Evidence-based Treatments For Posttraumatic Stress Disorder Research Articles

The relationship between emotion regulation difficulties and PTSD outcomes during group cognitive processing therapy for PTSD.

Emotion regulation difficulties (difficulty regulating the experience, occurrence, and expression of emotions) are associated with the severity of posttraumatic stress disorder (PTSD) symptoms across trauma types (e.g., childhood abuse, sexual assault, combat trauma). Despite emerging research suggesting that evidence-based treatments for PTSD, including cognitive processing therapy (CPT), are effective in improving emotion regulation difficulties, some have argued that these therapies may not be as safe or acceptable to patients compared to non-trauma focused treatments. Accordingly, the current study sought to determine the impact of pre-treatment emotion regulation difficulties on PTSD treatment outcomes and dropout, as well as whether emotion regulation difficulties improve over the course of treatment with group CPT among individuals with PTSD. One hundred and one individuals with PTSD participated in group CPT. Repeated measures t-tests found significant pre- to post-treatment improvements for emotion regulation difficulties (d = .79). Further, hierarchical linear modeling and logistic regression analyses revealed that pre-treatment emotion regulation difficulties were neither significantly associated with changes in PTSD symptoms over the course of treatment (d = -.07) nor with treatment dropout (OR = 1.00). These findings suggest that CPT delivered in a group setting to individuals with PTSD can lead to significant improvement in emotion regulation and that emotion regulation difficulties do not negatively impact treatment outcome or patient retention. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Evaluating a community-based training program for evidence-based treatments for PTSD using the RE-AIM framework.

Community mental health providers increasingly serve veterans with posttraumatic stress disorder (PTSD). However, recent surveys find that less than 20% of community providers are adequately trained to implement evidence-based treatments (EBTs) for PTSD. Since 2017, the STRONG STAR Training Initiative (SSTI) model has adapted traditional learning collaboratives aimed at increasing availability of EBTs for PTSD in community settings. This study reports on STRONG STAR program evaluation using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to assess dissemination and implementation outcomes. Between January 2018 and January 2020, 280 mental health providers from 25 states participated. Providers initiating EBTs for PTSD with 930 patients, reaching 29% who had PTSD among their caseload. Overall, 238 of patients who initiated EBT completed treatment. Patients who completed treatment demonstrated a 32.51-point decrease, t(237) = 25.27, p < .001, in PTSD symptom severity and an 8.73-point decrease, t(231) = 19.95, p < .001, in depression symptom severity following treatment. High rates of SSTI providers continued implementing EBT for PTSD at 6 months (cognitive processing therapy [CPT]: 95%; prolonged exposure [PE]: 72%) and 1-year (CPT: 87%; PE: 77%) posttraining, similar to outcomes reported by community and Department of Veterans Affairs providers. In reporting on the first evaluation of a National Training Program for community-based mental health providers, we look ahead to continued work in refining scalable models for building provider competence in delivery of EBTs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The role of the consultant in consultation for an evidence-based treatment for PTSD.

Consultation is an important implementation strategy to improve treatment fidelity and clinical outcomes, yet research has not identified the aspects of consultation that differentially affects clinician skill development and client symptom change. Thus, the present study investigated the effect of the consultant, consultation activities, and consultants' (n = 6) perceptions of consultees (n = 60) on post-traumatic stress disorder (PTSD) treatment fidelity and client outcomes. In addition, we assessed the accuracy of consultants' evaluations of clinicians using the Perceived Enthusiasm, Skill, and Participation scale (P-ESP). Results indicated that there was a significant effect of consultant on adherence to, but not competence in, delivering Cognitive Processing Therapy (CPT). The effect of the consultant on PTSD symptom change was not significant. Consultants significantly differed in their discussion of CPT strategies and their application to individual cases, but did not differ on reviewing and providing feedback on fidelity. Consultant perceptions as assessed by the P-ESP were not associated with clinicians' current levels of adherence or competence, suggesting that consultants may not accurately assess clinician skill during consultation. Client PTSD symptom change neither predicted, nor was predicted by, consultants' perceptions of their consultees' skill. This article outlines potential reasons for consultant effects and possible biases at play that may reduce the accuracy of consultant perceptions and presents suggestions on alternative strategies to assess clinician skill during consultation. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Complex PTSD and treatment outcomes in TF-CBT for youth: a naturalistic study

