Linguistic and affective characteristics of script-driven imagery for adults with posttraumatic stress order: Associations with clinical outcomes during deep transcranial magnetic stimulation.

Brief exposure to traumatic memories using script-driven imagery (SDI) has been proposed as a promising treatment for posttraumatic stress disorder (PTSD). This study investigated the effect of SDI plus active versus sham deep transcranial magnetic stimulation (TMS) in a secondary analysis of a randomized controlled trial for adults with PTSD (N = 134). Linguistic features of scripts and self-reported distress during a 12-session deep TMS treatment protocol were examined as they related to (a) baseline PTSD symptom severity, (b) trauma characteristics, and (c) treatment outcomes. Linguistic Inquiry and Word Count (LIWC) software was used to analyze the following linguistic features of SDIs: negative emotion, authenticity, and cognitive processing. More use of negative emotion words was associated with less severe self-reported and clinician-rated baseline PTSD symptom severity, r = -.18, p = .038. LIWC features did not differ based on index trauma type, range: F(3, 125) = 0.29-0.49, ps = .688-.831. Between-session reductions in self-reported distress across SDI trials predicted PTSD symptom improvement across both conditions at 5-week, B = -15.68, p = .010, and 9-week endpoints, B = -16.38, p = .011. Initial self-reported distress and linguistic features were not associated with treatment outcomes. The findings suggest that individuals with PTSD who experience between-session habituation to SDI-related distress are likely to experience a corresponding improvement in PTSD symptoms.

Development of a patient-centered text message-based platform for the self-management of interstitial cystitis/bladder pain syndrome symptoms.

OBJECTIVE: To develop a patient-centered text message-based platform that promotes self-management of symptoms of interstitial cystitis/bladder pain syndrome (IC/BPS). METHODS: Adult women with IC/BPS interested in initiating a first- or second-line treatments per American Urological Association guidelines (recategorized as "behavioral/non-pharmacologic treatments" and "oral medicines" in the 2022 version) participated in rapid cycle innovation consisting of iterative cycles of contextual inquiry, prototype design and development. We delivered treatment modules and supportive messages using an algorithm-driven interactive messaging prototype through a HIPAA-compliant texting platform. Patients provided feedback through narrative text messages and an exit interview. Feedback was analyzed qualitatively and used to iteratively revise the platform until engagement ≥ 85% and accuracy ≥ 80% were achieved. The final version consisted of four treatment module categories (patient education and behavioral modification, cognitive behavioral therapy, pelvic floor physical therapy, and guided mindfulness practices) and supportive messages delivered through an automated algorithm over 6 weeks. RESULTS: Thirty IC/BPS patients with moderate symptom bother (median IC Problem Index score 9, range 6-12) participated in five cycles of contextual inquiry. Qualitative analysis identified three overarching concepts that informed the development of the platform: preference for patient centered terms, desire to gain self-efficacy in managing symptoms, and need for provider support. Patients preferred the term "interstitial cystitis" to "bladder pain syndrome" which carried the stigma of chronic pain. Patients reported greater self-efficacy in managing symptoms through improved access to mind-body and behavioral treatment modules that helped them to gain insight into their motivations and behaviors. The concept of provider support was informed by shared decision making (patients could choose preferred treatment modules) and reduced sense of isolation (weekly check in messages to check on symptom bother). CONCLUSION: A patient centered text message-based platform may be clinically useful in the self-management of IC/BPS symptoms.

Psychological and Cognitive Functioning Among Patients Receiving Outpatient Rehabilitation for Post-COVID Sequelae: An Observational Study.

