Mental health and psychosocial support in humanitarian settings: research priorities for 2021-30.

We describe an effort to develop a consensus-based research agenda for mental health and psychosocial support (MHPSS) interventions in humanitarian settings for 2021-30. By engaging a broad group of stakeholders, we generated research questions through a qualitative study (in Indonesia, Lebanon, and Uganda; n=101), consultations led by humanitarian agencies (n=259), and an expert panel (n=227; 51% female participants and 49% male participants; 84% of participants based in low-income and middle-income countries). The expert panel selected and rated a final list of 20 research questions. After rating, the MHPSS research agenda favoured applied research questions (eg, regarding workforce strengthening and monitoring and evaluation practices). Compared with research priorities for the previous decade, there is a shift towards systems-oriented implementation research (eg, multisectoral integration and ensuring sustainability) rather than efficacy research. Answering these research questions selected and rated by the expert panel will require improved partnerships between researchers, practitioners, policy makers, and communities affected by humanitarian crises, and improved equity in funding for MHPSS research in low-income and middle-income countries.

Calibration and reliability testing of a novel asynchronous photographic plaque scoring system in young children.

OBJECTIVES: The Simplified Oral Hygiene Index for Maxillary Incisors (OHI-MIS) is a novel plaque scoring system adapted for young children. This study describes calibration training and testing used to establish the inter- and intra-rater reliability for OHI-MIS measured from clinical photographs. METHODS: Two raters from the Coordinated Oral Health Promotion Chicago (CO-OP) and one from the Behavioral EConomics for Oral health iNnovation (BEECON) randomized controlled trials (RCTs) underwent calibration with gold standard raters, followed by annual re-calibration. Raters from CO-OP also completed inter-rater reliability testing; all three raters completed intra-rater reliability testing rounds. Photographs were obtained from children aged 9-39 months. RESULTS: All three raters achieved greater than 0.77 Lin's Concordance Correlation (LCC) versus gold standard consensus during calibration. All three raters had LCC ≥0.83 at recalibration 1 year later. CO-OP trial raters scored 604 photos (151 sets of 4 photographs); mostly both raters were somewhat/very confident in their scoring (≥89%), describing the most photos as "clear" (90% and 81%). The CO-OP inter-rater LCC for total OHI-MIS score was 0.86, changing little when low quality or confidence photos were removed. All three raters demonstrated high intra-rater reliability (≥0.83). CONCLUSIONS: The OHI-MIS plaque scoring system on photos had good reliability within and between trials following protocol training and calibration. OHI-MIS provides a novel asynchronous plaque scoring system for use in young children. Non-clinicians in field or clinical settings can obtain photographs, offering new opportunities for research and clinical care.

Sex hormones and repolarization dynamics during the menstrual cycle in women with congenital long QT syndrome.

BACKGROUND: Women with congenital long QT syndrome (LQTS) experience increased cardiac event risk after the onset of adolescence, perhaps stemming from the known modulating effects of sex hormones on the cardiac potassium channels. OBJECTIVE: We hypothesized that the effect of sex hormones on cardiac ion channel function may modify electrocardiographic (ECG) parameters associated with the propensity for ventricular tachyarrhythmias during the menstrual cycle in women with LQTS. METHODS: We prospectively enrolled 65 women with congenital LQTS (type 1 LQTS [LQT1], n = 24 [36.9%]; type 2 LQTS [LQT2], n = 20 [30.8%]) and unaffected female relatives (n = 21 [32.3%]). Patients underwent three 7-day ECG recordings during their menstrual cycles. Simultaneous saliva testing of sex hormone levels was conducted on the first day of each 7-day ECG recording cycle. RESULTS: The mean age was 35 ± 8 years, without a significant difference among the groups. In women with LQT2, linear mixed effects models showed significant inverse correlations of the corrected QT interval with progesterone levels (P < .001) and with the progesterone to estradiol ratio (P < .001). Inverse relationships of the R-R interval with estradiol levels (P = .003) and of the T-wave duration with testosterone levels (P = .014) were also observed in women with LQT2. In contrast, no significant associations were observed between ECG parameters and sex hormone levels in women with LQT1 or unaffected relatives. CONCLUSION: This is the first study to prospectively assess correlations between repolarization dynamics and sex hormone levels during the menstrual cycle in women with congenital LQTS. Our findings show genotype-specific unique corrected QT dynamics during the menstrual cycle that may affect the propensity for ventricular tachyarrhythmia in women with LQTS, particularly women with LQT2.

Social determinants of psychological distress in Sierra Leone.

