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1.
JMIR Mhealth Uhealth ; 12: e49393, 2024 Jul 18.
Artigo em Inglês | MEDLINE | ID: mdl-39036876

RESUMO

Background: Mobile mental health apps are a cost-effective option for managing mental health problems, such as posttraumatic stress disorder (PTSD). The efficacy of mobile health (mHealth) apps depends on engagement with the app, but few studies have examined how users engage with different features of mHealth apps for PTSD. Objective: This study aims to examine the relationship between app engagement indices and PTSD symptom reduction using data from an unblinded pilot randomized controlled trial of "Renew" (Vertical Design), an exposure-based app for PTSD with and without coaching support. Because exposure is an effective approach for treating PTSD, we expected that engagement with exposure activities would be positively related to symptom reduction, over and above overall app usage. Methods: Participants were veterans (N=69) with clinically significant PTSD symptoms who were recruited online using Facebook advertisements and invited to use the Renew app as often as they wanted over a 6-week period. Participants completed screening and assessments online but provided informed consent, toured the app, and completed feedback interviews via telephone. We assessed users' self-reported PTSD symptoms before and after a 6-week intervention period and collected app usage data using a research-instrumented dashboard. To examine overall app engagement, we used data on the total time spent in the app, the number of log-in days, and the number of points that the user gained in the app. To examine engagement with exposure components, we used data on total time spent completing exposure activities (both in vivo and imaginal), the number of in vivo exposure activities completed, and the number of characters written in response to imaginal exposure prompts. We used hierarchical regression analyses to test the effect of engagement indices on change in PTSD symptoms. Results: Usage varied widely. Participants spent an average of 166.09 (SD 156.52) minutes using Renew, over an average of 14.7 (SD 10.71) mean log-in days. Engagement with the exposure components of the app was positively associated with PTSD symptom reduction (F6,62=2.31; P=.04). Moreover, this relationship remained significant when controlling for overall engagement with the app (ΔF3,62=4.42; P=.007). The number of characters written during imaginal exposure (ß=.37; P=.009) and the amount of time spent completing exposure activities (ß=.36; P=.03) were significant contributors to the model. Conclusions: To our knowledge, this is the first study to show a relationship between symptom improvement and engagement with the active therapeutic components of an mHealth app (ie, exposure) for PTSD. This relationship held when controlling for overall app use, which suggests that it was engagement with exposure, specifically, that was associated with symptom change. Future work to identify ways of promoting greater engagement with self-guided exposure may help improve the effectiveness of mHealth apps for PTSD.


Assuntos
Aplicativos Móveis , Transtornos de Estresse Pós-Traumáticos , Humanos , Transtornos de Estresse Pós-Traumáticos/terapia , Transtornos de Estresse Pós-Traumáticos/psicologia , Aplicativos Móveis/estatística & dados numéricos , Aplicativos Móveis/normas , Masculino , Feminino , Pessoa de Meia-Idade , Adulto , Telemedicina/instrumentação , Telemedicina/estatística & dados numéricos , Veteranos/psicologia , Veteranos/estatística & dados numéricos , Terapia Implosiva/métodos , Terapia Implosiva/instrumentação , Terapia Implosiva/estatística & dados numéricos , Projetos Piloto , Idoso
2.
J Clin Psychiatry ; 82(3)2021 05 25.
Artigo em Inglês | MEDLINE | ID: mdl-34033709

RESUMO

Objective: To evaluate the efficacy of psychosocial treatments for posttraumatic stress disorder (PTSD) among individuals with a comorbid severe mental illness (SMI; ie, schizophrenia, bipolar disorder, major depressive disorder).Data Sources: PubMed, PsycINFO, CINAHL, and Cochrane Library were searched from January 1998 to March 2020 using keywords related to PTSD, treatment, and severe mental illness.Study Selection: All clinical trials for PTSD psychotherapy among individuals with SMI were included. From 38 potentially eligible studies, a total of 14 clinical trials across 684 individuals with comorbid SMI and PTSD were identified and included in the analysis.Data Extraction: Data on demographic, SMI diagnosis, symptom severity, sample attrition, and treatment protocol received were extracted. Effect size calculations and subsequent meta-analyses were conducted using the Meta-Analysis Package for R (metafor) version 2.1-0 in R (3.6.0).Results: PTSD treatments had a large effect on PTSD outcomes among individuals with SMI, with patients experiencing a standard deviation reduction in PTSD symptomatology pre- to post-treatment (g = -1.009, P < .001, k = 34). Prolonged exposure (g = -1.464; P < .001; SE = 0.276; k = 5), eye movement desensitization and reprocessing (g = -1.351; P < .001; SE = 0.276; k = 5), and brief treatment program (g = -1.009; P < .001; SE = 0.284; k = 5) had the largest effects on PTSD symptoms.Conclusions: Although underrepresented in the PTSD literature, PTSD psychotherapies are effective for individuals with SMI. Treatments with an exposure-based component may have greater efficacy in this clinical population.


