Life review therapy for older adults with depressive symptoms in general practice: results of a pilot evaluation.

OBJECTIVE: General practices play an important role in the detection and treatment of depressive symptoms in older adults. An adapted version of the indicated preventive life review therapy group intervention called Looking for Meaning (LFM) was developed for general practice and a pilot evaluation was conducted. DESIGN: A pretest-posttest design was used. One week before and one week after the intervention participants filled out questionnaires. SETTING: In six general practices in the Netherlands the adapted intervention was given. PARTICIPANTS: Inclusion criteria were > 60 years and a score of 5 or higher on the Center for Epidemiological Studies Depression Scale (CES-D). INTERVENTION: The length and number of LFM sessions were shortened and the intervention was given by one mental health care nurse practitioner (MHCNP). MEASUREMENTS: The impact on mental health was analyzed by depressive symptoms (CES-D) as the primary outcome and anxiety symptoms (HADS-A), psychological well-being (PGCMS) and mastery (PMS) as secondary outcomes. An evaluative questionnaire was included to evaluate the feasibility and acceptability. RESULTS: Most participants were satisfied with the adaptations of the number (72%) and length (72%) of sessions. The overall sample showed a significant decrease in depressive symptoms after the intervention. No impact was found on psychological well-being, anxiety symptoms and mastery. CONCLUSIONS: The intervention is feasible and acceptable for older adults with depressive symptoms and has an impact on their depressive symptoms.

Intensive prolonged exposure treatment for adolescent complex posttraumatic stress disorder: a single-trial design.

BACKGROUND: The current study evaluated the effectiveness and safety of intensive prolonged exposure (PE) targeting adolescent patients with complex posttraumatic stress disorder (PTSD) and comorbid disorders following multiple interpersonal trauma. METHODS: Ten adolescents meeting full diagnostic criteria for PTSD were recruited from a specialized outpatient mental health clinic and offered a standardized intensive PE. The intensive PE consisted of three daily 90-min exposure sessions delivered on five consecutive weekdays, followed by 3 weekly 90-min booster sessions. In a single-trial design, the participants were randomly allocated to one of five baseline lengths (4-8 weeks) before starting the intensive PE. Before, during, and after intensive PE completion, self-reported PTSD symptom severity was assessed weekly as a primary outcome (a total of 21 measurements). Furthermore, clinician-administered PTSD diagnostic status and symptom severity (primary outcome), as well as self-reported comorbid symptoms (secondary outcomes), were assessed at four single time points (baseline-to-6-month follow-up). RESULTS: Time-series analyses showed that self-reported PTSD symptom severity significantly declined following treatment (p = .002). Pre-postgroup analyses demonstrated significant reductions of clinician-administered PTSD symptom severity and self-reported comorbidity that persisted during the 3- and 6-month follow-ups (all ps < .05), where 80% of adolescents had reached diagnostic remission of PTSD. There was neither treatment dropout nor any adverse events. CONCLUSIONS: The results of this first proof of concept trial suggest that intensive PE can be effective and safe in an adolescent population with complex PTSD, although the gains achieved need to be confirmed in a randomized controlled trial.

Intensive prolonged exposure therapy for chronic PTSD patients following multiple trauma and multiple treatment attempts.

Background: Suboptimal response and high dropout rates leave room for improvement of trauma-focused treatment (TFT) effectiveness in ameliorating posttraumatic stress disorder (PTSD) symptoms. Objective: To explore the effectiveness and safety of intensive prolonged exposure (iPE) targeting chronic PTSD patients with a likely diagnosis of ICD-11 Complex PTSD following multiple interpersonal trauma and a history of multiple treatment attempts. Method: Participants (N = 73) received iPE in 12 × 90-minute sessions over four days (intensive phase) followed by four weekly 90-minute booster prolonged exposure (PE) sessions (booster phase). The primary outcomes, clinician-rated severity of PTSD symptoms, and diagnostic status (Clinician-Administered PTSD Scale; CAPS-IV) were assessed at baseline, post-treatment, and at three and six months. Treatment response trajectories were identified and predictors of these trajectories explored. Results: Mixed model repeated measures analysis of CAPS-IV scores showed a baseline-to-posttreatment decrease in PTSD symptom severity (p < .001) that persisted during the three- and six-month follow-ups with large effect sizes (Cohen's d > 1.2); 71% of the participants responded. None of the participants dropped out during the intensive phase and only 5% during the booster phase. Adverse events were extremely low and only a minority showed symptom exacerbation. Cluster analysis demonstrated four treatment response trajectories: Fast responders (13%), Slow responders (26%), Partial responders (32%), and Non-responders (29%). Living condition and between-session fear habituation were found to predict outcome. Participants living alone were more likely to belong to the Partial responders than to the Non-responders cluster, and participants showing more between-session fear habituation were more likely to belong to the Fast responders than to the Non-responders cluster. Conclusions: The results of this open study suggest that iPE can be effective in PTSD patients with multiple interpersonal trauma and after multiple previous treatment attempts. In addition, in this chronic PTSD population iPE was safe.