ABSTRACT Background: Complex posttraumatic stress disorder (CPTSD) has recently been added to the ICD-11 diagnostic system for classification of diseases. The new disorder adds three symptom clusters to posttraumatic stress disorder (PTSD) related to disturbances in self-organization (affect dysregulation, negative self-concept, and disturbances in relationships). Little is known whether recommended evidence-based treatments for PTSD in youth are helpful for youth with CPTSD. Objectives: This study examined whether Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is useful in reducing PTSD and CPTSD in traumatized youth. Methods: Youth (n = 73, 89.0% girls, M age = 15.4 SD = 1.8) referred to one of 23 Norwegian child and adolescent mental health clinics that fulfilled the criteria for PTSD or CPTSD according to ICD-11 and received TF-CBT were included in the study. Assessments were conducted pre-treatment, and every fifth session. Linear mixed effects models were run to investigate whether youth with CPTSD and PTSD responded differently to TF-CBT. Results: Among the 73 youth, 61.6% (n = 45) fulfilled criteria for CPTSD and 38.4% (n = 28) fulfilled criteria for PTSD. There were no differences in sex, age, birth country, trauma type, number of trauma types or treatment length across groups. Youth with CPTSD had a steeper decline in PTSD and CPTSD compared to youth with PTSD. The groups reported similar levels of PTSD and CPTSD post-treatment. The percentage of youth who dropped out of treatment was not different across groups. Further, the groups did not differ significantly in number of received treatment sessions. Conclusions: This is the first study to examine whether TF-CBT is helpful for youth who have CPTSD using a validated instrument for measuring CPTSD. The results suggest that TF-CBT may be useful for treating CPTSD in youth. These are promising findings that should be replicated in studies with larger sample sizes.

Implementation of evidence-based treatment for PTSD in Norway: clinical outcomes and impact of probable complex PTSD

ABSTRACT Background: Posttraumatic stress disorder (PTSD) is a long-lasting and debilitating psychological disorder that affects a large portion of the population. Treatments such as Cognitive therapy for PTSD (CT-PTSD) and Eye movement desensitization and reprocessing (EMDR) have been shown to be effective and cost-efficient in clinical trials, but uptake and evidence of positive outcomes in real-world clinical services are limited. Implementation efforts have been hampered by providers’ concerns about the feasibility of trauma-focused treatments in more complex presentations (i.e. Complex PTSD). Objective: To evaluate the effectiveness of CT-PTSD and EMDR in a real-world setting, as implemented in Norwegian outpatient mental health clinics for adults, and investigate the impact of probable Complex PTSD status on treatment outcomes. Methods: Clinicians from 15 different outpatient clinics received training and supervision in EMDR or CT-PTSD as part of a national implementation project. 104 clinicians recruited and treated 196 participants with PTSD. Symptoms of PTSD, depression and anxiety were assessed session-by-session and used to estimate pre-post effect sizes. Mixed-models were employed to investigate the impact of complex PTSD. Results: Both EMDR and CT-PTSD were associated with significant reductions in PTSD symptoms, with large effect sizes. Probable Complex PTSD was associated with higher levels of symptoms before and after treatment but did not significantly impact the effectiveness of treatment. Conclusion: The use of evidence-based treatments for PTSD in routine clinical service is associated with good treatment outcomes, also for patients with Complex PTSD.

Touch: An integrative review of a somatosensory approach to the treatment of adults with symptoms of post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a complex experience which can adversely affect a person's health and engagement in daily life. Some evidence-based treatments for PTSD, including pharmacological and psychological interventions, reduce the severity of some of the associated symptoms, although they have shown limited efficacy. Somatosensory approaches can be used to assist a person to regulate their autonomic nervous system. This review identifies touch-based interventions in the treatment of PTSD and examines the role of touch with this population. An integrative literature review was conducted to examine touch-based interventions which addressed the symptoms of PTSD in adults. Quantitative, qualitative and conceptual data were identified from eight databases, findings were appraised and synthesised using thematic analysis strategies, the Mixed Methods Appraisal Tool (MMAT) and the Critical Appraisal Skill Program (CASP). A total of 39 articles were included, describing eleven different touch-based interventions. Three key themes were identified: (i) catalogue of touch-based interventions being utilised in the treatment of PTSD; (ii) proposed mechanisms explaining the effects of touch-based interventions with PTSD; (iii) touch-based interventions which may reduce the symptoms of PTSD. Touch can play an important role in emotional regulation and the reduction of symptoms of PTSD. With a growing evidence base for the efficacy of these interventions, one intervention, Emotional Freedom Technique, prevailed. Methodological diversity and a paucity of conceptual frameworks mean that findings should be interpreted with caution. Developing a theoretical understanding for the underlying mechanisms of why touch-based treatments may be effective is required.