Assuntos
Transtorno Bipolar/terapia , Transtorno Depressivo Maior/terapia , Avaliação de Resultados em Cuidados de Saúde , Psicoterapia/estatística & dados numéricos , Esquizofrenia/terapia , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Transtornos de Estresse Pós-Traumáticos/terapia , Transtorno Bipolar/epidemiologia , Comorbidade , Transtorno Depressivo Maior/epidemiologia , Dessensibilização e Reprocessamento através dos Movimentos Oculares/estatística & dados numéricos , Humanos , Terapia Implosiva/estatística & dados numéricos , Psicoterapia Breve/estatística & dados numéricos , Esquizofrenia/epidemiologia
3.
J Dev Orig Health Dis ; 12(5): 811-818, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33292902

RESUMO

New guidelines for peanut allergy prevention in high-risk infants recommend introducing peanut during infancy but do not address breastfeeding or maternal peanut consumption. We assessed the independent and combined association of these factors with peanut sensitization in the general population CHILD birth cohort (N = 2759 mother-child dyads). Mothers reported peanut consumption during pregnancy, timing of first infant peanut consumption, and length of breastfeeding duration. Child peanut sensitization was determined by skin prick testing at 1, 3, and 5 years. Overall, 69% of mothers regularly consumed peanuts and 36% of infants were fed peanut in the first year (20% while breastfeeding and 16% after breastfeeding cessation). Infants who were introduced to peanut early (before 1 year) after breastfeeding cessation had a 66% reduced risk of sensitization at 5 years compared to those who were not (1.9% vs. 5.8% sensitization; aOR 0.34, 95% CI 0.14-0.68). This risk was further reduced if mothers introduced peanut early while breastfeeding and regularly consumed peanut themselves (0.3% sensitization; aOR 0.07, 0.01-0.25). In longitudinal analyses, these associations were driven by a higher odds of outgrowing early sensitization and a lower odds of late-onset sensitization. There was no apparent benefit (or harm) from maternal peanut consumption without breastfeeding. Taken together, these results suggest the combination of maternal peanut consumption and breastfeeding at the time of peanut introduction during infancy may help to decrease the risk of peanut sensitization. Mechanistic and clinical intervention studies are needed to confirm and understand this "triple exposure" hypothesis.


Assuntos
Aleitamento Materno/métodos , Terapia Implosiva/normas , Exposição Materna , Hipersensibilidade a Amendoim/prevenção & controle , Adulto , Aleitamento Materno/estatística & dados numéricos , Feminino , Humanos , Terapia Implosiva/métodos , Terapia Implosiva/estatística & dados numéricos , Hipersensibilidade a Amendoim/epidemiologia , Gravidez , Fatores de Risco
4.
Australas Psychiatry ; 28(3): 257-263, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31637929

RESUMO

OBJECTIVE: Prolonged exposure (PE) therapy is an evidence-based psychological treatment of post-traumatic stress disorder (PTSD), yet uptake amongst practitioners is less than desirable. The aim of this study was to evaluate the efficacy of a PE training workshop plus intensive consultation programme to improve practitioners' self-efficacy and outcome expectations as well as uptake of PE for emergency service patients with PTSD. METHOD: Forty-five psychologists attended a PE training workshop in Sydney. Participants completed questionnaires at pre- and post-workshop and six-month follow-up. RESULTS: The findings suggest that participation in the programme was associated with improvements in practitioners' beliefs in their ability to deliver PE to patients, an increase in their use of a range of PE components and an increase in their use of in vivo exposure with a greater proportion of patients. CONCLUSION: Effective training approaches for evidence-based treatments of PTSD should incorporate intensive consultation following training. Future studies should consider additional strategies to encourage practitioners to deliver PE to more patients with PTSD.


Assuntos
Terapia Implosiva/estatística & dados numéricos , Psicologia/educação , Transtornos de Estresse Pós-Traumáticos/terapia , Educação/métodos , Feminino , Humanos , Masculino , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Encaminhamento e Consulta , Autoeficácia , Resultado do Tratamento
5.
Psychiatr Serv ; 70(7): 553-560, 2019 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-30966944

