Psychotherapy For Posttraumatic Stress Disorder Research Articles

Trauma-focused evidence-based psychotherapy for post-traumatic stress disorder delivered via video telehealth in the Veterans Health Administration.

Trauma-focused evidence-based psychotherapy (EBP) is the recommended treatment for post-traumatic stress disorder (PTSD). During and after the COVID-19 pandemic, veterans began to initiate general mental health services delivered via video telehealth at high rates. Our goal in the current project was to describe the percentage as well as the demographic, military, and clinical characteristics of veterans receiving PTSD EBPs via video telehealth versus in-person. Using data from the VA electronic health record, we identified a national cohort of all-era veterans who received individual PTSD EBP between April 2022 and April 2023 (n = 24,447). We used multivariable hierarchical Bayesian logistic regression to model the probability of receiving at least 50% of their EBP care via video telehealth. In our sample, 74.4% of veterans who received PTSD EBP used video telehealth for at least one EBP session and 66.8% of veterans received at least half of their EBP sessions by video telehealth. Female veterans, younger veterans, and veterans with fewer mental health comorbidities were more likely to have received their PTSD EBP via video telehealth. Additional strong interaction effects for Black female veterans, Hispanic female veterans, female officer veterans, and Black officer veterans. Video telehealth delivery of PTSD EBPs was more common than in-person delivery of PTSD EBPs. Consistent with underlying trends in telehealth services, female veterans, and particularly female, racial/ethnic minority veterans were more likely to receive PTSD EBP via video telehealth. Future research designed to contextualize the observed differences in video telehealth delivery of PTSD EBPs should consider the role of social determinants of health.

Criticality is Associated with Future Psychotherapy Response in Patients with Post-Traumatic Stress Disorder—A Pilot Study

Background Trauma-focused psychotherapy is treatment of choice for post-traumatic stress disorder (PTSD). However, about half of patients do not respond. Recently, there is increased interest in brain criticality, which assesses the phase transition between order and disorder in brain activity. Operating close to this borderline is theorized to facilitate optimal information processing. We studied if brain criticality is related to future response to treatment, hypothesizing that treatment responders’ brains function closer to criticality. Methods Functional magnetic resonance imaging resting-state scans were acquired from 46 male veterans with PTSD around the start of treatment. Psychotherapy consisted of trauma-focused cognitive behavioral therapy, eye movement desensitization and reprocessing, or a combination thereof. Treatment response was assessed using the Clinician-Administered PTSD Scale, and criticality was assessed using an Ising temperature approach for seven canonical brain networks (ie, the visual, somatomotor, dorsal attention, ventral attention, limbic, frontoparietal and default mode networks) to measure distance to criticality. Results The brains of prospective treatment responders were closer to criticality than nonresponders (P = 0.017), while no significant interaction effect between group and brain network was observed (P = 0.486). In addition, average criticality across networks correlated with future treatment response (P = 0.028). Conclusion These results show that the brains of prospective PTSD psychotherapy treatment responders operate closer to criticality than nonresponders, and this occurs across the entire brain instead of in separate canonical brain networks. These results suggest that effective psychotherapy is mediated by brains operating closer to criticality.

Which PTSD clusters and symptoms are central to reducing suicidal ideation? A network and cross-lagged analysis among individuals receiving cognitive processing therapy

