Enhancing social functioning in older veterans with PTSD: Rationale and design of an intervention and initial RCT.

BACKGROUND: Older Veterans with Posttraumatic Stress Disorder (PTSD) are often socially isolated and have complex comorbid physical health problems. Aging-related stressors can exacerbate PTSD symptoms. These factors contribute to greater impairment in social functioning and decreased quality of life (QoL). Evidence-based psychotherapies for PTSD often address these issues, but not all older Veterans with PTSD seek help for these challenges, some don't want to engage in trauma-focused treatment, some drop out prematurely, and some still have residual symptoms upon completion. Thus, additional interventions that directly target social functioning among older Veterans with PTSD are needed. METHODS: In this paper we describe the development of and feasibility evaluation plan for, "Enhancing Social Functioning for older Veterans with PTSD (ESVP)," a social functioning group intervention for older (>60 years) Veterans with PTSD. This project involved four phases of work: 1) Intervention development, 2) Review of intervention and potential modifications using focus groups, 3) Intervention pilot testing and modification, and 4) A randomized feasibility trial comparing the intervention with a support group control. Intervention modules address interpersonal relationships, effective communication, anger management, social skills, social support/activities, and behavioral activation. CONCLUSION: This project details the iterative process used to develop the ESVP intervention designed to enhance social functioning in older Veterans with PTSD, and to evaluate feasibility. Analyses are underway to examine feasibility of conducting ESVP with a sample of older Veterans with PTSD. Findings from the final project phase, the randomized feasibly trial, will inform the design and implementation of a future trial. CLINICALTRIALS: gov Identifier: NCT02803125.

Written exposure therapy for veterans with co-occurring substance use disorders and PTSD: Study design of a randomized clinical trial.

There are high rates of posttraumatic stress disorder (PTSD) among treatment-seeking veterans with substance use disorders (SUD). While addiction programs traditionally do not address PTSD, there is evidence that trauma treatments for individuals with this comorbidity have improved PTSD and SUD outcomes. Written exposure therapy (WET), a five-session evidence-based psychotherapy (EBP) for PTSD, has high patient satisfaction, and lower dropout compared to other EBPs for PTSD. WET may be ideally suited for clinical settings that may not have the trauma expertise found in PTSD specialty clinics, given it requires less training time, treatment sessions, preparation time, and therapist involvement than existing EBPs, and no homework assignments. This paper describes the design, methodology, and protocol of a randomized clinical trial to evaluate whether treatment as usual (TAU) plus WET (n = 51) is superior to TAU plus a neutral topic writing condition (n = 51) on both PTSD and addiction outcomes for veterans in SUD treatment. The primary hypothesis is that participants assigned to TAU+WET, compared to those in TAU+ neutral topic writing, will report reduced symptoms of PTSD. The secondary hypothesis is that veterans receiving WET will have greater decreases in number of days of substance use compared to TAU+ neutral topic controls at follow-up. Assessments will take place at baseline, post-treatment, 8-week, and 12-week follow-up. Exploratory aims will examine the association between heart rate variability and treatment outcomes. If results prove promising, they will support WET as an effective brief, easy to disseminate, adjunct to current SUD treatment for veterans with comorbid PTSD. Trial registration: ClinicalTrials.gov ID NCT05327504.

Exacerbated PTSD symptoms among older U.S. military veterans during the COVID-19 pandemic: Results from the national health and resilience in veterans study.

