Using Machine Learning to Predict Antidepressant Treatment Outcome From Electronic Health Records.

Objective: To evaluate if a machine learning approach can accurately predict antidepressant treatment outcome using electronic health records (EHRs) from patients with depression. Method: This study examined 808 patients with depression at a New York City-based outpatient mental health clinic between June 13, 2016 and June 22, 2020. Antidepressant treatment outcome was defined based on trend in depression symptom severity over time and was categorized as either "Recovering" or "Worsening" (i.e., non-Recovering), measured by the slope of individual-level Patient Health Questionnaire-9 (PHQ-9) score trajectory spanning 6 months following treatment initiation. A patient was designated as "Recovering" if the slope is less than 0 and as "Worsening" if the slope was no less than 0. Multiple machine learning (ML) models including L2 norm regularized Logistic Regression, Naive Bayes, Random Forest, and Gradient Boosting Decision Tree (GBDT) were used to predict treatment outcome based on additional data from EHRs, including demographics and diagnoses. Shapley Additive Explanations were applied to identify the most important predictors. Results: The GBDT achieved the best results of predicting "Recovering" (AUC: 0.7654 ± 0.0227; precision: 0.6002 ± 0.0215; recall: 0.5131 ± 0.0336). When excluding patients with low PHQ-9 scores (<10) at baseline, the results of predicting "Recovering" (AUC: 0.7254 ± 0.0218; precision: 0.5392 ± 0.0437; recall: 0.4431 ± 0.0513) were obtained. Prior diagnosis of anxiety, psychotherapy, recurrent depression, and baseline depression symptom severity were strong predictors. Conclusions: The results demonstrate the potential utility of using ML in longitudinal EHRs to predict antidepressant treatment outcome. Our predictive tool holds the promise to accelerate personalized medical management in patients with psychiatric illnesses.

Longitudinal Trajectories of Symptom Change During Antidepressant Treatment Among Managed Care Patients with Co-Occurring Depression and Anxiety.

Depression and anxiety are highly correlated, yet little is known about the course of each condition when presenting concurrently. This study aimed to identify longitudinal patterns and changes in depression and anxiety symptoms during antidepressant treatment, and evaluate clinical factors associated with each response pattern. Self-report Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) scores were used to track the courses of depression and anxiety respectively over a three-month window, and group-based trajectory modeling was used to derive subgroups of patients who have similar response patterns. Multinomial regression was used to associate various clinical variables with trajectory subgroup membership. Of the 577 included adults, 373 (64.6%) were women, and the mean age was 39.3 (SD: 12.9) years. Six depression and six anxiety trajectory subgroups were computationally derived; three depression subgroups demonstrated symptom improvement, and three exhibited nonresponse. Similar patterns were observed in the six anxiety subgroups. Factors associated with treatment nonresponse included higher pretreatment depression and anxiety severity and poorer sleep quality, while better overall health and younger age were associated with higher rates of remission. Synchronous and asynchronous paths to improvement were also observed between depression and anxiety. High baseline depression or anxiety severity alone may be an insufficient predictor of treatment nonresponse. These findings have the potential to motivate clinical strategies aimed at treating depression and anxiety simultaneously.

Enhancing exposure therapy for posttraumatic stress disorder (PTSD): a randomized clinical trial of virtual reality and imaginal exposure with a cognitive enhancer.

Posttraumatic stress disorder (PTSD) is a significant public health issue. Yet, there are limited treatment options and no data to suggest which treatment will work for whom. We tested the efficacy of virtual reality exposure (VRE) or prolonged imaginal exposure (PE), augmented with D-cycloserine (DCS) for combat-related PTSD. As an exploratory aim, we examined whether brain-derived neurotrophic factor (BDNF) and fatty acid amide hydrolase (FAAH) moderated treatment response. Military personnel with PTSD (n = 192) were recruited into a multisite double-blind randomized controlled trial to receive nine weeks of VRE or PE, with DCS or placebo. Primary outcome was the improvement in symptom severity. Randomization was stratified by comorbid depression (MDD) and site. Participants in both VRE and PE showed similar meaningful clinical improvement with no difference between the treatment groups. A significant interaction (p = 0.45) suggested VRE was more effective for depressed participants (CAPS difference M = 3.51 [95% CI 1.17-5.86], p = 0.004, ES = 0.14) while PE was more effective for nondepressed participants (M = -8.87 [95% CI -11.33 to -6.40], p < 0.001, ES = -0.44). The main effect of DCS vs. placebo was not significant. Augmentation by MDD interaction (p = 0.073) suggested that depressed participants improved more on placebo (M = -8.43 [95% CI -10.98 to -5.88], p < 0.001, ES = -0.42); DCS and placebo were equally effective for nondepressed participants. There was an apparent moderating effect of BDNF Val66Met polymorphism on DCS augmentation (ES = 0.67). Met66 allele carriers improved more on DCS (ES = -0.25). FAAH 385 A carriers improved more than non-carriers (ES = 0.33), particularly those with MDD (ES = 0.62). This study provides a step toward precision therapeutics for PTSD by demonstrating that comorbid MDD and genetic markers may help guide treatment selection.ClinicalTrials.gov Identifier: NCT01352637.