OBJECTIVES: To describe the characteristics of individuals receiving outpatient rehabilitation for post-acute sequelae of SARS-CoV-2 infection (PASC). Further, to examine factors associated with variation in their psychological and cognitive functioning and health-related quality of life. DESIGN: Observational study. SETTING: Outpatient COVID-19 recovery clinic at a large, tertiary, urban health system in the US. PARTICIPANTS: COVID-19 survivors with persistent sequelae (N=324). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Multivariable logistic and linear regression models were used to examine factors associated with COVID survivors' experience of severe anxiety, severe depression, post-traumatic stress disorder (PTSD), cognitive impairment, and self-reported health-related quality of life. RESULTS: About 38% of survivors seeking care for their persistent COVID symptoms suffered from severe anxiety, 31.8% from severe depression, 43% experiencing moderate to severe PTSD symptomology, and 17.5% had cognitive impairment. Their health-related quality of life was substantially lower than that of the general population (-26%) and of persons with other chronic conditions. Poor and African American/Black individuals experienced worse psychological and cognitive sequelae after COVID19 infection, even after controlling for age, sex, initial severity of the acute infection, and time since diagnosis. CONCLUSIONS: Evidence of consistent disparities in outcomes by the patients' race and socioeconomic status, even among those with access to post-acute COVID rehabilitation care, are concerning and have significant implications for PASC policy and program development.

Worry about COVID-19 as a predictor of future insomnia.

The coronavirus disease 2019 (COVID-19) pandemic resulted in significant increases in insomnia, with up to 60% of people reporting increased insomnia. However, it is unclear whether exposure to risk factors for the virus or worries about COVID-19 are more strongly associated with insomnia. Using a three-part survey over the course of the first 6 months of the pandemic, we evaluated associations between COVID-19 exposures, COVID-19 worries, and insomnia. We hypothesised that COVID-19-related worries and exposure to risk of COVID-19 would predict increases in insomnia. Participants (N = 3,560) completed a survey at three time-points indicating their exposures to COVID-19 risk factors, COVID-19-related worries, and insomnia. COVID-19 worry variables were consistently associated with greater insomnia severity, whereas COVID-19 exposure variables were not. COVID-19 worries decreased significantly over time, and there were significant interactions between change in COVID-19 worries and change in insomnia severity over time. Individuals who experienced increases in COVID-19 worries also experienced increases in insomnia severity. Changes in worry during the COVID-19 pandemic were associated with changes in insomnia; worries about COVID-19 were a more consistent predictor of insomnia than COVID-19 exposures. Evidence-based treatments targeting virus-related worries may improve insomnia during this and future calamities.

How do women with interstitial cystitis/bladder pain syndrome make treatment choices?

INTRODUCTION AND HYPOTHESIS: There is a relative lack of data regarding how patients weigh various factors when choosing a treatment strategy for interstitial cystitis/bladder pain syndrome (IC/BPS). Our aim is to describe patient experience with their current and prior treatments and discuss factors they consider when choosing a treatment. METHODS: Twenty-one women with IC/BPS participated in five focus groups moderated by a psychologist. Focus groups were conducted until thematic saturation was reached. Group discussions were transcribed and independently coded by two reviewers. Emergent themes and concepts were identified using grounded theory methodology. Data on symptoms and beliefs regarding medications were collected using validated questionnaires: Interstitial Cystitis Symptom and Problem Index (ICSI and ICPI) and Beliefs in Medications Questionnaire-Specific (BMQ-S). RESULTS: The median age of participants was 42 years, and all had some college education. Median score (range) for the ICSI was 12 (4, 20) and for the ICPI was 10 (3, 16), indicating moderate symptom burden. Most patients had tried only first- or second-line treatments. The median BMQ-S score was 2, indicating a neutral attitude toward medication. Several themes were identified. Patients expressed interest in self-management of symptoms using a structured care plan that incorporates guided self-care practices and care that can be delivered virtually. Patients desired to minimize treatment side effects by reducing prescription medications and avoiding surgical procedures. Finally, patients had considerable interest in alternative treatments; however, they wanted these treatments to be evidence-based. CONCLUSIONS: Women with IC/BPS have a strong interest in guided programs that teach self-care practices and deliver alternative treatments through remote platforms.

Trauma Exposure and PTSD in Philadelphia Community Mental Health.

