Comparisons Between Young, Middle-Aged, and Older Adult Sexual and Gender Minority Male Sexual Assault Survivors.

OBJECTIVE: This study compared sexual abuse histories and depressive symptoms between younger, middle-aged, and older sexual and gender minority (SGM) male survivors. DESIGN: Participants completed a brief, online screener as part of a large comparative effectiveness psychotherapy trial. SETTING: SGM males 18 years or older, residing in the U.S. or Canada, were recruited online. PARTICIPANTS: This study included younger (aged 18-39; n = 1,435), middle-aged (aged 40-59; n = 546), and older (aged 60+; n = 40) SGM men who reported a history of sexual abuse/assault. MEASUREMENTS: Participants were asked about their sexual abuse history, experience of other traumas, symptoms of depression, and past 60-day mental health treatment engagement. RESULTS: Older SGM men reported a lower rate of occurrence of adult sexual assault, exposure to other traumas, and depression. However, older and younger groups did not differ on any childhood sexual assault variable, the frequency of or number of attackers for adult sexual assault, the frequency of accidents and other injury traumas, or the occurrence or frequency of mental health treatment. Trauma load, including childhood and adult sexual assault, were more strongly related to current depressive symptoms than age group. CONCLUSION: While there were some age-based or cohort differences in the rates of sexual trauma, the clinical response of both groups was similar. Implications for working clinically with middle-aged and older SGM men with untreated sexual assault-related mental health difficulties are discussed, including outreach and availability of gender- and older-inclusive survivor treatment and resources.

Training Male Sexual Abuse Survivors as Peer Leaders to Deliver Motivational Interviewing and Trauma-Informed Affirmative Care.

This paper provides a description and evaluation of training male sexual abuse survivors to deliver Motivational Interviewing (MI) and Motivational Interviewing with Trauma-Informed Affirmative Care (MI-AC) online to sexual and gender minority (SGM) men with sexual assault histories and depression. After a search and selection process, 26 men with lived experience of sexual abuse received MI training that included the use of role-playing, video demonstrations, and practice followed by weekly supervision while co-leading groups. Peer leaders completed several measures pre and post training, including beliefs about MI and self-reported learning of MI and satisfaction with the training. A sample of MI and MI-AC audio sessions were independently rated for adherence and competence. Peer leaders' beliefs about MI changed over time, while self-rated skill level stayed consistent. Peer leaders demonstrated good adherence to the MI and MI-AC conditions. Results suggest that men with lived experience of sexual trauma effectively learned to deliver MI and/or MI-AC to SGM male survivors in online groups. These interventions have the potential to expand the reach of limited services for this population as well as reduce their depression and assist in SGM men with histories of sexual abuse entering into formal mental health services.

Comparisons Between Patients Diagnosed with PTSD in Primary Care Versus Mental Health Care in Five Large Civilian Health Care Systems.

Posttraumatic stress disorder (PTSD) is a serious mental health disorder that may not be adequately detected or treated in primary care (PC). The purpose of this study was to compare the clinical characteristics and health care utilization of PTSD patients diagnosed in PC versus in specialty mental health care (MHC) across five large, civilian, not-for-profit healthcare systems. Electronic claims and medical record data on patients treated during 2014 were analyzed. Treatment was considered in terms of initiation and dose (i.e., psychotherapy sessions; pharmacotherapy-prescription psychotropics). Of 5256 patients aged 15-88 with a diagnosis of PTSD, 84.4% were diagnosed by a MHC provider. Patients diagnosed by MHC providers had 4 times the rate of and more enduring psychotherapy than those diagnosed by PC providers. Receipt of psychotropics varied by provider type, with generally higher prescription fill levels for patients in MHC. Strategies to better align patient needs with access and treatment modality in PC settings are needed.

Implementation Patterns of Two Evidence-Based Psychotherapies in Veterans Affairs Residential Posttraumatic Stress Disorder Programs: A Five-Point Longitudinal National Investigation.