Research has demonstrated that the impact of the coronavirus 2019 (COVID-19) pandemic on the mental health of United States (U.S.) veterans was less negative than originally anticipated. However, U.S. veterans are susceptible to exacerbation of post-traumatic stress disorder (PTSD) symptomology in late life. The aims of this study were to examine the extent to which older U.S. veterans experienced an exacerbation of PTSD symptoms during the COVID-19 pandemic, and to identify pre- and peri-pandemic factors that conferred risk for symptom exacerbation. Participants were U.S. military veterans aged 60 and older who completed three waves of the 2019-2022 National Health and Resilience in Veterans Study (NHRVS) (n=1858). PTSD symptoms were measured at all waves using the PTSD Checklist for DSM-5, and a latent growth mixture model was conducted to compute latent slopes of change of PTSD symptoms over the 3-year period. 159 (8.3%) participants experienced a worsening of PTSD symptomology over the pandemic period. Factors related to PTSD exacerbation were incident trauma exposure between Waves 1 and 2, more medical conditions with onset prior to the pandemic, and peri-pandemic social restriction stress. Number of incident traumas moderated the relationship between both number of pre-pandemic medical conditions and pre-pandemic social connectedness, and exacerbated PTSD symptoms. These results suggest that the pandemic did not confer additional risk for PTSD exacerbation than would be expected over a 3-year period for older veterans. Those who experience incident trauma exposure should be monitored for symptom exacerbation.

Psychiatric comorbidities in older adults with posttraumatic stress disorder: A systematic review.

BACKGROUND: Psychiatric comorbidity is high in adults with posttraumatic stress disorder (PTSD), with up to 90% having at least one additional condition, and two-thirds having two or more other diagnoses. With an increasing aging population in industrialized counties, knowing which psychiatric disorders frequently co-occur in older adults with PTSD can have implications to improve diagnosis and treatment. This systematic literature review explores the current empirical literature on psychiatric comorbidity in older adults with PTSD. METHOD: Literature databases PubMed, Embase, PsycINFO, and CINAHL were searched. The following inclusion criteria were applied: research done since 2013, PTSD diagnosis based on diagnostic criteria according to Diagnostic and Statistics Manual-Fifth Edition, International Classification of Diseases-10th Revision (ICD-10), or ICD-11, and studies include individuals aged 60 years or older. RESULTS: Of 2068 potentially relevant papers identified, 246 articles were examined based on titles and abstracts. Five papers met the inclusion criteria and were included. Major depressive disorder and alcohol use disorder were the most frequently studied and diagnosed psychiatric comorbidities in older adults with PTSD. CONCLUSIONS AND IMPLICATIONS: Screening for depression and substance use in older adults should include an assessment of trauma and PTSD. Additional studies in the general older adult population with PTSD and a broader range of comorbid psychiatric disorders are needed.

Characteristics and Correlates of Ten-Year Trajectories of Posttraumatic Stress Symptoms in Older U.S. Military Veterans.

OBJECTIVES: To examine the nature and correlates of 10-year trajectories of posttraumatic stress disorder (PTSD) symptoms in older U.S. military Veterans. DESIGN AND SETTING: A nationally representative web-based survey of older U.S. Veterans who participated in the National Health and Resilience in Veterans Study over 5 waves between 2011 and 2021. PARTICIPANTS: A total of 1,843 U.S. Veterans aged 50 and older (mean age = 67). MEASUREMENTS: PTSD symptoms were assessed using the PTSD Checklist. Self-report measures at baseline assessed sociodemographic characteristics; trauma exposures; psychiatric and substance use disorders; mental, cognitive, and physical functioning; and psychosocial factors including expectations of aging. Latent growth mixture modeling identified the nature and correlates of 10-year PTSD symptom trajectories. RESULTS: Most of the sample had no/low PTSD symptoms (88.7%), while 6.0% had consistently subthreshold symptoms, 2.7% consistently high symptoms, and 2.6% increasing symptoms. Relative to the no/low symptom group, the subthreshold and high symptom groups reported more medical conditions and cognitive difficulties, with younger age and more lifetime traumatic events additionally linked to the high symptom trajectory. Relative to the no/low symptom group, Veterans with increasing symptoms were more likely to report functional disability and lifetime nicotine use disorder, cognitive difficulties, negative expectations regarding physical and emotional aging, and traumatic events over the study period. CONCLUSIONS: Despite high rates of trauma exposure, most older Veterans do not evidence symptomatic PTSD trajectories; however, about 11% do. Results underscore the importance of assessing PTSD symptoms in this population and considering longitudinal trajectories as well as associated risk and protective factors.