OBJECTIVE: Based on feedback received during post-training consultation within a Prolonged Exposure (PE) implementation initiative, additional assessment training was added to help community providers identify patients who met criteria for posttraumatic stress disorder (PTSD) symptom severity and were considered appropriate for PTSD treatment. The current study investigated the rates of trauma exposure and PTSD in the community sample, as well as the percentage of individuals deemed "appropriate" for PE by community therapists. METHOD: Clinicians involved in the PE Initiative administered the Post-traumatic Diagnostic Scale for DSM-5 (PDS-5) to 10,260 individuals across 13 community agencies. Clinicians were also asked to report whether patients were perceived as appropriate for PE. RESULTS: Consistent with our hypothesis, the rates of potential PTSD in Philadelphia community mental health (58.2% of our total sample) far exceeded national averages (8.3%). Contrary to our hypothesis, 100% of patients who scored above the clinical cutoff for PTSD were considered appropriate for PE by their community clinician. CONCLUSIONS: The results of this study emphasize the high prevalence of PTSD among individuals presenting for treatment to community mental health centers. Despite common misconceptions that patients are often perceived as ineligible or not appropriate for PE, 100% of patients in the PE Initiative who scored above the clinical cutoff for PTSD were considered good candidates for treatment according to their clinicians. This suggests that with sufficient training and post-training consultation, as provided in this community initiative, community clinicians may be more likely to perceive PE as an appropriate treatment option.

Consultation and professional development within the prolonged exposure initiative.

Previous studies have identified that ongoing consultation and organizational support are key factors in sustaining evidence-based implementation initiatives in community mental health. Clinician-level factors likely influence implementation but are not well delineated. This study assessed clinician-reported professional development incentives for participating in consultation in prolonged exposure (PE) therapy to guide future evidence-based practice (EBP) initiatives. Providers in the PE initiative (N = 22) completed a survey asking about their motivations to participate, the impact of consultation on the implementation of PE and their professional development goals, and the impact of organizational-level support on their goals and on organizational-level clinician turnover. Of the respondents, 10 had decided to pursue additional training to become PE consultants at their agencies. Providers (response rate = 22/35) reported joining the PE Initiative to learn an evidence-based practice in general (not PE specifically) and increase their skill in treating posttraumatic stress disorder. Providers largely found ongoing consultation helpful and reported that consultation provided the feedback and support necessary to achieve their professional goals. Providers who decided to pursue PE consultant training reported that expanding upon supervision and clinical skills were strong motivators. Providers largely attributed clinician turnover within the PE Initiative to organizational-level factors. Ongoing consultation facilitated providers' professional development goals. The survey identified several areas for further exploration, including how consultation can reduce clinician turnover, and how taking on additional responsibility within implementation initiatives can facilitate provider engagement in the EBP.

Under-documentation of psychiatric diagnoses among persons living with HIV in electronic medical records.

Persons living with HIV (PLWH) are significantly more likely to meet criteria for a psychiatric disorder compared to the general population. To our knowledge there are no prior studies that report rates of psychiatric diagnosis documentation in electronic medical records (EMRs) of PLWH. The goal for this study was to report the rates of a variety of psychiatric diagnoses among PLWH in electronic medical records. Participants (n = 2,336) were enrolled in the Center for AIDS Research (CFAR) Longitudinal Database study at the University of Pennsylvania, Philadelphia, PA. Diagnostic codes were extracted from the EMR for depressive disorders, alcohol and substance use disorders, PTSD, sleep disorders, and adjustment disorders and were compared to rates from national epidemiological studies. Rates of Major Depressive Disorder in the EMR were comparable to prior reports on HIV-infected samples. In contrast, rates of PTSD, substance use disorders, alcohol use disorders, adjustment disorders and insomnia from the EMR were all markedly lower compared to national estimates for HIV-infected samples. While clinicians appropriately documented evidence of Major Depressive Disorder, other psychiatric comorbidities were largely overlooked. These findings suggest a potential bias in how clinicians either detect or document psychiatric disorders in PLWH.

