Josef I. Ruzek

Feasibility, acceptability, and potential efficacy of the PTSD Coach app: A pilot randomized controlled trial with community trauma survivors.

OBJECTIVEnPosttraumatic stress disorder (PTSD) is a major public health concern. Although effective treatments exist, affected individuals face many barriers to receiving traditional care. Smartphones are carried by nearly 2 thirds of the U.S. population, offering a promising new option to overcome many of these barriers by delivering self-help interventions through applications (apps). As there is limited research on apps for trauma survivors with PTSD symptoms, we conducted a pilot feasibility, acceptability, and potential efficacy trial of PTSD Coach, a self-management smartphone app for PTSD.nnnMETHODnA community sample of trauma survivors with PTSD symptoms (N = 49) were randomized to 1 month using PTSD Coach or a waitlist condition. Self-report assessments were completed at baseline, postcondition, and 1-month follow-up. Following the postcondition assessment, waitlist participants were crossed-over to receive PTSD Coach.nnnRESULTSnParticipants reported using the app several times per week, throughout the day across multiple contexts, and endorsed few barriers to use. Participants also reported that PTSD Coach components were moderately helpful and that they had learned tools and skills from the app to manage their symptoms. Between conditions effect size estimates were modest (d = -0.25 to -0.33) for PTSD symptom improvement, but not statistically significant.nnnCONCLUSIONSnFindings suggest that PTSD Coach is a feasible and acceptable intervention. Findings regarding efficacy are less clear as the study suffered from low statistical power; however, effect size estimates, patterns of within group findings, and secondary analyses suggest that further development and research on PTSD Coach is warranted. (PsycINFO Database Record

Evaluation of an Implementation Model: A National Investigation of VA Residential Programs

AbstractnThis national investigation utilizes qualitative data to evaluate an implementation model regarding factors influencing provider use of two evidence-based treatments for posttraumatic stress disorder (PTSD). Semi-structured qualitative interviews with 198 mental health providers from 38 Department of Veterans Affairs’ (VA) residential treatment programs were used to explore these issues regarding prolonged exposure (PE) and cognitive processing therapy (CPT) in VA residential PTSD programs. Several unique and some overlapping predictors emerged. Leadership was viewed as an influence on implementation for both CPT and PE, while a lack of dedicated time and resources was viewed as a deterrent for both. Compatibility of CPT with providers’ existing practices and beliefs, the ability to observe noticeable patient improvement, a perceived relative advantage of CPT over alternative treatments, and the presence of a supportive peer network emerged as influential on CPT implementation. Leadership was associated with PE implementation. Implications for the design and improvement of training and implementation efforts are discussed.n

Predictors of Emotional Adjustment following Traumatic Injury: Personal, Social, and Material Resources

INTRODUCTIONnThe identification of factors influencing emotional adjustment after injury may elucidate the design of assessment and treatment procedures in emergency medicine settings and suggest targets for early intervention to prevent the later development of psychological impairment. Personal, social, and material resources may be influential factors and require further evaluation.nnnHYPOTHESESnGreater experiential avoidance, social constraints on discussing the trauma experience, and loss of material resources would be associated with more of the symptoms of post-traumatic stress and depression following traumatic injury.nnnMETHODSnParticipants (n = 47) at a mean of 7.4 months post-injury, completed a telephone interview assessment, including evaluation of sociodemographic characteristics, conservation of resources, social constraints, acceptance and commitment, and symptoms of post-traumatic stress disorder (PTSD) and depression. Hypotheses were tested using multivariate regression analyses.nnnRESULTSnOnly greater social constraints were uniquely predictive of greater PTSD symptomatology. Higher levels of experiential avoidance, social constraints, and loss of material resources all were associated with greater levels of depression.nnnCONCLUSIONnAssessment of personal coping style, receptivity of social network, and loss of potential material resources following traumatic injury may facilitate identification of individuals at-risk for poorer post-injury adaptation. Psychosocial interventions targeting such individuals may be promising.

Presentation and prevalence of PTSD in a bipolar disorder population: a STEP-BD examination.

BACKGROUNDnCo-occurring psychiatric diagnoses have a negative impact on quality of life and change the presentation and prognosis of bipolar disorder (BD). To date, comorbidity research on patients with BD has primarily focused on co-occurring anxiety disorders and trauma history; only recently has there been a specific focus on co-occurring PTSD and BD. Although rates of trauma and PTSD are higher in those with bipolar disorder than in the general population, little is known about differences across bipolar subtypes.nnnMETHODSnUsing the NIMH STEP-BD dataset (N=3158), this study evaluated whether there were baseline differences in the prevalence of PTSD between participants with bipolar disorder I (BDI) and bipolar disorder II (BDII), using the MINI and the Davidson Trauma Scale. Differences in PTSD symptom clusters between patients with BDI and BDII were also evaluated.nnnRESULTSnA significantly greater proportion of participants with BDI had co-occurring PTSD at time of study entry (Χ(2)(1)=12.6; p<.001). BDI and BDII subgroups did not significantly differ in re-experiencing, avoidance, or arousal symptoms.nnnLIMITATIONSnThe analysis may suggest a correlational relationship between PTSD and BD, not a causal one. Further, it is possible this population seeks treatment more often than individuals with PTSD alone. Finally, due to the episodic nature of BD and symptom overlap between the two disorders, misdiagnosis is possible.nnnCONCLUSIONSnPTSD may be more prevalent in patients with BDI. However, the symptom presentation of PTSD appears similar across BD subtypes. Individuals should be thoroughly assessed for co-occurring diagnoses in an effort to provide appropriate treatment.

