Veteran Beliefs About the Causes of Gulf War Illness and Expectations for Improvement.

BACKGROUND: Individuals' beliefs about the etiology of persistent physical symptoms (PPS) are linked to differences in coping style. However, it is unclear which attributions are related to greater expectations for improvement. METHOD AND RESULTS: A cross-sectional regression analysis (N = 262) indicated that Veterans with Gulf War Illness (GWI) who attributed their GWI to behavior, (e.g., diet and exercise), had greater expectations for improvement (p = .001) than those who attributed their GWI to deployment, physical, or psychological causes (p values > .05). CONCLUSIONS: Findings support the possible clinical utility of exploring perceived contributing factors of PPS, which may increase perceptions that improvement of PPS is possible. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02161133.

Randomized controlled trial protocol of health coaching for veterans with complex chronic pain.

BACKGROUND: Pain predominant multisymptom illness (pain-CMI) refers to symptom-based conditions where pain is a primary symptom. There is initial evidence that health coaching may be efficacious in treating pain-CMI because it can be tailored to the veteran's goals and emphasizes long-term behavior change, which may indirectly impact the maintaining factors of pain-CMI (e.g., catastrophizing, poor pain control, and limited activity). This paper describes the study protocol and rationale of a randomized controlled trial that will compare the efficacy of remote-delivered health coaching in reducing disability and pain impairment for veterans with pain-CMI to remote-delivered supportive psychotherapy. METHODS: This randomized controlled trial will consist of two treatment arms: remote-delivered health coaching and remote-delivered supportive psychotherapy, the active control. Each treatment condition will consist of twelve, weekly one-on-one meetings with a study provider. In addition to the baseline assessment, participants will also complete 6-week (mid-treatment), 12-week (post-treatment), and 24-week (follow-up) assessments that consist of questionnaires that can be completed remotely. The primary aims for this study are to determine whether health coaching reduces disability and pain impairment as compared to supportive psychotherapy. We will also examine whether health coaching reduces physical symptoms, catastrophizing, limiting activity, and increasing pain control as compared to supportive psychotherapy. DISCUSSION: This study will contribute to the existing literature on pain-CMI and report the effectiveness of a novel, remote-delivered behavioral intervention.

Protocol for a type 1 hybrid effectiveness/implementation clinical trial of collaborative specialty care for Veterans with Gulf War Illness.

AIMS: We describe a clinical trial which is seeking to determine the effectiveness and understand implementation outcomes for tele-collaborative specialty care for Veterans with Gulf War Illness (GWI). MAIN METHODS: This study will be a hybrid type 1 randomized effectiveness-implementation trial comparing tele-collaborative specialty care to electronic consultation for Gulf War Veterans with GWI (N = 220). In tele-collaborative specialty care, the specialty provider team will deliver health coaching and problem-solving treatment to Veterans and recommend a plan for analgesic optimization. In electronic consultation, the specialty provider team will make a one-time recommendation to the primary care team for locally delivered health coaching, problem-solving treatment and analgesic optimization. The primary aim will be to determine the effectiveness of tele-collaborative specialty care as compared to electronic consultation to reduce disability related to GWI. Our secondary aim will be to understand implementation outcomes. SIGNIFICANCE: There is a need to improve care for Veterans with GWI. A potentially useful model to improve care is tele-collaborative specialty care, where the specialists work with the primary care provider to synergistically treat the patients. DISCUSSION: This is the first clinical trial to prospectively compare different models of care for Veterans with GWI. This responds to multiple calls for research to improve treatment for Veterans with GWI, including from the National Academy of Medicine.

Doctor Recommendations are Related to Patient Interest and Use of Behavioral Treatment for Chronic Pain and Addiction.

