Trauma exposure correlates among patients receiving care in federally qualified health centers.

Over 80% of adults in the general population experience trauma. Rates of patients with posttraumatic stress disorder (PTSD) are high in primary care settings and are likely to be even higher in federally qualified health centers (FQHCs). Trauma exposure has been linked to psychiatric symptoms and physical health comorbidities, though little research has focused on FQHC patients. This study addresses this by examining clinical and sociodemographic correlates of specific trauma types among FQHC patients. We analyzed secondary data from patients who screened positive for PTSD and were receiving health care in FQHCs in a clinical trial (N = 978). Individuals who did versus did not experience a specific trauma type were compared using between-group tests. In the sample, 91.3% of participants were exposed to a DSM-5 Criterion A traumatic event, with 79.6% experiencing two or more trauma types. Witnessing a life-threatening event (57.3%) and physical assault (55.7%) were the most common traumatic experiences. Physical health comorbidities and worse physical health functioning were associated with a higher likelihood of exposure to all trauma types, with effect sizes larger than PTSD, ds = 0.78-1.35. Depressive and anxiety symptoms were also associated with a higher likelihood of experiencing nearly all trauma types to a lesser magnitude. People of color, OR = 2.45, and individuals experiencing financial inequities, OR = 1.73, had higher odds of experiencing serious accidents as well as other trauma types. The findings highlight the need for trauma-informed care, including routine trauma and PTSD screening, for FQHC patients.

Bipolar disorder: Managing the peaks and valleys.

Bipolar disorder is a psychiatric illness that is relatively common among patients presenting for treatment in primary care clinics. Physicians in primary care often face difficult decisions about how and when to intervene when a patient is experiencing depressive, manic, or hypomanic episodes consistent with bipolar disorder. This article reviews the literature on how to assess and diagnose bipolar disorder in primary care, and how to choose from the array of treatment options that exist. The psychotherapy and pharmacotherapy evidence base provides guidance on how to help patients effectively manage this ailment. Collaboration among health and mental health practitioners is key in helping manage the "peaks and valleys" of bipolar disorder. Special considerations need to be made to routinely assess for impulsivity, suicidality, and patient progress throughout the course of treatment.

Effectiveness and clinical response rates of a residential eating disorders facility.

The purpose of this study was to determine the effectiveness of a residential treatment program for adults and adolescents with eating disorders across a wide spectrum of measures. Data on body mass, eating disorder severity, depression, anxiety, and two measures of quality of life were collected on 139 consecutively admitted adolescents and 111 adults at a residential treatment program (N = 250). The same measures were completed at post-treatment. Group level analyses showed that adults and adolescents improved on all measures analyzed. Only 1.7% of adolescents and 2.3% of adults were below a Body Mass Index of 18.5 at discharge. Positive results across diagnoses and ages are reported for three subscales of the Eating Disorder Inventory-3, with clinical response rates reported. Using clinical responder analyses, it was found that for all individuals struggling with secondary issues, 74.7% were responders on the Beck Depression Inventory-II, 41.0% on the Beck Anxiety Inventory, 63.5% on a measure of quality of life, and 95.8% were responders on the physical subscale and 72.6% on the mental subscale of the SF-36-v2. This study suggests that residential treatment for eating disorders is effective at the group level, and it was effective for the majority of individuals within the group.

Who seeks residential treatment? A report of patient characteristics, pathology, and functioning in females at a residential treatment facility.

There has been a growth in the availability and use of residential treatment for eating disorders. Yet there is a paucity of information on the individuals who seek this treatment. This study provides data on 259 consecutive patients (116 adults and 143 adolescents) entering residential treatment for their eating disorders. Upon admission all patients provided individual characteristics data and the following measures: the Eating Disorder Inventory-3 (EDI-3), the Beck Depression Inventory-II, the Beck Anxiety Inventory, the Eating Disorder Quality of Life (EDQOL), and the SF-36 Health Survey-Version 2. Findings are presented by diagnosis (anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified) and age (adult and adolescent). Results show that 61% of adolescents and 80% of adults were above the clinical cutoff for depression, and 59% of adolescents and 78% of adults were above the clinical cutoff for anxiety. Scores on the EDI-3 are presented by subscale and diagnosis. Very low quality of life is reported for both adults and adolescents on the EDQOL. For both adolescents and adults the SF-36 showed average population scores for the physical scale but very low mental scores. Implications for these findings and future directions for this work are discussed.