PURPOSE: Growing evidence demonstrates that daily stressors such as family violence, unemployment, and living conditions play an important part in causing psychological distress. This paper investigates the impact of distressing events and day-to-day living conditions on psychological distress in the fragile context of Sierra Leone. METHODS: A cross-sectional survey was conducted with 904 adults (454 men, 450 women) in 5 districts of Sierra Leone. The survey questionnaire comprised the Sierra Leone Psychological Distress scale and measures of demographic variables and personal characteristics, current life circumstances and potentially distressing events. RESULTS: Multiple regression results identified three factors to be the greatest contributors to psychological distress: family conflict (ß = 0.185, p < 0.001) and inability to afford basic needs (ß = 0.175, p < 0.001). Gender differences were evident: factors predicting men's psychological distress included severe sickness or injury (ß = 0.203, p < 0.001) and being unable to afford basic needs (ß = 0.190, p < 0.001); for women, predicting factors were family conflict (ß = 0.212, p < 0.001), perceived poor health (ß = 0.192, p < 0.001) and inability to afford basic needs (ß = 0.190, p < 0.001). CONCLUSION: Initiatives to promote good mental health and psychosocial wellbeing in Sierra Leone should focus on enhancing income-generating and employment opportunities, promoting access to education, and strengthening family relationships.

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

OBJECTIVE: 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. METHOD: 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. RESULTS: 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. CONCLUSIONS: 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).

Delivering Intensive PTSD Treatment Virtually: The Development of a 2-Week Intensive Cognitive Processing Therapy-Based Program in Response to COVID-19.

Of the many vulnerable groups affected by the spread of COVID-19, veterans have been especially impacted by the pandemic. Beginning in March 2020, nationwide shelter-in-place orders rapidly led to widespread job loss and economic upheaval; disruption and breakdown of multiple support systems; and increases in family stress, all of which may exacerbate underlying PTSD symptoms. Although telehealth has proven an effective means of delivering evidence-based psychotherapies for PTSD, little is known about the delivery of these treatments in an intensive, daily format over telehealth. There is growing need for intensive treatment options to reduce treatment-interfering barriers such as high dropout rates. In order to address this gap in the literature, this paper details several design considerations as well as patient selection procedures for a 2-week virtual intensive treatment program (vITP) for veterans with posttraumatic stress disorder (PTSD), consisting of daily individual Cognitive Processing Therapy (CPT) and other adjunctive interventions. We also describe two cases of veterans who successfully completed the vITP including their clinical outcomes, therapist reflections on the process, feedback regarding the program, as well as challenges patients encountered with the telehealth platform. Intensive evidence-based psychotherapy for PTSD delivered through a virtual format seems to show promise, but more systemic research is needed.

Increasing Mindfulness Skills of Veterans With PTSD Through Daily Mindfulness Training Incorporated Into an Intensive Treatment Program.

OBJECTIVES: Mindfulness training is frequently included as part of an integrative care approach to treating PTSD in veterans. However, the utility and acceptability of daily group mindfulness training in an intensive treatment program (ITP) for PTSD have not been explored. The study objectives were to determine: (a) whether mindfulness skills significantly increased from pre- to post-treatment and (b) if daily group mindfulness training was acceptable to veterans. METHODS: Veterans (N = 170 outpatients, age M = 40.7 (SD 9.3), 67.6% male) in this prospective study were consecutively enrolled in a 3-week ITP that included daily mindfulness group sessions. Mindfulness skills were assessed using the Five Facet of Mindfulness Questionnaire (FFMQ) at intake and post-treatment. Acceptability was assessed using an anonymous post-treatment program satisfaction survey. RESULTS: Paired t tests demonstrated significant increases in overall mindfulness skills from pre- to post-treatment (t(169) = - 6.33, p < 0.001, d = 0.49). Small to medium effect sizes were observed across subscales: describing, (t(169) = - 5.91, p < 0.001, d = 0.38); acting with awareness, (t(169) = - 3.70, p < 0.001, d = 0.29); nonjudging, (t(169) = - 7.54, p < 0.001, d = 0.58); and nonreactivity, (t(169) = - 4.84, p < 0.001, d = 0.41). Most veterans (n = 125, 74.4%) found daily mindfulness training moderately to very helpful. CONCLUSIONS: Veterans' mindfulness skills significantly increased over the course of a 3-week ITP, and mindfulness training was found acceptable. Mindfulness training can be delivered daily as part of an ITP for veterans with PTSD, and mindfulness skills can meaningfully increase over the course of 3 weeks. A significant limitation is the lack of control condition.