Academic/State/Federal Collaborations and the Improvement of Practices in Disaster Mental Health Services and Evaluation

Academic, state, and federal agencies collaborated over the last 9xa0years to improve disaster mental health services and evaluation. This process, which included literature reviews, a number of expert panels, and case studies, is described. The products resulting from this process have included the development of a systematic cross-site evaluation of the federally funded crisis counseling program and field guides for interventions aimed at providing services to distressed individuals in the immediate aftermath of disasters and to individuals needing resilience skills training weeks or months after the event. Future improvement of disaster mental health services calls for continued research, evaluation, training, and intervention development.

Maintenance and Reach of Exposure Psychotherapy for Posttraumatic Stress Disorder 18 Months After Training

This study examined aspects of clinicians work environment that facilitated sustained use of prolonged exposure (PE) therapy. Surveys were completed by 566 U.S. Department of Veterans Affairs clinicians 6 and 18 months after intensive training in PE. The number of patients treated with PE at 18 months (reach) was modeled as a function of clinician demographics, clinician beliefs about PE, and work context factors. There were 342 clinicians (60.4%) who used PE at 6 and 18 months after training, 58 (10.2%) who used PE at 18 but not 6 months, 95 (16.7%) who used PE at 6 but not 18 months, and 71 (12.5%) who never adopted PE. Median reach was 12% of clinicians appointments with patients with posttraumatic stress disorder. Reach was predicted by flow of interested patients (incident response ratio [IRR] = 1.21 to 1.51), PEs perceived effectiveness (IRR = 1.04 to 1.31), working in a PTSD specialty clinic (IRR = 1.06 to 1.26), seeing more patients weekly (IRR = 1.04 to 1.25), and seeing fewer patients in groups (IRR = 0.83 to 0.99). Most clinicians trained in PE sustained use of the treatment, but on a limited basis. Strategies to increase reach of PE should address organizational barriers and patient engagement.

Mobile mental health interventions following war and disaster

Mobile technologies offer potentially critical ways of delivering mental health support to those experiencing war, ethnic conflict, and human-caused and natural disasters. Research on Internet interventions suggests that effective mobile mental health technologies can be developed, and there are early indications that they will be acceptable to war and disaster survivors, and prove capable of greatly increasing the reach of mental health services. Promising mhealth interventions include video teleconferencing, text messaging, and smartphone-based applications. In addition, a variety of social media platforms has been used during and immediately after disasters to increase agility in responding, and strengthen community and individual resilience. Globally, PTSD Coach has been downloaded over 243,000 times in 96 countries, and together with large-scale use of social media for communication during disasters, suggests the potential for reach of app technology. In addition to enabling improved self-management of post-trauma problems, mobile phone interventions can also enhance delivery of face-to-face care by mental health providers and increase the effectiveness of peer helpers and mutual aid organizations. More research is needed to establish the efficacy of mhealth interventions for those affected by war and disaster. Research should also focus on the identification of active elements and core processes of change, determination of effective ways of increasing adoption and engagement, and explore ways of combining the various capabilities of mobile technologies to maximize their impact.

Testing a comprehensive model of implementation and sustained use for EBTs for PTSD: A national investigation in VA residential settings