Suicide risk among persons living with HIV.

Persons living with HIV (PLWH) are significantly more likely to die by suicide compared to the general population. This is the first study to examine the impact of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), insomnia, and substance use disorders on suicidal ideation/behavior among PLWH using electronic medical record (EMR) data. We also evaluated the mutual influence of interactions between PTSD and substance use disorders on suicide risk, consistent with the substance abuse, violence exposure, and HIV/AIDS "SAVA" syndemic model. Participants (n = 2336) were HIV+ individuals recruited through the Center for AIDS Research (CFAR). Participants provided informed consent for extraction of their EMR. As hypothesized, univariate analyses revealed that PTSD, MDD, insomnia, alcohol and other substance use disorders (cocaine abuse and cocaine dependence, opioid abuse and dependence, cannabis abuse, other psychoactive substance abuse and dependence, and polysubstance use disorder) were each positively associated with suicidal ideation/behavior. Also as hypothesized, a multivariable analysis found that alcohol and cocaine dependence, MDD, and PTSD were significant predictors of suicidal ideation/behavior. Contrary to hypotheses, none of the interactions between PTSD and substance use disorders were significantly associated with suicidal ideation/behavior.

Conducting Prolonged Exposure for PTSD During the COVID-19 Pandemic: Considerations for Treatment.

The unprecedented effects and duration of the COVID-19 crisis are likely to elevate the population's level of anxiety due to psychological stress, economic hardship, and social isolation. This effect may be especially potent for individuals with preexisting mental health conditions, such as posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) therapy is a highly effective treatment for PTSD across trauma-exposed populations, and has been implemented effectively via telehealth. Nevertheless, PE implementation via telehealth may require specific adaptations during the COVID-19 crisis due to public health mandates calling for sheltering in place and physical distancing. This paper discusses strategies for implementing PE for PTSD during the COVID-19 pandemic, which may also be applied to other situations in which physical distancing must be considered.

Reduction in Suicidal Ideation from Prolonged Exposure Therapy for Adolescents.

OBJECTIVE: Adolescents with posttraumatic stress disorder (PTSD) are at higher risk for suicide compared to adolescents without PTSD. This study aimed to explore whether PTSD treatment reduces suicidal ideation in adolescents and whether the degree of reduction in PTSD was associated with reduction in suicidal ideation. METHODS: Adolescent females with PTSD from a sexual assault (55% Black, 15.3 years, SD = 1.5) were randomized to either prolonged exposure therapy for adolescents (PE-A, n= 31) or client-centered therapy (CCT, n = 30). They reported on suicidal ideation, depression and PTSD at pre- and post-treatment, every therapy session, and follow-up, and about 40% endorsed suicidal ideation at baseline. RESULTS: There was a significant reduction in a single-item measure of suicidal ideation during treatment across all participants. The Time in Treatment × Condition interaction was significant (p < .05, d = 0.52), indicating a significantly steeper reduction in suicidal ideation in PE-A compared to in CCT. The degree of reduction in PTSD (ps < .05, d = 0.26-0.54) and depression symptoms (ps < .05, d= 0.54-0.81) in treatment and follow-up was associated with the speed of suicidal ideation reduction in treatment and follow-up. CONCLUSIONS: Adolescents randomized to PE-A had significantly faster reductions in suicidal ideation compared to those randomized to CCT. Greater reduction in PTSD and depression symptoms were associated with faster reduction in suicidal ideation. Clinically, this study demonstrates that adolescents who have suicidal ideation without current intent may benefit from PE-A.

The pattern of symptom change during prolonged exposure therapy and present-centered therapy for PTSD in active duty military personnel.

