Exploring the importance of predisposing, enabling, and need factors for promoting Veteran engagement in mental health therapy for post-traumatic stress: a multiple methods study.

PURPOSE: This study explored Veteran and family member perspectives on factors that drive post-traumatic stress disorder (PTSD) therapy engagement within constructs of the Andersen model of behavioral health service utilization. Despite efforts by the Department of Veterans Affairs (VA) to increase mental health care access, the proportion of Veterans with PTSD who engage in PTSD therapy remains low. Support for therapy from family members and friends could improve Veteran therapy use. METHODS: We applied a multiple methods approach using data from VA administrative data and semi-structured individual interviews with Veterans and their support partners who applied to the VA Caregiver Support Program. We integrated findings from a machine learning analysis of quantitative data with findings from a qualitative analysis of the semi-structured interviews. RESULTS: In quantitative models, Veteran medical need for health care use most influenced treatment initiation and retention. However, qualitative data suggested mental health symptoms combined with positive Veteran and support partner treatment attitudes motivated treatment engagement. Veterans indicated their motivation to seek treatment increased when family members perceived treatment to be of high value. Veterans who experienced poor continuity of VA care, group, and virtual treatment modalities expressed less care satisfaction. Prior marital therapy use emerged as a potentially new facilitator of PTSD treatment engagement that warrants more exploration. CONCLUSIONS: Our multiple methods findings represent Veteran and support partner perspectives and show that amid Veteran and organizational barriers to care, attitudes and support of family members and friends still matter. Family-oriented services and intervention could be a gateway to increase Veteran PTSD therapy engagement.

An examination of relationship satisfaction as a predictor of outcomes of brief couple therapy for posttraumatic stress disorder.

The pretreatment quality of intimate relationships can promote or interfere with couple therapy for posttraumatic stress disorder (PTSD) treatment response. We tested whether baseline relationship satisfaction predicted clinical and process outcomes in two dyadic treatments for PTSD. Using data from a randomized trial comparing brief cognitive behavioral conjoint therapy (bCBCT) for PTSD to PTSD family education (PFE) among 137 military veterans and their partners (N = 274, Mage = 42.3 years, 46.7% White, 81.0% male veteran partner), we examined whether baseline relationship satisfaction (Couples Satisfaction Index; CSI-32) predicted change in PTSD symptom severity (Clinician Administered PTSD Scale for DSM-5; CAPS-5), psychosocial functioning (Brief Inventory of Psychosocial Functioning; B-IPF), and relationship satisfaction at posttreatment and 6-month follow-up. We also explored associations with process outcomes (working alliance, treatment satisfaction, dropout). In both treatment conditions, neither partner's baseline CSI-32 score moderated change in veteran CAPS-5 or B-IPF score or any process variable. However, baseline CSI-32 scores moderated both partners' CSI-32 score change during bCBCT and PFE; participants who scored in the distressed range at baseline (n = 123) experienced significant improvements in relationship satisfaction, ß = .199, whereas there was no change among those in the nondistressed range at baseline (n = 151), ß = .025. Results suggest bCBCT and PFE are effective in improving PTSD symptoms and psychosocial functioning regardless of whether a couple is experiencing clinically significant relationship distress; further, these treatments improve relationship satisfaction for the most distressed individuals.

Posttraumatic stress disorder and relationship functioning: Examining gender differences in treatment-seeking veteran couples.

