The Medical Costs of Determining Eligibility and Waiting for a Kidney Transplantation.

BACKGROUND: Recent efforts to increase access to kidney transplant (KTx) in the United States include increasing referrals to transplant programs, leading to more pretransplant services. Transplant programs reconcile the costs of these services through the Organ Acquisition Cost Center (OACC). OBJECTIVE: The aim of this study was to determine the costs associated with pretransplant services by applying microeconomic methods to OACC costs reported by transplant hospitals. RESEARCH DESIGN, SUBJECTS, AND MEASURES: For all US adult kidney transplant hospitals from 2013 through 2018 (n=193), we crosslinked the total OACC costs (at the hospital-fiscal year level) to proxy measures of volumes of pretransplant services. We used a multiple-output cost function, regressing total OACC costs against proxy measures for volumes of pretransplant services and adjusting for patient characteristics, to calculate the marginal cost of each pretransplant service. RESULTS: Over 1015 adult hospital-years, median OACC costs attributable to the pretransplant services were $5 million. Marginal costs for the pretransplant services were: initial transplant evaluation, $9k per waitlist addition; waitlist management, $2k per patient-year on the waitlist; deceased donor offer management, $1k per offer; living donor evaluation, procurement and follow-up: $26k per living donor. Longer time on dialysis among patients added to the waitlist was associated with higher OACC costs at the transplant hospital. CONCLUSIONS: To achieve the policy goals of more access to KTx, sufficient funding is needed to support the increase in volume of pretransplant services. Future studies should assess the relative value of each service and explore ways to enhance efficiency.

Treating a common comorbidity: Pain outcomes following a 3-week cognitive processing therapy-based intensive treatment for posttraumatic stress disorder address.

Posttraumatic stress disorder (PTSD) commonly co-occurs with pain and has been implicated in the maintenance of chronic pain. However, limited research has examined whether intervening for PTSD can hinder or optimize treatment outcomes for co-occurring pain and PTSD. In the present study, we examined changes in pain, PTSD, and depressive symptoms among 125 veterans completing a 3-week cognitive processing therapy (CPT)-based intensive treatment program (ITP) for PTSD. We also explored whether pretreatment pain interference predicted changes in PTSD and depressive symptom severity and whether larger changes in pain interference over the course of treatment were associated with larger changes in PTSD and depressive symptom severity. Linear mixed models revealed that participants' pain interference decreased throughout treatment, d = 0.15, p = .039. Higher levels of pretreatment pain interference were associated with higher PTSD, p = .001, and depressive symptom severity, p = .014, over time. Larger reductions in pain interference corresponded to more improvement in PTSD symptoms, ß = -.03; p < .001, but not depressive symptoms. These findings indicate that ITPs for PTSD can reduce pain interferences, albeit to a small degree, and that reductions in pain interference can contribute to reductions in PTSD symptom severity. Future studies should examine which treatment components contribute to larger changes in symptom severity for veterans with co-occurring pain and PTSD.

Posttraumatic cognition change trajectories in veterans with PTSD who completed an intensive Cognitive Processing Therapy treatment program.

Negative posttraumatic cognitions (NPCs) have been linked to symptoms of PTSD and are an important target of cognitive behavioral treatments for PTSD, including Cognitive Processing Therapy (CPT). Yet to be explored are the different change trajectories of NPCs during CPT. Knowledge of such change trajectories could elucidate common NPC change processes within CPT and their relationship to PTSD symptom severity. We examined NPC change trajectories in a group of 443 veterans who completed a 2-week intensive CPT program. We identified four NPC trajectory groups termed start high end high, start high end moderate, start moderate end low, and start low end low. Most of the groups showed an increase in NPCs at the midpoint of treatment before ultimately decreasing. As predicted, baseline PTSD symptom severity predicted change trajectory group membership. Also, NPC change trajectories were associated with PTSD severity at the end of treatment such that individuals in smaller NPC change groups had higher PTSD symptoms at the end of treatment, and vice versa. Clinicians can use this knowledge to make predictions of a particular client's NPC change trajectory and set expectations for what progress in treatment may look like, including normalizing increases in NPCs from the start of treatment.

