD and Depressive Symptoms. Behav Ther 2019; 50:910-923. [PMID: 31422847 DOI: 10.1016/j.beth.2019.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 01/22/2019] [Accepted: 01/24/2019] [Indexed: 01/30/2023]
Abstract
While evidence-based interventions can help the substantial number of veterans diagnosed with comorbid PTSD and depression, an emerging literature has identified sleep disturbances as predictors of treatment nonresponse. More specifically, predicting effects of residual insomnia and nightmares on postintervention PTSD and depressive symptoms among veterans with comorbid PTSD and depression has remained unclear. The present study used data from a clinical trial of Behavioral Activation and Therapeutic Exposure (BA-TE), a combined approach to address comorbid PTSD and depression, administered to veterans (N = 232) to evaluate whether residual insomnia and nightmare symptoms remained after treatment completion and, if so, whether these residual insomnia and nightmare symptoms were associated with higher levels of comorbid PTSD and depression at the end of treatment. Participants (ages 21 to 77 years old; 47.0% Black; 61.6% married) completed demographic questions, symptom assessments, and engagement-related surveys. Hierarchical multiple linear regression models demonstrated that residual insomnia was a significant predictor of PTSD and depression symptom reduction above and beyond the influence of demographic and engagement factors (e.g., therapy satisfaction). Consistent with previous research, greater residual insomnia symptoms were predictive of smaller treatment gains. Findings illustrate the potential significance of insomnia during the course of transdiagnostic treatment (e.g., PTSD and depression), leading to several important clinical assessment and treatment implications.
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Affiliation(s)
| | - Cynthia L Lancaster
- Ralph H. Johnson Veterans Affairs Medical Center; Medical University of South Carolina
| | | | - Daniel F Gros
- Ralph H. Johnson Veterans Affairs Medical Center; Medical University of South Carolina
| | | | - Ron Acierno
- College of Nursing, Medical University of South Carolina; Ralph H. Johnson Veterans Affairs Medical Center
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47
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Gilmore AK, Davidson TM, Leone RM, Wray LB, Oesterle DW, Hahn CK, Flanagan JC, Gill-Hopple K, Acierno R. Usability Testing of a Mobile Health Intervention to Address Acute Care Needs after Sexual Assault. Int J Environ Res Public Health 2019; 16:E3088. [PMID: 31450676 PMCID: PMC6747119 DOI: 10.3390/ijerph16173088] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
Sexual assault is associated with a range of poor mental health outcomes. To enhance access to care by this population, technology-based mental health interventions have been implemented in the emergency room; however, more accessible and easily disseminated interventions are needed. The aim of the present study was to test the usability of a mobile health intervention targeting alcohol and drug misuse, suicide prevention, posttraumatic stress symptoms, coping skills, and referral to formal assistance for individuals who have experienced sexual assault. Feedback on the usability of the intervention was collected from individuals who received a sexual assault medical forensic examination (n = 13), and feedback on the usability and likelihood of recommending the application was collected from community providers (n = 25). Thematic analysis was used to describe qualitative data. Content themes related to aesthetics, usability, barriers to resources, and likes/dislikes about the intervention arose from interviews following the intervention. Participants found the intervention to be user friendly and endorsed more likes than dislikes. Providers rated the intervention as being helpful and would recommend it to survivors of sexual assault. Findings suggest that the intervention is usable and fit for future effectiveness testing, filling an important gap in treatment for individuals who experience sexual assault.
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Affiliation(s)
- Amanda K Gilmore
- College of Nursing, Medical University of South Carolina, Charleston, SC 29425, USA.
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA.
| | - Tatiana M Davidson
- College of Nursing, Medical University of South Carolina, Charleston, SC 29425, USA
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Ruschelle M Leone
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Lauren B Wray
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Daniel W Oesterle
- College of Nursing, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Christine K Hahn
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Julianne C Flanagan
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Kathleen Gill-Hopple
- Forensic Nursing Services, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Ron Acierno
- Ralph H. Johnson VA Medical Center, Charleston, SC 29425, USA
- Department of Psychiatry, University of Texas Health Science Center, Houston, TX 77030, USA
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Acierno R. A comment on Wong and Waite, "Elder mistreatment predicts later physical and psychological health: Results from a national longitudinal study," JEAN Issue 29(1), pp. 15-42. J Elder Abuse Negl 2019; 29:186-187. [PMID: 28328307 DOI: 10.1080/08946566.2017.1310074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 10/19/2022]
Abstract
Wong and Waite present a longitudinal study of elder abuse and its effects. However, they contend that their data do not support the protective effects of social support, a finding in contrast with virtually all existing research on the topic. Closer inspection of their variables indicates that they misclassify elder abuse insofar as their results are actually in terms of only one type of elder abuse, psychological abuse, ignoring physical and sexual abuse. They also define "elder abuse" using only one question: "Is there anyone who insults you or puts you down?" Finally, they measure social support with the single item: "if they generally feel they can open up to, and rely on, these significant others." It is not, therefore, surprising that they observed that social support was not protective considering health outcomes.