ABSTRACT Background: Posttraumatic stress disorder (PTSD) is associated with suicidal ideation (SI) and SI tends to improve over the course of evidence-based psychotherapy for PTSD. However, it remains unclear which PTSD clusters and symptoms are central to changes in SI throughout treatment. Objective: To use (1) network analysis to identify the PTSD clusters and symptoms most uniquely related to SI (at baseline and post-treatment); and (2) cross-lagged analyses to examine whether these PTSD clusters and symptoms prospectively predicted decreases in SI over the course of cognitive processing therapy (CPT). Method: Participants were 188 individuals with PTSD receiving CPT as part of an implementation-effectiveness trial. At each session, DSM-IV PTSD clusters and symptoms were assessed using the PTSD Checklist and SI was assessed using the Outcome Questionnaire-45. Results: Multi-staged cross-sectional network analyses indicated that at baseline and post-treatment the avoidance and reexperiencing clusters were uniquely associated with SI. Within these clusters, the symptoms uniquely associated with SI were recurrent thoughts and dreams of trauma, restricted range of affect, and sense of foreshortened future at baseline; and sense of foreshortened future, restricted range of affect, recurrent dreams of trauma, feelings of detachment from others, memory impairment, avoidance of reminders of trauma, and psychological cue reactivity at post-treatment. Multilevel cross-lagged analyses indicated that the avoidance cluster and the restricted range of affect and sense of foreshortened future symptoms, uniquely predicted next-session decreases in SI. Conclusions: These findings suggest that reductions in SI within treatment may be due to direct targeting of avoidance, affect, and future-related cognitions. Further research remains necessary to determine whether the present findings extend to DSM-5 PTSD clusters and symptoms.

Esketamine facilitate psychotherapies for Post-Traumatic Stress Disorder: A retrospective case series of six patients

Esketamine facilitate psychotherapies for Post-Traumatic Stress Disorder: A retrospective case series of six patients

Healthcare costs and resource utilization of patients with chronic post-traumatic stress disorder: a retrospective US claims analysis of commercially insured patients.

Aim: Exploring the healthcare costs and resource use among privately insured US patients with post-traumatic stress disorder (PTSD). Methods: This study used Merative MarketScan data. The index date was defined as the first PTSD claim. Study period included a 1-year pre-index and 2-year post-index follow-up. Cases with only acute PTSD, cancer, or insurance gap during the study period were excluded. The PTSD with (PwC) and PTSD without comorbidities (PwoC) cohorts were defined by the presence/absence of comorbid mental health conditions (schizophrenia, bipolar and major depressive disorder). Baseline PTSD (BP) cohort included PwoC cases with only index PTSD event and without FDA-approved PTSD medications or psychotherapy. Sub-analysis is conducted among patients with PTSD and substance/alcohol use disorder. Study cohorts were matched in a 1:1:1 ratio. Results: The matched sample included 5076 patients (1681 PwC, 1681 PwoC, 1714 BP). PwC patients had higher 2-year PTSD-related costs than PwoC and BP patients ($3762 vs $1750 and $841; all p<0.001). The same trend was noted among all-cause and anxiety-related costs. PwC patients had higher 2-year PTSD-related inpatient and emergency department (ED) rates than PwoC (10.2% vs 1.7% and 6.8% vs 2.6%, all p<0.001) and inpatient and outpatient rates than BP (10.2% vs 2.1% and 98.0% vs 93.1%; all p≤0.004). The sub-analysis had 3776 patients (3154 PwC, 537 PwoC, 85 BP). PwC had higher 2-year PTSD-related costs than PwoC and BP ($7668 vs $2919 and $1,483; all p<0.001). The same trend was noted in all-cause and anxiety-related costs. PwC also had higher 2-year PTSD-related inpatient and ED rates than PwoC (25.6% vs 10.4% and 12.7% vs 5.2%; all p<0.001) and inpatient and outpatient rates than BP (25.6% vs 8.2% and 95.5% vs 84.7%; all p<0.001). Conclusion: PTSD is associated with high healthcare costs and resource use. The highest economic burden was observed in patients with PTSD and mental health comorbidities.

Clinic-Level Predictors of Psychotherapy Dosage in the Military Health System.

