Using an ecological momentary assessment protocol to understand problem anger in veterans.

BACKGROUND AND OBJECTIVES: Problem anger is highly destructive, and is one of the most commonly reported issues in military and veteran populations. The goal of this study was to use ecological momentary assessment (EMA) to explore and characterize moment-to-moment experiences of problem anger in a sample of Australian veterans. METHODS: Sixty veterans with problem anger (measured on the Dimensions of Anger Reactions Scale) completed measures of anger and anger rumination, before and after a 10-day EMA period which assessed the frequency, intensity, and expression of momentary anger experiences. RESULTS: Findings showed that 75% of respondents indicated some level of anger during EMA monitoring. In 25% of cases, anger was reported as severe. Moreover, anger was expressed verbally in 43% of cases, and expressed physically in 27% of cases. While anger fluctuated frequently during the day, more severe anger was more likely to be reported in the late afternoon/early evening. Problem anger symptoms decreased significantly over time, from pre-EMA to post EMA (p < .001). LIMITATIONS: The generalizability of findings is limited to a predominantly male sample, with low levels of risk of harm or violence. The study was also limited in the selection of outcome variables assessed and the lack of a control group; other momentary factors could influence experience of problem anger and provide further explanation of study results. CONCLUSIONS: EMA is a valuable assessment tool for individuals with problem anger, and the potential for EMA as an intervention needs to be explored further.

Efficacy of synchronous telepsychology interventions for people with anxiety, depression, posttraumatic stress disorder, and adjustment disorder: A rapid evidence assessment.

Telepsychology holds promise as a treatment delivery method that may increase access to services as well as reduce barriers to treatment accessibility. The aim of this rapid evidence assessment was to assess the evidence for synchronous telepsychology interventions for 4 common mental health conditions (depression, anxiety, posttraumatic stress disorder, and adjustment disorder). Randomized controlled trials published between 2005 and 2016 that investigated synchronous telepsychology (i.e., telephone delivered, video teleconference delivered, or Internet delivered text based) were identified through literature searches. From an initial yield of 2,266 studies, 24 were included in the review. Ten studies investigated the effectiveness of telephone-delivered interventions, 11 investigated the effectiveness of video teleconference (VTC) interventions, 2 investigated Internet-delivered text-based interventions, and 2 were reviews of multiple telepsychology modalities. There was sufficient evidence to support VTC and telephone-delivered interventions for mental health conditions. The evidence for synchronous Internet-delivered text-based interventions was ranked as "unknown." Telephone-delivered and VTC-delivered psychological interventions provide a mode of treatment delivery that can potentially overcome barriers and increase access to psychological interventions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

What Are Effective Psychological Interventions for Veterans With Sleep Disturbances? A Rapid Evidence Assessment.

BACKGROUND: Insomnia and related sleep disturbances commonly occur in veterans, with prevalence rates as high as 90% reported in some studies. Military-specific factors such as sleep disturbances during military training and deployment, as well as a higher prevalence of post-traumatic stress disorder (PTSD), which is known to poorly impact sleep, may contribute to higher insomnia rates in veterans. Although evidence-based guidelines for the treatment of insomnia exist, the unique nature of veterans sleep problems means they may differ in their response to treatment. The aim of this study was to review the evidence for interventions for veterans with sleep disturbances. METHODS: This literature review used a rapid evidence assessment methodology, also known as rapid review. The rapid evidence assessment methodology involves rigorously locating, appraising, and synthesising the evidence while making concessions to the breadth or the depth of the process in order to significantly decrease the length of the process. EMBASE, MEDLINE (PubMed), PsychINFO, Cochrane, Clinical Guidelines Portal (Australia), and the National Guideline Clearinghouse (United States) were searched for peer-reviewed literature and guidelines published from 2004 to August 2015 that investigated psychological interventions for veterans with sleep disturbances. The literature was assessed in terms of strength (quality, quantity, and level of evidence), direction, and the consistency, generalizability, and applicability of the findings to the population of interest. These assessments were then collated to determine an overall ranking of level of support for each intervention: "Supported" (clear, consistent evidence of a beneficial effect), "Promising" (evidence suggestive of a beneficial effect but further research is required), "Unknown" (insufficient evidence of beneficial effect and further research is required), and "Not Supported" (clear consistent evidence of no effect or negative harmful effect). FINDINGS: From an initial yield of 1,131 articles, 18 studies met the inclusion criteria for review. The majority of the studies investigated the effectiveness of cognitive behavioral therapy for insomnia (CBTi; n = 10). Five studies investigated CBTi with an adjunctive psychotherapy, typically for PTSD-related sleep disturbances. One further study investigated sleep hygiene education (a component of CBTi) with pharmacotherapy. Two final studies investigated hypnotherapy and mind-body bridging, respectively. Overall, the quality of the studies was mixed, with some high and some poor quality studies. DISCUSSION: There was sufficient evidence to support CBTi with adjunctive psychotherapy for veterans with PTSD-related sleep disturbances, although the evidence for CBTi in the treatment of general sleep disturbance for veterans was ranked as "promising." This indicates a beneficial effect, but more research is needed to confidently establish efficacy in a veteran population. There is currently insufficient evidence to support the use of sleep hygiene education and pharmacotherapy, hypnotherapy, or mind-body bridging. Further research dismantling the components of CBTi is needed to identify which are the critical components. Such research has the potential to lead to brief, targeted, and accessible treatments that overcome the time and stigma-related barriers to care that veterans often face.

