The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline.

DESCRIPTION: The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline (CPG) and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against. METHODS: Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed. RECOMMENDATIONS: The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder (PTSD) with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.

A clinician's guide to the 2023 VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder.

A clinical practice guideline (CPG) is a rigorously established set of recommendations based on currently available evidence about the efficacy, safety, acceptability, and feasibility of interventions to assist with clinical decision-making. The 2023 Department of Veterans Affairs /Department of Defense Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder is described herein. The CPG recommendations are accompanied by a clinical algorithm, which incorporates principles of evidence-based practice, shared decision-making, and functional and contextual assessments of goals and outcomes. An overview of the CPG recommendations is combined with a discussion of questions that clinicians and patients may face in implementing the CPG and suggestions for how to effectively work with the CPG.

Addressing Fear of Negative Consequences of Overdose Response: A Qualitative Study of the Perceptions of Service Industry Workers Who Encounter an Opioid Overdose in an Urban Commercial District in Atlanta, Georgia.

BACKGROUND: The increased contamination of illicit drugs with fentanyl in the United States drug market has contributed to escalating mortality from drug overdose. Leisure and hospitality service industry workers are encountering opioid-triggered overdoses in their workplaces, such as restaurants and bars. Consequently, this increases the need for overdose education and naloxone distribution (OEND) training, which has been limited. We aimed to describe the experiences among service industry workers encountering an overdose in their workplace. METHODS: We conducted in-depth qualitative interviews with service industry workers in Little Five Points (L5P), Atlanta, between October 2019 and April 2020 and triangulated methods with participant observations and fieldwork. Purposive criterion sampling methods were applied to recruit from different establishments in the L5P commercial district, which comprised restaurants, bars, retail shops, and theaters. After an initial seed sample was identified by engaging key stakeholders during fieldwork (business owners, managers, and the business association), a snowball sample followed for a final sample of N = 15. To contextualize the local population of harm reduction workers, people who use drugs and/or obtain safer drug consumption supplies in L5P (sterile syringes, safer using kits, naloxone), and service industry workers and their customers in L5P, the first author volunteered with an Atlanta syringe services program from October 2019 to April 2020. The first author conducted participant observations during the syringe exchange program and field notes were taken during observation (44 hours). This engagement ensured a rich, thick description. We used a pragmatic approach to thematic data analysis for this study. Data were analyzed iteratively and inductively from interviews and observations. Two independent researchers reviewed transcripts to identify passages in the data related to the question of interest. The passages were contextualized within the full data set independently to understand the relationships in developing a theory of what was commonly occurring across participants' experiences, and these relationships led to emerging salient themes regarding encountering an opioid overdose at work. RESULTS: One salient theme related to overdose response emerged with the service industry workers included fear of negative consequences of overdose response, specifically, fear of disease transmission from artifacts of drug use and overdose response, including the spread of blood-borne disease, violence, and exposure to unintentional overdose. When discussing drug use, participants' beliefs about the potential for personal danger from drug use artifacts (syringes and discarded drugs) and violence were identified as barriers to opioid overdose responses. CONCLUSIONS/IMPLICATIONS FOR OCCUPATIONAL HEALTH PRACTICE: Our findings provide valuable insights for tailoring OEND training for service industry workers to confront fears associated with opioid overdose response in their places of work to decrease mortality from the opioid epidemic. Harm reduction approaches need to be sensitive to the places in which overdose occurs and who the overdose responder is likely to be, which requires appropriately tailoring OEND training for service industry workers.

End Users' Perceived Engagement with Clinical Dashboards: A Rapid Review.

