ORION: A novel solution for tracking service members exposed to trauma and providing targeted outreach.

In response to the USS Fitzgerald (FTZ) and USS John S. McCain (JSM) collisions in 2017, Navy Medicine developed the Organizational Incident Operational Nexus (ORION) to track Service members and conduct targeted outreach (Caring Contacts) to those at elevated risk for psychological injury after unit-level, non-combat trauma exposure. A 1-year pilot was conducted to test the feasibility of implementing ORION. During the pilot, crews from the FTZ and JSM received Caring Contacts twice, once in winter/spring of 2018 and once in the summer/fall of 2018. Caring Contacts included reaching out to Service members over email, checking in with Service members over the phone, and connecting them to mental health resources, if desired. Sixty-two percent of the crews of the FTZ and JSM completed Caring Contacts. The Caring Contacts were well received and one in five Service members requested assistance connecting to mental healthcare through ORION. Additionally, all paygrades from enlisted to officers and 66% of Service members who separated from Service requested assistance connecting to mental healthcare through ORION. Findings from the Caring Contacts also demonstrated that 50% of the crews needed mental health support after the collision, with 30% of Sailors reporting accessing care since the collision and an additional 20% requesting care during the Caring Contacts. Overall, results suggest Service members greatly benefited from ORION's proactive approach to confidential outreach. Navy Medicine is now working toward implementing ORION throughout the enterprise and collecting more data to refine the program. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Bostwick Autoderm and Implant Technique: Improved Outcomes for Obese Patients in Immediate Breast Reconstruction.

BACKGROUND: The Bostwick autoderm technique uses the patient's own deepithelialized mastectomy flap for lower pole coverage of an implant, similar to the use of acellular dermal matrix. The skin is closed over the autoderm flap in a Wise pattern. Unlike acellular dermal matrix, autoderm is perfused tissue that offers immediate protection for the implant. Because of this extra protective vascularized layer, implants can often be salvaged in cases of wound breakdown. METHODS: A retrospective review of 370 patients and 592 immediate implant reconstructed breasts was performed. RESULTS: Four hundred twenty-two (71 percent) were reconstructed with autoderm, 93 (16 percent) with total muscle coverage, and 77 (13 percent) with acellular dermal matrix. Higher body mass index patients were overrepresented in the autoderm group. Ninety-one of the reconstructions in the autoderm group (21.3 percent) were performed on patients with a body mass index greater than 35 kg/m2 compared to four (4.3 percent) in the total muscle coverage group and two (2.6 percent) in the acellular dermal matrix group. Despite this higher proportion of obese patients, the complication rate in the autoderm group was similar to that of the acellular dermal matrix group. The implant loss rate for all reconstructions was 3.4 percent. There were 17 losses (4 percent) in the autoderm group, zero in the total muscle coverage group, and 20 (3.4 percent) in the acellular dermal matrix group. There were 15 patients and 28 breasts that had prepectoral reconstruction. CONCLUSION: The autoderm flap is a safe, reliable, and resource-conscientious technique for immediate, implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Prolonged Response of a Patient with Relapsed Acute Myeloid Leukemia to a Novel Oral Bromodomain Extraterminal Inhibitor (BETi).

Acute myeloid leukemia (AML) is an aggressive clonal bone marrow cancer characterized by high rates of relapse and mortality. A middle-aged woman with AML relapsed twice after achieving complete remission with induction therapy and subsequent salvage therapy. She was then enrolled in a clinical trial with the bromodomain extraterminal inhibitor (BETi) mivebresib and achieved complete remission with incomplete count recovery (CRi) with monotherapy. Subsequently, she relapsed and was transitioned to combination therapy with mivebresib plus venetoclax and achieved CR again. The patient required eltrombopag to decrease platelet dependence in both arms of the trial and exhibited less myelosuppression with the combination therapy. The exceptional response to mivebresib demonstrated by this patient underscores the therapeutic potential of mivebresib.

Engaging Survivors of Human Trafficking: Complex Health Care Needs and Scarce Resources.

