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While considerable resources are dedicated to preparing patients and their significant others for the process of physical recovery and rehabilitation following illness/injury, provision of information and support regarding the trajectory of psychosocial recovery from these stressors is not the standard of care in clinical medical settings. Given the strong influence of social environment on cognitive-emotional processing and psychosocial adjustment following illness and injury, it is important to identify interventions that help medical patients and their families to create a family environment that is conducive to processing and support. In this article, we (a) briefly review relevant literature on the psychosocial impact of illness and injury, the importance of cognitive-emotional processing and social environment to illness/injury-related adjustment, and existing models of intervention in the medical setting; (b) describe a brief intervention we have developed and pilot-tested to promote cognitive-emotional processing among medical patients and their families; (c) describe our clinical experiences with the intervention to date; and (d) offer suggestions for delivery of the intervention in clinical practice and for conducting research on its efficacy.

The authors examined the degree to which provider characteristics, such as profession, treatment orientation, prior experience in treating posttraumatic stress disorder (PTSD), prior experience with prolonged exposure (PE) therapy, and attitudes about PE, were related to the clinical outcomes of veterans receiving care from clinicians participating in the national Department of Veterans Affairs (VA) PE Training Program. Positive patient outcomes were achieved by providers of every profession, theoretical orientation, level of clinical experience treating PTSD, and prior PE training experience. With 1,105 providers and 32 predictors (13 provider variables), power was at least 90% power to detect an effect of β = .15. Profession was the only provider characteristic significantly related to outcomes, but the mean effect (a 2 point difference on the PTSD Checklist) was too small to be clinically meaningful. The results support the intensive training model used in the VA PE training program and demonstrate that clinicians of varying backgrounds can be trained using interactive training workshops followed by case consultation to deliver PE effectively.

The past couple of decades have witnessed a veritable explosion of technology development and services with nearly ubiquitous uptake of innovative electronic products. In fact, today about 40 % of the earth’s population has access to the Internet, and there are almost as many mobile phone subscriptions as there are people on the planet (International Telecommunications Union [ITU] 2014). Virtually overnight, we have become reliant on these technologies for many of our everyday activities, such as finding information, shopping, banking, and staying connected to friends and family. Modes of communication have multiplied to include options such as no-cost web-based video calling, instant messaging at home or on the go, and asynchronous microblogging tools for connected self-reflection. The latest generation of mobile phones, called smartphones, offers capabilities and functions that only a few short years ago were unimaginable or only available on stationary computers. As these technologies continue to transform our everyday lives, their potential to address the tremendous unmet mental healthcare needs of trauma survivors is also beginning to be realized through innovative telemental health (TMH) approaches.

In this article, the authors review the current empiric literature on early interventions. Findings on the effects, course, help-seeking, and recovery from disasters are first reviewed, with recommendations given that are pertinent to intervention following mass casualties. In reviewing the most commonly used interventions, it is clear that evidence from well-controlled studies showing that early intervention can help prevent longer-term problems is limited. The authors discuss the approaches that have received the most attention or empiric support as early interventions following trauma, which include psychologic debriefing, cognitive-behavioral interventions, eye movement desensitization and processing (EMDR) and other neoteric approaches, and psychopharmacology. At this time, the most promising results for prevention of psychopathology have been achieved with brief four- or five-session cognitive-behavioral therapy. In contrast, randomized clinical trials on psychologic debriefing currently suggest that this approach is either ineffective at preventing psychopathology, or contributive to post-traumatic stress disorder symptoms. Research support is currently lacking for EMDR and pharmacotherapy as early interventions. A major challenge to the field is to integrate the practical experience and knowledge of professional responders with well-controlled, timely intervention research, and to effectively disseminate these findings to practitioners in the field.

Despite potential advantages in scalability and efficiency of web-based training for trauma providers, few controlled trials of feasibility and effectiveness of web-based mental health training have been performed. Our study compared web-based training in 3 intervention skills (motivation enhancement [ME], goal setting [GS], behavioral task assignment [BTA]) with web-based training plus telephone consultation, and a no-training control. The primary outcome measures included objective measures of skills acquisition (standardized patient assessments). Results showed significant differences among the training conditions. The overall tests of differences among the groups were statistically significant for ME and BTA skills (p.001 and p = .005, respectively), but not for GS (p = .245). The web training plus consultation group improved in ME skills by 0.35 units compared to 0.12 units in the web only group (p.001) and no change in the control group (p = .001). For BTA skills, the web training plus consultation improved by 0.27 units compared to 0.17 units in the web only group (p = .175) and no change in the control group (p = .004). Overall, these findings support the use of web-based dissemination for large-scale training programs for trauma providers in health care delivery systems. Further studies are needed to clarify the specific role of consultation as an adjunct to web-based training.