Posttraumatic stress disorder (PTSD) symptoms are robustly associated with intimate relationship dysfunction among veterans, but most existing research has focused on male veterans and their female partners. Links between PTSD and relationship functioning may differ between female-veteran couples and male-veteran couples. The current study used actor-partner interdependence models (APIMs) to test the associations between PTSD symptoms (i.e., veteran self-report or significant others' collateral-report) and each partner's reports of six domains of relationship functioning, as well as whether these links were moderated by the gender composition of the couple. Data were from 197 mixed-gender couples (N = 394 individuals) who completed baseline assessments for a larger randomized controlled trial of a couple-based PTSD treatment. Significant others' collateral PTSD reports were associated with their own ratings of relationship satisfaction, negotiation, psychological aggression, sexual pleasure, and sexual desire frequency, |ß|s = .19-.67, and with veterans' ratings of negotiation and sexual desire frequency, |ß|s = .20-.48. In contrast, veterans' self-reported PTSD symptoms were only associated with their own ratings of psychological aggression, ß = .16. Gender moderated the associations between significant others' collateral PTSD reports and five of the six outcome variables; findings from exploratory subgroup analyses suggested links between reported PTSD symptoms and relationship functioning were generally more maladaptive for male-veteran couples, whereas female veterans showed more neutral or even helpful impacts of higher partner-perceived PTSD symptoms. These findings have implications for clinicians treating relational impacts of PTSD and emphasize the need for further research with female-veteran couples.

Utilizing the couple relationship to prevent suicide: A preliminary examination of Treatment for Relationships and Safety Together.

OBJECTIVE: To evaluate the feasibility, preliminary effects, and acceptability of the first comprehensive couple-based treatment for suicide, called Treatment for Relationships and Safety Together (TR&ST). METHOD: In a preliminary examination, five couples (N = 10) participated in 10 weekly sessions of TR&ST. All couples included a veteran who reported active suicidal ideation at baseline and their partner. Couples completed measures of relationship functioning, perceived burdensomeness, thwarted belonging, and suicidal ideation at baseline, mid-treatment, and posttreatment. RESULTS: TR&ST was feasible to deliver. Veteran and partner relationship functioning improved and veteran perceived burdensomeness, thwarted belonging, and suicidal ideation decreased. There were no suicide related behaviors, hospitalizations, or crisis line calls during the study. TR&ST seemed acceptable to couples (100% retention and high satisfaction ratings). CONCLUSION: Couple-based suicide prevention may provide an additional avenue for suicide prevention in veterans.

The association between anger experiences and expression and veteran suicidal thoughts in intimate couple relationships.

OBJECTIVE: Anger has been identified as a risk factor for suicide in veterans with posttraumatic stress disorder (PTSD), theoretically because it erodes social support networks. In romantic relationships, the transactional properties of anger on suicidal ideation (SI) have not been explored. METHODS: Veterans (n = 138) and their significant others (S-Os; total N = 276) completed assessments on anger and SI as part of a baseline assessment in a treatment outcome study for veterans with PTSD and their S-Os. Actor Partner Interdependence Moderation Model (APIMoM) with Multilevel Modeling (MLM) was conducted. RESULTS: Veteran and S-Os verbal and anger expression were associated with veteran's SI, while S-Os' physical anger expression was associated with veteran's SI. S-Os' feeling angry was associated with veteran's SI. Veteran angry temperament was associated with veteran SI. DISCUSSION: Anger should be considered an assessment and treatment target in veterans with PTSD with SI and their S-Os.

Giving Back to Families: Evidence and Predictors of Persons with Serious Mental Illness Contributing Help and Support to Families.

Persons with serious mental illness (SMI) often rely on family for significant assistance and support, but the contributions made by persons with SMI to their families have been overlooked. This study assessed the extent to which persons with SMI contribute help or support to their families and identified significant predictors of contribution using an analysis of 1 year of clinicians' electronic health record (EHR) notes. EHR notes with reference to families of 226 Veterans with SMI were extracted and classified as suggesting help being given to and/or received from families. Forty-one percent of the sample contributed to family in a variety of ways. More frequent contact with family and being female were significant predictors of contribution. This study underlines the potential for reciprocal relationships within families of individuals with SMI. Clinicians can help clients and families maximize the support they provide to one another and possibly improve outcomes.

Structured Approach Therapy for Combat-Related PTSD in Returning U.S. Veterans: Complementary Mediation by Changes in Emotion Functioning.

