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.

Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans: A Randomized Clinical Trial.

Importance: Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness. Objective: To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans. Design, Setting, and Participants: This randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021. Interventions: Participants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions. Main Outcomes and Measures: The primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life. Results: Analyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21-80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1-40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5-41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89-1.08]) and CPT (SMD, 0.71 [95% CI, 0.61-0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53-4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00-1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12-1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24-2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events. Conclusions and Relevance: This randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT01928732.

An intervention mapping process to increase evidence-based psychotherapy within a complex healthcare system.

In response to recommendations from the Special Committee on posttraumatic stress disorder (PTSD), the United States Department of Veterans Affairs, Veterans Health Administration (VHA) chartered a workgroup to identify strategies for improving the reach and fidelity of evidence-based psychotherapies (EBPs) implemented by VHA through clinician training initiatives. The workgroup, which comprised stakeholders in a variety of roles within the VHA, used an Intervention Mapping process, a practical approach to designing change strategies based on theory, evidence, and stakeholder input. High-level recommendations centered around implementation of recent VHA/Department of Defense (VA/DoD) treatment guidelines. In addition to recommended first-line and suggested second-line treatments, the guidelines include measurement-based care and shared decision making around EBPs and their alternatives to ensure that care is goal-oriented and patient-centered. To support increased reach and fidelity, the workgroup made four broad recommendations: (a) enhancing leadership support; (b) alignment of policies, programs, and processes that influence reach of EBPs as recommended in clinical practice guidelines, including implementation support to accompany EBP trainings; (c) use of clinical data to inform decision making at multiple levels, and to provide fidelity support when outcomes are lower than expected or desired; and (d) increasing veteran and stakeholder education and awareness of guideline recommendations and availability of EBPs. These recommendations accompanied a more detailed set of recommended steps for implementation. This article describes the Intervention Mapping process and a summary of resulting workgroup recommendations. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A model comparison approach to trauma-related guilt as a mediator of the relationship between PTSD symptoms and suicidal ideation among veterans.

BACKGROUND: Suicidal ideation (SI) is a serious issue affecting U.S. veterans, and those with posttraumatic stress disorder (PTSD) are at an especially high risk of SI. Guilt has been associated with both PTSD and SI and may therefore be an important link between these constructs. METHODS: The present study compared models of trauma-related guilt and used path analysis to examine the direct and indirect effects of PTSD and trauma-related guilt on SI among a sample of 988 veterans receiving outpatient PTSD treatment at a Veterans Affairs (VA) specialty clinic. RESULTS: Results showed that a model of trauma-related guilt including guilt-cognitions and global guilt (but not distress) provided the best model fit for the data. PTSD and trauma-related guilt had direct effects on SI, and PTSD exhibited indirect effects on SI via trauma-related guilt. LIMITATIONS: The use of cross-sectional data limits the ability to make causal inferences. A treatment-seeking sample composed primarily of Vietnam veterans limits generalizability to other populations. CONCLUSIONS: Trauma-related guilt, particularly guilt cognitions, may be an effective point of intervention to help reduce SI among veterans with PTSD. This is an important area of inquiry, and suggestions for future research are discussed.

Prevalence and correlates of cannabis use in an outpatient VA posttraumatic stress disorder clinic.

Recent research has documented high rates of comorbidity between cannabis use disorders and posttraumatic stress disorder (PTSD) in veterans. However, despite possible links between PTSD and cannabis use, relatively little is known about cannabis use in veterans who present for PTSD treatment, particularly among samples not diagnosed with a substance use disorder. This study examined the prevalence of cannabis use and the psychological and functional correlates of cannabis use among a large sample of veterans seeking treatment at a Veterans Affairs (VA) PTSD specialty clinic. Male veterans (N = 719) who presented at a VA specialty outpatient PTSD clinic completed measures of demographic variables, combat exposure, alcohol, cannabis and other drug use, and PTSD and depressive symptoms. The associations among demographic, psychological, and functional variables were estimated using logistic regressions. Overall, 14.6% of participants reported using cannabis in the past 6 months. After controlling for age, race, service era, and combat exposure, past 6-month cannabis use was associated with unmarried status, use of tobacco products, other drug use, hazardous alcohol use, PTSD severity, depressive symptom severity, and suicidality. The present findings show that cannabis use is quite prevalent among veterans seeking PTSD specialty treatment and is associated with poorer mental health and use of other substances. It may be possible to identify and treat individuals who use cannabis in specialty clinics (e.g., PTSD clinics) where they are likely to present for treatment of associated mental health issues. (PsycINFO Database Record