A latent profile analysis of moral emotions following moral transgressions.

OBJECTIVE: Moral transgressions (MTs), events that violate one's moral code, are associated with the moral emotions of guilt and shame. However, there may be different patterns by which people experience guilt and shame that affect distress following MTs. METHOD: Undergraduates (N = 1371) exposed to an MT completed self-report assessments. This study used latent profile analysis (LPA) to examine profiles based on guilt cognitions, internalized shame, and distress in relation to a reported MT. Cognitive flexibility, years since the MT, and deliberate and intrusive rumination were examined as variables to determine how these factors predicted profile membership. RESULTS: Results from the LPA revealed a three-profile solution: a low moral distress profile (n = 1002), a moderate moral distress profile (n = 262), and a shame prominent profile (n = 107). Results indicated that higher levels of deliberate and intrusive rumination and lower levels of cognitive flexibility significantly increased the likelihood of belonging to the moderate moral distress or shame prominent profiles compared to the low moral distress profile. Higher levels of intrusive rumination and lower levels of cognitive flexibility also significantly increased the likelihood of belonging to the shame prominent profile over the moderate distress profile. CONCLUSION: Three different profiles emerged, with the shame prominent profile being driven primarily by internalized shame. Results suggest that intrusive rumination and cognitive inflexibility are risk factors to experiencing adverse responses to MTs.

Demonstration of Hong-Ou-Mandel interference in an LNOI directional coupler.

Interference between single photons is key for many quantum optics experiments and applications in quantum technologies, such as quantum communication or computation. It is advantageous to operate the systems at telecommunication wavelengths and to integrate the setups for these applications in order to improve stability, compactness and scalability. A new promising material platform for integrated quantum optics is lithium niobate on insulator (LNOI). Here, we realise Hong-Ou-Mandel (HOM) interference between telecom photons from an engineered parametric down-conversion source in an LNOI directional coupler. The coupler has been designed and fabricated in house and provides close to perfect balanced beam splitting. We obtain a raw HOM visibility of (93.5 ± 0.7) %, limited mainly by the source performance and in good agreement with off-chip measurements. This lays the foundation for more sophisticated quantum experiments in LNOI.

Moving toward precision PTSD treatment: predicting veterans' intensive PTSD treatment response using continuously updating machine learning models.

BACKGROUND: Considerable heterogeneity exists in treatment response to first-line posttraumatic stress disorder (PTSD) treatments, such as Cognitive Processing Therapy (CPT). Relatively little is known about the timing of when during a course of care the treatment response becomes apparent. Novel machine learning methods, especially continuously updating prediction models, have the potential to address these gaps in our understanding of response and optimize PTSD treatment. METHODS: Using data from a 3-week (n = 362) CPT-based intensive PTSD treatment program (ITP), we explored three methods for generating continuously updating prediction models to predict endpoint PTSD severity. These included Mixed Effects Bayesian Additive Regression Trees (MixedBART), Mixed Effects Random Forest (MERF) machine learning models, and Linear Mixed Effects models (LMM). Models used baseline and self-reported PTSD symptom severity data collected every other day during treatment. We then validated our findings by examining model performances in a separate, equally established, 2-week CPT-based ITP (n = 108). RESULTS: Results across approaches were very similar and indicated modest prediction accuracy at baseline (R2 ~ 0.18), with increasing accuracy of predictions of final PTSD severity across program timepoints (e.g. mid-program R2 ~ 0.62). Similar findings were obtained when the models were applied to the 2-week ITP. Neither the MERF nor the MixedBART machine learning approach outperformed LMM prediction, though benefits of each may differ based on the application. CONCLUSIONS: Utilizing continuously updating models in PTSD treatments may be beneficial for clinicians in determining whether an individual is responding, and when this determination can be made.

The role of time since trauma on treatment outcomes of veterans in two intensive posttraumatic stress disorder treatment programs.