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Affiliation(s)
- Ron Acierno
- a College of Nursing , Medical University of South Carolina , Charleston , South Carolina , USA
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49
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Gilmore AK, Walsh K, Frazier P, Ledray L, Acierno R, Ruggiero KJ, Kilpatrick DG, Resnick HS. Prescription Opioid Misuse After a Recent Sexual Assault: A Randomized Clinical Trial of a Video Intervention. Am J Addict 2019; 28:376-381. [PMID: 31242340 DOI: 10.1111/ajad.12922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 04/03/2019] [Accepted: 05/10/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Prescription opioid (PO) misuse is increasing and is associated with overdose. Individuals who experienced a recent sexual assault are at risk for increased substance use, yet limited interventions target PO misuse after sexual assault. The current study examined the efficacy of video interventions on PO misuse after sexual assault. METHODS Adolescent girls and women (n = 154) were recruited in the context of a sexual assault medical forensic exam in the emergency department. Effects of a prevention of post-rape stress (PPRS) video and a pleasant imagery and relaxation instruction (PIRI) video were compared with treatment as usual (TAU) during a sexual assault medical forensic exam on PO misuse. Participants reported if they had used POs for non-medical purposes since the sexual assault at 1.5 month follow-up. RESULTS Results from a logistic regression analysis indicated that participants with a prior sexual assault were less likely to misuse prescription opioids 1.5 months after the assault in the PIRI condition compared with TAU. There were no main effects for video condition and no interactions for the PPRS condition on PO misuse. DISCUSSION AND CONCLUSIONS Providing the PIRI video, or teaching other types of mindfulness or relaxation exercises, may be warranted as a secondary prevention for individuals during the sexual assault medical forensic exam for those with a prior sexual assault history. SCIENTIFIC SIGNIFICANCE This research provides an initial examination of the impact of mindfulness skills recently after traumatic event exposure on PO misuse. (Am J Addict 2019;28:376-381).
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Affiliation(s)
- Amanda K Gilmore
- Department of Nursing, College of Nursing, Medical University of South Carolina, Charleston, SC.,Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Kate Walsh
- Department of Psychology, Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
| | - Patricia Frazier
- Department of Psychology, University of Minnesota, Minneapolis, MN
| | | | - Ron Acierno
- Department of Nursing, College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Kenneth J Ruggiero
- Department of Nursing, College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Dean G Kilpatrick
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Heidi S Resnick
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC
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Burnes D, Acierno R, Hernandez-Tejada M. Help-Seeking Among Victims of Elder Abuse: Findings From the National Elder Mistreatment Study. J Gerontol B Psychol Sci Soc Sci 2019; 74:891-896. [PMID: 30329112 PMCID: PMC6566322 DOI: 10.1093/geronb/gby122] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES The vast majority of elder abuse (EA) victims remain hidden from formal institutional response systems. Guided by the Behavioral Model of Health Services Use, this study examined factors that facilitate or impede formal help-seeking among victims of elder emotional abuse, physical abuse, and sexual abuse. METHODS Data came from a national, population-based EA study in the United States with a representative sample (n = 304) of past-year victims. Gold-standard strategies were used to assess EA subtypes. Multivariate logistic regression was conducted to identify help-seeking facilitators/barriers. RESULTS Help-seeking through reporting to police or other authorities occurred among only 15.4% of EA victims. Help-seeking was higher among victims of physical abuse, poly-victimization, or those with a perpetrator having prior police trouble. Help-seeking was lower among victims who were dependent upon their perpetrator and in cases where the perpetrator had a large friendship network. DISCUSSION This study highlights the hidden nature of EA as a problem in our society and the need to develop strategies that incorporate victim, perpetrator, and victim-perpetrator relationship factors to promote greater help-seeking among victims.
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Affiliation(s)
- David Burnes
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Ron Acierno
- Department of Research, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | - Melba Hernandez-Tejada
- Department of Research, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
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