The Development of a Brief Version of the Insomnia Severity Index (ISI-3) in Older Adult Veterans with Posttraumatic Stress Disorder.

Objective/Background: The Insomnia Severity Index (ISI) is an insomnia self-report measure used to identify individuals at risk for insomnia disorder. Although the full ISI is only seven questions, a briefer version would allow more efficient and pragmatic administration in routine practice settings. Reliable and valid brief measures can support measurement-based care. The present study was a proof-of-concept study that developed a brief version of the ISI, the ISI-3, in a sample of older adult veterans with posttraumatic stress disorder (PTSD), a group which is at increased risk for insomnia.Patients/Methods: Participants included 86 older veterans with combat- or military-related PTSD. Veterans completed a clinician-administered PTSD diagnostic interview, self-report measures of insomnia and other psychosocial questionnaires, and two neuropsychological assessments. The factor structure of the ISI was examined to reduce the measure into a brief version. The reliability and validity of the ISI-3 were examined.Results: Principal axis factoring yielded a one-factor solution, which reproduced 59% of the item variance. Item reduction procedures resulted in three items, which best represented this factor ("Insomnia Impact;" ISI-3). For the ISI-3, internal consistency was good (α =.89). Convergent validity was demonstrated via moderate to high positive correlations between the ISI-3 and other measures of sleep disturbance. Divergent validity was demonstrated via non-significant correlations between the ISI-3 and unrelated measures and moderate correlations with self-reported depression.Conclusions: The ISI-3 is a psychometrically valid brief version of the ISI. Clinicians can administer the ISI-3 to screen for insomnia and monitor changes in insomnia during treatment.

Home-based delivery of variable length prolonged exposure therapy: A comparison of clinical efficacy between service modalities.

OBJECTIVE: This study examined clinical and retention outcomes following variable length prolonged exposure (PE) for posttraumatic stress disorder (PTSD) delivered by one of three treatment modalities (i.e., home-based telehealth [HBT], office-based telehealth [OBT], or in-home-in-person [IHIP]). METHOD: A randomized clinical trial design was used to compare variable-length PE delivered through HBT, OBT, or IHIP. Treatment duration (i.e., number of sessions) was determined by either achievement of a criterion score on the PTSD Checklist for Diagnostic and Statistical Manual-5 (DSM-5; PTSD Checklist for DSM-5) for two consecutive sessions or completion of 15 sessions. Participants received PE via HBT (n = 58), OBT (n = 59) or IHIP (n = 58). Data were collected between 2012 and 2018, and PTSD was diagnosed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), administered at baseline, posttreatment, and 6 months following treatment completion. The primary clinical outcome was CAPS-5 PTSD severity. Secondary outcomes included self-reported PTSD and depression symptoms, as well as treatment dropout. RESULTS: The clinical effectiveness of PE did not differ by treatment modality across any time point; however, there was a significant difference in treatment dropout. Veterans in the HBT (odds ratio [OR] = 2.67; 95% confidence interval [CI] = 1.10, 6.52; p = .031) and OBT (OR = 5.08; 95% CI = 2.10; 12.26; p < .001) conditions were significantly more likely than veterans in IHIP to drop out of treatment. CONCLUSIONS: Providers can effectively deliver PE through telehealth and in-home, in-person modalities although the rate of treatment completion was higher in IHIP care.

The Impact of Depression Severity on Treatment Outcomes Among Older Male Combat Veterans with Posttraumatic Stress Disorder.

