Comparative effectiveness of evidence-based psychotherapies for PTSD delivered in VA residential PTSD treatment.

BACKGROUND: Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are first-line treatments for posttraumatic stress disorder (PTSD). There have been few direct comparisons of CPT and PE intended to determine their comparative effectiveness, none of which have examined outcomes among military veterans receiving these treatments in a residential setting such as the Department of Veterans Affairs (VA) residential rehabilitation treatment programs (RRTPs). Such work is essential given that these veterans are among the most complex and severely symptomatic patients with PTSD treated in VA. In this study we compared changes in PTSD and depressive symptoms across admission, discharge, four months and 12 months following discharge among veterans who received CPT or PE within VA RRTPs. METHODS: Using linear mixed models conducted on program evaluation data derived from the electronic medical record and follow-up surveys, we compared self-reported PTSD and depressive symptom outcomes among 1130 veterans with PTSD who were treated with individual CPT (n = 832, 73.5%) or PE (n = 297, 26.5%) in VA PTSD RRTPs in fiscal years 2018-2020. RESULTS: PTSD and depressive symptom severity did not significantly differ at any time points. The CPT and PE groups both showed large-sized reductions in PTSD (CPT d = 1.41, PE d = 1.51) and depression (CPT d = 1.01, PE d = 1.09) from baseline to 12-month follow-up. CONCLUSIONS: Outcomes for PE and CPT do not differ among a highly complex population of veterans with severe PTSD and several comorbid conditions that can make it difficult to engage in treatment.

An examination of relationship satisfaction as a predictor of outcomes of brief couple therapy for posttraumatic stress disorder.

The pretreatment quality of intimate relationships can promote or interfere with couple therapy for posttraumatic stress disorder (PTSD) treatment response. We tested whether baseline relationship satisfaction predicted clinical and process outcomes in two dyadic treatments for PTSD. Using data from a randomized trial comparing brief cognitive behavioral conjoint therapy (bCBCT) for PTSD to PTSD family education (PFE) among 137 military veterans and their partners (N = 274, Mage = 42.3 years, 46.7% White, 81.0% male veteran partner), we examined whether baseline relationship satisfaction (Couples Satisfaction Index; CSI-32) predicted change in PTSD symptom severity (Clinician Administered PTSD Scale for DSM-5; CAPS-5), psychosocial functioning (Brief Inventory of Psychosocial Functioning; B-IPF), and relationship satisfaction at posttreatment and 6-month follow-up. We also explored associations with process outcomes (working alliance, treatment satisfaction, dropout). In both treatment conditions, neither partner's baseline CSI-32 score moderated change in veteran CAPS-5 or B-IPF score or any process variable. However, baseline CSI-32 scores moderated both partners' CSI-32 score change during bCBCT and PFE; participants who scored in the distressed range at baseline (n = 123) experienced significant improvements in relationship satisfaction, ß = .199, whereas there was no change among those in the nondistressed range at baseline (n = 151), ß = .025. Results suggest bCBCT and PFE are effective in improving PTSD symptoms and psychosocial functioning regardless of whether a couple is experiencing clinically significant relationship distress; further, these treatments improve relationship satisfaction for the most distressed individuals.

The impact of trauma-focused psychotherapy for posttraumatic stress disorder on interpersonal functioning: A systematic review and meta-analysis of randomized clinical trials.

Interpersonal functioning is a common concern for people with postttraumatic stress disorder (PTSD) but is not a key target of most trauma-focused psychotherapies (TFPs). We preregistered and undertook a systematic review and meta-analysis of randomized clinical trials (RCTs) examining the efficacy of TFPs for improving interpersonal functioning. Studies were identified through the PTSD Trials Standardized Data Repository, scholarly databases, and the solicitation of unpublished data from the PTSD research community following current PRISMA guidelines. We used random effects meta-analysis to estimate within-group change (i.e., pre- to posttreatment) in interpersonal functioning. Meta-analytic findings yielded a medium total effect of TFP on interpersonal functioning, g = 0.54, 95% CI [0.37, 0.72], with high between-study heterogeneity. Sensitivity analyses yielded substantively equivalent point estimates when outliers were excluded, g = 0.55, and when only the most well-established individual TFPs were included, g = 0.57. In contrast, allocation to a control condition was associated with little average change in interpersonal functioning, g = 0.04 [-0.12, 0.21]. Formal tests did not yield clear evidence of publication bias. Bias-corrected estimates varied but centered around a medium effect, gs = 0.41-1.11. There was a medium-to-large association between change in interpersonal functioning and change in PTSD symptoms, rs = -.35--.44. The extant literature on TFPs and interpersonal functioning is small and heterogeneous, indicating the need for more focused attention on this outcome. Results suggest that, on average, TFPs are moderately efficacious for improving interpersonal functioning; however, additional treatment may be needed to meet the desired level of improvement.