The opioid crisis has highlighted the importance of improving patients' access to behavioral treatments for chronic pain and addiction. What is not known is if patients are interested in receiving these treatments. In this cross-sectional study, over 1,000 participants with chronic pain were surveyed using an anonymous online questionnaire on Amazon Mechanical Turk to investigate participants' use of and interest in pharmacological and behavioral treatments for chronic pain and addiction. Participants also indicated whether their doctor had recommended these treatments. The majority of participants reported using medication for their pain (83.19%) and that their doctor recommended medication (85.05%), whereas fewer participants reported using (67.45%) and being recommended to (62.82%) behavioral treatments. We found 63.67% of participants screened positive for possible opioid misuse; those who screened positive were more interested in receiving behavioral treatments than those who did not screen positive. Participants who received treatment recommendations were more likely to be interested in receiving those treatments as compared to participants who did not. The results suggest that recommendations for behavioral treatments and interest in those treatments are related. Results also suggest that patients endorsing behaviors consistent with opioid misuse are interested in behavioral treatments. PERSPECTIVE: This study provides information around chronic pain patients' treatment interests, treatment receipt, and recommendation receipt for behavioral pain management and addiction treatment. This study could help facilitate communication between patients and doctors regarding available treatments for chronic pain and pain treatment-related addiction problems.

Coping with Medically Unexplained Physical Symptoms: the Role of Illness Beliefs and Behaviors.

BACKGROUND: Medically unexplained syndromes (MUS) are both prevalent and disabling. While illness beliefs and behaviors are thought to maintain MUS-related disability, little is known about which specific behavioral responses to MUS are related to disability or the way in which beliefs and behaviors interact to impact functioning. The purpose of the present study was to examine the relationship between illness beliefs and disability among patients with MUS, and assess the extent to which behaviors mediate this relationship. METHODS: The study examined data from the baseline assessment of a multi-site randomized controlled trial (RCT). Participants were 248 veterans with MUS. Illness beliefs, behavioral responses to illness, and disability were assessed through self-report questionnaire. Data were analyzed using mediation analysis. RESULTS: Threat-related beliefs predicted greater disability through decreased activity and increased practical support seeking. Protective beliefs predicted less disability through reductions in all-or-nothing behavior and limiting behavior. CONCLUSIONS: These outcomes suggest that all-or-nothing behavior, limiting behavior, and practical support seeking are important in the perpetuation of disability among those with MUS. This has implications for improving MUS treatment by highlighting potential treatment targets. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02161133.

Neuroimaging predictors of response to cognitive remediation and social skills training: A pilot study in veterans with schizophrenia.

Neuroimaging may predict response to cognitive remediation therapy and social skills training (CRT + SST) in schizophrenia. Identifying biological predictors of response is crucial for treatment decision making given not all patients respond to such interventions. Nineteen veterans with schizophrenia enrolled in an 8-week trial of CRT + SST. Ten participants completed diffusion tensor imaging (DTI) at baseline. Baseline fractional anisotropy (FA) in the superior longitudinal fasciculus (SLF) and overall average FA predicted improvements in visual-spatial working memory, and social cognition, respectively. Neuroimaging may be useful in identifying therapeutic targets in schizophrenia.

Cost-effectiveness of individual versus group female-specific cognitive behavioral therapy for alcohol use disorder.

OBJECTIVE: To determine the relative cost-effectiveness of individual female-specific cognitive behavioral therapy (I-FS-CBT) versus group female-specific cognitive behavioral therapy (G-FS-CBT). METHODS: This cost-effectiveness study is based on a randomized controlled trial in which 155 women seeking treatment for alcohol use disorder at an academic outpatient clinic were randomized to 12 manual-guided sessions of I-FS-CBT (n = 75) or G-FS-CBT (n = 80). The primary patient outcomes were the number of drinking days and the number of heavy drinking days during the 12-week treatment and 1-year follow-up periods. All cost data (including resource utilizations) were collected prospectively alongside the trial. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were used to determine the cost-effectiveness of I-FS-CBT relative to G-FS-CBT. Results are presented from the provider perspective. RESULTS: During the 12-week treatment period, G-FS-CBT is likely to be cost-effective when the threshold value to decision-makers of one fewer drinking day (or one fewer day of heavy drinking) is less than $141 (or $258), and I-FS-CBT is likely to be cost-effective if the threshold is greater than $141 (or $258). During the 1-year follow-up period, G-FS-CBT is likely to be cost-effective when the threshold value to decision-makers of one fewer drinking day (or one fewer day of heavy drinking) is less than $54 (or $169), and I-FS-CBT is likely to be cost-effective if the threshold is greater than $54 (or $169). The results are robust to sensitivity analyses on several key cost parameters. CONCLUSIONS: Compared to I-FS-CBT, G-FS-CBT holds promise as a cost-effective approach, in both the short run and the long run, for improving drinking outcomes of women with alcohol use disorder.