The development of a contextually appropriate measure of psychological distress in Sierra Leone.

BACKGROUND: Studies of psychological distress in Sierra Leone have typically used measures which were developed for use in other contexts, and which often have not been adapted or validated for use in Sierra Leone. This has resulted in a lack of reliable information about the patterns of psychological distress within the population, which is a barrier to the development of effective and appropriate mental health services. The aim of the study was to develop a locally-appropriate measure of psychological distress for Sierra Leone. METHODS: The new measure consists of two instruments: the Sierra Leone Psychological Distress Scale (SLPDS) and a gendered measure of ability to carry out daily tasks-a Function scale-as an indication of the severity of distress. A three-phase mixed methods exploratory sequential study was conducted. Phase 1 was item generation and testing, leading to the development of a set of potential items for both instruments. Phase 2 was a small pilot study (N = 202) leading to the selection of the final set of items for both measures. Phase 3 was a validation phase where the SLPDS and the Function scale were administered with a larger sample of 904 respondents. Item analysis was used to assess the internal consistency of the scales, and Exploratory Factor Analysis to explore the properties of the SLPDS. RESULTS: Exploratory factor analysis using the principal axis factoring with an oblique rotation identified a three-factor structure for the 18-item SLPDS. Internal consistency for the SLPDS (Cronbach's alpha = 0.89) and three subscales was good (Cronbach's alpha > 0.73). The internal reliability of the male and female versions of the Function scale was also found to be acceptable (Cronbach's alpha = 0.90 for the female scale and 0.79 for the male scale). CONCLUSIONS: Together the SLPD and Function scales provide a locally-validated tool which will enable government bodies and local and international non-governmental organisations in Sierra Leone to assess mental health and psychosocial needs. This will support both effective service provision and the evaluation of initiatives designed to improve mental health and psychosocial wellbeing.

Treatment response trajectories in a three-week CPT-Based intensive treatment for veterans with PTSD.

Response to weekly evidence-based PTSD treatments varies. Little is known about response trajectories and predictors in intensive PTSD treatments. This study sought to identify different trajectories of symptom change among veterans who completed a 3-week CPT-based intensive PTSD treatment program and examined potential predictors of trajectory group membership. Four hundred fifty-two veterans completed the program. Demographics, PTSD and depression severity, negative posttrauma cognitions, and alcohol use were assessed at intake and evaluated as possible predictors of group membership. Group based trajectory modeling was used to determine distinct groups based on PTSD symptom trajectory over the course of treatment, as well as predictors of group membership. Four distinct treatment trajectories were identified: Fast responders (15.3%), steady responders (32.0%), partial responders (38.4%), and minimal responders (14.4%). Fast and steady responders reported substantial symptom reductions and dropped below the "probable PTSD" threshold, with fast responders achieving improvements after just one week of treatment. Partial responders experienced clinically significant reductions but remained above the "probable PTSD" threshold. Minimal responders reported the highest baseline PTSD symptoms and changed the least throughout treatment. Negative posttrauma cognitions as well as self-reported and clinician-rated PTSD symptom severity assessed at intake successfully predicted trajectory membership. The identified trajectories closely resemble findings in the limited existing literature on intensive PTSD treatment trajectories. Results suggest that some individuals may improve with even shorter interventions and others might benefit from additional treatment sessions. Overall, findings support the importance of evaluating individual- and group-level treatment responses.

Impact of hazardous alcohol use on intensive PTSD treatment outcomes among veterans.

Background: Intensive treatment programmes (ITPs) for posttraumatic stress disorder (PTSD) produce large symptom reductions and have generally higher completion rates compared to traditional weekly care. Although ITPs do not appear to increase substance use, it has yet to be determined whether their effectiveness differs for veterans with and without hazardous alcohol use (HAU). Objective: This study examined the effectiveness of a 3-week Cognitive Processing Therapy-based ITP for 538 veterans with PTSD (66.0% male; mean age = 41.22 years) and with (n = 193) or without HAU (n = 343) for reducing PTSD and depression symptoms. Method: Veterans' PTSD (PCL-5) and depression (PHQ-9) symptoms were assessed at pre-treatment, during treatment, and at post-treatment. HAU (AUDIT-C total score ≥4 for males; ≥3 for females) was measured at intake. Results: Treatment completion rates were high for both individuals who endorsed HAU (92.68%) and those who did not (93.37%), likely due to veterans being housed near the treatment facility. Mixed effects regression models revealed a significant time by alcohol use interaction when predicting both PCL-5 (p < .001) and PHQ-9 (p = .003), suggesting time-trends over the course of the ITP differed based on alcohol use. Veterans who endorsed HAU improved to a statistically significantly lesser extent. However, endpoint differences between groups for both outcomes were small (Cohen's ds between 0.15 and 0.20). Conclusions: Veterans with and without HAU reported significant reductions in PTSD and depression symptoms and completed the ITP at comparably high rates. Findings support the effectiveness of intensive PTSD treatment programmes for individuals with PTSD and HAU. Future studies should utilize controlled designs to evaluate whether intensive PTSD treatment can reduce HAU.

