National Center for PTSD

Written exposure therapy (WET) is a brief psychotherapy for posttraumatic stress disorder (PTSD). Although WET is designed to be delivered in five sessions, implementation data collected from trained mental health care providers suggest that therapists sometimes add more sessions without sufficient justification. We conducted a mixed-methods examination to understand why therapists added WET sessions and whether adding sessions improved treatment outcomes. Participants were drawn from a larger trial where therapists were permitted to deliver five to seven WET sessions. This study included 77 client participants who were randomly assigned to receive WET and nine therapist participants who delivered WET during the trial. Results showed that PTSD symptom severity trajectories at follow-up assessment were not significantly different between client participants who received five sessions and those who received more than five. Only 15.7% of participants who received supplemental WET sessions displayed a clinically meaningful reduction in PTSD symptom severity, while 11.8% displayed a clinically meaningful increase in PTSD symptom severity. Qualitative interviews with therapists indicated that their decision to add sessions was largely driven by the client avoiding writing about the traumatic event in early treatment sessions or due to a very complex or lengthy traumatic event that required additional sessions to provide repeated exposure to the trauma memory. Taken together, the findings suggest that adding WET sessions is unnecessary most of the time, but therapists have a strong preference for having flexibility in adding treatment sessions.

This study explored the association between changes in pain and related health outcomes and posttraumatic stress disorder (PTSD) symptoms following cognitive processing therapy (CPT) in an active duty military sample. Based on the mutual maintenance model, we hypothesized that PTSD symptom reductions would be associated with improvements in pain and health symptoms following CPT. This secondary, intent‐to‐treat analysis included data from a parent trial of 127 active duty U.S. Army soldiers diagnosed with PTSD who were receiving variable‐length CPT. We used mixed‐effect regression models with repeated measures to examine whether treatment responders (i.e., individuals with a reduction of 11 points or more on the PCL‐5) demonstrated improvements in pain and health outcomes posttreatment. Models included fixed effects of visit (baseline and 1‐month follow‐up), clinically significant PTSD improvement classification (present or absent), and the respective interaction. There were significant interactions on pain interference, F (1, 75.92) = 6.32, p = .014; perceived life control, F (1, 95.59) = 5.17, p = .025; affective distress, F (1, 83.15) = 9.77 p = .002; mental health, F (1, 96.27) = 20.75, p < .001; physical health, F (1, 84.97) = 3.98, p = .049; and somatic symptoms, F (1, 80.64) = 6.08, p = .016. These interactions revealed that participants with clinically significant PTSD improvement following CPT also demonstrated certain better pain and health outcomes compared to nonresponders. Service members with pain and health issues in addition to PTSD who respond to CPT may also report improvements in these issues posttreatment, increasing the value of connecting them to treatment.

Many veterans who begin evidence-based therapies for posttraumatic stress disorder (PTSD) discontinue care prior to treatment completion. Examination of individual-level factors as predictors of dropout has been inconclusive, and it may be important to examine organizational factors as predictors. The present study investigates the role of both individual variables (i.e., gender identity, age, racial background, ethnicity, perceived barriers to treatment) and organizational variables (i.e., time from evaluation to individual treatment, number of preparatory sessions, and inclusion of family in an informational session) in predicting treatment discontinuation. Participants consisted of 557 veterans who presented to a Veterans Affairs PTSD specialty clinic and began trauma-focused treatment (86.89% male, 50.99% White, 47.94% Operation Iraqi Freedom/Operation Enduring Freedom). Most veterans reported at least one barrier to treatment (85.10%). A total of 53.32% of veterans completed a course of evidence-based trauma-focused therapy, while 46.68% discontinued. In a series of logistic regression models, older age significantly predicted treatment completion (OR = 1.017, p = .007), and longer time from evaluation to treatment initiation significantly predicted treatment discontinuation (OR = 0.992, p = .045). Findings highlight older age as a reliable predictor of treatment completion among veterans. Findings add to the existing literature by demonstrating that improving organizational-level variables (i.e., reducing wait time from evaluation to treatment initiation) may be particularly helpful in facilitating treatment completion across demographic groups, even in the presence of barriers to treatment.