Clinical dashboards are an emerging and fast-evolving technology used to support frontline clinicians' practice. Understanding end users' perceived engagement with clinical dashboards is essential to co-design, implementation, and adoption. There is a lack of literature exploring the integration of dashboards into clinical workflow. This rapid review explores clinical end users' perceived engagement with dashboards that support workflow. We conducted a literature search in PubMed and CINAHL. Four articles met our eligibility criteria. Findings reveal variations in taxonomy and measures used to evaluate clinicians' perceived engagement. There are also a variety of reported barriers and facilitators to adoption. Standardized frameworks and vocabulary are needed to facilitate a common understanding of clinical end users' perceived engagement with dashboards.

Relationships Between Strong Black Woman Belief, Coping Behaviors, Perceived Social Support, and Psychological Distress Symptoms for Black Mothers After Stillbirth.

INTRODUCTION: Psychological distress symptoms (symptoms of depression, anxiety, and posttraumatic stress) are common following stillbirth. Black women who experience stillbirth are less likely to seek support than White women, consistent with the strong Black woman (SBW) construct, which expects Black women to tolerate stress and trauma gracefully, without seeking help. METHODS: In this cross-sectional study we sought to determine the relative contributions of SBW belief, perceived lack of social support, and culturally relevant coping behaviors to psychological distress symptoms in Black women bereaved by stillbirth. We partnered with a stillbirth support organization to recruit a sample of 91 Black women bereaved by stillbirth in the 3 years prior to study participation. The online study survey measured SBW belief, culturally relevant coping behaviors, perceived social support, and psychological distress symptoms along with sociodemographics, pregnancy history, and stillbirth characteristics. We used stepwise selection in multiple linear regression to determine the relative contributions of SBW belief, perceived social support, and coping behaviors to measures of psychological distress symptoms in our sample. RESULTS: Higher SBW belief, lower perceived social support, and higher collective coping (coping behaviors involving other people) were associated with increases in all 3 measures of psychological distress symptoms, controlling for age and other traumatic events. DISCUSSION: Further understanding of the influence of SBW belief on Black women's psychological distress following stillbirth may assist with the development of culturally appropriate interventions to mitigate psychological distress symptoms in this group.

Yoga vs Cognitive Processing Therapy for Military Sexual Trauma-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial.

Importance: First-line treatment for posttraumatic stress disorder (PTSD) in the US Department of Veterans Affairs (VA), ie, trauma-focused therapy, while effective, is limited by low treatment initiation, high dropout, and high treatment refraction. Objective: To evaluate the effectiveness of Trauma Center Trauma-Sensitive Yoga (TCTSY) vs first-line cognitive processing therapy (CPT) in women veterans with PTSD related to military sexual trauma (MST) and the hypothesis that PTSD outcomes would differ between the interventions. Design, Setting, and Participants: This multisite randomized clinical trial was conducted from December 1, 2015, to April 30, 2022, within 2 VA health care systems located in the southeast and northwest. Women veterans aged 22 to 71 years with MST-related PTSD were enrolled and randomized to TCTSY or CPT. Interventions: The TCTSY intervention (Hatha-style yoga focusing on interoception and empowerment) consisted of 10 weekly, 60-minute group sessions, and the CPT intervention (cognitive-based therapy targeting modification of negative posttraumatic thoughts) consisted of 12 weekly, 90-minute group sessions. Main Outcome and Measures: Sociodemographic data were collected via self-report survey. The primary outcome, PTSD symptom severity, was assessed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and PTSD Checklist for DSM-5 (PCL-5). Assessments were conducted at baseline, midintervention, 2 weeks post intervention, and 3 months post intervention. Results: Of 200 women veterans who consented to participate, the intent-to-treat sample comprised 131 participants (mean [SD] age, 48.2 [11.2] years), with 72 randomized to TCTSY and 59 randomized to CPT. Treatment was completed by 47 participants (65.3%) in the TCTSY group and 27 (45.8%) in the CPT group, a 42.6% higher treatment completion rate in the TCTSY group (P = .03). Both treatment groups improved over time on the CAPS-5 (mean [SD] scores at baseline: 36.73 [8.79] for TCTSY and 35.52 [7.49] for CPT; mean [SD] scores at 3 months: 24.03 [11.55] for TCTSY and 22.15 [13.56]) and the PCL-5 (mean [SD] scores at baseline: 49.62 [12.19] for TCTSY and 48.69 [13.62] for CPT; mean [SD] scores at 3 months: 36.97 [17.74] for TCTSY and 31.76 [12.47]) (P < .001 for time effects). None of the group effects or group-by-time effects were significant. Equivalence analyses of change scores were not significantly different between the TCTSY and CPT groups, and the two one-sided test intervals fell within the equivalence bounds of plus or minus 10 for CAPS-5 for all follow-up time points. Conclusions and Relevance: In this comparative effectiveness randomized clinical trial, TCTSY was equivalent to CPT in reducing PTSD symptom severity, with both groups improving significantly. The higher treatment completion rate for TCTSY indicates its higher acceptability as an effective and acceptable PTSD treatment for women veterans with PTSD related to MST that could address current VA PTSD treatment limitations. Trial Registration: ClinicalTrials.gov Identifier: NCT02640690.

