Heart rate during sleep in PTSD patients: Moderation by contact with a service dog.

There is growing interest in the potential health benefits of dog ownership in both the lay and scientific communities. Large reductions in risk for cardiovascular disease and all-cause mortality in dog owners relative to non-owners have been observed in epidemiological samples. Persons diagnosed with posttraumatic stress disorder exhibit elevated risk for cardiovascular disease. The current study tested a sample of 45 U.S. military veterans with deployment-related posttraumatic stress disorder employing an intensive, longitudinal, within-subjects design contrasting sleep heart rate on nights with and without a service dog. As participants were engaged in residential psychiatric treatment, sleep opportunities, waking activities, meals, and medications, were consistently scheduled. The primary recording methodology, mattress actigraphy, enabled passive quantification of heart rate over a total sample of 1097 nights. Service dog contact was associated with reduced sleep heart rate especially in participants with more severe PTSD. Longer-term longitudinal studies will be needed to assess the durability and asymptotic magnitude of this effect. An unexpected effect of nights in study was associated with increased heart rate consistent with hospitalization-associated deconditioning.

Longitudinal profiles of sleep during residential PTSD treatment.

We investigated longitudinal profiles of objectively measured sleep periods (SP) over the course of residential treatment for posttraumatic stress disorder (PTSD) in a cohort of U.S. male veterans. Participants (N = 190) slept on mattress-actigraphy systems in a Veterans Affairs (VA) residential PTSD program. The final sample included 4078 sleep periods. Latent class mixed model analyses were used to identify between-subject profiles in sleep period durations, controlling for daily medication intake, over the first fifty days of residency. Logistic regression was used to determine the association of pre-treatment characteristics with identified profiles. Three longitudinal profiles of sleep period characterized most of the sample: 'stable' (56%), 'decreasing' (35%), and 'increasing' (8%). Less severe pre-treatment PTSD avoidance symptoms predicted membership in the 'decreasing' class and increased depression symptoms were predictive of membership in the 'increasing' class. Nearly half of the sample reported a summary change of 1 h or more over the course of the initial 50-nights in the program. Future work is needed to identify how these profiles might drive inpatient treatment decisions regarding the provision of adjunctive sleep-focused treatment such as cognitive-behavioral treatment for insomnia or hypnotic medications.

Training Staff Across the Veterans Affairs Health Care System to Use Mobile Mental Health Apps: A National Quality Improvement Project.

BACKGROUND: The National Center for PTSD, within the Department of Veterans Affairs (VA), has developed a suite of free, publicly available, evidence-informed apps that can reach an increasing number of veterans and bridge gaps in care by providing resources to those who are not engaged in mental health treatment. To expand the reach of these apps, staff across VA service lines learned about these apps, their features and limitations, and how to introduce them to veterans. OBJECTIVE: This study aimed to develop, disseminate, and evaluate a training for multidisciplinary staff as part of a national quality improvement project to increase the reach of mobile mental health apps as a resource for veterans. METHODS: Sites from all of VA's 18 geographic regions enrolled in this project. At each site, a minimum of 25 VA staff members who had direct contact with veterans, including staff from the mental health service line and all other service lines, were recruited to participate. Training included a 3-hour multidisciplinary core module, and a 1-hour clinical integration module designed specifically for mental health clinicians. Owing to the COVID-19 pandemic, the trainings were adapted to a live, web-based format. Pre- and posttraining surveys assessed program reach (ie, participants enrolled per site), satisfaction, and effectiveness of the training as measured by changes in knowledge, basic skills, and behavioral intentions to use apps with veterans. RESULTS: A total of 1110 participants representing 34 disciplines at 19 VA sites completed the training. Overall, 67% (743/1109) of participants were mental health staff members. Sites averaged 58.4 participants (SD 36.49, median [IQR] 51). Most (961/1024, 93.85%) participants were satisfied with the training and reported that they (941/1018, 92.44%) would recommend it to others. App knowledge scores significantly increased from pretraining (mean 80.8% correct, SD 15.77%) to posttraining (mean 91.1% correct, SD 9.57%; P<.001). At posttraining, participants also reported greater confidence in their ability to show veterans how to download (z=-13.86; P<.001) and use VA mental health apps (z=-15.13; P<.001). There was near universal endorsement by staff for their intentions to recommend apps to veterans as well as their ability to think of at least one specific veteran to whom they could recommend an app. Staff also reported a strong motivation to encourage other VA staff to share apps with veterans. CONCLUSIONS: The training far exceeded the initial goals for staff recruitment and training for all three metrics. Overall, 33% (366/1109) of participants came from service lines outside of mental health, indicating the feasibility of introducing these mental health resources during medical appointments and in other contexts.