Guanfacine Augmentation of a Combined Intervention of Computerized Cognitive Remediation Therapy and Social Skills Training for Schizotypal Personality Disorder.

OBJECTIVE: Impaired cognition is a hallmark of schizophrenia spectrum disorders, including schizotypal personality disorder, and it is the best predictor of functional outcome. Cognitive remediation therapy has demonstrated efficacy for improving cognition, augmenting other rehabilitation efforts in schizophrenia, and effecting gains in real-world functioning. Pharmacological augmentation of cognitive remediation has been attempted, but the effects of augmentation on combined therapies, such as cognitive remediation and social skills training, have not been studied. METHODS: Twenty-eight participants with schizotypal personality disorder enrolled in an 8-week, randomized, double-blind, placebo-controlled trial of guanfacine plus cognitive remediation and social skills training (15 guanfacine, 13 placebo). Cognition was assessed with the MATRICS (Measurement and Treatment Research to Improve Cognition in Schizophrenia) Consensus Cognitive Battery (MCCB), social cognition with the Movie for the Assessment of Social Cognition (MASC), and functional capacity with the University of California San Diego Performance-Based Skills Assessment (UPSA). RESULTS: A statistically significant pre- versus posttreatment effect was observed for MCCB speed of processing, verbal learning, and visual learning and UPSA total score. A significant time-by-medication (guanfacine, placebo) interaction was observed for MCCB reasoning and problem solving and UPSA total score; the time-by-treatment interaction approached significance for MASC hypomentalizing errors. CONCLUSIONS: Both guanfacine and cognitive remediation plus social skills training were well tolerated, with no side effects or dropouts. Participants treated with cognitive remediation, social skills training, and guanfacine demonstrated statistically significant improvements in reasoning and problem solving, as well as in functional capacity and possibly social cognition, compared with those treated with cognitive remediation, social skills training, and placebo. Cognitive remediation plus social skills training may be an appropriate intervention for individuals with schizotypal personality disorder, and guanfacine appears to be a promising pharmaceutical augmentation to this psychosocial intervention.

Helpful ways providers can communicate about persistent medically unexplained physical symptoms.

BACKGROUND: Communication between patients and providers about persistent "medically unexplained" physical symptoms (MUS) is characterized by discordance. While the difficulties are well documented, few studies have examined effective communication. We sought to determine what veterans with Gulf War Illness (GWI) perceive as the most helpful communication from their providers. Veterans with GWI, a type of MUS, have historically had complex relationships with medical providers. Determining effective communication for patients with particularly complex relationships may help identify the most critical communication elements for all patients with MUS. METHODS: Two hundred and-ten veterans with GWI were asked, in a written questionnaire, what was the most useful thing a medical provider had told them about their GWI. Responses were coded into three categories with 10 codes. RESULTS: The most prevalent helpful communication reported by patients was when the provider offered acknowledgement and validation (N = 70). Specific recommendations for managing GWI or its symptoms (N = 48) were also commonly reported to be helpful. In contrast, about a third of the responses indicated that nothing about the communication was helpful (N = 63). There were not differences in severity of symptoms, disability or healthcare utilization between patients who found acknowledgement and validation, specific recommendations or nothing helpful. CONCLUSIONS: Previous research has documented the discord between patients and providers regarding MUS. This study suggests that most patients are able to identify something helpful a provider has said, particularly acknowledgement and validation and specific treatment recommendations. The findings also highlight missed communication opportunities with a third of patients not finding anything helpful.

Heterogeneity in pathways to abstinence among women in treatment for alcohol use disorder.

