Web-Based Problem-solving Training With and Without Peer Support in Veterans With Unmet Mental Health Needs: Pilot Study of Feasibility, User Acceptability, and Participant Engagement.

BACKGROUND: eHealth tools have the potential to meet the mental health needs of individuals who experience barriers to accessing in-person treatment. However, most users have less than optimal engagement with eHealth tools. Coaching from peer specialists may increase their engagement with eHealth. OBJECTIVE: This pilot study aims to test the feasibility and acceptability of a novel, completely automated web-based system to recruit, screen, enroll, assess, randomize, and then deliver an intervention to a national sample of military veterans with unmet mental health needs; investigate whether phone-based peer support increases the use of web-based problem-solving training compared with self-directed use; and generate hypotheses about potential mechanisms of action for problem-solving and peer support for future full-scale research. METHODS: Veterans (N=81) with unmet mental health needs were recruited via social media advertising and enrolled and randomized to the self-directed use of a web-based problem-solving training called Moving Forward (28/81, 35%), peer-supported Moving Forward (27/81, 33%), or waitlist control (26/81, 32%). The objective use of Moving Forward was measured with the number of log-ins. Participants completed pre- and poststudy measures of mental health symptoms and problem-solving confidence. Satisfaction was also assessed post treatment. RESULTS: Automated recruitment, enrollment, and initial assessment methods were feasible and resulted in a diverse sample of veterans with unmet mental health needs from 38 states. Automated follow-up methods resulted in 46% (37/81) of participants completing follow-up assessments. Peer support was delivered with high fidelity and was associated with favorable participant satisfaction. Participants randomized to receive peer support had significantly more Moving Forward log-ins than those of self-directed Moving Forward participants, and those who received peer support had a greater decrease in depression. Problem-solving confidence was associated with greater Moving Forward use and improvements in mental health symptoms among participants both with and without peer support. CONCLUSIONS: Enrolling and assessing individuals in eHealth studies without human contact is feasible; however, different methods or designs are necessary to achieve acceptable participant engagement and follow-up rates. Peer support shows potential for increasing engagement in web-based interventions and reducing symptoms. Future research should investigate when and for whom peer support for eHealth is helpful. Problem-solving confidence should be further investigated as a mechanism of action for web-based problem-solving training. TRIAL REGISTRATION: ClinicalTrials.gov NCT03555435; http://clinicaltrials.gov/ct2/show/NCT03555435.

Serving Veterans in their Communities: Evaluation of an Online Resource for Behavioral Health Care Providers.

Many veterans receive behavioral health care services from providers in their communities. The Community Provider Toolkit (the Toolkit) is a website developed by the National Center for PTSD and the Department of Veterans Affairs intended to provide community mental health care providers with key veteran-focused educational resources. This mixed-methods study examined the potential impact of the Toolkit on provider knowledge and behaviors. Sixty-four clinicians in the community who currently or plan to provide services to veterans were surveyed. The majority of providers found the website useful and easy to navigate. After visiting the site, many providers found additional online and educational resources that they would add to a hypothetical treatment plan. Forty-five providers completed a 1-month follow-up survey focused on use of the Toolkit. Results indicate that the Toolkit may be a valuable tool for increasing provider knowledge about veteran-specific resources.

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.

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.

Military-related experiences and late-life depressive symptomatology among Japanese-American world war II veterans.