This article aims to enrich the conceptualization and implementation of community-based health outreach focused on housing stabilization and homeless prevention from a public health framework. First, it will conceptualize community-based homeless outreach. Next, it will identify and describe selected influencers of homeless outreach as well as review homeless outreach best practices. Finally, the clinical application of these theoretical approaches in a homeless outreach project with U.S. military Veterans will be highlighted. The public health prevention framework allows for a granular appreciation of housing instability to operationalize homeless outreach from primary (i.e., stably housed) to secondary (i.e., at risk of homelessness) to tertiary (i.e., homeless) prevention measures. This article will address how intersectional identities relate to stigma and shame and how the internalization of these factors may impact engagement in homeless prevention and outreach services. A review of international best practices in homeless outreach, including the impact of social identity, will be presented. Finally, this article will highlight the clinical application of critical time intervention and trauma-informed care as demonstrated in a quality improvement project that provides secondary homeless prevention outreach services to transitioning U.S. Army Veterans. This article will use commentary from outreach services clinicians, military Veteran consultants, clinical vignettes, and a literature review. Taken together, this article will advance public health practices and policies by drawing attention to biases in current homeless outreach services and by adding to the understanding of identity as related to housed status and its implication to the provision and acceptance of homeless outreach services.

Smartphones enable people to access the online world from anywhere at any time. Despite the benefits of this technology, there is growing concern that smartphone use could adversely impact cognitive functioning and mental health. Correlational and anecdotal evidence suggests that these concerns may be well-founded, but causal evidence remains scarce. We conducted a month-long randomized controlled trial to investigate how removing constant access to the internet through smartphones might impact psychological functioning. We used a mobile phone application to block all mobile internet access from participants’ smartphones for 2 weeks and objectively track compliance. This intervention specifically targeted the feature that makes smartphones “smart” (mobile internet) while allowing participants to maintain mobile connection (through texts and calls) and nonmobile access to the internet (e.g. through desktop computers). The intervention improved mental health, subjective well-being, and objectively measured ability to sustain attention; 91% of participants improved on at least one of these outcomes. Mediation analyses suggest that these improvements can be partially explained by the intervention's impact on how people spent their time; when people did not have access to mobile internet, they spent more time socializing in person, exercising, and being in nature. These results provide causal evidence that blocking mobile internet can improve important psychological outcomes, and suggest that maintaining the status quo of constant connection to the internet may be detrimental to time use, cognitive functioning, and well-being.

Background: Veterans with substance use disorders (SUDs) are at elevated risk of dying by suicide. We examine sex and age differences in rates and means of suicide death among veterans with alcohol (AUD) and/or opioid use disorder (OUD) diagnoses. Methods: Cohort study of all veterans with AUD and/or OUD diagnoses who received Veterans Health Administration care and died of any cause between January 2016 to December 2020. We assessed risk of suicide death and lethal means as a function of sex, age and their interaction. Results: Among veterans with AUD and/or OUD, 119,693 died of any cause during the study period. Suicides represented 4.5% (n = 5,419) of all deaths, with women 2.25 times (95% CI [1.97–2.55]) more likely to die by suicide than men and dying at a significantly younger age than men. Suicide deaths accounted for 21.28 and 32.25 years of potential life lost for men and women, respectively. Intentional poisoning was the most common means of death across sexes. Women were 2.08 times (95% CI [1.61–2.71]) more likely to die by poisoning-related suicide (78.2%) than men (59.72%). Men were 1.73 times (95% CI [1.13–2.77]) more likely to die by firearms-related suicide (13.78%) than women (8.06%). Conclusion: Among veterans diagnosed with AUD and/or OUD, women were more likely to die by suicide, at a younger age, than men. Poisoning was the primary means of suicide death across sexes. These national-level data highlight the urgency of suicide risk assessment and prevention among women veterans with SUD.