Human trafficking, also known as modern-day slavery, is an egregious human rights violation associated with wide-ranging medical and mental health consequences. Because of the extensive health problems related to trafficking, health care providers play a critical role in identifying survivors and engaging them in ongoing care. Although guidelines for recognizing affected patients and a framework for developing response protocols in health care settings have been described, survivors' ongoing engagement in health care services is very challenging. High rates of disengagement, lost contact, premature termination, and attrition are common outcomes. For interventions to be effective in this marginalized population, challenges in engaging survivors in long-term therapeutic primary and mental health care must be better understood and overcome. This article uses the socioecological model of public health to identify barriers to engagement; offers evidence- and practice-based recommendations for overcoming these barriers; and proposes an interdisciplinary call to action for developing more flexible, adaptable models of care.

Professional quality of life normative benchmarks.

OBJECTIVE: Those responsible for the care of trauma survivors can experience both beneficial and detrimental consequences resulting from their professional demands. Research has demonstrated that among professional caregivers, compassion satisfaction (CS), burnout (BO), and compassion fatigue (CF) are important factors contributing to professional quality of life. The current research aims to provide normative information regarding the factors contributing to professional quality of life among those who interact with survivors of trauma. The Professional Quality of Life (ProQOL) Scale is a widely used measure of CS, BO, and CF. The most recent iteration of the ProQOL manual provides normative data to assist in the interpretation of scores. However, a review of the literature reporting raw scores on the ProQOL suggests that mean scores and cutoff scores for the 25th and 75th percentiles may be misleading. METHOD: A review of 30 studies (total sample size of 5,612) was conducted and normative values are presented. RESULTS: The mean (standard deviation) level of CS, CF, and BO were 37.7 (6.5), 16.7 (5.7), and 22.8 (5.4), respectively. CONCLUSIONS: Values gathered from the literature review tend to align well with one another and suggest that within a given sample, CS scores tend to be higher than BO scores, and BO scores tend to be slightly higher than CF scores. (PsycINFO Database Record

Screening for Complicated Grief in a Military Mental Health Clinic.

INTRODUCTION: Bereavement is one of the most common and stressful life experiences one can endure. Typical grief reactions follow a course of recovery in which individuals come to terms with the loss and resume functioning within weeks to months. However, for some, grief remains indefinitely distressing. Complicated Grief (CG) refers to significant chronic impairment that stems from bereavement. Military service members experience myriad factors that likely increase their risk for developing CG. Such factors include unique bonds between service members, exposure to constant and extreme levels of stress, multiple losses, separation from family and loved ones, witnessing/learning about sudden violent and traumatic deaths, and handling human remains. The aim of this project was to explore the practicality and efficiency of screening for CG within a busy military mental health clinic, and also explore relationships between contextual variables related to a death that might be associated with screening positive for CG. MATERIALS AND METHODS: As part of a clinical needs assessment, patients from a single mental health clinic at Naval Medical Center San Diego completed a brief grief survey that asked if they experienced a death of a person close to them, collected metrics related to losses they have experienced and included validated screeners for CG (The Brief Grief Questionnaire [BGQ] and the Inventory for Complicated Grief [ICG]). No data concerning gender, age, marital status, socioeconomic status, diagnosis, or purpose of visit (i.e., initial or follow-up visit) were collected. Institutional review board approval was obtained. RESULTS: In our sample of service members presenting to an adult outpatient military mental health clinic, 43.5% reported having experienced a loss that still impacts them. Of that group, 61.7% screened positive on the BGQ, 59.2% screened positive on the ICG using a cutoff of 25, and 46.1% screened positive on the ICG using the cutoff of 30. These findings suggest that military service members seeking mental health treatment who endorsed experiencing a loss are at high risk for experiencing persisting, impairing grief. Additionally, patients who either lost a fellow service member and/or experienced loss while on deployment reported significantly higher scores on the BGQ or ICG than if they did not report those factors. Furthermore, correlations between total number of losses and ICG scores suggest that service members who experienced multiple losses may be more susceptible to CG symptoms. CONCLUSION: The findings from this preliminary investigation suggest that many service members receiving care in military mental health care are experiencing grief-related symptoms and distress, and a brief screen for grief can help capture many of those with grief related impairment. Research shows that CG needs to be directly targeted to treat its symptoms and associated impairment. We recommend that military mental health clinics consider adding some type of grief screener to their standard intake as well as making providers aware of the importance of monitoring potential grief reactions in their patients.

Psychological Impact of Deploying in Support of the U.S. Response to Ebola: A Systematic Review and Meta-Analysis of Past Outbreaks.

