The development of a posttraumatic stress disorder (PTSD) consultation program to support system-wide implementation of high-quality PTSD care for veterans.

Among veterans, there is a 7% lifetime prevalence of posttraumatic stress disorder (PTSD; Goldstein et al., 2016), with this diagnosis being linked to poor health and quality of life (Goldstein et al., 2016; Schnurr et al., 2009). Veterans with PTSD may present for treatment in a variety of health care settings, meaning that providers across all of these settings need information about how to care for veterans with PTSD. Despite a number of ongoing efforts to ensure that veterans have access to effective, recovery-oriented treatments for PTSD within Veterans Affairs (VA), there is a need for further improvement and likely an even greater need for improvement in non-VA settings. A variety of consultation and technical assistance models exist, though research has lagged in this area. This article reports the rationale, development, and initial outcomes of the PTSD Consultation Program, a centralized consultation program started in 2011, which is available to all providers offering care to veterans with PTSD on an "on-request" basis. From 2011 to 2022, there have been 17,417 consultation requests, with about three quarters coming from VA providers, most often related to resources or treatment questions. The program has also flexibly responded to current events and crises. Survey feedback indicates high satisfaction. Data indicate that this type of on-request consultation may be an effective method to utilize the expertise of a few providers to help support a broader range of providers in implementing high-quality PTSD-or other types of specialty-care. Future research can link these data to more distal outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Pretreatment relationship characteristics predict outcomes from an uncontrolled trial of intensive, multicouple group PTSD treatment.

Cognitive behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD; Monson & Fredman, 2012) is associated with improvements in patients' and partners' mental health and relationship satisfaction. Some pretreatment relationship characteristics have predicted CBCT for PTSD outcomes for patients, but findings were limited to a single community sample consisting primarily of female patients with male partners. A better understanding of whether pretreatment relationship characteristics predict outcomes in other patient populations and whether there are partners who may be particularly responsive to couple therapy for PTSD could optimize treatment matching. This study investigated whether pretreatment partner accommodation and relationship satisfaction predicted patient and partner treatment outcomes from an uncontrolled trial of an abbreviated, intensive, multicouple group version of CBCT for PTSD conducted with 24 active-duty military or veteran couples (96% male patients/female partners). In general, changes in patients' PTSD and comorbid symptoms and relationship satisfaction did not vary by pretreatment partner accommodation or patients' own pretreatment relationship satisfaction. In contrast, pretreatment relationship characteristics predicted partner outcomes. Partners who engaged in higher levels of accommodation pretreatment and partners who reported lower levels of pretreatment relationship satisfaction experienced greater declines in psychological distress following treatment. Also, partners who began the study relationally distressed exhibited significant increases in relationship satisfaction following treatment, whereas those who were not relationally distressed did not. Findings suggest that improvements generally do not vary by pretreatment relationship characteristics for patients, whereas partners who begin treatment with elevated relationship risk factors may be especially likely to experience improvement across outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The PTSD Criterion A debate: A brief history, current status, and recommendations for moving forward.

Posttraumatic stress disorder (PTSD) Criterion A, also known as the "stressor criterion," has been a major source of debate ever since PTSD was added to the third edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM) in 1980. Since then, the traumatic stress field has held an ongoing debate about how to best define Criterion A and the events that it covers. Because of the COVID-19 pandemic and recent race-based incidents, the Criterion A debate has been reinvigorated. In this paper, we review briefly the history of Criterion A and changes in its language across different editions of the DSM. We then describe the four main positions held by scholars involved in the Criterion A debate and carefully examine the support for those positions. We conclude by offering recommendations for moving forward.

Intraverbal Assessment for Persons with Aphasia or Other Acquired Brain Injury.

An intraverbal assessment was administered to older adults with aphasia, using a hierarchy of questions that required increasingly complex verbal discriminative stimulus control. Five categories of errors were defined and analyzed for putative stimulus control, with the aim to identify requisite assessment components leading to more efficient and effective treatments. Evocative control over intraverbal error responses was evident throughout the database, as shown by commonalities within four distinct categories of errors; a fifth category, representing a narrow majority of errors, was less clear in terms of functional control over responses. Generally, questions requiring increasingly complex intraverbal stimulus control resulted in weaker verbal performance for those with aphasia. A new 9-point intraverbal assessment model is proposed, based on Skinner's functional analysis of verbal behavior. The study underscores that loss or disruption of a formerly sophisticated language repertoire presents differently than the fledgling language skills and errors of new learners, such as typically developing children and those with autism or developmental disabilities. Thus, we would do well to consider that rehabilitation may require a different approach to intervention than habilitation. We offer several thematic topics for future research in this area.

Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial.

Importance: Improved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD). Objective: To determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD. Design, Setting, and Participants: This randomized clinical trial was conducted among military personnel and veterans at 4 sites in Texas from 2017 to 2019. Assessors were blinded to conditions. Data were analyzed from November 2020 to October 2022. Interventions: The interventions were massed-PE, which included 15 therapy sessions of 90 minutes each over 3 weeks, vs intensive outpatient program PE (IOP-PE), which included 15 full-day therapy sessions over 3 weeks with 8 treatment augmentations. The IOP-PE intervention was hypothesized to be superior to massed-PE. Main Outcomes and Measures: Coprimary outcomes included the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) administered at baseline and posttreatment follow-ups. Measures ranged from 0 to 80, with higher scores indicating greater severity. Diagnostic remission and reliable change were secondary outcomes. Results: Among 319 military personnel and veterans screened, 234 were randomized (mean [SD] age, 39.20 [7.72] years; 182 [78%] male participants), with 117 participants randomized to IOP-PE and 117 participants randomized to massed-PE. A total of 61 participants (26%) were African American, 58 participants (25%) were Hispanic, and 102 participants (44%) were White; 151 participants (65%) were married. Linear mixed-effects models found that CAPS-5 scores decreased in both treatment groups at the 1-month follow-up (IOP-PE: mean difference, -13.85 [95% CI, -16.47 to -11.23]; P < .001; massed-PE: mean difference, -14.13 [95% CI, -16.63 to -11.62]; P < .001). CAPS-5 change scores differed from 1- to 6-month follow-ups (mean difference, 4.44 [95% CI, 0.89 to 8.01]; P = .02). PTSD symptoms increased in massed-PE participants during follow-up (mean difference, 3.21 [95% CI, 0.65 to 5.77]; P = .01), whereas IOP-PE participants maintained treatment gains (mean difference, 1.23 [95% CI, -3.72 to 1.27]; P = .33). PCL-5 scores decreased in both groups from baseline to 1-month follow-up (IOP-PE: mean difference, -21.81 [95% CI, -25.57 to -18.04]; P < .001; massed-PE: mean difference, -19.96 [95% CI, -23.56 to -16.35]; P < .001) and were maintained at 6 months (IOP-PE: mean change, -0.21 [95% CI, -3.47 to 3.06]; P = .90; massed-PE: mean change, 3.02 [95% CI, -0.36 to 6.40]; P = .08). Both groups had notable PTSD diagnostic remission at posttreatment (IOP-PE: 48% [95% CI, 36% to 61%] of participants; massed-PE: 62% [95% CI, 51% to 73%] of participants), which was maintained at 6 months (IOP-PE: 53% [95% CI, 40% to 66%] of participants; massed-PE: 52% [95% CI, 38% to 66%] of participants). Most participants demonstrated reliable change on the CAPS-5 (61% [95% CI, 52% to 69%] of participants) and the PCL-5 (74% [95% CI, 66% to 81%] of participants) at the 1-month follow-up. Conclusions and Relevance: These findings suggest that PE can be adapted into compressed treatment formats that effectively reduce PTSD symptoms. Trial Registration: ClinicalTrials.gov Identifier: NCT03529435.

Behaviorally-Oriented Intensive Aphasia Program: Collaboration Leads to Optimal Outcomes.

Aphasia is an acquired disorder affecting all language components across modalities. While common therapeutic approaches can result in some improvements, multiple studies establish that intensive therapeutic interventions are most effective; however, these approaches are not well defined. In addition, behaviorally-oriented approaches have been shown to be effective for other conditions, but have not yet been introduced to the treatment of aphasia. The purpose of the current study was to examine the efficacy of a novel, behaviorally-oriented, intensive communication intervention for aphasia (BICA) designed by a speech-language pathologist (second author) and a Board Certified Behavior Analyst (first author) for a 71-year-old woman with post-stroke aphasia. Using a case study design, the participant was provided with 12 hours/week of therapy for 12 weeks focusing on functional communication goals using a behavioral interpretation of language and stimulus control transfer procedures. The behavior analyst determined conceptually systematic interventions based on targets selected by the speech-language pathologist. The participant demonstrated substantial improvements in written language expression and comprehension, reading fluency, oral language expression, naming, and improved quality of life. Given the substantial gains the participant made in oral and written language post-stroke using the BICA therapy, further study is warranted.