Reading the mind in the eyes in PTSD: Limited Moderation by the presence of a service dog.

Persons with posttraumatic stress disorder (PTSD) frequently experience relationship failures in family and occupational domains resulting in loss of social supports. Prior research has implicated impairments in social cognition. The Reading the Mind in the Eyes Test (RMET) measures a key component of social cognition, the ability to infer the internal states of other persons based on features of the eyes region of the face; however, studies administering this popular test to persons with PTSD have yielded mixed results. This study assessed RMET performance in 47 male U.S. military Veterans with chronic, severe PTSD. Employing a within-subjects design that avoided selection biases, it aimed specifically to determine whether components of RMET performance, including accuracy, response latency, and stimulus dwell time, were improved by the company of a service dog, an intervention that has improved social function in other populations. RMET accuracies and response latencies in this PTSD sample were in the normal range. The presence of a familiar service dog did not improve RMET accuracy, reduce response latencies, or increase dwell times. Dog presence increased the speed of visual scanning perhaps consistent with reduced social fear.

Randomized clinical trial of capnometry-assisted respiratory training in veterans with posttraumatic stress disorder hyperarousal.

OBJECTIVE: To investigate whether capnometry-assisted antihyperventilation respiratory training, successful in treating panic, and sleep hygiene instructions would reduce posttraumatic stress disorder (PTSD) hyperarousal symptoms in U.S. military veterans. METHOD: We conducted a parallel, nonblinded clinical trial and randomized 80 veterans with PTSD hyperarousal into treatment or wait list. Primary treatment outcomes from baseline to 1st follow-up were analyzed using mixed modeling. Baseline physiological measures were compared between the PTSD hyperarousal group and a no-PTSD group (n = 68). RESULTS: Baseline respiration rate but not partial-pressure of end-tidal carbon dioxide (PCO2) was higher in the PTSD hyperarousal group than in the no-PTSD group during 3 min of quiet sitting, indicating no difference in baseline hyperventilation. There was no significant effect of the intervention on PTSD hyperarousal symptoms or hyperventilation compared to wait list, but treatment did lower respiratory rate. CONCLUSION: This intervention did not reduce PTSD hyperarousal symptoms, perhaps due to differences between underlying mechanisms of PTSD hyperarousal and panic disorder or to differences between veteran and civilian populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Tracking positive and negative affect in PTSD inpatients during a service dog intervention.

Though popular across many audiences, engagement with a service dog has undergone limited empirical evaluation as a complementary or alternative treatment for posttraumatic stress disorder (PTSD). The present study took advantage of a service dog training intervention underway in a Department of Veterans Affairs residential PTSD treatment program to perform a within-subjects comparison of a range of phenotypic markers. The present report considers negative and positive affect, assessed throughout the day, contrasting weeks when participants were or were not accompanied by their service dog. Fifty-four veterans were studied for 2-6 weeks. Negative and positive affect were sampled five times per day using items from the Positive and Negative Affect Schedule. Participants also wore a single-patch ECG/activity recorder and slept on beds recording sleep actigraphically. Linear mixed effects regression was employed to estimate the effect of the presence of service dog on momentary affect in the context of other presumable influences. Missing data were managed using methods applicable to random and nonrandom missingness. In this sample, the presence of a service dog was associated with reduced negative and increased positive affect, with both effects diminishing over time. Only negative affect was associated with time in residential treatment, and only positive affect was associated with concurrent heart rate, activity, and the interaction of activity and prior-night actigraphic sleep efficiency. These results concur with prior reports of reduced PTSD symptomology in association with the presence of a service dog, and with the distinct neurocircuitries underlying defensive and appetitive emotion and motivation. Limitations derive from the artificial environment and brief duration of study. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Mobile Mental Health Apps from the National Center for PTSD: Digital Self-Management Tools for Co-Occurring Disorders.

Mobile mental health apps can help bridge gaps in access to care for those with substance use disorders and dual diagnoses. The authors describe a portfolio of free, publicly available mobile mental health apps developed by the National Center for PTSD. The authors also demonstrate how this suite of primarily non-substance use disorder-specific mobile mental health apps may support the active ingredients of substance use disorder treatment or be used for self-management of substance use disorder and related issues. The potential advantages of these apps, as well as limitations and considerations for future app development, are discussed.

Two Independent Predictors of Nightmares in Posttraumatic Stress Disorder.