Behavioral Epidemic of Loneliness in Older U.S. Military Veterans: Results From the 2019-2020 National Health and Resilience in Veterans Study.

OBJECTIVE: This study aimed to characterize the current prevalence of loneliness, and the relation between loneliness severity and mental and physical health conditions, suicidality, and functional measures in a predominantly older sample of U.S. military veterans. METHODS: This cross-sectional study used data from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of U.S. veterans (N = 4,069; mean age = 62) from November 2019 through March 2020. Veterans were classified into one of 3 groups based on their current level of loneliness (hardly ever, sometimes, often) on an adapted version of the Revised UCLA Loneliness Scale. A comprehensive range of mental and physical health, and functioning variables were assessed using valid and reliable self-report assessments. RESULTS: A total of 56.9% of veterans endorsed feeling lonely sometimes (37.2%) or often (19.7%). Loneliness severity was independently associated with a range of mental health (odds ratios [ORs] = 1.21-33.30), physical health (ORs = 1.21-6.80), and functional difficulties (d's = 0.09-0.59). Relative to hardly ever feeling lonely, feeling lonely often or sometimes was associated with a more than 12- and three-fold greater likelihood of current suicidal ideation (29.0% versus 7.3% versus 1.5%), even after adjustment for sociodemographic, military, and psychiatric risk factors. CONCLUSIONS: Loneliness is highly prevalent in U.S. military veterans, with more than half endorsing feeling lonely sometimes or often, and 1-of-5 reporting feeling lonely often. Loneliness severity was independently associated with a broad range of mental and physical health and functional measures, ias well as suicidal ideation. Results underscore the importance of loneliness as a transdiagnostic prevention and intervention target in the U.S. veteran population.

Addressing co-occurring suicidal thoughts and behaviors and posttraumatic stress disorder in evidence-based psychotherapies for adults: A systematic review.

Posttraumatic stress disorder (PTSD) is a well-established risk factor for suicidal thoughts and behaviors. Historically, guidelines for treating PTSD have recommended against the use of trauma-focused therapies for patients who are at high risk for suicide, likely due to concerns about potential suicide-related iatrogenesis, specifically the "triggering" of suicidal behaviors. This systematic review examined evidence of the impact of treatments specifically designed to treat PTSD or suicide on both PTSD- and suicide-related outcomes. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a total of 33 articles met the full inclusion criteria: 23 examining PTSD treatments, four examining suicide-focused treatments, and six examining combined treatments. PTSD and combined treatments reduced both PTSD- and suicide-related outcomes, with most studies focusing on cognitive processing therapy or prolonged exposure. Suicide-focused treatments (e.g., cognitive therapies for suicide prevention) also reduced suicide-related outcomes, but the findings were mixed for their impact on PTSD-related outcomes. Overall, PTSD treatments had the most support, primarily due to a larger number of studies examining their outcomes. This supports current clinical guidelines, which suggest utilizing PTSD treatments for individuals who have PTSD and are at risk for suicide. Suicide-focused and combined treatments also appeared to be promising formats, although additional research is needed. Future research should seek to compare the effectiveness of the approaches to the treatment of PTSD and suicidal thoughts and behaviors concurrently as well as to inform guidelines aimed at supporting decisions about the selection of an appropriate treatment approach.

Evidence-based posttraumatic stress disorder treatment in a community sample: Military-affiliated versus civilian patient outcomes.