RESUMO

OBJECTIVE: This observational study examined the association between patient outcomes at 39 U.S. Department of Veterans Affairs residential treatment programs for veterans with posttraumatic stress disorder (PTSD) and the degree of adoption of two evidence-based psychotherapies, prolonged exposure and cognitive processing therapy. The hypothesis was that a higher degree of adoption would be associated with better outcomes. METHODS: Providers (N=171) completed a qualitative interview and quantitative survey about their level of adoption of prolonged exposure delivered individually and cognitive processing therapy delivered in individual or group formats. On the basis of responses, programs were assigned to one of three adoption categories: little or no adoption of either therapy (N=8), some adoption, (N=9), and high adoption (N=22). A linear mixed model compared patient outcomes (e.g., PTSD and depression symptom severity, substance use, and distress) between adoption groups. RESULTS: The sample of veterans consisted of 2,834 who completed an assessment of PTSD symptoms and functioning at program intake and again at either program discharge or at 4 months postdischarge. Improvements in PTSD, distress, and alcohol use were noted over time for all programs, with decreases at follow-up. No effects of adoption group or a group × time interaction were noted for any outcome. CONCLUSIONS: Moderate to large effects were noted across all programs. However, programs that used prolonged exposure and cognitive processing therapy with most or all patients did not see greater reductions in PTSD or depression symptoms or alcohol use, compared with programs that did not use these evidence-based psychotherapies.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Depressão/terapia , Terapia Implosiva/métodos , Avaliação de Processos e Resultados em Cuidados de Saúde , Tratamento Domiciliar/métodos , Transtornos de Estresse Pós-Traumáticos/terapia , Veteranos , Adulto , Terapia Cognitivo-Comportamental/estatística & dados numéricos , Comorbidade , Depressão/epidemiologia , Feminino , Humanos , Terapia Implosiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Angústia Psicológica , Tratamento Domiciliar/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Estados Unidos/epidemiologia , United States Department of Veterans Affairs , Veteranos/estatística & dados numéricos
6.
Psychiatr Serv ; 70(8): 703-713, 2019 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-31010409

RESUMO

OBJECTIVE: The aim of this study was to systematically review variables associated with initiation of trauma-centered cognitive-behavioral therapy (TC-CBT) among individuals with posttraumatic stress disorder (PTSD). METHODS: PubMed, PsycINFO, Web of Science, Published International Literature on Traumatic Stress (PILOTS), and Scopus were searched in a systematic manner up to 2018, and 26 relevant studies were recovered and analyzed. RESULTS: The average weighted initiation rate was 6% in larger hospital systems with a high rate of trauma and 28% in outpatient mental health settings (range 4%-83%). Older age (odds ratio [OR]=1.56, 95% confidence interval [CI]=0.51-1.61), female gender (OR=1.18, 95% CI=1.08-1.27), black or other racial-ethnic minority group (OR=1.16, 95% CI=1.03-1.28), Veterans Affairs PTSD service connection status (OR=2.30, 95% CI=2.18-2.42), mental health referral (OR=2.28, 95% CI=1.05-3.50), greater staff exposure to TC-CBT (OR=2.30, 95% CI=2.09-2.52), adaptability of TC-CBT to staff workflow (OR=4.66, 95% CI=1.60-7.72), greater PTSD severity (OR=1.46, 95% CI=1.13-1.78), and comorbid depression (OR=1.21, 95% CI=1.14-1.29) increased the likelihood of TC-CBT initiation, whereas delayed treatment reduced the likelihood of TC-CBT initiation (OR=0.93, 95% CI=0.92-0.95). Qualitative studies showed that mental health beliefs (stigma and lack of readiness), provider organizational factors (low availability, privacy issues), and patient lack of time (logistics) were perceived as barriers to initiation by patients and providers. CONCLUSIONS: TC-CBT initiation increased among patients who were older and female. Initiation was also higher among providers who had more exposure to TC-CBT in their work environment and when TC-CBT fit into their existing workflow.


Assuntos
Terapia Cognitivo-Comportamental/estatística & dados numéricos , Terapia Implosiva/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/terapia , Humanos
7.
Psychol Med ; 49(11): 1761-1775, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30857567

RESUMO

BACKGROUND: The 11th revision to the WHO International Classification of Diseases (ICD-11) identified complex post-traumatic stress disorder (CPTSD) as a new condition. There is a pressing need to identify effective CPTSD interventions. METHODS: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of psychological interventions for post-traumatic stress disorder (PTSD), where participants were likely to have clinically significant baseline levels of one or more CPTSD symptom clusters (affect dysregulation, negative self-concept and/or disturbed relationships). We searched MEDLINE, PsycINFO, EMBASE and PILOTS databases (January 2018), and examined study and outcome quality. RESULTS: Fifty-one RCTs met inclusion criteria. Cognitive behavioural therapy (CBT), exposure alone (EA) and eye movement desensitisation and reprocessing (EMDR) were superior to usual care for PTSD symptoms, with effects ranging from g = -0.90 (CBT; k = 27, 95% CI -1.11 to -0.68; moderate quality) to g = -1.26 (EMDR; k = 4, 95% CI -2.01 to -0.51; low quality). CBT and EA each had moderate-large or large effects on negative self-concept, but only one trial of EMDR provided useable data. CBT, EA and EMDR each had moderate or moderate-large effects on disturbed relationships. Few RCTs reported affect dysregulation data. The benefits of all interventions were smaller when compared with non-specific interventions (e.g. befriending). Multivariate meta-regression suggested childhood-onset trauma was associated with a poorer outcome. CONCLUSIONS: The development of effective interventions for CPTSD can build upon the success of PTSD interventions. Further research should assess the benefits of flexibility in intervention selection, sequencing and delivery, based on clinical need and patient preferences.