Antecedentes: Los programas de tratamiento intensivo (ITPs, por sus siglas en inglés) para el trastorno de estrés postraumático (TEPT) producen grandes disminuciones sintomáticas ygeneralmente tienen tasasmás altas de finalización comparados con los tratamientos tradicionales semanales. Apesar de que los ITPs no parecen aumentar el uso de sustancias, se debe aún determinar si su efectividad difiere para los veteranos con ysin uso nocivo de alcohol (HAU, por sus siglas en inglés).Objetivo: Este estudio evaluó la efectividad para la reducción de síntomas del TEPT yla depresión de un ITP de tres semanas basado en la terapia de procesamiento cognitivo en 538 veteranos con TEPT (66,0% varones; promedio de edad = 41,22 años) con (n = 193) osin HAU (n = 343).Método: Se evaluaron aveteranos con síntomas del TEPT (PCL-5) yla depresión (PHQ-9) antes del tratamiento, durante el tratamiento ydespués del tratamiento. El HAU (puntaje total del AUDIT-C ≥4 para varones; ≥3 para mujeres) fue medido al ingreso.Resultados: Las tasas de finalización del tratamiento fueron altas tanto para los individuos que tenían un HAU (92,68%) como en aquellos que no lo tenían (93,37%), probablemente debido aque los veteranos vivían cerca de las instalaciones donde se brindaba del tratamiento. Los modelos de regresión de efectos mixtos revelaron una interacción significativa en el periodo en el que se consume alcohol yla predicción tanto de los puntajes en la PCL-5 (p<.001) como en el PHQ-9 (p=.003), sugiriendo que en el curso del ITP existen tendencias de temporalidad basadas en el uso de alcohol. Los veteranos que aceptaron presentar un HAU mejoraron en menor medida, con significancia estadística. Sin embargo, la diferencia en los resultados finales del tratamiento entre ambos grupos fue pequeña (ds de Cohen entre 0.15 y0.20).Conclusiones: Los veteranos con ysin HAU reportaron una disminución significativa en los síntomas del TEPT yla depresión. Además, completaron el ITP atasas comparativamente altas. Los hallazgos apoyan la efectividad de los programas de tratamiento intensivos para TEPT en individuos con TEPT yHAU. Los próximos estudios deben utilizar diseños controlados para evaluar si el tratamiento intensivo para el TEPT puede reducir el HAU.

Factors contributing to emotional distress in Sierra Leone: a socio-ecological analysis.

BACKGROUND: There is increasing global evidence that mental health is strongly determined by social, economic and environmental factors, and that strategic action in these areas has considerable potential for improving mental health and preventing and alleviating mental disorders. Prevention and promotion activities in mental health must address the needs prioritised by local actors. The aim of this study was to identify stressors with the potential to influence emotional wellbeing and distress within the general population of Sierra Leone, in order to contribute to an inter-sectoral public mental health approach to improving mental health within the country. METHODOLOGY: Respondents were a convenience sample of 153 respondents (60 women, 93 men) from five districts of Sierra Leone. Using freelisting methodology, respondents were asked to respond to the open question 'What kind of problems do women/men have in your community?'. Data analysis involved consolidation of elicited problems into a single list. These were then organised thematically using an adaptation of the socio-ecological model, facilitating exploration of the interactions between problems at individual, family, community and societal levels RESULTS: Overall, respondents located problems predominantly at community and societal levels. Although few respondents identified individual-level issues, they frequently described how problems at other levels contributed to physical health difficulties and emotional distress. Women identified significantly more problems at the family level than men, particularly related to relationships with an intimate partner. Men identified significantly more problems at the societal level than women, primarily related to lack of infrastructure. Men and women were equally focused on problems related to poverty and lack of income generating opportunities. CONCLUSION: Poverty and inability to earn an income underpinned many of the problems described at individual, family and community level. Actions to address livelihoods, together with improving infrastructure and addressing gender norms which are harmful to both men and women, are likely key to improving the wellbeing of the Sierra Leone population.

Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans?

Background: It has been suggested that current frontline posttraumatic stress disorder (PTSD) treatments are not effective for the treatment of moral injury and that individuals who have experienced morally injurious events may respond differently to treatment than those who have not. However, these claims have yet to be empirically tested. Objective: This study evaluated the rates of morally injurious event exposure and morally injurious index trauma and their impact on PTSD (PCL-5) and depression symptom (PHQ-9) reductions during intensive PTSD treatment. Method: Data from 161 USA military combat service members and veterans (91.3% male; mean age = 39.94 years) who participated in a 3-week Cognitive Processing Therapy (CPT)-based intensive PTSD treatment programme (ITP) was utilized. Morally injurious event exposure was established via the Moral Injury Event Scale (MIES). Index traumas were also coded by the treating clinician. Linear mixed effects regression analyses were conducted to examine if differences in average effects or trends over the course of treatment existed between veterans with morally injurious event exposure or index trauma and those without. Results: Rates of morally injurious event exposure in this treatment sample were high (59.0%-75.2%). Morally injurious event exposure and the type of index trauma did not predict changes in symptom outcomes from the ITP and veterans reported large reductions in PTSD (d = 1.35-1.96) and depression symptoms (d = 0.95-1.24) from pre- to post-treatment. Non-inferiority analyses also demonstrated equivalence across those with and without morally injurious event exposure and index events. There were no significant gender differences. Conclusions: The present study suggests that PTSD and depression in military veterans with morally injurious event exposure histories may be successfully treated via a 3-week CPT-based ITP.

Antecedentes: Se ha sugerido que los tratamientos actuales de primera línea para el trastorno de estrés postraumático (TEPT) no son efectivos para el tratamiento del daño moral y que las personas que han experimentado eventos moralmente dañinos pueden responder de manera diferente al tratamiento que las que no lo han hecho. Sin embargo, estas afirmaciones aún no se han probado empíricamente.Objetivo: Este estudio evaluó las tasas de exposición a eventos moralmente dañinos y trauma índice moralmente dañino y su impacto en las reducciones de síntomas del TEPT (PCL-5) y de depresión (PHQ-9) durante el tratamiento intensivo para TEPT.Método: Se utilizaron datos de 161 miembros y veteranos del servicio militar de combate de los Estados Unidos (91,3% hombres; edad promedio = 39,94 años) que participaron en un programa de tratamiento intensivo de TEPT (ITP en su sigla en inglés) basado en la Terapia de procesamiento cognitivo (CPT en su sigla en inglés) durante 3 semanas. La exposición a eventos moralmente dañinos se estableció mediante la Escala de eventos de daño moral (MIES en su sigla en inglés). Los traumas índice también fueron codificados por el médico tratante. Se llevaron a cabo análisis de regresión de efectos mixtos lineales para examinar si existían diferencias en los efectos promedio o las tendencias durante el curso de tratamiento en los veteranos con exposición a eventos moralmente perjudiciales o trauma índice y los que no.Resultados: Las tasas de exposición a eventos moralmente dañinos en esta muestra de tratamiento fueron altas (59,0% −75,2%). La exposición a eventos moralmente dañinos y el tipo de trauma índice no predijeron cambios en los resultados de los síntomas de la ITP y los veteranos reportaron grandes reducciones en los síntomas de TEPT (d = 1.35-1.96) y de depresión (d = 0.95-1.24) entre el pre- y post- tratamiento. Los análisis de no inferioridad también demostraron equivalencia entre aquellos con y sin exposición a eventos moralmente dañinos y eventos índice. No hubo diferencias de género significativas.Conclusiones: El presente estudio sugiere que el TEPT y la depresión en los veteranos militares con antecedentes de exposición a eventos moralmente dañinos pueden tratarse con éxito mediante un IPT basado en CPT de 3 semanas.

Impact of intensive treatment programs for posttraumatic stress disorder on suicidal ideation in veterans and service members.

Intensive treatment programs (ITPs) are treating veterans with posttraumatic stress disorder (PTSD) and suicidal ideation (SI). The reduction of SI is a target to the abatement of suicide risk. This study examined whether ITPs utilizing PTSD treatments reduce SI and whether SI reduction is associated with PTSD symptom improvement. Veterans (N = 684) enrolled in a 2-week Prolonged Exposure (PE)-ITP or a 3-week Cognitive Processing Therapy (CPT)-ITP. Study data were drawn from self-report measures [PTSD Checklist for DSM-5 (PCL-5); item 9 of the Patient Health Questionnaire-9 (PHQ-9)] administered at intake and throughout treatment. The ITPs produced large treatment effects for PTSD. SI scores also decreased over time. Lower PTSD symptom severity was associated with less severe SI in both the PE-ITP and CPT-ITP. In conclusion, both PE- and CPT-ITPs effectively treat PTSD and reduce SI among veterans in as little as 2 weeks of intensive PTSD treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Perioperative Symptom Severity of Higher Patient Health Questionnaire-9 Scores Between Genders in Single-Level Lumbar Fusion.

