Four Decades of Military Posttraumatic Stress: Protocol for a Meta-analysis and Systematic Review of Treatment Approaches and Efficacy.

BACKGROUND: Over 85% of active members of the Canadian Armed Forces have been exposed to potentially traumatic events linked to the development of posttraumatic stress disorder (PTSD). At the time of transition to civilian life, as high as 1 in 8 veterans may be diagnosed with PTSD. Given the high prevalence of PTSD in military and veteran populations, the provision of effective treatment considering their unique challenges and experiences is critical for mental health support and the well-being of these populations. OBJECTIVE: This paper presents the protocol for a meta-analysis and systematic review that will examine the effectiveness of treatment approaches for military-related PTSD. METHODS: This PROSPERO-preregistered meta-analysis is being conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Cochrane guidelines. A comprehensive search of the literature was conducted using the databases PsycInfo, Medline, Embase, CINAHL, and ProQuest Dissertation & Theses. Effect sizes will be computed based on changes in PTSD symptom scores over time across studies using validated PTSD scales. A multilevel meta-analysis will examine the overall effects, between-study effects, and within-study effects of available evidence for PTSD treatments in military populations. Effect sizes will be compared between pharmacotherapeutic, psychotherapeutic, and alternative/emerging treatment interventions. Finally, meta-regression and subgroup analyses will explore the moderating roles of clinical characteristics (eg, PTSD symptom clusters), treatment approaches (eg, therapeutic orientations in psychotherapy and alternative therapies and classifications of drugs in pharmacotherapy), as well as treatment characteristics (eg, length of intervention) on treatment outcomes. RESULTS: The literature search was completed on April 14, 2021. After the removal of duplicates, a total of 12,002 studies were screened for inclusion. As of July 2021, title and abstract screening has been completed, with 1469 out of 12,002 (12.23%) studies included for full-text review. Full review is expected to be completed in the summer of 2021, with initial results expected for publication by early winter of 2021. CONCLUSIONS: This meta-analysis will provide information on the current state of evidence on the efficacy and effectiveness of various treatment approaches for military-related PTSD and identify factors that may influence treatment outcomes. The results will inform clinical decision-making for service providers and service users. Finally, the findings will provide insights into future treatment development and practice recommendations to better support the well-being of military and veteran populations. TRIAL REGISTRATION: PROSPERO CRD42021245754; https://tinyurl.com/y9u57c59. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/33151.

An evaluation of large group cognitive behaviour therapy with mindfulness (CBTm) classes.

BACKGROUND: Ensuring equitable and timely access to Cognitive Behaviour Therapy (CBT) is challenging within Canada's service delivery model. The current study aims to determine acceptability and effectiveness of 4-session, large, Cognitive Behaviour Therapy with Mindfulness (CBTm) classes. METHODS: A retrospective chart review of adult outpatients (n = 523) who attended CBTm classes from 2015 to 2016. Classes were administered in a tertiary mental health clinic in Winnipeg, Canada and averaged 24 clients per session. Primary outcomes were (a) acceptability of the classes and retention rates and (b) changes in anxiety and depressive symptoms using Generalized Anxiety Disorder 7-item (GAD-7) and Patient Health Questionnaire 9-item (PHQ-9) scales. RESULTS: Clients found classes useful and > 90% expressed a desire to attend future sessions. The dropout rate was 37.5%. A mixed-effects linear regression demonstrated classes improved anxiety symptoms (GAD-7 score change per class = - 0.52 [95%CI, - 0.74 to - 0.30], P < 0.001) and depressive symptoms (PHQ-9 score change per class = - 0.65 [95%CI, - 0.89 to - 0.40], P < 0.001). Secondary analysis found reduction in scores between baseline and follow-up to be 2.40 and 1.98 for the GAD-7 and PHQ-9, respectively. Effect sizes were small for all analyses. CONCLUSIONS: This study offers preliminary evidence suggesting CBTm classes are an acceptable strategy to facilitate access and to engage and maintain clients' interest in pursuing CBT. Clients attending CBTm classes experienced improvements in anxiety and depressive symptoms. Symptom improvement was not clinically significant. Study limitations, such as a lack of control group, should be addressed in future research.

Imagery vividness ratings during exposure treatment for posttraumatic stress disorder as a predictor of treatment outcome.