Assuntos
Terapia Cognitivo-Comportamental/estatística & dados numéricos , Dessensibilização e Reprocessamento através dos Movimentos Oculares/estatística & dados numéricos , Terapia Implosiva/estatística & dados numéricos , Classificação Internacional de Doenças , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/terapia , Humanos
8.
Psychiatry Res ; 277: 52-57, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30755338

RESUMO

The earliest neuroimaging studies in post-traumatic stress disorder (PTSD) utilized positron emission tomography (PET) to examine the brain's response to glucocorticoid administration given predominant neurobiological models of the stress response focusing on that neuroendocrine system. This work revealed that the anterior cingulate cortex and amygdala, which is now considered part of the salience network, play a role in treatment response, and set the stage for subsequent magnetic resonance (MR) imaging studies focused on understanding the role of the salience network in the neurobiology of treatment response in PTSD. This selective review discusses magnetic resonance (MR) imaging studies that have been used to predict treatment response to cognitive-behavioral therapy (CBT) or prolonged exposure (PE) in PTSD, which have demonstrated abnormalities in processing involving the salience network, including the amygdala, anterior cingulate cortex and insula. Increased attention to environmental cues may signal alarm resulting in hypervigilance and overactive action-monitoring for the detection of threatening stimuli and an inability to integrate concomitant emotional and sensory functions in PTSD. Successful psychotherapy treatment response in PTSD appears to involve the ability to downregulate amygdala activity to trauma-related stimuli through improved regulation of attention by the anterior cingulate cortex and concomitant internal emotional states mediated by the insula. In addition, the ability to better modulate (normalize) the salience network following psychotherapy in PTSD may be associated with better crosstalk between untargeted inner thought (i.e., task-negative network) and the ability to focus attention on stimulus-dependent demands (i.e., task positive network).


Assuntos
Terapia Cognitivo-Comportamental/estatística & dados numéricos , Terapia Implosiva/estatística & dados numéricos , Imageamento por Ressonância Magnética/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/diagnóstico por imagem , Transtornos de Estresse Pós-Traumáticos/terapia , Adulto , Tonsila do Cerebelo/diagnóstico por imagem , Atenção/fisiologia , Encéfalo/diagnóstico por imagem , Córtex Cerebral/diagnóstico por imagem , Emoções/fisiologia , Feminino , Giro do Cíngulo/diagnóstico por imagem , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Valor Preditivo dos Testes , Transtornos de Estresse Pós-Traumáticos/psicologia , Resultado do Tratamento , Adulto Jovem
9.
J Anxiety Disord ; 61: 18-26, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30646997

RESUMO

A proposed advantage of virtual reality exposure therapy for anxiety disorders is that people will be less likely to drop out of treatment prematurely if the treatment involves facing one's fear in a virtual world rather than the real world, but this has yet to be empirically tested. The present meta-analyses assess the odds of dropout from virtual reality exposure therapy compared to in vivo exposure therapy, estimate the overall rate of dropout from virtual reality exposure treatment, and test potential moderating variables. The odds ratio meta-analysis indicated that there was no significant difference in the likelihood of attrition from virtual reality exposure therapy relative to in vivo exposure therapy. The overall attrition rate for virtual reality exposure therapy across 46 studies with a combined sample size of 1057 participants was 16%. This rate is slightly lower than other estimates of dropout from in vivo therapy and from cognitive-behavioral therapy for anxiety disorders. Incorporation of between-session intervention (i.e., homework) was identified as a moderator; specifically, inclusion of between-session interventions in the treatment was associated with better retention. Overall, the findings of the present study indicate that virtual reality exposure and in vivo exposure therapy show similar rates of attrition.