Intersectionality in nursing research: A scoping review.

Background: An intersectional approach to health research provides an analytical foundation to explain the multidimensionality of health status, resource accessibility, privilege, oppression, and current and historical context. The use of intersectionality in health research has known limitations. Its use in health-related fields too often focuses on outcomes, such as health disparities, rather than processes, such as power structures and social determinants. Objective: This scoping review serves to examine how intersectionality has been implemented by nurses in the peer-reviewed literature. We offer insight into how it may be incorporated to inform future nursing research and healthcare provision. Design & Methods: Systematic searches of PubMed (n = 257), SCOPUS (n = 807), EMBASE (n = 396), CINAHL (n = 224), and Health Source: Nursing and Academics (n = 491), published since the seminal publication on intersectionality (1989 - 2023), identified 131 research articles that met inclusion and exclusion criteria. Data extraction and synthesis were used to describe the breadth and depth of the literature specific to the application of intersectionality in nursing research. Results: The included studies used intersectionality to examine the intersections of numerous identities, such as race, gender, and immigration status. However, most studies were descriptive/observational in nature, underreported their methods, and conducted deficit-based research instead of strength-based inquiries. Of note, the vast majority of included articles were published within the last five years. Conclusions: Future researchers using intersectionality as a framework can improve their approach by reporting clear definitions and operationalization of intersectionality. Observational science dominated the included studies; future research should focus on intervention development and evaluation using an intersectional lens. Lastly, caution should be placed on research that focuses solely on deficits among marginalized communities, which places scientists at risk of perpetuating stereotypes or enhancing already-existing stigmas.

Optimizing remote access to urinary incontinence treatments for women veterans (PRACTICAL): Study protocol for a pragmatic clinical trial comparing two virtual care options.

OBJECTIVES: In this pragmatic clinical trial, the primary objective is to increase access to behavioral treatment of urinary incontinence (UI) for women Veterans by comparing the effectiveness of two virtual care delivery modalities. METHODS: Veterans Affairs (VA) clinical sites in AL, GA, NC will virtually randomize 286 women Veterans with UI (ie, stress, urge, or mixed). We will compare the effectiveness of our mHealth UI application (MyHealtheBladder) to a single VA Video Connect (VVC) session delivered by trained UI providers. Women without improvement after 8 weeks will receive an optimization VVC visit using a sequential, multiple assignment, randomized trial (SMART) design. The primary outcome is UI symptom improvement at 12-weeks with or without optimization; secondary outcomes include improvements in lower urinary tract symptoms, adherence, retention rates, perceptions of improvement, and visit-related miles saved. Sample size needed to identify a 2.5-point change (range 0-21) in the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI SF) from baseline to 12-weeks post-randomization is 200 participants. Allowing for an attrition rate of 25%, 286 participants are required. KEY RESULTS: Study team initiated remote recruitment on April 2020. Recruitment is on target with a 75% retention rate. We expect completion in fall of 2023 (clinicaltrials.govNCT04237753). DISCUSSION/CONCLUSION: Engaging women Veterans with virtual modalities for initial UI treatment may increase access to UI care while also improving symptoms. After assessing efficacy, adherence, and retention, the next step is to implement the most effective option for remote delivery of evidence-based behavioral UI treatment for women Veterans. TRIAL REGISTRATION: ClinicalTrials.gov number NCT04237753.