BACKGROUND: Although many providers recommend alcohol abstinence as an initial step in the treatment of alcohol use disorders (AUD), there is a scarcity of research on specific behavioral strategies to achieve this step. The current study examined efficacy of a unique abstinence planning intervention for alcohol in a cognitive behavioral therapy (CBT) outpatient protocol. DESIGN: 128 women enrolled in a randomized controlled trial of CBT for AUD at a university-based clinic comprised the sample. MEASUREMENTS: Session 1 manual-guided interventions included an abstinence planning discussion in which each woman chose a specific plan for achieving initial abstinence in collaboration with her therapist. Drinking data were collected via participant logs during the 16week within-treatment period and via Timeline Follow-Back interview at 12month follow-up. FINDINGS: For 32.8% (n=42) of women who stopped drinking during the pre-treatment assessment period, their abstinence plan was to maintain abstinence (MA). 18.0% (n=23) of women chose a "cold turkey" approach (CT, abrupt cessation without medical assistance), and 46.1% (n=59) chose a "winding down" approach (WD, systematic reduction of drinking toward a specified quit date). Generalized Estimating Equations (GEE) analyses showed that type of abstinence plan chosen was differentially associated with percent days drinking (PDD) in later treatment (weeks 7-16) (p<0.01) and during 12month follow-up (p<0.01). Women in the WD group had the highest PDD for both time frames and women in the CT group drank more frequently during later treatment compared to those in the MA group. The association between plan and PDD during follow-up was moderated by early treatment PDD (weeks 1-7; p<0.01), such that women in the MA and WD groups had lower follow-up PDD if they were able to decrease their drinking during early treatment. CONCLUSIONS: Women who were maintaining abstinence at treatment entry or had planned to stop using alcohol abruptly (i.e., "cold turkey") after starting treatment had better overall drinking outcomes than those who chose to wind down. A plan to wind-down drinking appeared to be the most appealing option to women in the study and, among those who were able to successfully execute this winding down approach, was related to positive long-term drinking outcomes.

Visual-spatial working memory performance and temporal gray matter volume predict schizotypal personality disorder group membership.

BACKGROUND: Prior work shows individuals with schizotypal personality disorder (SPD) evince temporal lobe volume abnormalities similar to schizophrenia but sparing of prefrontal cortex, which may mitigate psychosis and the severe neurocognitive impairments observed in schizophrenia. This study examined the extent to which frontal-temporal gray matter volume and neurocognitive performance predict: (1) SPD group membership in a demographically-balanced sample of 51 patients and 37 healthy controls; and (2) symptom severity in SPD. METHODS: Dimensional gray-matter volume (left frontal-temporal regions (Brodmann area (BA) 10, 21, 22)) and neurocognitive performance on key memory tasks (California Verbal Learning Test (CVLT), Dot Test, Paced Auditory Serial Addition Test (PASAT)), all salient to schizophrenia-spectrum disorders were examined in a multi-variable model. RESULTS: Middle temporal gyrus (BA21) volume and spatial-working memory (Dot Test) performance were significant predictors of SPD group membership likelihood, with poorer working-memory performance indicating increased probability of SPD membership. Combining across regional volumes or cognitive measures resulted in fair-to-good discrimination of group membership, but including neurocognitive and non-collinear regional volume measures together resulted in a receiver-operating-characteristic (ROC) curve with improved diagnostic discrimination. Larger BA10 volume in dorsolateral prefrontal cortex (DLPFC) significantly predicted less symptom severity in SPD. CONCLUSIONS: These findings suggest that temporal lobe volume and spatial-working memory performance are promising biological/phenotype markers for likelihood of SPD classification, while greater DLPFC volume may serve as a protective factor.

Women's motivators for seeking treatment for alcohol use disorders.

This study examined types of internal and external motivations for seeking treatment and the predictive utility of different types of motivation among 180 women with an alcohol use disorder (AUD) participating in a two-armed trial testing different individual and couple therapies for AUDs. Reasons for seeking treatment were coded for type of internal or external motivation. Most women (97%) cited internal reasons for seeking help, including: concern about progression of AUD (61.1%), health (43.3%), mental health (38.9%), and family (38.3%). Occupational concerns, an internal motivator cited by 6% of women, were associated with better drinking outcomes; interpersonal-family concerns were associated with poorer outcomes. Some motivators for seeking treatment may not be related to sustained changes in drinking, suggesting that understanding motivators for treatment may be inadequate to maintain change. Reasons for help-seeking may need to be addressed in treatment to produce long-lasting change.