Sequenced Treatment Effectiveness for Posttraumatic Stress (STEPS) Trial: A protocol for a pragmatic comparative effectiveness trial with baseline results.

BACKGROUND: There have only been two efficacy trials reporting a head-to-head comparison of medications and psychotherapy for PTSD, and neither was conducted in primary care. Therefore, this protocol paper describes a pragmatic trial that compares outcomes of primary care patients randomized to initially receive a brief trauma-focused psychotherapy or a choice of three antidepressants. In addition, because there are few trials examining the effectiveness of subsequent treatments for patients not responding to the initial treatment, this pragmatic trial also compares the outcomes of those switching or augmenting treatments. METHOD: Patients screening positive for PTSD (n = 700) were recruited from the primary care clinics of 7 Federally Qualified Health Centers (FQHC) and 8 Department of Veterans Affairs (VA) Medical Centers and randomized in the ratio 1:1:2 to one of three treatment sequences: 1) selective serotonin reuptake inhibitor (SSRI) followed by augmentation with Written Exposure Therapy (WET), 2) SSRI followed by a switch to serotonin-norepinephrine reuptake inhibitor (SNRI), or 3) WET followed by a switch to SSRI. Participants complete surveys at baseline, 4 months, and 8 months. The primary outcome is PTSD symptom severity as measured by the PTSD Checklist (PCL-5). RESULTS: Average PCL-5 scores (M = 52.8, SD = 11.1) indicated considerable severity. The most common bothersome traumatic event for VA enrollees was combat (47.8%), and for FQHC enrollees was other (28.2%), followed by sexual assault (23.4%), and child abuse (19.8%). Only 22.4% were taking an antidepressant at baseline. CONCLUSION: Results will help healthcare systems and clinicians make decisions about which treatments to offer to patients.

Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial.

The objective of this study was to test whether treatment acceptability, exposure engagement, and completion rates could be increased by integrating acceptance and commitment therapy (ACT) with traditional exposure and response prevention (ERP). 58 adults (68% female) diagnosed with obsessive-compulsive disorder (OCD; M age = 27, 80% white) engaged in a multisite randomized controlled trial of 16 individual twice-weekly sessions of either ERP or ACT + ERP. Assessors unaware of treatment condition administered assessments of OCD, depression, psychological flexibility, and obsessional beliefs at pretreatment, posttreatment, and six-month follow-up. Treatment acceptability, credibility/expectancy, and exposure engagement were also assessed. Exposure engagement was high in both conditions and there were no significant differences in exposure engagement, treatment acceptability, or dropout rates between ACT + ERP and ERP. OCD symptoms, depression, psychological inflexibility, and obsessional beliefs decreased significantly at posttreatment and were maintained at follow-up in both conditions. No between-group differences in outcome were observed using intent to treat and predicted data from multilevel modeling. ACT + ERP and ERP were both highly effective treatments for OCD, and no differences were found in outcomes, processes of change, acceptability, or exposure engagement.

Enhancing Extinction Learning in Posttraumatic Stress Disorder With Brief Daily Imaginal Exposure and Methylene Blue: A Randomized Controlled Trial.