To address the impact of combat-related posttraumatic stress disorder (PTSD) on U.S. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans, the investigators developed a 12-session manualized PTSD treatment for couples called structured approach therapy (SAT). A randomized controlled trial had shown that 29 OEF/OIF veterans with combat-related PTSD who had participated in SAT showed significantly greater reductions in PTSD compared to 28 veterans receiving a 12-session PTSD family education intervention (Sautter, Glynn, Cretu, Senturk, & Vaught, 2015). We conducted supplemental follow-up and mediation analyses, which tested the hypothesis that changes in emotion functioning play a significant role in the decreases in PTSD symptoms primarily observed in veterans who had received SAT. Veterans assigned to the SAT condition showed significantly greater decreases than those assigned to PTSD family education in emotion regulation problems (p < .001, Cohen's f(2) = .18) and fear of intense emotions (p < .001, Cohen's f(2) = .152). Decreases in both emotion regulation problems (mediated effect:ab̂= .36), and fear of intense emotions (mediated effect:ab̂ = .24) were found to be complementary mediators of reductions in PTSD symptoms greater with SAT. These findings suggest that SAT may aid veterans in improving their ability to regulate trauma-related emotions.

Multiple deployments and combat trauma: do homefront stressors increase the risk for posttraumatic stress symptoms?

Multiple deployments are common among military personnel who served in Operation Enduring Freedom and Operation Iraqi Freedom and are associated with greater posttraumatic stress symptoms (PTSS). Homefront stressors (i.e., family, occupational problems) resulting from deployments may increase the risk of PTSS. Moreover, with multiple deployments, a new deployment may occur while still experiencing homefront stressors from previous tours. This prospective study assessed whether homefront stressors from a previous tour increased the risk of PTSS after a new deployment. It also examined the effects of homefront stressors at postdeployment. Survey data were obtained from U.S. National Guard soldiers with previous deployments prior to (Wave 1) and after (Wave 2) a new deployment to Iraq (N = 196). Homefront stressors reported at Wave 1 (ß = .154, p = .015) and Wave 2 (ß = .214, p = .002) were both significantly predictive of PTSS at postdeployment, even after adjusting for warzone stressors, predeployment PTSS, and other variables. A pattern of chronic homefront stressors (i.e., homefront stressors at pre- and postdeployment) was associated with higher levels of PTSS at postdeployment (ß = .220, p = .002). Service members with multiple deployments are at greater risk for PTSS if deployed with homefront stressors from previous tours and/or face these stressors at postdeployment.

Serious mental illness-Psychology's call to action: If not us, who? If not now, when?

While psychology has much to contribute to the care of individuals living with a serious mental illness (SMI), psychologists have been and continue to be underrepresented as their treatment providers. However, serving those living with an SMI presents an urgent public health need. In this article, we provide an overview of the historical role of psychology in the care of individuals with SMIs, and we argue that a confluence of factors renders this a propitious time for psychologists to increase their commitment to the care of those living with an SMI. These factors include (a) the availability of strengths-based and/or functional assessment tools and effective psychosocial interventions, often created or empirically tested and enhanced by psychologists, (b) the continuing evolution of a recovery movement which brings more optimism to the field, and (c) the establishment, over the past 15 years, of an APA recognized and approved infrastructure to provide and recognize formal SMI Psychology training and expertise. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Implementation of Cognitive Behavioral Therapy for psychosis via telehealth: An expert consultation and clinical service model.

Individuals living with psychosis are often underserved in the United States, partly due to the dearth of providers trained in evidence-based practices for this population. One such practice is Cognitive Behavioral Therapy for psychosis, which the Substance Abuse and Mental Health Services Administration has identified as a standard of care for this population. The explosion of telehealth, in large part due to the COVID-19 pandemic, has led to increased opportunities for virtual psychotherapy. Telehealth offers a number of benefits, such as the ability to address service inequities, including lack of access to a local provider well-trained in the modality of therapy needed. The current article describes the National Psychosis Telehealth Program within the National Expert Consultation and Specialized Services (formerly VA National Telemental Health Center) program, U.S. Department of Veterans Affairs. The goal of this telehealth program is to utilize an expert consultation model and offer a remote individual, time-limited Cognitive Behavioral Therapy for psychosis protocol to Veterans across the nation in order to decrease access disparities to this relatively scarce service. We share our initiation activities and lessons learned as we developed this program in hopes of encouraging others to consider similar efforts at their sites. We also include a typical, complex case that serves to illustrate the challenges and benefits of this approach. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Mortality and suicidality in veterans health administration patients with newly-identified early episode psychosis.