Objectives: To examine military service-related variables and late-life depressive symptomatology among older Japanese-American males.Method: This study is a secondary data analysis of a longitudinal, community-based study. A sample of 2669 participants (771 World War II veterans, 1898 civilians) was drawn from the Honolulu-Asia Aging Study. Depressive symptoms were assessed twice across a 9-year period with the Center for Epidemiologic Studies-Depression scale. Covariates included sociodemographic, physical health, health behavior, and psychosocial variables. Combat exposure and symptomatology were examined among a subset of 426 veterans. Cross-sectional and longitudinal designs were analyzed with linear regression.Results: Veterans and civilians did not differ in depression scores. Baseline depression scores significantly predicted follow-up depression scores. For the full sample, lower ratings of quality of life satisfaction, daily activity control and general health were associated with higher depression scores both cross-sectionally and longitudinally. Among veterans, light combat exposure was marginally associated with lower depression scores and longitudinally, previous depression scores and poorer health ratings were significant predictors of depression scores.Conclusion: Results suggest that military service does not affect late-life depressive symptomatology. However, combat exposure may play a marginal role in increased symptoms. Reasons for results include the possibility that other factors are more relevant to late-life depression, symptomatology naturally decreasing over time, or type of combat exposure measurement. Results expand literature by examination of an ethnoracial group not studied often and longitudinal examination of late-life depressive symptoms within a military-related context. Stakeholders should be knowledgeable of the distinct issues presented when serving aging veterans.

TELEMEDICINE VERSUS IN-PERSON DELIVERY OF COGNITIVE PROCESSING THERAPY FOR WOMEN WITH POSTTRAUMATIC STRESS DISORDER: A RANDOMIZED NONINFERIORITY TRIAL.

BACKGROUND: This study examined the effectiveness of telemedicine to provide psychotherapy to women with posttraumatic stress disorder (PTSD) who might be unable to access treatment. Objectives were to compare clinical and process outcomes of PTSD treatment delivered via videoteleconferencing (VTC) and in-person (NP) in an ethnically diverse sample of veteran and civilian women with PTSD. METHODS: A randomized controlled trial of Cognitive Processing Therapy, an evidence-based intervention for PTSD, was conducted through a noninferiority design to compare delivery modalities on difference in posttreatment PTSD symptoms. Women with PTSD, including 21 veterans and 105 civilians, were assigned to receive psychotherapy delivered via VTC or NP. Primary treatment outcomes were changes in PTSD symptoms in the completer sample. RESULTS: Improvements in PTSD symptoms in the VTC condition (n = 63) were noninferior to outcomes in the NP condition (n = 63). Clinical outcomes obtained when both conditions were pooled together (N = 126) demonstrated that PTSD symptoms declined substantially posttreatment (mean = -20.5, 95% CI -29.6 to -11.4) and gains were maintained at 3- (mean = -20.8, 95% CI -30.1 to -11.5) and 6-month followup (mean = -22.0, 95% CI -33.1 to -10.9. Veterans demonstrated smaller symptom reductions posttreatment (mean = -9.4, 95% CI -22.5 to 3.7) than civilian women (mean = -22.7, 95% CI -29.9 to -15.5. CONCLUSIONS: Providing psychotherapy to women with PTSD via VTC produced outcomes comparable to NP treatment. VTC can increase access to specialty mental health care for women in rural or remote areas.

Predictors of anger treatment outcomes.

OBJECTIVE: This study investigated predictors of therapeutic outcomes for veterans who received treatment for dysregulated anger. METHOD: Data are from a randomized controlled trial investigating the effectiveness of video teleconferencing compared to in-person delivery of anger management therapy (AMT) among 125 military veterans. Multilevel modeling was used to assess 2 types of predictors (demographic characteristics and mental health factors) of changes in anger symptoms after treatment. RESULTS: Results showed that while veterans benefited similarly from treatment across modalities, veterans who received two or more additional mental health services and who had longer commutes to care showed the greatest improvement on a composite measure of self-reported anger symptoms. CONCLUSION: Results highlight that veterans with a range of psychosocial and mental health characteristics benefited from AMT, while those receiving the most additional concurrent mental health services had better outcomes.

The impact of trauma-focused psychotherapies on anger: A systematic review and meta-analysis.