Assuntos
Transtornos de Ansiedade/terapia , Terapia de Exposição à Realidade Virtual/estatística & dados numéricos , Transtornos de Ansiedade/psicologia , Terapia Cognitivo-Comportamental/estatística & dados numéricos , Medo , Humanos , Terapia Implosiva/estatística & dados numéricos , Razão de Chances , Pacientes Desistentes do Tratamento/estatística & dados numéricos , Probabilidade
10.
Psychother Res ; 29(4): 415-431, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-29179647

RESUMO

OBJECTIVE: The present meta-analysis evaluates the efficacy of group psychotherapy for post-traumatic stress disorder (PTSD) in adults directly compared to no treatment or active treatments examined in randomized controlled trials (RCTs). METHOD: Electronic databases were searched for eligible studies. Effects on PTSD symptoms, depression, and anxiety were extracted. Between- and within-group effect sizes (Hedges' g) were calculated using a random-effects model. Data were adjusted to account for dependencies among observations in groups. RESULTS: Twenty RCTs were included comprising 2244 individuals. Results showed significant effects of group psychotherapy in reducing symptoms of PTSD compared to no-treatment control groups (k = 13; g = 0.70; 95% CI: 0.41; 0.99). No significant differences in efficacy were found between group psychotherapy and other active treatments (k = 8; g = 0.13; 95% CI: -0.16; 0.42). Moderator analyses confirmed gender and trauma type as important moderators of within-treatment effects for PTSD. CONCLUSIONS: Group treatments are associated with improvements in symptoms of PTSD. Particularly, the efficacy of exposure-based cognitive-behavioral group therapy (group CBT) is empirically well demonstrated. Still little is known about the effects of group treatment approaches other than CBT and the comparative efficacy to alternative treatments such as individual therapy or pharmacotherapy. Clinical or Methodological Significance of this Article: This review provides an empirical base for group therapy as a viable treatment alternative for future PTSD practice guidelines. Although less is known about its comparative efficacy to alternative PTSD treatments such as individual therapy or pharmacotherapy, sufficient evidence exists to recommend group therapy (particularly exposure-based group CBT) for those who might not be able to access alternative treatments. Trauma type and gender proved to be important moderators of group treatment outcome. The results further indicate that the evidence base of recommendations for group therapy in current international treatment guidelines needs to be updated.


Assuntos
Terapia Cognitivo-Comportamental/estatística & dados numéricos , Terapia Implosiva/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Psicoterapia de Grupo/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/terapia , Humanos
11.
J Anxiety Disord ; 62: 53-60, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30550959

RESUMO

The United States Department of Veterans Affairs (VA) provides Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) for PTSD at all of its facilities, but little is known about systematic differences between patients who do and do not initiate these treatments. VA administrative data were analyzed for 6,251 veterans receiving psychotherapy over one year in posttraumatic stress disorder (PTSD) specialty clinics at nine VA medical centers. CPT and PE were initiated by 2,173 (35%) patients. Veterans' probability of initiating either CPT or PE (considered together) was 29% lower (adjusted odds ratio = .61) if they had a psychiatric hospitalization within the same year, and 15% lower (AOR = .78) if they had service-connected disability for PTSD. Veterans' probability of starting CPT or PE was 19% lower (AOR = .74) if they were Hispanic or Latino, 10% lower (AOR = .84), if they were male rather than female, and 9% lower (AOR = .87) if they were divorced, separated or widowed rather than currently married. Probability of receiving CPT or PE was also lower if verans had more co-occurring psychiatric diagnoses (AOR per diagnosis = .88), were older (AOR per every five years = .95), or lived further away from the VA clinic (AOR per every ten miles = .98). Nonetheless, most patients initiating CPT or PE had two or more comorbidities and were service-connected for PTSD. Observed gender, age and ethnic differences in initiation of CPT and PE appear unrelated to clinical suitability and warrant further study.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Terapia Cognitivo-Comportamental/estatística & dados numéricos , Terapia Implosiva/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/terapia , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Cognição/fisiologia , Comorbidade , Utilização de Instalações e Serviços , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos de Estresse Pós-Traumáticos/psicologia , Estados Unidos , United States Department of Veterans Affairs , Veteranos/psicologia
12.
J Anxiety Disord ; 58: 8-17, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29929139

RESUMO

Exposure therapy is a highly effective, evidence-based treatment technique for children and adolescents with anxiety disorders. Regardless, therapists in the community are reported to use exposure relatively rarely compared with other approaches. The goal of the present study was to identify how practicing clinicians treat youth with anxiety disorders across the United States and what factors contribute to their use of exposure therapy. Recruited from public directories, 257 private practice therapists who treat anxious youth were surveyed. Non-exposure cognitive-behavioral techniques like cognitive restructuring and relaxation techniques were used significantly more frequently than exposure. Providers with more training in exposure therapy and fewer negative beliefs about this approach reported using exposure significantly more in the treatment of youth with social anxiety, obsessive-compulsive, and panic disorders. Self-identification as an anxiety disorder specialist significantly predicted exposure use for youth with posttraumatic stress disorder. Most therapists in private practice have minimal training in exposure therapy, perceive a lack of training options, and believe there would be a benefit to acquiring more training. The implications of these findings are discussed, including how to optimally design training opportunities in exposure therapy.


