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Many Veterans who complete prolonged exposure (PE) or cognitive processing therapy (CPT) report residual symptoms, but it is unclear how to best address the mental health needs of these individuals. Examining patterns of mental health service utilization following completion of these two treatments may provide insight into how to best serve this group of individuals. In a large cohort of Veterans (N = 12,514) who sought treatment in the Veterans Health Administration during Fiscal Years 2015-2019, logistic regression models were used to assess the odds of initiating an additional course of trauma-focused (i.e., PE or CPT) or depression-focused psychotherapy in the year following completion of PE or CPT based on demographic, psychiatric, and treatment effectiveness-related variables. Approximately 9% of Veterans engaged in either trauma-(6%) or depression-(3%) related psychotherapy in the year following discharge from PE or CPT. Factors associated with increased odds of trauma-focused treatment initiation included having a sleep disorder diagnosis (OR = 1.23), a substance use disorder diagnosis (OR = 1.27), or experiencing military sexual trauma (OR = 1.64). Factors associated with increased odds of depression-focused treatment initiation included having a depression diagnosis (OR = 2.02). This study suggests that certain subgroups of Veterans who engage in PE or CPT (e.g., Veterans with comorbid sleep or substance use problems) are more likely to seek additional evidence-based treatment and may require augmentations to maximize clinical benefits, either during the initial course of treatment or subsequent to PTSD treatment., Competing Interests: Declarations Conflict of interest The authors declare no relevant competing interests.The authors have no conflict of interest to disclose. Informed Consent This analysis was conducted using a national sample from the VA’s Corporate Data Warehouse, so direct informed consent was not obtained from individual participants. The authors obtained local IRB approval to conduct this study. Public Health Significance This study highlights the importance of tracking longitudinal treatment engagement patterns for individuals who complete PTSD treatment. Individuals with PTSD and key comorbidities (e.g., sleep or substance use problems) are more likely to seek additional treatment., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

This state of the science review provides an overview of the history and findings of cognitive processing therapy (CPT), one of the most recommended treatments for posttraumatic stress disorder, acute stress disorder, and comorbid conditions. After an introduction to CPT and the randomized controlled trials that have been conducted, the effects of CPT on comorbid conditions are reviewed, as well as new combination treatments. Cognitive mediators of change are described. Different formats for CPT that have been developed are described, as well as patient, therapy, and therapist factors in outcome; applicability across diverse populations; efforts to disseminate CPT; and ongoing studies into the future., (Copyright © 2024 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.)

The Veterans Health Administration (VHA) has rolled out evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD); however, reach has remained low, and there is a need for briefer interventions. The National Center for PTSD conducted a facilitated learning collaborative to train clinicians and support VHA PTSD teams in their adoption of an emerging best practice, written exposure therapy (WET). Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) evaluation framework, the present study utilized longitudinal data from 178 clinicians and 556 patients across seven training cohorts to evaluate key clinical and implementation outcomes and whether clinic (i.e., implementation climate) or clinician factors (i.e., treatment attitudes) were associated with effectiveness and implementation. Intent-to-treat analyses indicated WET was effective in reducing PTSD ( d = 0.54) and depression symptoms ( d = 0.39). Data indicated that 87.60% of clinicians reported using WET 6 months postconsultation. Clinic-wide reach was modest after training (14.53% of individuals with PTSD); however, WET-trained clinicians continued to offer WET to an average of 87.38% of their patients. Fidelity remained high after training, with essential session elements most often being offered "always" ( M = 6.65 on a scale from 1 to 7). More positive postconsultation clinician treatment attitudes predicted higher posttraining rates of having patients engaged in WET. Clinician treatment attitudes and implementation climate did not predict any other implementation or effectiveness outcomes examined. Results suggest that WET implementation is advancing in VHA, with good clinical outcomes. Data provide evidence that a facilitated learning collaborative can be used to support and scale EBPs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objectives: Cognitive processing therapy (CPT) is an evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, little is known about how interrelationships between PTSD symptoms change over the course of treatment. The current study examined baseline, midtreatment, and posttreatment PTSD symptom