OBJECTIVE: Anger is one of the most prevalent concerns among individuals with posttraumatic stress disorder (PTSD) and is often a residual symptom following PTSD treatment. The purpose of this systematic review and meta-analysis was to determine how effective trauma-focused PTSD psychotherapies are in reducing anger. METHOD: The study was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This study conducted a systematic review of studies that reported the effect of trauma-focused treatments on anger outcomes. Additionally, a meta-analysis was conducted with a subset of studies that used randomized controlled trials (RCTs) methodologies to compare trauma-focused PTSD treatments to nontrauma-focused and control conditions. RESULTS: The systematic review included 16 studies with a total of 1,846 participants. In 11 of the studies, there was a significant decrease in an anger dimension following treatment. Eight studies with 417 total participants met inclusion criteria for the meta-analysis. The meta-analysis yielded a pooled effect size of PTSD treatment on anger of Hedges's g = 0.33. CONCLUSION: Overall, trauma-focused treatments for PTSD significantly improve anger, but the magnitude of change is small-to-medium. Additional research is needed to determine how best to maximize anger outcomes following trauma-focused treatment or determine if and when targeted anger treatment is needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Impact and efficiency of treatment across two PTSD clinical trials comparing in-person and telehealth service delivery formats.

The intent of this study is to examine treatment impact and efficiency observed when cognitive behavioral treatments for posttraumatic stress disorder (PTSD) are delivered in-person or using telehealth. This study pooled data from 268 veterans enrolled in two PTSD clinical trials. In both trials, treatment was delivered using in-home telehealth (telehealth arm), in-home in-person (in-home arm), and in-office care, where patients traveled to the Department of Veterans Affairs for either office-based telehealth or office-based in-person care (office arm). Average age was 44 (SD = 12.57); 80.9% were males. The PTSD Checklist for DSM-5 (PCL-5) was used to assess symptom severity. Treatment impact was measured by (a) the proportion of participants who completed at least eight treatment sessions and (b) the proportion with a reliable change of ≥ 10 points on the PCL-5. Treatment efficiency was measured by the number of days required to reach the end point. The proportion of participants who attended at least eight sessions and achieved reliable change on the PCL-5 differed across treatment formats (ps < .05). Participants in the in-home (75.4%) format were most likely to attend at least eight treatment sessions, followed by those in the telehealth (58.3%) and office (44.0%) formats, the latter of which required patients to travel. Participants in the in-home (68.3%, p < .001) format were also more likely to achieve reliable change, followed by those in the telehealth (50.9%) and office (44.2%) formats. There were no significant differences in the amount of time to complete at least eight sessions. Delivery of therapy in-home results in a significantly greater likelihood of achieving both an adequate dose of therapy and a reliable decrease in PTSD symptoms compared to telehealth and office formats. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Telemedicine: a cost-reducing means of delivering psychotherapy to rural combat veterans with PTSD.

BACKGROUND: Although effective psychotherapies for posttraumatic stress disorder (PTSD) exist, high percentages of Veterans in need of services are unable to access them. One particular challenge to providing cost-effective psychological treatments to Veterans with PTSD involves the difficulty and high cost of delivering in-person, specialized psychotherapy to Veterans residing in geographically remote locations. The delivery of these services via clinical videoteleconferencing (CVT) has been presented as a potential solution to this access to care problem. MATERIALS AND METHODS: This study is a retrospective cost analysis of a randomized controlled trial investigating telemedicine service delivery of an anger management therapy for Veterans with PTSD. The parent trial found that the CVT condition provided clinical results that were comparable to the in-person condition. Several cost outcomes were calculated in order to investigate the clinical and cost outcomes associated with the CVT delivery modality relative to in-person delivery. RESULTS: The CVT condition was significantly associated with lower total costs compared with the in-person delivery condition. The delivery of mental health services via CVT enables Veterans who would not normally receive these services access to empirically based treatments. Additional studies addressing long-term healthcare system costs, indirect cost factors at the patient and societal levels, and the use of CVT in other geographic regions of the United States are needed. CONCLUSIONS: The results of this study provide evidence that CVT is a cost-reducing mode of service delivery to Veterans with PTSD relative to in-person delivery.