Deliberate self-harm and suicidal ideation among male Iraq/Afghanistan-era veterans seeking treatment for PTSD.

The objectives of the present research were to examine the prevalence of deliberate self-harm (DSH) among 214 U.S. male Iraq/Afghanistan-era veterans seeking treatment for posttraumatic stress disorder (PTSD) and to evaluate the relationship between DSH and suicidal ideation within this population. Approximately 56.5% (n = 121) reported engaging in DSH during their lifetime; 45.3% (n = 97) reported engaging in DSH during the previous 2 weeks. As hypothesized, DSH was a significant correlate of suicidal ideation among male Iraq/Afghanistan-era veterans, OR = 3.88, p < .001, along with PTSD symptom severity, OR = 1.03, p < .001, and combat exposure, OR = 0.96, p = .040. A follow-up analysis identified burning oneself, OR = 17.14, p = .017, and hitting oneself, OR = 7.93, p < .001, as the specific DSH behaviors most strongly associated with suicidal ideation. Taken together, these findings suggest that DSH is quite prevalent among male Iraq/Afghanistan-era veterans seeking treatment for PTSD and is associated with increased risk for suicidal ideation within this population. Routine assessment of DSH is recommended when working with male Iraq/Afghanistan veterans seeking treatment for PTSD.

The influence of depressive symptoms on suicidal ideation among U.S. Vietnam-era and Afghanistan/Iraq-era veterans with posttraumatic stress disorder.

Major depressive disorder (MDD) co-occurs frequently with posttraumatic stress disorder (PTSD), and both disorders are linked to suicidal ideation. An emergent literature examines suicidal ideation in U.S. Afghanistan/Iraq-era veterans. Little research, however, has studied the role of PTSD and comorbid MDD on suicidal ideation across service eras. Therefore, this study aimed to examine the impact of depression on suicidal ideation in Afghanistan/Iraq-era and Vietnam-era veterans with PTSD. The sample included 164 Vietnam and 98 Afghanistan/Iraq veterans diagnosed with PTSD at a VA outpatient PTSD Clinic. Using structured interviews, 63% of the Vietnam sample and 45% of the Afghanistan/Iraq sample were diagnosed with comorbid current MDD. Measures included self-report assessments of PTSD and depressive symptoms and the Personality Assessment Inventory. Results of analyses suggested that in veterans of both eras, PTSD, MDD, and their interaction were significantly related to suicidal ideation (PTSD: η(2) = .01; MDD: η(2) = .10; PTSD × MDD: η(2) = .02). For veterans reporting greater depressive symptoms, there was a stronger relationship between PTSD symptoms and suicidal ideation. These results suggest that veterans from both eras display a similar clinical presentation and highlight the need to consider depressive symptoms when assessing veterans with PTSD. Future research should examine suicidal ideation and behaviors as they change over time in these two cohorts.

The effect of nicotine and trauma context on acoustic startle in smokers with and without posttraumatic stress disorder.

