Background:Growing evidence suggests that disruptions in rest-activity rhythms may serve as relevant markers of posttraumatic stress disorder (PTSD). Despite the emergence of machine learning methods applied to actigraphy and self-report data, few studies have used these approaches to identify individuals with clinically diagnosed PTSD. Prior work has focused on predicting probable PTSD based on self-report measures, yet discrepancies exist between clinical diagnoses and probable PTSD derived from self-reports. Objective:This study explored whether wrist actigraphy and sleep logs could be used to accurately predict clinician-rated PTSD diagnosis and probable diagnosis of PTSD based on established self-report cutoffs (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [PCL-5] ≥31 and ≥38) among trauma-exposed service members and veterans. We also explored which features were most strongly predictive of each outcome and whether models were able to predict PTSD diagnosis even when accounting for other mental health disorders. Methods:Wrist actigraphy data and daily sleep logs were collected over 1 week from trauma-exposed male service members and veterans (N=36; mean age 41, SD 5.3 y). Candidate features were identified using univariate feature selection. Extreme gradient boosting models were trained using leave-one-subject-out cross-validation to predict the diagnosis of PTSD and probable diagnosis of PTSD based on 2 self-report cutoffs (PCL-5≥31 and ≥38). Performance metrics were then calculated at the person level. Linear regression was used to assess the discriminant validity of model-predicted scores and each PTSD outcome specifically, relative to other mental health diagnoses. Results:Machine learning models predicting PTSD diagnosis and probable PTSD based on the PCL-5≥31 threshold demonstrated satisfactory performance in this sample. The diagnosis model achieved an area under the curve (AUC) of 0.83 (95% CI 0.61-1.00), with high accuracy (88%) and specificity (96%) and moderate sensitivity (63%). The PCL-5≥31 model yielded comparable performance (AUC=0.84, 95% CI 0.71-0.98) with balanced sensitivity (73%) and specificity (82%). For both models, a combination of subjective and objective features was the most impactful. These models were able to predict PTSD even when accounting for non-PTSD mental health diagnoses, as model-predicted scores were significantly associated with 2 outcomes: clinician-rated PTSD (B=0.19; P=.002) and probable PTSD based on a PCL-5≥31 cutoff (B=0.24; P=.003). In contrast, the model predicting probable PTSD based on the PCL-5≥38 threshold performed poorly (AUC=0.47, 95% CI 0.24-0.69), with a nonsignificant relationship between model-predicted scores and the outcome (B<0.01; P=.89). Conclusions:Both subjective and objective rest-activity features may improve the prediction of PTSD. Further research is needed to validate these findings and explore the use of integrating wearable sensor data and subjective information to support PTSD assessment.

Brain derived neurotrophic factor (BDNF) may play an important role in the success of treatment for posttraumatic stress disorder (PTSD). Pre- and post-treatment blood samples were analyzed for 40 veterans who completed a 3-week intensive outpatient treatment for PTSD. The treatment included Cognitive Processing Therapy, mindfulness, and yoga as core treatment components. PTSD symptoms were assessed at pre-treatment, post-treatment, and 3-month follow-up. Participants reported large decreases in PTSD symptoms from pre-to post-treatment (d = 1.46, p < 0.001) and pre-treatment to 3-month follow-up (d = 0.91, p < 0.001). Unexpectedly, participants demonstrated a decrease in BDNF from pre-to post-treatment (d = 0.64, p < 0.001). Changes in BDNF from pre-to post-treatment were not significantly associated with PTSD symptom improvement. However, higher levels of post-treatment BDNF were significantly associated with lower PTSD symptoms at 3-month follow-up (n = 27, r = -0.57, p = 0.002) and greater improvements in PTSD symptoms from pre-treatment to 3-month follow-up (n = 27, r = 0.50, p = 0.008). Higher levels of post-treatment BDNF may facilitate the long-term success of intensive PTSD treatment. Further research with larger samples is needed to evaluate the processes by which BDNF may affect consolidation of improvements after completion of PTSD treatment.