Seeking safety intervention for comorbid post-traumatic stress and substance use disorder: A meta-analysis.

PROBLEM STATEMENT: Seeking Safety (SS) is a widely implemented cognitive-behavioral therapy for comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD). It is a present-focused coping skills model that is highly flexible, with varied methods of delivery, to maximize acceptability and client access. The purpose of this meta-analysis is to examine the effect of SS on comorbid PTSD and SUD across randomized control trials (RCTs). In addition, ours is the first meta-analysis to examine the dose-response of SS by comparing delivery of all 25 SS topics versus fewer. METHODS AND DESIGN: Articles published before January 2, 2023 (CINAHL n = 16, PsycINFO n = 31, MEDLINE n = 27, Cochrane n = 38, and Scopus n = 618) were searched. Seven studies were included for meta-analysis and dose-response analysis. RESULTS: Based on effect sizes (ES), meta-analysis revealed that SS has a medium group, time (p = .04), and time by group effect on substance use per the Addiction Severity Index at 3 months and a small effect on Clinician-Administered PTSD Scale scores by group, a large effect by time, and a medium time by group (p = .002) effect at 6 months. Based on the pooled ES examining various measures across multiple timepoints, SS had small to medium effects on substance use by time, group, or time by group and medium to large effects on PTSD symptoms by time, group, or time by group (except for the group effect at 3-month follow-up). Significant effects were found for substance use by time at 3 and 6 months and for PTSD postintervention, at 6 months and 9 months by group, time, and time by group while only by time at 3 months. Meta-regression revealed that partial dose versions of SS generally function as well as the full dose version of SS when observing long-term effects (greater than 3 months). DISCUSSION: Findings suggest SS has merit in treating PTSD symptoms and SUD. Based on the summarized effect sizes, SS appears more effective in reducing PTSD than substance use, which converges with the larger treatment outcome literature that consistently finds this. We explore reasons that treatment of SUD is more challenging than treating PTSD and offer suggestions for practitioners. We emphasize the need for future studies to utilize common measures and provide full details of treatment delivery for optimal comparison across studies.

State of the Knowledge of VA Military Sexual Trauma Research.

Despite substantial efforts to counter sexual assault and harassment in the military, both remain persistent in the Armed Services. In February 2021, President Biden directed the U.S. Department of Defense to establish a 90-day Independent Review Commission on Sexual Assault in the Military (IRC) to assess the department's efforts and make actionable recommendations. As servicemembers discharge from the military, effects of military sexual trauma (MST) are often seen in the Veterans Health Administration (VA). In response to an IRC inquiry about VA MST research, we organized an overview on prevalence, adverse consequences, and evidence-based treatments targeting the sequelae of MST. Women are significantly more likely to experience MST than their male counterparts. Other groups with low societal and institutional power (e.g., lower rank) are also at increased risk. Although not all MST survivors experience long-term adverse consequences, for many, they can be significant, chronic, and enduring and span mental and physical health outcomes, as well as cumulative impairments in functioning. Adverse consequences of MST come with commonalities shared with sexual trauma in other settings (e.g., interpersonal betrayal, victim-blaming) as well as unique aspects of the military context, where experiences of interpersonal betrayal may be compounded by perceptions of institutional betrayal (e.g., fear of reprisal or ostracism, having to work/live alongside a perpetrator). MST's most common mental health impact is posttraumatic stress disorder, which rarely occurs in isolation, and may coincide with major depression, anxiety, eating disorders, substance use disorders, and increased suicidality. Physical health impacts include greater chronic disease burden (e.g., hypertension), and impaired reproductive health and sexual functioning. Advances in treatment include evidence-based psychotherapies and novel approaches relying on mind-body interventions and peer support. Nonetheless, much work is needed to enhance detection, access, care, and support or even the best interventions will not be effective.