RATIONALE: Exaggerated startle response is a prominent feature of posttraumatic stress disorder (PTSD) although results examining differences in the acoustic startle response (ASR) between those with and without PTSD are mixed. One variable that may affect ASR among persons with PTSD is smoking. Individuals with PTSD are more likely to smoke and have greater difficulty quitting smoking. While smokers with PTSD report that smoking provides significant relief of negative affect and PTSD symptoms, the effects of smoking or nicotine deprivation on startle reactivity among smokers with PTSD are unknown. OBJECTIVES: The purposes of the current study were to (1) examine baseline acoustic startle response (ASR) in smokers with and without PTSD under conditions of overnight abstinence, (2) evaluate the effect of smoking on ASR, and (3) evaluate the contextual effects of trauma versus neutral script presentations. METHODS: ASR was measured among 48 smokers with and without PTSD in the context of a 2 (group: PTSD vs. non-PTSD) x 2 (context: trauma vs. neutral) x 3 (smoking condition: usual brand cigarette vs. denicotinized cigarette vs. no smoking) design. RESULTS: Effects of modest size indicated that (1) PTSD participants demonstrated higher ASR (2) compared to non-PTSD participants, PTSD participants reported greater negative affect following a trauma-related script, and (3) following a trauma-related script and smoking a usual brand cigarette, PTSD participants demonstrated higher ASR. CONCLUSIONS: Although many smokers with PTSD report that smoking reduces PTSD symptoms, results suggest that smoking may actually potentiate or maintain an exaggerated startle response.

The effects of cigarette smoking on script-driven imagery in smokers with and without posttraumatic stress disorder.

The study investigated the effects of smoking a nicotinized or denicotinized cigarette on craving, affect and posttraumatic stress disorder (PTSD) symptoms while recalling neutral, stressful and traumatic events in smokers with and without PTSD. Smokers completed laboratory sessions during which they were presented with audiotapes of personalized scripts followed by smoking a cigarette. The effect of the script and cigarette conditions on dependent variables was evaluated. There was a main effect of script type across groups for smoking craving, negative affect and PTSD symptoms, with increased symptoms in trauma and stressful conditions. Responses were significantly higher in PTSD smokers. Smoking either cigarette type resulted in decreased craving, negative affect and PTSD symptoms in both groups. A second script presentation following smoking elicited similar responses, suggesting the ameliorative effect of having smoked a cigarette was short-lived. These results support that context and non-pharmacologic effects of smoking are important variables in smoking craving and mood, particularly in smokers with PTSD.

Adverse school context moderates the outcomes of selective interventions for aggressive children.

Drawing on social ecological theory and empirical studies on the role of school context in aggression, the authors argue that school adversity is an important consideration in choosing selective interventions for aggressive children. The moderating role of school adversity on intervention effectiveness is illustrated with data from a randomized clinical trial study investigating 2 selective interventions administered to 86 aggressive 2nd and 3rd graders. The authors expected that PrimeTime, an intervention targeting child competencies, would be more effective in low-adversity schools, whereas Lunch Buddy, an intervention targeting peer ecology, would be more effective in high-adversity schools. Hierarchical linear regression analyses showed significant posttreatment effects on composite measures of aggression and achievement for the interaction between the level of school adversity and treatment condition.

Cigarette smoking, ambulatory cardiovascular monitoring, and mood in Vietnam veterans with and without chronic posttraumatic stress disorder.

This study investigated the association among cigarette smoking, posttraumatic stress disorder (PTSD), and ambulatory cardiovascular and mood monitoring in 117 male Vietnam combat veterans (61 with PTSD and 56 without PTSD). Positive smoking status was associated with higher systolic blood pressure (SBP) and heart rate (HR), as well as greater diastolic blood pressure (DBP) variability. Compared to individuals without PTSD, PTSD patients had higher HR, anger/hostility ratings, and depression/anxiety ratings. Significant diagnosis by smoking status interactions were found indicating that compared to nonsmokers with PTSD, smokers with PTSD had higher DBP, mean arterial pressure (MAP), and positive affect. Ad lib cigarette smoking during the previous 30 min did not have a significant effect on mood or cardiovascular parameters, except in non-PTSD smokers who reported lower depression/anxiety ratings after smoking. Findings suggest that the effect of smoking on cardiovascular parameters may be amplified in smokers in PTSD. Findings suggest that the interrelationships among cardiovascular parameters, cigarette smoking, and PTSD deserve more research attention.