Assuntos
Transtornos de Ansiedade/psicologia , Transtornos de Ansiedade/terapia , Terapia Implosiva/métodos , Terapia Implosiva/estatística & dados numéricos , Inquéritos e Questionários , Adolescente , Ansiedade/psicologia , Ansiedade/terapia , Criança , Feminino , Humanos , Masculino , Transtorno de Pânico/psicologia , Transtorno de Pânico/terapia , Fobia Social/psicologia , Fobia Social/terapia , Terapia de Relaxamento , Transtornos de Estresse Pós-Traumáticos/psicologia , Transtornos de Estresse Pós-Traumáticos/terapia , Estados Unidos/epidemiologia
13.
Adm Policy Ment Health ; 45(4): 519-529, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29450781

RESUMO

To derive a method of identifying use of evidence-based psychotherapy (EBP) for post-traumatic stress disorder (PTSD), we used clinical note text from national Veterans Health Administration (VHA) medical records. Using natural language processing, we developed machine-learning algorithms to classify note text on a large scale in an observational study of Iraq and Afghanistan veterans with PTSD and one post-deployment psychotherapy visit by 8/5/15 (N = 255,968). PTSD visits were linked to 8.1 million psychotherapy notes. Annotators labeled 3467 randomly-selected psychotherapy notes (kappa = 0.88) to indicate receipt of EBP. We met our performance targets of overall classification accuracy (0.92); 20.2% of veterans received ≥ one session of EBP over the study period. Our method can assist with identifying EBP use and studying EBP-associated outcomes in routine clinical practice.


Assuntos
Algoritmos , Terapia Cognitivo-Comportamental/estatística & dados numéricos , Medicina Baseada em Evidências/estatística & dados numéricos , Terapia Implosiva/estatística & dados numéricos , Aprendizado de Máquina , Processamento de Linguagem Natural , Transtornos de Estresse Pós-Traumáticos/terapia , Terapia Familiar/estatística & dados numéricos , Humanos , Psicoterapia/estatística & dados numéricos , Psicoterapia de Grupo/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos , United States Department of Veterans Affairs , Veteranos/psicologia
14.
Psychol Serv ; 15(4): 429-436, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28287769

RESUMO

Prior single-site and regional studies have documented difficulties in implementing prolonged exposure (PE) and cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) into practice in Veterans Affairs (VA) Medical Centers, estimating that between 6% and 13% of VA patients with PTSD receive PE or CPT (Lu, Plagge, Marsiglio, & Dobscha, 2016; Mott et al., 2014; Shiner et al., 2013). However, these studies examined data from fiscal years 2008-2012, and therefore may not reflect more recent utilization patterns. Beginning in 2007, the VA invested heavily in increasing implementation of PE and CPT, including nationwide training rollouts and consultation. Given the length of time required for successful implementation of new practices, it is important to evaluate use of PE and CPT over time. We examined current use of PE and CPT at 1 VA medical center PTSD specialty clinic and compared this to prior rates for the same clinic. Chart reviews for all patients receiving a PTSD clinic initial evaluation between January 1, 2015, and May 31, 2015, indicated that 52% of patients began a course of PE or CPT within the 1-year follow-up period, representing a 5-fold increase from 2008 to 2012. We discuss changes in clinic structure, processes, training, and clinician support that might account for the successful implementation of PE and CPT in this clinic. We also present data on alternative referrals provided to patients not engaging in PE and CPT, and predictors of engagement in PE and CPT. (PsycINFO Database Record (c) 2018 APA, all rights reserved).


Assuntos
Terapia Cognitivo-Comportamental/estatística & dados numéricos , Terapia Implosiva/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/terapia , United States Department of Veterans Affairs/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Adulto , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Feminino , Humanos , Masculino , Serviços de Saúde Mental/estatística & dados numéricos , Pessoa de Meia-Idade , Estados Unidos
15.
Behav Res Ther ; 91: 43-50, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28147254

RESUMO

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) are commonly co-occurring disorders associated with more adverse consequences than PTSD alone. Prolonged exposure therapy (PE) is one of the most efficacious treatments for PTSD. However, among individuals with PTSD-SUD, 35-62% of individuals drop out of trauma-focused exposure treatments. Thus, it is important to identify predictors of PTSD treatment dropout among substance abusers with PTSD in order to gain information about adapting treatment strategies to enhance retention and outcomes. The current study explored pre-treatment predictors of early termination from PE treatment in a sample of 85 individuals receiving concurrent treatment for PTSD and a SUD in a residential treatment facility as part of a randomized controlled trial. The results indicated that less education and more anxiety sensitivity uniquely predicted PE treatment dropout. Demographic variables, PTSD severity, SUD severity, mental health comorbidities, and emotion regulation difficulties did not predict treatment dropout. These results suggest that adding pre-treatment interventions that address anxiety sensitivity, and promote social adjustment and cognitive flexibility, could possibly improve PE retention rates in clients with high anxiety or low education.