Neuropeptide Y (NPY) is a 36-amino acid peptide that is widely expressed throughout the limbic system. Recent evidence has highlighted NPY as a marker of resilience to posttraumatic psychopathology, which may be due to its association with neural regions involved with emotion regulation. This study examined whether plasma NPY levels moderated the relationship between emotion regulation and psychopathology in a sample of adult survivors of childhood interpersonal trauma, a population known to be at high risk for psychopathology. Adults exposed to an interpersonal criterion A trauma during childhood (N = 54) were recruited from an urban population at a midwestern medical center and completed a baseline study visit as part of a larger clinical trial. Participants gave a blood sample in order to assess circulating levels of NPY and answered questions related to emotion regulation and mood-related pathology. Results of a moderated multiple regression showed that the overall model was significant R-2 = 0.26, F (5, 48) = 3.46, p < .01. Difficulties in emotion regulation was significantly predictive of psychopathology (unstandardized B = 0.032, p < .01), and this relationship was significantly moderated by levels of NPY (unstandardized B = -0.001, p < .05) such that the relationship between emotion regulation and psychopathology was weaker for those with higher levels of NPY. Results suggest that higher levels of NPY may lessen the association between emotion regulation and posttraumatic psychopathology in survivors of childhood interpersonal trauma. Further investigation of the contribution of NPY to psychopathology in this population is warranted.

Background: Over a decade and a half of research has resulted in inconsistent evidence for the efficacy of dcycloserine (DCS), a partial glutamatergic N-methyl-D-aspartate agonist, for augmenting exposure-based cognitive behavioral therapy (CBT) for anxiety- and fear-based disorders. These variable findings have motivated the search for moderators of DCS augmentation efficacy. Methods: In this secondary analysis of a previous randomized clinical trial, we evaluated the value of de novo threat conditioning outcomes-degree of threat acquisition, extinction, and extinction retention-for predicting treatment response to exposure-based CBT for social anxiety disorder, applied with and without DCS augmentation in a sample of 59 outpatients. Results: We found that average differential skin conductance response (SCR) during extinction and extinction retention significantly moderated the prediction of clinical response to DCS: participants with poorer extinction and extinction retention showed relatively improved treatment response with DCS. No such effects were found for expectancy ratings, consistent with accounts of DCS selectively aiding lower-order but not higher-order extinction learning. Conclusions: These findings provide support for extinction and extinction retention outcomes from threat conditioning as potential pre-treatment biomarkers for DCS augmentation benefits. Independent of DCS augmentation, the current study did not support threat conditioning outcomes as useful for predicting response to exposure-based CBT.

Background: Positive valence emotions serve functions that may facilitate response to exposure therapy - they encourage approach behavior, diminish perceived threat reactivity, and enhance assimilation of new information in memory. Few studies have examined whether positive emotions predict exposure therapy success and extant findings are mixed. Methods: We conducted a secondary analysis of an exposure therapy trial for social anxiety disorder to test the hypothesis that patients endorsing higher trait positive emotions at baseline would display the greatest treatment response. N = 152 participants enrolled in a randomized controlled trial of D-cycloserine augmentation completed five sessions of group exposure therapy. Pre-treatment positive emotionality was assessed using the NEO Five-Factor Inventory. Social anxiety symptoms were assessed throughout treatment by blinded evaluators using the Liebowitz Social Anxiety Scale. Results: Accounting for baseline symptom severity, multilevel growth curve models revealed that patients with higher pre-treatment positive emotionality displayed faster social anxiety symptom reductions and lower scores at 3-month follow-up. This predictive effect remained significant after controlling for baseline depression and extraversion (without the positive emotionality facet). Conclusions: These findings add to emerging evidence suggesting that explicitly targeting and enhancing positive emotions during exposure to perceived threat may improve treatment outcomes for anxiety and fear-based disorders. Trial registration: ClinicalTrials.gov: NCT02066792 https://clinicaltrials.gov/ct2/show/NCT02066792