Research on the impact of time since trauma (TST) on posttraumatic stress disorder (PTSD) treatment outcomes lacks consensus and has not been examined in cognitive processing therapy (CPT)-based intensive PTSD treatment programs (ITPs). Furthermore, little is known about how TST impacts other trauma-related outcomes, such as depressive symptoms and negative posttrauma cognitions. We examined whether TST predicted severity and changes in PTSD and depressive symptoms and negative posttrauma cognitions, controlling for trauma type (combat or military sexual trauma), age, sex, and race, in two separate samples of veterans with PTSD who completed 2-week (n = 132) or 3-week (n = 407) CPT-based ITPs. In the 3-week sample, PTSD symptom reduction differed based on TST; however, these differences lacked clinical significance, TST x Time R2 b = .002, and were not replicated in the 2-week sample, R2 b < .001. TST did not significantly predict depressive symptoms, R2 b = .005, or negative posttrauma cognition severity or changes, R2 b = .002, in the 3-week sample. In the 2-week sample, linear mixed-effects models indicated that TST also did not significantly predict PTSD or depressive symptoms, R2 b s < .001, or negative posttrauma cognition severity or changes, R2 b s = .002. These findings suggest that TST is not a clinically relevant predictor of PTSD symptoms, depressive symptoms, or negative posttrauma cognitions among individuals engaged in CPT-based ITPs. Future research should investigate the association between TST and trauma-related outcomes in more trauma type- and age-diverse samples within different intensive treatment settings.

Abnormal intestinal milieu in posttraumatic stress disorder is not impacted by treatment that improves symptoms.

Posttraumatic stress disorder (PTSD) is a psychiatric disorder, resulting from exposure to traumatic events. Current recommended first-line interventions for the treatment of PTSD include evidence-based psychotherapies, such as cognitive processing therapy (CPT). Psychotherapies are effective for reducing PTSD symptoms, but approximately two-thirds of veterans continue to meet diagnostic criteria for PTSD after treatment, suggesting there is an incomplete understanding of what factors sustain PTSD. The intestine can influence the brain and this study evaluated intestinal readouts in subjects with PTSD. Serum samples from controls without PTSD (n = 40) from the Duke INTRuST Program were compared with serum samples from veterans with PTSD (n = 40) recruited from the Road Home Program at Rush University Medical Center. Assessments included microbial metabolites, intestinal barrier, and intestinal epithelial cell function. In addition, intestinal readouts were assessed in subjects with PTSD before and after a 3-wk CPT-based intensive treatment program (ITP) to understand if treatment impacts the intestine. Compared with controls, veterans with PTSD had a proinflammatory intestinal environment including lower levels of microbiota-derived metabolites, such as acetic, lactic, and succinic acid, intestinal barrier dysfunction [lipopolysaccharide (LPS) and LPS-binding protein], an increase in HMGB1, and a concurrent increase in the number of intestinal epithelial cell-derived extracellular vesicles. The ITP improved PTSD symptoms but no changes in intestinal outcomes were noted. This study confirms the intestine is abnormal in subjects with PTSD and suggests that effective treatment of PTSD does not alter intestinal readouts. Targeting beneficial changes in the intestine may be an approach to enhance existing PTSD treatments.NEW & NOTEWORTHY This study confirms an abnormal intestinal environment is present in subjects with PTSD. This study adds to what is already known by examining the intestinal barrier and evaluating the relationship between intestinal readouts and PTSD symptoms and is the first to report the impact of PTSD treatment (which improves symptoms) on intestinal readouts. This study suggests that targeting the intestine as an adjunct approach could improve the treatment of PTSD.

Projecting the Economic Impact of Compensating Living Kidney Donors in the United States: Cost-Benefit Analysis Demonstrates Substantial Patient and Societal Gains.