BACKGROUND: Few studies have investigated the patterns of posttraumatic stress disorder (PTSD) symptom change in prolonged exposure (PE) therapy. In this study, we aimed to understand the patterns of PTSD symptom change in both PE and present-centered therapy (PCT). METHODS: Participants were active duty military personnel (N = 326, 89.3% male, 61.2% white, 32.5 years old) randomized to spaced-PE (S-PE; 10 sessions over 8 weeks), PCT (10 sessions over 8 weeks), or massed-PE (M-PE; 10 sessions over 2 weeks). Using latent profile analysis, we determined the optimal number of PTSD symptom change classes over time and analyzed whether baseline and follow-up variables were associated with class membership. RESULTS: Five classes, namely rapid responder (7-17%), steep linear responder (14-22%), gradual responder (30-34%), non-responder (27-33%), and symptom exacerbation (7-13%) classes, characterized each treatment. No baseline clinical characteristics predicted class membership for S-PE and M-PE; in PCT, more negative baseline trauma cognitions predicted membership in the non-responder v. gradual responder class. Class membership was robustly associated with PTSD, trauma cognitions, and depression up to 6 months after treatment for both S-PE and M-PE but not for PCT. CONCLUSIONS: Distinct profiles of treatment response emerged that were similar across interventions. By and large, no baseline variables predicted responder class. Responder status was a strong predictor of future symptom severity for PE, whereas response to PCT was not as strongly associated with future symptoms.

Distress Intolerance and Smoking Topography in the Context of a Biological Challenge.

INTRODUCTION: Distress intolerance (DI), one's perceived or behavioral incapacity to withstand distress, is implicated in psychopathology and smoking. This study evaluated the effect of DI on smoking reinforcement in the context of a carbon dioxide (CO2) biological challenge. METHODS: Adult daily smokers (n = 90; 48.9% female) were randomized to receive a single inhalation/breath of 35% CO2-enriched air (n = 45) or compressed room air (n = 45). Perceived DI was assessed before the challenge. Smoking reinforcement was examined via average post-challenge puff volume across puffs and at the puff-to-puff level. RESULTS: Higher DI was associated with an increased average puff volume (b = -4.7, p = .031). CO2 produced decreased average puff volume compared with room air (b = -7.7, p = .018). There was a DI* condition interaction (ƒ2 = 0.02), such that CO2 decreased average puff volume compared with room air in smokers with higher DI (b = -13.9, t = -3.06, p = .003), but not lower DI. At the puff-to-puff level, there was a significant interaction between DI, condition, and cubic time (b = 0.0003, p =. 037). Specifically, room air produced large initial puff volumes that decreased from puff to puff over the cigarette for high- and low-DI smokers. CO2 produced persistent flat volumes from puff to puff over the cigarette for higher DI smokers, whereas CO2 produced puff volumes like that of room air in lower DI smokers. DISCUSSION: Findings suggest DI heightens smoking reinforcement generally, and in the context of intense cardiorespiratory distress, is associated with stable and persistent smoking. DI is a promising therapeutic target that, if addressed through psychological intervention, may improve cessation outcomes by decreasing smoking reinforcement. IMPLICATIONS: This study contributes to our understanding of the relationship between DI and smoking reinforcement, via examining these processes in response to acute cardiorespiratory distress. Specifically, we found that smokers who are less tolerant of distress, as opposed to those who are more tolerant, evince a decrease in average puff volume, and consistently low puff-to-puff volume, in response to a biological stressor. These findings suggest that smokers high in DI alter smoking behavior following acute cardiorespiratory distress, perhaps to reduce overstimulation, yet also persist in smoking in a manner that suggests an inability to achieve satiation.

Climate Change and Mental Health.

This JAMA Insights discusses the adverse effects of climate change on mental health and proposes solutions to help mitigate those effects.

Relation between lifespan polytrauma typologies and post-trauma mental health.