AbstractMajor depressive disorder (MDD) is a heterogeneous condition characterized by depressed mood and/or loss of interest/pleasure in activities, among other symptoms. Most currently available treatments for depression were developed on the hypothesis that depressive symptoms arise from a depletion of monoamines within the central nervous system (CNS). However, clinical understanding has advanced to identify brain network dysregulation as the primary driver of depression, with monoamines playing a lesser role. Prolonged inability to regulate brain networks may lead to the core symptoms and clinical presentation of MDD. Depression has been linked to impaired neuronal activity in brain networks (e.g., central executive network [CEN], default mode network [DMN], and salience network [SN]). It is hypothesized that improvement in depressive symptoms may result from restoring balance in brain networks governing mood.γ-aminobutyric acid (GABA) is critical for maintaining and restoring excitatory-inhibitory balance in the brain and regulating brain networks. Approximately one-third of neurons in the CNS are GABAergic, regulating network activity throughout the brain, including regions involved in mood, sleep, and cognition. GABA activates GABAA receptors (GABAAR), inhibiting neuronal activity through phasic (via synaptic GABAAR) and tonic (via extrasynaptic GABAAR) currents. Tonic GABA currents may play a particularly important role in regulating network activity, since they produce a large net inhibitory effect and are also involved in controlling the excitability of inhibitory interneurons, the key regulators of rhythmic brain network activity.Zuranolone is an investigational oral GABAAR positive allosteric modulator and neuroactive steroid. In clinical trials, treatment with zuranolone has shown significant improvement over placebo in depressive symptoms in adults with MDD or postpartum depression, with a generally well-tolerated and consistent safety profile.The hypothesized mechanism of zuranolone differs from monoamine-based antidepressants and from benzodiazepines. Unlike benzodiazepines, which bind to the α/γ subunit interface in synaptic GABAAR and enhance phasic inhibitory currents, zuranolone binds to the α/β subunit interface present in nearly all GABAAR, leading to enhanced phasic (synaptic) and tonic (extrasynaptic) inhibitory currents. Furthermore, in vitro evidence suggests that whereas benzodiazepines are associated with GABAAR downregulation, zuranolone upregulates the surface expression of GABAAR.In conclusion, by upregulating GABAAR expression and increasing phasic and tonic inhibitory GABAergic signaling, zuranolone may rapidly restore and maintain excitatory-inhibitory balance in brain networks, thus allowing the brain to potentially respond appropriately to internal and external stimuli.FundingSage Therapeutics, Inc., and Biogen Inc.

OBJETIVO: Os autores examinaram a freqüência de eventos vitais significativos (estressores) durante o ano que antecedeu o transtorno do pânico e sua relação com história de ansiedade na infância, história familiar de ansiedade, comorbidades e curso da doença. MATERIAIS E MÉTODOS: 223 pacientes foram acompanhados em um estudo naturalístico, longitudinal do transtorno do pânico. RESULTADOS: Apesar de 80% dos pacientes com transtorno do pânico referirem a presença de um fator estressor durante o ano anterior ao início da sua doença, sua freqüência é mais elevada em pacientes com história de ansiedade na infância e comorbidade com depressão na vida adulta. CONCLUSÕES: A presença de eventos vitais significativos não está associada com a presença de outros transtornos de ansiedade na vida adulta e nem com história familiar de ansiedade. Apesar de sua associação com história de ansiedade na infância e depressão, a presença de um fator estressor identificável não está associado a severidade ou ao curso do transtorno do pânico.