OBJECTIVES: The aim of this study was to show how the US government could save approximately 47 000 patients with chronic kidney failure each year from suffering on dialysis and premature death by compensating living kidney donors enough to completely end the kidney shortage. METHODS: Supply and demand analysis was used to estimate the number of donated kidneys needed to end the kidney shortage and the level of compensation required to encourage this number of donations. These results were then input into a detailed cost-benefit analysis to estimate the economic value of kidney transplantation to (1) the average kidney recipient and their caregiver, (2) taxpayers, and (3) society in general. RESULTS: We estimate half of patients diagnosed with kidney failure each year-approximately 62 000 patients-could be saved from suffering on dialysis and premature death if they could receive an average of 1½ kidney transplants. However, currently there are only enough donated kidneys to save approximately 15 000 patients. To encourage sufficient donations to save the other 47 000 patients, the government would have to compensate living kidney donors approximately $77 000 (±50%) per donor. The value of transplantation to an average kidney recipient (and caregiver) would be approximately $1.5 million, and the savings from the recipient not needing expensive dialysis treatments would be approximately $1.2 million. CONCLUSIONS: This analysis reveals the huge benefit that compensating living kidney donors would provide to patients with kidney failure and their caregivers and, conversely, the huge cost that is being imposed on these patients and their families by the current legal prohibition against such compensation.

Evaluating changes in negative posttrauma cognition as a mechanism of PTSD severity changes in two separate intensive treatment programs for veterans.

BACKGROUND: A wealth of evidence has illustrated that reductions in negative posttrauma cognitions (NPCs) predict improvement in posttraumatic stress disorder (PTSD) symptoms during treatment. Yet, the specific temporal arrangement of changes in these constructs is less well understood. This study examined the temporal association between NPC changes and PTSD symptom changes in two distinct intensive PTSD treatment samples. METHODS: Data from 502 veterans who completed a 3-week CPT-based intensive PTSD treatment program was used to test the extent to which lagged NPC measurement predicted the next occurring PTSD severity measurement using linear mixed effects regression models. PTSD severity was assessed every other day during treatment. NPCs were assessed at three treatment timepoints. A second sample of 229 veterans who completed a 2-week CPT-based intensive PTSD treatment program was used to replicate these findings. RESULTS: Across both intensive PTSD treatment programs, NPCs generally increased from intake the end of the first treatment week, which was followed by gradual decreases in NPCs throughout the rest of both programs. Change in NPCs during both the 3-week (b = .21, p < .001, R2 = .38) and the 2-week programs (b = 0.20, p < .001, R2 = .24) were significant predictors of change in PTSD symptom severity. However, the reverse was true as well, with change in PTSD severity predicting latter change in NPCs during both the 3-week (b = 1.51, p < .001, R2 = .37) and 2-week (b = 1.37, p < .001, R2 = .33) programs, further raising questions about temporality of the association between NPCs and PTSD symptom severity during treatment. CONCLUSIONS: The present study demonstrated that changes in NPCs may not temporally precede changes in PTSD symptom severity in PTSD treatment samples. Instead, we observed earlier PTSD symptom changes and a bidirectional association between the two constructs across both samples. Clinically, the study supports the continued focus on NPCs as an important treatment target as they are an important indicator of successful PTSD treatment, even if they may not be a direct mechanism of treatment-based changes in PTSD severity. Future research should attempt to identify alternative mechanisms of change in CPT.

"You're going to look at me differently": A qualitative study of disclosure experiences among survivors of military sexual assault.

