Brooke A. Bartlett

Empirical Examinations of Modifications and Adaptations to Evidence-Based Psychotherapies: Methodologies, Impact, and Future Directions

This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.

Alcohol use and suicidality in firefighters: Associations with depressive symptoms and posttraumatic stress

Both suicidality and alcohol use disorders are significant public health concerns among firefighters, and alcohol use is associated with increased suicide risk. In addition, firefighters endorse high rates of symptoms of depression and posttraumatic stress disorder (PTSD). Thus, the current investigation examined associations between alcohol dependence and suicide risk among a large sample of firefighters. Specifically, this study examined the indirect effects of alcohol dependence on suicidality outcomes via both depression and posttraumatic stress, using structural equation modeling. A total of 2883 male firefighters completed a self-report survey, containing measures of alcohol use, suicidality, PTSD, and depressive symptoms. Results indicated good model fit. The latent alcohol dependence variable was directly related to the latent suicide risk variable. However, when depression and posttraumatic stress latent variables were added into the model, alcohol dependence was no longer associated with suicide risk. Furthermore, alcohol dependence was indirectly related to suicide risk via latent depression and posttraumatic stress variables. Indirect effects were established after controlling for relevant covariates. Clinical implications are discussed.

Eating disorder symptoms in female veterans: The role of childhood, adult, and military trauma exposure.

Objective: Eating disorders are understudied among female U.S. military veterans, who may be at increased risk due to their high rates of trauma exposure and trauma-related sequelae. The current study sought to examine whether different types of trauma in childhood and adulthood confer differential risk for eating disorder symptoms (EDSs) in this population. Method: We analyzed survey data from a sample of female Veterans Health Administration patients (N = 186) to examine the association between 5 trauma types (i.e., childhood physical abuse, adult physical assault, childhood sexual abuse, adult sexual assault, and military-related trauma) and EDS severity. Results: Approximately 14% of the sample reported clinical levels (i.e., standardized Eating Disorder Diagnostic Scale score ≥16.5) of EDSs. Multiple traumatization was associated with increased EDSs. Adult physical assault, adult sexual assault, and military-related trauma were individually associated with more severe eating disorder symptomatology, though only military-related trauma was uniquely associated with disordered eating in the full model. Discussion: EDSs are common among female veterans, and trauma exposures are differentially associated with symptom severity. It is critical to assess for EDSs in female veterans, particularly those with a history of military-related trauma, to facilitate detection and appropriate treatment.

Examining weight and eating behavior by sexual orientation in a sample of male veterans

OBJECTIVE Eating disorders are understudied in men and in sexual minority populations; however, extant evidence suggests that gay men have higher rates of disordered eating than heterosexual men. The present study examined the associations between sexual orientation, body mass index (BMI), disordered eating behaviors, and food addiction in a sample of male veterans. METHOD Participants included 642 male veterans from the Knowledge Networks-GfK Research Panel. They were randomly selected from a larger study based on previously reported trauma exposure; 96% identified as heterosexual. Measures included the Eating Disorder Diagnostic Scale, the Yale Food Addiction Scale, and self-reported height and weight. RESULTS Heterosexual and sexual minority men did not differ significantly in terms of BMI. However, gay and bisexual men (n=24) endorsed significantly greater eating disorder symptoms and food addiction compared to heterosexual men. CONCLUSIONS Our findings that sexual minority male veterans may be more likely to experience eating disorder and food addiction symptoms compared to heterosexual male veterans highlight the importance of prevention, assessment, and treatment efforts targeted to this population.

Intimate partner violence and disordered eating among male and female veterans

Intimate partner violence (IPV) affects many women and men in the United States and has been associated with numerous mental health conditions, including disordered eating (DE). Veterans may be especially vulnerable to experiencing both of these serious problems given the unique aspects and stressors relevant to military culture, including high rates of trauma exposure. We aimed to estimate the prevalence of past-year IPV among independent samples of male (N = 642) and female (N = 198) veterans and to examine the association between past-year IPV and DE. Mplus 7.0 was used to estimate associations between multiple types of IPV and DE, controlling for age, body mass index, military sexual trauma, and other military trauma. Approximately 14.86% of male veterans and 12.79% of female veterans reported experiencing some form of past-year IPV. All forms of past-year IPV, including physical, sexual, and psychological/emotional, were significantly associated with DE in both samples, after adjusting for covariates. IPV was relatively common among male and female veterans, and those who experience IPV may be particularly vulnerable to DE. Findings extend the knowledge base regarding IPV and its health effects among an understudied population, and may be a catalyst for further research and clinical inquiry to target improving psychiatric care for male and female veterans who experience IPV.

