Search

A top priority for the Veteran’s Healthcare Administration is improving access to high-quality mental healthcare. Mobile and telemental healthcare are a vital component of increasing access for veterans. The Veteran’s Healthcare Administration is making efforts to further broaden how veterans receive their care through VA Video Connect, which allows veterans to connect with their provider from their residence or workplace. In this mixed-methods study, successes and challenges associated with the rapid implementation of VA Video Connect telemental health appointments are examined through (1) administrative data and (2) qualitative interviews at one medical center. Within 1 year of the telehealth initiative, the number of providers experienced with telemental health increased from 15% to 85%, and telehealth appointments increased from 5376 to 14,210. Provider reported barriers included administrative challenges and concerns regarding care. Having an implementation model of telehealth champions and a team of experienced mental health providers allowed for rapid adoption of telehealth. Utilizing a similar model in other settings will further enable more veterans with depression and anxiety to have access to evidence-based psychotherapy, regardless of location or national crisis. With the dramatic increase in both training for providers as well as veteran use of telemental healthcare during the COVID-19 pandemic response, future research should aim to better understand which teams were able to switch to telehealth easily versus those which struggled, along with examining system-wide and provider-level factors that facilitated continued use of telehealth after social distancing requirements related to COVID-19 were relaxed. Electronic supplementary material The online version of this article (10.1007/s41347-020-00161-8) contains supplementary material, which is available to authorized users.

Background: Identifying and enhancing protective beliefs is essential in reducing suicide risk among military-affiliated individuals. The goal of this study was to examine if specific reasons for living impact the relationship between PTSD and suicidal cognitions among military-affiliated individuals in primary care settings. Methods: Participants included 2,685 U.S. military personnel and their adult beneficiaries recruited from primary care clinics. Participants completed the Primary Care Posttraumatic Stress Disorder Screen, Suicide Cognitions Scale, and Brief Reasons for Living Inventory. Results: Responsibility to family and survival and coping beliefs—were related to suicidal cognitions with higher levels associated with less suicidal cognitions and a weaker relationship between PTSD and suicidal cognitions. By contrast, fear of suicide and fear of social disapproval were associated with more suicidal cognitions, and the link between positive PTSD screen and suicidal cognitions was stronger for individuals with higher levels of fear of social disapproval. Moral objection did not predict suicidal cognitions and did not moderate the relationship between PTSD and suicidal cognitions. Limitations: The limitations of the study include that measures were done in primary care and brief screeners were often used. Additionally, the study is cross-sectional in nature, whereas some of the symptoms and outcome variables likely fluctuate over time. Conclusions: Findings suggest not all reasons for living are not equally influential and, among military-affiliated individuals with a positive PTSD screen, bolstering reasons for living related to responsibility to family and survival and coping skills could be particularly impactful in reducing suicide cognitions.

Objectives Exposure-based psychotherapies for posttraumatic stress disorder (PTSD) are effective for many, but not all patients. It is important to determine for whom these treatments work and to examine predictors of success. Method An 8-week modified prolonged exposure (PE) treatment, including components of behavioral activation and reducing the number of imaginal exposure sessions, was administered to a sample of 231 Veterans (mean age = 45.7 years, standard deviation = 14.89). Growth mixture modeling was used to model PTSD symptom trajectories across the 8-week intervention and a postintervention appointment. Further, baseline demographics, social support, clinician-rated PTSD symptoms, anxiety, and depression were examined as predictors of trajectories. Results Three classes emerged, labeled responders (n = 35), nonresponders (n = 190), and immediate responders (n = 6). The only significant baseline difference between responders and nonresponders was higher anxiety symptoms in the nonresponders. At follow-up time points, there were higher levels of clinician-rated PTSD, anxiety, and depression symptoms and lower social support in the nonresponders compared to the responders. Conclusion Findings suggest that modifying standard PE treatments by reducing imaginal exposure sessions while adding behavioral activation may not be advisable for most Veterans with PTSD.