Comparisons Between Young, Middle-Aged, and Older Adult Sexual and Gender Minority Male Sexual Assault Survivors.

OBJECTIVE: This study compared sexual abuse histories and depressive symptoms between younger, middle-aged, and older sexual and gender minority (SGM) male survivors. DESIGN: Participants completed a brief, online screener as part of a large comparative effectiveness psychotherapy trial. SETTING: SGM males 18 years or older, residing in the U.S. or Canada, were recruited online. PARTICIPANTS: This study included younger (aged 18-39; n = 1,435), middle-aged (aged 40-59; n = 546), and older (aged 60+; n = 40) SGM men who reported a history of sexual abuse/assault. MEASUREMENTS: Participants were asked about their sexual abuse history, experience of other traumas, symptoms of depression, and past 60-day mental health treatment engagement. RESULTS: Older SGM men reported a lower rate of occurrence of adult sexual assault, exposure to other traumas, and depression. However, older and younger groups did not differ on any childhood sexual assault variable, the frequency of or number of attackers for adult sexual assault, the frequency of accidents and other injury traumas, or the occurrence or frequency of mental health treatment. Trauma load, including childhood and adult sexual assault, were more strongly related to current depressive symptoms than age group. CONCLUSION: While there were some age-based or cohort differences in the rates of sexual trauma, the clinical response of both groups was similar. Implications for working clinically with middle-aged and older SGM men with untreated sexual assault-related mental health difficulties are discussed, including outreach and availability of gender- and older-inclusive survivor treatment and resources.

Training Male Sexual Abuse Survivors as Peer Leaders to Deliver Motivational Interviewing and Trauma-Informed Affirmative Care.

This paper provides a description and evaluation of training male sexual abuse survivors to deliver Motivational Interviewing (MI) and Motivational Interviewing with Trauma-Informed Affirmative Care (MI-AC) online to sexual and gender minority (SGM) men with sexual assault histories and depression. After a search and selection process, 26 men with lived experience of sexual abuse received MI training that included the use of role-playing, video demonstrations, and practice followed by weekly supervision while co-leading groups. Peer leaders completed several measures pre and post training, including beliefs about MI and self-reported learning of MI and satisfaction with the training. A sample of MI and MI-AC audio sessions were independently rated for adherence and competence. Peer leaders' beliefs about MI changed over time, while self-rated skill level stayed consistent. Peer leaders demonstrated good adherence to the MI and MI-AC conditions. Results suggest that men with lived experience of sexual trauma effectively learned to deliver MI and/or MI-AC to SGM male survivors in online groups. These interventions have the potential to expand the reach of limited services for this population as well as reduce their depression and assist in SGM men with histories of sexual abuse entering into formal mental health services.

Subjective cognitive difficulties and posttraumatic stress disorder interact to increase suicide risk among middle-aged and older US military veterans.

OBJECTIVES: To examine the role of subjective cognitive difficulties (SCD), posttraumatic stress disorder (PTSD), and their interaction in predicting suicidal ideation and current suicidal intent in middle-aged and older United States (US) military veterans. DESIGN: Population-based cross-sectional study. SETTING AND PARTICIPANTS: Data were analyzed from the 2019 to 2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 3602 US veterans aged 50 years and older (mean age = 69.0). MEASUREMENTS: Questionnaires including the Medical Outcomes Study Cognitive Functioning Scale (SCD), PTSD Checklist for DSM-5 (PTSD), Patient Health Questionnaire-9 (suicidal ideation in the previous two weeks), and the Suicide Behaviors Questionnaire-Revised (current suicidal intent). RESULTS: A total of 154 (4.4%) veterans screened positive for current PTSD, 239 (6.7%) reported past two-week suicidal ideation, and 37 (1.0%) reported current suicidal intent. The probability of suicidal ideation among veterans with both SCD and PTSD was more than six times higher than that observed in the full sample (44.5% vs. 6.7%) and more than 2.5 times higher than that observed in veterans with SCD and no PTSD (44.5% vs. 17.5%). Veterans with both subjective memory and concentration difficulties were more likely to report suicidal intent, though the interaction between SCD and PTSD was not significantly associated with suicidal intent. CONCLUSION: Middle-aged and older U.S. veterans with subjective cognitive impairment and PTSD report higher rates of suicidal ideation than those with SCD alone. Interventions targeting SCD and PTSD may mitigate suicide risk among middle-aged and older veterans.