Posttraumatic stress disorder (PTSD) is a psychiatric disorder, resulting from exposure to traumatic events. Current recommended first-line interventions for the treatment of PTSD include evidence-based psychotherapies, such as cognitive processing therapy (CPT). Psychotherapies are effective for reducing PTSD symptoms, but approximately two-thirds of veterans continue to meet diagnostic criteria for PTSD after treatment, suggesting there is an incomplete understanding of what factors sustain PTSD. The intestine can influence the brain and this study evaluated intestinal readouts in subjects with PTSD. Serum samples from controls without PTSD (n = 40) from the Duke INTRuST Program were compared with serum samples from veterans with PTSD (n = 40) recruited from the Road Home Program at Rush University Medical Center. Assessments included microbial metabolites, intestinal barrier, and intestinal epithelial cell function. In addition, intestinal readouts were assessed in subjects with PTSD before and after a 3-wk CPT-based intensive treatment program (ITP) to understand if treatment impacts the intestine. Compared with controls, veterans with PTSD had a proinflammatory intestinal environment including lower levels of microbiota-derived metabolites, such as acetic, lactic, and succinic acid, intestinal barrier dysfunction [lipopolysaccharide (LPS) and LPS-binding protein], an increase in HMGB1, and a concurrent increase in the number of intestinal epithelial cell-derived extracellular vesicles. The ITP improved PTSD symptoms but no changes in intestinal outcomes were noted. This study confirms the intestine is abnormal in subjects with PTSD and suggests that effective treatment of PTSD does not alter intestinal readouts. Targeting beneficial changes in the intestine may be an approach to enhance existing PTSD treatments.NEW & NOTEWORTHY This study confirms an abnormal intestinal environment is present in subjects with PTSD. This study adds to what is already known by examining the intestinal barrier and evaluating the relationship between intestinal readouts and PTSD symptoms and is the first to report the impact of PTSD treatment (which improves symptoms) on intestinal readouts. This study suggests that targeting the intestine as an adjunct approach could improve the treatment of PTSD.

Background Approximately 40% of Emergency Department (ED) patients with chest pain meet diagnostic criteria for panic-related anxiety, but only 1–2% are correctly diagnosed and appropriately managed in the ED. A stepped-care model, which focuses on providing evidence-based interventions in a resource-efficient manner, is the state-of-the art for treating panic disorder patients in medical settings such as primary care. Stepped-care has yet to be tested in the ED setting, which is the first point of contact with the healthcare system for most patients with panic symptoms. Methods This multi-site randomized controlled trial (RCT) aims to evaluate the clinical, patient-centred, and economic effectiveness of a stepped-care intervention in a sample of 212 patients with panic-related anxiety presenting to the ED of Singapore’s largest public healthcare group. Participants will be randomly assigned to either: 1) an enhanced care arm consisting of a stepped-care intervention for panic-related anxiety; or 2) a control arm consisting of screening for panic attacks and panic disorder. Screening will be followed by baseline assessments and blocked randomization in a 1:1 ratio. Masked follow-up assessments will be conducted at 1, 3, 6, and 12 months. Clinical outcomes will be panic symptom severity and rates of panic disorder. Patient-centred outcomes will be health-related quality of life, daily functioning, psychiatric comorbidity, and health services utilization. Economic effectiveness outcomes will be the incremental cost-effectiveness ratio of the stepped-care intervention relative to screening alone. Discussion This trial will examine the impact of early intervention for patients with panic-related anxiety in the ED setting. The results will be used to propose a clinically-meaningful and cost-effective model of care for ED patients with panic-related anxiety. Trial registration ClinicalTrials.gov NCT03632356. Retrospectively registered 15 August 2018.

Intensive treatment programs (ITPs) are treating veterans with posttraumatic stress disorder (PTSD) and suicidal ideation (SI). The reduction of SI is a target to the abatement of suicide risk. This study examined whether ITPs utilizing PTSD treatments reduce SI and whether SI reduction is associated with PTSD symptom improvement. Veterans (N = 684) enrolled in a 2-week Prolonged Exposure (PE)-ITP or a 3-week Cognitive Processing Therapy (CPT)-ITP. Study data were drawn from self-report measures [PTSD Checklist for DSM-5 (PCL-5); item 9 of the Patient Health Questionnaire-9 (PHQ-9)] administered at intake and throughout treatment. The ITPs produced large treatment effects for PTSD. SI scores also decreased over time. Lower PTSD symptom severity was associated with less severe SI in both the PE-ITP and CPT-ITP. In conclusion, both PE- and CPT-ITPs effectively treat PTSD and reduce SI among veterans in as little as 2 weeks of intensive PTSD treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Sexual revictimization refers to exposure to more than one incident of rape and is a known risk factor for poor mental health among civilians. This construct has been understudied among veterans. In addition, although individuals who have experienced revictimization generally have greater symptom severity than those who have experienced one rape, it is unclear whether these differences persist following treatment. This study examined differences between veterans who reported histories of revictimization ( n =111) or a single rape ( n = 45), over the course of a 3-week intensive cognitive processing therapy (CPT)-based treatment program for veterans with posttraumatic stress disorder (PTSD). The sample consisted of predominately female (70.5%) post–9/11 veterans (82.7%). Self-reported PTSD and depression symptom severity were assessed regularly throughout the course of treatment. Controlling for non-interpersonal trauma exposure and whether veterans were seeking treatment for combat or military sexual trauma, sexual revictimization was generally associated with greater pretreatment distress and impairment. However, sexual revictimization did not impact rates of PTSD or depression symptom change over the course of intensive treatment, or overall improvement in these symptoms posttreatment. Our findings suggest that the rates of sexual revictimization are high among treatment-seeking veterans with PTSD. Although veteran survivors of sexual revictimization tend to enter treatment with higher levels of distress and impairment than their singly victimized peers, they are equally as likely to benefit from treatment.

