Enhanced Skills Training in Affective and Interpersonal Regulation versus Treatment as Usual for ICD-11 Complex PTSD: A Pilot Randomised Controlled Trial (The RESTORE Trial).

INTRODUCTION: Complex PTSD (CPTSD) is a relatively new condition in ICD-11. This pilot randomised controlled trial aimed to compare a four-module intervention developed to target all symptoms of ICD-11 CPTSD, namely Enhanced Skills in Affective and Interpersonal Regulation (ESTAIR) with treatment as usual (TAU). The purpose of the study was to assess feasibility, safety, acceptability, and preliminary outcomes at the end of treatment and 3-month follow-up. METHODS: A total of N = 56 eligible veterans with CPTSD were randomised to either ESTAIR (n = 28) or TAU (n = 28). Linear mixed models were conducted to assess CPTSD severity, the primary outcome, as measured by the International Trauma Questionnaire (ITQ). RESULTS: Treatment dropout in ESTAIR and TAU was low and equivalent (18% vs. 11%; χ2 (1) = 1.19, p = 0.275), and study retention was high, supporting the feasibility of the study. No serious adverse effects and very few adverse effects occurred, none of which were deemed related to the study. ESTAIR provided significantly greater reduction in CPTSD severity across time for ITQ PTSD (p < 0.001) and DSO (p < 0.001) symptoms. CPTSD pre-to-post effect sizes for ESTAIR were large (PTSD d = 1.78; DSO d = 2.00). Remission of probable CPTSD diagnosis at post-treatment was substantially greater in ESTAIR compared to TAU with only 13.6% versus 84% (p < 0.001) retaining the diagnosis. CONCLUSION: A trial of ESTAIR versus TAU for the treatment of ICD-11 CPTSD indicates the potential efficacy of ESTAIR as well as its feasibility, safety, and acceptability.

Associations between International Trauma Questionnaire complex posttraumatic stress disorder symptom clusters and moral injury in a sample of U.K. treatment-seeking veterans: A network approach.

OBJECTIVE: Complex posttraumatic stress disorder (CPTSD) and moral injury are receiving increasing empirical attention. The network approach offers a novel method to understand the association between such mental health constructs. METHOD: The present study investigated: (a) the network structure of CPTSD symptom clusters according to the International Trauma Questionnaire to determine centrality (i.e., the most influential symptom cluster) and (b) the network structure of CPTSD symptom clusters and moral injury symptoms according to the Moral Injury Outcome Scale to determine bridge symptoms (i.e., the symptoms linking comorbid presentation of CPTSD and moral injury) within a clinical sample of veterans. RESULTS: Emotional dysregulation, avoidance, and interpersonal difficulties were found to be most central in the CPTSD network, and interpersonal difficulties, negative self-concept, and emotional dysregulation were found to be the strongest bridge symptoms in the CPTSD and moral injury network. CONCLUSIONS: The two networks suggest a key role of disturbance in self-organization symptoms in the presentation of CPTSD and its association with moral injury among treatment-seeking veterans. Despite the limitations of the present study, it offers an insightful starting point as the first network analysis study of CPTSD in treatment-seeking veterans as well as its association with moral injury. Implications in terms of points of intervention and further research are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Using statistical techniques to understand the unique needs of military personnel experiencing mental health difficulties: moving away from assuming patient homogeneity to understanding heterogeneity.

Gold standard treatments for military personnel seeking support for mental health difficulties are often standardised and manualised to ensure high levels of treatment fidelity. While manualised treatments are preferable to less evidence-based idiosyncratic approaches, they may not fully account for the differences in symptom profiles present in patients with the same psychological diagnosis. Indeed, recent findings have highlighted that a significant proportion of individuals do not benefit from the 'gold standard' treatments. This brief report discusses the utility of statistical techniques, specifically latent profile analysis and network analysis, to support the transition to more evidence-based idiosyncratic, personalised care for clinical military, and general, populations. Further incorporation of such analysis methods may support arriving at a framework to support the personalisation of care in terms of the selection and adaption of evidence-based approach treatments based on individual clinical need.

Adversity during military service: the impact of military sexual trauma, emotional bullying and physical assault on the mental health and well-being of women veterans.

INTRODUCTION: Despite making up about 11% of the UK military, there remains limited investigation on the impact of adversity women experience during their service in the UK military. Military adversity can result in a range of well-being difficulties that may persist following transition out of military. The present study therefore examined the prevalence and correlates of different types of military adversity (defined as sexual harassment, sexual assault, emotional bullying and physical assault) within a community sample of UK women veterans. METHODS: Participants were recruited from a UK charity supporting women veterans. 750 women veterans completed an online survey collecting information on sociodemographic and military factors, military adversity, as well as mental health and well-being difficulties. Associations between variables were explored using multivariate logistic regressions. RESULTS: The findings indicate a high prevalence of military adversity (22.5% sexual harassment, 5.1% sexual assault, 22.7% emotional bullying and 3.3% physical assault). Younger women, those who held an officer rank during service and those who reported having a combat or combat support role during service were most at risk of military adversity. All types of adversity were significantly associated with probable post-traumatic stress disorder. Sexual harassment was additionally significantly associated with physical somatisation; sexual assault with alcohol difficulties; and emotional bullying with common mental health difficulties, low social support and loneliness. CONCLUSIONS: This study indicates that UK women veterans are at risk of a range of adverse experiences during military service and provides evidence of the impact of such adversities on mental health and well-being. Further research is required to better understand these relationships.