Posttraumatic stress disorder (PTSD) and depression are highly comorbid within the veteran population. Research studies have yielded divergent findings regarding the effect of depression on PTSD treatment outcomes. The present study investigated the influence of pretreatment depression severity on PTSD and depression symptom trajectories among 85 older (i.e., ≥ 60 years) male veterans with military-related PTSD who received either prolonged exposure or relaxation training as part of a randomized controlled trial. Participants were categorized as having no/mild depression (n = 23) or moderate/severe depression (n = 62). The PTSD Checklist (PCL-S) and Patient Health Questionnaire (PHQ-9) were completed at pretreatment, each of 12 therapy sessions, posttreatment, and 6-month follow-up, for a total of up to 15 data points per participant. Multilevel modeling (MLM) was used to evaluate the impact of pretreatment depression severity on piecewise symptom trajectories (i.e., active treatment and follow-up periods) over time and to determine whether treatment condition moderated the trajectories. The final MLM results showed significant main effects of depression severity on PCL-S scores, B = 10.84, p = .043 and PHQ-9 scores, B = 7.09, p = .001, over time. No significant interactions emerged for either the PCL-S or PHQ-9, indicating that although older veterans with more severe depression endorsed higher PTSD and depression scores across time, the symptom trajectories were not moderated by depression severity, treatment condition, or their interaction.

Older Adults with PTSD: Brief State of Research and Evidence-Based Psychotherapy Case Illustration.

Although lifetime exposure to potentially traumatic events among older adults is fairly high, rates of full-blown post-traumatic stress disorder (PTSD) are estimated at about 4.5%, a rate lower than that for middle-aged and young adults. Nevertheless, PTSD seems to be an under-recognized and under-treated condition in older adults. Assessment and treatment can be challenging in this population for various reasons, including potential cognitive or sensory decline and comorbid mental and physical disorders. This article provides highlights of the empirical research on PTSD in late life, including information on its effects on cognition and physical health. The bulk of this piece is spent on reviewing the theory, description of, and efficacy for an evidence-based psychotherapy, Prolonged Exposure (PE), for PTSD. A detailed successful application of PE with an older veteran with severe, chronic PTSD in the Department of Veterans Affairs Health Care System is presented. Evidence-based psychotherapy for PTSD can be safely and effectively used with older individuals.

Intimate Partner Violence PTSD and Neural Correlates of Inhibition.

Posttraumatic stress disorder (PTSD) has been linked to deficits in response inhibition, and neuroimaging research suggests this may be due to differences in prefrontal cortex recruitment. The current study examined relationships between PTSD from intimate partner violence (IPV) and neural responses during inhibition. There were 10 women with PTSD from IPV and 12 female control subjects without trauma history who completed the stop signal task during functional magnetic resonance imaging. Linear mixed models were used to investigate group differences in activation (stop-nonstop and hard-easy trials). Those with PTSD exhibited greater differential activation to stop-nonstop trials in the right dorsolateral prefrontal cortex and the anterior insula and less differential activation in several default mode regions (d = 1.12-1.22). Subjects with PTSD exhibited less differential activation to hard-easy trials in the lateral frontal and the anterior insula regions (driven by less activation to hard trials) and several default mode regions (i.e., medial prefrontal cortex, posterior cingulate; driven by greater activation to easy trials; d = 1.23-1.76). PTSD was associated with difficulties disengaging default mode regions during cognitive tasks with relatively low cognitive demand, as well as difficulties modulating executive control and salience processing regions with increasing cognitive demand. Together, these results suggest that PTSD may relate to decreased neural flexibility during inhibition.

Is Post-Traumatic Stress Disorder Associated with Premature Senescence? A Review of the Literature.

OBJECTIVE: Post-traumatic stress disorder (PTSD) has major public health significance. Evidence that PTSD may be associated with premature senescence (early or accelerated aging) would have major implications for quality of life and healthcare policy. We conducted a comprehensive review of published empirical studies relevant to early aging in PTSD. METHOD: Our search included the PubMed, PsycINFO, and PILOTS databases for empirical reports published since the year 2000 relevant to early senescence and PTSD, including: 1) biomarkers of senescence (leukocyte telomere length [LTL] and pro-inflammatory markers), 2) prevalence of senescence-associated medical conditions, and 3) mortality rates. RESULTS: All six studies examining LTL indicated reduced LTL in PTSD (pooled Cohen's d = 0.76). We also found consistent evidence of increased pro-inflammatory markers in PTSD (mean Cohen's ds), including C-reactive protein = 0.18, Interleukin-1 beta = 0.44, Interleukin-6 = 0.78, and tumor necrosis factor alpha = 0.81. The majority of reviewed studies also indicated increased medical comorbidity among several targeted conditions known to be associated with normal aging, including cardiovascular disease, type 2 diabetes mellitus, gastrointestinal ulcer disease, and dementia. We also found seven of 10 studies indicated PTSD to be associated with earlier mortality (average hazard ratio: 1.29). CONCLUSION: In short, evidence from multiple lines of investigation suggests that PTSD may be associated with a phenotype of accelerated senescence. Further research is critical to understand the nature of this association. There may be a need to re-conceptualize PTSD beyond the boundaries of mental illness, and instead as a full systemic disorder.