Both pharmacotherapy and psychotherapy are effective treatments for posttraumatic stress disorder (PTSD). Better understanding factors that are associated with engaging in these different treatment options may improve treatment utilization and outcomes. This issue is especially important among veterans returning from Iraq and Afghanistan, given high rates of those seeking PTSD treatment. This study examined potential predictors of the type of treatment (psychotherapy, pharmacotherapy, or both) 232 returning veterans (92% male, mean age = 33.38) engaged in within 1 year of seeking treatment at a VA PTSD clinic. Results indicated that 32.3% of returning veterans engaged in pharmacotherapy only, 23.7% engaged in psychotherapy only, and 44.0% engaged in both. Veterans who engaged in pharmacotherapy only or in both pharmacotherapy and psychotherapy had higher pretreatment PTSD and depression symptoms than did those who engaged in psychotherapy only. History of pharmacotherapy treatment was associated with engagement in pharmacotherapy only or both pharmacotherapy and psychotherapy, as compared with psychotherapy only. Treatment engagement type was not significantly associated with differences in age, gender, race/ethnicity, service branch, alcohol use/misuse, history of psychotherapy, distance from the VA, or PTSD service connection. Implications for enhancing PTSD treatment engagement are discussed. (PsycINFO Database Record

Introduction Post-traumatic stress disorder (PTSD) has been linked to a variety of adverse mental and physical health outcomes including distressed relationships. Involving romantic partners in PTSD treatment appears to be a promising new avenue for PTSD treatment; however, additional research is necessary to clarify veteran preferences for inclusion of significant others in treatment and relationship characteristics that may influence such preferences. Accordingly, the present study was designed to evaluate Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veterans' desire to include romantic partners in trauma-focused care (n = 74) and to explore psychological and relationship variables associated with preference for partner inclusion in PTSD treatment. Materials and methods This study surveyed male (N = 74) OEF/OIF/OND combat veterans seeking mental health services at a Veterans Health Administration PTSD treatment program. Relationships between PTSD symptoms, romantic relationship functioning, and interest in including their romantic partner in PTSD treatment were examined. Results Consistent with previous research, OEF/OIF/OND veterans seeking treatment at a specialty PTSD program report low relationship satisfaction. The majority of participants reported that PTSD symptoms interfere with relationship functioning; specifically, numbing symptoms were a significant predictor of PTSD-related relationship impairment. A minority (26%) of participants reported a desire to include their romantic partner in PTSD treatment. Greater behavioral avoidance and communication difficulties were associated with increased interest in including a romantic partner in PTSD treatment. Conclusion We confirmed that OEF/OIF/OND veterans seeking PTSD treatment experience PTSD-related problems in romantic relationships, low-relationship satisfaction, and relationship satisfaction was positively associated with perceived communication and problem-solving skills. A minority of veterans were interested in involving significant others in their PTSD treatment; however, in the present study, veterans were not given information about the various ways that a romantic partner might be involved in treatment, and they were not presented with specific conjoint therapies (e.g., Cognitive-Behavioral Conjoint Therapy for PTSD, Strategic Approach Therapy). For veterans with PTSD, relationship distress, and communication difficulties, conjoint psychotherapies may offer a way of increasing engagement in PTSD treatment by parsimoniously addressing multiple treatment targets at once (PTSD symptoms, relationship distress, communication problems) and providing veteran-centered care.

Sexual relationship development in adolescence can be affected by substance use. Substance use and risky sexual behavior frequently co-occur, and their co-occurrence is associated with short- and long-term negative consequences. The relationship appears to be bidirectional in nature, with substance use acting as a risk factor for risky sexual behavior and risky sexual behavior acting as a risk factor for substance use. Proposed mechanisms to explain this relationship include personality traits such as impulsivity or sensation-seeking tendencies, expectancies about how substances will affect sexual experiences, and effects of media messages that normalize substance use and sexual behavior for adolescents. Peer influence, family factors, and a constellation of problem behaviors that reinforce one another can also play a role. However, there are no integrative models to explain the relationship between substance use and sexual relationship development.