OBJECTIVE: To examine the potential psychological impact of deploying in support of the U.S. response to Ebola in west Africa by systematic review and meta-analysis. METHODS: Peer-reviewed articles published between January 2000 and December 2014 were identified using PubMed, PsycINFO, and Web of Science. Thirty-two studies involving 26,869 persons were included in the systematic review; 13 studies involving 7,785 persons were included in the meta-analysis. Pooled standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated. RESULTS: Reflecting the sociodemographics of the military, those who are younger, single, not living with family, have fewer years of work experience, lower education, and lower income are at increased risk for psychological distress, alcohol/drug misuse, post-traumatic stress disorder (PTSD), depression, and/or anxiety as a result of their perceived risk of infection. Effect sizes for post-traumatic stress disorder, depressive, and anxiety symptoms were considered small (SMD = 0.12, 95% CI = -0.23 to 0.47), moderate (SMD = 0.40, 95% CI = 0.24-0.51), and small (SMD = 0.08, 95% CI = -0.09 to 0.25), respectively; however, only the effect size for depressive symptoms was statistically significant. CONCLUSIONS: Deployed service members may return with clinically significant problems, the most notable of which is depression. Delivering resilience training and fostering altruistic acceptance may protect service members from developing mental health disorders.

Preventing PTSD and Depression and Reducing Health Care Costs in the Military: A Call for Building Resilience Among Service Members.

The present study investigates the role of psychological resilience in protecting against the development of post-traumatic stress disorder (PTSD), depression, and comorbid PTSD and depression; and estimates the percent reductions in incidence of, and associated treatment cost savings for, each condition as a function of increasing resilience. A retrospective cohort of mental health care-seeking service members (n = 2,171) completed patient-reported outcome measures approximately every 10 weeks as part of the Psychological Health Pathways program. Patients with low resilience were at significantly greater odds for developing physical, behavioral, and mental health conditions, particularly sleep disorder (adjusted odds ratio [AOR] = 2.60, 95% confidence interval [CI] = 1.81-3.73), perceived stress (AOR = 2.86, 95% CI = 1.05-7.75), and depression (AOR = 2.89, 95% CI = 2.34-3.57) compared to patients with moderate/high resilience. Increasing resilience across services by 20% is estimated to reduce the odds of developing PTSD, depression, and comorbid PTSD and depression by 73%, 54%, and 93%, respectively; the incidence by 32%, 19%, and 61%, respectively; and save approximately $196, $288, and $597 million in annual treatment costs, respectively, or approximately $1.1 billion total (a 35% reduction in costs). Using resilience as a preventive model may reduce health care utilization and costs in an already overtaxed health care system.

Outcomes from eye movement desensitization and reprocessing in active-duty service members with posttraumatic stress disorder.

OBJECTIVE: Eye movement desensitization and reprocessing (EMDR) is one of the therapy interventions recommended by the Veterans Affairs and Department of Defense Clinical Practice Guidelines. However, the literature concerning the effectiveness of this treatment modality in military service members is sparse. This study investigated the efficacy of EMDR in active-duty service members. METHOD: We conducted an effectiveness study with a record review from active-duty military mental health clinics where clinical outcomes had been monitored over a 10-week period using self-report measures of posttraumatic stress and disability. Symptom scores were examined over time in 331 service members who met presumptive criteria for the disorder on the PTSD Checklist-Military Version (PCL-M), who were in psychotherapy, and who received (n = 46) or didn't receive (n = 285) EMDR. RESULTS: Results indicated that patients receiving EMDR had significantly fewer therapy sessions over 10 weeks but had significantly greater gains in their PCL-M scores than did individuals not receiving EMDR. CONCLUSIONS: Randomized, controlled trials are still needed, but these findings provide further support for the use of EMDR in service members with PTSD. (PsycINFO Database Record

Treatment of Mental or Physical Health Problems in a Combat Zone: Comparisons of Postdeployment Mental Health and Early Separation From Service.