Home-based clinical video teleconferencing care: Clinical considerations and future directions.

Clinical video teleconferencing (CVT) is a treatment delivery modality that can be used to provide services to clinical populations that experience barriers to accessing mental health care. Recently, home-based CVT (HBCVT) has been developed in order to deliver treatment via CVT to patients in their homes. A number of clinical considerations, including the appropriate clinical population and individual patient factors, need to be taken into account when delivering CVT. Particular challenges can exist when setting up the home environment for HBCVT. Concerns about maintaining patient privacy while living in shared spaces, ensuring adequate CVT technology in the patient's home, and conducting risk management remotely are important to consider when delivering treatment via CVT. Since treatments delivered via CVT are often conducted across state lines, novel ethical and legal issues such as privacy laws, licensing of providers, prescribing practices, and insurance reimbursements need to be addressed when conducting services via these modalities. Future research on HBCVT will provide researchers and clinicians with information regarding which patients are most appropriate for treatment delivered via this modality and help further develop evidence for the cost-effectiveness of CVT and HBCVT clinical practice guidelines.

Age differences in treatment response to a collaborative care intervention for anxiety disorders.

BACKGROUND: Some data suggest that older adults with anxiety disorders do not respond as well to treatment as do younger adults. AIMS: We examined age differences in outcomes from the Coordinated Anxiety Learning and Management (CALM) study, an effectiveness trial comparing usual care to a computer-assisted collaborative care intervention for primary care patients with panic disorder, generalised anxiety disorder, post-traumatic stress disorder (PTSD), and/or social anxiety disorder. This is the first study to examine the efficacy of a collaborative care intervention in a sample that included both younger and older adults with anxiety disorders. We hypothesised that older adults would show a poorer response to the intervention than younger adults. METHOD: We examined findings for the overall sample, as well as within each diagnostic category (clinicaltrials.gov identifier: NCT00347269). RESULTS: The CALM intervention was more effective than usual care among younger adults overall and for those with generalised anxiety disorder, panic disorder and social anxiety disorder. Among older adults, the intervention was effective overall and for those with social anxiety disorder and PTSD but not for those with panic disorder or generalised anxiety disorder. The effects of the intervention also appeared to erode by the 18-month follow-up, and there were no significant effects on remission among the older adults. CONCLUSIONS: These results are consistent with the findings of other investigators suggesting that medications and psychotherapy for anxiety disorders may not be as effective for older individuals as they are for younger people.

Psychometrics of the Overall Anxiety Severity and Impairment Scale (OASIS) in a sample of women with and without trauma histories.

Many women have unidentified anxiety or trauma histories that can impact their health and medical treatment-seeking behavior. This study examined the sensitivity, specificity, efficiency, and sensitivity to change of the Overall Anxiety Severity and Impairment Scale (OASIS) for identifying an anxiety disorder in a female sample with and without trauma history related to intimate partner violence (IPV). Forty-three women with full or partial PTSD from IPV and 41 women without PTSD completed the OASIS. All participants with trauma history completed the Clinician Administered PTSD Scale. This report is a secondary analysis of a study on the neurobiology of psychological trauma in survivors of IPV recruited from the community. A cut-score of 5 best discriminated those with PTSD from those without, successfully classifying 91% of the sample with 93% sensitivity and 90% specificity. The measure showed strong sensitivity to change in a subsample of 20 participants who completed PTSD treatment and strong convergent and divergent validity in the full sample. This study suggests that the OASIS can identify the presence of an anxiety disorder among a female sample of IPV survivors when PTSD is present.