The national roll-outs of evidence-based psychotherapies in the Department of Veterans Affairs (VA) afford an unusual opportunity to study both implementation and sustainability. Although unique in some aspects of management and resources, the VA also serves as an excellent laboratory to understand the implementation of best practices as it is a more organized and controlled environment, free of the barriers faced in other more fragmented segments of the U.S. health care system. In a two-year NIMH grant, we utilized a theory-based model to collect baseline data regarding the adoption of two evidence-based treatments for Posttraumatic Stress Disorder (PTSD), Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), in a national sample of 38 VA PTSD residential treatment programs with over 200 providers. In a subsequently funded NIMH R01, we are extending our investigation with the same population and model to see: (1) how well PE and CPT are sustained over time, (2) what organizational and individual factors influence sustainability, and (3) what effects implementation and sustained use of PE and CPT have on patient outcomes. Implications for implementation in and outside of the VA health care system will be discussed. n nUpdates on measurement of a model of implementation for health care: advances toward a testable theory n nOne comprehensive theoretical model for understanding implementation of innovations was initially developed by Rogers (1962) and elaborated on by others (Greenhalgh et al. 2005). This model construed implementation as a complex process influenced by five broad constructs: (a) perceived characteristics of innovation, (b) potential adopter characteristics, (c) communication and influence, (d) system antecedents and readiness, and (e) outer context. Although a considerable evidence-base was used to develop the model, the authors did not fully operationalize their model, making it difficult to test formally. Our group undertook a systematic review of the literature and, using an iterative process, we examined existing measures and utilized or adapted items. Where no one measure was deemed appropriate, we developed other items to measure the constructs through consensus. The review and iterative process of team consensus identified three types of data that could be used to operationalize the constructs in the model: survey items, interview questions and administrative data. Over three waves of data collection concerning the implementation of two evidence-based psychotherapies disseminated nationally within Department of Veterans Affairs, we have made changes to the quantitative measurement of aspects of this model including the exclusion of the measurement of some constructs (e.g., learning style, locus of control, tolerance of ambiguity) as well as refinement of others (e.g., needs, motivation, knowledge-seeking). This presentation will review these changes as well as psychometric properties of other constructs and their items. n nTesting the model using quantitative data for implementation of two evidence-based psychotherapies for PTSD in VA residential treatment programs: outcomes for two yearly time points n nThis study examined the implementation of two evidence-based psychotherapies, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), in the Department of Veterans Affairs (VA) residential Posttraumatic Stress Disorder treatment programs. The current analyses focused on continued implementation a year after an initial assessment of implementation and of provider and site variables thought to be related to implementation. Seventy-five providers from 38 programs provided complete quantitative data on both baseline and follow-up. At one year follow-up, there was continued effect of supportive organizational context (i.e., dedicated time and resources and incentives and mandates) on the implementation of both PE and CPT delivered in a group format. n nUnlike at baseline, effects of perceived characteristics of treatment on implementation of PE and of supportive organizational context on CPT delivered individually were no longer significant. Rather, social connections predicted a lower likelihood of implementation of CPT individually. These effects all remained, even after taking into account baseline levels of implementation. n nImplementation of two evidence-based psychotherapies for PTSD in VA residential treatment programs: patient-level outcomes n nThis presentation will discuss the effects of implementation of two EBTs for PTSD (PE and CPT) in the U.S. Department of Veterans Affairs (VA) residential treatment programs on patients PTSD symptom severity, alcohol and drug use, and treatment satisfaction. The instruments were administered to patients upon admission and four months post-discharge. The short form of the Mississippi Scale for Combat-Related PTSD was used to measure PTSD and alcohol and drug abuse were measured using the composite indexes from the Addiction Severity Index. Controlling for length of stay and baseline symptoms, implementation of PE and CPT predicted improvement in PTSD symptom severity and alcohol use. The implications of these findings are that two EBTs for PTSD can be feasibly and effectively disseminated to routine clinical settings and implementation produces favorable patient outcomes.

The Influence of Team Functioning and Workload on Sustainability of Trauma-Focused Evidence-Based Psychotherapies

OBJECTIVEnIt has been over a decade since the U.S. Department of Veterans Affairs (VA) began formal dissemination and implementation of two trauma-focused evidence-based psychotherapies (TF-EBPs). The objective of this study was to examine the sustainability of the TF-EBPs and determine whether team functioning and workload were associated with TF-EBP sustainability.nnnMETHODSnThis observational study used VA administrative data for 6,251 patients with posttraumatic stress disorder (PTSD) and surveys from 78 providers from 10 purposefully selected PTSD clinical teams located in nine VA medical centers. The outcome was sustainability of TF-EBPs, which was based on British National Health System Sustainability Index scores (possible scores range from 0 to 100.90). Primary predictors included team functioning, workload, and TB-EBP reach to patients with PTSD. Multiple linear regression models were used to examine the influence of team functioning and workload on TF-EBP sustainability after adjustment for covariates that were significantly associated with sustainability.nnnRESULTSnSustainability Index scores ranged from 53.15 to 100.90 across the 10 teams. Regression models showed that after adjustment for patient and facility characteristics, team functioning was positively associated (B=9.16, p<.001) and workload was negatively associated (B=-.28, p<.05) with TF-EBP sustainability.nnnCONCLUSIONSnThere was considerable variation across teams in TF-EBP sustainability. The contribution of team functioning and workload to the sustainability of evidence-based mental health care warrants further study.

Telemental Health Approaches for Trauma Survivors

The past couple of decades have witnessed a veritable explosion of technology development and services with nearly ubiquitous uptake of innovative electronic products. In fact, today about 40 % of the earth’s population has access to the Internet, and there are almost as many mobile phone subscriptions as there are people on the planet (International Telecommunications Union [ITU] 2014). Virtually overnight, we have become reliant on these technologies for many of our everyday activities, such as finding information, shopping, banking, and staying connected to friends and family. Modes of communication have multiplied to include options such as no-cost web-based video calling, instant messaging at home or on the go, and asynchronous microblogging tools for connected self-reflection. The latest generation of mobile phones, called smartphones, offers capabilities and functions that only a few short years ago were unimaginable or only available on stationary computers. As these technologies continue to transform our everyday lives, their potential to address the tremendous unmet mental healthcare needs of trauma survivors is also beginning to be realized through innovative telemental health (TMH) approaches.