Within the Veterans Affairs (VA), management of self-harm is a major clinical priority. However, there is limited information on risks for self-harm among VA patients with emerging psychotic disorders relative to VA patients with other emerging mental health conditions. Using information from fiscal years 2010 through 2018, a national cohort of VA patients 30 or younger was classified based on mental health diagnoses into three groups: 1) early episode psychosis (EEP), 2) non-early episode psychosis mental health (non-EEP MH), or 3) no mental health (no MH). Analyses focused on cohort members' risk for all-cause mortality, suicide mortality, and non-fatal suicide attempts (NFSA) during the year following initial diagnosis of mental health conditions (or first year of VA care, for the no MH group). In unadjusted analyses, the EEP group had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the non-EEP MH and no MH groups and the non-EEP MH had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the no MH group. After adjusting for demographics and care receipt, EEP status was unrelated to all-cause mortality but associated with increased suicide mortality risk and NFSA. Non-EEP MH status was associated with reduced risk of all-cause mortality but increased risk for NFSA. In the year following first diagnosis, VA patients with EEP are at increased risk for suicide mortality and self-harm even after accounting for other risk factors. Clinical services targeting this crucial time can help promote safety for this vulnerable group.

Design of a randomized clinical trial of brief couple therapy for PTSD augmented with intranasal oxytocin.

BACKGROUND: Leveraging military veterans' intimate relationships during treatment has the potential to concurrently improve posttraumatic stress disorder (PTSD) symptoms and relationship quality. Cognitive-Behavioral Conjoint Therapy (CBCT) and an 8-session Brief Cognitive-Behavioral Conjoint Therapy (bCBCT) are manualized treatments designed to simultaneously improve PTSD and relationship functioning for couples in which one partner has PTSD. Although efficacious in improving PTSD, the effects of CBCT on relationship satisfaction are small, especially among veterans. Intranasal oxytocin, which targets mechanisms of PTSD and relationship quality, may enhance the efficacy of bCBCT. METHOD/DESIGN: The purpose of this 4-year clinical trial is to compare the outcomes of bCBCT augmented with intranasal oxytocin versus bCBCT plus placebo. We will also explore potential mechanisms of action: self-reported communication skills, empathy, and trust. We will recruit 120 dyads (i.e., veteran with PTSD and their intimate partner) from the VA San Diego Healthcare System. Veterans will be administered 40 international units of oxytocin (n = 60) or placebo (n = 60) 30 min before each of 8 bCBCT sessions delivered via telehealth. Clinical and functioning outcomes will be assessed at five timepoints (baseline, mid-treatment, post-treatment, and 3- and 6-month follow-up). CONCLUSION: Study findings will reveal the efficacy of oxytocin-assisted brief couple therapy for PTSD, which could serve as highly scalable option for couples coping with PTSD, as well as provide preliminary evidence of interpersonal mechanisms of change. CLINICALTRIALS: govIdentifier:NCT06194851.

Feasibility of a family-involved intervention to increase engagement in evidenced-based psychotherapies for posttraumatic stress disorder: A pilot study.

