PTSD and Risk of Incident Cardiovascular Disease in Aging Veterans.

OBJECTIVES: To determine if late-life posttraumatic stress disorder (PTSD) is associated with cardiovascular disease in a sample of older veterans, and whether the association is independent of medical and psychiatric comorbities. DESIGN: Retrospective cohort study conducted using the Department of Veterans Affairs (VA) National Patient Care Database (2000-2011). SETTING: VA medical centers in the United States. PARTICIPANTS: A total of 138,341 veterans 55 years and older without cardiovascular disease at study baseline (2000-2003). MEASUREMENTS: PTSD and cardiovascular disease (as defined by diagnoses of: cerebrovascular disease [CVD], congestive heart failure [CHF], myocardial infarction [MI], and peripheral vascular disease [PVD]) were identified by ICD-9 codes during study baseline (2000-2003) and follow-up (2004-2011), respectively. RESULTS: 3% of veterans (N = 4,041) had a baseline diagnosis of PTSD. Unadjusted increased risk of incidence of CVD was 80%, CHF was 56%, MI was 82%, and PVD was 60% in veterans with PTSD compared with those without PTSD. After adjustment for demographics, medical comorbidities, substance use, and psychiatric comorbidities, veterans with late-life PTSD were at a 45% increased risk for incident CVD, 26% increased risk for incident CHF, 49% increased risk for incident MI, and 35% increased risk for PVD compared with veterans without late-life PTSD. CONCLUSIONS: Findings highlight the longitudinal impact of PTSD on increasing the incidence of cardiovascular disease in older adults. This study implies the need for greater monitoring and treatment of PTSD in older persons, particularly older veterans, to assist in preventing adverse outcomes, such as cardiovascular disease, over the long term.

Trauma Exposure and Risk of Suicidal Ideation Among Older Adults.

OBJECTIVE: To determine if trauma exposure is associated with suicidal ideation in a nationally representative sample of older adults. METHODS: This study included 3,277 participants 55 years and older involved in the Collaborate Psychiatric Epidemiology Surveys (2001-2003). RESULTS: Of the 84.8% of older adults who were exposed to any trauma, 2.2% endorsed late-life suicidal ideation. Multivariable models fully adjusted for sociodemographics, post-traumatic stress disorder, major depressive disorder, and substance use revealed exposure to serious accidents/illness was associated with suicidal ideation (odds ratio: 2.55; 95% confidence interval: 1.16-5.59; Wald χ(2) = 5.47, df = 1, p = 0.019). Investigation of specific traumas within the category revealed that life-threatening illness was specifically associated with suicidal ideation in older adults (odds ratio: 2.12; 95% confidence interval: 1.34-3.36; Wald χ(2) = 10.33, df = 1, p = 0.001). CONCLUSION: These findings highlight the need for monitoring of suicidal ideation among older adults who have been informed of a life-threatening illness diagnosis.

TRAUMA EXPOSURE AND RISK OF SUICIDAL IDEATION AMONG ETHNICALLY DIVERSE ADULTS.

BACKGROUND: Little is known about the association between trauma exposure and suicidal ideation across racial/ethnic groups. Our study aim was to determine the association between trauma exposure and suicidal ideation in a nationally representative ethnically diverse sample of adults. METHODS: This study included 14,866 White, Hispanic, Black, and Asian participants 18 years and older involved in the Collaborate Psychiatric Epidemiology Surveys (2001-2003), comprised of three nationally representative studies (NCS-R, NSAL, and NLAAS). Lifetime history of suicidal ideation as assessed in the World Health Organization's World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (WMH-CIDI). RESULTS: Of the 81% respondents who reported being exposed to trauma as assessed in the WMH-CIDI, 12.1% endorsed lifetime suicidal ideation. Additionally, of the 19% who did not report trauma, 1.1% endorsed lifetime suicidal ideation. Fully adjusted, multivariable logistic regression models revealed two traumas consistently associated with significantly higher odds for suicidal ideation across all four racial groups examined: Assaultive/interpersonal violence and child maltreatment. Asians, in particular, had the highest likelihood for suicidal ideation in both trauma categories, with a near threefold increased odds for assaultive/interpersonal violence exposure (OR: 2.56; 95% CI: 1.71-3.83) and nearly ninefold increased odds for child maltreatment exposure (OR: 8.43; 95% CI: 4.91-14.49). DISCUSSION: Suicidal ideation in racially/ethnically diverse American adults is strongly associated with assaultive/interpersonal violence and child maltreatment, independent of PTSD, MDD, and substance use. These findings highlight the need for monitoring of suicidal behavior following assaultive/interpersonal trauma and child maltreatment, regardless of the presence of a psychiatric disorder.