Trauma Center Trauma-Sensitive Yoga Versus Cognitive Processing Therapy for Women Veterans With PTSD Who Experienced Military Sexual Trauma: A Feasibility Study.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a common sequela to military sexual trauma (MST) among women veterans. Yoga has shown promise in research examining its benefit for symptoms and sequela of PTSD. AIMS: The objective of this study was to evaluate the feasibility of a randomized controlled trial (RCT) of Trauma Center Trauma-Sensitive Yoga (TCTSY) for women veterans with PTSD related to MST. METHOD: In this feasibility study, the final sample included women veterans (n = 41) with PTSD related to MST accessing health care in a Veterans Affairs Health Care System in the southeast United States; the majority were African American (n = 33; 80.5%). Interventions used established protocols of 10 weekly sessions of group TCTSY versus 12 weekly sessions of group Cognitive Processing Therapy (CPT). PTSD was assessed via clinical interview and participant report. Additional data collection included multiple participant-reported outcomes commonly associated with PTSD and psychophysiological measures. We also collected data regarding participant satisfaction and feasibility-related feedback from participants and providers. RESULTS: Feasibility and acceptability were evaluated via demand, practicality, fidelity, and acceptability. This was measured by expressed interest, attendance, program completion, barriers to care and satisfaction with treatment, and satisfaction with interventions and data collection. CONCLUSIONS: Results indicate the RCT design and TCTSY implementation were feasible; a full-scale RCT was subsequently conducted to determine efficacy of the experimental intervention. Recommendations for successful research strategies are provided.

Findings from a pilot study of Trauma Center Trauma-Sensitive Yoga versus cognitive processing therapy for PTSD related to military sexual trauma among women Veterans.

OBJECTIVE: The study objective was to explore the preliminary efficacy of trauma-sensitive yoga compared to cognitive processing therapy (CPT) for women Veterans with posttraumatic stress disorder (PTSD) related to military sexual trauma (MST) in a pilot randomized control trial (RCT). We then compared these results to published interim results for the subsequent full-scale RCT. METHOD: The analytic sample included women Veterans (N = 41) with PTSD related to MST accessing healthcare in a southeastern Veterans Affairs Health Care System. The majority were African American, non-Hispanic (80.5 %). The protocol-driven group interventions, Trauma Center Trauma-Sensitive Yoga (TCTSY; n = 17) and the evidence-based control condition, CPT (n = 24), were delivered weekly for 10 and 12 sessions, respectively. Multilevel linear models (MLM) were used to compare changes over time between the two groups. RESULTS: The primary outcomes presented here are PTSD symptom severity and diagnosis, assessed using the Clinician Administered PTSD Scale (CAPS) and the PTSD Symptom Checklist (PCL) total scores. PTSD symptom severity on both clinician-administered (CAPS) and self-reported (PCL) measures, improved significantly (p < .005) over time, with large within group effect sizes (0.90-0.99) consistent with the subsequent RCT. Participants in the TCTSY group showed clinically meaningful improvements earlier than the CPT group participants from baseline on the CAPS and PCL Total scores. CONCLUSIONS: Results support published findings of the effectiveness of TCTSY in the treatment for PTSD related to MST among women Veterans, particularly African American women. TCTSY warrants consideration as an adjunctive, precursor, or concurrent treatment to evidence-based psychotherapies. Future research should include patient preference, men with sexual trauma, and civilian populations.