STUDY OBJECTIVES: Understanding nightmares (NM) and disturbing dreams (DD) in posttraumatic stress disorder (PTSD) has been limited by the unpredictability of these events and their nonappearance in the sleep laboratory. This study used intensive, longitudinal, ambulatory methods to predict morning reports of NM/DD in veterans in whom chronic, severe PTSD was diagnosed. METHODS: Participants were 31 male United States military veterans engaged in residential treatment for PTSD and participating in a service animal training intervention. Participants slept on mattress actigraphs and provided reports of momentary mood, as well as morning NM/DD reports, for up to 6 weeks. Mattress actigraphy provided sleep-period heart rate and respiratory sinus arrhythmia (RSA), and an actigraphic estimate of sleep efficiency. On one night, a respiratory event index (REI) was obtained using an ambulatory system. RESULTS: A total of 468 morning reports were obtained, of which 282 endorsed NM/DD during the prior night, and 186 did not. After accounting for multiple predictors, only elevated REI and lower prior-night sleep RSA predicted morning endorsement of NM/DD. These two predictors did not interact. CONCLUSIONS: Elevated REI and lower sleep period RSA were independently predictive of NM/DD. The former result is consistent with studies showing that sleep-disordered breathing (SDB) is a factor in NM/DD, and that continuous positive airway pressure (CPAP) can reduce these symptoms in patients with comorbid PTSD and SDB. The latter result implicates dysregulated arousal modulation during sleep in trauma-related NM/DD. It is consistent with findings that NM/DD are reported in patients without SDB and can persist in patients with comorbid PTSD and SDB even when CPAP successfully remediates SDB.

Assessing sleep quality using self-report and actigraphy in PTSD.

Sleep disturbance is commonly reported by participants with post-traumatic stress disorder, but objective evidence of poor sleep is often absent. Here we compared self-report and actigraphic evaluations of sleep between veterans with post-traumatic stress disorder and controls. Participants reported their sleep retrospectively for the month before the recording night and on the recording night. On the recording night, they wore an Actiwatch-64 and were instructed to press the marker button upon getting into bed, each time they awoke, and at their final awakening. The post-traumatic stress disorder group reported much worse sleep than controls on the Pittsburgh Sleep Quality Index for the previous month and somewhat poorer sleep on the recording night. However, on the recording night, neither diary nor actigraphic measures of number of awakenings, total time in bed, nor time lying awake after sleep onset differed between participants with and without post-traumatic stress disorder. Diary-reported number of awakenings was fewer than actigraphically captured awakenings. These results suggest a memory bias towards remembering worse sleep on the nights before the recording night.

Canine companionship is associated with modification of attentional bias in posttraumatic stress disorder.

Attentional bias towards aversive stimuli has been demonstrated in the anxiety disorders and in posttraumatic stress disorder, and attentional bias modification has been proposed as a candidate treatment. This study rigorously assessed attentional bias towards aversive and pleasant visual imagery associated with the presence or absence of a familiar service canine in 23 veterans with chronic military-related posttraumatic stress disorder. Participants were repeatedly tested with and without their service canines present on two tasks designed to elicit spontaneous visual attention to facial and scenic image pairs, respectively. Each stimulus contrasted an emotive image with a neutral image. Via eye-tracking, the difference in visual attention directed to each image was analyzed as a function of the valence contrast and presence/absence of the canine. Across both tasks, the presence of a familiar service canine attenuated the normative attentional bias towards aversive image content. In the facial task, presence of the service canine specifically reduced attention toward angry faces. In that task, as well, accumulated days with the service canine similarly modulated attention toward facial emotion. The results suggest that the presence of a familiar service canine is associated with attenuation of attentional bias to aversive stimuli in chronic military-service-related posttraumatic stress disorder. Questions remain regarding the generalization of such effects to other populations, their dependence on the familiarity, breed, and training of the canine, and on social context.

Adapting a computer-delivered brief alcohol intervention for veterans with Hepatitis C.

OBJECTIVE: This study adapted an existing computer-delivered brief alcohol intervention (cBAI) for use in Veterans with the hepatitis C virus (HCV) and examined its acceptability and feasibility in this patient population. METHODS: A four-stage model consisting of initial pilot testing, qualitative interviews with key stakeholders, development of a beta version of the cBAI, and usability testing was used to achieve the study objectives. RESULTS: In-depth interviews gathered feedback for modifying the cBAI, including adding HCV-related content such as the health effects of alcohol on liver functioning, immune system functioning, and management of HCV, a preference for concepts to be displayed through "newer looking" graphics, and limiting the use of text to convey key concepts. Results from usability testing indicated that the modified cBAI was acceptable and feasible for use in this patient population. CONCLUSIONS: The development model used in this study is effective for gathering actionable feedback that can inform the development of a cBAI and can result in the development of an acceptable and feasible intervention for use in this population. Findings also have implications for developing computer-delivered interventions targeting behavior change more broadly.

Receptivity to alcohol-related care among U.S. women Veterans with alcohol misuse.