Posttraumatic stress disorder (PTSD) is a significant mental health issue among military service members and veterans. Although the U.S. Department of Veterans Affairs (VA) provides crucial resources for behavioral health care, many veterans seek mental health services through community clinics. Previous research illustrates that military and veteran patients benefit less from evidence-based treatments (EBTs) for PTSD than civilians. However, most PTSD treatment outcome research on military and veteran populations is conducted in VA or military settings. Little is known about outcomes among military-affiliated patients in community settings. The primary aim of this study was to directly compare civilian versus military-affiliated patient outcomes on PTSD and depression symptoms using the PTSD Checklist for DSM-5 (PCL-5) and the nine-item Patient Health Questionnaire (PHQ-9) in a community setting. Participants (N = 502) included military-affiliated (veteran, Guard/Reservist, active duty) and civilian patients who engaged in cognitive processing therapy (CPT) or prolonged exposure (PE) for PTSD in community clinics. Both groups demonstrated significant reductions on the PCL-5, military-affiliated: d = -0.91, civilian: d = -1.18; and PHQ-9, military-affiliated: d = -0.65, civilian: d = -0.88, following treatment. However, military-affiliated patients demonstrated smaller posttreatment reductions on the PCL-5, Mdiff = 5.75, p = .003, and PHQ-9, Mdiff = 1.71, p = .011, compared to civilians. Results demonstrate that military-affiliated patients benefit from EBTs for PTSD, albeit to a lesser degree than civilians, even in community settings. These findings also highlight the importance of future research on improving EBTs for military personnel with PTSD.

Social cognitive mechanisms in healthcare worker resilience across time during the pandemic.

PURPOSE: Healthcare workers are at increased risk for mental health problems during disasters such as the COVID-19 pandemic. Identifying resilience mechanisms can inform development of interventions for this population. The current study examined pathways that may support healthcare worker resilience, specifically testing enabling (social support enabled self-efficacy) and cultivation (self-efficacy cultivating support) models. METHODS: Healthcare workers (N = 828) in the Rocky Mountain West completed self-report measures at four time points (once per month from April to July of 2020). We estimated structural equation models to explore the potential mediating effects that received social support and coping self-efficacy had (at time 2 and time 3) between traumatic stress symptom severity (at time 1 and time 4). Models included covariates gender, age, minority status, and time lagged co-variations between the proposed mediators (social support and coping self-efficacy). RESULTS: The full model fit the data well, CFI = .993, SRMR = .027, RMSEA = .036 [90% CIs (0.013, 0.057)]. Tests of sequential mediation supported enabling model dynamics. Specifically, the effects of time 1 traumatic stress severity were mediated through received social support at time 2 and time 3 coping self-efficacy, in sequential order to reduce time 4 traumatic stress severity. CONCLUSIONS: Findings show the importance of received social support and coping self-efficacy in mitigating psychopathology risk. Interventions can support mental health by focusing on social resource engagement that facilitates coping empowerment, which may decrease risk for mental health job-related problems among frontline healthcare workers exposed to highly stressful events.

Defining focal brain stimulation targets for PTSD using neuroimaging.

INTRODUCTION: Focal brain stimulation has potential as a treatment for posttraumatic stress disorder (PTSD). In this review, we aim to inform selection of focal brain stimulation targets for treating PTSD by examining studies of the functional neuroanatomy of PTSD and treatment response. We first briefly review data on brain stimulation interventions for PTSD. Although published data suggest good efficacy overall, the neurobiological rationale for each stimulation target is not always clear. METHODS: Therefore, we assess pre- and post-treatment (predominantly psychotherapy) functional neuroimaging studies in PTSD to determine which brain changes seem critical to treatment response. Results of these studies are presented within a previously proposed functional neural systems model of PTSD. RESULTS: While not completely consistent, research suggests that downregulating the fear learning and threat and salience detection circuits (i.e., amygdala, dorsal anterior cingulate cortex and insula) and upregulating the emotion regulation and executive function and contextual processing circuits (i.e., prefrontal cortical regions and hippocampus) may mediate PTSD treatment response. CONCLUSION: This literature review provides some justification for current focal brain stimulation targets. However, the examination of treatment effects on neural networks is limited, and studies that include the stimulation targets are lacking. Further, additional targets, such as the cingulate, medial prefrontal cortex, and inferior parietal lobe, may also be worth investigation, especially when considering how to achieve network level changes. Additional research combining PTSD treatment with functional neuroimaging will help move the field forward by identifying and validating novel targets, providing better rationale for specific treatment parameters and personalizing treatment for PTSD.

