Lessons Learned in Implementing VA Video Connect for Evidence-Based Psychotherapies for Anxiety and Depression in the Veterans Healthcare Administration.

A top priority for the Veteran's Healthcare Administration is improving access to high-quality mental healthcare. Mobile and telemental healthcare are a vital component of increasing access for veterans. The Veteran's Healthcare Administration is making efforts to further broaden how veterans receive their care through VA Video Connect, which allows veterans to connect with their provider from their residence or workplace. In this mixed-methods study, successes and challenges associated with the rapid implementation of VA Video Connect telemental health appointments are examined through (1) administrative data and (2) qualitative interviews at one medical center. Within 1 year of the telehealth initiative, the number of providers experienced with telemental health increased from 15% to 85%, and telehealth appointments increased from 5376 to 14,210. Provider reported barriers included administrative challenges and concerns regarding care. Having an implementation model of telehealth champions and a team of experienced mental health providers allowed for rapid adoption of telehealth. Utilizing a similar model in other settings will further enable more veterans with depression and anxiety to have access to evidence-based psychotherapy, regardless of location or national crisis. With the dramatic increase in both training for providers as well as veteran use of telemental healthcare during the COVID-19 pandemic response, future research should aim to better understand which teams were able to switch to telehealth easily versus those which struggled, along with examining system-wide and provider-level factors that facilitated continued use of telehealth after social distancing requirements related to COVID-19 were relaxed.

Emotional Processing of Imaginal Exposures Predicts Symptom Improvement: Therapist Ratings Can Assess Trajectory in Prolonged Exposure for Posttraumatic Stress Disorder.

Research on mechanisms of change in prolonged exposure therapy (PE), an evidence-based treatment for posttraumatic stress disorder (PTSD), is ongoing. Two putative mechanisms of change are engagement during imaginal exposure and trauma-related belief change. The PE Therapist Questionnaire (PETQ), a novel measure based on the emotional processing theory underlying PE, was developed as a practical tool for therapists to use to assess (a) patient engagement during imaginal exposures and (b) perspective shifts during postimaginal processing. Patients (N = 151) at a U.S. Veterans Affairs medical center PTSD specialty clinic completed self-report measures of PTSD and depression symptoms prior to sessions. Study therapists (n = 17) completed the PETQ postsession. Rational construction and psychometric analyses suggested a two-component solution for the PETQ: imaginal and processing. The imaginal factor did not relate to PTSD and depression symptoms. The processing factor correlated with current and next-session PTSD and depression symptoms, with medium effect sizes, rs = -.41 to -.45, ps < .001. Controlling for current-session PTSD and depression, a higher level of processing predicted lower next-session PTSD severity, with a small effect size, ß = -.38, p < .04. Postexposure emotional processing, which supports positive changes in maladaptive trauma-related beliefs and tolerance of emotional distress, predicted future symptom improvement, highlighting the importance of processing components in PE. Further, the use of therapist observations may offer ancillary methods less influenced by correlation of within-patient subjective ratings and concomitant risk of construct overlap in mechanisms research.

An adjunctive human-animal interaction intervention for veterans with PTSD: study protocol for a randomized controlled trial.

BACKGROUND: Posttraumatic stress disorder (PTSD) rarely remits over time, and if left untreated, leads to significant distress, functional impairment, and increased health care costs. Fortunately, effective evidence-based treatments (EBTs) for PTSD, such as Prolonged Exposure (PE), exist. Despite their availability and efficacy, a significant number of individuals with PTSD do not initiate treatment when offered or dropout prematurely. One proposed theory suggests that the emotional-numbing symptoms of PTSD (e.g., blunted affect, apathy) can serve as a barrier to engaging in, and successfully completing, treatment; and the broad human-animal interaction (HAI) literature available suggests that HAI can potentially reduce emotional numbing related to PTSD. Accordingly, this manuscript describes an ongoing, federally funded, randomized controlled trial testing the efficacy of RESCUE, an HAI intervention, as a viable adjunctive treatment component for PE. METHODS/DESIGN: The study will include 70 veterans with PTSD treated at a Southeastern Veterans Affairs Medical Center (VAMC). All participants in the trial receive up to 12 sessions of PE. Participants are randomly assigned 1:1 to (1) volunteer at a local animal shelter or (2) volunteer at a community agency of their choice as part of their in-vivo exposure exercises for PE. Outcomes will be examined via standard clinical interviews, self-report questionnaires, and thematic interviews. DISCUSSION: It is hypothesized that participants in the HAI condition will report greater decreases in emotional-numbing symptoms and increased treatment compliance and completion rates relative to those in the community volunteer condition. If successful, RESCUE, could be easily incorporated into standard PE and broadly disseminated. TRIAL REGISTRATION: ClinicalTrials.gov. ID: NCT03504722. Retrospectively registered on 2 May 2017.