"The effects of web-prolonged exposure among military personnel and veterans with posttraumatic stress disorder": Correction.

Reports an error in "The effects of web-prolonged exposure among military personnel and veterans with posttraumatic stress disorder" by Carmen P. McLean, Edna B. Foa, Katherine A. Dondanville, Christopher K. Haddock, Madeleine L. Miller, Sheila A. M. Rauch, Jeffery S. Yarvis, Edward C. Wright, Brittany N. Hall-Clark, Brooke A. Fina, Brett T. Litz, Jim Mintz, Stacey Young-McCaughan and Alan L. Peterson (Psychological Trauma: Theory, Research, Practice, and Policy, 2021[Sep], Vol 13[6], 621-631). In the original article, "for the STRONG STAR Consortium" was missing from the end of the author line. In addition, the numbering and text of the affiliations for Edward C. Wright, Brittany N. Hall-Clark, Brooke A. Fina, Brett T. Litz, Jim Mintz, Stacey Young-McCaughan, and Alan L. Peterson were incorrect because of duplicated affiliation details and associated typographical errors. Finally, in the References, "for the STRONG STAR Consortium" and "on behalf of the STRONG STAR Consortium" were missing from the ends of the author lists for Foa et al. (2018) and Resick et al. (2015), respectively. The online version of this article has been corrected. (The following abstract of the original article appeared in record 2020-86687-001). OBJECTIVE: Web-based treatments address many of the logistical and stigma-related barriers to in-person behavioral health care. Prior studies of web-based treatments for posttraumatic stress disorder (PTSD) did not employ gold-standard treatments and have not compared to in-person therapy. METHOD: We compared a web version of Prolonged Exposure Therapy, "Web-PE," to in-person Present-Centered Therapy (PCT) in a randomized controlled trial (RCT) with 40 military personnel with PTSD seeking treatment at Fort Hood, Texas. Due to recruitment challenges, we terminated the RCT and subsequently examined the effects of Web-PE in an uncontrolled open trial with 34 service members and veterans recruited nationwide. Both studies assessed PTSD, depressive symptoms, and health functioning at baseline and 1 and 3 months posttreatment; the RCT also included a 6-month assessment. RESULTS: Results of the RCT showed no differential impact for Web-PE and PCT, although more PCT participants achieved clinically significant change at one of the follow-up assessments. Both treatment conditions significantly reduced self-reported and blind independent interviewer-assessed symptoms of PTSD. Results of the open trial showed that Web-PE was associated with significant reductions in self-reported PTSD symptoms, with a much larger effect size than in the RCT. CONCLUSIONS: Web-PE significantly reduced PTSD symptoms in both studies, although the reductions in PTSD symptoms were greater among open trial participants, who were specifically seeking a web-based treatment. Future research should evaluate Web-PE relative to another web-based treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Perceptions and experiences of web-prolonged exposure for posttraumatic stress disorder: A mixed-methods study.

OBJECTIVE: Web-based prolonged exposure therapy (Web-PE) has potential to increase the reach of effective posttraumatic stress disorder (PTSD) treatment. While there is initial support for the efficacy of Web-PE, no studies have examined the perceptions and experiences of participants receiving PE in this novel, Web based format. METHOD: We used a mixed-methods convergent design to examine and integrate quantitative and qualitative data of participant perceptions and experiences of Web-PE. Treatment-seeking active duty military personnel or veterans (N = 29) who received Web-PE completed posttreatment surveys about perceptions of Web-PE and a brief qualitative interview. Thematic coding was used to identify qualitative themes, which were integrated with quantitative data in a joint display. RESULTS: Although many were initially skeptical of experiencing benefit, participants reported that Web-PE was helpful. They appreciated the flexibility of online therapy and reported that self-motivation was important for engagement. Web-PE therapists were well-regarded, although additional therapist support and technical improvements to the Web-PE program were suggested. Scores on the perceptions of Web-PE survey, PTSD survey, and other quantitative data corroborated the qualitative themes. CONCLUSION: Perceptions and experience of Web-PE are favorable and help to highlight the strengths (e.g., flexibility) and challenges (e.g., requiring self-motivation) associated with Web-treatment for PTSD. The results of this study may inform further development of Web-PE or other Web-based treatment programs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Testing the role of aerobic exercise in the treatment of posttraumatic stress disorder (PTSD) symptoms in U.S. active duty military personnel: a pilot study.