CERV-PTSD is a randomized controlled trial of two of the most effective treatments for PTSD, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). Despite solid evidence that both treatments are effective, there is limited evidence about their effectiveness relative to one another. The primary objective is to compare the effectiveness of PE and CPT for reducing PTSD symptom severity in a healthcare system that offers both treatments. The secondary objective is to compare the effectiveness of PE and CPT for reducing the severity of comorbid mental health problems and service utilization as well as improving functioning and quality of life. The tertiary objective is to examine whether discrepancy between patient preferences and treatment assignment reduces the effectiveness of each treatment. Exploratory analyses will examine whether demographic and clinical characteristics predict differential response to PE and CPT. The study is designed to randomize 900 male and female veterans with PTSD due to any traumatic military event to receive PE or CPT. The standard dose of treatment is 12 weekly sessions but veterans who improve more rapidly may finish in fewer sessions and veterans who improve more slowly may have additional sessions. The primary outcome is improvement in PTSD symptoms, measured during and after treatment and then 3 and 6 months later. As a large multi-site trial with men and women, CERV-PTSD is designed to advance the delivery of care for PTSD by providing conclusive information about whether one treatment is better than the other, overall, and for different types of patients.

This study examines the implementation of two evidence-based psychotherapies, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), in the Department of Veterans Affairs residential Posttraumatic Stress Disorder treatment programs. Two hundred and one providers from 38 programs completed an online survey concerning implementation of PE delivered on an individual basis and CPT delivered in individual and group formats. For PE, a supportive organizational context (dedicated time and resources, and incentives and mandates) and overall positive view of the treatment were related to its implementation. For both group and individual CPT, only the supportive organizational context was significantly associated with outcome. Implications for implementation efforts are discussed.

This study examines pretraining attitudes toward prolonged exposure (PE) therapy in a sample of 1,275 mental health clinicians enrolled in a national PE training program sponsored by the U.S. Department of Veterans Affairs. Attitudes assessed via survey included values placed on outcomes targeted by PE, outcome expectancies (positive expectancies for patient improvement and negative expectancies related to patient deterioration, clinician time burden, and clinician emotional burden), and self-efficacy for delivering PE. Results indicated that clinicians were receptive to learning PE and had positive expectations about the treatment, but expressed concerns that PE might increase patient distress. Responses varied by clinician characteristics with psychologists, clinicians working in specialty PTSD treatment settings (as opposed to those in mental health clinics and other clinic types), and those with a primarily cognitive-behavioral orientation expressing attitudes that were most supportive of learning and implementing PE across various indicators. Implications for addressing attitudinal barriers to implementation of PE therapy are discussed.

Male inpatient veterans with chronic combat-related post-traumatic stress disorder (PTSD) participated in trauma focus group treatment and were assessed immediately before group participation and after group completion at time of discharge. Standard measures of core PTSD symptoms, depression, and anxiety were used. In addition, changes in PTSD symptoms were tracked on a weekly basis for the duration of group participation. Results indicated that a single direct elicitation of war-related traumatic memories in a group setting was not associated with symptom worsening. However, veterans also did not show improvement in symptoms severity. Possible reasons for this lack of impact are discussed along with implications for future treatment design and evaluation.

Many combat veterans with PTSD have co-occurring symptoms of other forms of psychopathology; however, there have been limited studies examining personality disorders among this population. The few extant studies typically have assessed only two or three personality disorders or examined a small sample, resulting in an incomplete picture and scope of comorbidity. This study assessed all DSM-III-R personality disorders in 107 veterans in a specialized, inpatient unit. Using the Structured Clinical Interview for DSM-III-R Personality Disorders, 79.4% of the participants were diagnosed with at least one personality disorder: 29.9% received only one diagnosis, 21.5% had two, 15.9% had three, and 12.1% had four or more. The most frequent single diagnoses were Avoidant (47.2%), Paranoid (46.2%), Obsessive-Compulsive (28.3%), and Antisocial (15.1%) personality disorders.

In times of disaster, emergency mental health services must be delivered in the field. This chapter reviews the current state of the literature and future trends in disaster mental health.

Although individual therapy involving imaginal experiencing of the traumatic event has been found to be effective in treating PTSD, there is evidence that few trauma therapists actually use the technique. Moreover, symptom improvement has been found to favor intrusive symptoms, whereas avoidance and hyperarousal have been less affected. Additionally, there are several published reports documenting difficulties in implementing the treatment, ranging from client refusal, adverse reactions, and therapist inexperience. In this article we outline an alternative group form of exposure therapy, manualized trauma focus group therapy (TFGT), designed to overcome some of these implementation obstacles and to enhance the effects of imaginal exposure to include those chronic PTSD symptoms of avoidance and social isolation. We describe the cognitive behavioral and developmental models from which the approach was derived, present clinical guidelines and an illustrative session, discuss complications we have encountered in TFGT pilot studies, and offer suggestions for improving future implementation. © 1997 John Wiley & Sons, Inc.

The purpose of this 4 year, randomized trial and comparative effectiveness study is to design, implement and evaluate a cost effective, web based self paced training program to provide skills-oriented continuing education for mental health professionals. The objective is to learn whether novel, internet-based training methods, with or without web-centered supervision, may provide an effective means to train increasing numbers of mental health providers in relevant, evidence-based clinical skills. The study will launch during the first quarter of the second year grant cycle. There are no research findings to date.