The present study examined the patterns of adoption of two evidence-based psychotherapies (EBPs)-prolonged exposure (PE) and cognitive processing therapy (CPT)-in U.S. Department of Veterans Affairs (VA) residential posttraumatic stress disorder (PTSD) treatment programs. A total of 526 providers from 39 programs nationwide completed online quantitative surveys and qualitative interviews, collected at five assessment points between 2008 and 2015, concerning the use of PE and CPT. By the midpoint of the study period, responders from most programs reported having adopted one or both EBPs as either core components of their programs or "tracks" for certain patients within their programs, adoption rates were 52.8% of programs at Time 3, 61.0% at Time 4, and 66.7% at Time 5. Evaluation of adoption patterns over time suggested that CPT was used in more programs and with more patients within programs compared to PE. At Time 5, respondents from half of the programs reported little or no adoption of PE, whereas the CPT adoption rate was reported to be "little or none" for one-fifth of the programs. The adoption of PE was generally slower compared to CPT adoption. The slower rate of adoption may be related to the resource-intensive nature of implementing PE on an individual basis in a residential setting as compared to the multiple ways CPT can be delivered: individually or in group settings, and with or without the inclusion of the trauma narrative. Strategies to improve sustainability measurement and implications for implementation science are discussed.

Trauma and Aging.

PURPOSE OF REVIEW: The aim of this paper is to present a succinct summary of the major scientific findings on trauma, posttraumatic stress disorder (PTSD), and aging over the past few years. RECENT FINDINGS: There have been several reports from longitudinal investigations using representative samples of veterans regarding traumatic exposure and subsequent effects on health and functioning. There has also been further documentation of the significant association between PTSD and dementia as well as accelerated aging in late life. Several studies indicate that older adults with PTSD are at risk of not receiving timely and appropriate mental health treatment, indicating that targeted outreach could be helpful in increasing service use and improving care. The current knowledge base would benefit from more research on traumatized older adults from non-industrialized countries, as well as those in North America from diverse backgrounds, including ethnic and racial minorities, women, and those with cognitive impairments. Studies limited to adults aged 65 and over as well as those addressing disparities in the availability of mental health-related services within this population are warranted.

The role of evidence-based therapy relationships on treatment outcome for adults with trauma: A systematic review.

OBJECTIVE: The purpose of this paper was to systematically review and synthesize the empirical literature on the effects of evidence-based therapy relationship (EBR) variables in the psychological treatment for adults who experienced trauma-related distress. METHOD: Studies were identified using comprehensive searches of PsycINFO, Medline, Published International Literature on Traumatic Stress, and Cumulative Index to Nursing and Allied Health Literature databases. Included in the review were articles published between 1980 and 2015, in English that reported on the impact of EBRs on treatment outcome in clinical samples of adult trauma survivors. RESULTS: Nineteen unique studies met inclusion criteria. The bulk of the studies were on therapeutic alliance and the vast majority found that alliance was predictive of or associated with a reduction in various symptomotology. Methodological concerns included the use of small sample sizes, little information on EBRs beyond alliance as well as variability in its measurement, and non-randomized assignment to treatment conditions or the lack of a comparison group. CONCLUSIONS: More research is needed on the roles of client feedback, managing countertransference, and other therapist characteristics on treatment outcome with trauma survivors. Understanding the role of EBRs in the treatment of trauma survivors may assist researchers, clinicians, and psychotherapy educators to improve therapist training as well as client engagement and retention in treatment.

Post-traumatic stress disorder in older adults: a systematic review of the psychotherapy treatment literature.

OBJECTIVES: Older adults represent the fastest growing segment of the US and industrialized populations. However, older adults have generally not been included in randomized clinical trials of psychotherapy for post-traumatic stress disorder (PTSD). This review examined reports of psychological treatment for trauma-related problems, primarily PTSD, in studies with samples of at least 50% adults aged 55 and older using standardized measures. METHODS: A systematic review of the literature was conducted on psychotherapy for PTSD with older adults using PubMed, Medline, PsychInfo, CINAHL, PILOTS, and Google Scholar. RESULTS: A total of 42 studies were retrieved for full review; 22 were excluded because they did not provide at least one outcome measure or results were not reported by age in the case of mixed-age samples. Of the 20 studies that met review criteria, there were: 13 case studies or series, three uncontrolled pilot studies, two randomized clinical trials, one non-randomized concurrent control study and one post hoc effectiveness study. Significant methodological limitations in the current older adult PTSD treatment outcome literature were found reducing its internal validity and generalizability, including non-randomized research designs, lack of comparison conditions and small sample sizes. CONCLUSION: Select evidence-based interventions validated in younger and middle-aged populations appear acceptable and efficacious with older adults. There are few treatment studies on subsets of the older adult population including cultural and ethnic minorities, women, the oldest old (over 85), and those who are cognitively impaired. Implications for clinical practice and future research directions are discussed.