The purpose of this pilot study was to determine if the efficacy of imaginal exposure for symptoms of posttraumatic stress disorder (PTSD) could be improved by adding aerobic exercise. We hypothesized that aerobic exercise would enhance the efficacy of exposure therapy. Active duty service members with clinically significant symptoms of posttraumatic stress (PTSD Checklist-Stressor-Specific Version, [PCL-S], ≥25) were randomized into one of four conditions: exercise only; imaginal exposure only; imaginal exposure plus exercise; no exercise/no exposure therapy (control). Participants (N = 72) were primarily male, Army, noncommissioned officers ranging in age from 22 to 52. PTSD symptom severity decreased over time (p < .0001); however, there were no significant differences between the experimental conditions. The prediction that imaginal exposure augmented with aerobic exercise would be superior to either imaginal exposure alone or aerobic exercise alone was not supported, suggesting that engaging in exercise and imaginal exposure simultaneously may not be any better than engaging in either activity alone. A better understanding of individually administered and combined exercise and exposure therapy interventions for PTSD is warranted.

Secondary individual outcomes following multicouple group therapy for posttraumatic stress disorder: An uncontrolled pilot study with military dyads.

Cognitive-behavioral conjoint therapy (CBCT) for posttraumatic stress disorder (PTSD) has demonstrated efficacy for improving PTSD and comorbid symptoms and relationship adjustment. To enhance treatment efficiency and scalability, we developed a 2-day, abbreviated, intensive, multicouple group version of CBCT for PTSD (AIM-CBCT for PTSD). Prior work demonstrated that AIM-CBCT for PTSD wasassociated with reductions in PTSD and comorbid symptoms in a sample of 24 post-9/11 active duty military or veteran couples who received the treatment in a retreat format over a single weekend. The current study investigated secondary outcomes regarding trauma-related cognitions, psychosocial impairment, and insomnia. For trauma-related cognitions, reductions were nonsignificant and small at 1-month follow-up, ds = -0.14 to -0.32. However, by 3-month follow-up, there were significant, medium effect size reductions in total trauma-related cognitions, d = -0.68, and negative views of self and others, ds = -0.64 and -0.57, respectively, relative to baseline. There was also a nonsignificant, small-to-medium effect-size reduction in self-blame, d = -0.43, p = .053, by 3-month follow-up. For psychosocial impairment, there were significant and medium-to-large and large effect size reductions by 1- and 3-month follow-ups, ds = -0.73 and -0.81, respectively. There were nonsignificant, small effect size reductions in insomnia at both 1- and 3-month follow-ups relative to baseline, ds = -0.30 and -0.34, respectively. These findings suggest that AIM-CBCT for PTSD is associated with reductions in maladaptive posttraumatic cognitions and psychosocial impairment but that adjunctive interventions may be needed to address insomnia.

The impact of racial identity and school composition on affirmative action attitudes of African American college students.

Affirmative Action remains a controversial policy that incites a variety of reactions. Some believe it's an unjust policy that discriminates against applicants, while others view it as a policy aimed at fighting against past inequalities and discrimination. Little is known about African American endorsement of the policy. Two hundred and seven Black students from a predominantly White institution (PWI) and a historically Black university (HBCU) participated in the current study to examine the impact of racial identity on affirmative action attitudes (AA). Results indicated that school type and race centrality significantly predicted AA attitudes. Students who attended a HBCU were less likely to endorse AA compared to students at the PWI and those higher in race centrality were more likely to endorse AA. This study is one of the first to investigate the impact of the educational environment on the affirmative action attitudes of African Americans.

A Closer Examination of Relational Outcomes from a Pilot Study of Abbreviated, Intensive, Multi-Couple Group Cognitive-Behavioral Conjoint Therapy for PTSD with Military Dyads.

Cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD) is associated with improvements in patients' PTSD symptoms, partners' psychological distress, and relationship satisfaction. However, little is known about whether CBCT for PTSD is associated with changes in other relationship domains that have theoretical and clinical relevance to the relational context of PTSD. The current study is a secondary analysis of relational outcomes from an uncontrolled, within-group trial designed to examine whether an abbreviated, intensive, multi-couple group version of CBCT for PTSD (AIM-CBCT for PTSD) delivered in a retreat during a single weekend was associated with improvements in PTSD symptoms and relationship satisfaction. In this investigation, we examined whether AIM-CBCT for PTSD is also associated with improvements in ineffective arguing, supportive dyadic coping by partner, joint dyadic coping, and partners' accommodation of patients' PTSD symptoms. Participants were 24 couples who included a post-9/11 U.S. service member or veteran with PTSD. At 1- and 3-month follow-up, patients reported significant reductions in couples' ineffective arguing (ds = -.71 and -.78, respectively) and increases in supportive dyadic coping by partners relative to baseline (ds = .50 and .44, respectively). By 3-month follow-up, patients also reported significant increases in couples' joint dyadic coping (d = .57), and partners reported significant reductions in their accommodation of patients' PTSD symptoms (d = -.44). Findings suggest that AIM-CBCT for PTSD is associated with improvements in multiple relationship domains beyond relationship satisfaction but that these may be differentially salient for patients and partners.

La terapia cognitivo-conductual conjunta para el trastorno por estrés postraumático (TCC para el TEPT) está asociada con mejoras en los síntomas de TEPT de los pacientes, en el distrés psicológico de sus parejas y en la satisfacción con la relación. Sin embargo, se sabe poco acerca de si la TCC para el TEPT está asociada con cambios en otros aspectos de la relación que son de interés teórico y clínico para el contexto relacional del TEPT. El presente estudio es un análisis secundario de los resultados relacionales de un ensayo intragrupal no controlado diseñado para analizar si una versión grupal multipareja, intensiva y abreviada de la TCC para el TEPT (MIA-TCC para el TEPT) practicada en un retiro durante un solo fin de semana estuvo asociada con mejoras en los síntomas de TEPT y en la satisfacción con la relación. En esta investigación, analizamos si la MIA-TCC para el TEPT también está asociada con mejoras en las discusiones ineficaces, en el afrontamiento diádico comprensivo de la pareja del paciente, en el afrontamiento diádico conjunto y en la adaptación de las parejas de los pacientes a sus síntomas de TEPT. Los participantes fueron 24 parejas en las que había un miembro o veterano de las Fuerzas Armadas de los Estados Unidos que prestó servicio con posterioridad al 11/9 y que tenía TEPT. En el seguimiento del mes y de los tres meses, los pacientes informaron reducciones significativas de las discusiones ineficaces de la pareja (ds = -0.71 y -0.78, respectivamente) y aumentos del afrontamiento diádico comprensivo de sus parejas en relación con el momento basal (ds = 0.50 y 0.44, respectivamente). En el seguimiento de los tres meses, los pacientes también informaron aumentos significativos del afrontamiento diádico conjunto de las parejas (d = 0.57), y sus parejas informaron reducciones significativas de su adaptación a los síntomas de TEPT de los pacientes (d = -0.44). Los resultados sugieren que la MIA-TCC para el TEPT está asociada con mejoras en varios aspectos de las relaciones aparte del de la satisfacción en la pareja, pero que estos pueden tener una importancia diferente para los pacientes y sus parejas.

The effects of web-prolonged exposure among military personnel and veterans with posttraumatic stress disorder.

[Correction Notice: An Erratum for this article was reported online in Psychological Trauma: Theory, Research, Practice, and Policy on Mar 14 2022 (see record 2022-44650-001). In the original article, "for the STRONG STAR Consortium" was missing from the end of the author line. In addition, the numbering and text of the affiliations for Edward C. Wright, Brittany N. Hall-Clark, Brooke A. Fina, Brett T. Litz, Jim Mintz, Stacey Young-McCaughan, and Alan L. Peterson were incorrect because of duplicated affiliation details and associated typographical errors. Finally, in the References, "for the STRONG STAR Consortium" and "on behalf of the STRONG STAR Consortium" were missing from the ends of the author lists for Foa et al. (2018) and Resick et al. (2015), respectively. The online version of this article has been corrected.] Objective: Web-based treatments address many of the logistical and stigma-related barriers to in-person behavioral health care. Prior studies of web-based treatments for posttraumatic stress disorder (PTSD) did not employ gold-standard treatments and have not compared to in-person therapy. METHOD: We compared a web version of Prolonged Exposure Therapy, "Web-PE," to in-person Present-Centered Therapy (PCT) in a randomized controlled trial (RCT) with 40 military personnel with PTSD seeking treatment at Fort Hood, Texas. Due to recruitment challenges, we terminated the RCT and subsequently examined the effects of Web-PE in an uncontrolled open trial with 34 service members and veterans recruited nationwide. Both studies assessed PTSD, depressive symptoms, and health functioning at baseline and 1 and 3 months posttreatment; the RCT also included a 6-month assessment. RESULTS: Results of the RCT showed no differential impact for Web-PE and PCT, although more PCT participants achieved clinically significant change at one of the follow-up assessments. Both treatment conditions significantly reduced self-reported and blind independent interviewer-assessed symptoms of PTSD. Results of the open trial showed that Web-PE was associated with significant reductions in self-reported PTSD symptoms, with a much larger effect size than in the RCT. CONCLUSIONS: Web-PE significantly reduced PTSD symptoms in both studies, although the reductions in PTSD symptoms were greater among open trial participants, who were specifically seeking a web-based treatment. Future research should evaluate Web-PE relative to another web-based treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Intensive, Multi-Couple Group Therapy for PTSD: A Nonrandomized Pilot Study With Military and Veteran Dyads.

Cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD; Monson & Fredman, 2012) is efficacious in improving PTSD symptoms and relationship adjustment among couples with PTSD. However, there is a need for more efficient delivery formats to maximize engagement and retention and to achieve faster outcomes in multiple domains. This nonrandomized trial was designed to pilot an abbreviated, intensive, multi-couple group version of CBCT for PTSD (AIM-CBCT for PTSD) delivered over a single weekend for 24 couples that included an active-duty service member or veteran with PTSD who had deployed in support of combat operations following September 11, 2001. All couples completed treatment. Assessments conducted by clinical evaluators 1 and 3 months after the intervention revealed significant reductions in clinician-rated PTSD symptoms (ds = -0.77 and -0.98, respectively) and in patients' self-reported symptoms of PTSD (ds = -0.73 and -1.17, respectively), depression (ds = -0.60 and -0.75, respectively), anxiety (ds = -0.63 and -0.73, respectively), and anger (ds = -0.45 and -0.60, respectively), relative to baseline. By 3-month follow-up, partners reported significant reductions in patients' PTSD symptoms (d = -0.56), as well as significant improvements in their own depressive symptoms (d = -0.47), anxiety (d = -0.60), and relationship satisfaction (d = 0.53), relative to baseline. Delivering CBCT for PTSD through an abbreviated, intensive multi-couple group format may be an efficient strategy for improving patient, partner, and relational well-being in military and veteran couples with PTSD.

A Mixed-Surface Polyamidoamine Dendrimer for In Vitro and In Vivo Delivery of Large Plasmids.

Drug delivery to the brain is highly hindered by the presence of the blood-brain barrier (BBB), which prevents the entry of many potential drugs/biomolecules into the brain. One of the current strategies to achieve gene therapy for neurodegenerative diseases involves direct injection of a viral vector into the brain. There are various disadvantages of viral vectors, including limitations of cargo size and safety concerns. Nanomolecules, such as dendrimers, serve as an excellent alternative to viral delivery. In this study, as proof-of-concept, we used a surface-modified dendrimer complex and delivered large plasmids to cells in vitro and in vivo in healthy rats via intracranial injection. The dendrimers were biodegradable by chemicals found within cells and toxicity assays revealed that the modified dendrimers were much less toxic than unmodified amine-surface dendrimers. As mentioned in our previous publication, these dendrimers with appropriately modified surfaces are safe, can deliver large plasmids to the brain, and can overcome the cargo size limitations associated with viral vectors. The biocompatibility of this dendritic nanomolecule and the ability to finely tune its surface chemistry provides a gene delivery system that could facilitate future in vivo cellular reprograming and other gene therapies.

A pilot randomized controlled trial of cognitive behavioral treatment for trauma-related nightmares in active duty military personnel.