To better understand potential risk factors for post-traumatic stress disorder (PTSD) and homelessness in veterans, we studied trauma exposure and responses in archival data on 115 homeless veterans.Rates of exposure to military and a variety of civilian high magnitude stressor (HMS) and persistent post-traumatic distress (PPD) events and symptoms of post-traumatic stress were assessed. The relationships between frequency of different trauma types and symptoms of post-traumatic stress were examined.Exposure to both HMS and PPD events were extremely high in this sample, with particularly high exposure to adult (82%) and childhood (62%) interpersonal violence HMS events and HMS events during military service (53%). Exposure to both military and civilian PPD events was associated with significantly higher levels of PTSD symptoms than exposure to no PPD events or only civilian PPD events, and almost all HMS event types were significantly correlated with both PTSD and dissociation symptoms.Post-traumatic symptoms and military and civilian traumatic stressors of all types should be assessed in homeless veterans because they may be contributing to poor social and occupational functioning.

Co-occurring psychiatric diagnoses have a negative impact on quality of life and change the presentation and prognosis of bipolar disorder (BD). To date, comorbidity research on patients with BD has primarily focused on co-occurring anxiety disorders and trauma history; only recently has there been a specific focus on co-occurring PTSD and BD. Although rates of trauma and PTSD are higher in those with bipolar disorder than in the general population, little is known about differences across bipolar subtypes.Using the NIMH STEP-BD dataset (N=3158), this study evaluated whether there were baseline differences in the prevalence of PTSD between participants with bipolar disorder I (BDI) and bipolar disorder II (BDII), using the MINI and the Davidson Trauma Scale. Differences in PTSD symptom clusters between patients with BDI and BDII were also evaluated.A significantly greater proportion of participants with BDI had co-occurring PTSD at time of study entry (Χ(2)(1)=12.6; p.001). BDI and BDII subgroups did not significantly differ in re-experiencing, avoidance, or arousal symptoms.The analysis may suggest a correlational relationship between PTSD and BD, not a causal one. Further, it is possible this population seeks treatment more often than individuals with PTSD alone. Finally, due to the episodic nature of BD and symptom overlap between the two disorders, misdiagnosis is possible.PTSD may be more prevalent in patients with BDI. However, the symptom presentation of PTSD appears similar across BD subtypes. Individuals should be thoroughly assessed for co-occurring diagnoses in an effort to provide appropriate treatment.

Does the Integration of Peers into the Treatment of Adults with Posttraumatic Stress Disorder Improve Access to Mental Health Care? A Literature Review and Conceptual Model Posttraumatic Stress Disorder (PTSD), which has been associated with significant impairment in socio-occupational functioning, continues to be a mental health diagnosis of relevance and importance both domestically in the U.S and globally. In the United States, perhaps one of the most current pressing public health concerns is treating PTSD in veterans who served in the recent conflicts in Iraq and Afghanistan. Up to 13% of veterans from the conflicts in Iraq and Afghanistan have combat-related PTSD and despite the availability of evidence based treatments, which ameliorate core PTSD symptoms and prevent further negative consequences such as substance abuse and suicide, help seeking veterans often do not follow up with the recommended course of psychological, or pharmacological therapies.

When crisis situations involving veterans occur, responding police officers find themselves playing an important role in the spectrum of health and mental health services for those veterans. Crisis response training can help officers respond in a manner that increases safety and optimizes outcomes for all people involved. Yet, current crisis response police training models are only accessible to select officers. Nor do they emphasize the unique challenges and strengths that impact veterans who experience acute symptoms of mental illness. In the current study, we report the results from the first generation of training, collaboratively designed to enhance officers' (a) knowledge of relevant topics, including posttraumatic stress disorder and traumatic brain injury, (b) attitudes about veterans, and (c) and skills helpful in identifying and deescalating veterans and referring them to treatment. Officers completed in-class evaluations (N = 314), and a subsample (n = 53) completed 3-month follow-up evaluations. Pre- versus posttest comparisons indicated significant improvements in total score, and individually in knowledge, attitudes, and skills. Consistent with previous literature, the specific in-class gains were not retained on follow-up. However, responding officers widely endorsed use of de-escalation techniques during, and a positive impact of the training on, their interactions with veterans in the 3 months following the training. Implications for future training and policy are discussed.

Prolonged exposure (PE) is an effective first-line treatment for posttraumatic stress disorder (PTSD), regardless of the type of trauma, for Veterans and military personnel. Extensive research and clinical practice guidelines from various organizations support this conclusion. PE is effective in reducing PTSD symptoms and has also demonstrated efficacy in reducing comorbid issues such as anger, guilt, negative health perceptions, and depression. PE has demonstrated efficacy in diagnostically complex populations and survivors of single- and multiple-incident traumas. The PE protocol includes four main therapeutic components (i.e., psychoeducation, in vivo exposure, imaginal exposure, and emotional processing). In light of PE's efficacy, the Veterans Health Administration designed and supported a PE training program for mental health professionals that has trained over 1,300 providers. Research examining the mechanisms involved in PE and working to improve its acceptability, efficacy, and efficiency is underway with promising results.