This study aimed to describe the demand for, supply of, and clinic processes associated with behavioral health care delivery in the Military Health System and to examine the clinic-level factors associated with receipt of a minimally adequate dosage of psychotherapy. This retrospective study used administrative behavioral health data from eight military treatment facilities (N=25,433 patients; N=241,028 encounters) that were participating in a larger implementation study of evidence-based psychotherapy for posttraumatic stress disorder. Minimally adequate dosage of psychotherapy was defined in two ways: at least three sessions within a 90-day period and at least six sessions within a 90-day period. The authors then used a path model to examine clinic-level factors hypothesized to predict psychotherapy dosage, including care demand, supply, and processes. Patients had an average of 2.5 psychotherapy appointments per quarter. Wait times for intake, between intake and the first psychotherapy session, and between follow-up sessions all averaged 17 days or longer. Path modeling showed that a higher patient-to-encounter ratio was associated with a longer wait time between follow-up psychotherapy appointments. In turn, a longer wait time between appointments was associated with a lower probability of receiving an adequate dosage of psychotherapy. However, a greater proportion of care delivered in groups was associated with a greater probability of receiving at least six sessions of psychotherapy. Receipt of a minimally adequate dosage of psychotherapy in the Military Health System is hindered by clinic staffing and workflows that increase wait times between follow-up psychotherapy appointments.

Predictors of study dropout in cognitive-behavioural therapy with a trauma focus for post-traumatic stress disorder in adults: An individual participant data meta-analysis

BackgroundAvailable empirical evidence on participant-level factors associated with dropout from psychotherapies for post-traumatic stress disorder (PTSD) is both limited and inconclusive. More comprehensive understanding of the various factors that contribute...

Personalizing cognitive processing therapy with a case formulation approach to intentionally target impairment in psychosocial functioning associated with PTSD

Posttraumatic stress disorder (PTSD) is a debilitating condition often accompanied by significant functional impairments affecting quality of life and well-being. While Cognitive Processing Therapy (CPT) is a leading, evidence-based psychotherapy for PTSD, demonstrating substantial efficacy in core symptom reduction, its impact on psychosocial functioning is less well-established. The Personalizing Cognitive Processing Therapy with a Case Formulation Approach (Personalizing Approaches to Therapy: PATh) study aims to enhance CPT by explicitly targeting functional impairments and idiosyncratic challenges to optimal therapy outcomes (COTOs), comparing its efficacy against standard CPT in improving psychosocial functioning, quality of life, well-being, and core PTSD and depression symptoms. This randomized controlled trial involves 200 Veterans across eight Veterans Health Administration clinical sites, assigned to either Case Formulation CPT (CF-CPT) or standard CPT. Providers will deliver up to 20 sessions per patient, with assessments at baseline, mid-treatment, post-treatment, and three months follow-up. It is hypothesized that Veterans receiving CF-CPT will show greater improvements in functioning, quality of life, well-being, and symptom reduction, alongside higher treatment completion rates compared to standard CPT. Secondary outcomes will examine specific clinical challenges and their influence on treatment outcomes. This study investigates whether a personalized, flexible CPT protocol can enhance functional recovery in PTSD treatment without compromising the efficacy of the traditional approach, potentially impacting clinical practices and patient outcomes by promoting holistic recovery for veterans with PTSD.

What's in a treatment name? How people with posttraumatic stress disorder (PTSD) symptoms interpret and react to PTSD treatment names.

Prior research has rarely examined how people understand or react to the names of psychological treatments. In the case of evidence-based psychotherapies for posttraumatic stress disorder (PTSD), such reactions may be relevant to the low rates of uptake of such treatments. Participants who screened positive for PTSD (n = 887) completed questions assessing their initial reactions to PTSD treatment names as well as how a different name would affect their openness to treatment. In addition, they gave brief responses to open-ended questions about the reason for their initial reactions, and content analysis was used to better understand these reasons. The results indicated that among the treatment name options, cognitive processing therapy (CPT) and present-centered therapy (PCT) were viewed most positively. Approximately 40% of the sample preferred plain language alternatives for treatment names. Content analyses focused on descriptions of the treatments-which could be accurate or inaccurate-as well as whether respondents evaluated a treatment name itself as positive or negative. Some names conveyed treatments more accurately (e.g., CPT and written exposure therapy) than others (e.g., eye movement desensitization and reprocessing and prolonged exposure [PE]). Some names were also evaluated more positively (e.g., PCT) than others (e.g., PE). The general term "trauma-focused therapy" was seen as positive and clear. Addressing the ways patients react to psychological terms and treatment names could help clarify misperceptions about evidence-based psychotherapies and promote more widespread uptake of effective treatments for PTSD.

