A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration.

Since 2006, the Veterans Health Administration (VHA) has instituted policy changes and training programs to support system-wide implementation of two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). To assess lessons learned from this unprecedented effort, we used PubMed and the PILOTS databases and networking with researchers to identify 32 reports on contextual influences on implementation or sustainment of EBPs for PTSD in VHA settings. Findings were initially organized using the exploration, planning, implementation, and sustainment framework (EPIS; Aarons et al. in Adm Policy Ment Health Health Serv Res 38:4-23, 2011). Results that could not be adequately captured within the EPIS framework, such as implementation outcomes and adopter beliefs about the innovation, were coded using constructs from the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (Glasgow et al. in Am J Public Health 89:1322-1327, 1999) and Consolidated Framework for Implementation Research (CFIR; Damschroder et al. in Implement Sci 4(1):50, 2009). We highlight key areas of progress in implementation, identify continuing challenges and research questions, and discuss implications for future efforts to promote EBPs in large health care systems.

Sexual abuse characteristics associated with survivor psychopathology.

OBJECTIVE: This study was designed to examine predictors of psychopathology in non-clinically referred, sexually abused (SA) children, ages 6-16 years, 30-60 days following abuse disclosure and termination. METHOD: Eighty SA children were administered a structured diagnostic interview and a variety of rating-scale instruments. Several forms of psychopathology were assessed, including posttraumatic stress, global functioning, anxiety, depression, and externalizing behavior. Abuse interviews also were used to guide the collection of demographic (victim age, gender) and abuse-related information (e.g., frequency of abuse). RESULTS: Abuse-related factors and demographic variables accounted for greater than half of the variance predicting global functioning, and accurately predicted posttraumatic stress disorder (PTSD) status for 86% of the participants. Also, analyses yielded significant predictors of parent-reported attention problems and sexual behavior. Of additional importance, none of the abuse-related and demographic variables predicted scores on measures of general anxiety, depression, and externalizing behavior. CONCLUSIONS: Specific demographic and sexual abuse information may, to some extent, be used to identify children who are at increased risk for short-term post-abuse psychopathology. Although the present findings suggest that such information may not be useful in the prediction of general anxiety, depression, and externalizing behavior, demographic and abuse-related variables importantly appear to account for significant variance in the prediction of global functioning, posttraumatic stress, attentiveness, and sexual behavior. Additional research is needed to improve mental health professionals' ability to identify SA children who are at high risk for psychopathology.

PTSD scale of the Child Behavior Checklist: concurrent and discriminant validity with non-clinic-referred sexually abused children.

Several assessment instruments include measures that are purported to assess characteristics of posttraumatic stress disorder (PTSD). Although these measures are used often by researchers and clinicians, few are supported by extensive validity data. The PTSD scale of the Child Behavior Checklist (CBCL) is one that has not yet encountered significant challenges to its validity. We examine the concurrent and discriminant validity of the CBCL-PTSD scale. Participants included 63 non-clinic-referred sexually abused (SA) children, 60 non-SA psychiatric outpatient children, and 61 non-SA, non-clinic-referred schoolchildren. Results revealed questionable concurrent validity for this scale, and suggest poor discriminant validity between SA children and non-SA psychiatric outpatients.

Discriminant validity of self-reported anxiety and depression in children: generalizability to clinic-referred and ethnically diverse populations.

In the present study, we investigated the relation of childhood anxiety and depression with 240 children (56% clinical referrals, 44% nonclinical referrals) ages 8 to 14 years. Participants were administered the State-Trait Anxiety Inventory for Children (STAIC) and the Children s Depression Inventory (CDI), two commonly used self-report measures of childhood anxiety and depression. The principal focus of this study was to examine the discriminant validity of these measures at the level of individual items through factor analysis. Although high correlations were found between overall scores on the CDI and STAIC, factor analysis yielded distinct factors of anxiety and depression. Thus, with the inclusion of clinic-referred and ethnically diverse groups, the present study provided support for the generalizability of findings of similar research with non-clinic-referred, primarily-Caucasian samples.

Using item analysis to facilitate interpretation of empirical findings.

Researchers often present and interpret empirical findings with reference to hypothetical constructs and diagnostic labels. Such interpretations commonly are based upon "summary" scores obtained through interview, self-report, or rating-scale assessment instruments. Although there are advantages associated with communicating empirical findings through analysis with summary scores, there also are weaknesses that may limit the interpretability of empirical findings and impede theory development. We discuss the importance of item analysis as a tool that may guide presentation of empirical findings, and we describe how it may be used to minimize these limitations of assessment, facilitate data interpretation, and increase the opportunity for theoretical advances.

Mathematics anxiety and working memory: support for the existence of a deficient inhibition mechanism.

A current theory of anxiety effects in cognition claims that anxiety disrupts normal processing within the working memory system. We examined this theory in the context of a reading task, for participants who were high or low in assessed mathematics anxiety. The task was designed to measure the ability to inhibit attention to distracting information and the effects of this ability on explicit memory performance. The results suggested that math-anxious individuals have a deficient inhibition mechanism whereby working memory resources are consumed by task-irrelevant distracters. A consequence of this deficiency was that explicit memory performance was poorer for high-anxious individuals. Based on these results, the recommendation is made that Eysenck and Calvo's (1992) processing efficiency theory be integrated with Connelly, Hasher, and Zack's (1991) inhibition theory to portray more comprehensively the relation between anxiety and performance.

Experimental cytoxan cystitis and prevention by acetylcysteine.

Cytoxan (cyclophosphamide) given to rats intraperitoneally produced a severe cystitis within four hours with marked inflammatory edema and hemorrhagic ulcerations of the mucosa. An in vivo staining test with methylene blue showed deep staining of the urothelium as has been demonstrated with other types of urothelial injuries; uninjured urothelium does not stain. The cytoxan cystitis is probably not due to cytoxan itself, but to a breakdown product acrolein, an aldehyde appearing in the urine. Rat experiments demonstrated that acrolein instilled intravesically produced a cystitis similar to that found with cytoxan injected intraperitoneally. The cystitis due either to cytoxan or acrolein was prevented by simultaneous intravesical administration of an aldehyde inactivating agent, acetylcysteine (mucomyst).

Protective effects of heparin and other sulfated glycosaminoglycans on crystal adhesion to injured urothelium.

Heparin was found to prevent calcium oxalate crystal adhesion to chemically injured rat bladder urothelium. Heparin was the only polysaccharide tested which restored injured urothelium to the functional status of normal, uninjured urothelium with respect to anticrystal adhesion properties. Other sulfated glycosaminoglycans, sulfated polysaccharides and monosaccharides were without restorative or protective effects. 3H-heparin was found to bind to injured urothelium but not to normal urothelium.

Elevation of the metastable limits and absence of container surface nucleation for calcium oxalate crystallization in a urothelial-lined system as compared to glass containers.

We studied the metastable limits of calcium oxalate supersaturation in glass tubes and in urothelial-lined rat bladders from a solvent system consisting of 0.9 per cent saline. The metastable limit was significantly elevated at 30 min in the urothelial-lined system as compared to the glass-surfaced containers. Heterogeneous nucleation on the container surfaces consistently occurred with the saline solvent in glass tubes as the metastable limit was exceeded. Intraluminal or free-floating crystals (? homogenous nucleation) without container-adherent crystals occurred with the saline solvent in urothelial-lined containers. This study reveals important properties of crystallization in urothelium and emphasizes the potential errors in extrapolating from crystallization studies in vitro in glass containers to crystallization phenomena in biological systems.