Ketamine-enhanced prolonged exposure therapy in veterans with PTSD: A randomized controlled trial protocol.

BACKGROUND: The 2023 VA/DoD Clinical Practice Guideline for the Management of PTSD recommends individual, manualized trauma-focused such as Prolonged Exposure (PE) over pharmacologic interventions for the primary treatment of PTSD. Unfortunately, clinical trials of trauma-based therapies in the military and veteran population showed that 30% to 50% of patients did not demonstrate clinically meaningful symptom change. Ketamine, an FDA-approved anesthetic with potent non-competitive glutamatergic N-methyl-d-aspartate antagonistic properties, has demonstrated to enhance the recall of extinction learning and decrease fear renewal without interference of extinction training in preclinical studies. METHODS: We plan to conduct a single site RCT comparing three ketamine treatment vs. active placebo (midazolam) adjunct to PE therapy among Veterans with PTSD. Pharmacological phase will start simultaneously with PE session 1. Infusions will be administered 24 h. prior to PE session for the first 3 weeks. After PE is completed (session 10), patients will be assessed during a 3-month follow-up period at various time points. We estimate that out of 100 veterans, 80 will reach time point for primary outcome measure and will be considered for primary analysis. Secondary outcomes include severity of depression and anxiety scores, safety and tolerability of ketamine-enhanced PE therapy, cognitive performance during treatment and early improvement during PE related to the rate of dropouts during PE therapy. DISCUSSION: Results of the proposed RCT could provide scientific foundation to distinguish the essential components of this approach, enhance the methodology, elucidate the mechanisms involved, and identify sub-PTSD populations that most likely benefit from this intervention.

MMPI-2-RF characteristics of veterans seeking treatment for military sexual trauma.

Military sexual trauma (MST) is defined as experiences of sexual assault or repeated, threatening, harassment during military service. MST events may not qualify within posttraumatic stress disorder (PTSD) Criterion A, making symptoms associated with MST unique from trauma-related disorders. Little research has been done to understand those presenting for MST treatment. Thus, this article provides Minnesota Multiphasic Personality Inventory 2-Restructured Form (MMPI-2-RF) scores of 33 U.S. veterans who experienced MST in an effort to better understand psychological and personality characteristics of this important and unique group of veterans. Our sample comprised mainly African American, female, U.S. Army veterans seeking treatment of MST at a Department of Veterans Affairs specialty clinic. A majority of participants reported an attempted or actual rape during their service, averaging 1.87 (SD = 1.33) MST events. The most common diagnoses assigned by diagnosticians at intake were PTSD, mood disorders, and personality disorders. With regard to MMPI-2-RF results, the sample generated elevated scores on somatic, mood, anxiety, and interpersonal dysfunction scales. Implications of these findings and areas of future research are discussed. (PsycINFO Database Record

Posttraumatic stress disorder and suicidal ideation, plans, and impulses: The mediating role of anxiety sensitivity cognitive concerns among veterans.

BACKGROUND: Although the relationship between posttraumatic stress disorder (PTSD) and suicide has been firmly established, research on underlying mechanisms has been disproportionately low. The cognitive concerns subscale of anxiety sensitivity (AS), which reflects fears of cognitive dyscontrol, has been linked to both PTSD and suicide and thus may serve as an explanatory mechanism between these constructs. METHODS: The sample consisted of 60 male veterans presenting to an outpatient Veteran Affairs (VA) clinic for psychological services. Upon intake, veterans completed a diagnostic interview and brief battery of self-report questionnaires to assist with differential diagnosis and treatment planning. RESULTS: Results revealed a significant association between PTSD symptom severity and higher suicidality (i.e., ideation, plans, and impulses), even after accounting for relevant demographic and psychological constructs. Moreover, AS cognitive concerns mediated this association. LIMITATIONS: Limitations include the small sample size and cross-sectional nature of the current study. CONCLUSIONS: These findings add considerably to a growing body of literature examining underlying mechanisms that may help to explain the robust associations between PTSD and suicide. Considering the malleable nature of AS cognitive concerns, research is needed to determine the extent to which reductions in this cognitive risk factor are associated with reductions in suicide among at risk samples, such as those included in the present investigation.

Spiritual struggles and suicide in veterans seeking PTSD treatment.

OBJECTIVE: Research indicates that trauma can precipitate a loss of faith and struggles in the spiritual domain, leading to increased suicide risk. However, little is known about the specific types of spiritual struggles that may confer risk. This brief report examines the utility of a newly developed measure, the Religious and Spiritual Struggles Scale in gauging suicide risk in veterans. METHOD: As part of their initial assessment, 52 veterans presenting to an outpatient posttraumatic stress disorder and substance use clinic were administered self-report symptom measures. RESULTS: Multiple regression analyses revealed that divine struggles and struggles with the ultimate meaning were significantly and positively associated with increased suicide risk, even after controlling for relevant demographic (e.g., being male and Caucasian) and psychological variables (e.g., posttraumatic stress disorder symptoms as well as alcohol and substance use symptoms). CONCLUSIONS: Results provide preliminary support for use of the Religious and Spiritual Struggles Scale with veterans and highlight the potential utility in assessing for spiritual struggles when assessing suicide risk. (PsycINFO Database Record

Associations between lower order anxiety sensitivity dimensions and DSM-5 posttraumatic stress disorder symptoms.

Anxiety sensitivity (AS), a well-established individual difference variable reflecting a tendency to fear bodily sensations associated with arousal, has been implicated in the development and maintenance of posttraumatic stress disorder (PTSD). Despite these associations, little research has examined the relations between AS subfactors (eg physical, cognitive, and social) and PTSD symptoms and none have examined these associations in the context of DSM-5 (Diagnostic Statistical Manual of Mental Disorders, Fifth Edition) PTSD clusters (ie intrusion, avoidance, negative alterations in cognitions/mood, and arousal). Participants included 50 veterans presenting to an outpatient Veteran Affairs Clinic for psychological services. Upon intake, veterans completed a brief battery of self-report questionnaires to assist with differential diagnosis and treatment planning. Results revealed unique associations between lower order AS dimensions, in particular the cognitive concerns dimension, and all four DSM-5 PTSD symptom clusters. Given the malleable nature of AS cognitive concerns, as well as the growing number of veterans in need of care, future research should determine the extent to which targeting this cognitive risk factor reduces PTSD symptom severity among veterans.

Implementing an Assessment Clinic in a Residential PTSD Program.

Creating useful treatment plans can help improve services to consumers of mental health services. As more evidence-based practices are implemented, deciding what treatment, at what time, for whom becomes an important factor in facilitating positive outcomes. Readiness for trauma-focused treatments for Posttraumatic Stress Disorder (PTSD) such as Cognitive Processing Therapy or Prolonged Exposure Therapy may influence whether an individual can successfully complete either protocol. In addition, components of adjunctive therapies such as Acceptance and Commitment Therapy or Dialectical Behavior Therapy may be useful in moving a particular patient toward readiness and successful completion of treatment. Psychological assessment adds valuable data to inform these types of treatment decisions. This paper describes the implementation of a psychological assessment clinic in a residential PTSD treatment setting. Barriers to implementation, use of the data, and Veterans' reactions to the feedback provided to them are included.