BACKGROUND: Most individuals experience more than one trauma. Hence, it is important to consider the count and types of traumas (polytraumatization) in relation to post-trauma mental health. METHOD: The current study examined the relation of polytraumatization patterns to PTSD clusters (intrusions, avoidance, negative alterations in cognitions and mood [NACM], and alterations in arousal and reactivity [AAR]), depression, and impulsivity facets (lack of perseverance, lack of premeditation, negative urgency, sensation seeking) using a web-based sample of 346 participants. Age, gender, race, and ethnicity were covariates. RESULTS: Results of latent class analyses indicated a three-class solution: Low Experience, Moderate Experience - Predominent Threat/Indirect PTEs (Moderate Experience), and High Experience - Predominant Interpersonal PTEs (High/Interpersonal). Multinomial logistic regression results indicated that ethnicity and gender were significant covariates in predicting Low versus High/Interpersonal Class, and Moderate Experience versus High/Interpersonal Class membership, respectively. The High/Interpersonal Class had higher scores on most PTSD clusters, depression, and the impulsivity facets of lack of perseverance and negative urgency compared to the other classes. The Low and Moderate Experience Classes differed on PTSD's avoidance and AAR clusters (lower in the former). CONCLUSIONS: Individuals exposed to multiple PTE types, particularly interpersonal traumas, may be at risk for more severe post-trauma symptoms.

Associative learning versus fear habituation as predictors of long-term extinction retention.

Violation of unconditioned stimulus (US) expectancy during extinction training may enhance associative learning and result in improved long-term extinction retention compared to within-session habituation. This experiment examines variation in US expectancy (i.e., expectancy violation) as a predictor of long-term extinction retention. It also examines within-session habituation of fear-potentiated startle (electromyography, EMG) and fear of conditioned stimuli (CS) throughout extinction training as predictors of extinction retention. Participants (n = 63) underwent fear conditioning, extinction and retention and provided continuous ratings of US expectancy and EMG, as well as CS fear ratings before and after each phase. Variation in US expectancy throughout extinction and habituation of EMG and fear was entered into a regression as predictors of retention and reinstatement of levels of expectancy and fear. Greater variation in US expectancy throughout extinction training was significantly predictive of enhanced extinction performance measured at retention test, although not after reinstatement test. Slope of EMG and CS fear during extinction did not predict retention of extinction. Within-session habituation of EMG and self-reported fear is not sufficient for long-term retention of extinction learning, and models emphasizing expectation violation may result in enhanced outcomes.

Changes in self-efficacy and outcome expectancy as predictors of anxiety outcomes from the CALM study.

BACKGROUND: Although self-efficacy (SE) and outcome expectancy (OE) have been well researched as predictors of outcome, few studies have investigated changes in these variables across treatments. We evaluated changes in OE and SE throughout treatment as predictors of outcomes in a large sample with panic disorder, generalized anxiety disorder, social anxiety disorder, or posttraumatic stress disorder. We hypothesized that increases in SE and OE would predict reductions in anxiety and depression as well as improvement in functioning. METHODS: Participants (mean age = 43.3 years, SD = 13.2, 71.1% female, 55.5% white) were recruited from primary care centers throughout the United States and were randomized to receive either Coordinated Anxiety Learning and Management (CALM) treatment - composed of cognitive behavioral therapy, psychotropic medication, or both - or usual care. SE and OE ratings were collected at each session for participants in the CALM treatment (n = 482) and were entered into a structural equation model as predictors of changes in Brief Symptom Inventory, Anxiety Sensitivity Index, Patient Health Questionnaire (PHQ), and Sheehan Disability Scale outcomes at 6, 12, and 18 months after baseline. RESULTS: The best-fitting models predict symptom levels from OE and SE and not vice versa. The slopes and intercept of OE significantly predicted change in each outcome variable except PHQ-8. The slope and intercept of SE significantly predicted change in each outcome variable. CONCLUSION: Over and above absolute level, increases in SE and OE were significant predictors of decreases in symptoms and increases in functioning. Implications for treatment are discussed, as well as future directions of research.

Inflammatory Bowel Diseases-related Disability: Risk Factors, Outcomes, and Interventions.