Prolonged exposure therapy for older veterans with posttraumatic stress disorder: a pilot study.

OBJECTIVES: : The purpose of this pilot study was to assess the feasibility and preliminary efficacy of prolonged exposure psychotherapy in older Veterans with posttraumatic stress disorder (PTSD). Exposure therapy has broad empirical support for PTSD, but it has not been studied systematically in older adults, partly due to published concerns that older adults would not tolerate the treatment. METHODS: : The trial followed a prospective pre-post design of 11 men recruited from a Veterans Affairs (VA) PTSD Clinical Team program. After baseline assessment, eight participants completed prolonged exposure therapy. Results were compared with a nonrandomized treatment-as-usual comparison group. The traumatic events identified by the Veterans in our samples had occurred, on average, 40 years prior to their study participation. RESULTS: : Results revealed that conducting 6 weeks of exposure therapy with older Veterans with PTSD was feasible and efficacious, with evidence of some superiority to treatment-as-usual therapy. CONCLUSIONS: : As hypothesized, Veterans showed a significant decrease in symptoms of PTSD (clinician-rated and self-reported) following exposure therapy.

Older patients with schizophrenia: does military veteran status matter?

OBJECTIVE: : The objective of this study was to examine the influence of military veteran status within a data set of older patients with schizophrenia or schizoaffective disorder. METHODS: : The data set was examined to determine whether veteran status influenced psychopathology, quality of life, cognitive performance, and everyday functioning among 746 male participants. RESULTS: : There were no significant differences between the groups on measures of premorbid functioning or psychopathology. Veterans in the sample were older, had a higher likelihood of being married (or previously married), had a lower likelihood of living in a board-and-care facility, and had a later age of onset of schizophrenia compared with nonveterans. Though veterans reported worse physical health, they also had better everyday functioning and better performance on some cognitive tasks than nonveterans. Fewer veterans endorsed current use of substances than nonveterans. CONCLUSIONS: : There were several differences based on veteran status, including everyday functioning, health-related quality of life, cognitive performance, and current substance use.

Improving recognition of late life anxiety disorders in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: observations and recommendations of the Advisory Committee to the Lifespan Disorders Work Group.

BACKGROUND: Recognition of the significance of anxiety disorders in older adults is growing. The revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) provides a timely opportunity to consider potential improvements to diagnostic criteria for psychiatric disorders for use with older people. The authors of this paper comprise the Advisory Committee to the DSM5 Lifespan Disorders Work Group, the purpose of which was to generate informative responses from individuals with clinical and research expertise in the field of late-life anxiety disorders. METHODS: This paper reviews the unique features of anxiety in later life and synthesizes the work of the Advisory Committee. RESULTS: Suggestions are offered for refining our understanding of the effects of aging on anxiety and other disorders (e.g., mood disorders) and changes to the DSM5 criteria and text that could facilitate more accurate recognition and diagnosis of anxiety disorders in older adults. Several of the recommendations are not limited to the study of anxiety but rather are applicable across the broader field of geriatric mental health. CONCLUSIONS: DSM5 should provide guidelines for the thorough assessment of avoidance, excessiveness, and comorbid conditions (e.g., depression, medical illness, cognitive impairment) in anxious older adults.

Spiritual wellbeing mediates PTSD change in veterans with military-related PTSD.