Multilevel factors in providers' decisions to utilize CPT in military- and veteran-serving treatment settings.

Numerous guidelines exist to inform decision-making regarding psychological treatment of patients with posttraumatic stress disorder (PTSD). While strides have been made in the implementation of evidence-based psychotherapies (EBPs) for PTSD in the United States. Department of Veterans Affairs (VA), a large population of veterans does not receive such services. Research has been conducted on veterans' decisions to enroll in EBPs; however, less is known about providers' perspectives related to offering trauma-focused therapies to the military and veteran population, particularly outside the United States. This study utilizes baseline data from a larger investigation aimed to support the sustained implementation of cognitive processing therapy (CPT) in U.S. VA and Canadian Operational Stress Injury (OSI) and Department of Defense settings. Providers who trained in CPT (N = 55) participated in interviews regarding their opinions of CPT, preferred treatments for PTSD, and their process in assessing appropriate PTSD treatments for each patient. A directed content analysis approach was used to identify themes for providers' decision-making to utilize CPT within the context of four Consolidated Framework for Implementation Research (CFIR) domains. In the outer setting domain, providers reported disconnect from policy and leadership as a barrier, and in the inner setting CFIR domain, providers reported multiple facilitators: available resources, leadership support, and compatibility with CPT. The CFIR domain for characteristics of the individuals aligned with a theme of theoretical orientation and training as a facilitator. The intervention characteristics domain aligned with facilitators and barriers; complexity of CPT was a barrier, but relative advantage and perceived strength of evidence were facilitators toward implementation. The systems surrounding and supporting EBP delivery within the U.S. VA, Canada OSI, and Canadian Forces clinics have more similarities than differences regarding barriers and facilitators to delivering CPT. Despite variability in funding and training, provider experiences across all three systems suggest similar themes. Further investigation is needed to determine whether these findings extend to community samples or sites not yet offering EBPs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Glimpse into the "Black Box": Which Elements of Consultation in an EBP are Associated with Client Symptom Change and Therapist Fidelity?

Background: Consultation is an implementation strategy that improves delivery and clinical outcomes for Cognitive Processing Therapy (CPT), an evidence-based practice (EBP) for posttraumatic stress disorder (PTSD). However, little is known about the specific components of consultation that influence the fidelity of treatment delivery or clinical outcomes. Methods: The current study examined whether specific activities performed during CPT consultation meetings were associated with better fidelity to the CPT protocol among 60 newly trained therapists or improved clinical outcomes among 135 clients treated by these therapists. Consultation activities that fall under three broad categories (discussion of the application of CPT to individual cases, review/feedback on fidelity, and technical difficulties) were measured by consultant checklists for each consultation session. Treatment fidelity (adherence to the protocol and competence of delivery) was rated by trained observers for a random sample of therapists' CPT sessions following consultation. The self-reported PTSD Checklist-IV assessed PTSD symptom change. Results: Multilevel regression analyses indicated that higher therapist consultation attendance predicted a greater decrease in their clients' PTSD symptoms and that attendance was not associated with observer-rated treatment fidelity. Discussion of the application of specific CPT strategies was the only consultation activity that was significantly associated with greater improvement in PTSD symptoms. Lastly, no consultation activities were significantly associated with treatment fidelity. Conclusions: Our findings suggest that specific consultation strategies such as emphasizing the discussion of the application of specific CPT strategies to individual cases during consultation meetings may be effective in improving the clinical outcomes of CPT.

Leveraging routine clinical materials and mobile technology to assess CBT fidelity: the Innovative Methods to Assess Psychotherapy Practices (imAPP) study.