The Psychotherapy in MDMA-Assisted Psychotherapy

This Viewpoint discusses the critical yet overlooked role of the psychotherapy component in assessing the validity of the trials of midomafetamine/3,4-methylenedioxymethamphetamine (MDMA)–assisted psychotherapy for posttraumatic stress disorder.

The effectiveness and value of midomafetamine-assisted psychotherapy for posttraumatic stress disorder.

The effectiveness and value of midomafetamine-assisted psychotherapy for posttraumatic stress disorder.

Stimulation of an entorhinal-hippocampal extinction circuit facilitates fear extinction in a post-traumatic stress disorder model.

Effective psychotherapy of post-traumatic stress disorder (PTSD) remains challenging owing to the fragile nature of fear extinction, for which the ventral hippocampal CA1 (vCA1) region is considered as a central hub. However, neither the core pathway nor the cellular mechanisms involved in implementing extinction are known. Here, we unveil a direct pathway, where layer 2a fan cells in the lateral entorhinal cortex (LEC) target parvalbumin-expressing interneurons (PV-INs) in the vCA1 region to propel low-gamma-band synchronization of the LEC-vCA1 activity during extinction learning. Bidirectional manipulations of either hippocampal PV-INs or LEC fan cells sufficed for fear extinction. Gamma entrainment of vCA1 by deep brain stimulation (DBS) or noninvasive transcranial alternating current stimulation (tACS) of LEC persistently enhanced the PV-IN activity in vCA1, thereby promoting fear extinction. These results demonstrate that the LEC-vCA1 pathway forms a top-down motif to empower low-gamma-band oscillations that facilitate fear extinction. Finally, application of low-gamma DBS and tACS to a mouse model with persistent PTSD showed potent efficacy, suggesting that the dedicated LEC-vCA1 pathway can be stimulated for therapy to remove traumatic memory trace.

Scoping review of spirituality-integrated psychotherapies for posttraumatic stress disorder.

Scoping review of spirituality-integrated psychotherapies for posttraumatic stress disorder.

Reciprocal changes in functioning and PTSD symptoms over the course of psychotherapy

Psychotherapies for posttraumatic stress disorder (PTSD) assume that PTSD symptom improvement will lead to improvements in functioning. Yet, few studies have examined the dynamic interplay between these constructs. Using a random intercepts cross-lagged panel model, we examined the association between functioning and PTSD, both modeled as a total score and as the DSM-5 subclusters, across twelve sessions of treatments that chiefly target functioning. Participants were 161 Veterans with PTSD enrolled in a randomized controlled trial comparing present centered therapy and an enhanced version of adaptive disclosure. Overall, PTSD symptoms, measured as the total PTSD score, led to changes in functioning more frequently than functioning predicting PTSD symptoms, although these effects did not appear until session 7. In terms of subclusters, functioning predicted changes in the PTSD subclusters B (intrusions), C (avoidance), and E (alterations in arousal and reactivity) at more timepoints compared to timepoints at which these subclusters predicted functioning. The dynamic relationships between PTSD and functioning in the context of functioning-focused treatments are complex, with functioning playing an important role in reduction of some of the core symptoms of PTSD.

Task-shifting of prolonged exposure for primary care (PE-PC) for PTSD in a semirural setting in South Africa: A pilot implementation study.