Context The rising rate of overweight and obese individuals among developing countries despite focused efforts on prevention and treatment underscores not only the need to better define the physiological factors that contribute to weight problems, but also the need to elucidate the neurobiological mechanisms of the self-regulatory failure over eating that leads to weight problems. Emergent findings suggest an overlapping model of addiction and compulsive overeating. Objective Our goal was to examine whether neural hyper-responsivity to reward typically associated with substance abuse could also be seen in individuals exhibiting binge-eating behavior. Design Participants completed self-assessments of demographic information and eating behavior. Neurofunctional data were collected via functional MRI (fMRI) scans while participants were exposed to personally relevant high-calorie cues. Setting The participants were recruited from the general community. Participants Twenty‐six individuals with high body mass index (BMI) > 25 and moderate binge‐eating behavior as assessed by the Binge Eating Scale (BES) were recruited for this study. Main Outcome Measures fMRI BOLD response during exposure to high-calorie taste cues. Results The results showed that exposure to high-calorie taste cues elicited fMRI BOLD response in the reward system of individuals with high BMI, and, more importantly, that this hyper-responsivity increases with greater number of binge‐eating symptoms (cluster-corrected p z = 1.9). Conclusions These findings support an overlapping neural model of addiction and self-regulatory failure over eating that may lead to problems with weight in humans. These findings offer insight into the prevention and treatment of disordered eating.

As previous work has highlighted the significance of the cannabinoid receptor 1 (CNR1) and fatty acid amide hydrolase (FAAH) genes with respect to cannabis dependence (CD), this study sought to characterize the neural mechanisms that underlie these genetic effects. To this end, we collected DNA samples and fMRI data using a cue-elicited craving paradigm in thirty-seven 3-day-abstinent regular marijuana users. The participants were grouped according to their genotype on two single-nucleotide polymorphisms (SNPs) earlier associated with CD phenotypes: rs2023239 in CNR1 and rs324420 in FAAH. Between-group comparisons showed that carriers of the CNR1 rs2023239 G allele had significantly greater activity in reward-related areas of the brain, such as the orbitofrontal cortex (OFC), inferior frontal gyrus (IFG), and anterior cingulate gyrus (ACG), during exposure to marijuana cues, as compared with those with the A/A genotype for this SNP. The FAAH group contrasts showed that FAAH rs324420 C homozygotes also had greater activation in widespread areas within the reward circuit, specifically in the OFC, ACG, and nucleus accumbens (NAc), as compared with the FAAH A-allele carriers. Moreover, there was a positive correlation between neural response in OFC and NAc and the total number of risk alleles (cluster-corrected p

Treatment engagement rates are low for individuals with comorbid posttraumatic stress disorder (PTSD) and alcohol use disorders across available interventions and treatment modalities. A better understanding of who does and does not engage in treatment can help improve retention, completion, and subsequent treatment outcomes.Forty female survivors of intimate partner violence with PTSD and alcohol use disorder participated in a randomized controlled trial comparing twenty-five 90-minute sessions of either modified Seeking Safety or Facilitated Twelve-Step in a community-based outpatient clinic. This study examined differences in demographics and pre-treatment PTSD symptoms and alcohol use between participants who engaged in treatment (attended ≥ 6 sessions, n = 18) and those who dropped out (n = 22).There were no significant differences in PTSD or alcohol use disorder symptoms between treatment conditions. Women who engaged in therapy versus those who did not were significantly older (M = 46.2, SD = 9.14 vs. M = 38.95, SD = 10.49, respectively; p =.027), and had fewer dependents (M =.17, SD =.38, range = 0-1 vs. M =.95, SD = 1.66, range = 1-7, respectively; p =.046). Greater avoidance/numbing PTSD symptoms (OR = 1.13, p =.028, 95% CI [1.02-1.25]) and more years of heavy drinking (OR = 1.04, p =.03, 95% CI [1.00-1.07]) were also significantly associated with treatment engagement.This study replicates previous findings suggesting a need for additional retention strategies for younger women with dependents in comorbid PTSD and alcohol use disorder treatment. This is an analysis of data collected as part of a clinical trial registered as NCT00607412, at www.clinicaltrials.gov.

Guilt related to combat trauma is highly prevalent among veterans returning from Iraq and Afghanistan. Trauma-related guilt has been associated with increased risk for posttraumatic psychopathology and poorer response to treatment. Trauma Informed Guilt Reduction (TrIGR) therapy is a 4-module cognitive-behavioral psychotherapy designed to reduce guilt related to combat trauma. The goals of this study were to describe the key elements of TrIGR and report results of a pilot study with 10 recently deployed combat veterans. Ten combat veterans referred from a VA Posttraumatic Stress Disorder (PTSD) or mental health clinic completed TrIGR over 4 to 7 sessions. Nine veterans completed the posttreatment assessment. This initial pilot suggests that TrIGR may help to reduce trauma-related guilt severity and associated distress. Changes in trauma-related guilt were highly correlated with reductions in PTSD and depression symptoms over the course of treatment, suggesting a possible mechanistic link with severity of posttraumatic psychopathology. TrIGR warrants further evaluation as an intervention for reducing guilt related to traumatic experiences in combat.