Neurocognitive mechanisms of poor social connection in posttraumatic stress disorder: Evidence for abnormalities in social working memory.

BACKGROUND: Poor social connection is a central feature of posttraumatic stress disorder (PTSD), but little is known about the neurocognitive processes associated with social difficulties in this population. We examined recruitment of the default network and behavioral responses during social working memory (SWM; i.e., maintaining and manipulating social information on a moment-to-moment basis) in relation to PTSD and social connection. METHODS: Participants with PTSD (n = 31) and a trauma-exposed control group (n = 21) underwent functional magnetic resonance imaging while completing a task in which they reasoned about two or four people's relationships in working memory (social condition) and alphabetized two or four people's names in working memory (nonsocial condition). Participants also completed measures of social connection (e.g., loneliness, social network size). RESULTS: Compared to trauma-exposed controls, individuals with PTSD reported smaller social networks (p = .032) and greater loneliness (p = .038). Individuals with PTSD showed a selective deficit in SWM accuracy (p = .029) and hyperactivation in the default network, particularly in the dorsomedial subsystem, on trials with four relationships to consider. Moreover, default network hyperactivation in the PTSD group (vs. trauma-exposed group) differentially related to social network size and loneliness (p's < .05). Participants with PTSD also showed less resting state functional connectivity within the dorsomedial subsystem than controls (p = .002), suggesting differences in the functional integrity of a subsystem key to SWM. CONCLUSIONS: SWM abnormalities in the default network may be a basic mechanism underlying poorer social connection in PTSD.

A Preliminary Examination of Endogenous Peripheral Oxytocin in a Pilot Randomized Clinical Trial of Oxytocin-Enhanced Psychotherapy for Posttraumatic Stress Disorder.

BACKGROUND: Preclinical and clinical research suggests that the oxytocin system is implicated in the development and maintenance of stress and anxiety-related psychiatric conditions, such as posttraumatic stress disorder (PTSD). Recent research also suggests that intranasal oxytocin holds promise as a treatment for PTSD. However, little is known about the relationship between levels of peripheral oxytocin and PTSD symptom severity, PTSD treatment response, and repeated intranasal oxytocin administration. METHODS: In the current study, we examined associations between PTSD symptom severity and peripheral oxytocin levels measured in plasma before and after a course of prolonged exposure (PE) for PTSD (n = 13); participants were randomized to adjunctive intranasal oxytocin (n = 6) or placebo (n = 7). RESULTS: Baseline peripheral oxytocin levels were not associated with baseline PTSD symptom severity. Change in peripheral oxytocin levels did not differ by treatment condition and did not correspond to change in PTSD symptoms. CONCLUSIONS: This proof-of-concept study illustrates the acceptability and feasibility of measuring peripheral oxytocin among individuals engaged in psychotherapy for PTSD and informs the utilization of these procedures in future adequately powered studies.

Courses of suicidal ideation among military veterans in residential treatment for posttraumatic stress disorder.

BACKGROUND: Suicidal thoughts are common among veterans with posttraumatic stress disorder (PTSD). The aim of this study was to examine the prevalence and correlates of four courses of suicidal (SI) among veterans receiving residential PTSD treatment. METHODS: A total of 1,807 veterans receiving residential PTSD treatment at Department of Veterans Affairs medical facilities who completed self-report measures at admission and discharge were included. RESULTS: The prevalence of SI courses were No SI (33.6%), Remitted SI (23.0%), SI onset (6.0%), and Chronic SI (37.4%). There were group differences between the four SI courses in PTSD symptoms at baseline, magnitude of PTSD symptom change during treatment, race/ethnicity and baseline depression, substance use, physical functioning, and pain. Chronic SI was associated with highest baseline PTSD, depression, substance use, pain and worse physical functioning. Remitted SI course was associated with greatest pre-posttreatment PTSD improvement, followed by No SI, Chronic SI, and SI Onset. Multinomial logistic regressions revealed that PTSD symptom improvement and baseline PTSD symptoms most consistently related to symptomatic SI courses compared to less symptomatic or No SI courses. Receipt of trauma-focused psychotherapy (none, some, or adequate) and length of stay were not related to SI courses and did not differ between groups. CONCLUSIONS: Findings indicate that treating PTSD symptoms could be impactful for reducing suicidal thoughts. Although many veterans had remitted or reduced severity of SI at discharge, a significant proportion of veterans reported SI at discharge (43.4%), potentially highlighting the need for suicide specific treatment interventions within the context of PTSD treatment.

