Michele Spoont

Modulatory role of serotonin in neural information processing: implications for human psychopathology

Investigation of the role of 5-hydroxytryptophan (5-HT), which functions as a modulator in the central nervous system, across behavioral contexts suggests that a general principle of transmitter function may be derived that is independent of specific behaviors and specific neural loci. A functional principle of 5-HT action in neural information processing in the central nervous system is proposed. Extremes deviations in 5-HT activity result in biases in information processing that may have direct effects on behavior. Such biases may predispose to pathological conditions such as violent suicide and aggression.

General Behavior Inventory Identification of Unipolar and Bipolar Affective Conditions in a Nonclinical University Population

Validated the General Behavior Inventory (GBI), revised to identify unipolar as well as bipolar affective conditions, in a nonclinical sample (n = 201) against naive, interview-derived diagnoses. For bipolar and unipolar conditions, respectively, the GBI had high positive (.94, .87) and negative (.99, .93) predictive power with the effect of prevalence considered, adequate sensitivity (.78, .76), high specificity (.99, .99), and adequate selection ratios for sampling of affective and nonaffective subjects from nonclinical populations for research purposes. The utility of the GBI in several different research contexts is discussed.

A Qualitative Study of Determinants of PTSD Treatment Initiation in Veterans

Although there are effective treatments for Posttraumatic Stress Disorder (PTSD), many PTSD sufferers wait years to decades before seeking professional help, if they seek it at all. An understanding of factors affecting treatment initiation for PTSD can inform strategies to promote help-seeking. We conducted a qualitative study to identify determinants of PTSD treatment initiation among 44 U.S. military veterans from the Vietnam and Afghanistan/Iraq wars; half were and half were not receiving treatment. Participants described barriers to and facilitators of treatment initiation within themselves, the post-trauma socio-cultural environment, the health care and disability systems, and their social networks. Lack of knowledge about PTSD was a barrier that occurred at both the societal and individual levels. Another important barrier theme was the enduring effect of experiencing an invalidating socio-cultural environment following trauma exposure. In some cases, system and social network facilitation led to treatment initiation despite individual-level barriers, such as beliefs and values that conflicted with help-seeking. Our findings expand the dominant model of service utilization by explicit incorporation of factors outside the individual into a conceptual framework of PTSD treatment initiation. Finally, we offer suggestions regarding the direction of future research and the development of interventions to promote timely help-seeking for PTSD.

Validity of PTSD diagnoses in VA administrative data: Comparison of VA administrative PTSD diagnoses to self-reported PTSD Checklist scores

Little research has been done on the validity of posttraumatic stress disorder (PTSD) diagnoses that are found in Department of Veterans Affairs (VA) administrative data, even though they are often used in VA research. We compared PTSD diagnoses found in VA administrative data with PTSD Checklist (PCL) scores self-reported by 4,777 newly diagnosed participants in a national postal survey study. Using PCL scores of at least 50 as the gold standard, we compared positive predictive values (PPVs) for at least one versus at least two PTSD diagnoses (found within 4 months of the first) in VA administrative data overall and by subgroups of interest: age, sex, and clinic where first diagnosed. The overall PPV was 75% for at least one PTSD diagnosis and 82% for at least two PTSD diagnoses. Similarly, the PPV significantly increased for all subgroup analyses when at least two PTSD diagnoses were used. The increase in PPV was greatest for those first diagnosed in primary care and for those older than 65. To select a sample of veterans with more definitive PTSD from administrative data, researchers should select those veterans with at least two PTSD diagnoses as opposed to at least one.

Treatment Initiation and Dropout From Prolonged Exposure and Cognitive Processing Therapy in a VA Outpatient Clinic