The unique and interactive effects of anxiety sensitivity and emotion dysregulation in relation to posttraumatic stress, depressive, and anxiety symptoms among trauma-exposed firefighters

BACKGROUND Firefighters are chronically exposed to traumatic events. Relatedly, past work has documented high rates of psychiatric problems, such as posttraumatic stress symptoms and depression, among firefighters. Less is known regarding anxiety symptoms among firefighters. Moreover, little work has examined risk/maintenance factors related to these symptoms among firefighters. Doing so may be important to developing interventions tailored to trauma-exposed firefighters. The current study examined symptoms of posttraumatic stress, depression, panic disorder, and social anxiety among trauma-exposed firefighters. PROCEDURE Using structural equation modeling, the main and interactive effects of anxiety sensitivity and emotion dysregulation were examined in relation to these symptom outcomes. Participants included 787 male urban firefighters reporting at least one past traumatic event. RESULTS There was a statistically significant main effect of anxiety sensitivity on each outcome. Emotion dysregulation exerted a statistically significant main effect on posttraumatic stress, depression, and social anxiety symptoms. Interactive effects of anxiety sensitivity and emotion dysregulation did not reach statistical significance but examination of effect sizes suggests that interactive effects may be present for posttraumatic stress symptoms (R2 = 0.011), depression (R2 = 0.008), and panic (R2 = 0.016) such that emotion dysregulation is more strongly related to outcomes when anxiety sensitivity levels are relatively lower. All effects were evident after controlling for trauma severity and history of armed forces service. CONCLUSION Overall, results suggest that anxiety sensitivity and emotion dysregulation represent unique risk/maintenance factors related to a broad range of emotional symptoms among trauma-exposed firefighters. These findings replicate patterns found among the general population and extend the findings to potentially vulnerable firefighters.

Posttraumatic Stress and Suicidality Among Firefighters: The Moderating Role of Distress Tolerance

Firefighters report high rates of suicidality and posttraumatic stress disorder (PTSD). This investigation explored the moderating role of distress tolerance (DT) in the association between PTSD symptomatology and suicidality in firefighters. Covariates included trauma load, depressive symptom severity, gender, race, age, and education. The sample was comprised of 765 (94.0% male; Mage = 38.8, SD = 8.6) trauma-exposed firefighters who completed a questionnaire battery. Structural equation modeling was employed. PTSD symptom severity was significantly, positively associated with global suicide risk, suicidal ideation/attempt, frequency of suicidal ideation, lifetime threat of suicide, and perceived likelihood of future suicide attempts. Lower levels of DT were significantly associated with higher frequency of past-year suicidal ideation. Significant interactive effects were noted; firefighters with higher levels of PTSD symptom severity and low levels of DT had the highest levels of global suicide risk and perceived likelihood of future suicide attempt. Clinical and research implications are discussed.

Understanding mental health among military veterans in the fire service

Firefighters who have previously served in the military may be at potentially higher risk for worsened mental health outcomes. This investigation examined the mental health of military veterans, as compared to non-veterans, in the fire service. We hypothesized that firefighters who endorsed military veteran status would have higher rates of mental health symptoms, in comparison to firefighters who did not endorse prior service in the military. Age, gender, and race/ethnicity were used as covariates. The sample was comprised of 910 career firefighters, 209 (23.0%) of whom endorsed military veteran status. One-way analyses of covariance were employed. The military veteran subsample reported significantly higher levels of sleep disturbance, depression, and posttraumatic stress symptom severity in comparison to the non-veteran subsample; however, effect sizes were small indicating that between group differences are actually negligible. Results highlight the need to improve our understanding of risk and resilience factors for firefighters who have served in the military, as this line of inquiry has potentially important mental health intervention implications for this exceptionally understudied population.