The Use of Evaluation Panels During the Development of a Digital Intervention for Veterans Based on Cognitive Behavioral Therapy for Insomnia: Qualitative Evaluation Study.

BACKGROUND: Individuals enrolling in the Veterans Health Administration frequently report symptoms consistent with insomnia disorder. Cognitive behavioral therapy for insomnia (CBT-I) is a gold standard treatment for insomnia disorder. While the Veterans Health Administration has successfully implemented a large dissemination effort to train providers in CBT-I, the limited number of trained CBT-I providers continues to restrict the number of individuals who can receive CBT-I. Digital mental health intervention adaptations of CBT-I have been found to have similar efficacy as traditional CBT-I. To help address the unmet need for insomnia disorder treatment, the VA commissioned the creation of a freely available, internet-delivered digital mental health intervention adaptation of CBT-I known as Path to Better Sleep (PTBS). OBJECTIVE: We aimed to describe the use of evaluation panels composed of veterans and spouses of veterans during the development of PTBS. Specifically, we report on the methods used to conduct the panels, the feedback they provided on elements of the course relevant to user engagement, and how their feedback influenced the design and content of PTBS. METHODS: A communications firm was contracted to recruit 3 veteran (n=27) and 2 spouse of veteran (n=18) panels and convene them for three 1-hour meetings. Members of the VA team identified key questions for the panels, and the communications firm prepared facilitator guides to elicit feedback on these key questions. The guides provided a script for facilitators to follow while convening the panels. The panels were telephonically conducted, with visual content displayed via remote presentation software. The communications firm prepared reports summarizing the panelists' feedback during each panel meeting. The qualitative feedback described in these reports served as the raw material for this study. RESULTS: The panel members provided markedly consistent feedback on several elements of PTBS, including recommendations to emphasize the efficacy of CBT-I techniques; clarify and simplify written content as much as possible; and ensure that content is consistent with the lived experiences of veterans. Their feedback was congruent with previous studies on the factors influencing user engagement with digital mental health interventions. Panelist feedback influenced multiple course design decisions, including reducing the effort required to use the course's sleep diary function, making written content more concise, and selecting veteran testimonial videos that emphasized the benefits of treating chronic insomnia symptoms. CONCLUSIONS: The veteran and spouse evaluation panels provided useful feedback during the design of PTBS. This feedback was used to make concrete revisions and design decisions consistent with existing research on improving user engagement with digital mental health interventions. We believe that many of the key feedback messages provided by these evaluation panels could prove useful to other digital mental health intervention designers.

Training Staff Across the Veterans Affairs Health Care System to Use Mobile Mental Health Apps: A National Quality Improvement Project.

BACKGROUND: The National Center for PTSD, within the Department of Veterans Affairs (VA), has developed a suite of free, publicly available, evidence-informed apps that can reach an increasing number of veterans and bridge gaps in care by providing resources to those who are not engaged in mental health treatment. To expand the reach of these apps, staff across VA service lines learned about these apps, their features and limitations, and how to introduce them to veterans. OBJECTIVE: This study aimed to develop, disseminate, and evaluate a training for multidisciplinary staff as part of a national quality improvement project to increase the reach of mobile mental health apps as a resource for veterans. METHODS: Sites from all of VA's 18 geographic regions enrolled in this project. At each site, a minimum of 25 VA staff members who had direct contact with veterans, including staff from the mental health service line and all other service lines, were recruited to participate. Training included a 3-hour multidisciplinary core module, and a 1-hour clinical integration module designed specifically for mental health clinicians. Owing to the COVID-19 pandemic, the trainings were adapted to a live, web-based format. Pre- and posttraining surveys assessed program reach (ie, participants enrolled per site), satisfaction, and effectiveness of the training as measured by changes in knowledge, basic skills, and behavioral intentions to use apps with veterans. RESULTS: A total of 1110 participants representing 34 disciplines at 19 VA sites completed the training. Overall, 67% (743/1109) of participants were mental health staff members. Sites averaged 58.4 participants (SD 36.49, median [IQR] 51). Most (961/1024, 93.85%) participants were satisfied with the training and reported that they (941/1018, 92.44%) would recommend it to others. App knowledge scores significantly increased from pretraining (mean 80.8% correct, SD 15.77%) to posttraining (mean 91.1% correct, SD 9.57%; P<.001). At posttraining, participants also reported greater confidence in their ability to show veterans how to download (z=-13.86; P<.001) and use VA mental health apps (z=-15.13; P<.001). There was near universal endorsement by staff for their intentions to recommend apps to veterans as well as their ability to think of at least one specific veteran to whom they could recommend an app. Staff also reported a strong motivation to encourage other VA staff to share apps with veterans. CONCLUSIONS: The training far exceeded the initial goals for staff recruitment and training for all three metrics. Overall, 33% (366/1109) of participants came from service lines outside of mental health, indicating the feasibility of introducing these mental health resources during medical appointments and in other contexts.