Most survivors of sexual assault who disclose their experience do so within their social network. Prior research on disclosure among individuals who experience sexual trauma has mainly focused on childhood sexual abuse, college-aged women, or disclosure to formal sources of support (e.g., treatment providers). There is limited research on disclosure among veteran survivors of military sexual assault (MSA). The current qualitative study aimed to explore the disclosure experiences of treatment-seeking survivors of MSA. Participants were 17 veterans (n = 13 women, n = 4 men), aged 33-65 years, who reported experiencing MSA. During semistructured interviews, participants were asked about their experiences disclosing MSA to informal support persons (e.g., family members, partners, friends). A narrative thematic analysis identified 11 themes that emerged throughout different aspects of the disclosure, including (a) preparation and reason for disclosure (reactive or spontaneous disclosures, disclosure as an explanation/obligation), (b) expectations about the disclosure experience (no expectations, negative expectations grounded in socialized beliefs, positive expectations based on specific relationships, mismatch between experience and expectation), (c) the actual disclosure experience (negative experiences of personalization, supportive responses, share shame), and (d) military context (disclosing to another member of the military, reporting dynamics). Additional subthemes were nested within these categories. The findings indicated common experiences across participants, particularly regarding disclosure rationale. Key differences were largely influenced by contextual factors (e.g., response of the disclosure recipient). These findings hold implications for clinicians working with survivors of MSA who are preparing for and coping with the consequences of disclosure.

Addressing co-occurring suicidal thoughts and behaviors and posttraumatic stress disorder in evidence-based psychotherapies for adults: A systematic review.

Posttraumatic stress disorder (PTSD) is a well-established risk factor for suicidal thoughts and behaviors. Historically, guidelines for treating PTSD have recommended against the use of trauma-focused therapies for patients who are at high risk for suicide, likely due to concerns about potential suicide-related iatrogenesis, specifically the "triggering" of suicidal behaviors. This systematic review examined evidence of the impact of treatments specifically designed to treat PTSD or suicide on both PTSD- and suicide-related outcomes. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a total of 33 articles met the full inclusion criteria: 23 examining PTSD treatments, four examining suicide-focused treatments, and six examining combined treatments. PTSD and combined treatments reduced both PTSD- and suicide-related outcomes, with most studies focusing on cognitive processing therapy or prolonged exposure. Suicide-focused treatments (e.g., cognitive therapies for suicide prevention) also reduced suicide-related outcomes, but the findings were mixed for their impact on PTSD-related outcomes. Overall, PTSD treatments had the most support, primarily due to a larger number of studies examining their outcomes. This supports current clinical guidelines, which suggest utilizing PTSD treatments for individuals who have PTSD and are at risk for suicide. Suicide-focused and combined treatments also appeared to be promising formats, although additional research is needed. Future research should seek to compare the effectiveness of the approaches to the treatment of PTSD and suicidal thoughts and behaviors concurrently as well as to inform guidelines aimed at supporting decisions about the selection of an appropriate treatment approach.

Treating posttraumatic stress disorder at home in a single week using 1-week virtual massed cognitive processing therapy.

Posttraumatic stress disorder (PTSD) treatments are increasingly delivered in massed formats and have shown comparable results to standard, weekly treatment. To date, massed cognitive processing therapy (CPT), delivered daily, has been delivered primarily in combination with adjunctive services and among veteran populations, but it has not been rigorously evaluated as a standalone intervention. The present study evaluated 1-week massed CPT delivered virtually (i.e., via telehealth) to a community sample of trauma-exposed individuals (N = 24). Using a single-arm open-label design, participants received CPT twice per day for 5 days. The results indicated that most participants completed treatment (n = 23, 95.8%), and no adverse events were reported. Participants exhibited large reductions in clinician-rated, d = 2.01, and self-reported PTSD symptoms, d = 2.55, as well as self-reported depressive symptoms, d = 1.46. On average, participants reported a 5-point PTSD symptom reduction and 1-point reduction in depressive symptoms for each treatment day. Reductions in PTSD and depressive symptoms were maintained at 3-month follow-up. Overall, 1-week massed CPT delivered virtually was shown to be feasible and to result in rapid symptom reductions that were sustained over time. Virtual massed CPT has the potential to increase access to effective treatments and help trauma survivors restore aspects of their lives in short amounts of time.

The organ procurement costs of expanding deceased donor organ acceptance criteria: Evidence from a cost function model.