Changes in Dosing and Dose Timing of D-Cycloserine Explain Its Apparent Declining Efficacy for Augmenting Exposure Therapy for Anxiety-related Disorders: An Individual Participant-data Meta-analysis.

The apparent efficacy of d-cycloserine (DCS) for enhancing exposure treatment for anxiety disorders appears to have declined over the past 14 years. We examined whether variations in how DCS has been administered can account for this "declining effect". We also investigated the association between DCS administration characteristics and treatment outcome to find optimal dosing parameters. We conducted a secondary analysis of individual participant data obtained from 1047 participants in 21 studies testing the efficacy of DCS-augmented exposure treatments. Different outcome measures in different studies were harmonized to a 0-100 scale. Intent-to-treat analyses showed that, in participants randomized to DCS augmentation (n = 523), fewer DCS doses, later timing of DCS dose, and lower baseline severity appear to account for this decline effect. More DCS doses were related to better outcomes, but this advantage leveled-off at nine doses. Administering DCS more than 60 minutes before exposures was also related to better outcomes. These predictors were not significant in the placebo arm (n = 521). Results suggested that optimal DCS administration could increase pre-to-follow-up DCS effect size by 50%. In conclusion, the apparent declining effectiveness of DCS over time may be accounted for by how it has been administered. Optimal DCS administration may substantially improve outcomes. Registration: The analysis plan for this manuscript was registered on Open Science Framework (https://osf.io/c39p8/).

The relationship between posttraumatic and depressive symptoms during virtual reality exposure therapy with a cognitive enhancer.

Two studies suggest that reductions in posttraumatic symptoms (Aderka et al., 2013) and cognitions (Zalta et al., 2014) precede reductions in depressive symptoms during prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) in female assault survivors. The present study explored the temporal relationship between posttraumatic and depressive symptoms in a randomized trial of D-Cycloserine (DCS) versus placebo augmented virtual reality exposure (VRE) therapy for chronic World Trade Center-related PTSD following the September 11, 2001 terrorist attacks. Twenty-five male and female participants were randomly assigned to receive either 100 mg DCS (N = 13) or placebo (N = 12) 90 min before 12 weekly VRE sessions. Participants contributed a total of 280 weekly PTSD Checklist (PCL; Weathers et al., 1993) and Beck Depression Inventory-second edition (BDI-II; Beck et al., 1996) symptom scores. Two sets of mediation analyses for longitudinal mixed models assessed the effects of 1) lagged PCL on BDI-II (Model 1), and 2) lagged BDI-II on PCL (Model 2) in the VRE-DCS and VRE-Placebo treatment groups, respectively. Results revealed reciprocal relations between posttraumatic and depressive symptoms during VRE treatment, although reductions in posttraumatic symptoms led to subsequent reductions in depressive symptoms to a greater extent than the converse. These effects were stronger in the DCS-enhanced group. Findings suggest that VRE primarily decreases posttraumatic symptoms, which in turn leads to decreased depressive symptoms, and that DCS may strengthen these effects.

Using electronic health records to characterize prescription patterns: focus on antidepressants in nonpsychiatric outpatient settings.