Mental health apps and U.S. military veterans: Perceived importance and utilization of the National Center for Posttraumatic Stress Disorder app portfolio.

U.S. veterans have historically experienced more mental health concerns as compared to the general population, yet face a variety of barriers to accessing care. Evidence-based and accessible resources, such as mobile apps, are needed to respond to the unique needs of a diverse veteran population. The U.S. Department of Veterans Affairs (VA's) National Center for Posttraumatic Stress Disorder has created a one-of-a-kind portfolio of mental health apps to target the needs of veterans and support the self-management of common concerns related to posttraumatic stress disorder. Using data from a nationally representative sample of U.S. veterans, the present study sought to examine how veterans perceived the importance of making each self-management app available to other Veterans; factors impacting veterans' intent to try each app; and actual uptake of each app. Results revealed that while 46.7%-75.0% of veterans reported that the apps are important for veterans, 5.8%-19.2% reported that they would be likely to download the apps, and only 5.0% reported having ever used any of them. Veterans who used any of the apps were more likely to be employed, have served two or more deployments, be married or partnered, use the VA as their primary source of health care, had more medical conditions, and were less likely to identify as Black. With respect to future app use, Black veterans were to 2-5 times more likely than White veterans to indicate a desire to download each of the apps. Other variables that showed consistent associations with increased likelihood of app download included greater smartphone utilization, being married or having a partner, lower household income, and history of mental health treatment. Implications of these results for the broader dissemination of mental health apps and promotion of their uptake are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

PTSD Coach Version 3.1: A Closer Look at the Reach, Use, and Potential Impact of This Updated Mobile Health App in the General Public.