Comparative effectiveness of trauma-focused and non-trauma-focused psychotherapy for PTSD among veterans with comorbid substance use disorders: Protocol & rationale for a randomized clinical trial

BackgroundCo-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) is common and concurrent treatment is recommended. Relatively little is known about which evidence-based psychotherapies for PTSD are most effective for patients with varying substance use profiles. We aim to examine the comparative effectiveness of trauma-focused therapy (TFT) and non-trauma-focused therapy (NTFT) among Veterans with PTSD and SUD. TFT has been found to be effective among those with PTSD/SUD, though effects are smaller and rates of treatment non-completion are higher than in those without SUD. NTFTs suggested for the treatment of PTSD, such as Present Centered Therapy, (PCT) have not been examined among those with co-occurring SUD, despite lower rates of treatment dropout. We will also examine the comparative effectiveness of TFT and NTFT for patients with varying SUD severity, type of substances used, and patient treatment preference. Method420 Veterans with PTSD and SUD will be randomized in a prospective, pragmatic comparative effectiveness trial at 14 Veterans Health Administration facilities. Participants will receive either TFT (Prolonged Exposure or Cognitive Processing Therapy) or NTFT (PCT) after enrolling in concurrent SUD treatment-as-usual. Assessments will occur at baseline, posttreatment, 3- and 6 -months posttreatment. Main outcomes are PTSD symptom severity and PTSD treatment dropout. Clinician, patient, and leadership stakeholder panels advise study activities, and a process evaluation will identify strategies to enhance the implementation of evidence-based PTSD treatments in SUD care settings. ConclusionsResults will provide critical information to guide clinicians when recommending PTSD treatments to patients with comorbid SUD.ClinicalTrials.gov Identifier: NCT04581434.

Management of Chronic Pain and PTSD in Veterans With tDCS+Prolonged Exposure: A Pilot Study

Chronic pain and posttraumatic stress disorder (PTSD) are prevalent comorbid conditions, particularly in Veterans; however, there are few integrated treatments for chronic pain and PTSD. Instead, interventions are typically implemented separately and may involve addictive opioids. Although there are highly effective, non-pharmacological treatments for PTSD, they are plagued by high dropout, which may be exacerbated by comorbid pain, as these PTSD treatments typically require increased activity. Importantly, a noninvasive pain treatment, tDCS (transcranial direct current stimulation) shows indications of effectiveness and may be integrated with psychological treatments, even when delivered via telehealth. This study examines the feasibility and initial efficacy of integrating home telehealth tDCS with prolonged exposure (PE), an evidence-based PTSD treatment. Thirty-nine Veterans were contacted, 31 consented to evaluation, 21 were enrolled, and 16 completed treatment and provided pre- and post-treatment data at one of two Veterans Affairs Medical Centers. Transcranial direct current stimulation sessions corresponded with PE exposure assignments, as there is theoretical reason to believe that tDCS may potentiate extinction learning featured in PE. Patients evinced significant improvement in both pain interference and PTSD symptoms and a trend toward improvement in depression symptoms. However, a significant change in pain intensity was not observed, likely because of the small sample size. The findings provide initial support for the feasibility of an entirely home-based, integrated treatment for comorbid PTSD and pain.

Child Posttraumatic Stress after Parental Cancer: Associations with Individual and Family Factors.

ObjectiveThis study aimed to examine the severity of posttraumatic stress disorder (PTSD) symptoms in children of parents with cancer and to identify individual and family factors associated with these symptoms.MethodsThe sample consisted of 175 children (52% girls, aged M = 11.98, SD = 3.20, range = 6–20 years) from 92 families, of which 90 parents with a current or past cancer diagnosis and 71 healthy co-parents also completed questionnaires. Children reported on PTSD symptoms, trauma-related cognitions, emotion regulation difficulties, general family functioning, and family communication. Both parents reported on their own PTSD symptoms. Associations were investigated using multilevel regression.ResultsTwenty-seven percentage of the children showed clinically relevant PTSD symptoms. Intraclass correlations indicated that children from the same family showed little overlap in these symptoms. Multilevel analyses showed that child trauma-related cognitions and emotion regulation difficulties were related to higher levels of PTSD symptoms at the individual level. General family functioning was only related to child PTSD symptoms at the family level. Child PTSD severity was unrelated to parental PTSD symptoms and family communication at the family level when taking into account the other factors.ConclusionsThe current study highlights the psychological impact of parental cancer on children. Individual factors contributed more strongly to child PTSD symptoms than family factors. Trauma-related cognitions and emotion regulation difficulties might be targeted through specific psychoeducation for children and parents, family-oriented support and interventions, and evidence-based treatments for child PTSD.