The primary aim of this study was to evaluate whether being treated for mental health or nonbattle physical injury during military combat deployment was associated with higher risk for postdeployment mental disorders and poorer career outcomes than seen in the general combat-deployed population. Service members treated in theater for mental health (n = 964) or noncombat injury (n = 853) were compared with randomly sampled personnel (n = 7,220) from the general deployed population on diagnosed mental disorders and early separation from service. Deployment, medical, and career information were obtained from Department of Defense archival databases. Over half of the personnel who received mental health treatment while deployed were diagnosed with 1 or more mental disorders postdeployment and/or were separated from service before completing their full-term enlistment. This was significantly higher than expected compared to the general deployed group, adjusting for demographic/military characteristics and mental health history (adjusted odds ratios [ORs] ranging 1.62 to 2.96). Frequencies of problems also were higher in the mental health-treated group than in the group treated for nonbattle physical injuries (significant adjusted ORs ranging 1.65 to 2.58). The documented higher risks for postdeployment adjustment problems suggested that especially those treated in theater by mental health providers might benefit from postdeployment risk-reduction programs.

Development and Validation of a Brief Measure of Psychological Resilience: An Adaptation of the Response to Stressful Experiences Scale.

Resilience helps determine how people respond to stress. The Response to Stressful Events Scale (RSES) is an existing 22-item measure of resilience. We investigate the psychometric properties of the RSES and develop a 4-item measure of resilience using the most discriminating items from the RSES. Among two samples of military personnel presenting to mental health clinics, we see that the abbreviated resilience measure displays comparable internal consistency and test-retest reliability (versus the existing RSES). Among a sample of deployed military personnel, the abbreviated scale relates to validated measures of psychological strain. The 4-item abbreviated RSES measure is a brief, reliable, and valid measure of resilience.

Operational Stress and Correlates of Mental Health Among Joint Task Force Guantanamo Bay Military Personnel.

Military personnel deployed to Joint Task Force Guantanamo Bay (JTF-GTMO) faced numerous occupational stressors. As part of a program evaluation, personnel working at JTF-GTMO completed several validated self-report measures. Personnel were at the beginning, middle, or end of their deployment phase. This study presents data regarding symptoms of posttraumatic stress disorder, alcohol abuse, depression, and resilience among 498 U.S. military personnel deployed to JTF-GTMO in 2009. We also investigated individual and organizational correlates of mental health among these personnel. Findings indicated that tenure at JTF-GTMO was positively related to adverse mental health outcomes. Regression models including these variables had R2 values ranging from .02 to .11. Occupation at JTF-GTMO also related to mental health such that guards reported poorer mental health than medical staff. Reluctance to seek out mental health care was also related to mental health outcomes. Those who reported being most reluctant to seek out care tended to report poorer mental health than those who were more willing to seek out care. Results suggested that the JTF-GTMO deployment was associated with significant psychological stress, and that both job-related and attitude-related variables were important to understanding mental health symptoms in this sample.

Interactive effects of stress and individual differences on alcohol use and posttraumatic stress disorder among personnel deployed to Guantanamo Bay.

This study examines the role of factors such as perceived stress, neuroticism, beliefs in psychotherapy stigma, resilience, and demographics in understanding posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) among deployed military personnel. Results show that personnel who screened positive for PTSD were more likely to screen positive for AUD (versus those who did not screen positive for PTSD). Perceived stress, neuroticism, and psychotherapy stigma all have direct multivariate relationships with PTSD symptoms. Moderated regression analyses show that the positive relationship between perceived stress and PTSD symptoms is significantly stronger among those scoring high on neuroticism and psychotherapy stigma. The positive relationship between perceived stress and AUD symptoms is only significant among those scoring high on psychotherapy stigma. Given the moderating role of psychotherapy stigma in the relationship between perceived stress and PTSD symptoms and the relationship between perceived stress and AUD symptoms efforts to reduce the stigma associated with mental health care in the military should be expanded. Also, the current research adds to the literature highlighting the role of neuroticism as a key variable in understanding PTSD.

Expression level and subcellular localization of heme oxygenase-1 modulates its cytoprotective properties in response to lung injury: a mouse model.