Previous research indicates women Veterans have a potentially large, unmet need for alcohol-related care but are under-represented in treatment settings. The purpose of this study was to identify factors associated with women Veterans' receptivity to a recommendation for alcohol-related care when they present to Veterans Affairs (VA) primary care with alcohol misuse. Semi-structured interviews were conducted from 2012-2013 with 30 women Veterans at two VA facilities who screened positive for alcohol misuse during a primary care visit and discussed their alcohol use with their primary-care provider. Qualitative analyses identified 9 themes women used to describe what affected their receptivity to a recommendation for alcohol-related care (i.e., VA specialty substance use disorder services). The most common themes positively associated with women's receptivity included self-appraisal of their drinking behavior as more severe, the provider's presentation of treatment options, availability of gender-specific services, and worse physical and mental health. The themes identified here may have important implications for the clinical strategies providers can use to present alcohol-related care options to women Veterans to facilitate their use of care. These strategies include educating women about the health effects of alcohol misuse and increasing providers' knowledge about available care options (within the care organization or the community), including the availability of gender-specific services.

Factors Affecting Women's Disclosure of Alcohol Misuse in Primary Care: A Qualitative Study with U.S. Military Veterans.

BACKGROUND: One in five women veterans screens positive for alcohol misuse. Women may be less likely than men to disclose alcohol use to a primary care provider (PCP), resulting in women being less likely to receive effective interventions. We sought to qualitatively examine factors that may affect women veterans' willingness to disclose alcohol use to a PCP. METHODS: Between October 2012 and May 2013, in-depth interviews were conducted with 30 women veterans at two Department of Veterans Affairs (VA) medical facilities. Qualitative data analyses identified common themes representing factors that influence women's decision to disclose alcohol use to a PCP. FINDINGS: Nine themes were endorsed by women veterans as influencing their willingness to disclose alcohol use to their PCP. Themes included provider behaviors perceived as encouraging or discouraging disclosure of alcohol misuse, perceived positive relationship with provider, negative emotions such as concerns about being judged or labeled an "alcoholic," health concerns about drinking, non-health-related concerns about drinking, self-appraisal of drinking behavior, social support, and clinic factors. CONCLUSIONS: Our findings demonstrate the importance of social relationships, comfort with one's provider, and education on the potential harms (especially health related) associated with alcohol in encouraging disclosure of alcohol use in women veterans. Our results also support VA national health care efforts, including the provision of brief alcohol counseling and the use of primary care clinics specializing in the care of women veterans.

Alcohol and drug misuse, abuse, and dependence in women veterans.

We conducted a systematic literature review on substance misuse, abuse, and dependence in women veterans, including National Guard/reserve members. We identified 837 articles published between 1980 and 2013. Of 56 included studies, 32 reported rates of alcohol misuse, binge drinking, or other unhealthy alcohol use not meeting diagnostic criteria for abuse or dependence, and 33 reported rates of drug misuse or diagnosed alcohol or drug use disorders. Rates ranged from 4% to 37% for alcohol misuse and from 7% to 25% for binge drinking; among Veterans Health Administration (VA) health-care system outpatients, rates ranged from 3% to 16% for substance use disorder. Studies comparing women veterans and civilians reported no clear differences in binge or heavy drinking. Substance misuse rates were generally lower among women veterans than men veterans. Substance misuse was associated with higher rates of trauma, psychiatric and medical conditions, and increased mortality and suicide rates. Most studies included only VA patients, and many used only VA medical record data; therefore, the reported substance misuse rates likely do not reflect true prevalence. Rates also varied by assessment method, source of data, and the subgroups studied. Further efforts to develop epidemiologically valid prevalence estimates are needed to capture the true health burden of substance misuse in women veterans, particularly those not using VA care.

Autonomic arousal during actigraphically estimated waking and sleep in male veterans with PTSD.

Physiological hyperarousal is manifested acutely by increased heart rate, decreased respiratory sinus arrhythmia, and increased skin conductance level and variability. Yet it is uncertain to what extent such activation occurs with the symptomatic hyperarousal of posttraumatic stress disorder (PTSD). We compared 56 male veterans with current PTSD to 54 males who never had PTSD. Subjects wore ambulatory devices that recorded electrocardiograms, finger skin conductance, and wrist movement while in their normal environments. Wrist movement was monitored to estimate sleep and waking periods. Heart rate, but not the other variables, was elevated in subjects with PTSD equally during waking and during actigraphic sleep (effect sizes, Cohen's d, ranged from 0.63 to 0.89). The length of the sleep periods and estimated sleep fragmentation did not differ between groups. Group heart rate differences could not be explained by differences in body activity, PTSD hyperarousal symptom scores, depression, physical fitness, or antidepressant use.