Juliette M. Mott

A meta-analytic review of exposure in group cognitive behavioral therapy for posttraumatic stress disorder.

Although the efficacy of exposure is well established in individual cognitive behavioral treatments for posttraumatic stress disorder (PTSD), some clinicians and researchers have expressed concerns regarding the use of in-session disclosure of trauma details through imaginal exposure in group cognitive behavioral therapy (GCBT) for PTSD. Thus, the aim of the present study was to conduct a systematic review of the empirical support for GCBT in the treatment of PTSD and to compare GCBT protocols that encourage the disclosure of trauma details via in-session exposure to GCBT protocols that do not include in-session exposure. Randomized controlled trials that assessed the efficacy of GCBT for PTSD were included in the meta-analysis. A total of 651 participants with PTSD were included in the 12 eligible GCBT treatment conditions (5 conditions included in-group exposure, 7 conditions did not include in-group exposure). The overall pre-post effect size of GCBT for PTSD (ES=1.13 [SE=0.22, 95% CI: 0.69 to 1.56, p<.001]). suggests that GCBT is an effective intervention for individuals with PTSD. No significant differences in effect sizes were found between GCBT treatments that included in-group exposure and those that did not. Although the attrition rate was higher in treatments that included exposure in-group, this rate is comparable to attrition rates in individual CBT treatments and pharmacotherapy for PTSD. The results from this meta-analysis suggest that concerns about the potentially negative impact of group exposure may be unwarranted, and support the use of exposure-based GCBT as a promising treatment option for PTSD.

Changes in Psychotherapy Utilization Among Veterans With Depression, Anxiety, and PTSD

OBJECTIVE Large-scale health care systems such as the Veterans Health Administration (VHA) have recently invested heavily in the expansion of psychotherapy services. This study examined longitudinal changes in use of psychotherapy at the VHA during a period of substantial programmatic change targeting increased availability and quality of mental health care. METHODS This retrospective cohort study used data from the VHA National Patient Care Database outpatient treatment files to identify patients with a new-onset diagnosis of depression, anxiety, or posttraumatic stress disorder during fiscal years (FYs) 2004 (N=424,428), 2007 (N=494,318), and 2010 (N=583,733). Use of psychotherapy during the 12 months after diagnosis was assessed. RESULTS The proportion of patients receiving any psychotherapy increased across the three study time points (FY 2004, 21%; FY 2007, 22%; and FY 2010, 27%). Amount of psychotherapy also increased such that with time a growing proportion of patients received eight or more psychotherapy sessions. The median time between diagnosis and start of psychotherapy decreased from 56 to 47 days from FY 2004 to FY 2010. Consistent with VHA expansion efforts, more substantial increases in psychotherapy reach, amount, and timeliness occurred between FY 2007 and 2010 than between FY 2004 and FY 2007. CONCLUSIONS These findings highlight recent increases in the use of VHA psychotherapy and correspond to substantial efforts to improve access to mental health services. Despite these advances, most newly diagnosed patients received no psychotherapy or a low-intensity amount of psychotherapy. Additional efforts to promote veteran engagement in needed mental health services appear warranted.

Characteristics of U.S. Veterans Who Begin and Complete Prolonged Exposure and Cognitive Processing Therapy for PTSD

This retrospective chart-review study examined patient-level correlates of initiation and completion of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) among treatment-seeking U.S. veterans. We identified all patients (N = 796) in a large Veterans Affairs PTSD and anxiety clinic who attended at least 1 individual psychotherapy appointment with 1 of 8 providers trained in EBP. Within this group, 91 patients (11.4%) began EBP (either Cognitive Processing Therapy or Prolonged Exposure) and 59 patients (7.9%) completed EBP. The medical records of all EBP patients (n = 91) and a provider-matched sample of patients who received another form of individual psychotherapy (n = 66) were reviewed by 4 independent raters. Logistic regression analyses revealed that Iraq and Afghanistan veterans were less likely to begin EBP than veterans from other service eras, OR = 0.48, 95% CI = [0.24, 0.94], and veterans who were service connected for PTSD were more likely than veterans without service connection to begin EBP, OR = 2.33, 95% CI = [1.09, 5.03]. Among those who began EBP, Iraq and Afghanistan veteran status, OR = 0.09, 95% CI = [0.03, 0.30], and a history of psychiatric inpatient hospitalization, OR = 0.13, 95% CI = [0.03, 0.54], were associated with decreased likelihood of EBP completion.

Attributional style and anxiety sensitivity as maintenance factors of posttraumatic stress symptoms: A prospective examination of a diathesis-stress model.