CLINICAL PRACTICE GUIDELINES The Department of Veterans Affairs (VA)/Department of Defense (DOD) clinical practice guidelines (CPGs) are recommendations that are made to VA/DOD healthcare providers regarding their approaches to treatment of a variety of medical conditions. They are based on the best available clinical evidence and are designed to achieve the most desirable outcomes based on a variety of clinical situations. In general, CPGs have been defined as "systematically developed statements to assist practitioner and patient in making decisions about appropriate healthcare for specific clinical circumstances" [1]. CPGs are being used throughout healthcare systems as a means of enhancing quality, reducing costs, and optimizing performance. Good CPGs can change the process of healthcare and improve outcomes by providing recommendations for the management of patients and supporting the development of standards to assess outcomes. A CPG should also assist in healthcare providers' education and training, likewise educating the patients; help in making informed decisions; and improve communication between the patient and provider. A CPG, when implemented, will influence practice patterns. GUIDELINE DEVELOPMENT There have been many recommended approaches to CPG development methodologies. The World Health Organization (WHO) assessed models of CPG development used internationally and identified the following best practices in CPG development [2]: * Developed by multidisciplinary CPG development working groups (WGs). * Explicit, transparent use of systematic reviews of evidence to develop recommendations. * Documentation of the CPG development process (including disclosure of interest declarations at all levels of involvement). * Include ratings of the evidence associated with key recommendations. * Defined and explicit process for consultation and peer review of the draft CPG. * Multiple level outputs, including versions (modules) for specialists, primary care professionals, and patients. The development and the underlying principles of the process used to develop the VA/DOD CPGs are very much consistent with the principles described by the WHO and those practiced by other healthcare organizations that have developed CPGs (e.g., National Institute for Health and Clinical Excellence and Institute for Clinical Systems Improvement). The VA/DOD process is also consistent with the proposed eight standards for developing trustworthy CPGs published recently by the Institute of Medicine [3]. CPGs are usually developed by groups of clinicians. Clinicians regularly make difficult choices about treatment options. Often, there is uncertainty about the value of different options, and practice can vary widely. CPGs can be seen as one way of assisting clinicians in decision-making. In an ideal world, CPGs would be based on evidence derived from rigorously conducted empirical studies. In practice, there are only few areas of care where sufficient research based evidence exists. In such situations, the development of comprehensive CPGs will inevitably have to be based partly on consensus of the opinions and experience of clinicians and others in the subject at hand. A technology assessment published in 1998, reviewed 177 primary research and review articles that studied the factors that affect the decisions that emerge from consensus development approaches and assessed the implications of the findings for the development of CPGs [4]. A group consensus process brings to bear a wider range of direct knowledge and experience. The interaction among the group members can stimulate consideration of a wider range of options, and debates can challenge old ideas and generate new ones. However, several issues need to be addressed and pitfalls need to be avoided when a group of experts is attempting to reach consensus. For example, the choice and mixture of participants, the bias and conflict of interest they may bring with them, and the cost of bringing people together. …

Background Greenhalgh et al. used a considerable evidence-base to develop a comprehensive model of implementation of innovations in healthcare organizations [1]. However, these authors did not fully operationalize their model, making it difficult to test formally. The present paper represents a first step in operationalizing Greenhalgh et al.’s model by providing background, rationale, working definitions, and measurement of key constructs. Methods A systematic review of the literature was conducted for key words representing 53 separate sub-constructs from six of the model’s broad constructs. Using an iterative process, we reviewed existing measures and utilized or adapted items. Where no one measure was deemed appropriate, we developed other items to measure the constructs through consensus. Results The review and iterative process of team consensus identified three types of data that can been used to operationalize the constructs in the model: survey items, interview questions, and administrative data. Specific examples of each of these are reported. Conclusion Despite limitations, the mixed-methods approach to measurement using the survey, interview measure, and administrative data can facilitate research on implementation by providing investigators with a measurement tool that captures most of the constructs identified by the Greenhalgh model. These measures are currently being used to collect data concerning the implementation of two evidence-based psychotherapies disseminated nationally within Department of Veterans Affairs. Testing of psychometric properties and subsequent refinement should enhance the utility of the measures.

The close interplay between mental health and physical health makes it critical to integrate mental and behavioral health considerations into all aspects of public health and medical disaster management. Therefore, the National Biodefense Science Board (NBSB) convened the Disaster Mental Health Subcommittee to assess the progress of the US Department of Health and Human Services (HHS) in integrating mental and behavioral health into disaster and emergency preparedness and response activities. One vital opportunity to improve integration is the development of clear and directive national policy to firmly establish the role of mental and behavioral health as part of a unified public health and medical response to disasters. Integration of mental and behavioral health into disaster preparedness, response, and recovery requires it to be incorporated in assessments and services, addressed in education and training, and founded on and advanced through research. Integration must be supported in underlying policies and administration with clear lines of responsibility for formulating and implementing policy and practice.(Disaster Med Public Health Preparedness. 2012;6:60–66)

The staff of the Pentagon Family Assistance Center was closely exposed to the intense grief experienced by those who had suddenly lost their loved ones following the crash of American Airlines Flight 77 into the Pentagon on September 11, 2001. In addition, some Pentagon Family Assistance Center workers were in the Pentagon when it was attacked, and others lost friends or colleagues in the event. A "Brief Education and Support" group intervention, designed to avoid the detailed exploration of traumatic experiences, was used to help workers recognize and understand their reactions to the event, and, as appropriate, to normalize those reactions. A second aim was to support positive coping and warn against problematic coping. The groups were characterized by much sharing of emotional and behavioral reactions to the work and to the Pentagon crash, and they were useful in prompting reflection on ways of coping. They appeared to offer one acceptable and effective way of educating emergency workers about their traumatic stress reactions, normalizing those reactions, and promoting adaptive coping.