A case series examining PTSD and depression symptom reductions over the course of a 2-week virtual intensive PTSD treatment program for veterans.

Evidence-based treatments for posttraumatic stress disorder (PTSD) can be effectively delivered over telehealth. There are, however, no studies that examine the effectiveness of delivering evidence-based treatments for PTSD in an intensive format via telehealth. Telehealth may be well-suited as a delivery modality because it may address barriers specific to intensive treatments. To address this gap, we report on a case series of ten consecutively enrolled veterans (60% male; mean age 42.3, SD = 6.3) who participated in a virtual 2-week, cognitive processing therapy (CPT)-based intensive program. All (100%) participants completed treatment and reported large reductions in PTSD and depression symptoms pre- to posttreatment (Hedge's gws = 2.83 and gws = 1.97, respectively), pre- to 3-month follow-up (Hedge's gws = .99 and gws = 1.24, respectively), as well as very high satisfaction. Results of this case series suggest that evidence-based treatments for PTSD can be effectively delivered in intensive formats over telehealth and lay the foundation for more rigorously designed and larger scale research comparing virtual to in-person delivered intensive PTSD treatments. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A randomized trial of brief couple therapy for PTSD and relationship satisfaction.

This three-arm randomized trial tested a brief version of cognitive-behavioral conjoint therapy (bCBCT) delivered in two modalities compared to couples' psychoeducation in a sample of U.S. veterans with posttraumatic stress disorder (PTSD) and their intimate partners. Couples were randomized to receive (a) in-person, office-based bCBCT (OB-bCBCT), (b) bCBCT delivered via home-based telehealth (HB-bCBCT), or (c) an in-person psychoeducation comparison condition (PTSD family education [OB-PFE]). Primary outcomes were clinician-assessed PTSD severity (Clinician Administered PTSD Scale), self-reported psychosocial functioning (Brief Inventory of Psychosocial Functioning), and relationship satisfaction (Couples Satisfaction Index) at posttreatment and through 6-month follow-up. PTSD symptoms significantly decreased by posttreatment with all three treatments, but compared to PFE, PTSD symptoms declined significantly more for veterans in OB-bCBCT (between-group d = 0.59 [0.17, 1.01]) and HB-bCBCT (between-group d = 0.76 [0.33, 1.19]) treatments. There were no significant differences between OB-bCBCT and HB-bCBCT. Psychosocial functioning and relationship satisfaction showed significant small to moderate improvements, with no differences between treatments. All changes were maintained through 6-month follow-up. A briefer, more scalable version of CBCT showed sustained effectiveness relative to an active control for improving PTSD symptoms when delivered in-person or via telehealth. Both bCBCT and couples' psychoeducation improved psychosocial and relational outcomes. These results could have a major impact on PTSD treatment delivery within large systems of care where access to brief, evidence-based PTSD treatments incorporating family members are needed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Evidence-based posttraumatic stress disorder treatment in a community sample: Military-affiliated versus civilian patient outcomes.

Posttraumatic stress disorder (PTSD) is a significant mental health issue among military service members and veterans. Although the U.S. Department of Veterans Affairs (VA) provides crucial resources for behavioral health care, many veterans seek mental health services through community clinics. Previous research illustrates that military and veteran patients benefit less from evidence-based treatments (EBTs) for PTSD than civilians. However, most PTSD treatment outcome research on military and veteran populations is conducted in VA or military settings. Little is known about outcomes among military-affiliated patients in community settings. The primary aim of this study was to directly compare civilian versus military-affiliated patient outcomes on PTSD and depression symptoms using the PTSD Checklist for DSM-5 (PCL-5) and the nine-item Patient Health Questionnaire (PHQ-9) in a community setting. Participants (N = 502) included military-affiliated (veteran, Guard/Reservist, active duty) and civilian patients who engaged in cognitive processing therapy (CPT) or prolonged exposure (PE) for PTSD in community clinics. Both groups demonstrated significant reductions on the PCL-5, military-affiliated: d = -0.91, civilian: d = -1.18; and PHQ-9, military-affiliated: d = -0.65, civilian: d = -0.88, following treatment. However, military-affiliated patients demonstrated smaller posttreatment reductions on the PCL-5, Mdiff = 5.75, p = .003, and PHQ-9, Mdiff = 1.71, p = .011, compared to civilians. Results demonstrate that military-affiliated patients benefit from EBTs for PTSD, albeit to a lesser degree than civilians, even in community settings. These findings also highlight the importance of future research on improving EBTs for military personnel with PTSD.