A potential solution to the deceased donor organ shortage is to expand donor acceptability criteria. The procurement cost implications of using nonstandard donors is unknown. Using 5 years of US organ procurement organization (OPO) data, we built a cost function model to make cost projections: the total cost was the dependent variable; production outputs, including the number of donors and organs procured, were the independent variables. In the model, procuring one kidney or procuring both kidneys from double/en bloc transplantation from a single-organ donor resulted in a marginal cost of $55 k (95% confidence interval [CI] $28 k, $99 k) per kidney, and procuring only the liver from a single-organ donor results in a marginal cost of $41 k (95% CI $12 k, $69 k) per liver. Procuring two kidneys for two candidates from a donor lowered the marginal cost to $36 k (95% CI $22 k, $66 k) per kidney, and procuring two kidneys and a liver lowers the marginal cost to $24 k (95% CI $17 k, $45 k) per organ. Economies of scale were observed, where high OPO volume was correlated with lower costs. Despite higher cost per organ than for standard donors, kidney transplantation from nonstandard donors remained cost-effective based on contemporary US data.

Estimated impact of novel coronavirus-19 and transplant center inactivity on end-stage renal disease-related patient mortality in the United States.

To predict whether the COVID-19 pandemic and transplant center responses could have resulted in preventable deaths, we analyzed registry information of the US end-stage renal disease (ESRD) patient population awaiting kidney transplantation. Data were from the Organ Procurement and Transplantation Network (OPTN), the US Centers for Disease Control and Prevention, and the United States Renal Data System. Based on 2019 OPTN reports, annualized reduction in kidney transplantation of 25%-100% could result in excess deaths of wait-listed (deceased donor) transplant candidates from 84 to 337 and living donor candidate excess deaths from 35 to 141 (total 119-478 potentially preventable deaths of transplant candidates). Changes in transplant activity due to COVID-19 varied with some centers shutting down while others simply heeded known or suspected pandemic risks. Understanding potential excess mortality for ESRD transplant candidates when circumstances compel curtailment of transplant activity may inform policy and procedural aspects of organ transplant systems allowing ways to best inform patients and families as to potential risks in shuttering organ transplant activity. Considering that more than 700 000 Americans have ESRD with 100 000 awaiting a kidney transplant, our highest annual estimate of 478 excess total deaths from postponing kidney transplantation seems modest.

Delivering Intensive PTSD Treatment Virtually: The Development of a 2-Week Intensive Cognitive Processing Therapy-Based Program in Response to COVID-19.

Of the many vulnerable groups affected by the spread of COVID-19, veterans have been especially impacted by the pandemic. Beginning in March 2020, nationwide shelter-in-place orders rapidly led to widespread job loss and economic upheaval; disruption and breakdown of multiple support systems; and increases in family stress, all of which may exacerbate underlying PTSD symptoms. Although telehealth has proven an effective means of delivering evidence-based psychotherapies for PTSD, little is known about the delivery of these treatments in an intensive, daily format over telehealth. There is growing need for intensive treatment options to reduce treatment-interfering barriers such as high dropout rates. In order to address this gap in the literature, this paper details several design considerations as well as patient selection procedures for a 2-week virtual intensive treatment program (vITP) for veterans with posttraumatic stress disorder (PTSD), consisting of daily individual Cognitive Processing Therapy (CPT) and other adjunctive interventions. We also describe two cases of veterans who successfully completed the vITP including their clinical outcomes, therapist reflections on the process, feedback regarding the program, as well as challenges patients encountered with the telehealth platform. Intensive evidence-based psychotherapy for PTSD delivered through a virtual format seems to show promise, but more systemic research is needed.

The cost of procuring deceased donor kidneys: Evidence from OPO cost reports 2013-2017.

Using 5 years of US organ procurement organization (OPO) data, we determined the cost of recovering a viable (ie, transplanted) kidney for each of 51 OPOs. We also examined the effects on OPO costs of the recovery of nonviable (ie, discarded) kidneys and other OPO metrics. Annual cost reports from 51 independent OPOs were used to determine the cost per recovered kidney for each OPO. A quadratic regression model was employed to estimate the relationship between the cost of kidneys and the number of viable kidneys recovered, as well as other OPO performance indicators. The cost of transplanted kidneys at individual OPOs ranged widely from $24 000 to $56 000, and the average was $36 000. The cost of a viable kidney tended to decline with the number of kidneys procured up to 549 kidneys per year and then increase. Of the total 81 401 kidneys recovered, 66 454 were viable and 14 947 (18.4%) were nonviable. The costs of kidneys varied widely over the OPOs studied, and costs were a function of the recovered number of viable and nonviable organs, local cost levels, donation after cardiac death, year, and Standardized Donor Rate Ratio. Cost increases were 3% per year.