The Need for a Diagnostic Instrument to Assess Post-Traumatic Stress Disorder in People with Dementia: Findings from a Delphi Study.

Cognitive and behavioral aspects may mask posttraumatic stress disorder (PTSD) in people with dementia. PTSD severely lowers quality of life in people with dementia. Proper recognition of PTSD is essential to ensure adequate treatment. However, a valid diagnostic tool for PTSD in dementia is lacking. A Delphi study was conducted among 20 Dutch and 6 international experts in the field of PTSD and dementia care or research. The aim was to reach consensus in 3 rounds on the added value, form, content, and application for developing such an instrument. The first round confirmed the need for a new diagnostic tool for research and clinical practice. Consensus was reached on 23 statements regarding the support base and 19 related to content of the instrument. In the third round, opinions on several conceptual problems were gathered. Based on the experts' opinions, a draft version of an instrument, the TRAuma and DEmentia-interview (TRADE-interview), was developed. Clinical and research implications of this new measure are discussed.

A roadmap for preventing and responding to trauma: Practical guidance for advancing community-engaged research.

OBJECTIVE: Community-engaged research (CEnR) is an approach to inquiry that centers scientist-community partnerships characterized by mutuality and reciprocity, and is well-aligned with trauma-informed principles, such as trustworthiness, transparency, and fostering empowerment. METHOD: The current paper considers definitions and applications of CEnR, highlighting examples from the trauma literature, from the formulation of research questions to the dissemination of research findings. CONCLUSION: To realize CEnR's promise to contribute to innovation, scientific understanding, and increased impact in the trauma field will require a shift in training and institutions. Fortunately, a growing interest in advocacy, public psychology, and diversity, equity, and inclusion presents an opportunity for synergy. Practical guidance is offered for supporting CEnR by preparing students, investing in faculty, and building infrastructure. Clinical Impact Statement: Community-engaged research (CEnR) focuses on equitable scientist-community partnerships in research, and shares principles with trauma-informed work. By prioritizing community collaboration, CEnR has the potential to lead to innovation, scientific understanding, and increased impact in the trauma field. For example, CEnR approaches emphasize dissemination to public audiences, which could help educate the public and policymakers about trauma and its impact. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Study design and interventions for a peer-delivered motivational interviewing group treatment for sexual and gender minority male sexual trauma survivors.

Sexual abuse of boys and men is a public health problem that has received relatively little attention from clinical scholars and researchers. Given unique pathways for development of and recovery from trauma-related emotional distress, sexual abuse survivors who identify as men may require distinct psychosocial interventions to engage in formal mental health care and assist in symptom reduction. This paper describes the rationale for and methodology of a randomized controlled trial comparing the effectiveness of Motivational Interviewing (MI) versus MI with affirmative care (MI-AC) for sexual and gender minority men who have been sexually traumatized. This study is designed to randomly assign 356 participants to either condition of six online group sessions delivered by two trained peers with lived experience of sexual trauma. Assessments will be conducted at baseline, post-treatment, 60- and 120-day follow-up. The primary hypotheses are that participants assigned to MI-AC, compared to those in MI only, will report reduced symptoms of depression and increased levels of engagement in formal mental health treatment. Additional hypotheses relate to secondary outcome variables, including post-traumatic stress disorder, suicidality, and substance use.