Effect of Written Exposure Therapy vs Cognitive Processing Therapy on Increasing Treatment Efficiency Among Military Service Members With Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) occurs more commonly among military service members than among civilians; however, despite the availability of several evidence-based treatments, there is a need for more efficient evidence-based PTSD treatments to better address the needs of service members. Written exposure therapy is a brief PTSD intervention that consists of 5 sessions with no between-session assignments, has demonstrated efficacy, and is associated with low treatment dropout rates, but prior randomized clinical trials of this intervention have focused on civilian populations. To investigate whether the brief intervention, written exposure therapy, is noninferior in the treatment of PTSD vs the more time-intensive cognitive processing therapy among service members diagnosed with PTSD. The study used a randomized, noninferiority design with a 1:1 randomization allocation. Recruitment for the study took place from August 2016 through October 2020. Participants were active-duty military service members diagnosed with posttraumatic stress disorder. The study was conducted in an outpatient setting for service members seeking PTSD treatment at military bases in San Antonio or Killeen, Texas. Participants received either written exposure therapy, which consisted of 5 weekly sessions, or cognitive processing therapy, which consisted of 12 twice-weekly sessions. Participants were assessed at baseline and at 10, 20, and 30 weeks after the first treatment session. The primary outcome measure was PTSD symptom severity assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Noninferiority was defined as the difference between the 2 groups being less than the upper bound of the 1-sided 95% CI-specified margin of 10 points on the CAPS-5. Overall, 169 participants were included in the study. Participants were predominantly male (136 [80.5%]), serving in the Army (167 [98.8%]), with a mean (SD) age of 34 (8) years. Eighty-five participants were randomly assigned to written exposure therapy, with 65 (76.5%) completing all treatment sessions, and 84 to cognitive processing therapy, with 47 (54.8%) completing all treatment sessions. Findings indicated that written exposure therapy was noninferior to cognitive processing therapy, with the largest difference in change in outcome between the treatment conditions of 3.96 points on the outcome measure. The 1-sided 95% CI upper limit was less than 10 points across time points in both groups and ranged from 4.59 at week 30 to 6.81 at week 10. Within-condition effect sizes ranged from a Cohen d of 0.48 for the written exposure therapy group in the intention-to-treat analysis at week 10 to 0.95 for the cognitive processing therapy group in the per-protocol analysis at week 10, and between-condition effect size ranged from 0.06 in the intention-to-treat analysis at week 30 to 0.22 in the per-protocol analysis at week 10. In this randomized clinical trial, support was found for an effective and more efficient PTSD treatment approach for service members. Future research should determine who does and does not benefit from PTSD treatment to best maximize treatment outcomes. ClinicalTrials.gov Identifier: NCT03033602.

Economic costs of implementing evidence-based telemedicine outreach for posttraumatic stress disorder in VA.