Diathesis-stress models of posttraumatic stress disorder (PTSD) assert that traumatic events function as stressors that interact with vulnerabilities to influence the development of PTSD. The present study prospectively examined negative attributional style (NAS) and anxiety sensitivity (AS) as maintenance factors for PTSD in female adult sexual assault victims. A diathesis-stress model was tested by examining interactions between the vulnerabilities and negative life events. The present study included both the traditional three-factor model of PTSD (re-experiencing, avoidance and emotional numbing, and arousal) and the dysphoria four-factor model of PTSD (re-experiencing, avoidance, arousal, and dysphoria). Robust regression analyses revealed that negative life events at Time 2 significantly predicted increases in all clusters of the three-factor model (i.e., re-experiencing, avoidance and numbing, and arousal) and the re-experiencing, arousal, and dysphoria clusters of the four-factor model (but not avoidance). Neither NAS nor AS significantly independently predicted any of the symptom clusters for either model. Both NAS and AS interacted with negative life events to predict increases in the avoidance and numbing symptoms. However, examination of the dysphoria four-factor model of PTSD revealed that the NAS and AS interactions with negative life events only predicted dysphoria symptoms.

Brief cognitive behavioral therapy in primary care: a hybrid type 2 patient-randomized effectiveness-implementation design

BackgroundDespite the availability of evidence-based psychotherapies for depression and anxiety, they are underused in non-mental health specialty settings such as primary care. Hybrid effectiveness-implementation designs have the potential to evaluate clinical and implementation outcomes of evidence-based psychotherapies to improve their translation into routine clinical care practices.MethodsThis protocol article discusses the study methodology and implementation strategies employed in an ongoing, hybrid, type 2 randomized controlled trial with two primary aims: (1) to determine whether a brief, manualized cognitive behavioral therapy administered by Veterans Affairs Primary Care Mental Health Integration program clinicians is effective in treating depression and anxiety in a sample of medically ill (chronic cardiopulmonary diseases) primary care patients and (2) to examine the acceptability, feasibility, and preliminary outcomes of a focused implementation strategy on improving adoption and fidelity of brief cognitive behavioral therapy at two Primary Care-Mental Health Integration clinics. The study uses a hybrid type 2 effectiveness/implementation design to simultaneously test clinical effectiveness and to collect pilot data on a multifaceted implementation strategy that includes an online training program, audit and feedback of session content, and internal and external facilitation. Additionally, the study engages the participation of an advisory council consisting of stakeholders from Primary Care-Mental Health Integration, as well as regional and national mental health leaders within the Veterans Administration. It targets recruitment of 320 participants randomized to brief cognitive behavioral therapy (n = 200) or usual care (n = 120). Both effectiveness and implementation outcomes are being assessed using mixed methods, including quantitative evaluation (e.g., intent-to-treat analyses across multiple time points) and qualitative methods (e.g., focus interviews and surveys from patients and providers). Patient-effectiveness outcomes include measures of depression, anxiety, and physical health functioning using blinded independent evaluators. Implementation outcomes include patient engagement and adherence and clinician brief cognitive behavioral therapy adoption and fidelity.ConclusionsHybrid designs are needed to advance clinical effectiveness and implementation knowledge to improve healthcare practices. The current article describes the rationale and challenges associated with the use of a hybrid design for the study of brief cognitive behavioral therapy in primary care. Although trade-offs exist between scientific control and external validity, hybrid designs are part of an emerging approach that has the potential to rapidly advance both science and practice.Trial registrationNCT01149772 athttp://www.clinicaltrials.gov/ct2/show/NCT01149772

Increasing Engagement in Evidence-Based PTSD Treatment Through Shared Decision-Making: A Pilot Study

Within the Veterans Health Administration, post-traumatic stress disorder (PTSD) treatment decisions are left to the patient and provider, allowing substantial variability in the way treatment decisions are made. Theorized to increase treatment engagement, shared decision-making interventions provide a standardized framework for treatment decisions. This study sought to develop (phase 1) and pilot test the feasibility and potential effectiveness (phase 2) of a brief shared decision-making intervention to promote engagement in evidence-based PTSD treatment. An initial version of the intervention was developed and then modified according to stakeholder feedback. Participants in the pilot trial were 27 Iraq and Afghanistan Veterans recruited during an intake assessment at a Veterans Affairs PTSD clinic. Participants randomized to the intervention condition (n = 13) participated in a 30-minute shared decision-making session, whereas patients randomized to the usual care condition (n = 14) completed treatment planning during their intake appointment, per usual clinic procedures. Among the 20 study completers, a greater proportion of participants in the intervention condition preferred an evidence-based treatment and received an adequate (≥9 sessions) dose of psychotherapy. Results provide preliminary support for the feasibility and potential effectiveness of the intervention and suggest that larger-scale trials are warranted.