Is implementation of the 2013 Australian treatment guidelines for posttraumatic stress disorder cost-effective compared to current practice? A cost-utility analysis using QALYs and DALYs.

OBJECTIVE: To assess, from a health sector perspective, the incremental cost-effectiveness of three treatment recommendations in the most recent Australian Clinical Practice Guidelines for posttraumatic stress disorder (PTSD). The interventions assessed are trauma-focused cognitive behavioural therapy (TF-CBT) and selective serotonin reuptake inhibitors (SSRIs) for the treatment of PTSD in adults and TF-CBT in children, compared to current practice in Australia. METHOD: Economic modelling, using existing databases and published information, was used to assess cost-effectiveness. A cost-utility framework using both quality-adjusted life-years (QALYs) gained and disability-adjusted life-years (DALYs) averted was used. Costs were tracked for the duration of the respective interventions and applied to the estimated 12 months prevalent cases of PTSD in the Australian population of 2012. Simulation modelling was used to provide 95% uncertainty around the incremental cost-effectiveness ratios. Consideration was also given to factors not considered in the quantitative analysis but could determine the likely uptake of the proposed intervention guidelines. RESULTS: TF-CBT is highly cost-effective compared to current practice at $19,000/QALY, $16,000/DALY in adults and $8900/QALY, $8000/DALY in children. In adults, 100% of uncertainty iterations fell beneath the $50,000/QALY or DALY value-for-money threshold. Using SSRIs in people already on medications is cost-effective at $200/QALY, but has considerable uncertainty around the costs and benefits. While there is a 13% chance of health loss there is a 27% chance of the intervention dominating current practice by both saving dollars and improving health in adults. CONCLUSION: The three Guideline recommended interventions evaluated in this study are likely to have a positive impact on the economic efficiency of the treatment of PTSD if adopted in full. While there are gaps in the evidence base, policy-makers can have considerable confidence that the recommendations assessed in the current study are likely to improve the efficiency of the mental health care sector.

Support of cancer patients' spiritual needs and associations with medical care costs at the end of life.

BACKGROUND: Although spiritual care is associated with less aggressive medical care at the end of life (EOL), it remains infrequent. It is unclear if the omission of spiritual care impacts EOL costs. METHODS: A prospective, multisite study of 339 advanced cancer patients accrued subjects from September 2002 to August 2007 from an outpatient setting and followed them until death. Spiritual care was measured by patients' reports that the health care team supported their religious/spiritual needs. EOL costs in the last week were compared among patients reporting that their spiritual needs were inadequately supported versus those who reported that their needs were well supported. Analyses were adjusted for confounders (eg, EOL discussions). RESULTS: Patients reporting that their religious/spiritual needs were inadequately supported by clinic staff were less likely to receive a week or more of hospice (54% vs 72.8%; P = .01) and more likely to die in an intensive care unit (ICU) (5.1% vs 1.0%, P = .03). Among minorities and high religious coping patients, those reporting poorly supported religious/spiritual needs received more ICU care (11.3% vs 1.2%, P = .03 and 13.1% vs 1.6%, P = .02, respectively), received less hospice (43.% vs 75.3% ≥1 week of hospice, P = .01 and 45.3% vs 73.1%, P = .007, respectively), and had increased ICU deaths (11.2% vs 1.2%, P = .03 and 7.7% vs 0.6%, P = .009, respectively). EOL costs were higher when patients reported that their spiritual needs were inadequately supported ($4947 vs $2833, P = .03), particularly among minorities ($6533 vs $2276, P = .02) and high religious copers ($6344 vs $2431, P = .005). CONCLUSIONS: Cancer patients reporting that their spiritual needs are not well supported by the health care team have higher EOL costs, particularly among minorities and high religious coping patients.