networks during CPT for PTSD., Method: Adults with PTSD ( n = 107) received 12 sessions of CPT as part of a randomized trial. Self-reported PTSD symptoms were assessed at pretreatment, midtreatment, and posttreatment, and network analysis was used to examine the interrelationships between symptoms at these three timepoints. Linear regression was conducted to examine whether any baseline symptoms or midpoint symptoms predicted overall treatment change., Results: In the baseline PTSD network, feelings of detachment and feeling upset at reminders of the trauma were central to the symptom network. These symptoms were no longer central at midtreatment, possibly suggesting that CPT quickly reduces the importance of these symptoms. These findings were consistent with regression results that, after accounting for multiple comparisons, high baseline scores of feeling upset at trauma reminders predicted later treatment change. At the conclusion of treatment, strong negative emotions were the most central symptom and may be most important in maintaining or lowering other PTSD symptoms at the conclusion of treatment., Conclusions: Though replication is necessary, these findings offer insights into identifying which symptoms may be most predictive of treatment outcomes and the course by which CPT reduces PTSD symptoms. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: Anger is one of the most prevalent concerns among individuals with posttraumatic stress disorder (PTSD) and is often a residual symptom following PTSD treatment. The purpose of this systematic review and meta-analysis was to determine how effective trauma-focused PTSD psychotherapies are in reducing anger., Method: The study was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This study conducted a systematic review of studies that reported the effect of trauma-focused treatments on anger outcomes. Additionally, a meta-analysis was conducted with a subset of studies that used randomized controlled trials (RCTs) methodologies to compare trauma-focused PTSD treatments to nontrauma-focused and control conditions., Results: The systematic review included 16 studies with a total of 1,846 participants. In 11 of the studies, there was a significant decrease in an anger dimension following treatment. Eight studies with 417 total participants met inclusion criteria for the meta-analysis. The meta-analysis yielded a pooled effect size of PTSD treatment on anger of Hedges's g = 0.33., Conclusion: Overall, trauma-focused treatments for PTSD significantly improve anger, but the magnitude of change is small-to-medium. Additional research is needed to determine how best to maximize anger outcomes following trauma-focused treatment or determine if and when targeted anger treatment is needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Military service members and veterans (SMVs) are at risk for self-directed violence, including nonsuicidal self-injury (NSSI). While NSSI is an important construct worthy of independent study, it is understudied among SMVs and, when included in research, typically examined in the context of suicide risk. Consequently, lifetime prevalence rate estimates of NSSI among SMVs vary. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review and meta-analysis estimated the average lifetime NSSI prevalence among SMVs and explored demographic and methodological factors that may account for observed variability. Based on a search of Ovid MEDLINE, Embase, PsycINFO, and Web of Science, 47 samples from 42 articles across five countries met inclusion criteria. Results revealed an average NSSI lifetime prevalence rate of 15.76% among SMVs. Significantly higher prevalence rates were observed among clinical (28.14%) versus community (11.28%) samples and studies using interviews to assess NSSI (23.56%) versus self-report (13.44%) or chart review (7.84%). Lifetime prevalence increased as publication year increased and decreased as sample size increased. In contrast to prior literature, prevalence rates were comparable between active-duty SMVs, and studies collecting data anonymously versus those that did not. Lifetime prevalence was not moderated by age, gender, race, country, primary research focus, quality of NSSI operationalization, or whether NSSI methods were assessed. Findings suggest NSSI is a pervasive problem among military personnel, particularly within clinical settings, highlighting the need for systematic assessment of this important but understudied clinical phenomenon among SMVs. Further research is necessary to elucidate additional risk factors for NSSI among SMVs, including trauma exposure., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Participant training alone is typically insufficient to ensure adoption of a new treatment. This study provides preliminary data on a pilot program that implemented written exposure therapy (WET) through a virtual facilitated learning collaborative (VFLC) that combined clinician training with implementation support. Ninety-five mental health clinicians from Veterans Health Administration clinics enrolled in the VFLC. Clinicians received 6 hr of training in WET plus weekly group consultation on training cases for 12-16 weeks. Clinic leaders participated in monthly group calls with facilitators to develop and track implementation plans, address barriers, and