Synchronous Telehealth Yoga and Cognitive Processing Group Therapies for Women Veterans with Posttraumatic Stress Disorder: A Multisite Randomized Controlled Trial Adapted for COVID-19.

Background: Providing care over telehealth grew slowly until the COVID-19 pandemic. Since the onset of the COVID-19 pandemic, providing mental health care was readily adapted to virtual means; however, clinical trial research is nascent in adapting methods and procedures to the virtual world. Methods: We present protocol modifications to pivot a multisite randomized controlled trial study, conducted at Southeastern and Pacific Northwestern Veterans Affairs Health Care Systems, from being conducted in-person to virtually, following the onset of the COVID-19 pandemic. We measured outcomes of posttraumatic stress disorder (PTSD) symptoms and psychophysiological markers of stress among female Veterans with PTSD secondary to military sexual trauma. We collected qualitative data about provider and participant experiences with telehealth. Results: Across sites, 200 participants were consented (48 virtually), 132 were randomized (28 to virtual groups), and 117 completed data collection and treatment (69 completed all or some data collection or treatment virtually). Conclusions: The pivots made for this study were in response to the COVID-19 pandemic and offer innovative procedures leveraging technology and contributing to the broader landscape of conducting research virtually. Clinical Trials Number: NCT02640690.

Approach and avoidant coping among black transgender women who have experienced violence: A qualitative analysis.

Black transgender women face nearly universal exposure to violence. Coping behaviors among cisgender women who have survived violence are well delineated; however, there are relatively few studies examining coping strategies for transgender women. The purpose of this qualitative study was to identify and characterize coping behaviors employed by Black transgender women (from Baltimore, MD and Washington, DC metropolitan areas) following an experience of violence. Secondary qualitative data analysis was conducted using framework analysis to explore narratives of 19 Black transgender women. Themes regarding avoidant and approach coping behaviors were developed within the context of existing literature. Approach coping behavior themes included: Help-Seeking, Seeking Guidance and Support, Self-Protecting Behavior, Positive Reappraisal, Self-Affirmation, Self-Care, Connection to a Higher Power, and Acceptance. Avoidant coping behavior themes included: Cognitive Avoidance, Substance, Alcohol, and Tobacco Use, Emotional Discharge, and Seeking Alternative Rewards. Participants employed similar coping behaviors as seen among cisgender women survivors of violence. However, several unique applications of approach coping mechanisms were identified including self-protecting behavior and self-affirming behavior. Culturally informed application of the identified coping behaviors can be taught and integrated into trauma-informed mental health interventions to promote strength and resilience among Black transgender women. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Designing a Graphic Novel: Engaging Community, Arts, and Culture Into Public Health Initiatives.

The opioid epidemic was declared a national public health emergency in 2017. In Georgia, standing orders for the opioid antagonist, naloxone, have been implemented to reduce mortality from opioid overdoses. Service industry workers in the Atlanta, Georgia, inner-city community of Little Five Points (L5P) have access to naloxone, potentially expanding overdose rescue efforts in the community setting. To explore the issues facing L5P, our research brings together qualitative descriptive inquiry, ethnography, community-based research, a community advisory board, and a local artist to maximize community dissemination of research findings through a graphic novel that describes encountering an opioid overdose. This format was chosen due to the ethical responsibility to disseminate in participants' language and for its potential to empower and educate readers. This article describes the process of working on this study with the community and a local artist to create sample pages that will be tested for clarity of the message in a later phase. Working with an artist has revealed that while dissemination and implementation for collaboration begin before findings are ready, cross-collaboration with the artist requires early engagement, substantial funding, artist education in appropriate content, and member checking to establish community acceptability altering illustrations that reinforce negative stereotypes. By sharing the experiences of actions taken during an opioid overdose in L5P through a graphic novel, we can validate service industry workers' experiences, acknowledge their efforts to contribute to harm reduction, and provide much-needed closure to those who encounter opioid overdoses in the community.