BACKGROUND: Preoperative depression is associated with increased perioperative pain, worse physical function, reduced quality of life, and inferior outcomes. Few studies have evaluated depressive symptoms between genders for individuals undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). The purpose of this investigation was to assess the severity of Patient Health Questionnaire-9 (PHQ-9) scores among patients with depressive symptoms before and after single-level MIS TLIF. METHODS: A prospective surgical registry was retrospectively reviewed for spine surgeries between March 2016 and December 2018. We included patients with at least mild depressive symptoms (PHQ-9 scores ≥ 5) who underwent primary, single-level MIS TLIF and compared genders using χ2 tests and t tests. Genders were stratified by depressive symptom severity: mild (5-9), moderate (10-14), and moderately severe (≥15) and then analyzed at preoperative and postoperative intervals: 6 weeks, 12 weeks, 6 months, and 1 year. Finally, PHQ-9 scores were validated with a Pearson correlation test against the 12-item Short Form (SF-12) Mental Composite Score (MCS) and the Veterans RAND (VR-12) MCS. RESULTS: Of 75 subjects, 44.0% were women and the mean age was 49.9 years. The preoperative distribution among PHQ-9 subgroups was 38.7%, 26.6%, and 34.7% for mild, moderate, and moderately severe depressive symptoms, respectively. Among PHQ-9 stratifications both genders demonstrated intermittent statistically significant improvements in PHQ-9 scores. The moderately severe PHQ-9 subgroup had improvement at all postoperative time points. The PHQ-9 scores demonstrated a strong correlation with the SF-12 MCS and VR-12 MCS at all postoperative evaluations. CONCLUSION: At baseline and by the final 1-year follow-up there were no statistically significant PHQ-9 score differences between genders within any depressive symptom stratifications. Whereas some contend that men and women have substantial mental health differences, this study is aligned with growing evidence that demonstrates similar depressive symptoms between genders. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Men and women may be at an equivalent risk for perioperative depressive symptoms.

The influence of cognitive behavioral therapy on lumbar spine surgery outcomes: a systematic review and meta-analysis.

PURPOSE: As more patients undergo lumbar spine surgery, novel interventions may improve physical and mental health outcomes. Few studies summarize the benefit of cognitive behavioral therapy (CBT) among lumbar spine surgery patients. This study collects randomized control trial data to investigate the influence of CBT on patient reported outcomes among lumbar spine surgery patients. METHODS: Our study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and a medical library expert assisted in searching PubMed/MEDLINE, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, and Google Scholar. We calculated standardized mean differences (SMD) to evaluate the effect size of CBT versus control groups with a sensitivity analysis. RESULTS: Our meta-analysis included seven studies with a total of 531 patients. The majority of included studies evaluated lumbar fusion, with preoperative CBT performed by physiotherapists. The largest effects were observed for overall quality of life (SMD = 0.55 [95% CI 0.05, 1.05], p < 0.001, I2 = 86.7%) and psychological outcomes (SMD = 0.61 [95% CI 0.28, 0.94], p < 0.001, I2 = 89.7%) though disability and pain outcomes also favored CBT intervention. Included studies demonstrated low overall bias but large heterogeneity. Sensitivity analysis demonstrated negligible study design differences and revealed moderators including CBT session frequency and final follow-up duration (p < 0.001). CONCLUSION: Compared to usual care or alternative therapy control arms, CBT delivered the most improvement with overall quality of life and psychological outcomes. Among appropriately selected patients, CBT could improve perioperative disability, pain, quality of life, and psychological health following lumbar spine surgery.

Examining the Impact of Sexual Revictimization in a Sample of Veterans Undergoing Intensive PTSD Treatment.