Implementation science (IS) has received increased attention as it provides a means to bridge the know-do gap to implement evidence-based interventions in real-world settings. Against this backdrop, posttraumatic stress disorder (PTSD) is a global mental health concern (Koenen et al., 2017), especially in low- and middle-income countries characterized by limited trained health professionals, infrastructure, and limited access to evidence-based mental health care (Chen et al., 2017). Over the last 3 decades, effective trauma-focused psychotherapies (TFPs) for PTSD have been developed (Hamblen et al., 2019). Prolonged exposure therapy (PE) is a first-line TFP for PTSD (Hamblen et al., 2019), yet the dissemination and implementation of PE have been limited to specialty care settings in developed or industrialized countries (Booysen & Kagee, 2020). Implementation science provides an opportunity for disseminating and implementing TFPs like PE in low- and middle-income countries. This article describes mixed-method data from a pilot implementation study of an abbreviated version of PE, known as prolonged exposure for primary care (S. A. M. Rauch, Kim, et al., 2023), in a semirural city in the Eastern Cape of South Africa. Importantly, prolonged exposure for primary care shows a significant reduction in PTSD when provided by lay counselors and good feasibility and acceptability. In addition, we reflect on the barriers and facilitators related to implementation research within a low-resourced community, namely, (a) training lay counselors, (b) cultural diversity, and (c) mental health literacy. Mental health literacy is proposed as an essential component to consider in implementation science, especially in low-resourced communities. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Exploring the therapeutic potential of psychedelics: Fear extinction mechanisms and amygdala modulation

Classical psychedelics are increasingly receiving attention as potential therapeutic agents for treating post-traumatic stress disorder (PTSD). Research has explored various classical psychedelics in the context of fear learning, recall, and extinction in rodents. We provide an overview of the reported effects of these substances on behavioral responses to learned fear. The amygdala complex, a key brain region involved in fear learning and extinction, plays a central role in these processes. We discuss how psychedelics interact with various cell types in the amygdala and propose which neural circuits may be essential for the observed fear-suppressing effects following psychedelic administration in rodents. The rodent amygdala has functional homology with the human amygdala. Thus, insights gained from preclinical studies can inform the design and implementation of clinical trials for psychedelic-assisted psychotherapy for PTSD. Finally, we stress the importance of considering compound-specific pharmacology and the acute duration of action as key factors in guiding the future direction of this field.

MDMA Therapy for PTSD: Inching Closer to-or Farther From-Approval?

In recent years, scientists have initiated a renaissance in psychedelic research following decades of prohibition. Compounds such as ketamine, LSD, and psilocybin 'once primarily associated with recreational use' are now being investigated for their therapeutic potential, with promising results. An estimated 40-60% of people with post-traumatic stress disorder (PTSD) do not respond to selective serotonin reuptake inhibitors, which are the first-line medications for this condition. However, one standout among these psychedelics is methylenedioxy methamphetamine (MDMA), which has demonstrated exceptional efficacy in treating PTSD and medication-resistant depression. Growing results in research were so positive that, in 2017, the US Food and Drug Administration (FDA) designated MDMA-assisted psychotherapy as a breakthrough therapy. Though MDMA is not yet officially legal or approved for clinical use, Phase 3 trials are underway, and expanded access status was granted in 2020 in the United States and Israel. Preliminary clinical studies are extremely promising, and the FDA could approve MDMA-assisted psychotherapy for PTSD as early as 2024, offering a potential treatment for this crippling mental health condition that affects almost 3.5% of US adults.

A systematic review and meta-analysis of predictors of response to trauma-focused psychotherapy for posttraumatic stress disorder.