OBJECTIVE: To characterize nonpsychiatric prescription patterns of antidepressants according to drug labels and evidence assessments (on-label, evidence-based, and off-label) using structured outpatient electronic health record (EHR) data. METHODS: A retrospective analysis was conducted using deidentified EHR data from an outpatient practice at a New York City-based academic medical center. Structured "medication-diagnosis" pairs for antidepressants from 35 325 patients between January 2010 and December 2015 were compared to the latest drug product labels and evidence assessments. RESULTS: Of 140 929 antidepressant prescriptions prescribed by primary care providers (PCPs) and nonpsychiatry specialists, 69% were characterized as "on-label/evidence-based uses." Depression diagnoses were associated with 67 233 (48%) prescriptions in this study, while pain diagnoses were slightly less common (35%). Manual chart review of "off-label use" prescriptions revealed that on-label/evidence-based diagnoses of depression (39%), anxiety (25%), insomnia (13%), mood disorders (7%), and neuropathic pain (5%) were frequently cited as prescription indication despite lacking ICD-9/10 documentation. CONCLUSIONS: The results indicate that antidepressants may be prescribed for off-label uses, by PCPs and nonpsychiatry specialists, less frequently than believed. This study also points to the fact that there are a number of off-label uses that are efficacious and widely accepted by expert clinical opinion but have not been included in drug compendia. Despite the fact that diagnosis codes in the outpatient setting are notoriously inaccurate, our approach demonstrates that the correct codes are often documented in a patient's recent diagnosis history. Examining both structured and unstructured data will help to further validate findings. Routinely collected clinical data in EHRs can serve as an important resource for future studies in investigating prescribing behaviors in outpatient clinics.

Posttraumatic Stress Disorder, Functional Impairment, and Subjective Distress in World Trade Center Disaster Workers.

Posttraumatic stress disorder (PTSD) is associated with functional deficits, poor physical health, and diminished quality of life. Limited research has examined PTSD symptom clusters and their associations with functioning and distress among disaster recovery workers, a population at high risk for PTSD due to potential for repeated trauma. The purpose of this study was to investigate associations between overall PTSD severity, as well as PTSD symptom clusters, and social and occupational functioning and subjective distress in World Trade Center (WTC) disaster workers after the terrorist attacks on September 11, 2001 (9/11). Disaster workers deployed to the site of the attacks completed assessments at three time points over approximately 5 years post-9/11. Our sample consisted of participants who met criteria for PTSD or subthreshold PTSD at baseline (n = 514), 1-year (n = 289), and 2-year follow-up (n = 179). Adjusted linear regression indicated that Clinician Administered PTSD Scale (CAPS)-rated PTSD severity was positively associated with subjective distress, and deficits in social and occupational functioning, over time, CAPS Criterion F items; ßs = .20 to .62, ps < .001. The reexperiencing and avoidance/numbing symptom clusters were associated with increased subjective distress, the avoidance/numbing and hyperarousal clusters were associated with deficits in social functioning, and the reexperiencing and hyperarousal clusters were associated with worse occupational functioning. These associations were consistent across the study period. Findings point to the importance of targeting PTSD symptom clusters associated with specific areas of functional impairment, with the goal of improving global outcomes.

Differences in Attitudes Toward Immunosuppressant Therapy in a Multi-ethnic Sample of Kidney Transplant Recipients.

Barriers for renal transplant patients to immunosuppressant medication adherence are poorly understood, despite the high rate and toll of non-adherence. We sought to assess factors that contribute to barriers to immunosuppressive medication adherence in an ethnically diverse sample of 312 renal transplant patients recruited from three transplant centers across New York City. Transplant patients who were at least 6 months post-transplant completed questionnaires while waiting for their medical appointment. Ethnic differences were observed on barriers to immunosuppressant adherence. Black and Hispanic participants reported significantly more barriers to adherence compared to Caucasian participants. Differences in perception about the potential harm and necessity of immunosuppressant medications also were present. Using hierarchical multiple regression, age and income were significant predictors of reported barriers to adherence, even while controlling for ethnicity. The most robust predictor of reported barriers was the perception of the medication cost-benefit differential, i.e., the balance between concerns about immunosuppressant medications and their perceived helpfulness (B = - 0.5, p < .001), indicating that varying beliefs about the medication's necessity and utility rather than ethnicity explain the differences in barriers to medication adherence. Future interventions targeting non-adherence should aim to reduce the barriers to adherence by addressing perceived risks and benefits of taking immunosuppressant medication.

D-Cycloserine Augmentation of Exposure-Based Cognitive Behavior Therapy for Anxiety, Obsessive-Compulsive, and Posttraumatic Stress Disorders: A Systematic Review and Meta-analysis of Individual Participant Data.