Modeling the severity of drinking consequences in first-year college women: an item response theory analysis of the Rutgers Alcohol Problem Index.

OBJECTIVE: The present study examined the latent continuum of alcohol-related negative consequences among first-year college women using methods from item response theory and classical test theory. METHOD: Participants (N = 315) were college women in their freshman year who reported consuming any alcohol in the past 90 days and who completed assessments of alcohol consumption and alcohol-related negative consequences using the Rutgers Alcohol Problem Index. RESULTS: Item response theory analyses showed poor model fit for five items identified in the Rutgers Alcohol Problem Index. Two-parameter item response theory logistic models were applied to the remaining 18 items to examine estimates of item difficulty (i.e., severity) and discrimination parameters. The item difficulty parameters ranged from 0.591 to 2.031, and the discrimination parameters ranged from 0.321 to 2.371. Classical test theory analyses indicated that the omission of the five misfit items did not significantly alter the psychometric properties of the construct. CONCLUSIONS: Findings suggest that those consequences that had greater severity and discrimination parameters may be used as screening items to identify female problem drinkers at risk for an alcohol use disorder.

A "community-friendly" version of integrated group therapy for patients with bipolar disorder and substance dependence: a randomized controlled trial.

BACKGROUND: Integrated group therapy, a new treatment for patients with bipolar disorder and substance use disorder, has previously been found to be efficacious in reducing substance use, but its length (20 sessions) and need for highly trained therapists may limit its adoption in substance use disorder community treatment programs. This paper compares a briefer (12 session) version of integrated group therapy, led by substance use disorder counselors without previous cognitive-behavioral training or bipolar disorder experience, to group drug counseling. METHODS: Sixty-one patients with bipolar disorder and substance dependence, taking mood stabilizers, were randomized to 12 sessions of integrated group therapy (n=31) or group drug counseling (n=30). RESULTS: Analyses of primary outcomes showed trends favoring integrated group therapy, with greater reduction in substance use during follow-up and a greater decline in risk of mood episodes during treatment. Secondary analyses favored integrated group therapy, with a significantly greater likelihood of achieving total abstinence, a significantly shorter time to the first abstinent month, and a significantly greater likelihood of achieving a "good clinical outcome" (a composite measure encompassing both substance use and mood simultaneously). CONCLUSIONS: A shortened version of integrated group therapy can be delivered successfully by substance use disorder counselors, with better overall outcomes than those achieved with group drug counseling.

Engagement and retention in outpatient alcoholism treatment for women.

Reviews of the dropout literature note significant attrition from addiction treatment. However, consistent predictors have not been identified and few studies have examined factors related to retention and engagement for women in gender-specific treatment. The current study consisted of 102 women and their partners randomized to individual or couples outpatient alcoholism treatment. Women attended more treatment sessions if they were assigned to individual treatment, older, had fewer symptoms of alcohol dependence, had more satisfying marital relationships, had spouses who drank, and had matched preference for treatment condition. Women were more engaged in treatment (ie, completed more assigned homework) if they had fewer children at home, fewer alcohol dependence symptoms, later age of onset of alcohol diagnosis, more satisfying marital relationships, and spouses who accepted or encouraged their drinking. Results highlight important associations of treatment and relationship variables with treatment retention and engagement.

A prospective study examining the effects of gender and sexual/physical abuse on mood outcomes in patients with co-occurring bipolar I and substance use disorders.

OBJECTIVES: Prior research suggests possible gender differences in the longitudinal course of bipolar disorder. This study prospectively examined gender differences in mood outcomes and tested the effects of sexual/physical abuse and posttraumatic stress disorder (PTSD). METHODS: Participants (49 men, 41 women) with co-occurring bipolar I and substance use disorders (92% alcohol, 42% drug) were enrolled in a group treatment trial. They were followed for eight months, with monthly assessments, yielding 32 weeks of data. Primary outcome measures were number of weeks in each mood state, recurrences of depression or mania, and polarity shifts from depression to mania or vice versa. Negative binomial regression was used to examine the effects of gender, lifetime abuse, and PTSD on these outcomes. RESULTS: Participants met syndromal criteria for a mood episode on a mean of 27% of 32 weeks, with depression occurring most frequently. Compared to men, women reported significantly more weeks of mixed mania [relative rate (RR) = 8.53], fewer weeks of euthymia (RR = 0.58), more recurrences of mania (RR = 1.96), and more direct polarity shifts (RR = 1.49) (all p < 0.05). Women also reported significantly higher rates of lifetime sexual or physical abuse (68% versus 33%), which partially explained the relationships between gender and mixed mania and direct polarity shifts. CONCLUSIONS: Participants experienced persistent mood symptoms over time. Women consistently reported poorer mood outcomes, and lifetime abuse may help explain observed gender differences in mood outcomes. Further research is necessary to better understand the treatment implications of these findings.