After the September 11, 2001 terrorist attack on the Pentagon, the Department of Defense established a Family Assistance Center to provide a single source of information and services for the families of those missing and deceased. Twice daily briefings were conducted for families by top Department of Defense leadership so that information provided was timely, accurate, and authoritative. Within the Pentagon Family Assistance Center, families were able to receive mental health, spiritual, financial, legal, and benefits support/counseling from a wide range of helping agencies and organizations. Family members were also provided meals, lodging assistance, and assistance with travel arrangements. This centralization of services along with a clear and coherent command structure may provide a model to be emulated in future community disasters.

International clinical practice guidelines for the management of psychological trauma recommend Psychological First Aid (PFA) as an early intervention for survivors of potentially traumatic events. These recommendations are consensus-based, and there is little published evidence assessing the effectiveness of PFA. This is not surprising given the nature of the intervention and the complicating factors involved in any evaluation of PFA. There is, nevertheless, an urgent need for stronger evidence evaluating its effectiveness. The current paper posits that the implementation and evaluation of PFA within high risk organizational settings is an ideal place to start. The paper provides a framework for a phasic approach to implementing PFA within such settings and presents a model for evaluating its effectiveness using a logic- or theory-based approach which considers both pre-event and post-event factors. Phases 1 and 2 of the PFA model are pre-event actions, and phases 3 and 4 are post-event actions. It is hoped that by using the Phased PFA model and evaluation method proposed in this paper, future researchers will begin to undertake the important task of building the evidence about the most effective approach to providing PFA in high risk organizational and community disaster settings.

Objective: To examine the effectiveness of group cognitive processing therapy (CPT) relative to trauma-focused group treatment as usual (TAU) in the context of a Veterans Health Administration (VHA) posttraumatic stress disorder (PTSD) residential rehabilitation program. Method: Participants were 2 cohorts of male patients in the same program treated with either CPT (n 104) or TAU (n 93; prior to the implementation of CPT). Cohorts were compared on changes from pre- to posttreatment using the PTSD Checklist (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993) and other measures of symptoms and functioning. Minorities represented 41% of the sample, and the mean age was 52 years (SD 9.22). The CPT group was significantly younger and less likely to receive disability benefits for PTSD; however, these variables were not related to outcome. Results: Analyses of covariance controlling for intake symptom levels and cohort differences revealed that CPT participants evidenced more symptom improvement at discharge than TAU participants on the PCL, F(3, 193) 15.32, p .001, b 6.25, 95% CI [3.06, 9.44], and other measures. In addition, significantly more patients treated with CPT were classified as “recovered” or “improved” at discharge, 2 (1, N 197) 4.93, p .032. Conclusions: There is still room for improvement, as substantial numbers of veterans continue to experience significant symptoms even after treatment with CPT in a residential program. However, CPT appears to produce significantly more symptom improvement than treatment conducted before the implementation of CPT. The implementation of this empirically supported treatment in VHA settings is both feasible and sustainable and is likely to improve care for male veterans with military-related PTSD.

Unlike the post-Vietnam era, effective, specialized treatments for posttraumatic stress disorder (PTSD) now exist, although these treatments have not been widely available in clinical settings. The U.S. Department of Veterans Affairs (VA) is nationally disseminating 2 evidence-based psychotherapies for PTSD throughout the VA health care system. The VA has developed national initiatives to train mental health staff in the delivery of Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) and has implemented a variety of strategies to promote local implementation. In this article, the authors examine VA's national CPT and PE training initiatives and report initial patient, therapist, and system-level program evaluation results. Key issues, lessons learned, and next steps for maximizing impact and sustainability are also addressed.

Objective The objective was to develop a predictive screener that when given soon after injury will accurately differentiate those who will later develop depression or posttraumatic stress disorder (PTSD) from those who will not. Method This study used a prospective, longitudinal cohort design. Subjects were randomly selected from all injured patients in the emergency department; the majority was assessed within 1 week postinjury with a short predictive screener, followed with in-person interviews after 3 and 6 months to determine the emergence of depression or PTSD within 6 months after injury. Results A total of 192 completed a risk factor survey at baseline; 165 were assessed over 6 months. Twenty-six subjects [15.8%, 95% confidence interval (CI) 10.2–21.3] were diagnosed with depression, four (2.4%, 95% CI 0.7–5.9) with PTSD and one with both. The final eight-item predictive screener was derived; optimal cutoff scores were ≥2 (of 4) depression risk items and ≥3 (of 5) PTSD risk items. The final screener demonstrated excellent sensitivity and moderate specificity both for clinically significant symptoms and for the diagnoses of depression and PTSD. Conclusions A simple screener that can help identify those patients at highest risk for future development of PTSD and depression postinjury allows the judicious allocation of costly mental health resources.