BACKGROUND: With widespread smartphone ownership, mobile health apps (mHealth) can expand access to evidence-based interventions for mental health conditions, including posttraumatic stress disorder (PTSD). Research to evaluate new features and capabilities in these apps is critical but lags behind app development. The initial release of PTSD Coach, a free self-management app developed by the US Departments of Veterans Affairs and Defense, was found to have a positive public health impact. However, major stakeholder-driven updates to the app have yet to be evaluated. OBJECTIVE: We aimed to characterize the reach, use, and potential impact of PTSD Coach Version 3.1 in the general public. As part of characterizing use, we investigated the use of specific app features, which extended previous work on PTSD Coach. METHODS: We examined the naturalistic use of PTSD Coach during a 1-year observation period between April 20, 2020, and April 19, 2021, using anonymous in-app event data to generate summary metrics for users. RESULTS: During the observation period, PTSD Coach was broadly disseminated to the public, reaching approximately 150,000 total users and 20,000 users per month. On average, users used the app 3 times across 3 separate days for 18 minutes in total, with steep drop-offs in use over time; a subset of users, however, demonstrated high or sustained engagement. More than half of users (79,099/128,691, 61.46%) accessed one or more main content areas of the app (ie, Manage Symptoms, Track Progress, Learn, or Get Support). Among content areas, features under Manage Symptoms (including coping tools) were accessed most frequently, by over 40% of users (53,314/128,691, 41.43% to 56,971/128,691, 44.27%, depending on the feature). Users who provided initial distress ratings (56,971/128,691, 44.27%) reported relatively high momentary distress (mean 6.03, SD 2.52, on a scale of 0-10), and the use of a coping tool modestly improved momentary distress (mean -1.38, SD 1.70). Among users who completed at least one PTSD Checklist for DSM-5 (PCL-5) assessment (17,589/128,691, 13.67%), PTSD symptoms were largely above the clinical threshold (mean 49.80, SD 16.36). Among users who completed at least two PCL-5 assessments (4989/128,691, 3.88%), PTSD symptoms decreased from the first to last assessment (mean -4.35, SD 15.29), with approximately one-third (1585/4989, 31.77%) of these users experiencing clinically significant improvements. CONCLUSIONS: PTSD Coach continues to fulfill its mission as a public health resource. Version 3.1 compares favorably with version 1 on most metrics related to reach, use, and potential impact. Although benefits appear modest on an individual basis, the app provides these benefits to a large population. For mHealth apps to reach their full potential in supporting trauma recovery, future research should aim to understand the utility of individual app features and identify strategies to maximize overall effectiveness and engagement.

Temporary PTSD symptom increases among individuals receiving CPT in a hybrid effectiveness-implementation trial: Potential predictors and association with overall symptom change trajectory.

OBJECTIVE: Concern about symptom worsening with trauma-focused treatment may be one factor hindering the implementation of evidence-based treatments for PTSD, like cognitive processing therapy (CPT), despite evidence for their efficacy. Previous studies have examined the frequency and effect of symptom exacerbation, or temporary symptom increases, on outcomes, but primarily in randomized clinical trials. METHOD: We examined this issue in a community sample of participants receiving CPT from front-line clinicians learning to deliver CPT in a randomized controlled implementation trial of training strategies. Patient participants (n = 183) completed self-report measures of PTSD symptoms at each session. RESULTS: Most participants (67.3%) experienced at least one temporary symptom increase during CPT (only 1.6% continued to have higher symptoms by the end of treatment). Demographic variables, comorbid conditions (i.e., depression, anxiety, substance use), and baseline PTSD symptom levels did not predict symptom increases. Importantly, symptom increases did not predict treatment noncompletion, posttreatment PTSD symptom levels, or loss of probable PTSD diagnosis. Moreover, growth curve modeling revealed that temporary symptom increases did not predict the trajectory of PTSD symptoms over the course of treatment. CONCLUSIONS: The rates of symptom increases, which were higher than in previous studies, may be attributed to a routine care sample or to the differences in session timing and measurement. These results add to a nascent literature documenting that symptom increases may be a normal, transient part of treatment that do not impact a patient's ability to have symptom improvement during a course of CPT. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A randomized trial of brief couple therapy for PTSD and relationship satisfaction.

OBJECTIVE: This three-arm randomized trial tested a brief version of cognitive-behavioral conjoint therapy (bCBCT) delivered in two modalities compared to couples' psychoeducation in a sample of U.S. veterans with posttraumatic stress disorder (PTSD) and their intimate partners. METHOD: Couples were randomized to receive (a) in-person, office-based bCBCT (OB-bCBCT), (b) bCBCT delivered via home-based telehealth (HB-bCBCT), or (c) an in-person psychoeducation comparison condition (PTSD family education [OB-PFE]). Primary outcomes were clinician-assessed PTSD severity (Clinician Administered PTSD Scale), self-reported psychosocial functioning (Brief Inventory of Psychosocial Functioning), and relationship satisfaction (Couples Satisfaction Index) at posttreatment and through 6-month follow-up. RESULTS: PTSD symptoms significantly decreased by posttreatment with all three treatments, but compared to PFE, PTSD symptoms declined significantly more for veterans in OB-bCBCT (between-group d = 0.59 [0.17, 1.01]) and HB-bCBCT (between-group d = 0.76 [0.33, 1.19]) treatments. There were no significant differences between OB-bCBCT and HB-bCBCT. Psychosocial functioning and relationship satisfaction showed significant small to moderate improvements, with no differences between treatments. All changes were maintained through 6-month follow-up. CONCLUSIONS: A briefer, more scalable version of CBCT showed sustained effectiveness relative to an active control for improving PTSD symptoms when delivered in-person or via telehealth. Both bCBCT and couples' psychoeducation improved psychosocial and relational outcomes. These results could have a major impact on PTSD treatment delivery within large systems of care where access to brief, evidence-based PTSD treatments incorporating family members are needed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Group cognitive processing therapy delivered to veterans via telehealth: a pilot cohort.