Psilocybin, ketamine, and MDMA are psychoactive compounds that exert behavioral effects with distinguishable but also overlapping features. The growing interest in using these compounds as therapeutics necessitates preclinical assays that can accurately screen psychedelics and related analogs. We posit that a promising approach may be to measure drug action on markers of neural plasticity in native brain tissues. We therefore developed a pipeline for drug classification using light sheet fluorescence microscopy of immediate early gene expression at cellular resolution followed by machine learning. We tested male and female mice with a panel of drugs, including psilocybin, ketamine, 5-MeO-DMT, 6-fluoro-DET, MDMA, acute fluoxetine, chronic fluoxetine, and vehicle. In one-versus-rest classification, the exact drug was identified with 67% accuracy, significantly above the chance level of 12.5%. In one-versus-one classifications, psilocybin was discriminated from 5-MeO-DMT, ketamine, MDMA, or acute fluoxetine with >95% accuracy. We used Shapley additive explanation to pinpoint the brain regions driving the machine learning predictions. Our results suggest a unique approach for characterizing and validating psychoactive drugs with psychedelic properties.

Opportunities exist to improve patient experience in the emergency department for low-risk (ie, non-cardiac) chest pain patients with anxiety and panic as the underlying cause of symptoms. Referral to internet-based cognitive behavioral therapy (iCBT) with guided support is a scalable, evidence-based option that is underused, particularly among non-white patients. In collaboration with a diverse group of patient and community partners, we co-developed and tested an existing iCBT course for generalized anxiety disorder with delivery of guided support by a peer recovery specialist with concordant lived experience. We analyzed patient partner feedback from debriefing sessions during the testing phase using conventional content analysis. Results revealed overall positive experiences with both iCBT lessons and peer support calls. Key points derived from qualitative findings include: (1) iCBT lesson content resonated reasonably well with the diverse group of patient partners, (2) the peer relationship was key to individualizing application of content to various lived experiences, and (3) the guided discussion should be participant-driven and based on content that resonates most with the participant. In conclusion, iCBT with guided peer support was acceptable to patient partners involved in co-development and testing who were representative of a diverse patient population.

Background Public safety personnel (PSP) experience occupational stressors and potentially psychologically traumatic events, which increase the odds of screening positive for mental health disorders, and the risk of suicide. This study estimates suicidal ideation, planning, and attempts among Canadian PSP, and assesses associations with Emotional Resilience Skills Training (ERST). Method The current study uses a longitudinal prospective sequential experimental cohort design that engages participants for approximately 16 months. Participants ( n = 186, 60.5% men) were administered the structured Mini‐International Neuropsychiatric Interview at three time points relative to the ERST: pre‐training, post‐training, and 1‐year follow‐up. Results At pre‐training, PSP reported past‐month suicidal ideation ( n = 24; 12.9%), planning ( n = 7; 3.8%), and no attempts. At post‐training, PSP reported past‐month suicidal ideation ( n = 12; 10.1%), suicidal planning ( n < 5), and no attempts ( n = 0). At the 1‐year follow‐up, PSP reported past‐month suicidal ideation ( n = 7; 12.5%), and no planning ( n = 0) or attempts ( n = 0). Conclusions The results indicate suicide‐related challenges for PSP, particularly PSP who self‐identify as women and females. The results suggest sector‐specific differences in suicide attempts, indicating unique sector‐specific challenges among PSP. The results evidenced reductions in suicidal ideation and planning directly after ERST; however, attrition impacted analyses at 1‐year follow‐up. Additional sector‐specific mixed‐methods research would help inform suicide mitigation strategies. Trial Registration: ClinicalTrials.gov , NCT05530642. Hypotheses Registration: aspredicted.org, #90136. Registered 7 March 2022—Prospectively registered

Posttraumatic stress disorder (PTSD) is a disabling psychiatric disorder that arises after acute or chronic exposure to threatened death, serious injury, or sexual violence. The pathophysiology of PTSD is complex and involves dysregulation of multiple interacting brain regions and neurobiological systems including the sympathetic nervous system, the hypothalamic-pituitary-adrenal (HPA) axis, and the immune system. Deficient biosynthesis of neurosteroids that positively modulate GABAA receptor function, including allopregnanolone (Allo) and its equipotent stereoisomer pregnanolone (PA), also affects a subpopulation of individuals with PTSD and is associated with increased PTSD risk, severity, chronicity and treatment resistance. The synthesis of these neuroactive steroids by the brain, adrenal glands, and gonads may be influenced by stress, drugs, social isolation and other factors with impact on the balance of inhibitory versus excitatory (I/E) neurotransmission in brain. These neuroactive steroids are thus considered a potential target for new PTSD therapeutics. In this review, we first present studies in humans and rodents performed over the past 20 years that have shaped our current understanding of the role of Allo and PA in the pathophysiology of PTSD. We will also discuss the means by which rigorous measurement of neurosteroids can be used to identify individually-variable dysfunctional patterns of neurosteroidogenesis that could be targeted to prevent or treat PTSD. This broadened precision medicine approach to diagnosis of neuroendocrinopathies associated with PTSD may aid in reducing PTSD risk and facilitating the effective prescribing of PTSD therapeutics. We hope that such an approach will also forestall development of individually variable but common psychiatric, substance abuse, and medical PTSD-comorbidities.