Importance: Whether and under which conditions D-cycloserine (DCS) augments the effects of exposure-based cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders is unclear. Objective: To clarify whether DCS is superior to placebo in augmenting the effects of cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders and to evaluate whether antidepressants interact with DCS and the effect of potential moderating variables. Data Sources: PubMed, EMBASE, and PsycINFO were searched from inception to February 10, 2016. Reference lists of previous reviews and meta-analyses and reports of randomized clinical trials were also checked. Study Selection: Studies were eligible for inclusion if they were (1) double-blind randomized clinical trials of DCS as an augmentation strategy for exposure-based cognitive behavior therapy and (2) conducted in humans diagnosed as having specific phobia, social anxiety disorder, panic disorder with or without agoraphobia, obsessive-compulsive disorder, or posttraumatic stress disorder. Data Extraction and Synthesis: Raw data were obtained from the authors and quality controlled. Data were ranked to ensure a consistent metric across studies (score range, 0-100). We used a 3-level multilevel model nesting repeated measures of outcomes within participants, who were nested within studies. Results: Individual participant data were obtained for 21 of 22 eligible trials, representing 1047 of 1073 eligible participants. When controlling for antidepressant use, participants receiving DCS showed greater improvement from pretreatment to posttreatment (mean difference, -3.62; 95% CI, -0.81 to -6.43; P = .01; d = -0.25) but not from pretreatment to midtreatment (mean difference, -1.66; 95% CI, -4.92 to 1.60; P = .32; d = -0.14) or from pretreatment to follow-up (mean difference, -2.98, 95% CI, -5.99 to 0.03; P = .05; d = -0.19). Additional analyses showed that participants assigned to DCS were associated with lower symptom severity than those assigned to placebo at posttreatment and at follow-up. Antidepressants did not moderate the effects of DCS. None of the prespecified patient-level or study-level moderators was associated with outcomes. Conclusions and Relevance: D-cycloserine is associated with a small augmentation effect on exposure-based therapy. This effect is not moderated by the concurrent use of antidepressants. Further research is needed to identify patient and/or therapy characteristics associated with DCS response.

Pilot Study of a Telehealth-Delivered Medication-Augmented Exposure Therapy Protocol for PTSD.

Posttraumatic stress disorder (PTSD) is a serious condition, with certain occupations at increased risk due to greater trauma exposure. These same individuals face multiple barriers to care. This study aimed to investigate the feasibility of conducting a research trial with exposure therapy delivered via videoconferencing. Eleven adults working in occupations at risk with PTSD enrolled and seven completed 12 to 15 sessions. Individuals were randomized to receive the cognitive enhancer D-cycloserine or placebo, and participants provided saliva samples for genetic analysis. Treatment completers demonstrated decreases in PTSD and depressive symptomatology (measured by CAPS [p < 0.001, d = 2.79] and BDI-II [p = 0.004, d = 0.92]). Participants reported high therapeutic alliance, treatment satisfaction, and telehealth satisfaction. There were no significant technical, medication, or safety issues, and no clinical emergencies. The results suggest that it may be feasible to conduct clinical research using telehealth for PTSD and to use telehealth to increase access to care.

The treatment of posttraumatic stress disorder and related psychosocial consequences of burn injury: a pilot study.

Burn injuries are unique in their medical and psychological impact, yet there has been little exploration of psychiatric treatment for this population. This uncontrolled pilot study assessed feasibility, acceptability, and preliminary efficacy of a treatment protocol designed to address posttraumatic stress disorder, depression, coping with scarring, and community integration among adult burn survivors. A 14-session, manualized treatment protocol was created using cognitive-behavioral interventions including imaginal exposure, behavioral activation, cognitive restructuring, modeling, and in vivo exposure. Responses were measured using the Clinician Administered PTSD Scale, Beck Depression Index, Community Integration Questionnaire, Oswestry Disability Questionnaire, and Burn Specific Health Scale. Nine of 10 enrolled patients (60% women; mean = 42 years old) completed treatment. Burn size was 0.5% to 65%; mechanism of injury included flame (4), scald (5), and contact (1) burns. Mean acute hospitalization was 30.1 days (range = 13-87); mean time from injury to treatment was 3.2 months (range = 1-7). Baseline mean posttraumatic stress score was 68 on the Clinician Administered PTSD Scale (severe); scores decreased by 36% to a mean of 45.3 at posttreatment, with a large effect size. Baseline self-reported depression was 21 (moderate) on the Beck Depression Index, decreasing by 47% to a mean of 12 posttreatment (nonclinical). Change in community reintegration score was significant and large, and body image showed significant improvement. The protocol showed promise in the treatment of posttraumatic stress disorder, depression, self-image, and community reintegration following burn injury. These findings suggest that coping may improve with treatment and symptoms should not be dismissed as unavoidable consequences of burn injury.