Sexual revictimization refers to exposure to more than one incident of rape and is a known risk factor for poor mental health among civilians. This construct has been understudied among veterans. In addition, although individuals who have experienced revictimization generally have greater symptom severity than those who have experienced one rape, it is unclear whether these differences persist following treatment. This study examined differences between veterans who reported histories of revictimization (n =111) or a single rape (n = 45), over the course of a 3-week intensive cognitive processing therapy (CPT)-based treatment program for veterans with posttraumatic stress disorder (PTSD). The sample consisted of predominately female (70.5%) post-9/11 veterans (82.7%). Self-reported PTSD and depression symptom severity were assessed regularly throughout the course of treatment. Controlling for non-interpersonal trauma exposure and whether veterans were seeking treatment for combat or military sexual trauma, sexual revictimization was generally associated with greater pretreatment distress and impairment. However, sexual revictimization did not impact rates of PTSD or depression symptom change over the course of intensive treatment, or overall improvement in these symptoms posttreatment. Our findings suggest that the rates of sexual revictimization are high among treatment-seeking veterans with PTSD. Although veteran survivors of sexual revictimization tend to enter treatment with higher levels of distress and impairment than their singly victimized peers, they are equally as likely to benefit from treatment.

Loss of sympathetic innervation to islets of Langerhans in canine diabetes and pancreatitis is not associated with insulitis.

Canine diabetes mellitus (DM) affects 0.6% of the canine population and yet, its etiology is poorly understood. Most affected dogs are diagnosed as adults and are insulin-dependent. We compared pan-leukocyte and sympathetic innervation markers in pancreatic islets of adult dogs with spontaneous DM (sDM), spontaneous pancreatitis (sPanc), both (sDMPanc), toxin-induced DM (iDM) and controls. We found evidence of decreased islet sympathetic innervation but no significant infiltration of islets with leukocytes in all disease groups. We show that loss of sympathetic innervation is ongoing in canine DM and does not necessarily precede it. We further found selective loss of islet-associated beta cells in dogs with sDM and sDMPanc, suggesting that collateral damage from inflammation in the exocrine pancreas is not a likely cause of DM in these dogs. The cause of this selective loss of beta cells needs to be further elucidated but overall, our findings are not supportive of an autoimmune process as a cause of sDM in adult dogs. The loss of sympathetic innervation in sPanc in dogs that do not suffer from DM links the disease in the exocrine pancreas to a pathological process in the endocrine pancreas, suggesting pancreatitis might be a potential precursor to DM.

Maintenance of treatment gains up to 12-months following a three-week cognitive processing therapy-based intensive PTSD treatment programme for veterans.

BACKGROUND: Intensive treatment programmes (ITPs) have shown promise for reducing PTSD and depression symptoms. It is still unknown whether treatment gains are maintained following completion. OBJECTIVE: This study examined whether veterans were able to maintain treatment gains for up to 12 months after an ITP for PTSD and whether reductions in negative posttrauma cognitions predicted treatment gain maintenance. METHODS: 209 veterans (62.7% male, mean age = 40.86 years) completed a 3-week, CPT-based ITP for PTSD. Participants' PTSD (PCL-5) and depression (PHQ-9) symptoms were assessed at pre-treatment, post-treatment, and at 3-, 6-, and 12-month follow-up timepoints. RESULTS: Despite small symptom increases from post-treatment to 3-month follow-up, significant and clinically meaningful reductions in PTSD and depression symptoms were reported from intake to 12 months follow-up (averaging >18 points on the PCL-5 and >6 points on the PHQ-9; d = 1.28, and d = 1.18, respectively). Greater reductions in negative posttrauma cognitions during treatment were associated with lower PTSD (p <.001) and depression (p =.005) severity at follow-up. Most veterans who completed the aftercare survey followed treatment recommendations and reported seeing a mental health provider at 3-, 6-, and 12-months post-treatment. Aftercare treatment did not significantly predict whether veterans maintained treatment gains at follow-up. CONCLUSIONS: Overall maintenance of treatment gains long-term suggests veterans may be able to apply skills acquired during the ITP following treatment. These findings further support the feasibility and effectiveness of intensive, trauma-focused, evidence-based therapy delivery.