The purpose of this study is to design, implement and evaluate a web-based, self-paced training program to provide skills-oriented continuing education for mental health professionals. It is intended to reach a broad range of mental health providers presenting content that is highly relevant and easy to access. The program incorporates interactivity, practice, and modeling of three effective cognitive-behavioral skills components: goal-setting, motivation enhancement, and behavioral task assignment - as applied to treatment for Veterans with Posttraumatic Stress Disorder (PTSD). A randomized design will be used in which 120 participants will be randomly assigned to one of three conditions: (i) web-based training plus consultation, (ii) web-based training without consultation, and (iii) training as usual. The effectiveness of training will be evaluated by means of simulated patient interview assessment of core skills (primary outcome) and on-line questionnaire assessment of knowledge, perceived self-efficacy in skills use, and self-reported skills application with PTSD patients (secondary outcomes). Currently, project team, web programs for content delivery, protocol, simulated patient case, and evaluation materials have been developed. Study recruitment is planned to begin after local and DOD IRB approval, which is currently on schedule to occur in September, 2009.

Dissemination of evidence-based treatments for PTSD has become an important focus of activity in the aftermath of recent terrorist attacks (e.g., London underground and U.S. 9/11 attacks), natural disasters (e.g., Indian Ocean tsunami and Hurricane Katrina), and wars (e.g., in Iraq and Afghanistan). This has become a high priority need for all mental health training and service delivery organizations. Researchers and educators have begun to examine clinician and client perceptions and preferences regarding PTSD treatment processes, and health care systems are organizing more comprehensive efforts at training and system change. As this evolution of services moves forward, effective dissemination should be a major focus of health policy research for the next decade or more. This review critically evaluates the PTSD-related research and emerging theory related to four major sets of variables that affect dissemination: (1) Practitioner factors, (2) Training methods, (3) The practice innovation(s) being disseminated; and (4) Organization or system factors. We evaluate findings from recent studies in light of emerging models of dissemination, and in the final section of the paper, we consider five broad topics with particular implications for dissemination of PTSD-specific treatments. They are: (1) The content of dissemination (i.e., which treatment protocols or intervention methods should be prioritized); (2) Strict adherence versus flexibility in the use of treatment manuals and the role of fidelity assessment; (3) The need for collaboration with user audiences; (4) The potential role of web-based technologies in increasing the effectiveness and efficiency of dissemination; and (5) Development of dissemination infrastructures within organizations.

A growing body of empirical literature has systematically documented the reactions to research participation among participants in trauma-focused research. To date, the available data has generally presented an optimistic picture regarding participants' ability to tolerate and even find benefit from their participation. However, this literature has been largely limited to cross-sectional designs. No extant literature has yet examined the perceptions of participants with psychiatric illness who are participating in randomized clinical trials (RCTs) designed to evaluate the efficacy or effectiveness of novel trauma treatments. The authors posit that negative experiences of, or poor reactions to, the research experience in the context of a trauma-focused RCT may elevate the risk of participation. Indeed, negative reactions may threaten to undermine the potential therapeutic gains of participants and promoting early drop out from the trial. Empirically assessing reactions to research participation at the pilot-study phase of a clinical trial can both provide investigators and IRB members alike with empirical evidence of some likely risks of participation. In turn, this information can be used to help shape the design and recruitment methodology of the full-scale trial. Using data from the pilot study of the Women's Self-Defense Project as a case illustration, we provide readers with concrete suggestions for empirically assessing participants' perceptions of risk involved in their participation in behaviorally oriented clinical trials.

Given the personal and societal costs associated with acute impairment and enduring post-traumatic stress disorder (PTSD), the mental health response to disasters is an integral component of disaster response planning. The purpose of this paper is to explore the compatibility between cognitive-behavioral psychology and the disaster mental health model, and explicate how cognitivebehavioral perspectives and intervention methods can enhance the effectiveness of disaster mental health services. It is argued that cognitive-behavioral methods, if matched to the contexts of the disaster and the needs of individuals, will improve efforts to prevent the development of PTSD and other trauma-related problems in survivors of disaster or terrorist events. First, the similarities between models of care underlying both disaster mental health services and cognitive-behavioral therapies are described. Second, examples of prior cognitive-behavioral therapy-informed work with persons exposed to disaster and terrorism are provided, potential cognitive-behavioral therapy applications to disaster and terrorism are explored, and implications of cognitive-behavioral therapy for common challenges in disaster mental health is discussed. Finally, steps that can be taken to integrate cognitive-behavioral therapy into disaster mental health are outlined. The aim is to prompt disaster mental health agencies and workers to consider using cognitive-behavioral therapy to improve services and training, and to motivate cognitive-behavioral researchers and practitioners to develop and support disaster mental health response.

Trauma recovery Web sites are proliferating with limited supportive evidence for effectiveness. In this article, the authors review the current very early studies on trauma recovery Web sites highlighting the different approaches, the empirical support provided, and the critical development issues facing this exciting frontier. An example site based on social cognitive theory is also reviewed.