Introduction Poor sleep is prevalent among individuals with social anxiety disorder (SAD) and may negatively affect exposure therapy outcomes. Poor sleep may impair memory and learning, and thus compromise fear extinction learning thought to take place in exposure therapy. We examined poor sleep as a predictor of exposure therapy outcomes for SAD and the moderating role of d-cycloserine (DCS) on this relationship. Methods Participants were 152 individuals with a primary diagnosis of SAD. As part of a randomized clinical trial evaluating the efficacy of DCS for enhancing the effects of exposure therapy, they completed self-report baseline measure of sleep quality, and self-report sleep diaries assessing sleep duration (total sleep time [TST]) and sleep quality the nights before and after treatment sessions. Results Poorer baseline sleep quality was significantly associated with slower improvement over time and worse symptom outcomes at the end of treatment and follow-up after controlling for baseline symptoms of depression and social anxiety. Greater TST the night before treatment predicted lower SAD symptoms at the next session, after controlling for symptoms at the previous session. There was no relation between prior or subsequent night sleep quality on symptoms at the next session. No associations were moderated by DCS. Conclusions We replicated and extended findings indicating that poor sleep quality is associated with poorer exposure therapy outcomes for SAD. Assessing for sleep difficulties before treatment initiation and incorporating sleep interventions into treatment may enhance exposure therapy outcomes for SAD.