STUDY OBJECTIVES: The aim of this study was to obtain preliminary data on the efficacy, credibility, and acceptability of Exposure, relaxation, and rescripting therapy for military service members and veterans (ERRT-M) in active duty military personnel with trauma-related nightmares. METHODS: Forty participants were randomized to either 5 sessions of ERRT-M or 5 weeks of minimal contact control (MCC) followed by ERRT-M. Assessments were completed at baseline, posttreatment/postcontrol, and 1-month follow-up. RESULTS: Differences between ERRT-M and control were generally medium in size for nightmare frequency (Cohen d = -0.53), nights with nightmares (d = -0.38), nightmare severity (d = -0.60), fear of sleep (d = -0.44), and symptoms of insomnia (d = -0.52), and depression (d = -0.51). In the 38 participants who received ERRT-M, there were statistically significant, medium-sized decreases in nightmare frequency (d = -0.52), nights with nightmares (d = -0.50), nightmare severity (d = -0.55), fear of sleep (d = -0.48), and symptoms of insomnia (d = -0.59), posttraumatic stress disorder (PTSD) (d = -0.58) and depression (d = -0.59) from baseline to 1-month follow-up. Participants generally endorsed medium to high ratings of treatment credibility and expectancy. The treatment dropout rate (17.5%) was comparable to rates observed for similar treatments in civilians. CONCLUSIONS: ERRT-M produced medium effect-size reductions in nightmares and several secondary outcomes including PTSD, depression, and insomnia. Participants considered ERRT-M to be credible. An adequately powered randomized clinical trial is needed to confirm findings and to compare ERRT-M to an active treatment control. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Title: A Pilot Randomized Controlled Trial of Treatment for Trauma-Related Nightmares In Active Duty Military Personnel; Identifier: NCT02506595; URL: https://clinicaltrials.gov/ct2/show/NCT02506595.

A Preliminary Investigation of Ethnic Differences in Resistance in Multisystemic Therapy.

Therapy process research suggests that an inverted U-shaped trajectory of client resistance, referred to as the struggle-and-working-through pattern, predicts positive treatment outcomes. However, this research may lack external validity given the exclusive focus on European Americans. This preliminary study explores differences in resistance patterns in a sample of African American and European American juvenile drug offenders and their families (n = 41) participating in Multisystemic Therapy. Resistance was coded from session recordings at the beginning, middle, and end of treatment. There were significant ethnic differences in (a) mean resistance at midtreatment, (b) resistance trajectories, and (c) predictive relationships between resistance trajectories and criminal desistance. Notably, a negative quadratic (i.e., inverted U-shaped) resistance trajectory was more characteristic of European Americans who desisted from crime, whereas a positive quadratic (U-shaped) resistance pattern was more characteristic of African Americans who desisted. There was no relationship between resistance trajectory and later drug abstinence (i.e., cannabis). Within the context of evidence-based therapies, core treatment processes may vary significantly as a function of client ethnicity. We recommend that clinical scientists make efforts to test for ethnic differences in treatment process so that therapies like Multisystemic Therapy can be understood in a more comprehensive and nuanced manner.

Intensive prolonged exposure therapy for combat-related posttraumatic stress disorder: Design and methodology of a randomized clinical trial.

Combat-related posttraumatic stress disorder (PTSD) is the most common psychological health condition in military service members and veterans who have deployed to the combat theater since September 11, 2001. One of the highest research priorities for the Department of Defense and the Department of Veterans Affairs is to develop and evaluate the most efficient and efficacious treatments possible for combat-related PTSD. However, the treatment of combat-related PTSD in military service members and veterans has been significantly more challenging than the treatment of PTSD in civilians. Randomized clinical trials have demonstrated large posttreatment effect sizes for PTSD in civilian populations. However, recent randomized clinical trials of service members and veterans have achieved lesser reductions in PTSD symptoms. These results suggest that combat-related PTSD is unique. Innovative approaches are needed to augment established evidence-based treatments with targeted interventions that address the distinctive elements of combat-related traumas. This paper describes the design, methodology, and protocol of a randomized clinical trial to compare two intensive prolonged exposure therapy treatments for combat-related PTSD in active duty military service members and veterans and that can be administered in an acceptable, efficient manner in this population. Both interventions include intensive daily treatment over a 3-week period and a number of treatment enhancements hypothesized to result in greater reductions in combat-related PTSD symptoms. The study is designed to advance the delivery of care for combat-related PTSD by developing and evaluating the most potent treatments possible to reduce PTSD symptomatology and improve psychological, social, and occupational functioning.

Effect of Prolonged Exposure Therapy Delivered Over 2 Weeks vs 8 Weeks vs Present-Centered Therapy on PTSD Symptom Severity in Military Personnel: A Randomized Clinical Trial.