Academic, state, and federal agencies collaborated over the last 9 years to improve disaster mental health services and evaluation. This process, which included literature reviews, a number of expert panels, and case studies, is described. The products resulting from this process have included the development of a systematic cross-site evaluation of the federally funded crisis counseling program and field guides for interventions aimed at providing services to distressed individuals in the immediate aftermath of disasters and to individuals needing resilience skills training weeks or months after the event. Future improvement of disaster mental health services calls for continued research, evaluation, training, and intervention development.

Given the devastation caused by disasters and mass violence, it is critical that intervention policy be based on the most updated research findings. However, to date, no evidence-based consensus has been reached supporting a clear set of recommendations for intervention during the immediate and the mid-term post mass trauma phases. Because it is unlikely that there will be evidence in the near or mid-term future from clinical trials that cover the diversity of disaster and mass violence circumstances, we assembled a worldwide panel of experts on the study and treatment of those exposed to disaster and mass violence to extrapolate from related fields of research, and to gain consensus on intervention principles. We identified five empirically supported intervention principles that should be used to guide and inform intervention and prevention efforts at the early to mid-term stages. These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self- and community efficacy, 4) connectedness, and 5) hope.

The sequelae of sexual trauma, including symptoms or diagnosis of posttraumatic stress disorder (PTSD), may impact women's anxiety and avoidance of preventive healthcare measures such as breast, pelvic, and rectal examinations. As sexual trauma is unfortunately a common occurrence among female patients, particularly veterans, understanding how it influences examination-related distress may improve provision of care to this population. We explored the impact of clinician gender and examination type (breast, pelvic, rectal, and dental) on anticipated examination-related anxiety among women veterans with a history of sexual trauma.We present a cross-sectional pilot study that examines anticipated examination-related distress among 31 female veterans with a history of sexual trauma. Sexual trauma history was verified by chart review. Self-report instruments assessed patient demographics and patients' anticipated anxiety during breast, pelvic, rectal, and dental examinations (stratified by gender of clinician). The PTSD Checklist-Civilian Version (PCL-C) assessed symptom severity.The women reported significantly more anticipated anxiety during breast, pelvic, and rectal examinations, (p0.05) when clinician gender was male. Severity of PTSD symptoms was generally unrelated to anticipated examination-related anxiety.Anticipated anxiety was found to be a function of both examination type and clinician gender but not of PTSD symptom severity. These findings emphasize the importance of screening for sexual trauma and the careful consideration of female veterans' unique needs during sensitive medical procedures.

This article reports preliminary data on trauma and post-traumatic stress disorder (PTSD) prevalence, as well as test psychometrics, among 35 cognitively intact veterans residing in long-term care settings. Participants received a traumatic event screening, the Mini-Mental Status Examination, Combat Exposure Scale (CES), PTSD Checklist (PCL), and Mississippi Combat PTSD Scale (M-PTSD). Results demonstrated adequate reliability for the CES, PCL, and M-PTSD for use in these settings, with several significant intercorrelations. A high prevalence of trauma exposure was found, in particular combat. Based on the PCL and M-PTSD, although most veterans did not meet full PTSD diagnostic criteria, a moderate proportion met partial criteria. The need for assessment and treatment of trauma exposure and PTSD in Veterans Affairs long-term care settings is emphasized.

Introduction:The identification of factors influencing emotional adjustment after injury may elucidate the design of assessment and treatment procedures in emergency medicine settings and suggest targets for early intervention to prevent the later development of psychological impairment. Personal, social, and material resources may be influential factors and require further evaluation.Hypotheses:Greater experiential avoidance, social constraints on discussing the trauma experience, and loss of material resources would be associated with more of the symptoms of posttraumatic stress and depression following traumatic injury.Methods:Participants (n = 47) at a mean of 7.4 months post-injury, completed a telephone interview assessment, including evaluation of sociodemographic characteristics, conservation of resources, social constraints, acceptance and commitment, and symptoms of post-traumatic stress disorder (PTSD) and depression. Hypotheses were tested using multivariate regression analyses.Results:Only greater social constraints were uniquely predictive of greater PTSD symptomatology. Higher levels of experiential avoidance, social constraints, and loss of material resources all were associated with greater levels of depression.Conclusion:Assessment of personal coping style, receptivity of social network, and loss of potential material resources following traumatic injury may facilitate identification of individuals at-risk for poorer post-injury adaptation. Psychosocial interventions targeting such individuals may be promising.

Despite limited resources, emergency medical settings will be called upon to play many roles in the context of disasters and terrorist attacks that are related to preparedness, surveillance, mental health services delivery, and staff care. Such settings are a central capture site for those individuals likely to be at highest risk for developing mental health and functional problems. Because much of the potential harm to survivors of disaster or terrorism (and their families) will be related to their mental health and role functioning, preparedness requires the active integration of behavioral health into emergency medicine in every component of disaster response. There are many challenges of doing this including: (1) finding ways to integrate activities of the medical care, emergency response, and public health systems; (2) determining whether an incident has actually occurred; (3) making differential diagnoses and managing other aspects of initial medical needs; and (4) coping with the risks associated with system overload and failure. Delivery of direct mental health care must include: (1) survivor and family education; (2) identification and referral of those requiring immediate care and followup; (3) group education and support services; and (4) individual counseling. In order for effective response to occur, the integration of psychosocial care into disaster response must occur prior to the disaster itself, and will depend on effective collaboration between medical and mental health care providers. At workplaces, emergency medical care centers must ensure that staff and their families are properly trained and supported with regard to their disaster functions and encouraged to develop personal/family disaster plans.