Planteamiento: La respuesta subóptima y las altas tasas de abandono dejan margen para la mejora de la eficacia del tratamiento centrado en el trauma (TCT) en la mejora de los síntomas del trastorno por estrés postraumático (TEPT). Objetivo: explorar la efectividad y la seguridad de la exposición prolongada intensiva (EPI) dirigida a pacientes con TEPT crónico con un probable diagnóstico de TEPT complejo de la CIE-11 después de múltiples traumas interpersonales y un historial de múltiples intentos de tratamiento. Método: Los participantes (N = 73) recibieron EPI en 12 sesiones de 90 minutos durante cuatro días (fase intensiva) seguidas de cuatro sesiones semanales de exposición prolongada (EP) de refuerzo de 90 minutos (fase de refuerzo). Los resultados principales, la gravedad de los síntomas del TEPT evaluados por el clínico y el estado diagnóstico evaluados por el clínico (Escala de TEPT administrada por el clínico, CAPS-IV, por sus siglas en inglés) se evaluaron al inicio, después del tratamiento, y a los tres y seis meses. Se identificaron las trayectorias de respuesta al tratamiento y se exploraron los predictores de estas trayectorias. Resultados: Los análisis de medidas repetidas de las puntuaciones de CAPS-IV desde un modelo mixto mostraron una disminución de la línea de base hasta el postratamiento en cuanto a la gravedad de los síntomas de TEPT (p <.001) que persistió durante los seguimientos a los 3 y 6 meses con tamaños de efecto grandes (d de Cohen> 1,2); el 71% de los participantes respondieron. Ninguno de los participantes abandonó durante la fase intensiva y solo el 5% lo hizo durante la fase de refuerzo. Los eventos adversos fueron extremadamente bajos y solo una minoría mostró exacerbación de los síntomas. El análisis de clusters demostró cuatro trayectorias de respuesta al tratamiento: los que responden rápidamente (13%), los que responden lentamente (26%), los que responden parcialmente (32%) y los que no responden (29%). Se descubrió que las condiciones de vida y la habituación al miedo entre sesiones predecían el resultado. Los participantes que vivían solos eran más propensos a pertenecer a los que responden parcialmente que al grupo de los que no responden, y los participantes que demostraron más habituación al miedo entre sesiones tenían más probabilidades de pertenecer a los que responden rápidamente que al grupo de los que no responden. Conclusiones: los resultados de este estudio abierto sugieren que la EPI puede ser efectiva en pacientes con TEPT con traumas interpersonales múltiples y después de múltiples intentos previos de tratamiento. Además, en esta población de TEPT crónico, la EPI era segura.

Therapist rotation: a novel approach for implementation of trauma-focused treatment in post-traumatic stress disorder.

Background: Trauma-focused treatments (TFTs) for patients with post-traumatic stress disorder (PTSD) are highly effective, yet underused by therapists.Objective: To describe a new way of implementing (adequate use of) TFTs, using a therapist rotation model in which one patient is treated by several therapists.Method: In this article, we will present two examples of working with therapist rotation teams in two treatment settings for TFT of PTSD patients. We explore the experiences with this model from both a therapist and a patient perspective.Results: Our findings were promising in that they suggested that this novel approach reduced the therapists' fear of providing TFT to PTSD patients, increased perceived readiness for TFT, and decreased avoidance behaviour within TFT sessions, possibly leading to better implementation of TFT. In addition, the therapeutic relationship as rated by patients was good, even by patients with insecure attachment styles.Conclusions: We suggest that therapist rotation is a promising novel approach to improve implementation of TFT for PTSD.