share resources. Clinicians completed the Perceived Characteristics of Intervention Scale and Implementation Climate Scale before training and after consultation, and the Intention Scale for providers after the program. Clinicians' positive perceptions of WET increased over time, t (85) = -8.80, p < .001, d = 0.95, and changes were moderated by how much reduction in symptoms their patients experienced, t (151) = -2.13, p = .035. The implementation climate for WET also improved over time, t (85) = -3.55, p < .001, d = 0.36. Consistent with the theory of planned behavior, clinicians' intention to continue using WET after training was influenced by their perceptions and attitudes about WET, subjective norms, and perceived behavioral control. The VFLC model was feasible and associated with increases in clinicians' and leaders' support for using WET. Patient outcomes predicted the amount of change in clinicians' perceptions about WET. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Objective: Written Exposure Therapy (WET) for posttraumatic stress disorder (PTSD) has been shown to be efficacious in clinical trials; however, research is needed to determine WET's effectiveness in clinical practice settings. Additionally, research is needed to understand whether patient characteristics or treatment delivery format moderate outcomes., Method: Patient outcomes ( n = 277) were assessed as part of a multisite training and implementation program in the Department of Veterans Affairs (VA). During treatment, patients completed self-report measures of PTSD, depression, and functional impairment. Patient characteristics (i.e., demographics, psychiatric comorbidity, trauma type) and treatment delivery format (i.e., telehealth vs. in-person) were assessed as treatment moderators., Results: Intent-to-treat analyses indicated that WET was effective in reducing PTSD symptoms ( d = .84), depression symptoms ( d = .47), and functional impairment ( d = .36) during treatment. Approximately one quarter of patients dropped out of treatment prematurely. No moderators of PTSD treatment outcome were observed; however, telehealth delivery was associated with lower dropout., Conclusions: WET was an effective approach across a range of patient characteristics in this sample of veterans with PTSD. WET was also effective whether delivered in-person or via telehealth. WET is a promising treatment option for veteran patients in VA clinical care settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Objective: Posttraumatic stress disorder (PTSD) is associated with elevated risk of coronary heart disease (CHD); however, the effects of PTSD treatment on CHD biomarkers is unknown. This study examined whether cognitive processing therapy (CPT) improves 24-hourheart rate variability (HRV), a predictor of CHD mortality., Methods: Individuals between the ages of 40 and 65 years with PTSD (n = 112) were randomized to receive 12 sessions of CPT or a Waiting List (WL) intervention comprised of 6 weekly telephone checks of emotional status. The primary outcome variable was 24-hour HRV estimated from the standard deviation of all normal R-R intervals (SDNN); secondary outcomes were the root mean square of successive differences between heart beats (RMSSD), low-frequency HRV (LF-HRV) and high-frequency HRV (HF-HRV). Secondary outcomes also included 24-hour urinary catecholamine excretion, plasma C-reactive protein (CRP), and flow-mediated dilation (FMD) of the brachial artery. For outcomes, linear mixed longitudinal models were used to estimate mean differences (Mdiff)., Results: Participants randomized to the CPT group did not show improved SDNN (M diff  = 9.8; 95%CI, -2.7 to 22.3; p = 0.12), the primary outcome variable, but showed improved RMSSD (M diff  = 3.8; 95% CI, 0.5 to 7.1; p = 0.02), LF- HRV (Mdiff =0.3; 95% CI, 0.1 to 0.5; p = 0.01), and HF-HRV (M diff  = 0.3; 95% CI, 0.0 to 0.6; p = 0.03) compared to WL. There were no differences between groups in catecholamine excretion, FMD, or inflammatory markers., Conclusion: Treating PTSD may not only improve quality of life but may also help ameliorate heightened CHD risk characteristics of PTSD., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Shame and guilt are key emotions known to amplify trauma-related symptoms in veterans. Maintenance of symptoms is facilitated by avoidance behaviors, such as substance use. However, limited research has examined the associations between shame, guilt, and substance use in daily life., Methods: The current study sought to examine the cross-lagged association between shame, guilt, and substance use. Forty veterans completed 28 days of experience sampling reporting on their current emotional experiences and use of substances., Results: Results suggest a reciprocal relationship among shame and guilt and substance use, such that shame and guilt separately predicted subsequent substance use, and substance use predicted subsequent shame and guilt., Conclusions: These results highlight the dynamic relationship among shame, guilt, and substance use and suggest the potential value of conceptualizing these clinical targets as mutually reinforcing to inform integrative intervention strategies that can interrupt the in-the-moment cascade of negative consequences., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier B.V.)