Telemedicine outreach for posttraumatic stress disorder (TOP) is a virtual evidence-based practice (EBP) involving telephone care management and telepsychology that engages rural patients in trauma-focused psychotherapy. This evaluation examined implementation and intervention costs attributable to deploying TOP from a health system perspective. Costs were ascertained as part of a stepped wedge cluster randomized trial at five sites within the Veterans Affairs (VA) Healthcare System. All sites initially received a standard implementation strategy, which included internal facilitation, dissemination of an internal facilitators operational guide, funded care manager, care managing training, and technical support. A subset of clinics that failed to meet performance metrics were subsequently randomized to enhanced implementation, which added external facilitation that focused on incorporating TOP clinical processes into existing clinic workflow. We measured site-level implementation activities using project records and structured activity logs tracking personnel-level time devoted to all implementation activities. We monetized time devoted to implementation activities by applying an opportunity cost approach. Intervention costs were measured as accounting-based costs for telepsychiatry/telepsychology and care manager visits, ascertained using VA administrative data. We conducted descriptive analyses of strategy-specific implementation costs across five sites. Descriptive analyses were conducted instead of population-level cost-effectiveness analysis because previous research found enhanced implementation was not more successful than the standard implementation in improving uptake of TOP. Over the 40-month study period, four of five sites received enhanced implementation. Mean site-level implementation cost per month was $919 (SD = $238) during standard implementation and increased to $1,651 (SD = $460) during enhanced implementation. Mean site-level intervention cost per patient-month was $46 (SD = $28) during standard implementation and $31 (SD = $21) during enhanced implementation. Project findings inform the expected cost of implementing TOP, which represents one factor health systems should consider in the decision to broadly adopt this EBP. Plain Language Summary: What is already known about the topic: Trauma-focused psychotherapy delivered through telemedicine has been demonstrated as an effective approach for the treatment of post-traumatic stress disorder (PTSD). However, uptake of this evidence-based approach by integrated health systems such as the Veterans Affairs (VA) Health Care System is low. What does this paper add: This paper presents new findings on the costs of two implementation approaches designed to increase adoption telemedicine outreach for PTSD from a health system perspective. What are the implications for practice, research, and policy: Cost estimates from this paper can be used by health systems to inform the relative value of candidate implementation strategies to increase adoption of evidence-based treatments for PTSD or other mental health conditions.

Complementary and Integrative Health Interventions for Insomnia in Veterans and Military Populations.

Insomnia can be a serious problem diminishing quality of life for Veterans and military populations with and without posttraumatic stress disorder (PTSD). Sleep disturbances are one of the symptoms of PTSD but even after evidence-based PTSD treatments, insomnia symptoms often remain. The primary approaches for treating insomnia are cognitive behavioral therapy for insomnia (CBT-I) and pharmacotherapy. However, each of these treatments has drawbacks. Complementary and Integrative Health (CIH) approaches such as mindfulness meditation, mantram meditation, yoga, and tai chi may provide alternative treatments for insomnia in military populations. This paper provides a brief review of studies on CIH interventions for sleep disturbances in Veterans. It also proposes possible mechanisms by which CIH practices may be effective, including increasing hippocampal volume and gamma-aminobutyric acid acid (GABA). Finally, the acceptability of CIH approaches among Veterans is discussed.

Addressing Moral Injury in Emergency Medicine

Moral injury, which is described as the psychological distress that results from actions, or lack of them, that go against one's beliefs or values, has become front and center among issues facing the practice of emergency medicine. Although it predates the COVID-19 outbreak, the pandemic has played a significant role in the increased rate of burnout, and even suicide, among emergency physicians. This paper includes several clinical vignettes to highlight incidents that may occur in the emergency department (ED) whenphysicians experience violations of their moral codes, leading to distress and moral injury. Thesescenarios explore the conflicts posed between competingbioethical principles such as beneficence, nonmaleficence, end-of-life decision-making, medical futility, respect for self-determination (autonomy), resource scarcity and triage, duty to care, and physician impairment. There are significant similarities between moral injury and post-traumatic stress disorder (PTSD), with some authors describing moral injury as a subset of PTSD. We explore these commonalities to provide coping mechanisms and mitigation strategies for those suffering from moral injury. Physicians experiencing moral injury may benefit from the many available evidence-based treatments for PTSD to identify and manage moral injury and to support patient care and personal well-being.

Psychobiological Treatment Response to a Two-Week Posttraumatic Stress Disorder and Mild Traumatic Brain Injury Integrated Treatment Program: A Case Report

Posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) demonstrate high prevalence and comorbidity among post-9/11 veterans. Veterans with this comorbidity often present with multiple co-occurring healthcare needs and increased clinical complexity. The current case report describes the clinical presentation of a veteran with mild TBI and PTSD, both before, during, and after treatment within a multidisciplinary 2-week intensive outpatient program involving prolonged exposure, evidence-based PTSD treatment, and Cognitive Symptom Management and Rehabilitation Therapy, evidence-based treatment for postconcussive symptoms. Mr. A was a 25-year-old White, transgender male who presented with a complex mental health history. At intake, presenting complaints included anxiety, panic attacks, nightmares, and depression secondary to military sexual trauma, as well as reported cognitive difficulties secondary to a concussion. He met current criteria for PTSD as well as panic disorder with agoraphobia. Head injury history consisted of a motor vehicle collision with less than 30 seconds loss of consciousness, brief posttraumatic amnesia, and alterations of consciousness. Mr. A demonstrated habituation during individual exposure sessions as assessed via skin conductance during imaginal exposures and decreased subjective ratings during in vivo exposures, as well as a decrease in trauma-potentiated startle response to trauma cues. Posttreatment data indicates significant reduction in neurobehavioral, posttraumatic stress, and depression symptoms and significant improvement in subjective cognitive functioning. The current findings support the feasibility and efficacy of short-term integrated treatment for complex clinical presentations and the need for larger scale research investigating combined PTSD and TBI intervention.