BACKGROUND: Identifying scalable strategies for assessing fidelity is a key challenge in implementation science. However, for psychosocial interventions, the existing, reliable ways to test treatment fidelity quality are often labor intensive, and less burdensome strategies may not reflect actual clinical practice. Cognitive behavioral therapies (CBTs) provide clinicians with a set of effective core elements to help treat a multitude of disorders, which, evidence suggests, need to be delivered with fidelity to maximize potential client impact. The current "gold standard" for rating CBTs is rating recordings of therapy sessions, which is extremely time-consuming and requires a substantial amount of initial training. Although CBTs can vary based on the target disorder, one common element employed in most CBTs is the use of worksheets to identify specific behaviors and thoughts that affect a client's ability to recover. The present study will develop and evaluate an innovative new approach to rate CBT fidelity, by developing a universal CBT scoring system based on worksheets completed in therapy sessions. METHODS: To develop a scoring system for CBT worksheets, we will compile common CBT elements from a variety of CBT worksheets for a range of psychiatric disorders and create adherence and competence measures. We will collect archival worksheets from past studies to test the scoring system and assess test-retest reliability. To evaluate whether CBT worksheet scoring accurately reflects clinician fidelity, we will recruit clinicians who are engaged in a CBT for depression, anxiety, and/or posttraumatic stress disorder. Clinicians and clients will transmit routine therapy materials produced in session (e.g., worksheets, clinical notes, session recordings) to the study team after each session. We will compare observer-rated fidelity, clinical notes, and fidelity-rated worksheets to identify the most effective and efficient method to assess clinician fidelity. Clients will also be randomly assigned to either complete the CBT worksheets on paper forms or on a mobile application (app) to learn if worksheet format influences clinician and client experience or differs in terms of reflecting fidelity. DISCUSSION: Scoring fidelity using CBT worksheets may allow clinics to test fidelity in a short and effective manner, enhancing continuous quality improvement in the workplace. Clinicians and clinics can use such data to improve clinician fidelity in real time, leading to improved patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT03479398 . Retrospectively registered March 20, 2018.

Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial.

BACKGROUND: Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation. METHODS: To compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics' capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS. DISCUSSION: It will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs. TRIAL REGISTRATION: NCT02449421 . Registered 02/09/2015.

Preventing loss of independence through exercise (PLIÉ): a pilot clinical trial in older adults with dementia.

BACKGROUND: Current dementia medications have small effect sizes, many adverse effects and do not change the disease course. Therefore, it is critically important to study alternative treatment strategies. The goal of this study was to pilot-test a novel, integrative group exercise program for individuals with mild-to-moderate dementia called Preventing Loss of Independence through Exercise (PLIÉ), which focuses on training procedural memory for basic functional movements (e.g., sit-to-stand) while increasing mindful body awareness and facilitating social connection. METHODS: We performed a 36-week cross-over pilot clinical trial to compare PLIÉ with usual care (UC) at an adult day program for individuals with dementia in San Francisco, CA. Assessments of physical performance, cognitive function, physical function, dementia-related behaviors, quality of life and caregiver burden were performed by blinded assessors at baseline, 18 weeks (cross-over) and 36 weeks. Our primary outcomes were effect sizes based on between-group comparisons of change from baseline to 18 weeks; secondary outcomes were within-group comparisons of change before and after cross-over. RESULTS: Twelve individuals enrolled (7 PLIÉ, 5 UC) and 2 withdrew (1 PLIÉ, 18 weeks; 1 UC, 36 weeks). Participants were 82% women (mean age, 84 ± 4 years); caregivers were 82% daughters (mean age, 56 ± 13 years). Effect sizes were not statistically significant but suggested potentially clinically meaningful (≥ 0.25 SDs) improvement with PLIÉ versus UC for physical performance (Cohen's D: 0.34 SDs), cognitive function (0.76 SDs) and quality of life (0.83 SDs) as well as for caregiver measures of participant's quality of life (0.33 SDs) and caregiver burden (0.49 SDs). Results were similar when within-group comparisons were made before and after cross-over. CONCLUSIONS: PLIÉ is a novel, integrative exercise program that shows promise for improving physical function, cognitive function, quality of life and caregiver burden in individuals with mild-to-moderate dementia. Larger randomized, controlled trials are warranted. TRIAL REGISTRATION: ClinicalTrials.gov NCT01371214.