Individual cognitive-behavioral therapy involving directed exposure to memories of traumatic events has been found to be effective in treating posttraumatic stress disorder. In this article, we present updated information on an alternative group form of exposure therapy: manualized trauma-focus group therapy (TFGT), designed as an efficient means of conducting directed exposure. We describe the cognitive-behavioral and developmental models from which the approach was derived, present an overview of session topics and a case illustration, provide guidelines for referring individuals to TFGT, and offer suggestions for future research.

Aim To develop a predictive screener that will accurately predict the future development of postinjury depression or post-traumatic stress disorder (PTSD). Methods A prospective, longitudinal cohort study of subjects randomly selected from patients requiring an Emergency Department (ED) visit for injury. A theoretically and empirically derived 45-item risk survey was administered soon after injury. A psychiatric diagnostic interview was conducted at 3 and 6 months to determine emergence of depression or PTSD. Multiple logistic regression analyses were performed separately for depression and PTSD, using a best-subset approach to select models at each step by comparing log-likelihood estimates. Results Of 175 (of 192 enrolled) available for follow-up, 16% developed depression and 2.3% developed PTSD. A logistic model retaining four depression items and five PTSD items emerged. One item predicted both depression and PTSD; hence the final screener is eight items. Receiver operating characteristic for depression and PTSD was 0.81 each. Optimal cut-off scores were >2 (out of 4) for depression and >3 (out of 5) for PTSD. Depression findings: sensitivity 0.81, specificity 0.71, PPV 0.34, NPV 0.95. PTSD findings: sensitivity 1.00, specificity 0.66, PPV 0.07, NPV 1.00. Conclusions Thirty million seek ED care annually for injury and a significant subset develop psychiatric disorders that that impede recovery. The high NPV for both depression and PTSD supports the role of this new instrument as a short, clinical screener: those who screen negative can be screened out from further monitoring, allowing precious resources to be focused on those at highest risk for the development of depression and PTSD.

Posttraumatic behavioral and emotional disturbances occur frequently among physically injured trauma survivors. Despite increasing investigative interest in the evaluation and treatment of psychological distress in acutely injured patients, few studies have assessed ethical considerations surrounding research participation. The authors empirically investigated ethical considerations in research participation among 117 physically injured, hospitalized, motor vehicle accident and assault survivors. Immediately following a 1-hour research interview, participants responded to 10 questions assessing the experience of research participation. The majority of study subjects found participating in the protocol a positive experience. Most of the hospitalized patients reported that they experienced control over initiation and discontinuation of the protocol and that they derived benefit from their research participation. A minority of participants reported that they experienced unwanted thoughts and unanticipated upset during the protocol and that they felt they could not refuse participation. However, over 95% of patients reported that the benefits of protocol participation outweighed the costs and that in retrospect they would again agree to participate. These results suggest that while a minority of participants may have difficulties with specific aspects of protocol enrollment, overall research participation is well tolerated by the majority of acutely injured, hospitalized, trauma survivors.

Importance Posttraumatic stress disorder (PTSD) is a pervasive and often debilitating condition that affects many individuals in the general population and military service members. Effective treatments for PTSD are greatly needed for both veterans returning from Iraq and Afghanistan and veterans of other eras. Prolonged exposure (PE) therapy has been shown to be highly efficacious in clinical trials involving women with noncombat trauma, but there are limited data on its effectiveness in real-world clinical practice settings and with veterans. Objective To evaluate the effectiveness of PE as implemented with veterans with PTSD in a large health care system. Design, Setting, and Participants This evaluation included 1931 veterans treated by 804 clinicians participating in the Department of Veterans Affairs (VA) PE Training Program. After completing a 4-day experiential PE training workshop, clinicians implemented PE (while receiving consultation) with a minimum of 2 veteran patients who had a primary diagnosis of PTSD. Main Outcomes and Measures Changes in PTSD and depression symptoms were assessed with the PTSD Checklist and the Beck Depression Inventory II, measured at baseline and at the final treatment session. Multiple and single imputation were used to estimate the posttest scores of patients who left treatment before completing 8 sessions. Demographic predictors of treatment dropout were also examined. Results Intent-to-treat analyses indicate that PE is effective in reducing symptoms of both PTSD (pre-post d = 0.87) and depression (pre-post d = 0.66), with effect sizes comparable to those reported in previous efficacy trials. The proportion of patients screening positive for PTSD on the PTSD Checklist decreased from 87.6% to 46.2%. Conclusions Clinically significant reductions in PTSD symptoms were achieved among male and female veterans of all war eras and veterans with combat-related and non–combat-related PTSD. Results also indicate that PE is effective in reducing depression symptoms, even though depression is not a direct target of the treatment.