Premature infants exposed to hyperoxia suffer acute and long-term pulmonary consequences. Nevertheless, neonates survive hyperoxia better than adults. The factors contributing to neonatal hyperoxic tolerance are not fully elucidated. In contrast to adults, heme oxygenase (HO)-1, an endoplasmic reticulum (ER)-anchored protein, is abundant in the neonatal lung but is not inducible in response to hyperoxia. The latter may be important, because very high levels of HO-1 overexpression are associated with significant oxygen cytotoxicity in vitro. Also, in contrast to adults, HO-1 localizes to the nucleus in neonatal mice exposed to hyperoxia. To understand the mechanisms by which HO-1 expression levels and subcellular localization contribute to hyperoxic tolerance in neonates, lung-specific transgenic mice expressing high or low levels of full-length HO-1 (cytoplasmic, HO-1-FL(H) or HO-1-FL(L)) or C-terminally truncated HO-1 (nuclear, Nuc-HO-1-TR) were generated. In HO-1-FL(L), the lungs had a normal alveolar appearance and lesser oxidative damage after hyperoxic exposure. In contrast, in HO-1-FL(H), alveolar wall thickness with type II cell hyperproliferation was observed as well worsened pulmonary function and evidence of abnormal lung cell hyperproliferation in recovery from hyperoxia. In Nuc-HO-1-TR, the lungs had increased DNA oxidative damage, increased poly (ADP-ribose) polymerase (PARP) protein expression, and reduced poly (ADP-ribose) (PAR) hydrolysis as well as reduced pulmonary function in recovery from hyperoxia. These data indicate that low cytoplasmic HO-1 levels protect against hyperoxia-induced lung injury by attenuating oxidative stress, whereas high cytoplasmic HO-1 levels worsen lung injury by increasing proliferation and decreasing apoptosis of alveolar type II cells. Enhanced lung nuclear HO-1 levels impaired recovery from hyperoxic lung injury by disabling PAR-dependent regulation of DNA repair. Lastly both high cytoplasmic and nuclear expression of HO-1 predisposed to long-term abnormal lung cellular proliferation. To maximize HO-1 cytoprotective effects, therapeutic strategies must account for the specific effects of its subcellular localization and expression levels.

Correlation of breast cancer axillary lymph node metastases with stem cell mutations.

IMPORTANCE: Mutations in oncogenes AKT1, HRAS, and PIK3CA in breast cancers result in abnormal PI3K/Akt signaling and tumor proliferation. They occur in ductal carcinoma in situ, in breast cancers, and in breast cancer stem and progenitor cells (BCSCs). OBJECTIVES: To determine if variability in clinical presentation at diagnosis correlates with PI3K/Akt mutations in BCSCs and provides an early prognostic indicator of increased progression and metastatic potential. DESIGN, SETTING, AND PARTICIPANTS: Malignant (BCSCs) and benign stem cells were collected from fresh surgical specimens via cell sorting and tested for oncogene mutations in a university hospital surgical oncology research laboratory from 30 invasive ductal breast cancers (stages IA through IIIB). MAIN OUTCOMES AND MEASURES: Presence of AKT1, HRAS, and PIK3CA mutations in BCSCs and their correlation with tumor mutations, pathologic tumor stage, tumor histologic grade, tumor hormone receptor status, lymph node metastases, and patient age and condition at the last follow-up contact. RESULTS: Ten tumors had mutations in their BCSCs. In total, 9 tumors with BCSC mutations and 4 tumors with BCSCs without mutations had associated tumor present in the lymph nodes (P = .001). CONCLUSIONS AND RELEVANCE: Tumors in which BCSCs have defects in PI3K/Akt signaling are significantly more likely to manifest nodal metastases. These oncogenic defects may be missed by gross molecular testing of the tumor and are markers of more aggressive breast cancer. Molecular profiling of BCSCs may identify patients who would likely benefit from PI3K/Akt inhibitors, which are being tested in clinical trials.

Psychiatric diagnoses and treatment of U.S. military personnel while deployed to Iraq.

Military personnel deployed in support of combat operations are at significantly higher risk for mental health problems. However, much of what we know about combat-related mental health comes from postdeployment assessments. This study describes the mental health of 1,336 treatment-seeking deployed U.S. military personnel and interventions recommended by military mental health providers in Iraq from January 2006 to January 2007. Cases were primarily young enlisted men, most of whom were on their first combat deployment. Marines made up the majority of the cases (60%), but there were also large numbers of Army and Navy personnel. The most common psychiatric diagnoses were anxiety disorders (31%, including 11% with posttraumatic stress disorder), followed by adjustment (27%) and mood disorders (25%, including 22% with depression). Medication was the most commonly prescribed treatment for patients with psychiatric diagnoses but was often combined with recommendations for psychotherapy/counseling and/or behavioral modifications. The findings illustrate the distribution of mental health conditions seen among treatment-seeking troops while actively serving in a combat environment and the interventions recommended for them. Further examination of postdeployment health outcomes may help to facilitate the development of more effective acute intervention strategies in theater.