OBJECTIVE: To assess the feasibility of a family-involved intervention, family support in mental health recovery (FAMILIAR), for veterans with posttraumatic stress disorder (PTSD) seeking psychotherapy at a single Veterans Administration Health System. METHOD: This mixed-methods study reports qualitative and quantitative findings from a single-group pilot of 24 veterans and their support partners (SPs) about experiences with the intervention and interviews with eight VA mental health clinicians and leaders and the study interventionist to explore intervention feasibility. Findings across data sources were merged within domains of Bowen and colleagues' pilot study feasibility framework. RESULTS: Out of 24 dyads, 16 veterans and 15 associated SPs completed the intervention. Participants viewed the intervention to be valuable and feasible. Veterans and SPs reported that they enrolled in the study to develop a shared understanding of PTSD and treatment. While participants identified few logistical barriers, finding a time for conjoint sessions could be a challenge. Veterans, SPs, and providers discussed benefits of the intervention, including that it facilitated conversation between the veteran and SP about PTSD and mental health care and helped to prepare the dyad for treatment. Providers noted potential challenges integrating family-involved interventions into clinical workflow in VA and suggested the need for additional training and standardized procedures for family-centered care. CONCLUSIONS: Our study identified potential implementation facilitators (e.g., standard operating procedures about session documentation, confidentiality, and family ethics) and challenges (e.g., clinical workflow integration) that require further study to bring FAMILIAR into routine clinical care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

NAVIGATE Program Directors' perspectives on treatment for early psychosis.

OBJECTIVE: Since the release of the Recovery After Initial Schizophrenia Episode-Early Treatment Program results in 2015, the United States Congress expanded funding for early intervention programs and these programs now exist in every state. The purpose of the present study was to understand the real-world experience of NAVIGATE Program Directors with respect to identifying and recruiting patients with early psychosis and engaging families in treatment. METHOD: Utilizing a mixed-methods sequential explanatory design, researchers surveyed 32 program directors in 13 states and engaged in 22 follow-up interviews to explore how NAVIGATE is being translated to serve individuals experiencing early psychosis and their families. RESULTS: We found that program directors using the NAVIGATE model encountered difficulty identifying diagnosis at admission and that supporting families of individuals experiencing psychosis was an important aspect of the program with unique complexity. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These findings have important implications for future mental health research on early intervention programs and may serve to stimulate future research on how early intervention mental health programs can better serve individuals recovering from psychosis and support their families. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

VA family service access and utilization in a national sample of veterans.

Relationship and family difficulties are common experiences for military veterans, who are able to access family services (i.e., couple and family therapy) through the Veterans Affairs (VA) Healthcare System. This study examines demographic, mental health, military, and referral source variables associated with referral to and utilization of family services using a large national VA dataset of 22,969 veterans who were referred to couple or family therapy from 2016 to 2019. Of those referred, 44.39% had a completed referral; among those who initiated therapy, 31.11% attended five or more sessions. Logistic regression was used to evaluate predictors of completed referrals and of attending five or more sessions of couple or family therapy. Veterans identifying as Black/African American, American Indian or Alaska Native were less likely to have a completed referral than non-Hispanic White veterans; moreover, veterans identifying as Black/African American or Hispanic were less likely to attend five or more sessions. Lower likelihood of a completed referral was also associated with rural county residence, being separated, post-9/11 service era, a substance use disorder diagnosis, and being referred by a psychiatrist, neurologist, physician, or nursing staff rather than a psychologist. Lower likelihood of attending five or more sessions was associated with a delay of 22 or more days to intake, an adjustment disorder diagnosis, and being referred from VA specialty care, or by a psychiatrist or neurologist. These findings may help inform efforts for outreach and service retention within VA family services in order to ensure equity in access to care and healthcare utilization. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Feasibility and acceptability of continuous identity cognitive therapy as a recovery-oriented suicide treatment for Veterans: A study protocol.