Antecedentes: Los programas de tratamiento intensivos (ITPs por sus siglas en inglés) han mostrado ser promisorios para reducir el TEPT y los síntomas depresivos. Se desconoce aún si las ganancias del tratamiento se mantienen después de la finalización. Este estudio examinó si los veteranos fueron capaces de mantener las ganancias del tratamiento después de 12 meses de un ITP para TEPT y si las reducciones de las cogniciones negativas postrauma predijeron la mantención de las ganancias del tratamiento.Método: 209 veteranos (62,7% varones, edad media=40,86 años) completaron una ITP de 3 semana basado en CPT. Los síntomas de TEPT (PCL-5) y depresión (PHQ-9) de los participantes se evaluaron pre-tratamiento,post tratamiento y a los 3,6 y 12 meses de seguimiento.Resultados: A pesar de un pequeño aumento de los síntomas a los tres meses de seguimiento después de terminado el tratamiento, se reportaron reducciones clínicamente significativas e importantes en el TEPT y síntomas depresivos desde el inicio hasta los 12 meses de seguimiento (un promedio ˃18 puntos en el PCL-5 y ˃6 puntos en el PHQ-9; d=1.28, y d=1.18, respectivamente. Las mayores reducciones en las cogniciones negativas postrauma durante el tratamiento se asociaron con una menor severidad del TEPT (p˂ .001) y depresión (p=.005) en el seguimiento. La mayoría de los veteranos que completaron la encuesta de cuidados posteriores siguieron las recomendaciones del tratamiento e informaron haber visto a algún profesional de salud mental a los 3, 6 y 12 meses post-tratamiento. Los cuidados posteriores al tratamiento no predijeron significativamente si los veteranos mantenían las ganancias del tratamiento en el seguimiento.Conclusiones: el mantenimiento general de las ganancias del tratamiento a largo plazo sugiere que los veteranos pueden aplicar las habilidades adquiridas durante la PTI después del tratamiento.Estos hallazgos respaldan aún más la viabilidad y efectividad de la administración en forma intensiva de una terapia basada en la evidencia y centrada en el trauma.

A Case Report of Cognitive Processing Therapy Delivered over a Single Week.

Although evidence-based treatments for posttraumatic stress disorder (PTSD), such as Cognitive Processing Therapy (CPT), have been developed and widely disseminated, the rate of veterans engaging in and completing these therapies is low. Alternative methods of delivery may be needed to help overcome key barriers to treatment. Delivering evidence-based therapies intensively may address practical barriers to treatment attendance as well as problems with avoidance. This report details the case of a combat veteran who received 10 sessions of Cognitive Processing Therapy delivered twice per day over a single, five-day work week (CPT-5). Post-treatment, the veteran reported large and clinically meaningful decreases in PTSD and depression symptom severity as well as in guilt cognitions, which is a purported mechanism of successful treatment. These effects persisted six weeks after treatment ended. Despite the intensive nature of the treatment, the veteran found CPT-5 tolerable and could cite many benefits to completing therapy in one work week. In conclusion, CPT-5 holds promise as a way to efficiently deliver an evidence-based therapy that is both clinically effective and acceptable to patients, although more rigorous clinical trials are needed to test this treatment delivery format.

Help-seeking, trust and intimate partner violence: social connections amongst displaced and non-displaced Yezidi women and men in the Kurdistan region of northern Iraq.

BACKGROUND: Conflict and displacement impact the social fabric of communities through the disruption of social connections and the erosion of trust. Effective humanitarian assistance requires understanding the social capital that shapes patterns of help-seeking in these circumstances - especially with stigmatised issues such as violence against women (VAW) and intimate partner violence (IPV). METHODS: A novel social mapping methodology was adopted amongst a Yezidi population displaced by ISIS (ISIS: Islamic State of Iraq and Syria, locally known as Da'esh) occupation and a neighbouring settled Yezidi population in the Kurdistan region of northern Iraq in late 2016. Six participatory workshops were conducted to identify available resources with respect to: meeting basic needs, dispute resolution and VAW. Subsequently, 51 individual interviews were conducted (segmented by gender and settlement status) to identify connectedness to, and trust in, the resources identified, with a focus on IPV against women. RESULTS: 90% of participants reported God as a key source of help in the previous 6 months, representing the most widely cited resource. Following God, the most accessed and trusted resources were family and community, with NGO (non-governmental organisation) provision being the least. Women drew more strongly upon familial resources than men (Χ 2 = 5.73, df = 1, p = 0.017). There was reduced trust in resources in relation to seeking help with IPV. A distinction between trust to provide emotional support and trust to resolve issues was identified. Settled women were 1.6 times more likely to trust community members and government services and 3.7 times more likely to trust NGOs than displaced women. CONCLUSIONS: Mapping social connections and trust provides valuable insight into the social capital available to support help-seeking in populations of humanitarian concern. For these Yezidi populations, family, religious and community resources were the most widely utilised and trusted. Trust was mostly reserved for family and their main religious leader regarding IPV against women. Lack of trust appeared to be a major barrier to stronger engagement with available NGO provision, particularly amongst displaced women. The role of faith and religious resources for this population is clearly significant, and warrants an explicitly faith-sensitive approach to humanitarian assistance.