Evidence-based treatment of post-traumatic stress disorder.

The term translational research is typically used to refer both to "bench to bedside" research, in which preclinical research findings inform the development of novel therapeutics, and to the dissemination of new treatments to the community to encourage the use of the new health practices and treatments. Both definitions are germane to understanding the evidence base for treatment of post-traumatic stress disorder (PTSD) today. This article offers (a) an overview of evidence-based treatments for PTSD, (b) a description of a translational model of PTSD, and (c) a discussion of common barriers to dissemination and implementation of the empirically validated treatments. Recent studies in the field are discussed with a focus on pharmacotherapies, psychotherapies, and combined treatments.

D-cycloserine augmentation of exposure therapy for post-traumatic stress disorder: a pilot randomized clinical trial.

Viewing post-traumatic stress disorder (PTSD) as a disorder of emotional learning, this study used a cognitive enhancer synergistically with virtual reality exposure (VRE) therapy for the treatment of PTSD. The main objective was to determine if a novel pharmacotherapy, D-cycloserine (DCS), enhanced the efficacy of the psychotherapy. Pre-clinical studies suggest that when fear extinction occurs during DCS administration, neuroplasticity may be enhanced. VRE therapy is a particularly promising format to test the hypothesis that DCS enhances extinction learning, as sensory fear cues are standardized across patients. In a pilot randomized, double-blind, placebo-controlled trial, 100 mg of DCS or placebo was administered 90 min before each weekly VRE session, to ensure peak plasma concentrations during the sessions in 25 patients with chronic PTSD. The primary outcome measure was the Clinician Administered PTSD Scale (CAPS). Secondary outcome measures included the Beck Depression Inventory-II and the State-Trait Anger Expression Inventory-2. Assessments occurred at pre-treatment, following sessions 3, 6, 10, post-treatment, and at 6 months. The difference in CAPS between the VRE-DCS (n=13) and VRE-placebo (n=12) groups increased over time beginning at 6 weeks, with medium to large between-group effect sizes immediately post-treatment and 6 months later (d=0.68 and d=1.13, respectively). A similar pattern was observed for depression, anger expression, and sleep. PTSD remission rates were significantly greater for the VRE-DCS group (46% vs 8% at post-treatment; 69% vs 17% at 6 months). Patients in the VRE-DCS group showed earlier and greater improvement in PTSD symptoms compared with the VRE-placebo group. These results suggest a promising new treatment for PTSD.

The longitudinal course of PTSD among disaster workers deployed to the World Trade Center following the attacks of September 11th.

This study examined the long-term mental health outcomes of 2,960 nonrescue disaster workers deployed to the World Trade Center site in New York City following the September 11, 2001 (9/11) terrorist attacks. Semistructured interviews and standardized self-report measures were used to assess the prevalence of posttraumatic stress disorder (PTSD) and other psychopathology 4 and 6 years after the attacks. Clinician-measured rates of PTSD and partial PTSD 4-years posttrauma were 8.4% and 8.9%, respectively, in a subsample of 727 individuals. Rates decreased to 5.8% and 7.7% for full and partial PTSD 6 years posttrauma. For the larger sample, self-report scores revealed probable PTSD and partial PTSD prevalence to be 4.8% and 3.6% at 4 years, and 2.4% and 1.8% at 6 years. Approximately 70% of workers never met criteria for PTSD. Although PTSD rates decreased significantly over time, many workers remained symptomatic, with others showing delayed-onset PTSD. The strongest predictors of ongoing PTSD 6 years following 9/11 were trauma history (odds ratio (OR) = 2.27, 95% confidence interval (CI) [1.06, 4.85]); the presence of major depressive disorder 1-2 years following the trauma (OR = 2.80, 95% CI [1.17, 6.71]); and extent of occupational exposure (OR = 1.31, 95% CI [1.13, 1.51]). The implications of the findings for both screening and treatment of disaster workers are discussed.

Prevalence and predictors of posttraumatic stress symptoms in utility workers deployed to the World Trade Center following the attacks of September 11, 2001.