Evaluation of an implementation model: a national investigation of VA residential programs.

This national investigation utilizes qualitative data to evaluate an implementation model regarding factors influencing provider use of two evidence-based treatments for posttraumatic stress disorder (PTSD). Semi-structured qualitative interviews with 198 mental health providers from 38 Department of Veterans Affairs' (VA) residential treatment programs were used to explore these issues regarding prolonged exposure (PE) and cognitive processing therapy (CPT) in VA residential PTSD programs. Several unique and some overlapping predictors emerged. Leadership was viewed as an influence on implementation for both CPT and PE, while a lack of dedicated time and resources was viewed as a deterrent for both. Compatibility of CPT with providers' existing practices and beliefs, the ability to observe noticeable patient improvement, a perceived relative advantage of CPT over alternative treatments, and the presence of a supportive peer network emerged as influential on CPT implementation. Leadership was associated with PE implementation. Implications for the design and improvement of training and implementation efforts are discussed.

Changes in implementation of two evidence-based psychotherapies for PTSD in VA residential treatment programs: a national investigation.

There has been little investigation of the natural course of evidence-based treatments (EBTs) over time following the draw-down of initial implementation efforts. Thus, we undertook qualitative interviews with the providers at 38 U.S. Department of Veterans Affairs' residential treatment programs for posttraumatic stress disorder (PTSD) to understand implementation and adaptation of 2 EBTs, prolonged exposure (PE), and cognitive processing therapy (CPT), at 2 time points over a 4-year period. The number of providers trained in the therapies and level of training improved over time. At baseline, of the 179 providers eligible per VA training requirements, 65 (36.4%) had received VA training in PE and 111 (62.0%) in CPT with 17 (9.5%) completing case consultation or becoming national trainers in both PE and CPT. By follow-up, of the increased number of 190 eligible providers, 87 (45.8%) had received VA training in PE and 135 (71.1%) in CPT, with 69 (36.3%) and 81 (42.6%) achieving certification, respectively. Twenty-two programs (57.9%) reported no change in PE use between baseline and follow-up, whereas 16 (42.1%) reported an increase. Twenty-four (63.2%) programs reported no change in their use of CPT between baseline and follow-up, 12 (31.6%) programs experienced an increase, and 2 (5.2%) programs experienced a decrease in use. A significant number of providers indicated that they made modifications to the manuals (e.g., tailoring, lengthening). Reasons for adaptations are discussed. The need to dedicate time and resources toward the implementation of EBTs is noted.

VA Residential Provider Perceptions of Dissuading Factors to the Use of Two Evidence-Based PTSD Treatments.

Providers (N = 198) from 38 Department of Veterans Affairs residential posttraumatic stress disorder treatment programs across the United States completed qualitative interviews regarding implementation of 2 evidence-based treatments: prolonged exposure and cognitive processing therapy. As part of this investigation, providers were asked how they decide which patients are appropriate for these treatments. Many indicated that they did not perceive any patient factors that dissuade their use of either evidence-based treatment. However, 3 broad categories emerged surrounding reasons that patients were perceived to be less suitable candidates for the treatments: the presence of psychiatric comorbidities, cognitive limitations, and low levels of patient motivation. Interestingly, providers' perceived reasons for limited or nonuse of a treatment did not correspond entirely to those espoused by treatment developers. Possible solutions to address provider concerns, including educational and motivational interventions, are noted.

Psychiatric and substance use disorders among adults over age 50 who use cannabis: A matched cohort study using electronic health record data.