Written exposure therapy for posttraumatic stress symptoms and suicide risk: Design and methodology of a randomized controlled trial with patients on a military psychiatric inpatient unit

Studies of active duty service members have shown that military personnel who screen positive for posttraumatic stress disorder (PTSD) are more than twice as likely to make a suicide attempt. Evidence-based PTSD treatments can reduce suicidal ideation; however, it can be challenging to provide evidence-based, trauma-focused, PTSD treatment to high-risk patients on an acute psychiatric inpatient unit because the priority of care is stabilization. Treatment for PTSD requires more time and resources than are typically afforded during inpatient hospitalizations. Written Exposure Therapy is an evidence-based, five-session, trauma-focused treatment for PTSD that may overcome the implementation challenges of providing PTSD treatment in an acute inpatient psychiatric treatment setting. This paper describes the design, methodology, and protocol of a randomized clinical trial. The goal of the study is to determine if five 60-min sessions of Written Exposure Therapy enhanced with Crisis Response Planning for suicide risk reduces the presence, frequency, and severity of suicidal ideation, suicidal behavior, rehospitalization, and non-suicidal, self-injurious behaviors. The study also will determine if Written Exposure Therapy for Suicide reduces posttraumatic stress symptom severity among military service members, veterans, and other adult military beneficiaries admitted to an acute psychiatric inpatient unit for comorbid suicide ideation or attempt and PTSD symptoms compared with Treatment as Usual. The study is designed to enhance the delivery of care for those in acute suicidal crisis with comorbid PTSD symptoms.

Using Theories of Posttraumatic Stress to Inform Perinatal Care Clinician Responses to Trauma Reactions.

Understanding of the importance of addressing trauma in health care is increasing rapidly. Health care providers may be actively seeking ways to address trauma sequelae affecting their patients with a trauma-informed continuum of care. Such a continuum includes a universal approach, targeted interventions (ie, practices and programs), and specialist treatment for posttraumatic stress disorder (PTSD), as well as responses to historic and intergenerational trauma. Client presentations and their needs are highly individualized. Therefore, an understanding of prominent theories of what causes PTSD may assist perinatal care professionals in adapting their practice to be trauma-informed and trauma-specific. The purpose of this article is to review 4 theories of PTSD relevant to perinatal practice and present an evidence-based practice framework that encourages collaborative choices consistent with client values and preferences. A brief summary of current evidence-based PTSD treatment guidelines is presented.

Understanding the association between material hardship and posttraumatic stress disorder: a test of the social selection and social causation hypotheses and an exploration of gender differences.

There is a well-established association between poverty and posttraumatic stress disorder (PTSD); however, little research has tested the temporality of the association. Using data from Waves IV (2008; N = 14,800) and V (2016-2018; N = 10,685) of the National Longitudinal Study of Adolescent to Adult Health, we examined temporal associations between material hardship (a specific operationalization of poverty) and PTSD, as well as assessed for potential gender differences in associations. We conducted logistic regression and generalized structural equation modeling to examine associations between material hardship and PTSD and assess for mediation and moderation by gender. Prior PTSD diagnoses were associated with an increased likelihood of material hardship (OR = 1.64; 95% CI 1.21, 2.21). The indirect effect of gender on material hardship through PTSD diagnoses was significant. Prior material hardship was associated with an increased likelihood of PTSD diagnoses (OR = 1.81; 95% CI 1.35, 2.42). The indirect effect of gender on PTSD diagnoses through material hardship was significant. There was no evidence of moderation by gender for either association. Results suggest reciprocal associations between material hardship and PTSD. Economic policies, as well as improved access to evidence-based PTSD treatments, may reduce the burden of both material hardships and PTSD.