Emerging data suggest that few veterans are initiating prolonged exposure (PE) and cognitive processing therapy (CPT) and dropout levels are high among those who do start the therapies. The goal of this study was to use a large sample of veterans seen in routine clinical care to 1) report the percent of eligible and referred veterans who (a) initiated PE/CPT, (b) dropped out of PE/CPT, (c) were early PE/CPT dropouts, 2) examine predictors of PE/CPT initiation, and 3) examine predictors of early and late PE/CPT dropout. We extracted data from the medical records of 427 veterans who were offered PE/CPT following an intake at a Veterans Health Administration (VHA) PTSD Clinical Team. Eighty-two percent (n = 351) of veterans initiated treatment by attending Session 1 of PE/CPT; among those veterans, 38.5% (n = 135) dropped out of treatment. About one quarter of veterans who dropped out were categorized as early dropouts (dropout before Session 3). No significant predictors of initiation were identified. Age was a significant predictor of treatment dropout; younger veterans were more likely to drop out of treatment than older veterans. Therapy type was also a significant predictor of dropout; veterans receiving PE were more likely to drop out late than veterans receiving CPT. Findings demonstrate that dropout from PE/CPT is a serious problem and highlight the need for additional research that can guide the development of interventions to improve PE/CPT engagement and adherence.

Long-term Outcomes of Disability Benefits in US Veterans With Posttraumatic Stress Disorder

CONTEXT Most studies examining the clinical impact of disability benefits have compared aid recipients with people who never applied for benefits. Such practices may bias findings against recipients because disability applicants tend to be much sicker than never-applicants. Furthermore, these studies ignore the outcomes of denied claimants. OBJECTIVE To examine long-term outcomes associated with receiving or not receiving Department of Veterans Affairs (VA) disability benefits for posttraumatic stress disorder (PTSD), the most common mental disorder for which veterans seek such benefits. DESIGN Comparison of outcomes between successful and unsuccessful applicants for VA disability payments. Because we could not randomize the receipt of benefits, we used exact matching by propensity scores to control for potential baseline differences. We examined clinical outcomes approximately 10 years later. SETTING AND PARTICIPANTS Stratified, nationally representative cohort of 3337 veterans who applied for VA PTSD disability benefits between January 1, 1994, and December 31, 1998. MAIN OUTCOME MEASURES Assessment on validated survey measures of PTSD; work, role, social, and physical functioning; employment; and poverty. We compared outcomes with earlier scores. Homelessness and mortality were assessed using administrative data. RESULTS Of still-living cohort members, 85.1% returned usable surveys. Symptoms of PTSD were elevated in both groups. After adjustment, awardees had more severe PTSD symptoms than denied claimants but were nonetheless more likely to have had a meaningful symptom reduction since their last assessment (-6.1 vs -4.4; SE, 0.1; P = .01). Both groups had meaningful improvements of similar magnitude in work, role, and social functioning (-0.15 vs -0.19; SE, 0.01; P = .94), but functioning remained poor nonetheless. Comparing awardees with denied claimants after adjustment, 13.2% vs 19.0% were employed (P = .11); 15.2% vs 44.8% reported poverty (P < .001); 12.0% vs 20.0% had been homeless (P = .02); and 10.4% vs 9.7% had died (P = .66). CONCLUSIONS Regardless of claim outcome, veterans who apply for PTSD disability benefits are highly impaired. However, receiving PTSD benefits was associated with clinically meaningful reductions in PTSD symptoms and less poverty and homelessness.

PTSD and treatment adherence: The role of health beliefs

Health beliefs have been shown to influence a myriad of medical treatment decisions. More recently, the impact of health beliefs on treatment decisions for mental illness has become a focus of study. This study examines the health beliefs and treatment behavior of veterans with posttraumatic stress disorder (PTSD). Using standard survey methodology, we assessed beliefs about the cause of PTSD, expected duration and controllability of symptoms, and life consequences of having PTSD. Treatment participation and medication compliance were assessed, as were common treatment correlates, such as patient-provider relationships, dosing frequency, side effect severity, number of prescribed medications, and use of drugs or alcohol to control PTSD symptoms. Explanatory models of PTSD, perceived controllability, and use of benzodiazepines were found to predict psychiatric medication use. Negative life consequences of PTSD were associated with participation in psychotherapy. Assessment of health beliefs may help providers to understand their patients’ treatment behavior and to facilitate treatment engagement.

Thermoregulatory response to thermal challenge in seasonal affective disorder: A preliminary report

It has recently been proposed that alterations in central dopamine (DA) functional activity may, in part, account for certain behavioral changes observed in seasonal affective disorder (SAD) during the winter. To explore this possibility, a preliminary study of thermoregulatory heat loss to an endogenous heat challenge--a strongly DA-dependent process--was undertaken in groups of four SAD woman and four nonpsychiatric control women across three conditions (winter, after successful phototherapy, and summer). Homeostatic heat loss during recovery from heat challenge in SAD, but not in control, subjects was found to be a significant function of light condition and of clinical state. Thermoregulatory heat loss in SAD subjects was significantly blunted in winter during depression, was similar in efficiency to control subjects after a successful antidepressant response to phototherapy, and tended to be more efficient than controls in summer during a euthymic state. Results raise the possibility that a common effect of phototherapy and summer light conditions is a facilitation of central DA activity in SAD.