Treatment for Anxiety and Depression via Clinical Videoconferencing: Evidence Base and Barriers to Expanded Access in Practice.

This review summarizes six decades of clinical outcome research relevant to evidence-based practices for depression and anxiety delivered via clinical videoconferencing. The authors conducted a literature search of previous systematic reviews and an updated search of publications specific to anxiety and depression. Overall, strong evidence supports the safety and clinical effectiveness of administering evidence-based psychotherapy for anxiety and depression via clinical videoconferencing among heterogeneous populations and age ranges, and in multiple care settings, with similar outcomes to in-person care. Despite the overall clinical effectiveness of the modality, the authors discuss common logistical and institutional barriers to long-term effective implementation. Future systems-level research is required to investigate replicable and sustainable models for implementing and expanding access to evidence-based psychotherapies via clinical videoconferencing.

Evidence-based psychotherapy (EBP) non-initiation among veterans offered an EBP for posttraumatic stress disorder.

Current efforts to disseminate evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) in Veterans Affairs Medical Centers (VAMCs) have made effective treatment options more available throughout the system. Yet many veterans identified as likely to benefit from such services choose not to utilize them. The evidence base regarding factors that contribute to treatment initiation among those offered EBPs is still in its early stages. The present study investigated clinical presentation, patient demographics, and environment of care factors as potential predictors of EBP treatment initiation among veterans offered such care. The sample consisted of 324 veterans (62% Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]; 77% male; age M = 42.95, SD = 12.57 years), who attended an intake evaluation at a VAMC outpatient PTSD Clinical Team, were diagnosed with PTSD, and offered a course of EBP. Overall, 72% of veterans (n = 232) who were offered an EBP initiated such treatment, and 28% of veterans (n = 92) did not initiate treatment. Veterans who initiated treatment were significantly older. Treatment initiation did not significantly differ by ethnicity, gender, or baseline PTSD severity. Significantly more veterans referred from mental health clinics initiated treatment than did veterans referred from primary care. This study examined treatment initiation among veterans who were offered EBP for PTSD. Rates of initiation differed across subgroups of veterans. Clinically, this suggests the need to tailor outreach efforts to younger veterans, OEF/OIF veterans, and veterans referred from primary care, and potentially including programming and education aimed at primary care referrers, to increase help-seeking. (PsycINFO Database Record

Patterns of therapeutic alliance: rupture-repair episodes in prolonged exposure for posttraumatic stress disorder.

OBJECTIVE: To better understand the role of therapeutic alliance in posttraumatic stress disorder (PTSD) treatment, we examined patterns of and shifts in alliance. First, we identified individuals with repaired ruptures, unrepaired ruptures, and no ruptures in alliance. Then, we explored group differences in these alliance events for clients with common clinical correlates (i.e., co-occurring depression and childhood abuse history) and whether or not the presence of these events influenced treatment outcome. METHOD: At pretreatment, clients (N = 116)-76.1% female, 66% Caucasian, age M = 36.7 years (SD = 11.3)--completed measures assessing PTSD diagnosis and severity (PTSD Symptom Scale Interview and Self-Report), depression diagnosis and severity (Structured Clinical Interview for DSM-IV and Beck Depression Inventory), and trauma history. During 10 weeks of prolonged exposure therapy, alliance (California Psychotherapy Alliance Scale) measures were completed. At posttreatment, PTSD and depression were reassessed. RESULTS: Ruptures in alliance were quite common (46%). No significant differences emerged in the frequency of repaired ruptures, unrepaired ruptures, or no ruptures between those with and without co-occurring major depressive disorder, χ²(2, N = 82) = 2.69, p = .26, or those with and without a history of childhood abuse, χ²(2, N = 81) = 0.57, p = .75. Unrepaired ruptures predicted worse treatment outcome (ß = .44, p = .001). CONCLUSIONS: The current study underscores the importance of attending to discontinuities in alliance throughout treatment.