Barriers to PTSD treatment-seeking by women veterans who experienced military sexual trauma decades ago: The role of institutional betrayal.

BACKGROUND: While some barriers to PTSD treatment engagement among veterans are well-identified, e.g., stigma, little is known about the barriers to VA PTSD treatment-seeking among women veterans who experienced military sexual trauma (MST) decades ago. PURPOSE: To explore the barriers to PTSD treatment-seeking of women veterans with PTSD related to MST experienced prior to 2000. METHOD: Data were collected from women veterans (n = 14) who had experienced MST and sought VA PTSD treatment. Data analyses utilized a constructivist grounded theory approach. FINDINGS: The context of the MST experience, including the military environment at the time, the era in which they experienced MST and the response of others to their reporting or disclosure of MST created decades-long barriers to PTSD treatment-seeking. DISCUSSION: Understanding institutional betrayal as a barrier to PTSD treatment-seeking among women veterans who experienced MST decades ago is necessary to develop effective targeted outreach and programs for this population.

Trauma-Sensitive Yoga for Post-Traumatic Stress Disorder in Women Veterans who Experienced Military Sexual Trauma: Interim Results from a Randomized Controlled Trial.

Objective: To conduct an interim analysis of data collected from an ongoing multisite randomized clinical trial (RCT) assessing the effectiveness of Trauma Center Trauma-Sensitive Yoga (TCTSY) for post-traumatic stress disorder (PTSD) among women veterans with PTSD related to military sexual trauma (MST). The purpose of the interim analysis was to assess outcomes from the primary site, which is geographically, demographically, culturally, and procedurally distinct from the second site. Design: RCT was conducted within a Veterans Administration Health Care System. Data collection included preintervention through 3 months postintervention. Participants: Enrollment for the main site was 152 women. The sample size for the intent-to-treat analysis was 104. The majority were African American (91.3%) with a mean age of 48.46 years. Intervention: The TCTSY intervention (n = 58) was conducted by TCTSY-certified yoga facilitators and consisted of 10 weekly 60-min group sessions. The control intervention, cognitive processing therapy (CPT; n = 46), consisted of 12 90-min weekly group sessions conducted per Veterans Administration protocol by clinicians in the PTSD Clinic. Outcome measures: The Clinician Administered PTSD Scale for DSM-5 (CAPS-5) was used to assess current PTSD diagnosis and symptom severity, including overall PTSD and four symptom clusters. The PTSD checklist for DSM-5 (PCL-5) was used to obtain self-report of PTSD symptom severity, including total score and four symptom clusters. Results: The findings reported here are interim results from one clinical site. For both the CAPS-5 and PCL-5, total scores and all four criterion scores decreased significantly (p < 0.01) over time in all five multilevel linear models within both TCTSY and CPT groups, without significant differences between groups. There were clinically meaningful improvements seen for both TCTSY and CPT with 51.1%-64.3% of TCTSY subjects and 43.5%-73.7% of CPT decreasing their CAPS-5 scores by 10 points or more. Effect sizes for total symptom severity were large for TCTSY (Cohen's d = 1.10-1.18) and CPT (Cohen's d = 0.90-1.40). Intervention completion was higher in TCTSY (60.3%) than in CPT (34.8%). Symptom improvement occurred earlier for TCTSY (midintervention) than for CPT (2 weeks postintervention). Safety: There were no unanticipated adverse events in this study. Conclusion: The results of this study demonstrate that TCTSY may be an effective treatment for PTSD that yields symptom improvement more quickly, has higher retention than CPT, and has a sustained effect. TCTSY may be an effective alternative to trauma-focused therapy for women veterans with PTSD related to MST. The study is registered in ClinicalTrials.gov (CTR no.: NCT02640690).

Clinical Complexity in Women Veterans: A Systematic Review of the Recent Evidence on Mental Health and Physical Health Comorbidities.