Predictors of not working among treatment-seeking UK veterans: a cross-sectional study.

INTRODUCTION: Many veterans do well reintegrating to civilian life following military service. Yet, many face difficulties in finding and securing work. Veterans are more likely than civilians to experience work difficulties, but there remains little research investigating contributing factors, particularly among samples of treatment-seeking veterans. As such, the study examines predictors of not working among UK treatment-seeking veterans. DESIGN: The study employed a cross-sectional design. METHODS: Of 667 treatment-seeking UK veterans, 403 (Mage =50.94) provided information on a range of demographic variables, military-related experiences, the total number of physical health conditions and mental health outcomes. Work status was categorised as not working due to illness (Mage =48.15), not working due to other reasons (Mage =61.92) and currently working (Mage = 46.13). RESULTS: Prevalence rates of not working was 69%. Not working was predicted by a greater number of physical health problems as well as more years since leaving the military. Not working due to poor health was independently predicted by symptoms of post-traumatic stress disorder (PTSD) and younger age, while not working due to other reasons was predicted by older age. CONCLUSIONS: The study revealed that treatment-seeking veterans of younger age with a high number of physical health difficulties, symptoms of PTSD and more years since leaving the military are most at risk of not working due to ill health. The findings have important implications for identifying veterans most at risk of not working and offer the opportunity to tailor rehabilitation programmes to promote successful veteran reintegration into civilian life.

The impact of the COVID-19 pandemic on treatment-seeking veterans in the United Kingdom with preexisting mental health difficulties: A longitudinal study.

Individuals with preexisting psychological difficulties are at risk of further deterioration of their mental well-being during the COVID-19 pandemic. This longitudinal study, conducted during the period between two national lockdowns, aimed to investigate the impact of the COVID-19 pandemic on veterans in the United Kingdom with preexisting mental health difficulties. Treatment-seeking veterans with preexisting mental health difficulties (N = 95) were surveyed in two waves. Wave 1 was conducted at the end of the first lockdown (June 2020-July 2020), and Wave 2 took place during the second lockdown (November 2020). Participants completed measures to assess symptoms of posttraumatic stress disorder (PTSD); common mental health difficulties (CMDs), including anxiety and depression; anger; and alcohol use. Initial analyses revealed no significant changes in symptoms of PTSD, CMDs, anger, or alcohol use between the lockdowns, ps = .247-.986. However, veterans who experienced more COVID-19-related stressors were more likely to experience increases in PTSD, odds ratio (OR) = 6.30, p = .002, and CMD symptoms, OR = 4.32, p = .025. Participants with lower levels of social support during the second lockdown were more likely to experience increased anger difficulties, OR = 0.91, p = .025. The findings suggest that although mental health among veterans in the United Kingdom may have remained relatively stable between the two lockdowns, those who reported more COVID-related stressors and lower levels of social support may have been particularly vulnerable to symptom exacerbation. Such findings hold important implications for tailoring support for veterans during the COVID-19 pandemic.

Piloting the feasibility of delivering Cognitive-Behavioral Conjoint Therapy online to military veterans and partners.

Cognitive-Behavior Conjoint Therapy (CBCT) for PTSD has demonstrated efficacy among military couples in which the veteran is experiencing PTSD. Yet, no studies to date have investigated delivering CBCT online. This brief report aims to describe the feasibility of delivering CBCT online to UK military couples. Six military veterans and their partners received CBCT, delivered using an online video platform. They completed mental health measures at the start and end of treatment as well as 12-weeks follow-up. Data trends suggested reduced psychological distress and trauma symptoms as well as increased wellbeing of veterans and partners. On the individual level, most veterans (83.3%) demonstrated clinically significant reductions in PTSD symptoms. Therapist reflections suggested client acceptability of treatment and highlighted considerations for delivering CBCT online. Clinical implications and the need for further empirical investigation of online-delivered CBCT are discussed.

Supporting the Mental Health Needs of Military Partners Through the Together Webinar Program: Pilot Randomized Controlled Trial.