Predictors of risk and resilience for posttraumatic stress disorder among ground combat Marines: methods of the Marine Resiliency Study.

The Marine Resiliency Study (MRS) is a prospective study of factors predictive of posttraumatic stress disorder (PTSD) among approximately 2,600 Marines in 4 battalions deployed to Iraq or Afghanistan. We describe the MRS design and predeployment participant characteristics. Starting in 2008, our research team conducted structured clinical interviews on Marine bases and collected data 4 times: at predeployment and at 1 week, 3 months, and 6 months postdeployment. Integrated with these data are medical and career histories from the Career History Archival Medical and Personnel System (CHAMPS) database. The CHAMPS database showed that 7.4% of the Marines enrolled in MRS had at least 1 mental health diagnosis. Of enrolled Marines, approximately half (51.3%) had prior deployments. We found a moderate positive relationship between deployment history and PTSD prevalence in these baseline data.

Theater Mental Health Encounter Data (TMHED): overview of study design and methods.

Research has documented higher risks for mental health problems among service members deployed to war zones, yet a research limitation has been that assessment has generally occurred often years after combat exposure. The Operational Stress Control and Readiness program integrated mental health practitioners with 1st Marine Division units serving in Iraq. This team documented mental health visits between January 2006 and January 2007 and developed the Theater Mental Health Encounter Database (TMHED). This report describes the TMHED study design, measures, and cases. Of 1336 patients (3180 patient visits), 10% were women, 75% were high school educated, 55% were mid-paygrade enlisted, and 63% were on their first combat deployment. Compared with the overall deployed population, patient percentages included higher percentages of Marines and Navy personnel but lower percentages of Army and Air Force personnel, more junior enlisted but fewer officers, and fewer college graduates. TMHED provides an unprecedented opportunity to study early psychiatric intervention in a combat zone and prospectively examines postdeployment health and career outcomes.

Predictors of burnout among military mental health providers.

Mental health treatment of military service members places unique demands on providers as their patients experience combat stress. This study assessed levels and predictors of burnout among mental health providers (N = 97) at military facilities, using a self-administered survey of demographic and work-related measures and the Maslach Burnout Inventory. Burnout levels were comparable to studies of civilian mental health providers but were less severe than those of the Maslach Burnout Inventory normative sample. Working more hours, having more patients with personality disorders, increased patient caseloads, female gender, and being a psychiatrist were predictive of higher burnout scores. Having more confidants at work, a greater percentage of patients with traumatic brain injury, more clinical experience, and being a psychologist predicted lower burnout scores. These findings suggest that burnout levels among military providers are similar to those among civilian providers and may be alleviated by interventions targeting general institutional risk factors.

A randomized, controlled trial of virtual reality-graded exposure therapy for post-traumatic stress disorder in active duty service members with combat-related post-traumatic stress disorder.

Abstract Virtual reality (VR)-based therapy has emerged as a potentially useful means to treat post-traumatic stress disorder (PTSD), but randomized studies have been lacking for Service Members from Iraq or Afghanistan. This study documents a small, randomized, controlled trial of VR-graded exposure therapy (VR-GET) versus treatment as usual (TAU) for PTSD in Active Duty military personnel with combat-related PTSD. Success was gauged according to whether treatment resulted in a 30 percent or greater improvement in the PTSD symptom severity as assessed by the Clinician Administered PTSD Scale (CAPS) after 10 weeks of treatment. Seven of 10 participants improved by 30 percent or greater while in VR-GET, whereas only 1 of the 9 returning participants in TAU showed similar improvement. This is a clinically and statistically significant result (χ(2) = 6.74, p < 0.01, relative risk 3.2). Participants in VR-GET improved an average of 35 points on the CAPS, whereas those in TAU averaged a 9-point improvement (p < 0.05). The results are limited by small size, lack of blinding, a single therapist, and comparison to a relatively uncontrolled usual care condition, but did show VR-GET to be a safe and effective treatment for combat-related PTSD.