In the United States (US), lesbian, gay, bisexual, transgender, and queer (LGBTQ) people experience disproportionate rates of suicidality associated with minority stress. This study aimed to investigate whether nonverbal expressions of experienced stigma (i.e., shame) predicted suicidal ideation among LGBTQ individuals with a focus on location-based disparities (comparing those living in a more rural setting to those living in a more urban setting). More specifically, we examined whether nonverbal expressions of shame predicted suicidal ideation three months later and whether this relationship was moderated by region. LGBTQ individuals (N = 133) from one rurally-situated and one urban location were videorecorded while talking about a time they felt bad about their LGBTQ identity in an observational, prospective (two-time point) design. Recordings were coded for the intensity of nonverbal expressions of shame (shoulders slumped, chest narrowed). Participants also completed several self-report measures including state shame and suicidal ideation at both the time of the recording and three months later. Moderation analyses revealed that for LGBTQ adults living in more rural settings, nonverbal shame, predicted increased suicidal ideation three months later (Bstd = 0.64, p = .005), and this was not the case for those living in more urban settings (Bstd = -0.08, p = 0.70). Self-reported shame did not predict suicidal ideation for LGBTQ adults from more rural or urban locations. These findings highlight the importance of recognizing nonverbal cues in context (i.e., in locations with more structural stigma) when assessing mental health risks and when shaping interventions for LGBTQ populations.

Risk of U.S. Army soldier suicide-related behaviors increases substantially after separation from service. As universal prevention programs have been unable to resolve this problem, a previously reported machine learning model was developed using pre-separation predictors to target high-risk transitioning service members (TSMs) for more intensive interventions. This model is currently being used in a demonstration project. The model is limited, though, in two ways. First, the model was developed and trained in a relatively small cross-validation sample (n = 4044) and would likely be improved if a larger sample was available. Second, the model provides no guidance on subtyping high-risk TSMs. This report presents results of an attempt to refine the model to address these limitations by re-estimating the model in a larger sample (n = 5909) and attempting to develop embedded models for differential risk of post-separation stressful life events (SLEs) known to mediate the association of model predictions with post-separation nonfatal suicide attempts (SAs; n = 4957). Analysis used data from the Army STARRS Longitudinal Surveys. The revised model improved prediction of post-separation SAs in the first year (AUC = 0.85) and second-third years (AUC = 0.77) after separation, but embedded models could not predict post-separation SLEs with enough accuracy to support intervention targeting.

Moral injury affects a variety of populations who make ethically complex decisions involving their own and others’ well-being, including combat veterans, healthcare workers, and first responders. Yet little is known about occupational differences in the prevalence of morally injurious exposures and outcomes in nationally representative samples of such populations. To examine prevalence of potentially morally injurious event (PMIE) exposure and clinically meaningful moral injury in three high-risk groups. Cross-sectional survey with responses weighted to national geodemographic benchmarks. Combat veterans, healthcare workers, and first responders (N=1232) in the USA. Moral Injury and Distress Scale (MIDS). Many combat veterans (49.3%), healthcare workers (50.8%), and first responders (41.6%) endorsed exposure to a PMIE. Clinically meaningful moral injury symptoms were endorsed by 6.5% of combat veterans, 7.3% of healthcare workers, and 4.1% of first responders. After adjusting for age, gender, race, and ethnicity, relative to first responders, combat veterans were more likely to endorse transgressing their values by what they did and healthcare workers were more likely to endorse witnessing others’ wrongful acts. Additionally, combat veterans (adjusted risk ratio (aRR) = 2.18, 95% confidence interval (95% CI) = 1.09, 2.16) and healthcare workers (aRR = 2.02, 95% CI = 1.03, 3.83) were over twice as likely to screen positive for clinically meaningful moral injury in comparison to first responders. No differences in exposures or outcomes emerged between combat veterans and healthcare workers. Results from these nationally representative samples of three high-risk populations suggest that exposure to PMIEs is common and a sizable minority report clinically meaningful moral injury.