Assuntos
Alcoolismo/epidemiologia , Alcoolismo/psicologia , Terapia Implosiva/estatística & dados numéricos , Pacientes Desistentes do Tratamento/psicologia , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Transtornos de Estresse Pós-Traumáticos/psicologia , Adulto , Alcoolismo/terapia , Feminino , Humanos , Masculino , Fatores de Risco , Transtornos de Estresse Pós-Traumáticos/terapia , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
16.
J Trauma Stress ; 30(1): 63-70, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-28103401

RESUMO

This study examined aspects of clinicians' work environment that facilitated sustained use of prolonged exposure (PE) therapy. Surveys were completed by 566 U.S. Department of Veterans Affairs clinicians 6 and 18 months after intensive training in PE. The number of patients treated with PE at 18 months (reach) was modeled as a function of clinician demographics, clinician beliefs about PE, and work context factors. There were 342 clinicians (60.4%) who used PE at 6 and 18 months after training, 58 (10.2%) who used PE at 18 but not 6 months, 95 (16.7%) who used PE at 6 but not 18 months, and 71 (12.5%) who never adopted PE. Median reach was 12% of clinicians' appointments with patients with posttraumatic stress disorder. Reach was predicted by flow of interested patients (incident response ratio [IRR] = 1.21 to 1.51), PE's perceived effectiveness (IRR = 1.04 to 1.31), working in a PTSD specialty clinic (IRR = 1.06 to 1.26), seeing more patients weekly (IRR = 1.04 to 1.25), and seeing fewer patients in groups (IRR = 0.83 to 0.99). Most clinicians trained in PE sustained use of the treatment, but on a limited basis. Strategies to increase reach of PE should address organizational barriers and patient engagement.


Assuntos
Terapia Implosiva/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/terapia , Atitude do Pessoal de Saúde , Feminino , Humanos , Terapia Implosiva/educação , Masculino , Visita a Consultório Médico/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Psiquiatria/educação , Psiquiatria/estatística & dados numéricos , Psicologia/educação , Psicologia/estatística & dados numéricos , Serviço Social/educação , Serviço Social/estatística & dados numéricos , Fatores de Tempo , Estados Unidos , United States Department of Veterans Affairs , Veteranos/psicologia , Local de Trabalho
17.
J Trauma Stress ; 29(6): 568-571, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27923267

RESUMO

Sleep has been implicated in learning processes that appear to underlie recovery from posttraumatic stress disorder (PTSD). The importance of quality and timing of sleep following exposure-based therapies has been suggested. The present study evaluated relationships between sleep and adaptive emotional processing following written narrative exposure (WNE) to memories of traumatic events experienced by participants with clinically significant PTSD symptoms. Participants included 21 urban-residing nontreatment-seeking adults with full or subthreshold symptoms of PTSD who completed 4 sessions of 30-min WNE with the first session either in the evening or the morning. There was a significant reduction of PTSD symptom severity after WNE sessions (partial η = .65), but there was no interaction between group assignment based on the initial session's proximity to sleep and initial reduction of PTSD symptom severity (partial η = .01). Polysomnography following evening WNE revealed increased duration of total sleep and N2%, reduced N3%, and increased eye movement density during REM sleep compared with baseline recordings (dz = 0.65 to 1.15). Reduced N3% and increased REM density were associated with less improvement of PTSD symptoms (r = .58 & -.63). These findings suggest a relationship between preservation of diminished arousal during sleep and adaptive trauma memory processing.


Assuntos
Adaptação Psicológica/fisiologia , Terapia Implosiva/estatística & dados numéricos , Sono REM/fisiologia , Transtornos de Estresse Pós-Traumáticos/terapia , Adulto , Feminino , Humanos , Masculino , Polissonografia , Índice de Gravidade de Doença , Fatores de Tempo , Adulto Jovem
18.
J Trauma Stress ; 29(6): 515-521, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27859588