Background: Suicide is a leading cause of death among Veterans, with rates significantly higher than the general population. To address this issue, it is crucial to develop and implement more effective treatments for Veterans with suicidal thoughts and/or behaviors, particularly those in the post-acute suicidal episode (PASE) stage. The present study aims to establish the feasibility and acceptability of a novel, recovery-oriented treatment called Continuous Identity Cognitive Therapy (CI-CT) for PASE Veterans. Methods: This 3-year open-label pilot study will include three one-arm trials and a pilot randomized controlled trial (RCT). A total of 57 Veterans with a history of an acute suicidal episode within the previous year will be recruited. Primary outcome measures will include changes in personal recovery, suicidal thoughts, and behaviors. Secondary outcomes will include changes in self-identity, life satisfaction, and hopefulness. Feasibility and acceptability will be assessed through attendance and retention rates, drop-out rates, and client satisfaction. Conclusion: This study aims to develop and evaluate the feasibility and acceptability of a novel recovery-oriented intervention for Veterans experiencing PASE. If the intervention is found to be feasible and acceptable, a manualized version will be finalized and a large-scale multi-site RCT will be designed to assess its clinical efficacy on a broader Veteran population. The results of this trial will aid in the development of effective treatment and provide valuable insights into the preliminary feasibility, acceptability, and effectiveness of this approach in reducing suicidal thoughts and behaviors and promoting recovery and rehabilitation in this population.

A Novel Psychosocial Intervention for Motivational Negative Symptoms in Schizophrenia: Combined Motivational Interviewing and CBT.

OBJECTIVE: Negative symptoms are a primary cause of disability in schizophrenia for which there are no established pharmacotherapies. This study evaluated a novel psychosocial intervention that combined two evidence-based practices-motivational interviewing and cognitive-behavioral therapy (MI-CBT)-for the treatment of motivational negative symptoms. METHODS: Seventy-nine participants with schizophrenia and moderate to severe negative symptoms were included in a randomized controlled trial comparing the 12-session MI-CBT treatment with a mindfulness control condition. Participants were assessed at three time points through the study period, which included 12 weeks of active treatment and 12 weeks of follow-up. The primary outcome measures were motivational negative symptoms and community functioning; the secondary outcomes included a posited biomarker of negative symptoms: pupillometric response to cognitive effort. RESULTS: Compared with the control group, participants in the MI-CBT group showed significantly greater improvements in motivational negative symptoms over the acute treatment period. Their gains relative to baseline were maintained at follow-up, although the differential benefit relative to control subjects was attenuated. There were nonsignificant effects toward improvements in community functioning and differential change in the pupillometric markers of cognitive effort. CONCLUSIONS: The results show that combining motivational interviewing with CBT yields improvements in negative symptoms, a feature of schizophrenia generally thought of as resistant to intervention. Motivational negative symptoms not only responded to the novel treatment, but the gains were maintained over the follow-up period. Implications for future studies and for improving the generalization of the negative symptom gains to daily functioning domains are discussed.

Family interventions in Schizophrenia: promise and pitfalls over 30 years.

The stress of living with unpredictable, disturbing schizophrenic symptoms can erode interpersonal relationships. Stressful family interactions are associated with poorer prognosis. Several investigators have developed educational or more intensive skills-based family programs to increase illness knowledge and improve prognosis in schizophrenia. An extensive body of research supports the benefits of participating in family-based treatments for schizophrenia, especially those of longer duration and emphasizing skill development, in reducing relapse rates. In spite of the data, these programs are underimplemented and underutilized. Barriers to their use likely arise from patients, relatives, and mental health professionals. Newer programs, which include novel engagement strategies, target subpopulations with poor prognoses, or use innovative technologies, may make these programs more accessible to a wider range of families. Engaging individuals with schizophrenia and their loved ones in a collaborative effort to design new, more consumer-driven family interventions is warranted.

Family therapy for schizophrenia: co-occurring psychotic and substance use disorders.

People with schizophrenia have a high prevalence of co-occurring substance use disorders, which is related to a worse course of psychiatric illness, more frequent relapses, and increased depression and suicide, compared with those with schizophrenia alone. The Family Intervention for Dual Diagnosis (FIDD) program, which includes psychoeducation and goal setting and focuses on building communication and problem-solving skills within the family, can aid in decreasing the stress related to having a close relationship with someone with a dual disorder. Here, the case of a young man with psychosis and marijuana dependence is examined. This article describes how the FIDD intervention helped him with his problematic substance use, as well as to build skills within his relationship for increased empathy and reduced interpersonal stress.