BACKGROUND: Recent attention has begun to be focused on the effects of disaster recovery work on nonrescue workers. The goal of this study was to assess the prevalence and predictors of posttraumatic stress disorder (PTSD) and related symptoms in a population of utility workers deployed to the World Trade Center (WTC) site in the aftermath of 9/11. METHODS: Utility workers deployed to the WTC site were screened at their place of employment between 10 and 34 months following the WTC attacks, utilizing both structured interviews and self-report measures. PTSD symptoms were assessed by the CAPS and the PCL; co-morbid disorders were also assessed. 2,960 individuals with complete CAPS and PCL data were included in the analyses. RESULTS: Eight percent of participants had symptoms consistent with full PTSD, 9.3% with subthreshold PTSD, 6% with MDD, 3.5% with GAD, and 2.5% with panic disorder. Although risk factors included psychiatric and trauma history, 51% of individuals with probable PTSD had neither; subjective perception of threat to one's life was the best predictor of probable PTSD. Extent of exposure predicted 89% of PTSD cases in those without a psychiatric or trauma history, but only 67% of cases among those with both. CONCLUSIONS: Nonrescue workers deployed to a disaster site are at risk for PTSD and depression. Extent of exposure affected the most vulnerable workers differently than the least vulnerable ones. These results suggest that the relationship among predictors of PTSD may be different for different vulnerability groups, and underscore the importance of screening, education, and prevention programs for disaster workers.

Evidence-based treatments for PTSD, new directions, and special challenges.

This paper provides a current review of existing evidence-based treatments for posttraumatic stress disorder (PTSD), with a description of psychopharmacologic options, prolonged exposure therapy, cognitive processing therapy, and eye movement desensitization and reprocessing, especially as they pertain to military populations. It further offers a brief summary of promising treatments with a developing evidence base, encompassing both psychotherapy and pharmacotherapy. Finally, challenges to the treatment of PTSD are summarized and future directions suggested.

Development and early evaluation of the Virtual Iraq/Afghanistan exposure therapy system for combat-related PTSD.

Numerous reports indicate that the growing incidence of posttraumatic stress disorder (PTSD) in returning Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) military personnel is creating a significant health care and economic challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. Virtual reality-delivered exposure therapy for PTSD has been previously used with reports of positive outcomes. The current paper will detail the development and early results from use of the Virtual Iraq/Afghanistan exposure therapy system. The system consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern contexts for exposure therapy, including a city and desert road convoy environment. The process for gathering user-centered design feedback from returning OEF/OIF military personnel and from a system deployed in Iraq (as was needed to iteratively evolve the system) will be discussed, along with a brief summary of results from an open clinical trial using Virtual Iraq with 20 treatment completers, which indicated that 16 no longer met PTSD checklist-military criteria for PTSD after treatment.

House calls revisited: leveraging technology to overcome obstacles to veteran psychiatric care and improve treatment outcomes.

Despite an increasing number of military service members in need of mental health treatment following deployment to Iraq and Afghanistan, numerous psychological and practical barriers limit access to care. Perceived stigma about admitting psychological difficulties as well as frequent long distances to treatment facilities reduce many veterans' willingness and ability to receive care. Telemedicine and virtual human technologies offer a unique potential to expand services to those in greatest need. Telemedicine-based treatment has been used to address multiple psychiatric disorders, including posttraumatic stress disorder, depression, and substance use, as well as to provide suicide risk assessment and intervention. Clinician education and training has also been enhanced and expanded through the use of distance technologies, with trainees practicing clinical skills with virtual patients and supervisors connecting with clinicians via videoconferencing. The use of these innovative and creative vehicles offers a significant and as yet unfulfilled promise to expand delivery of high-quality psychological therapies, regardless of clinician and patient location.

The nature and course of subthreshold PTSD.

This study investigated rates of subthreshold PTSD and associated impairment in comparison to no PTSD and full PTSD and prospectively followed the course of subthreshold symptoms over 3 years. 3360 workers dispatched to the WTC site following 9/11 completed clinician interviews and self-report measures at three time points each one year apart. At Time 1, 9.7% of individuals met criteria for subthreshold PTSD. The no PTSD, subthreshold PTSD, and full PTSD groups exhibited significantly different levels of impairment, rates of current MDD diagnosis, and self-reported symptoms of depression. At Time 2, 29% of the initial sample with subthreshold PTSD continued to meet criteria for subthreshold or full PTSD; at Time 3, this was true for 24.5% of the initial sample. The study lends credence to the clinical significance of subthreshold PTSD and emphasizes that associated impairment may be significant and longstanding. It also confirms clinical differences between subthreshold and full PTSD.