Healthcare-based social need screening and referral (S&R) among adult populations has produced equivocal results regarding social need resource connection. Assess the efficacy of S&R on resource connection (primary outcome) and unmet need reduction (secondary outcome). Intention-to-treat randomized controlled trial. Analyses adjusted for demographics (e.g., age, race), comorbidity (Elixhauser), and VA priority group (PG). Veterans with and at-risk for cardiovascular disease and one of more (hereafter “ ≥ 1”) social needs receiving healthcare at one of three Veterans Healthcare Administration (VHA) medical facilities. Study arms represented referral strategies of varying intensity. Arm 1 (control) received generic resource information; Arm 2 (low intensity) received generic and tailored resource information; Arm 3 (high intensity) received all the above plus social work navigation assistance. Post index surveys at 2-months assessed resource connection (connection to ≥ 1 new resources) and 6-months assessed need reduction (≥ 1 needs at the index screen no longer identified). A total of 479 Veterans were randomized: 50% were minoritized Veterans, mean age was 64, and 91% were male. Arm 3 was associated with greater resource connection but differences across study arms were not statistically significant. For example, compared to the control arm, participants in Arm 3 had higher but non-statistically significant odds of connecting to ≥ 1 resources (OR = 1.60, CI [.96, 2.67]). Among VHA-enrolled Veterans, a high-intensity S&R intervention was associated with a non-statistically significant increase in connection to social need resources. Further study needed to establish S&R efficacy. NCT04977583.

Although effective evidence-based trauma-focused psychotherapies for posttraumatic stress disorder (PTSD) are available, a significant proportion of patients show a suboptimal response or do not complete them. MDMA-assisted therapy (MDMA-AT) for PTSD is a promising intervention currently being evaluated in numerous studies worldwide, including investigation for potential Food and Drug Administration (FDA) approval in the United States. The concepts of set and setting are foundational in psychedelic therapy and refer to the mindset a person brings to therapy and the environment in which it takes place, respectively. Both are believed to play a critical role in the individual’s experience and efficacy of MDMA-AT. In this article, we describe the importance of set and setting in MDMA-AT for PTSD and outline the advantages and challenges of implementing this novel intervention in large healthcare settings such as the Veterans Health Administration (VHA). Mostly derived from our experience conducting clinical trials of MDMA-AT for PTSD in VHA, we present specific and practical suggestions for optimizing set and setting from both the participant’s and clinician’s perspective in a manner that both leverages the opportunities of such settings and adapts to their challenges. These recommendations are intended to inform future MDMA-AT for PTSD research and, potentially, eventual clinical implementation efforts in traditional healthcare systems.

Purpose of Review As evidence accumulates for the pernicious effects of exposure to potentially morally injurious events (PMIEs) on mental health, the need for improved measurement of moral injury has grown. This article summarizes the psychometric properties of scales that assess cognitive, emotional, social, and spiritual concerns linked to PMIE exposure and uses meta-analysis to describe associations between these scales and measures of posttraumatic stress and depression. Findings We reviewed 104 articles reporting results from 110 samples, in which 13 different scales were administered to assess the impacts of PMIE exposure (i.e., moral injury). Overall, the scales exhibited good to excellent internal consistency and moderate to large bivariate associations with posttraumatic stress (r = .63, 95% Confidence Interval [CI] [.55, .71]) and depression (r = .59, 95% CI [.51, .66]). Measures varied as to whether they indexed problems to a specific event, had a unidimensional or multidimensional factor structure, used a unipolar or bipolar response format to record item responses, used a cut score to distinguish moral injury from normative distress, were assessed for sensitivity to change over time, and were validated for use with multiple at-risk populations. Summary Assessment of moral injury has progressed tremendously. Recent scales extend prior work that focused on whether respondents endorsed PMIE exposure by measuring the potential impacts of an exposure. Mental health clinicians and researchers can use this article to choose a scale that best fits their moral injury measurement needs.