A recent evidence map focused on women veterans underscored the limited number of articles published on mental health comorbid with physical health conditions in this population. The quality of this small body of research has yet to be evaluated. The aim of this systematic review was to evaluate and synthesize research published between 2008 and 2015 and identified in the Women Veterans' Health Research Evidence Map as related to mental and physical health comorbidities among women veterans. Following PRISMA guidelines, 23 published studies were identified and 21 were included in the review. In general, significant associations between several mental health conditions (e.g., depression, posttraumatic stress disorder, substance use disorders) and physical health disorders (e.g., cardiovascular disease, diabetes, gastrointestinal disorders, hypertension, obesity, pain, and urinary symptoms) and health behaviors (e.g., preventative care and treatment adherence) were noted. The majority of studies were rated as low risk of bias, with selection and detection bias most frequently observed across studies. Additionally, gaps in the recent literature were observed, including the need for further investigation of the role of medical conditions in complicating mental health symptoms and care provision. Results underscore the importance of healthcare providers attending to women veterans' mental and physical health simultaneously and irrespective of setting. Further, while the Department of Veterans Affairs continues to make sizable gains in its focus on women veterans' health, continued research on several health domains is needed to ensure adequate understanding of the health needs of women veterans.

Nursing Policies and Protocols: Do Nurses Really Use Them?

BACKGROUND: Nursing policies and protocols exist to promote high-quality, safe, and effective nursing practice; however, there is little evidence demonstrating how nurses actually use them to inform their everyday, routine practice. PURPOSE: The purposes were to explore the extent to which nurses use nursing policies and protocols to guide their routine practice, and identify barriers and facilitators affecting the frequency with which nurses use nursing policies and protocols. METHODS: Licensed nurses (N = 235) providing direct care to inpatients and outpatients in a large medical center participated in an 18-question online survey. RESULTS: Most nurses access policies and protocols once a month or more; the greatest barrier to more frequent access was length of the policy or protocol. CONCLUSIONS: Organizations should make policies and protocols succinct, current, and easily accessible. Studies are needed to determine how policies and procedures can best meet the needs of stakeholders, including health care organizations, staff, and patients.

Association of Depression and Post-Traumatic Stress with Polyvictimization and Emotional Transgender and Gender Diverse Community Connection Among Black and Latinx Transgender Women.

Purpose: This study examines the relationship between polyvictimization, emotional transgender and gender diverse community connection (eTCC), and symptoms of depression and post-traumatic stress disorder (PTSD) among Black and Latinx transgender women in Baltimore, MD, and Washington, DC. Methods: A purposive sample (N = 197) completed surveys containing a 15-item Polyvictimization Inventory (encompassing sexual violence, physical violence, and threats of violence) and screeners for lifetime symptoms of PTSD and past 2-week symptoms of depression. Data were analyzed using linear regression modeling. Results: Most participants (91.4%) experienced at least one form of violence and 86.8% experienced multiple forms. The model including polyvictimization, age, and city explained 8% of the variance in depressive symptoms [F(2, 193) = 6.58, p < 0.001] and 15% of the variance in PTSD symptoms [F(2, 193) = 12.78, p < 0.001]. In separate models, polyvictimization was positively associated with symptoms of depression [b(SEb) = 0.08 (0.03), p < 0.01], and PTSD [b(SEb) = 0.13 (0.02), p < 0.001], controlling for age and city. eTCC was not significantly associated with polyvictimization or symptoms of PTSD and depression, and did not moderate the relationship between polyvictimization and symptoms. Conclusion: These findings highlight a high prevalence of violence experienced by participants and support the association between polyvictimization and poor mental health-consistent with the existing literature. Service providers who work with Black and Latinx transgender women should assess for polyvictimization as part of their routine mental health risk assessments to develop person-centered mental health interventions. Further inquiry is needed to identify factors that modify the relationship between polyvictimization and mental health, providing information to guide the development and timing of effective interventions.