Comparisons Between Patients Diagnosed with PTSD in Primary Care Versus Mental Health Care in Five Large Civilian Health Care Systems.

Posttraumatic stress disorder (PTSD) is a serious mental health disorder that may not be adequately detected or treated in primary care (PC). The purpose of this study was to compare the clinical characteristics and health care utilization of PTSD patients diagnosed in PC versus in specialty mental health care (MHC) across five large, civilian, not-for-profit healthcare systems. Electronic claims and medical record data on patients treated during 2014 were analyzed. Treatment was considered in terms of initiation and dose (i.e., psychotherapy sessions; pharmacotherapy-prescription psychotropics). Of 5256 patients aged 15-88 with a diagnosis of PTSD, 84.4% were diagnosed by a MHC provider. Patients diagnosed by MHC providers had 4 times the rate of and more enduring psychotherapy than those diagnosed by PC providers. Receipt of psychotropics varied by provider type, with generally higher prescription fill levels for patients in MHC. Strategies to better align patient needs with access and treatment modality in PC settings are needed.

Implementation Patterns of Two Evidence-Based Psychotherapies in Veterans Affairs Residential Posttraumatic Stress Disorder Programs: A Five-Point Longitudinal National Investigation.

The present study examined the patterns of adoption of two evidence-based psychotherapies (EBPs)-prolonged exposure (PE) and cognitive processing therapy (CPT)-in U.S. Department of Veterans Affairs (VA) residential posttraumatic stress disorder (PTSD) treatment programs. A total of 526 providers from 39 programs nationwide completed online quantitative surveys and qualitative interviews, collected at five assessment points between 2008 and 2015, concerning the use of PE and CPT. By the midpoint of the study period, responders from most programs reported having adopted one or both EBPs as either core components of their programs or "tracks" for certain patients within their programs, adoption rates were 52.8% of programs at Time 3, 61.0% at Time 4, and 66.7% at Time 5. Evaluation of adoption patterns over time suggested that CPT was used in more programs and with more patients within programs compared to PE. At Time 5, respondents from half of the programs reported little or no adoption of PE, whereas the CPT adoption rate was reported to be "little or none" for one-fifth of the programs. The adoption of PE was generally slower compared to CPT adoption. The slower rate of adoption may be related to the resource-intensive nature of implementing PE on an individual basis in a residential setting as compared to the multiple ways CPT can be delivered: individually or in group settings, and with or without the inclusion of the trauma narrative. Strategies to improve sustainability measurement and implications for implementation science are discussed.

Provider general attitudes versus specific perceptions of evidence-based psychotherapies for PTSD.

This study examined the role of attitudes toward evidence-based psychotherapies (EBPs) in predicting use of prolonged exposure (PE) and cognitive processing therapy (CPT), two EBPs for posttraumatic stress disorder (PTSD) among PTSD treatment providers within the Department of Veterans Affairs. Providers' general attitudes toward EBPs, as well as their specific perceptions of PE and CPT, were examined as potential predictors of use. One hundred fifty-nine providers from 38 Department of Veterans Affairs' residential PTSD programs across the United States completed an online survey that included the predictors listed as well as self-reported use of PE on an individual basis and CPT on an individual and on a group basis. Although general attitudes toward EBPs were related to use of individually administered CPT, they were not related to use of PE or group-administered CPT. For each of the 3 treatments, however, specific positive perceptions were related to use. In examination of other training, skill, and delivery-related variables, general attitudes appear more in line with perceptions and delivery of CPT than PE. Perhaps this is because of the unique exposure component of PE. Assessing provider perceptions of specific EBPs may help providers in guiding their own practice as well as aid treatment developers, trainers, and administrators to more effectively tailor dissemination and implementation efforts. (PsycINFO Database Record (c) 2020 APA, all rights reserved).