Introduction Behavioral and psychiatric symptoms of dementia (BPSD) occur frequently, representing a significant driver of the total costs of dementia in the US. Although antidepressants and atypical antipsychotics are often used in BPSD, they have limited effectiveness and significant toxicity. As a result, recent initiatives have focused on reducing polypharmacy and psychotropic prescribing in this population. Combinatorial pharmacogenomic testing has demonstrated utility in guiding prescribing for psychotropic medications in patients with depression by identifying medications unlikely to be safe or effective due to significant gene-drug interactions. Here we present data from two small, randomized, controlled trials (RCTs) designed to test the hypothesis that combinatorial pharmacogenomic testing could aid in treatment selection for BPSD. Methods The first RCT included residents being treated at the Bayleigh Chance retirement community in Maryland (inpatient RCT). The second RCT included patients from the University of Alabama at Birmingham Memory Disorders Clinic (outpatient RCT). Patients were eligible if they had a diagnosis of dementia with psychotic symptoms and/or behavioral disturbance and their condition was severe enough to trigger a consultation with a physician (inpatient RCT) or their physician was considering starting/changing a psychotropic medication (outpatient RCT). For the outpatient RCT, patients were also required to have a caregiver who spends at least 10 hours a week with them. Informed consent was obtained at the screening visit from patients’ legally authorized representatives. The inpatient RCT intended to enroll 50 patients and the outpatient RCT intended to enroll 100 patients. Both studies were stopped early due to slow enrollment. Patients were randomized 1:1 to treatment as usual (TAU) or the combinatorial pharmacogenomic-guided care arm. All patients received combinatorial pharmacogenomic testing (GeneSight, Assurex Health). Variants in multiple pharmacokinetic and pharmacodynamic genes were assessed and a weighted combinatorial algorithm categorized medications according to the level of predicted gene-drug interactions (GDI). For patients in the guided-care arm, physicians had access to the test report at the time of the baseline visit. Physicians were blinded to the test report until after the trial for patients in TAU. Assessments were performed at baseline, week 2 (AEs only, inpatient RCT only), week 4 (outpatient RCT only), week 8, and week 12. The primary outcome was the Neuropsychiatric Inventory (NPI), which assesses the presence and severity of BPSD across 12 domains. The nursing home version (NPI-NH) was used for the inpatient RCT and the NPI questionnaire (NPI-Q) was used for the outpatient RCT. A Mixed Model for Repeated Measures (MMRM) was utilized to evaluate NPI and included treatment, week, treatment-by-week interaction, baseline score, baseline score-by-week interaction as fixed effects. The presence of a condition (i.e. depression) was evaluated as a score >0 for the relevant domain on the NPI. Side effects were evaluated using the SA-EPS and MOSES scale (inpatient RCT) or the FIBSER scale (outpatient RCT). Changes in prescribing relative to a pre-test intended medication plan were evaluated in the outpatient RCT. Results A total of 12 patients were enrolled in the inpatient RCT (5 in TAU; 7 in guided-care) and 38 patients were enrolled in the outpatient RCT (19 in TAU; 19 in guided-care). At week 12, there were no significant differences in NPI or side effects between guided-care and TAU in either RCT (Table 1). However, the proportion of outpatients experiencing depression at week 12 was significantly lower in the guided-care arm versus TAU (p=0.0479). In the outpatient RCT, the proportion of patients prescribed at least one medication subject to GDI decreased from 58.8% (pre-test) to 25.0% (week 12) in the guided-care arm (Table 2). In contrast, there was an increase in the proportion of patients in TAU taking medications subject to GDI throughout the trial. A significantly higher proportion of patients in the guided-care arm had a reduction in the number of prescribed psychotropic medications by week 12 compared to TAU (Table 2). Conclusions Overall, there were no observed differences in overall neuropsychiatric symptoms or side effects among inpatients or outpatients who received pharmacogenomic-guided care compared to TAU. It should be noted that these studies were stopped early due to slow enrollment and were likely underpowered to detect any differences. However, there was a significant reduction in the proportion of outpatients with depression in the guided care arm, which is consistent with the validated use of combinatorial pharmacogenomic testing among patients with depression. There was also evidence that pharmacogenomic-guided care did inform prescribing, with reduced prescribing of medications subject to GDI and reduced psychotropic medication polypharmacy. Funding Myriad Neuroscience (Formerly Assurex Health)

Key PointsQuestionWhat is the best dosing regimen for augmenting exposure therapy for social anxiety disorder with D-cycloserine? FindingsIn this double-blind, placebo-controlled, randomized clinical trial involving 152 adults with social anxiety disorder, D-cycloserine augmented the treatment effects when administered before or after the exposure sessions. A tailored approach based on exposure success, as defined by low fear at the end of exposure practice, did not facilitate the therapy effects. MeaningD-cycloserine augments exposure therapy for social anxiety disorder, although further optimizing the effects of D-cycloserine augmentation requires research on identifying the targets for tailored approaches. This randomized clinical trial examines whether D-cycloserine administration augments exposure therapy for adults with social anxiety disorder. ImportanceFindings suggest that the efficacy of D-cycloserine (DCS) for enhancing exposure therapy may be strongest when administered after sessions marked by low fear at the conclusion of exposure practice. These findings have prompted investigation of DCS dosing tailored to results of exposure sessions. ObjectiveTo compare tailored postsession DCS administration with presession DCS administration, postsession DCS administration, and placebo augmentation of exposure therapy for social anxiety disorder. Design, Setting, and ParticipantsThis double-blind randomized clinical trial involved adults with social anxiety disorder enrolled at 3 US university centers. Symptom severity was assessed at baseline, weekly during treatment, and at 1-week and 3-month follow-up. Data analysis was performed from September 2019 to March 2020. InterventionsParticipants completed a 5-session treatment and received pills commensurate with their condition assignment at sessions 2 through 5, which emphasized exposure practice. Main Outcomes and MeasuresSymptom severity was evaluated by the Liebowitz Social Anxiety Scale and Social Phobic Disorders-Severity Form as administered by independent evaluators. ResultsA total of 152 participants were enrolled (mean [SD] age, 29.24 [10.16] years; 84 men [55.26%]). Compared with placebo, presession and postsession conditions showed greater symptom improvement (b=-0.25; 95% CI, -0.37 to -0.13; P<.001; d=1.07; and b=-0.20; 95% CI, -0.32 to -0.07; P=.002; d=0.85) and lower symptom severity (b=-0.51; 95% CI, -0.81 to -0.21; P<.001; d=0.76; and b=-0.49; 95% CI, -0.80 to -0.18; P=.002; d=0.72) at 3-month follow-up. No differences were found between presession and postsession conditions. The tailored condition showed no advantage over placebo. Compared with the tailored condition, presession and postsession conditions evidenced greater decreases (b=-0.22; 95% CI, -0.34 to -0.10; P<.001; d=0.94; and b=-0.17, 95% CI, -0.29 to -0.04; P=.008; d=0.72) and lower symptom severity (b=-0.44, 95% CI, -0.73 to -0.14; P=.004; d=0.64; and b=-0.41, 95% CI, -0.72 to -0.11; P=.008; d=0.61) at 3-month follow-up. Conclusions and RelevanceAdministration of DCS enhanced exposure therapy for social anxiety disorder when given before or after the exposure session. However, the study failed to achieve the aim to develop a tailored clinical application. Trial RegistrationClinicalTrials.gov Identifier: NCT02066792