Although trauma-focused psychotherapy (T-F psychotherapy) is the treatment of choice for posttraumatic stress disorder (PTSD), up to one half of patients do not respond to this treatment. Attempts to improve response to T-F psychotherapy have focused on augmenting fear extinction-based factors. Here, a systematic and meta-analytic review of predictors of T-F psychotherapy outcome was conducted with the goal of using an aggregate data-driven approach to elucidate baseline factors associated with treatment outcome. There were 114 studies that met inclusion criteria (N = 61, 970; Mage = 40.1 years; 40.1% female). There were 237 effect sizes across 24 meta-analytic categories. Poorer treatment response is associated with lower pretreatment levels of activation of fear-related brain regions, psychophysiological reactivity to fear provocation, trauma-related cognitions, anger, depression, high-risk alleles of genes linked to fear, lower levels of executive control, and social support. A range of other factors also predicted poorer responses including being male, non-Caucasian, older in age, early trauma occurrence, more trauma experience, history of combat trauma, as well as comorbid sleep, pain, poor quality life, and alcohol abuse difficulties. This review provides one potential explanation for the limited success of T-F psychotherapy augmentation strategies that have focused only on fear circuity mechanisms at the exclusion of other factors. Here, poor response relating to predictors of early trauma onset and comorbidity are consistent with clinical presentations of complex PTSD, which may suggest T-F psychotherapy is less effective for this condition. This collective evidence suggests that clinicians should consider a tailored approach that targets potential barriers to successful treatment response. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Trauma exposure, mental health, and mental health treatment among LGBTQ+ veterans and nonveterans.

The purpose of the study was to compare lesbian, gay, bisexual, transgender, queer+ (LGBTQ+) veterans' and nonveterans' prevalence of potentially traumatic events (PTEs) and other stressor exposures, mental health concerns, and mental health treatment. A subsample of veterans and nonveterans who identified as LGBTQ+ (N = 1,291; 851 veterans; 440 nonveterans) were identified from a national cohort of post-9/11 veterans and matched nonveterans. Majority of the sample identified as White (59.7%), men (40.4%), and gay or lesbian (48.6%). Measures included PTEs and other stressors, depression, anxiety, posttraumatic stress disorder (PTSD), and receipt of mental health treatment. Logistic regressions compared the likelihood of experiencing PTEs and other stressors, self-reported mental health diagnoses, and mental health treatment between LGBTQ+ veterans and nonveterans. Compared with LGBTQ+ nonveterans, LGBTQ+ veterans were more likely to report financial strain, divorce, discrimination, witnessing the sudden death of a friend or family member, and experiencing a serious accident or disaster. LGBTQ+ veterans reported greater depression, anxiety, and PTSD symptom severity than LGBTQ+ nonveterans. However, LGBTQ+ veterans were only more likely to receive psychotherapy for PTSD and did not differ from nonveterans in the likelihood of receiving any other types of mental health treatment. The study was the first to demonstrate that LGBTQ+ veterans have a greater prevalence of PTEs and other stressors and report worse mental health symptoms. These findings suggest that LGBTQ+ veterans may have unmet mental health treatment needs and need interventions to increase engagement in needed mental health services, especially for depression and anxiety. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Gender as a moderator of associations between military sexual trauma and posttraumatic stress disorder treatment utilization.

The present study sought to investigate whether gender moderates the relationship between military sexual trauma (MST) and posttraumatic stress disorder (PTSD) treatment utilization, among veterans with clinically significant PTSD symptoms. Participants were 2,664 veterans with probable PTSD from a nationwide, population-based survey. Participants reported sociodemographic information, history of MST (including military sexual harassment and military sexual assault), and lifetime receipt of PTSD psychotherapy and medication treatment. We found that gender significantly moderated relationships between (a) military sexual harassment and PTSD psychotherapy, (b) military sexual assault and PTSD psychotherapy, and (c) military sexual harassment and PTSD medication. For women, MST was associated with a greater likelihood of receiving treatment, but for men, MST was not associated with PTSD treatment. Future research is needed to better understand gender differences in how experiences of MST may affect engagement in PTSD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).