Depression precipitated by alcohol use in patients with co-occurring bipolar and substance use disorders.

OBJECTIVE: Bipolar disorder and substance use disorder frequently co-occur. However, little is known about the near-term effects of substance use on bipolar disorder. Thus, the present study tests whether alcohol use precipitates depression among patients with co-occurring bipolar disorder and substance use disorder. METHOD: This study uses data collected as part of 2 clinical trials (the first study was conducted from March 1999 through March 2004 and the second study was conducted from August 2003 through May 2007) of a manualized group therapy for patients with co-occurring bipolar disorder and substance dependence. One hundred fifteen participants were assessed at baseline and each month through month 8. Baseline diagnoses were made using the Structured Clinical Interview for DSM-IV, and monthly substance use and mood data were collected using the Longitudinal Interval Follow-Up Evaluation and the Addiction Severity Index. Generalized estimating equation methodology was used to analyze these longitudinal data. RESULTS: Our primary hypotheses were supported: days of alcohol use and an increase in days of alcohol use each significantly predicted the presence of a depressive episode in the subsequent month when controlling for current depression and current drug use. CONCLUSION: These data suggest that alcohol use in patients with bipolar disorder and substance dependence increases the risk of a depressive episode in the near term. TRIAL REGISTRATION: This study draws on data generated during 2 clinical trials. One was exempt from trial registration; clinicaltrials.gov Identifier for other trial: NCT00227838.

Predictors of dropout from group therapy among patients with bipolar and substance use disorders.

OBJECTIVE: Bipolar and substance use disorders frequently co-occur. Integrated treatment for these disorders has been shown to be effective at reducing substance use, but no study has examined attrition from dual diagnosis group therapy. The current study identified baseline demographic and clinical characteristics that predict treatment dropout among patients with co-occurring bipolar and substance use disorders. METHOD: Using binary and multivariate analyses, baseline data were analyzed as part of a randomized controlled trial of integrated group therapy for bipolar and substance use disorders. RESULTS: Cigarette smoking, recent mood episode, and lack of a college education were strong predictors of dropout after controlling for demographic and substance use variables. CONCLUSIONS: Given the strength of smoking as a predictor of dropout as well as the high rate of smoking among this population, a greater focus on the relationship between smoking and bipolar disorder is warranted.

HIV risk behavior among patients with co-occurring bipolar and substance use disorders: associations with mania and drug abuse.

BACKGROUND: Bipolar and substance use disorders frequently co-occur, and both are associated with impulsivity, impaired judgment, and risk-taking. OBJECTIVES: This study aimed to: (1) describe the rates of HIV sexual and drug risk behaviors among patients with co-occurring bipolar and substance use disorders, (2) test whether acute mania, psychiatric severity, and drug severity independently predict HIV risk, and (3) examine the relationship between specific substance dependencies and sexual risk behaviors. METHOD: Participants (N=101) were assessed for psychiatric diagnoses, substance abuse, and HIV risk behavior using structured clinical interviews and self-report questionnaires. RESULTS: The majority (75%) were sexually active in the past 6 months and reported high rates of sexual risk behaviors, including unprotected intercourse (69%), multiple partners (39%), sex with prostitutes (24%, men only), and sex trading (10%). In a multivariate linear regression model, recent manic episode, lower psychiatric severity, and greater drug severity were independent predictors of total HIV risk. Cocaine dependence was associated with increased risk of sex trading. CONCLUSIONS: Results underscore the importance of HIV prevention for this population.