Understanding how alcohol expectancies relate to alcohol use among individuals with concurrent alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) is important to understanding and treating this comorbidity. This study examined the role of positive and negative alcohol expectancies and PTSD symptoms in drinking behavior in a comorbid female sample. Participants were women (n = 33; 56% Caucasian) seeking AUD and PTSD treatment in an outpatient community co-occurring disorders program. Hypotheses related to drinking days and alcohol problems outcomes were evaluated using negative binomial hierarchical regression. PTSD symptoms were associated with fewer reported days of alcohol-related problems. Negative expectancies related to negative changes in social behavior associated with drinking days and cognitive and motor impairment associated with problems. Both the general positive expectancies score and specific global positive change subscale were uniquely associated with drinking and alcohol-related problems days after controlling for PTSD symptom severity and negative expectancies scores. Results suggest that both negative and positive expectancies about alcohol's effects are important correlates of drinking behavior among women with AUD and PTSD, with positive expectancies playing a potentially more salient role on use and consequences than symptom severity and negative expectancies.

In spite of evidence suggesting two possible mechanisms related to drug-seeking behavior, namely reward-seeking and harm avoidance, much of the addiction literature has focused largely on positive incentivization mechanisms associated with addiction. In this study, we examined the contributing neural mechanisms of avoidance of an aversive state to drug-seeking behavior during marijuana withdrawal. To that end, marijuana users were scanned while performing the monetary incentive delay task in order to assess positive and negative incentive processes. The results showed a group x incentive interaction, such that marijuana users had greater response in areas that underlie reward processes during positive incentives while controls showed greater response in the same areas, but to negative incentives. Furthermore, a negative correlation between withdrawal symptoms and response in the amygdala during negative incentives was found in the marijuana users. These findings suggest that although marijuana users have greater reward sensitivity and less harm avoidance than controls, that attenuated amygdala response, an area that underlies fear and avoidance, was present in marijuana users with greater marijuana withdrawal symptoms. This is concordant with models of drug addiction that involve multiple sources of reinforcement in substance use disorders, and suggests the importance of strategies that focus on respective mechanisms.

Posttraumatic stress disorder (PTSD) and alcohol/substance use disorder (A/SUD) are frequently comorbid. Comorbidity is associated with poorer psychological, functional, and treatment outcomes than either disorder alone. This review outlines biological mechanisms that are potentially involved in the development and maintenance of comorbid PTSD and A/SUD including neurotransmitter and hypothalamic–pituitary–adrenal dysregulation, structural differences in the brain, and shared genetic risk factors. The literature regarding pharmacological treatments that have been investigated for comorbid PTSD and A/SUD is also reviewed. Empirical data for each proposed mechanism and pharmacological approach is reviewed with the goal of making recommendations for future research. This article is part of a Special Issue entitled ‘Post-Traumatic Stress Disorder’.

Craving is one of the primary behavioral components of drug addiction, and cue-elicited craving is an especially powerful form of this construct. While cue-elicited craving and its underlying neurobiological mechanisms have been extensively studied with respect to alcohol and other drugs of abuse, the same cannot be said for marijuana. Cue-elicited craving for other drugs of abuse is associated with increased activity in a number of brain areas, particularly the reward pathway. This study used functional magnetic resonance imaging (fMRI) to examine cue-elicited craving for marijuana. Thirty-eight regular marijuana users abstained from use for 72 h and were presented with tactile marijuana-related and neutral cues while undergoing a fMRI scan. Several structures in the reward pathway, including the ventral tegmental area, thalamus, anterior cingulate, insula, and amygdala, demonstrated greater blood oxygen level dependent (BOLD) activation in response to the marijuana cue as compared with the neutral cue. These regions underlie motivated behavior and the attribution of incentive salience. Activation of the orbitofrontal cortex and nucleus accumbens was also positively correlated with problems related to marijuana use, such that greater BOLD activation was associated with greater number of items on a marijuana problem scale. Thus, cue-elicited craving for marijuana activates the reward neurocircuitry associated with the neuropathology of addiction, and the magnitude of activation of these structures is associated with severity of cannabis-related problems. These findings may inform the development of treatment strategies for cannabis dependence.