Feasibility and preliminary efficacy of dialectical behaviour therapy skills groups for Veterans with suicidal ideation: pilot.

BACKGROUND: Veterans are at high risk for suicide; emotion dysregulation may confer additional risk. Dialectical behaviour therapy (DBT) is a well-supported intervention for suicide attempt reduction in individuals with emotion dysregulation, but is complex and multi-component. The skills group component of DBT (DBT-SG) has been associated with reduced suicidal ideation and emotion dysregulation. DBT-SG for Veterans at risk for suicide has not been studied. AIMS: This study sought to evaluate the feasibility and acceptability of DBT-SG in Veterans and to gather preliminary evidence for its efficacy in reducing suicidal ideation and emotion dysregulation and increasing coping skills. METHOD: Veterans with suicidal ideation and emotion dysregulation (N = 17) enrolled in an uncontrolled pilot study of a 26-week DBT-SG as an adjunct to mental health care-as-usual. RESULTS: Veterans attended an average 66% of DBT-SG sessions. Both Veterans and their primary mental health providers believed DBT-SG promoted Veterans' use of coping skills to reduce suicide risk, and they were satisfied with the treatment. Paired sample t-tests comparing baseline scores with later scores indicated suicidal ideation and emotion dysregulation decreased at post-treatment (d = 1.88, 2.75, respectively) and stayed reduced at 3-month follow-up (d = 2.08, 2.59, respectively). Likewise, skillful coping increased at post-treatment (d = 0.85) and was maintained at follow-up (d = 0.91). CONCLUSIONS: An uncontrolled pilot study indicated DBT-SG was feasible, acceptable, and demonstrated potential efficacy in reducing suicidal ideation and emotion dysregulation among Veterans. A randomized controlled study of DBT-SG with Veterans at risk for suicide is warranted.

Clinically Significant Change in Posttraumatic Stress Disorder Symptoms Is Associated With Lower Levels of Aggression After Residential Treatment Discharge.

Although the link between posttraumatic stress disorder (PTSD) and aggression has been repeatedly demonstrated, to our knowledge no research has examined whether PTSD symptom reductions are linked to less aggression after treatment. The current study aimed to address this gap in the literature by examining the association between reductions in PTSD symptoms and posttreatment aggression among 2,275 veterans in residential treatment for PTSD across 35 Veterans Health Administration sites. We estimated a multilevel model that examined the effect of clinically significant PTSD symptom change on aggression at 4-month posttreatment follow-up, and found significant within-site and between-site contextual effects of clinically significant changes in PTSD symptoms on follow-up aggression. Findings revealed that veterans who reported clinically significant changes in their PTSD symptoms had lower levels of aggression at follow-up than veterans at the same treatment site who did not report clinically significant PTSD change. After we controlled for individual clinically significant PTSD change, participants in treatment sites where the rates of clinically significant PTSD change were higher overall had lower levels of aggression at follow-up. The model explained over one-fourth of the variability in aggression, R2 = .26. Findings from the current study extend previous research that has shown associations between PTSD and aggression, by revealing that clinically significant change in PTSD during residential treatment is associated with less aggression at follow-up. These findings suggest that interventions that effectively reduce PTSD symptoms may also help reduce risk for aggression.

Increased Resilience is Associated with Positive Treatment Outcomes for Veterans with Comorbid PTSD and Substance Use Disorders.