Antecedentes: Los tratamientos focalizados en el trauma (TFT en sus siglas en inglés) para pacientes con Trastorno de Estrés Traumático (TEPT) son altamente efectivos, pero todavía los terapeutas no los usan suficientemente. Objetivo: Describir una nueva forma de implementar (el adecuado uso de) tratamientos focalizados en el trauma, por medio del modelo de rotación de terapeuta, en el cual un paciente es tratado por varios terapeutas. Método: En este artículo, presentaremos dos ejemplos de trabajo con equipos de rotación de terapeutas en dos contextos de tratamiento para los TFT de pacientes con TEPT. Nosotros exploramos las experiencias con este modelo desde la perspectiva tanto del terapeuta como del paciente. Resultados: Nuestros hallazgos fueron prometedores en el sentido de que este enfoque original redujo el temor de los terapeutas de proveer los TFT a los pacientes con TEPT, incrementó la disposición percibida sobre los TFT, y disminuyó el comportamiento de evitación en las sesiones de los TFT, conllevando posiblemente a una mejor implementación de los TFT. Adicionalmente, la relación terapéutica fue evaluada por los pacientes como buena, incluso por aquellos pacientes con estilos de apego inseguro. Conclusiones: Nosotros sugerimos que la rotación de terapeuta es un enfoque original promisorio para mejorar la implementación de los TFT para TEPT.

Harm expectancy violation during exposure therapy for posttraumatic stress disorder.

Exposure therapy has proven efficacy in the treatment of posttraumatic stress disorder (PTSD). Emotional processing theory proposes that fear habituation is a central mechanism in symptom reduction, but the empirical evidence supporting this is mixed. Recently it has been proposed that violation of harm expectancies is a crucial mechanism of action in exposure therapy. But to date, changes in harm expectancies have not been examined during exposure therapy in PTSD. The goal of the current study was to examine harm expectancy violation as mechanism of change in exposure therapy for posttraumatic stress disorder (PTSD). Patients (N=50, 44 female) with a primary diagnosis of chronic PTSD received intensive exposure therapy. Harm expectancies, harm experiences and subjective units of distress (SUDs) were assessed at each imaginal exposure session, and PTSD symptoms were assessed pre- and posttreatment with the Clinician Administered PTSD Scale (CAPS). Results showed that harm expectancies were violated within and strongly declined in-between exposure therapy sessions. However, expectancy violation was not related to PTSD symptom change. Fear habituation measures were moderately related to PTSD symptom reductions. In line with theory, exposure therapy promotes expectancy violation in PTSD patients, but this is not related to exposure therapy outcome. More work is warranted to investigate mechanisms of change during exposure therapy in PTSD.

When do trauma experts choose exposure therapy for PTSD patients? A controlled study of therapist and patient factors.

To investigate when and why therapists opt for or rule out imaginal exposure (IE) for patients with posttraumatic stress disorder (PTSD), 255 trauma experts were randomized to two conditions in which they were presented with four cases in which the patients' comorbidity and treatment preferences were manipulated. The results confirmed IE to be an underutilized approach, with the majority of professionals being undertrained in the technique. As predicted, the patient factors influenced the expert's choice of therapy: in case of a comorbid depression, IE was significantly less preferred than medication. Also, IE was significantly more likely to be offered when patients expressed a preference for trauma-focused treatment. The therapist factors were also found to be importantly related to treatment preferences, with high credibility in the technique being positively related to the therapists' preference for IE. Perceived barriers to IE, such as a fear of symptom exacerbation and dropout, were negatively related to the perceived suitability of the treatment when patients had suffered multiple traumas in childhood. The results are discussed in the light of clinical implications and the need of exposure training for trauma professionals.

Feasibility of brief intensive exposure therapy for PTSD patients with childhood sexual abuse: a brief clinical report.

Despite the strong empirical support for the effectiveness of exposure-based treatments in ameliorating post-traumatic stress disorder (PTSD), improvement of treatment is wanted given relatively high dropout rates and challenges of treating patients with high comorbidity and treatment-interfering stressors. The purpose of the current paper is to introduce an intensive exposure treatment program, illustrated by four case descriptions of PTSD patients, who suffered multiple (sexual) traumas in childhood, had high levels of comorbidity and psychosocial stressors, and failed to improve during "regular" trauma-focused treatment programs. The program consisted of psychoeducation, prolonged imaginal exposure, exposure in vivo, exposure by drawings combined with narrative reconstructing, and writing assignments about central trauma-related cognitions. The treatment included 5 working days with individual sessions (in total 30 h of treatment) provided by a team of four therapists. The PTSD symptoms of all patients decreased substantially and the effect sizes were large (Cohen's d resp. 1.5 [pre-post], 2.4 [pre-FU1 month], and 2.3 [pre-FU3 months]). Also, none of the patients showed symptom worsening or dropped out. The evaluation of these four pilot cases suggests that it is possible to intensify exposure treatment, even for multiple traumatized PTSD patients with high comorbidity. We concluded that the first results of this new, intensive exposure program for PTSD patients with childhood sexual abuse are promising.