Gender Differences in the Clinical Presentation of PTSD and Its Concomitants in Survivors of Interpersonal Assault

This study compares a sample of PTSD-positive, female survivors of interpersonal assault (n = 162) to a sample of similarly traumatized male counterparts (n = 45) on a number of variables, including PTSD-symptom severity, depressive symptoms, anger, guilt, and health-related concerns. Results indicate that male and female interpersonal assault survivors presented similarly with respect to PTSD and depressive symptomatology and reported comparable levels of guilt and that women reported significantly more health-related complaints than men did. With respect to the experience of anger, men report significant elevations on the state anger subscale of the State-Trait Anger Expression Inventory compared to women.

Diagnostic specificity and mental health service utilization among veterans with newly diagnosed anxiety disorders

OBJECTIVE This study examined rates of specific anxiety diagnoses (posttraumatic stress disorder, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, social anxiety disorder, and specific phobia) and anxiety disorder not otherwise specified (anxiety NOS) in a national sample of Veterans and assessed their mental health service utilization. METHOD This study used administrative data extracted from Veteran Health Administration outpatient records to identify patients with a new anxiety diagnosis in fiscal year 2010 (N = 292,244). Logistic regression analyses examined associations among diagnostic specificity, diagnostic location, and mental health service utilization. RESULTS Anxiety NOS was diagnosed in 38% of the sample. Patients in specialty mental health were less likely to receive an anxiety NOS diagnosis than patients in primary care (odds ratio [OR] = 0.36). Patients with a specific anxiety diagnosis were more likely to receive mental health services than those with anxiety NOS (OR = 1.65), as were patients diagnosed in specialty mental health compared with those diagnosed in primary care (OR = 16.29). CONCLUSION Veterans diagnosed with anxiety NOS are less likely to access mental health services than those with a specific anxiety diagnosis, suggesting the need for enhanced diagnostic and referral practices, particularly in primary care settings.

Predisposing, enabling, and need factors as predictors of low and high psychotherapy utilization in veterans.

This study used national administrative data from the Veterans Health Administration (VHA) to examine predisposing, enabling, and need factors related to multiple levels of psychotherapy utilization in a sample of veterans with posttraumatic stress disorder (PTSD), depression, or anxiety. The database was queried for all veterans who were newly diagnosed with PTSD, depression, or anxiety during the 2010 fiscal year and received at least 1 outpatient psychotherapy session in the year following diagnosis (N = 130,331). Veterans were classified as low (51.0%; 1-3 sessions), moderate (38.3%; 4-18 sessions), high (8.7%; 19-51 sessions), or very high (1.9%; 52 or more sessions) psychotherapy users based on the total number of psychotherapy visits during the 1-year follow-up period. Multinomial logistic regression was used to examine predictors of utilization level. Predisposing factors of gender and marital status were modestly associated with utilization. Several need factors were strongly associated with utilization; very high users had higher rates of PTSD and substance use disorders, more comorbid psychiatric diagnoses, and more inpatient psychiatric visits. Very high users were also more likely to demonstrate enabling factors, including living closer to a VHA facility and seeking care at more complex facilities. Overall, need factors appeared to be most strongly linked to psychotherapy utilization. These results suggest many patients may not receive a clinically optimal dose of psychotherapy, highlighting the need to enhance retention in therapy for low utilizers and examine whether very high utilizers are benefitting from extensive courses of treatment.

Treating PTSD and Disordered Eating in the Wake of Military Sexual Trauma A Case Study

Despite high rates of comorbidity between posttraumatic stress disorder (PTSD) and disordered eating, there is little in the way of empirical research or practice guidelines to inform the treatment of these frequently co-occurring disorders. Clinicians who provide treatment for this patient population must navigate complicated decisions about whether these problems are best treated concurrently or sequentially, and which treatment approaches and modalities are most appropriate for the patient. The current clinical case describes the treatment of a female soldier who was admitted to a 25-day, trauma-focused inpatient program 3 months after she experienced military sexual trauma. Although treatment initially targeted her PTSD symptoms, she later disclosed her ongoing struggles with disordered eating, which raised complex questions about the most effective treatment approach. This case study illustrates the intricate link between PTSD and disordered eating, and highlights important clinical considerations relevant to the assessment and treatment of these commonly comorbid disorders.