OBJECTIVE: Resilience has been associated with less severe psychiatric symptomatology and better treatment outcomes among individuals with posttraumatic stress disorder (PTSD) and substance use disorders. However, it remains unknown whether resilience increases during psychotherapy within the comorbid PTSD and substance use disorder population with unique features of dual diagnosis, including trauma cue-related cravings. We tested whether veterans seeking psychotherapy for comorbid PTSD and substance use disorder reported increased resilience from pre- to posttreatment. We also tested whether increased resilience was associated with greater decreases in posttreatment PTSD and substance use disorder symptoms. METHODS: Participants were 29 male veterans (Mage = 49.07 years, SD = 11.24 years) receiving six-week residential day treatment including cognitive processing therapy for PTSD and cognitive behavioral therapy for substance use disorder. Resilience, PTSD symptoms, and trauma cue-related cravings were assessed at pre- and posttreatment. RESULTS: Veterans reported a large, significant increase in resilience posttreatment (Mdiff = 14.24, t = -4.22, p < .001, d = 0.74). Greater increases in resilience were significantly associated with fewer PTSD symptoms (ß = -0.37, p = .049, sr = -.36) and trauma-cued cravings (ß = -0.39, p = .006, sr = -.38) posttreatment when controlling for pretreatment scores and baseline depressive symptoms. CONCLUSIONS: Results suggest that evidence-based psychotherapy for comorbid PTSD and substance use disorder may facilitate strength-based psychological growth, which may further promote sustained recovery.

LONGITUDINAL COURSE OF POSTTRAUMATIC GROWTH AMONG U.S. MILITARY VETERANS: RESULTS FROM THE NATIONAL HEALTH AND RESILIENCE IN VETERANS STUDY.

BACKGROUND: Posttraumatic growth (PTG) is increasingly recognized as an important psychosocial phenomenon, but few studies have evaluated the longitudinal course of PTG. This study identified courses of PTG over a 2-year period in a contemporary, nationally representative sample of U.S. military veterans, and examined sociodemographic, military, trauma, medical, and psychosocial predictors of PTG course. METHODS: Data were based on a Web-based survey of a nationally representative sample of 1,838 U.S. veterans who reported at least one potentially traumatic event and provided data at two time points (October-December 2011 and September-October 2013). RESULTS: Five different courses of PTG were identified--Consistently Low (33.6%), Moderately Declining (19.4%), Increasing PTG (16.8%), Dramatically Declining (15.7%), and Consistently High (14.5%). More than half (59.4%) of veterans who reported at least "moderate" PTG maintained that level of PTG 2 years later. Posttraumatic stress disorder symptoms, medical conditions, purpose in life, altruism, gratitude, religiosity, and an active reading lifestyle predicted maintenance or increase in PTG. CONCLUSIONS: PTG has a heterogeneous course and is not only common, but can persist over time especially in the presence of posttraumatic stress and certain psychosocial factors. Clinicians and researchers should consider the personal growth that can result from trauma and help trauma survivors find ways to maintain this growth over time.

An examination of the roles of trauma exposure and posttraumatic stress disorder on emotion regulation strategies of Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn veterans.

Theories of posttraumatic stress disorder (PTSD) implicate emotional processes, including difficulties utilizing adaptive emotion regulation strategies, as critical to the etiology and maintenance of PTSD. Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn (OIF/OEF/OND) veterans report high levels of combat exposure and PTSD. We aimed to extend findings suggesting that emotion regulation difficulties are a function of PTSD, rather than combat trauma exposure or common comorbidities, to OIF/OEF/OND veterans, in order to inform models of PTSD risk and recovery that can be applied to returning veterans. We tested differences in emotion regulation, measured with the Difficulties in Emotion Regulation Scale and Emotion Regulation Questionnaire, among trauma-exposed veterans with (n = 24) or without PTSD (n = 22) and healthy civilian comparison participants (n = 27) using multivariate analyses of covariance, adjusting for major depressive disorder, anxiety disorders, and demographic variables (age, sex, and ethnicity). Veterans with PTSD reported more use of expressive suppression and more difficulties with emotion regulation than veterans without PTSD and healthy comparison participants. Groups did not differ on cognitive reappraisal. Findings suggest the key role of PTSD above and beyond trauma exposure, depression, and anxiety in specific aspects of emotion dysregulation among OIF/OEF/OND veterans. Interventions that help veterans expand and diversify their emotion regulation skills may serve as helpful adjunctive treatments for PTSD among OIF/OEF/OND veterans.

Borderline personality disorder and related constructs as risk factors for intimate partner violence perpetration.