Behavioral engagement level, variability, and diurnal rhythm as a function of bright light in bipolar II seasonal affective disorder: an exploratory study.

Six patients with bipolar II seasonal affective disorder (SAD) and seven normal control subjects rated their moods in winter at six fixed times each week-day during 1 week of dim and 2 weeks of bright light. The scales rated represent the mood dimension specifically associated with depression, a dimension here called behavioral engagement (BE). Compared with controls, depressed SAD subjects (1) showed lower BE levels across all rating times of the day, (2) were more likely to show diurnal variation in BE, (3) displayed more between-day instability in BE diurnal rhythm, and (4) exhibited greater short-term lability (change within 3 hours) in BE. Bright light reduced or eliminated all group differences in BE level and variability.

Does This Patient Have Posttraumatic Stress Disorder?: Rational Clinical Examination Systematic Review

IMPORTANCE Posttraumatic stress disorder (PTSD) is a relatively common mental health condition frequently seen, though often unrecognized, in primary care settings. Identifying and treating PTSD can greatly improve patient health and well-being. OBJECTIVE To systematically review the utility of self-report screening instruments for PTSD among primary care and high-risk populations. EVIDENCE REVIEW We searched MEDLINE and the National Center for PTSDs Published International Literature on Traumatic Stress (PILOTS) databases for articles published on screening instruments for PTSD published from January 1981 through March 2015. Study quality was rated using Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. STUDY SELECTION Studies of screening instruments for PTSD evaluated using gold standard structured clinical diagnostic interviews that had interview samples of at least 50 individuals. FINDINGS We identified 2522 citations, retrieved 318 for further review, and retained 23 cohort studies that evaluated 15 screening instruments for PTSD. Of the 23 studies, 15 were conducted in primary care settings in the United States (n = 14,707 were screened, n = 5374 given diagnostic interview, n = 814 had PTSD) and 8 were conducted in community settings following probable trauma exposure (ie, natural disaster, terrorism, and military deployment; n = 5302 were screened, n = 4263 given diagnostic interview, n = 393 were known to have PTSD with an additional 50 inferred by rates reported by authors). Two screens, the Primary Care PTSD Screen (PC-PTSD) and the PTSD Checklist were the best performing instruments. The 4-item PC-PTSD has a positive likelihood ratio of 6.9 (95% CI, 5.5-8.8) and a negative likelihood ratio of 0.30 (95% CI, 0.21-0.44) using the same score indicating a positive screen as used by the Department of Veterans Affairs in all of its primary care clinics. The 17-item PTSD Checklist has a positive likelihood ratio of 5.2 (95% CI, 3.6-7.5) and a negative likelihood ratio of 0.33 (95% CI, 0.29-0.37) using scores of around 40 as indicating a positive screen. Using the same score employed by primary care clinics in the Department of Veterans Affairs to indicate a positive screen, the 4-item PC-PTSD has a sensitivity of 0.69 (95% CI, 0.55-0.81), a specificity of 0.92 (95% CI, 0.86-0.95), a positive likelihood ratio of 8.49 (95% CI, 5.56-12.96) and a negative likelihood ratio of 0.34 (95% CI, 0.22-0.48). For the 17-item PTSD Checklist, scores around 40 as indicating a positive screen, have a sensitivity of 0.70 (95% CI, 0.64-0.77), a specificity of 0.90 (95% CI, 0.84-0.93), a positive likelihood ratio of 6.8 (95% CI, 4.7-9.9) and a negative likelihood ratio of 0.33 (95% CI, 0.27-0.40). CONCLUSIONS AND RELEVANCE Two screening instruments, the PC-PTSD and the PTSD Checklist, show reasonable performance characteristics for use in primary care clinics or in community settings with high-risk populations. Both are easy to administer and interpret and can readily be incorporated into a busy practice setting.