RESUMO

Chronic insomnia and recurrent nightmares are prominent features of posttraumatic stress disorder (PTSD). Evidence from adult research indicates that these sleep disturbances do not respond as well to cognitive-behavioral therapies for PTSD and are associated with poorer functional outcomes. This study examined the effect of prolonged exposure therapy for adolescents versus client-centered therapy on posttraumatic sleep disturbance, and the extent to which sleep symptoms impacted global functioning among adolescents with sexual abuse-related PTSD. Participants included 61 adolescent girls seeking treatment at a rape crisis center. The Child PTSD Symptom Scale-Interview (Foa, Johnson, Feeny, & Treadwell, 2001) was used to assess PTSD diagnosis and severity of symptoms, including insomnia and nightmares. The Children's Global Assessment Scale (Shaffer et al., 1983) was used to assess global functioning. There were significant main effects of time and treatment on insomnia symptoms. Additionally, there was a main effect of time on nightmares. Results also showed that insomnia and nightmares significantly predicted poorer global functioning posttreatment (R2 = .21). Despite significant improvements in posttraumatic sleep disturbance, there were still clinically significant insomnia symptoms after treatment, suggesting that additional interventions may be warranted to address residual sleep disturbance in PTSD.


Assuntos
Terapia Implosiva/estatística & dados numéricos , Psicoterapia Centrada na Pessoa/estatística & dados numéricos , Delitos Sexuais/psicologia , Transtornos do Sono-Vigília/terapia , Transtornos de Estresse Pós-Traumáticos/terapia , Adolescente , Sonhos/psicologia , Feminino , Humanos , Modelos Lineares , Índice de Gravidade de Doença , Transtornos do Sono-Vigília/psicologia , Transtornos de Estresse Pós-Traumáticos/psicologia , Fatores de Tempo
19.
J Trauma Stress ; 29(6): 507-514, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27859619

RESUMO

The present study evaluated secondary emotional and behavioral outcomes among adolescents who received prolonged exposure (PE-A) or client-centered therapy (CCT) for posttraumatic stress disorder (PTSD) in a randomized controlled trial. Participants were 61 adolescent girls (age: M = 15.33, SD = 1.50 years) with sexual abuse related PTSD seeking treatment at a community mental health clinic. Multilevel modeling was employed to evaluate group differences on the Youth Self-Report (YSR) over acute treatment and 12-month follow-up. Both treatment groups showed significant improvements on all YSR scales from baseline to 12-month follow-up. Adolescents who received PE-A showed significantly greater reductions than those receiving CCT on the Externalizing subscale (d = 0.70), rule-breaking behavior (d = 0.63), aggressive behavior (d = 0.62), and conduct problems (d = 0.78). No treatment differences were found on the Internalizing subscale or among other YSR problem areas. Both PE-A and CCT effectively reduced many co-occurring problems among adolescents with PTSD. Although PE-A focuses on PTSD and not on disruptive behaviors, PE-A was associated with greater sustained changes in externalizing symptoms, supporting broad effects of trauma-focused treatment on associated problem areas.


Assuntos
Terapia Implosiva/estatística & dados numéricos , Transtornos do Humor/terapia , Psicoterapia Centrada na Pessoa/estatística & dados numéricos , Estupro/psicologia , Transtornos de Estresse Pós-Traumáticos/terapia , Adolescente , Adulto , Agressão/psicologia , Feminino , Seguimentos , Humanos , Transtornos do Humor/psicologia , Comportamento Problema/psicologia , Autorrelato , Transtornos de Estresse Pós-Traumáticos/psicologia , Adulto Jovem
20.
J Trauma Stress ; 29(5): 474-477, 2016 10.
Artigo em Inglês | MEDLINE | ID: mdl-27681034

RESUMO

This retrospective analysis of previously existing nonrandomized clinical data examined the effectiveness of completing prolonged exposure (PE) or cognitive processing therapy (CPT) in a sample of 41 U.S. veterans at a Veterans Affairs medical center. The sample included 19 veterans with diagnoses of posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) and 22 veterans with PTSD only. Diagnostic groups did not significantly differ on PTSD and depression symptom reduction, F(2, 36) = 0.05, p = .951; Pillai's trace = 0.00, partial η2 = .00. Veterans who completed PE showed greater symptom reduction than those who completed CPT, F(2, 36) = 12.10, p < .001; Pillai's trace = 0.40, partial η2 = .40, regardless of TBI status. Overall, our results suggested that TBI status should not preclude individuals from being offered trauma-focused PTSD treatment.


Assuntos
Lesões Encefálicas Traumáticas/psicologia , Terapia Cognitivo-Comportamental/estatística & dados numéricos , Terapia Implosiva/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/terapia , Veteranos/psicologia , Adulto , Campanha Afegã de 2001- , Lesões Encefálicas Traumáticas/complicações , Estudos de Casos e Controles , Feminino , Humanos , Guerra do Iraque 2003-2011 , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Transtornos de Estresse Pós-Traumáticos/complicações , Transtornos de Estresse Pós-Traumáticos/psicologia , Estados Unidos , Adulto Jovem
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