Within exposure-based trauma treatments for posttraumatic stress disorder (PTSD), imagery vividness during imaginal exposure of the traumatic memory is an understudied but potentially important predictor of treatment outcome. Further, to our knowledge, this relationship has only been studied in women to date, and never among individuals with PTSD and substance use disorders which could impact ability to produce vivid mental imagery and its impact. The current study investigated whether imagery vividness ratings during in-session exposure predicted post-treatment PTSD symptom severity in a sample of men and women with comorbid PTSD and substance use disorders, and also examined whether gender moderated this relationship. A sample of 71 participants who received an exposure-based trauma treatment were included in the analyses. PTSD symptom severity was assessed using both the Clinician Administered PTSD Scale (CAPS) and the Impact of Event Scale-Revised (IES-R). Results varied according to method of assessing PTSD symptom severity. Higher imagery vividness was associated with better treatment outcome when assessed by the CAPS, with vividness in later sessions relating more strongly to outcome than vividness in earlier sessions. With the IES-R, higher imagery vividness ratings predicted more favorable treatment outcome for men, but less favorable treatment outcomes for women. Findings are discussed in the context of using imagery vividness to maximize treatment outcomes and future research directions involving scientific replication.

Protective factors for mental disorders and psychological distress in female, compared with male, service members in a representative sample.

OBJECTIVE: Although military interest in promoting psychological resilience is growing, resources protective against psychopathology have been understudied in female service members. Using a representative sample of Canadian Forces personnel, we investigated whether religious attendance, spirituality, coping, and social support were related to mental disorders and psychological distress in female service members, and whether sex differences occurred in these associations. METHOD: Religious attendance and spirituality were self-reported. Coping items were taken from 3 scales and produced 3 factors (active, avoidance, and self-medication). Social support was assessed with the Medical Outcomes Study Social Support Survey. Past-year mental disorders were diagnosed with the World Mental Health Composite International Diagnostic Interview. The Kessler Psychological Distress Scale assessed distress. Multivariate regression models investigated links between correlates and psychological outcomes within each sex. For associations that were statistically significant in only one sex, sex by correlate interactions were computed. RESULTS: In female service members, inverse relations were found between social support and MDD, any MDD or anxiety disorder, suicidal ideation, and distress. No associations were found between religious attendance and outcomes, and spirituality was associated with an increased likelihood of some outcomes. Active coping was related to less psychological distress, while avoidance coping and self-medication were linked to a higher likelihood of most outcomes. Although several statistically significant associations were found in only one sex, only one sex by correlate interaction was statistically significant. CONCLUSIONS: Social support was found to be inversely related to several negative mental health outcomes in female service members. Few differences between men and women reached statistical significance. Future research should identify additional helpful resources for female service members.

Objectif : Quoique l'intérêt militaire pour la promotion de la résilience psychologique va en grandissant, les ressources protectrices contre la psychopathologie ont été sous-étudiées chez les membres féminins des forces armées. À l'aide d'un échantillon représentatif du personnel des Forces canadiennes, nous avons recherché si la pratique religieuse, la spiritualité, l'adaptation, et le soutien social étaient liés aux troubles mentaux et à la détresse psychologique chez le personnel féminin des Forces, et si des différences selon le sexe survenaient dans ces associations. Méthode : La pratique religieuse et la spiritualité étaient auto-déclarées. Les items d'adaptation étaient tirés de 3 échelles et produisaient 3 facteurs (actif, évitement, et automédication). Le soutien social était évalué par le Medical Outcomes Study Social Support Survey. Les troubles mentaux de l'année précédente ont été diagnostiqués au moyen du World Mental Health Composite International Diagnostic Interview. L'Échelle de détresse psychologique de Kessler a évalué la détresse. Des modèles de régression multivariée ont servi à rechercher les liens entre les corrélats et les résultats psychologiques de chaque sexe. Pour les associations qui n'étaient statistiquement significatives que pour un sexe, les interactions des sexes par corrélat ont été calculées. Résultats : Chez les membres féminins des forces, des relations inverses ont été constatées entre le soutien social et le trouble dépressif majeur (TDM), tout TDM ou trouble anxieux, l'idéation suicidaire, et la détresse. Aucune association n'a été détectée entre la pratique religieuse et les résultats, et la spiritualité était associée à la probabilité accrue de certains résultats. L'adaptation active était liée à moins de détresse psychologique, tandis que l'adaptation par évitement et l'automédication étaient liées à la probabilité accrue de la plupart des résultats. Bien que plusieurs associations statisquement significatives n'aient été observées que chez un seul sexe, seulement une interaction des sexes par corrélat était statistiquement significative. Conclusions : Le soutien social s'est révélé être inversement lié à plusieurs résultats négatifs de santé mentale chez les membres féminins des forces armées. Peu de différences entre les hommes et les femmes ont atteint la signification statistique. La recherche future devrait identifier des ressources utiles additionnelles pour les membres féminins des forces armées.