BACKGROUND:The experience of Military Sexual Trauma (MST) in the form of sexual assault and sexual harassment is common during service in the U.S. Armed Forces and often leads to adverse health outcomes including posttraumatic stress disorder (PTSD). Improving treatment of MST-related PTSD across settings is important to optimize treatment for survivors. The delivery of Cognitive Processing Therapy (CPT) in an intensive treatment program (ITP) shows promise for rapid reduction of PTSD symptoms for veterans and service members (veterans). However, a recent outcome study suggested that this modality is significantly less effective in reducing symptoms of PTSD for survivors of MST compared to veterans recovering from combat trauma. METHODS:-The current study examines the utility of modifications made to a CPT-based ITP designed to treat PTSD secondary to MST in a mixedgender sample (N = 285). Treatment modifications included the introduction of skills-based groups in emotion regulation and interpersonal domains. Individual skills-consultation sessions were also offered to participants on an as-needed basis. Further, training was provided to both clinical and non-clinical staff to increase understanding of the unique experiences and needs of MST survivors. RESULTS:Program changes proved beneficial, resulting in PTSD treatment outcomes that were comparable for survivors of MST and combat traumas. LIMITATIONS:Further research is needed to determine which of these specific program changes were most impactful in improving symptom outcomes. CONCLUSIONS:Our findings suggest that short-term, intensive PTSD treatment for MST survivors may be improved by integrating present-focused, skills-based therapies and staff sensitivity training.

Objectives Mindfulness training is frequently included as part of an integrative care approach to treating PTSD in veterans. However, the utility and acceptability of daily group mindfulness training in an intensive treatment program (ITP) for PTSD have not been explored. The study objectives were to determine: (a) whether mindfulness skills significantly increased from pre- to post-treatment and (b) if daily group mindfulness training was acceptable to veterans. Methods Veterans (N = 170 outpatients, age M = 40.7 (SD 9.3), 67.6% male) in this prospective study were consecutively enrolled in a 3-week ITP that included daily mindfulness group sessions. Mindfulness skills were assessed using the Five Facet of Mindfulness Questionnaire (FFMQ) at intake and post-treatment. Acceptability was assessed using an anonymous post-treatment program satisfaction survey. Results Paired t tests demonstrated significant increases in overall mindfulness skills from pre- to post-treatment (t(169) = - 6.33, p < 0.001, d = 0.49). Small to medium effect sizes were observed across subscales: describing, (t(169) = - 5.91, p < 0.001, d = 0.38); acting with awareness, (t(169) = - 3.70, p < 0.001, d = 0.29); nonjudging, (t(169) = - 7.54, p < 0.001, d = 0.58); and nonreactivity, (t(169) = - 4.84, p < 0.001, d = 0.41). Most veterans (n = 125, 74.4%) found daily mindfulness training moderately to very helpful. Conclusions Veterans' mindfulness skills significantly increased over the course of a 3-week ITP, and mindfulness training was found acceptable. Mindfulness training can be delivered daily as part of an ITP for veterans with PTSD, and mindfulness skills can meaningfully increase over the course of 3 weeks. A significant limitation is the lack of control condition.