Commentary on the Special Issue on Moral Injury: Leveraging Existing Constructs to Test the Heuristic Model of Moral Injury.

The literature on moral injury (MI) is currently undermined by the lack of clear boundaries regarding the construct and a dearth of research on the processes by which potentially morally injurious events lead to MI. The heuristic continuum model of moral stressors proposes ways of distinguishing between moral frustrations, moral distress, and MI. In this commentary, we highlight five testable principles that can be derived from the heuristic model and evaluated using well-established constructs. Specifically, we describe meaningful distinctions between guilt and shame and address how these moral emotions can be used to distinguish between moral distress and MI. We also describe the potential role of event-related rumination, shame proneness, and cognitive flexibility in the development of MI following exposure to potentially morally injurious events. We believe that these principles offer critical next steps for the advancement of the MI field and illustrate how MI research can be generalized beyond the military context.

Examining Insomnia During Intensive Treatment for Veterans with Posttraumatic Stress Disorder: Does it Improve and Does it Predict Treatment Outcomes?

Previous research has demonstrated that sleep disturbances show little improvement with evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, sleep improvements are associated with PTSD treatment outcomes. The goal of the current study was to evaluate changes in self-reported insomnia symptoms and the association between insomnia symptoms and treatment outcome during a 3-week intensive treatment program (ITP) for veterans with PTSD that integrated cognitive processing therapy (CPT), mindfulness, yoga, and other ancillary services. As part of standard clinical procedures, veterans (N = 165) completed self-report assessments of insomnia symptoms at pre- and posttreatment as well as self-report assessments of PTSD and depression symptoms approximately every other day during treatment. Most veterans reported at least moderate difficulties with insomnia at both pretreatment (83.0%-95.1%) and posttreatment (69.1-71.3%). Statistically significant reductions in self-reported insomnia severity occurred from pretreatment to posttreatment; however, the effect size was small, d = 0.33. Longitudinal mixed-effects models showed a significant interactive effect of Changes in Insomnia × Time in predicting PTSD and depression symptoms, indicating that patients with more improvements in insomnia had more positive treatment outcomes. These findings suggest that many veterans continued to struggle with sleep disruption after a 3-week ITP, and successful efforts to improve sleep could lead to better PTSD treatment outcomes. Further research is needed to establish how adjunctive sleep interventions can be used to maximize both sleep and PTSD outcomes.

A Case Report of Cognitive Processing Therapy Delivered over a Single Week.

Although evidence-based treatments for posttraumatic stress disorder (PTSD), such as Cognitive Processing Therapy (CPT), have been developed and widely disseminated, the rate of veterans engaging in and completing these therapies is low. Alternative methods of delivery may be needed to help overcome key barriers to treatment. Delivering evidence-based therapies intensively may address practical barriers to treatment attendance as well as problems with avoidance. This report details the case of a combat veteran who received 10 sessions of Cognitive Processing Therapy delivered twice per day over a single, five-day work week (CPT-5). Post-treatment, the veteran reported large and clinically meaningful decreases in PTSD and depression symptom severity as well as in guilt cognitions, which is a purported mechanism of successful treatment. These effects persisted six weeks after treatment ended. Despite the intensive nature of the treatment, the veteran found CPT-5 tolerable and could cite many benefits to completing therapy in one work week. In conclusion, CPT-5 holds promise as a way to efficiently deliver an evidence-based therapy that is both clinically effective and acceptable to patients, although more rigorous clinical trials are needed to test this treatment delivery format.