BACKGROUND: Despite an increased risk of psychological difficulties, there remains a lack of evidence-based support for the mental health needs of military partners. OBJECTIVE: This study aims to investigate whether the Together Webinar Programme (TTP-Webinar), a 6-week structured, remote access group intervention would reduce military partners' experience of common mental health difficulties and secondary trauma symptoms. METHODS: A pilot randomized controlled trial was used to compare the TTP-Webinar intervention with a waitlist control. The sample was UK treatment-seeking veterans engaged in a mental health charity. A total of 196 military partners (1 male and 195 females; aged mean 42.28, SD 10.82 years) were randomly allocated to the intervention (n=97) or waitlist (n=99) condition. Outcome measures were self-reported measures of common mental health difficulties, secondary trauma symptoms, and overall quality of life rating. RESULTS: Compared with the waitlist, military partners in the TTP-Webinar had reduced common mental health difficulties (P=.02) and secondary trauma symptoms (P=.001). However, there was no difference in quality-of-life ratings (P=.06). CONCLUSIONS: The results suggest that TTP-Webinar is an effective intervention to support the mental health difficulties of military partners. This study provides promising evidence that webinars may be an appropriate platform for providing group-based support. TRIAL REGISTRATION: ClinicalTrials.gov NCT05013398; https://clinicaltrials.gov/ct2/show/NCT05013398.

Enhancing extinction with response prevention via imagery-based counterconditioning: Results on conditioned avoidance and distress.

BACKGROUND AND OBJECTIVES: Maladaptive avoidance is a core characteristic of anxiety-related disorders. Its reduction is often promoted using extinction with response prevention (ExRP) procedures, but these effects are often short-lived. Research has shown that pairing a feared stimulus with a stimulus of an incompatible valence (i.e., counterconditioning) may be effective in reducing fear. This laboratory study tested whether positive imagery during ExRP (i.e., imagery counterconditioning protocol) can also reduce avoidance. METHODS: In the counterconditioning procedure, participants imagined a positive sound. There were four phases. First, participants were presented with squares on a computer screen of which one (CS+) was paired with an aversive sound and another (CS-) was not. Second, they learned to avoid the negative sound in the presence of the CS+, via a key press. Third, they were assigned to either the Counterconditioning (that was asked to imagine a positive sound during ExRP) or No Counterconditioning group (standard ExRP). Finally, they performed a test phase that consisted of two parts: in the first part, avoidance responses were available for each CS and in the second part, these responses were prevented. RESULTS: The Counterconditioning intervention resulted in a short-lived reduction of distress associated with the CS+. However, groups did not differ in avoidance or distress during the test phases. LIMITATIONS: US-expectancy ratings were collected only at the end of the experiment. CONCLUSIONS: The results indicate that positive imagery during ExRP may be effective in reducing distress during the intervention. Explanations for the persistence of avoidance and fear are discussed.

Understanding the Link Between Traumatic Brain Injury Accompanied by Loss of Consciousness and Well-Being: A Sample of UK Military Veterans.

OBJECTIVE: To investigate the association between reported traumatic brain injury plus loss of consciousness (TBI + LOC) and a range of demographic, military, and physical and mental health factors among a sample of UK veterans seeking support for mental health difficulties. DESIGN: The present study was a cross-sectional study. PARTICIPANTS: Clinical records were used to identify a sample of treatment-seeking UK veterans (N = 3335), of which a total of 403 took part. MAIN MEASURES: Information on demographic characteristics, military experiences, and a range of physical and mental health difficulties was collected. RESULTS: Almost half of the sample (48%) reported a TBI + LOC, which was most strongly associated with drug use and childhood adversity. More modest associations also emerged with earlier service termination, likelihood of unemployment, as well as chronic pain and poor mobility. CONCLUSION: The findings suggested that TBI + LOC may not specifically be associated with symptoms of posttraumatic stress in a sample of treatment-seeking veterans. The demonstrated links between TBI + LOC and adverse childhood, drug use, physical health, and employment may be useful in improving the assessment and rehabilitation of veterans with TBI + LOC.

Exploring the Acceptability of The Together Webinar Programme for Military Partners: A Qualitative Study.

Background: Military partners appear at risk for developing psychological difficulties such as depression, generalized anxiety, and secondary trauma symptoms. Yet, evidence suggests that participants report an array of barriers that prevent them from seeking and engaging with mental health support. This includes stigma-related beliefs, work and childcare responsibilities, and distance to venue where support is offered. Introduction: The Together Webinar Programme (TTP-Webinar) was developed to increase the accessibility of mental health support for military partners. The efficacy of this program has been explored in a previous study. Materials and Methods: Data for this study were taken from 68 partners who provided qualitative feedback of the program. Thematic qualitative analysis was used to explore the views of participants about the acceptability of TTP-Webinar. Results: Four main themes were identified, namely perceived benefit, modality, general barriers, and areas for improvement. Discussion: Participants found it favorable to develop a better understanding of veterans' difficulties, to have their own difficulties normalized through sharing and discussion, and to feel part of a wider community. They also found the webinar format favorable as it increased the accessibility of support and provided them with an interactive safe platform. Conclusions: The study provides promising qualitative evidence for the use of TTP-Webinar in supporting the mental health needs of military partners.