Depression sudden gains and transient depression spikes during treatment for PTSD.

OBJECTIVE: We know little about how change unfolds in depression symptoms during posttraumatic stress disorder (PTSD) treatment or how patient characteristics predict depression symptom change. This study examined critical transition points in depression symptoms during PTSD treatment, namely, depression sudden gains, which are rapid symptom improvements and transient depression spikes, which are transient depression worsenings. Social support, one of the strongest predictors of PTSD development, was examined as a predictor of depression symptom discontinuities. METHOD: At pretreatment, 200 participants (76.6% female; 64.9% Caucasian; age M = 37.1, SD = 11.3 years) completed measures of PTSD severity (PTSD Symptom Scale-Self-Report), depression severity (Beck Depression Inventory), general social support (Inventory of Socially Supportive Behaviors; Social Support Questionnaire), and trauma-related social support (Social Reactions Questionnaire). During 10 weeks of prolonged exposure (PE) or sertraline, depression was assessed weekly. RESULTS: Overall, 18.0% of participants experienced a depression sudden gain, and 22.5% experienced a transient depression spike. The presence of a depression sudden gain predicted better treatment outcome, ß = -4.82, SE = 1.17, p = .001, 95% CI [-6.79, -2.90]. Higher perceptions of negative trauma-related reactions, albeit modestly, were associated with experiencing a transient depression spike (r = .18, p = .01). There were no differences in rates of depression sudden gains or transient depression spikes between treatments. CONCLUSIONS: Encouragingly, rapid improvements in depression symptoms are beneficial for PTSD treatment outcome, but transient spikes in depressive symptoms do not strongly influence outcome. Understanding symptom discontinuities may help us to personalize current PTSD treatment options.

"How will it help me?" Reasons underlying treatment preferences between sertraline and prolonged exposure in posttraumatic stress disorder.

Individuals with posttraumatic stress disorder (PTSD) often wait years before seeking treatment. Improving treatment initiation and adherence requires a better understanding of patient beliefs that lead to treatment preferences. Using a treatment-seeking sample (N = 200) with chronic PTSD, qualitative reasons underlying treatment preferences for either prolonged exposure (PE) or sertraline (SER) were examined. Reasons for treatment preference primarily focused on how the treatment was perceived to reduce PTSD symptoms rather than practical ones. The patients were more positive about PE than SER. Individual differences did not reliably predict underlying preference reasons, suggesting that what makes a treatment desirable is not strongly determined by current functioning, treatment, or trauma history. Taken together, this information is critical for treatment providers, arguing for enhancing psychoeducation about how treatment works and acknowledging preexisting biases against pharmacotherapy for PTSD that should be addressed. This knowledge has the potential to optimize and better personalize PTSD patient care.

Understanding factors associated with early therapeutic alliance in PTSD treatment: adherence, childhood sexual abuse history, and social support.

OBJECTIVE: Therapeutic alliance has been associated with better treatment engagement, better adherence, and less dropout across various treatments and disorders. In treatment of posttraumatic stress disorder (PTSD), it may be particularly important to establish a strong early alliance to facilitate treatment adherence. However, factors such as childhood sexual abuse (CSA) history and poor social support may impede the development of early alliance in those receiving PTSD treatment. We sought to examine treatment adherence, CSA history, and social support as factors associated with early alliance in individuals with chronic PTSD who were receiving either prolonged exposure therapy (PE) or sertraline. METHOD: At pretreatment, participants (76.6% female; 64.9% Caucasian; mean age = 37.1 years, SD = 11.3) completed measures of trauma history, general support (Inventory of Socially Supportive Behaviors), and trauma-related social support (Social Reactions Questionnaire). Over the course of 10 weeks of PE or sertraline, they completed early therapeutic alliance (Working Alliance Inventory) and treatment adherence measures. RESULTS: Early alliance was associated with PE adherence (r = .32, p < .05) and overall treatment completion (r = .19, p < .05). Only trauma-related social support predicted the strength of early alliance beyond the effects of treatment condition (ß = .23, p < .05); CSA history was not predictive of a lower early alliance. CONCLUSIONS: Given the associations with adherence, clinicians may find it useful to routinely assess alliance early in treatment. Positive trauma support, not CSA history, may be particularly important in the development of a strong early therapeutic alliance.