Background Intensive treatment programmes (ITPs) have shown promise for reducing PTSD and depression symptoms. It is still unknown whether treatment gains are maintained following completion. Objective This study examined whether veterans were able to maintain treatment gains for up to 12 months after an ITP for PTSD and whether reductions in negative posttrauma cognitions predicted treatment gain maintenance. Methods 209 veterans (62.7% male, mean age = 40.86 years) completed a 3-week, CPT-based ITP for PTSD. Participants' PTSD (PCL-5) and depression (PHQ-9) symptoms were assessed at pre-treatment, post-treatment, and at 3-, 6-, and 12-month follow-up timepoints. Results Despite small symptom increases from post-treatment to 3-month follow-up, significant and clinically meaningful reductions in PTSD and depression symptoms were reported from intake to 12 months follow-up (averaging >18 points on the PCL-5 and >6 points on the PHQ-9;d= 1.28, andd= 1.18, respectively). Greater reductions in negative posttrauma cognitions during treatment were associated with lower PTSD (p<.001) and depression (p=.005) severity at follow-up. Most veterans who completed the aftercare survey followed treatment recommendations and reported seeing a mental health provider at 3-, 6-, and 12-months post-treatment. Aftercare treatment did not significantly predict whether veterans maintained treatment gains at follow-up. Conclusions Overall maintenance of treatment gains long-term suggests veterans may be able to apply skills acquired during the ITP following treatment. These findings further support the feasibility and effectiveness of intensive, trauma-focused, evidence-based therapy delivery.

Electronic health records (EHRs) offer opportunities for research and improvements in patient care. However, challenges exist in using data from EHRs due to the volume of information existing within clinical notes, which can be labor intensive and costly to transform into usable data with existing strategies. This case report details the collaborative development and implementation of the postencounter form (PEF) system into the EHR at the Road Home Program at Rush University Medical Center in Chicago, IL to address these concerns with limited burden to clinical workflows. The PEF system proved to be an effective tool with over 98% of all clinical encounters including a completed PEF within 5 months of implementation. In addition, the system has generated over 325,188 unique, readily-accessible data points in under 4 years of use. The PEF system has since been deployed to other settings demonstrating that the system may have broader clinical utility.

Previous research has demonstrated that sleep disturbances show little improvement with evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, sleep improvements are associated with PTSD treatment outcomes. The goal of the current study was to evaluate changes in self-reported insomnia symptoms and the association between insomnia symptoms and treatment outcome during a 3-week intensive treatment program (ITP) for veterans with PTSD that integrated cognitive processing therapy (CPT), mindfulness, yoga, and other ancillary services. As part of standard clinical procedures, veterans (N = 165) completed self-report assessments of insomnia symptoms at pre- and posttreatment as well as self-report assessments of PTSD and depression symptoms approximately every other day during treatment. Most veterans reported at least moderate difficulties with insomnia at both pretreatment (83.0%-95.1%) and posttreatment (69.1-71.3%). Statistically significant reductions in self-reported insomnia severity occurred from pretreatment to posttreatment; however, the effect size was small, d = 0.33. Longitudinal mixed-effects models showed a significant interactive effect of Changes in Insomnia × Time in predicting PTSD and depression symptoms, indicating that patients with more improvements in insomnia had more positive treatment outcomes. These findings suggest that many veterans continued to struggle with sleep disruption after a 3-week ITP, and successful efforts to improve sleep could lead to better PTSD treatment outcomes. Further research is needed to establish how adjunctive sleep interventions can be used to maximize both sleep and PTSD outcomes.