OBJECTIVE: The memory-enhancing drug methylene blue (MB) administered after extinction training improves fear extinction retention in rats and humans with claustrophobia. Robust findings from animal research, in combination with established safety and data showing MB-enhanced extinction in humans, provide a foundation to extend this work to extinction-based therapies for posttraumatic stress disorder (PTSD) such as prolonged exposure (PE). METHODS: Patients with chronic PTSD (DSM-IV-TR; N = 42) were randomly assigned to imaginal exposure plus MB (IE + MB), imaginal exposure plus placebo (IE + PBO), or waitlist (WL/standard PE) from September 2011 to April 2013. Following 5 daily, 50-minute imaginal exposure sessions, 260 mg of MB or PBO was administered. Waitlist controls received PE following 1-month follow-up. Patients were assessed using the independent evaluator-rated PTSD Symptom Scale-Interview version (primary outcome), patient-rated PTSD, trauma-related psychopathology, and functioning through 3-month follow-up. RESULTS: Both IE + MB and IE + PBO showed strong clinical gains that did not differ from standard PE at 3-month follow-up. MB-augmented exposure specifically enhanced independent evaluator-rated treatment response (number needed to treat = 7.5) and quality of life compared to placebo (effect size d = 0.58). Rate of change for IE + MB showed a delayed initial response followed by accelerated recovery, which differed from the linear pattern seen in IE + PBO. MB effects were facilitated by better working memory but not by changes in beliefs. CONCLUSIONS: The findings provide preliminary efficacy for a brief IE treatment for PTSD and point to the potential utility of MB for enhancing outcome. Brief interventions and better tailoring of MB augmentation strategies, adjusting for observed patterns, may have the potential to reduce dropout, accelerate change, and improve outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01188694.

Does the Theoretical Perspective of Exposure Framing Matter? Acceptance, Fear Reduction/Cognitive Reappraisal, and Values-Framing of Exposure for Social Anxiety.

Exposure-based therapy represents a first line treatment for anxiety disorders, but it is often underused. One target for improving client engagement is manipulating the theoretical perspective from which exposure is framed. Ninety-six adults with elevated social anxiety were enrolled in a two-session exposure therapy intervention. Participants were randomized to one of four conditions: (a) fear reduction/cognitive reappraisal, (b) acceptance, (c) personal values, or (d) experimental control The first three included brief psychoeducation and condition-specific experiential exercises and rationale; all four included in-session speech exposure and between-session exposure for homework. Results revealed that compared to the experimental control, the three active conditions reported significantly higher treatment credibility, initial in-vivo exposure engagement, and improvement in social anxiety symptoms. The three active conditions showed few differences among themselves. This study demonstrates that a brief exposure intervention using a credible rationale led to initial engagement in exposure therapy and improvement in social anxiety symptoms.

Dropout rates in exposure with response prevention for obsessive-compulsive disorder: What do the data really say?

The purposes of this review were to: 1) determine the attrition rates for exposure with response prevention (ERP) for obsessive-compulsive disorder (OCD), 2) compare them to those in other treatments for OCD, and 3) identify predictors of ERP attrition. A systematic literature search of randomized controlled trials for ERP for OCD yielded 21 studies, representing 1400 participants. Attrition data were extracted for individual treatment conditions. The weighted mean dropout rate for ERP was 14.7% (95% CI [11.4%, 18.4%]). This figure was not statistically different from that of comparison conditions (e.g., cognitive therapy; OR=0.67-2.22, all ps>0.15). Only two studies reported refusal rates for ERP (weighted mean=4.0%; 95% CI [0.7%, 9.2%]), which precluded calculation of a reliable refusal rate for ERP. Based on these figures, we estimated an overall attrition rate of 18.7% for ERP. Treatment experience, therapist qualification, and number of treatment sessions did not significantly predict dropout rate. Our review indicates that ERP may have treatment dropout rates similar to other treatments for OCD.

The credibility of exposure therapy: Does the theoretical rationale matter?

OBJECTIVE: Little is understood about how the public perceives exposure-based therapy (ET) for treating anxiety and trauma-related disorders or how ET rationales affect treatment credibility. Distinct approaches to framing ET are practiced, including those emphasized in traditional cognitive behavioral therapy, acceptance and commitment therapy, and the more recent inhibitory learning model. However, their relative effect on ET's credibility remains unknown. METHOD: A final sample of 964 U.S. adults provided baseline views of ET. Participants rated ET treatment credibility following a simple ET definition (pre-rationale) and following randomization to rationale modules addressing ET goals, fear, and cognitive strategies from distinct theoretical perspectives (post-rationale). Baseline ET views, symptoms, and sociodemographic characteristics were examined as putative moderators and predictors. RESULTS: At baseline, the majority had never heard of ET. From pre- to post-rationale, ET treatment credibility significantly increased but the rationales' theoretical perspective had little impact. More negative baseline ET views, specific ethnic/racial minority group status, and lower education moderated or predicted greater increases in treatment credibility following the rationale. CONCLUSIONS: ET remains relatively unknown as a treatment for anxiety or trauma, supporting the need for direct-to-consumer marketing. Diverse theory-driven rationales similarly increased ET credibility, particularly among those less likely to use ET.