In this manuscript we systematically reviewed 29 articles from 2010 to 2014 that addressed the association between borderline personality disorder (BPD) and intimate partner violence (IPV) perpetration, with particular attention paid to the role of perpetrator sex. Our primary objective was to provide a summary of (1) the operationalization and measurement of BPD and IPV, (2) mechanisms of the BPD-IPV association, and (3)the current understanding of the role of perpetrator sex related to BPD and IPV. We observed three distinct operational definitions of BPD which are measured in a variety of ways. IPV measurement tends to be more consistent. Further, emotion perception, impulsivity, attachment, and substance use are proposed mechanisms to explain the BPD IPV relation. The findings regarding potential perpetrator sex differences in the BPD-IPV association are mixed. Finally, we also provide recommendations for future research and clinical practice.

Sources of Social Support and Trauma Recovery: Evidence for Bidirectional Associations from a Recently Trauma-Exposed Community Sample.

Although the association between post-traumatic stress disorder (PTSD) and social support is well documented, few studies have tested the causal pathways explaining this association at several points in the acute post-trauma recovery period or examined whether the association varies for different sources of social support. To address these gaps, 151 community individuals (mean age = 37.20 years, 69.5% women) exposed to trauma within the previous 6 months were recruited to complete measures of PTSD and social support from intimate partners, friends, and relatives four times in 1 year. In line with recent recommendations for research on social support and PTSD symptoms, random intercept cross-lagged panel modeling (RI-CLPM) was used to examine dynamic changes between PTSD severity and social support over time. The pattern of RI-CLPM cross-lagged coefficients indicated that positive deviations from one's expected stable level of total social support (across all sources) sped up the recovery of PTSD symptoms at the end of the post-trauma year, and more severe PTSD symptoms than expected based on one's expected stable level of PTSD started eroding social support midway through the assessment year. When specific sources of social support were analyzed separately, the association between within-person increases in social support from friends at any given time point accelerated the recovery from PTSD across the entire year. Among participants with intimate partners (n = 53), intimate partner support did not predict PTSD symptoms, but more severe PTSD symptoms at any given time point predicted less support at the following time point. Results from this longitudinal study provide additional support for the bidirectional relationship between PTSD and social support over time and suggest that perceived social support from friends may be especially helpful during trauma recovery.

Sustaining the collaborative chronic care model in outpatient mental health: a matrixed multiple case study.

BACKGROUND: Sustaining evidence-based practices (EBPs) is crucial to ensuring care quality and addressing health disparities. Approaches to identifying factors related to sustainability are critically needed. One such approach is Matrixed Multiple Case Study (MMCS), which identifies factors and their combinations that influence implementation. We applied MMCS to identify factors related to the sustainability of the evidence-based Collaborative Chronic Care Model (CCM) at nine Department of Veterans Affairs (VA) outpatient mental health clinics, 3-4 years after implementation support had concluded. METHODS: We conducted a directed content analysis of 30 provider interviews, using 6 CCM elements and 4 Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) domains as codes. Based on CCM code summaries, we designated each site as high/medium/low sustainability. We used i-PARIHS code summaries to identify relevant factors for each site, the extent of their presence, and the type of influence they had on sustainability (enabling/neutral/hindering/unclear). We organized these data into a sortable matrix and assessed sustainability-related cross-site trends. RESULTS: CCM sustainability status was distributed among the sites, with three sites each being high, medium, and low. Twenty-five factors were identified from the i-PARIHS code summaries, of which 3 exhibited strong trends by sustainability status (relevant i-PARIHS domain in square brackets): "Collaborativeness/Teamwork [Recipients]," "Staff/Leadership turnover [Recipients]," and "Having a consistent/strong internal facilitator [Facilitation]" during and after active implementation. At most high-sustainability sites only, (i) "Having a knowledgeable/helpful external facilitator [Facilitation]" was variably present and enabled sustainability when present, while (ii) "Clarity about what CCM comprises [Innovation]," "Interdisciplinary coordination [Recipients]," and "Adequate clinic space for CCM team members [Context]" were somewhat or less present with mixed influences on sustainability. CONCLUSIONS: MMCS revealed that CCM sustainability in VA outpatient mental health clinics may be related most strongly to provider collaboration, knowledge retention during staff/leadership transitions, and availability of skilled internal facilitators. These findings have informed a subsequent CCM implementation trial that prospectively examines whether enhancing the above-mentioned factors within implementation facilitation improves sustainability. MMCS is a systematic approach to multi-site examination that can be used to investigate sustainability-related factors applicable to other EBPs and across multiple contexts.