INTRODUCTION: Adults over age 50 increasingly use cannabis, but few studies have examined co-occurring psychiatric and substance use disorders (SUDs) in this population. The current study utilized electronic health record (EHR) data to compare adults age 50 + with ICD-10 cannabis codes (cases) and matched controls on common psychiatric and SUDs from 2016 to 2020. METHOD: Patients age 50 + from an integrated healthcare system in Hawai'i were identified using ICD-10 codes for cannabis (use, abuse, and dependence) from 2016 to 2018. In a matched cohort design, we selected non-cannabis-using controls (matched on sex and age) from the EHR (n = 275) and compared them to cases (patients with an ICD-10 cannabis code; n = 275) on depressive and anxiety disorders and SUDs (i.e., tobacco, opioid, and alcohol use disorders) over a two-year follow-up period. RESULTS: Participants were 62.8 years (SD = 7.3) old on average; and were White (47.8 %), Asian American (24.4 %), Native Hawaiian or Pacific Islander (19.3 %), or Unknown (8.5 %) race/ethnicity. Conditional multiple logistic regression was used to estimate odds ratios comparing cases vs controls. Participants with an ICD-10 cannabis code had a significantly greater risk of major depressive disorder (OR = 10.68, p < 0.0001) and any anxiety disorder (OR = 6.45, p < 0.0001), as well as specific anxiety or trauma-related disorders (e.g., generalized anxiety disorder, PTSD) and SUDs (ORs 2.72 - 16.00, p < 0.01 for all). CONCLUSIONS: Over a two-year period, diverse adults age 50 + in Hawai'i with ICD-10 cannabis codes experienced higher rates of subsequent psychiatric and SUDs compared to controls. These findings can guide efforts to inform older adults about possible cannabis-related risks.

Patient perspectives for improving treatment initiation for new episodes of depression in historically minoritized racial and ethnic groups.

OBJECTIVE: Depression is one of the costliest and most prevalent health conditions in the U.S. with 21 million adults having experienced at least one major depressive episode. Despite the availability of evidence-based treatments for depression, a large proportion of people with new diagnoses fail to initiate formal mental health treatment. Although individuals across all racial and ethnic groups fail to initiate treatment for depression, historically minoritized racial/ethnic groups are at even greater risk. METHOD: Thirty-four participants representing historically underserved racial and ethnic populations from two large health care systems in the U.S. participated in qualitative interviews or focus group to identify factors that impede and facilitate depression treatment initiation in primary care settings. RESULTS: Participants identified individual and systemic barriers and facilitators of treatment initiation for depression and suggested several ideas for increasing treatment engagement (i.e., increased communication and education from providers, community events, information on social media). CONCLUSION: Novel interventions are needed to improve treatment initiation following initial diagnosis of depression in primary care settings. Findings from this study offer suggestions for improving treatment initiation in traditionally underserved communities.

Chronic health conditions, acute health events, and healthcare utilization among adults over age 50 in Hawai'i who use cannabis: A matched cohort study.

BACKGROUND: Research on cannabis-related health outcomes in diverse older adults is limited. The current study utilized a matched cohort study design to compare older adults in Hawai'i with identified cannabis diagnoses and matched controls on chronic health conditions, acute health events, and healthcare utilization from 2016 to 2020. METHOD: Patients age 50 + were identified using ICD-10 diagnostic codes for cannabis use, abuse, and dependence using electronic health record data from an integrated health system (Kaiser Permanente Hawai'i). Those with cannabis diagnoses (n = 275) were compared to matched non-using controls (n = 275; based on age, sex) on chronic health conditions (coronary heart disease, hypertension, COPD, chronic non-cancer pain), acute health events (myocardial infarction, respiratory symptoms, stroke, persistent or cyclic vomiting, injuries), and healthcare utilization (outpatient, inpatient, and emergency department visits) following case identification for two years. RESULTS: Participants were 19.3% Native Hawaiian/Pacific Islander, 24.4% Asian, 47.8% White, and 8.5% Other/Unknown, with an average age of 62.8 years (SD=7.3). Adjusting for covariates as possible, participants with a cannabis diagnosis had significantly greater risk of coronary heart disease, chronic non-cancer pain, stroke, myocardial infarction, cyclic vomiting, and injuries, over time, compared to controls. Cannabis use was associated with any and greater frequency of outpatient, inpatient, and emergency department visits. CONCLUSIONS: In a diverse sample, older adults who used cannabis had worse health conditions and events and used more health services over a two-year period. Future studies should evaluate cannabis-related health outcomes, effects of cannabis problem severity, as well as implications for healthcare in aging populations.

Study design and interventions for a peer-delivered motivational interviewing group treatment for sexual and gender minority male sexual trauma survivors.