The diagnosis of inflammatory bowel disease (IBD) is a life-changing moment for most adults. Biomedical advances over the past 2 decades have resulted in unprecedented growth of therapeutic options for IBD. However, due to the incurable nature of IBD, medical and surgical intervention alone may not be adequate to completely normalize health status and prevent long-term disability. In the biopsychosocial model of health and disease, a person's health and function result from complex physical, psychosocial, and environmental interactions. Adapting the World Health Organization definition, IBD-related disability encompasses limitations in educational and employment opportunities, exclusions in economic and social activities, and impairments in physical and psychosocial function. Although the concept of IBD-related disability is a long-term treatment end point in the updated Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE-II) treatment guideline, it has received limited attention in the literature. This review article explores an etiological framework of the physical and psychosocial aspects that contribute to IBD-related disability. We also explore the impact of IBD-related disability on the direct and indirect costs of IBD. Lastly, we present the available evidence for interventions with the potential to improve function and reduce IBD-related disability.

A dynamical systems analysis of change in PTSD symptoms, depression symptoms, and suicidal ideation among military personnel during treatment for PTSD.

OBJECTIVE: The connections among posttraumatic stress disorder (PTSD), depression, and suicidal ideation are elusive because of an overreliance on cross-sectional studies. In this secondary analysis of pooled data from three clinical trials of 742 military personnel, we examined the dynamic relationships among PTSD, depression, and suicidal ideation severity assessed repeatedly during and after outpatient treatment for PTSD. METHODS: We conducted dynamical systems analyses to explore the potential for coordinated change over time in psychotherapy for PTSD. RESULTS: Over the course of psychotherapy, PTSD, depression, and suicidal ideation severity changed in coordinated ways, consistent with an interdependent network. Results of eigenvalue decomposition analysis indicated the dominant change dynamic involved high stability and resistance to change but indicators of cycling were also observed, indicating participants "switched" between states that resisted change and states that promoted change. Depression (B = 0.48, SE = 0.11) and suicidal desire (B = 0.15, SE = 0.01) at a given assessment were associated with greater change in PTSD symptom severity at the next assessment. Suicidal desire (B = 0.001, SE < 0.001) at a given assessment was associated with greater change in depression symptom severity at the next assessment. Neither PTSD (B = -0.004, SE = 0.007) nor depression symptom severity (B = 0.000, SE = 0.001) was associated with subsequent change in suicidal ideation severity. CONCLUSIONS: In a sample of treatment-seeking military personnel with PTSD, change in suicidal ideation and depression may precede change in PTSD symptoms but change in suicidal ideation was not preceded by change in PTSD or depression symptoms.

CBT competence in novice therapists improves anxiety outcomes.

OBJECTIVE: This study explores the relationships between therapist variables (cognitive behavioral therapy [CBT] competence, and CBT adherence) and clinical outcomes of computer-assisted CBT for anxiety disorders delivered by novice therapists in a primary care setting. METHODS: Participants were recruited for a randomized controlled trial of evidence-based treatment, including computer-assisted CBT, versus treatment as usual. Therapists (anxiety clinical specialists; ACSs) were nonexpert clinicians, many of whom had no prior experience in delivering psychotherapy (and in particular, very little experience with CBT). Trained raters reviewed randomly selected treatment sessions from 176 participants and rated therapists on measures of CBT competence and CBT adherence. Patients were assessed at baseline and at 6-, 12-, and 18-month follow-ups on measures of anxiety, depression, and functioning, and an average Reliable Change Index was calculated as a composite measure of outcome. CBT competence and CBT adherence were entered as predictors of outcome, after controlling for baseline covariates. RESULTS: Higher CBT competence was associated with better clinical outcomes whereas CBT adherence was not. Also, CBT competence was inversely correlated with years of clinical experience and trended (not significantly, though) down as the study progressed. CBT adherence was inversely correlated with therapist tenure in the study. CONCLUSIONS: Therapist competence was related to improved clinical outcomes when CBT for anxiety disorders was delivered by novice clinicians with technology assistance. The results highlight the value of the initial training for novice therapists as well as booster training to limit declines in therapist adherence.