Importance: Effective and efficient treatment is needed for posttraumatic stress disorder (PTSD) in active duty military personnel. Objective: To examine the effects of massed prolonged exposure therapy (massed therapy), spaced prolonged exposure therapy (spaced therapy), present-centered therapy (PCT), and a minimal-contact control (MCC) on PTSD severity. Design, Setting, and Participants: Randomized clinical trial conducted at Fort Hood, Texas, from January 2011 through July 2016 and enrolling 370 military personnel with PTSD who had returned from Iraq, Afghanistan, or both. Final follow-up was July 11, 2016. Interventions: Prolonged exposure therapy, cognitive behavioral therapy involving exposure to trauma memories/reminders, administered as massed therapy (n = 110; 10 sessions over 2 weeks) or spaced therapy (n = 109; 10 sessions over 8 weeks); PCT, a non-trauma-focused therapy involving identifying/discussing daily stressors (n = 107; 10 sessions over 8 weeks); or MCC, telephone calls from therapists (n = 40; once weekly for 4 weeks). Main Outcomes and Measures: Outcomes were assessed before and after treatment and at 2-week, 12-week, and 6-month follow-up. Primary outcome was interviewer-assessed PTSD symptom severity, measured by the PTSD Symptom Scale-Interview (PSS-I; range, 0-51; higher scores indicate greater PTSD severity; MCID, 3.18), used to assess efficacy of massed therapy at 2 weeks posttreatment vs MCC at week 4; noninferiority of massed therapy vs spaced therapy at 2 weeks and 12 weeks posttreatment (noninferiority margin, 50% [2.3 points on PSS-I, with 1-sided α = .05]); and efficacy of spaced therapy vs PCT at posttreatment. Results: Among 370 randomized participants, data were analyzed for 366 (mean age, 32.7 [SD, 7.3] years; 44 women [12.0%]; mean baseline PSS-I score, 25.49 [6.36]), and 216 (59.0%) completed the study. At 2 weeks posttreatment, mean PSS-I score was 17.62 (mean decrease from baseline, 7.13) for massed therapy and 21.41 (mean decrease, 3.43) for MCC (difference in decrease, 3.70 [95% CI,0.72 to 6.68]; P = .02). At 2 weeks posttreatment, mean PSS-I score was 18.03 for spaced therapy (decrease, 7.29; difference in means vs massed therapy, 0.79 [1-sided 95% CI, -∞ to 2.29; P = .049 for noninferiority]) and at 12 weeks posttreatment was 18.88 for massed therapy (decrease, 6.32) and 18.34 for spaced therapy (decrease, 6.97; difference, 0.55 [1-sided 95% CI, -∞ to 2.05; P = .03 for noninferiority]). At posttreatment, PSS-I scores for PCT were 18.65 (decrease, 7.31; difference in decrease vs spaced therapy, 0.10 [95% CI, -2.48 to 2.27]; P = .93). Conclusions and Relevance: Among active duty military personnel with PTSD, massed therapy (10 sessions over 2 weeks) reduced PTSD symptom severity more than MCC at 2-week follow-up and was noninferior to spaced therapy (10 sessions over 8 weeks), and there was no significant difference between spaced therapy and PCT. The reductions in PTSD symptom severity with all treatments were relatively modest, suggesting that further research is needed to determine the clinical importance of these findings. Trial Registration: clinicaltrials.gov Identifier: NCT01049516.

Design of a randomized controlled trial examining the efficacy and biological mechanisms of web-prolonged exposure and present-centered therapy for PTSD among active-duty military personnel and veterans.

Improved accessibility of effective and efficient evidence-based treatments (EBTs) for military personnel suffering with posttraumatic stress disorder (PTSD) is an urgent need to meet the growing demand for timely care. In addition, a better understanding of the mechanism of action of behavioral therapy can inform the delivery of care to meet accessibility demands. Effective EBTs for PTSD are available, but logistical and stigma-related barriers to accessing behavioral healthcare can deter military personnel from receiving these treatments. Web-based treatments represent an innovative way to overcome these barriers. The efficacy of previously developed web-based treatments for PTSD appears promising; however, they were not developed based on treatment protocols with strong empirical support for their efficacy. No study to date has examined web-based treatment of PTSD using a well-established evidence-based treatment, nor delineated the biological mechanisms through which a web-based treatment exerts its effects. This paper describes the rationale and methods of a randomized controlled trial comparing the efficacy and potential biological mediators of 10 sessions of a web-version of Prolonged Exposure (PE), "Web-PE," delivered over 8weeks compared to 10 sessions of in-person Present-Centered Therapy (PCT) delivered over 8weeks by a therapist in 120 active duty military personnel and veterans with PTSD.