The authors report clinical findings from the pilot cohort of the first prospective, noninferiority-designed randomized clinical trial evaluating the clinical outcomes of delivering a cognitive-behavioral group intervention for posttraumatic stress disorder (PTSD), cognitive processing therapy (CPT), via video teleconferencing (VT) compared to the in-person modality. The treatment was delivered to 13 veterans with PTSD residing on the Hawaiian Islands. Results support the general feasibility and safety of using VT. Both groups showed clinically meaningful reductions in PTSD symptoms and no significant between-group differences on clinical or process outcome variables. In keeping with treatment manual recommendations, a few changes were made to the CPT protocol to accommodate this population. Novel aspects of this trial and lessons learned are discussed.

Therapist adherence to manualized cognitive-behavioral therapy for anger management delivered to veterans with PTSD via videoconferencing.

Therapist adherence to a manualized cognitive-behavioral anger management group treatment (AMT) was compared between therapy delivered via videoconference (VC) and the traditional in-person modality, using data from a large, randomized controlled trial comparing the effectiveness of AMT for veterans with combat-related posttraumatic stress disorder. Therapist adherence was rated for the presence or absence of process and content treatment elements. Secondary analyses were conducted using a repeated measures ANOVA. Overall adherence to the protocol was excellent (M = 96%, SD = 1%). Findings indicate that therapist adherence to AMT is similar across delivery modalities and VC is a viable service delivery strategy that does not compromise a therapist's ability to effectively structure sessions and manage patient care.

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.

Predicting treatment dropout among veterans receiving prolonged exposure therapy.

OBJECTIVE: To examine whether dropout from prolonged exposure (PE) therapy can be predicted from demographic and outcomes data that would typically be available to clinicians. METHODS: Dropout was examined in 2,606 patients treated by clinicians in the U.S. Veterans Health Administration PE Training Program. PE typically consists of 8-15 sessions, with 8 sessions being considered a minimum therapeutic dose for most patients. Logistic regression was used to assess the impact of demographics, depression, trauma history, and PE target trauma on risk for dropout. Growth mixture modeling was used to study how posttraumatic stress disorder symptom patterns during the first 5 treatment encounters predicted dropout. RESULTS: In total, 782 patients (30.0%) completed fewer than 8 sessions of PE. Younger veterans were more likely to drop out of PE; odds ratio (OR) per year of age = 0.97, p < .01. Controlling for other factors, veterans who focused on childhood trauma were less likely to drop out than those focusing on combat trauma (OR = 0.51, p < .05). Dropout was unrelated to symptom course or symptom worsening between sessions. Nevertheless, clinicians attributed dropout to distress or avoidance in 45% of the patients who dropped out, citing other factors in 37% of dropout cases. CONCLUSIONS: Treatment dropout was predicted by age but not by initial symptom severity or symptom course early in treatment. Symptom exacerbation was rare and did not increase risk of dropout. Nonetheless, clinicians often attributed dropout to patients not tolerating PE. (PsycInfo Database Record (c) 2020 APA, all rights reserved).