BACKGROUND: A portable practice of repeating a mantram-a sacred word or phrase-has been shown to reduce the severity of posttraumatic stress disorder (PTSD) symptoms in veterans with military trauma. It is thought that the intervention re-directs attention and initiates relaxation to decrease symptom severity, but there may be other mechanisms that may contribute to this improvement. PURPOSE: We tested the hypothesis that increases in existential spiritual wellbeing (ESWB) would mediate reductions in self-reported PTSD symptoms following a group mantram intervention. METHOD: Veterans diagnosed with PTSD from war-related trauma completed 6 weeks of case management plus a group mantram intervention (n = 66) as part of a randomized trial. Measures included PTSD Checklist (PCL) and Functional Assessment of Chronic Illness Therapy-Spiritual Wellbeing. Path analysis was conducted on those who completed treatment to assess ESWB as a possible mediator of change in PCL from baseline to post-treatment. RESULTS: A significant indirect effect, -2.24, 95% CI (-4.17, -1.05) of the mantram intervention on PCL change was found. The path from the mantram intervention to ESWB change was significant and positive (B = 4.89, p < 0.0001), and the path from ESWB change to PCL change was significant and negative (B = -0.46, p = 0.001), thus supporting the hypothesis. CONCLUSIONS: Findings suggest that one contributing mechanism that partially explains how the mantram intervention reduces PTSD symptom severity in veterans may be by increasing levels of ESWB.

Do older veterans experience change in posttraumatic cognitions following treatment for posttraumatic stress disorder?

OBJECTIVE: It is unclear whether PTSD treatments improve negative posttraumatic cognitions (NPCs) and if changes in NPCs mediate treatment outcomes in older veterans. The current study examined if prolonged exposure therapy (PE) and relaxation therapy (RT) reduce NPCs over time in older adult veterans with PTSD. METHOD: This study analyzed data from a randomized controlled trial of 86 older male veterans with PTSD randomized to PE or RT. The Posttraumatic Cognitions Inventory (PTCI; Foa et al., 1999), which includes a total score and three subscales, Negative Cognitions of the Self (Self), Negative Cognitions of the World (World), and Self-Blame (Blame), was used to assess NPCs at pretreatment, posttreatment, and 6-month follow-up. RESULTS: Changes in NPCs differed by treatment condition. Veterans who received PE had significantly reduced overall NPCs and NPCs about the self at posttreatment, but these NPCs were no longer significantly different from baseline at the follow-up assessment. In contrast, NPCs about the world and self-blame did not significantly change following PE. NPCs did not change following RT. Effects of PE on decreased 6-month follow-up clinician-rated PTSD symptoms were conveyed through intervening effects of decreased posttreatment PTCI total scores, suggesting the utility of targeting posttraumatic cognitions as a mechanism of long-term PTSD symptom reduction. CONCLUSIONS: Given that reductions in overall negative cognitions are associated with lower clinician-administered PTSD scores 6 months after PE, clinicians could consider monitoring changes in these cognitions over the course of treatment. RT is not a recommended treatment approach to target NPCs in older adults with PTSD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Videoconferencing psychotherapy for veterans with PTSD: Results from a randomized controlled non-inferiority trial.

INTRODUCTION: Veterans with post-traumatic stress disorder (PTSD) face significant barriers that make it less likely for them to pursue treatment. A randomized controlled non-inferiority trial was used to determine if providing psychotherapy for PTSD via videoconference (VC) is as effective as in-person (IP) psychotherapy. METHODS: All eligible veterans (n = 207) received cognitive processing therapy (CPT) to treat PTSD symptoms in one of the two treatment modalities. Participant symptoms were collected at baseline, post-treatment, and six months after treatment completion. The primary outcome measure, the Clinician-Administered PTSD Scale (CAPS), was used to assess PTSD diagnosis and symptom severity. Secondary outcomes included two self-report measures of symptom severity, the Post-traumatic Stress Disorder Checklist - Specific (PCL-S) for PTSD and the Patient Health Questionnaire - 9 (PHQ-9) for depressive symptoms. A linear mixed-effects model was used to assess non-inferiority for participants who completed treatment (completers) and those who were randomized to treatment (intention-to-treat (ITT)). RESULTS: Both completer and ITT analyses showed that improvement in CAPS scores in the VC condition was non-inferior to that in the IP condition at six-month follow-up, but VC was inferior to IP for improvement in CAPS at post-treatment. Non-inferiority was supported by completer analyses for PCL-S and PHQ-9 in both post-treatment change and six-month follow-up change, and the ITT analysis supported the significant non-inferiority for PCL at post-treatment change. DISCUSSION: These findings generally suggest that CPT delivered via VC can be as effective as IP for reducing the severity of PTSD symptoms.