Response rates for CBT for anxiety disorders: Need for standardized criteria.

Full appreciation of the effectiveness of cognitive behavioral therapy (CBT) requires both effect size data and individual rates of positive response. Response rates are particularly helpful for clinicians when choosing among treatment options. However, systematic reviews on cross-study response rates have not been conducted, possibly due to the absence of a standardized metric for calculating response rates. We conducted a systematic review of the treatment outcome literature to determine overall response rates to CBT for anxiety disorders and whether current methods of defining treatment response influence overall response rates. Our database search (2000-2014) resulted in 87 studies that reported response rates and included at least one CBT condition. Results showed that overall treatment response rates across anxiety disorders averaged 49.5% at post-treatment and 53.6% at follow-up. Response rates varied significantly as a function of the properties used to define them. Measures that incorporated more than one criterion, the combination of a reliable change index with a clinical cutoff (a clinically significant change), and intent-to-treat samples yielded lower response rates at post-treatment. Blinded independent assessors yielded higher response rates than unblinded assessors. Based on previous empirical and theoretical work, we recommend that future studies use a clinically significant change index, in an intent-to-treat analysis (using a mixed-model approach), reflecting multiple modalities, and assessed by independent blinded assessors. Our results indicate that such measures are likely to reduce response rates, but may result in a less biased and more accurate representation of improvement and achievement of normative functioning.

Does change in distress matter? Mechanisms of change in prolonged exposure for PTSD.

BACKGROUND AND OBJECTIVES: Clinically, many individuals persist in prolonged exposure therapy (PE) for chronic PTSD despite continuing distress during recounting of the trauma memory (imaginal exposure). Theorists suggest that distress reduction is necessary for successful treatment outcome (e.g., Foa & Kozak, 1986), while others suggest otherwise (e.g., Craske et al., 2008). This study examined clinically reliable changes in distress, relations to broad clinical outcomes, and whether homework adherence affected this relationship. METHOD: In 116 patients with PTSD, first to last imaginal exposure sessions' peak and average distress was examined, calculating reliable change in distress. Homework adherence and helpfulness were examined. At post-treatment, PTSD symptoms (re-experiencing, avoidance, hyperarousal), depression, and functioning were examined. RESULTS: Patients exhibited a lack of reliable change in distress (64.7%) more than a reliable change in distress (35.3%). Although no difference in post-treatment PTSD diagnostic status, individuals experiencing a reliable change in distress reported lower PTSD severity (re-experiencing, hyperarousal), depression, and better functioning. Further, perceived helpfulness of imaginal homework had an indirect effect on this relationship. LIMITATIONS: This study did not utilize a distress tolerance self-report measure; however, examined self-reported distress during imaginal exposure. CONCLUSIONS: Results are encouraging for clinicians treating PTSD with PE, arguing that lack of reliable change in distress to the trauma memory does not result in treatment failure. Patient "buy in" to homework, rather than amount completed, was related to the process of distress reduction. Results suggest that distress reduction in imaginal exposure is not a key mechanism underlying therapeutic change in PE.

Acceptance and commitment therapy for anxiety and OCD spectrum disorders: an empirical review.

A fair amount of research exists on acceptance and commitment therapy (ACT) as a model and a treatment for anxiety disorders and OCD spectrum disorders; this paper offers a quantitative account of this research. A meta-analysis is presented examining the relationship between psychological flexibility, measured by versions of the Acceptance and Action Questionnaire (AAQ and AAQ-II) and measures of anxiety. Meta-analytic results showed positive and significant relationships between the AAQ and general measures of anxiety as well as disorder specific measures. Additionally, all outcome data to date on ACT for anxiety and OCD spectrum disorders are reviewed, as are data on mediation and moderation within ACT. Preliminary meta-analytic results show that ACT is equally effective as manualized treatments such as cognitive behavioral therapy. Future directions and limitations of the research are discussed.