Sexual abuse of boys and men is a public health problem that has received relatively little attention from clinical scholars and researchers. Given unique pathways for development of and recovery from trauma-related emotional distress, sexual abuse survivors who identify as men may require distinct psychosocial interventions to engage in formal mental health care and assist in symptom reduction. This paper describes the rationale for and methodology of a randomized controlled trial comparing the effectiveness of Motivational Interviewing (MI) versus MI with affirmative care (MI-AC) for sexual and gender minority men who have been sexually traumatized. This study is designed to randomly assign 356 participants to either condition of six online group sessions delivered by two trained peers with lived experience of sexual trauma. Assessments will be conducted at baseline, post-treatment, 60- and 120-day follow-up. The primary hypotheses are that participants assigned to MI-AC, compared to those in MI only, will report reduced symptoms of depression and increased levels of engagement in formal mental health treatment. Additional hypotheses relate to secondary outcome variables, including post-traumatic stress disorder, suicidality, and substance use.

Provider general attitudes versus specific perceptions of evidence-based psychotherapies for PTSD.

This study examined the role of attitudes toward evidence-based psychotherapies (EBPs) in predicting use of prolonged exposure (PE) and cognitive processing therapy (CPT), two EBPs for posttraumatic stress disorder (PTSD) among PTSD treatment providers within the Department of Veterans Affairs. Providers' general attitudes toward EBPs, as well as their specific perceptions of PE and CPT, were examined as potential predictors of use. One hundred fifty-nine providers from 38 Department of Veterans Affairs' residential PTSD programs across the United States completed an online survey that included the predictors listed as well as self-reported use of PE on an individual basis and CPT on an individual and on a group basis. Although general attitudes toward EBPs were related to use of individually administered CPT, they were not related to use of PE or group-administered CPT. For each of the 3 treatments, however, specific positive perceptions were related to use. In examination of other training, skill, and delivery-related variables, general attitudes appear more in line with perceptions and delivery of CPT than PE. Perhaps this is because of the unique exposure component of PE. Assessing provider perceptions of specific EBPs may help providers in guiding their own practice as well as aid treatment developers, trainers, and administrators to more effectively tailor dissemination and implementation efforts. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Trauma training: Competencies, initiatives, and resources.

Traumatic stress is currently not a required component of the standard curricula in graduate-level education in clinical and counseling psychology. However, due to the high prevalence of trauma and its potentially deleterious physical and mental health effects in the general and clinical populations, it is imperative that psychology graduate students and practitioners understand the relevance of trauma in their clients' lives and its impact in clinical research. A comprehensive model of trauma-focused empirically informed competencies (knowledge, skills, and attitudes) was developed at a national consensus conference in 2013 and approved by the American Psychological Association in 2015 as part of that organization's education and training policy. These trauma competencies predated the American Psychological Association's Posttraumatic Stress Disorder Guidelines, and provided consensus about the scientific, theoretical, ethical, and professional foundational knowledge, skills, and attitudes for all trauma-informed professional practice, not solely treatment. The two endeavors are related and potentially synergistic, but separate. Intended to guide training programs' curriculum development and psychologists' self-monitoring, the trauma competencies serve as aspirational goals for psychologists. Training issues in these and other trauma competencies are discussed. Perhaps, most importantly, the scientific literature on trauma is constantly evolving, and thus embracing an ever-evolving curriculum and lifelong-learning approach is essential. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Provider Perspectives on Choosing Prolonged Exposure or Cognitive Processing Therapy for PTSD: A National Investigation of VA Residential Treatment Providers.

As part of a longitudinal mixed-methods investigation on implementation of two evidence-based psychotherapies (EBPs) for Posttraumatic Stress Disorder, 164 mental health providers from 38 Department of Veterans Affairs (VA) residential treatment programs across the U.S. were asked questions about their decision-making for using Prolonged Exposure and Cognitive Processing Therapy. Many providers viewed both EBPs as equally efficacious and encouraged veterans to decide for themselves which treatment they wished to engage in. Some providers said that it was hard to know which EBP would be the most effective for a given patient, and that occasionally they started work with a veteran thinking that a particular EBP would work and were surprised when the veteran did not receive the full potential benefit of the intervention. Other providers noted that their decision-making regarding which EBP to use depended on the type and nature of the veterans' index trauma, memory of the trauma, and traumatic stress symptoms (e.g., fear versus guilt). Additional factors that impacted the choice of EBP included whether the patient already had one of the treatments before or if a provider deemed one as more compatible with their previous training. Implications for clinical practice as well as the design and improvement of training and implementation efforts are discussed.