Meta-analysis comparing different behavioral treatments for late-life anxiety.

OBJECTIVE: To evaluate the efficacy of different types of behavioral treatments for geriatric anxiety (cognitive behavior therapy [CBT] alone, CBT with relaxation training [RT], and RT alone). METHOD: The authors compared effect sizes from 19 trials. Analyses were based on uncontrolled outcomes (comparing posttreatment and pretreatment scores) and effects relative to control conditions on both anxiety and depressive symptoms. RESULTS: Treatments for older adults with anxiety symptoms were, on average, more effective than active control conditions. Effect sizes were comparable to those reported elsewhere for CBT for anxiety in the general population or for pharmacotherapy in anxious older adults. CBT (alone or augmented with RT) does not seem to add anything beyond RT alone, although a direct comparison is challenging given differences in control conditions. Effects on depressive symptoms were smaller, with no differences among treatment types. CONCLUSION: Results suggest that behavioral treatments are effective for older adults with anxiety disorders and symptoms. Results must be interpreted with caution given the limitations of the literature, including differing sample characteristics and control conditions across studies.

Modular psychotherapy for anxiety in older primary care patients.

OBJECTIVE: To develop and test a modular psychotherapy protocol in older primary care patients with anxiety disorders. DESIGN: Randomized, controlled pilot study. SETTING: University-based geriatric medicine clinics. PARTICIPANTS: Thirty-one elderly primary care patients with generalized anxiety disorder or anxiety disorder not otherwise specified. INTERVENTION: Modular form of psychotherapy compared with enhanced community treatment. MEASUREMENTS: Self-reported, interviewer-rated, and qualitative assessments of anxiety, worry, depression, and mental health-related quality of life. RESULTS: Both groups showed substantial improvements in anxiety symptoms, worry, depressive symptoms, and mental health-related quality of life. Most individuals in the enhanced community treatment condition reported receiving medications or some other form of professional treatment for anxiety. Across both conditions, individuals who reported major life events or stressors and those who used involvement in activities as a coping strategy made smaller gains than those who did not. CONCLUSIONS: Results suggest that modular psychotherapy and other treatments can be effective for anxiety in older primary care patients. Results further suggest that life events and coping through increased activity may play a role in the maintenance of anxiety in older adults.

Cognitive impairment and functioning in PTSD related to intimate partner violence.

Posttraumatic stress disorder (PTSD) has been associated with neuropsychological impairments across multiple domains, but consensus regarding the cognitive profile of PTSD has not been reached. In this study of women with PTSD related to intimate partner violence (n = 55) and healthy, demographically similar comparison participants (NCs; n = 20), we attempted to control for many potential confounds in PTSD samples. All participants were assessed with a comprehensive neuropsychological battery emphasizing executive functioning, including inhibition, switching, and abstraction. NCs outperformed PTSD participants on most neuropsychological measures, but the differences were significant only on speeded tasks (with and without executive functioning components). The PTSD group's mean performance was within the average range on all neuropsychological tests. Within the PTSD group, more severe PTSD symptoms were associated with slower processing speed, and more severe dissociative symptoms were associated with poorer reasoning performance. These results suggest that women with PTSD related to intimate partner violence demonstrate slower than normal processing speed, which is associated with the severity of psychiatric symptoms. We speculate that the cognitive slowing seen in PTSD may be attributable to reduced attention due to a need to allocate resources to cope with psychological distress or unpleasant internal experiences.

What Do Veterans Want? Understanding Veterans' Preferences for PTSD Treatment Delivery.

INTRODUCTION: Home-based delivery of psychotherapy may offer a viable alternative to traditional office-based treatment for post-traumatic stress disorder (PTSD) by overcoming several barriers to care. Little is known about patient perceptions of home-based mental health treatment modalities. This study assessed veterans' preferences for treatment delivery modalities and how demographic variables and trauma type impact these preferences. MATERIALS AND METHODS: Veterans with PTSD (N = 180) participating in a randomized clinical trial completed a clinician-administered PTSD assessment and were asked to identify their modality preference for receiving prolonged exposure: home-based telehealth (HBT), office-based telehealth (OBT), or in-home-in-person (IHIP). Ultimately, modality assignment was randomized, and veterans were not guaranteed their preferred modality. Descriptive statistics were used to examine first choice preference. Chi-square tests determined whether there were significant differences among first choice preferences; additional tests examined if age, sex, and military sexual trauma (MST) history were associated with preferences. RESULTS: The study includes 135 male veterans and 45 female veterans from all military branches; respondents were 46.30 years old, on average. Veterans were Caucasian (46%), African-American (28%), Asian-American (9%), American Indian or Alaskan Native (3%), Native Hawaiian or Pacific Islander (3%), and 11% identified as another race. Veterans experienced numerous trauma types (e.g., combat, sexual assault), and 29% had experienced MST. Overall, there was no clear preference for one modality: 42% of veterans preferred HBT, 32% preferred IHIP, and 26% preferred OBT. One-sample binomial tests assuming equal proportions were conducted to compare each pair of treatment options. HBT was significantly preferred over OBT (p = 0.01); there were no significant differences between the other pairs. A multinomial regression found that age group significantly predicted veterans' preferences for HBT compared to OBT (odds ratio [OR] = 10.02, 95% confidence interval [CI]: 1.63, 61.76). Older veterans were significantly more likely to request HBT compared to OBT. Veteran characteristics did not differentiate those who preferred IHIP to OBT. Because there were fewer women (n = 45), additional multinomial regressions were conducted on each sex separately. There was no age group effect among the male veterans. However, compared to female Veterans in the younger age group, older female Veterans were significantly more likely to request HBT over OBT (OR = 10.66, 95% CI: 1.68, 67.58, p = 0.012). MST history did not predict treatment preferences in any analysis. CONCLUSIONS: Fewer than 50% of the sample preferred one method, and each modality was preferred by at least a quarter of all participants, suggesting that one treatment modality does not fit all. Both home-based care options were desirable, highlighting the value of offering a range of options. The use of home-based care can expand access to care, particularly for rural veterans. The current study includes a diverse group of veterans and increases our understanding of how they would like to receive PTSD treatment. The study used a forced choice preference measure and did not examine the strength of preference, which limits conclusions. Future studies should examine the impact of modality preferences on treatment outcomes and engagement.

A randomized controlled trial of prolonged exposure therapy versus relaxation training for older veterans with military-related PTSD.

OBJECTIVE: Although prolonged exposure (PE) has strong support for treating posttraumatic stress disorder (PTSD), there is little research on PE for older adults. Likewise, Relaxation Training (RT) has shown some benefit for PTSD, but has not been adequately tested in this population. METHOD: This study represents the first randomized controlled trial of two active psychotherapies for PTSD among older adults. Male combat veterans (N = 87; mean age = 65 years) were randomly assigned to 12 sessions of PE (n = 41) or RT (n = 46). Clinician-administered and self-report assessments were conducted at pre-treatment, post-treatment, and six-month follow-up; self-reported symptoms were also measured at each treatment session. RESULTS: Multi-level modeling indicated that Clinician-Administered PTSD Scale scores significantly decreased from pre-treatment to follow-up, but the time by treatment condition interaction was not significant. Pre- to post-treatment change was large in PE and moderate in RT, but many gains were lost at follow-up. For self-reported PTSD symptoms, a significant time by treatment condition interaction emerged, suggesting that participants who received PE had both greater decreases in symptoms and a greater rebound in self-reported PTSD symptoms than those who received RT. Unlike PTSD symptoms, depression symptoms neither changed nor were moderated by treatment condition from pre-treatment to follow-up. For self-reported PTSD and depression symptoms assessed at each session, time significantly predicted symptom reductions across psychotherapy sessions. CONCLUSIONS: PE and RT are well-tolerated, feasible, and effective for older adults, though treatment gains were not maintained at follow-up. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00539279.