Adoption by VA Residential Programs of Two Evidence-Based Psychotherapies for PTSD: Effect on Patient Outcomes.

OBJECTIVE: This observational study examined the association between patient outcomes at 39 U.S. Department of Veterans Affairs residential treatment programs for veterans with posttraumatic stress disorder (PTSD) and the degree of adoption of two evidence-based psychotherapies, prolonged exposure and cognitive processing therapy. The hypothesis was that a higher degree of adoption would be associated with better outcomes. METHODS: Providers (N=171) completed a qualitative interview and quantitative survey about their level of adoption of prolonged exposure delivered individually and cognitive processing therapy delivered in individual or group formats. On the basis of responses, programs were assigned to one of three adoption categories: little or no adoption of either therapy (N=8), some adoption, (N=9), and high adoption (N=22). A linear mixed model compared patient outcomes (e.g., PTSD and depression symptom severity, substance use, and distress) between adoption groups. RESULTS: The sample of veterans consisted of 2,834 who completed an assessment of PTSD symptoms and functioning at program intake and again at either program discharge or at 4 months postdischarge. Improvements in PTSD, distress, and alcohol use were noted over time for all programs, with decreases at follow-up. No effects of adoption group or a group × time interaction were noted for any outcome. CONCLUSIONS: Moderate to large effects were noted across all programs. However, programs that used prolonged exposure and cognitive processing therapy with most or all patients did not see greater reductions in PTSD or depression symptoms or alcohol use, compared with programs that did not use these evidence-based psychotherapies.

Use of Reflective Journaling to Understand Decision Making Regarding Two Evidence-Based Psychotherapies for PTSD: Practice Implications.

As part of a longitudinal investigation on implementation of 2 evidence-based psychotherapies (EBPs) for posttraumatic stress disorder, psychotherapists from 38 Department of Veterans Affairs residential treatment programs across the United States were asked to complete reflective journals every 4 months for a 1-year time period in regard to their successes and challenges in using prolonged exposure and cognitive processing therapy. This paper provides content analysis on the reflective journals of 24 of these providers. Five main themes were identified: EBPs are great but not sufficient for patients in residential treatment with chronic posttraumatic stress disorder and complicated life circumstances, and thus, more treatment is necessary after discharge. Modifications were made or thought needed for optimal outcome and successful delivery of these 2 EBPs; some providers blended aspects of prolonged exposure and cognitive processing therapy; what happens when providers and patients do not agree on choice of which EBP to first implement; and provider concerns on when to discontinue an EBP. Reflective journaling appears to be a promising way for trainers and treatment developers to gather important information about the clinical application and decision-making process for front-line providers, which may offer insight into how to improve EBP implementation and sustainability. Incorporating reflective journaling and strategies for accomplishing this into training, supervision, and consultation may also be 1 strategy for increasing feedback, expanding implementation, and informing ways to increase sustainability of EBPs in populations with multiple clinical and psychosocial needs.

VA residential treatment providers' use of two evidence-based psychotherapies for PTSD: Global endorsement versus specific components.

OBJECTIVE: Despite a growing body of knowledge about the dissemination of evidence-based psychotherapies (EBPs), their actual use in clinical settings is not well understood. The purpose of the current study was to compare self-reported component use with global use for 2 EBPs for posttraumatic stress disorder (PTSD), prolonged exposure (PE), and cognitive processing therapy (CPT). METHOD: Around 174 providers from 38 VA PTSD residential treatment programs were asked about both global use and component use of PE and CPT. RESULTS: Among frequent users of these EBPs, component use was generally high, especially for low-intensity and nonspecific components. For each form of treatment, there were a small number of providers who reported using the treatment frequently but did not use most of the key components of the treatment. CONCLUSIONS: These findings highlight the importance of understanding the modifications that providers make to EBPs and suggest the importance of flexibility within fidelity to these treatments. (PsycINFO Database Record