Objective: A common concern is whether individuals with posttraumatic stress disorder (PTSD) and hazardous drinking will respond to PTSD treatment or need a higher dose. In a sample of active-duty military, we examined the impact of hazardous drinking on cognitive processing therapy (CPT) outcomes and whether number of sessions to reach good end-state or dropout differed by drinking status., Method: Participants included 127 service members participating in a clinical trial of variable-length CPT. The Quick Drinking Screen was used to characterize drinking. Participants were categorized as treatment responders when they reached good end-state (<20 on the PTSD Checklist for DSM-5 ) or nonresponders if they completed 24 sessions or 18 weeks of treatment without good end-state. Survival analyses were used to compare time to dropout or good end-state between those with and without hazardous drinking., Results: Those with hazardous drinking were as likely as those without to reach good end-state and no more likely to drop out. There were no differences in number of sessions to reach good end-state or dropout. On a gold-standard assessment, those with hazardous drinking evidenced more PTSD symptom reduction than those without. The overall proportion of participants with hazardous drinking decreased (30.7% to 18.6%), as did mean number of drinks per drinking day and drinks on the heaviest drinking day among those initially drinking hazardously., Conclusions: Results support using CPT for military personnel with PTSD and hazardous drinking and indicate that those with hazardous drinking can benefit from PTSD treatment without additional treatment sessions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background: This study was an examination of the puzzling finding that people assessed for symptoms of posttraumatic stress disorder (PTSD) consistently score higher on the self-report PTSD Checklist for DSM-5 (PCL-5) than the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Both scales purportedly assess PTSD severity with the same number of items, scaling, and scoring range, but differences in scores between measures make outcomes difficult to decipher. Objective: The purpose of this study was to examine several possible psychometric reasons for the discrepancy in scores between interview and self-report. Method: Data were combined from four clinical trials to examine the baseline and posttreatment assessments of treatment-seeking active duty military personnel and veterans. Results: As in previous studies, total scores were higher on the PCL-5 compared to the CAPS-5 at baseline and posttreatment. At baseline, PCL-5 scores were higher on all 20 items, with small to large differences in effect size. At posttreatment, only three items were not significantly different. Distributions of item responses and wording of scale anchors and items were examined as possible explanations of the difference between measures. Participants were more likely to use the full range of responses on the PCL-5 compared to interviewers. Conclusions: Suggestions for improving the congruence between these two scales are discussed. Administration of interviews by trained assessors can be resource intensive, so it is important that those assessing PTSD severity are afforded confidence in the equivalence of their assessment of PTSD regardless of the assessment method used.

This study examined the impact of a history of head injury (HHI) on posttraumatic stress disorder (PTSD) and depression symptoms in active duty military personnel following group and individual cognitive processing therapy (CPT). Data for these secondary analyses were drawn from a clinical trial comparing group and individual CPT. Service members (N = 268, 91.0% male) were randomized to 12 sessions of group (n = 133) or individual (n = 135) CPT. Most participants (57.1%) endorsed a deployment-related HHI, 92.8% of whom reported currently experiencing symptoms (CES) related to the head injury (i.e., HHI/CES). Patients classified as non-HHI/CES demonstrated large, significant improvements in PTSD symptom severity in both individual and group therapy, ds = 1.1, p < .001. Patients with HHI/CES status showed similar significant improvements when randomized to individual CPT, d = 1.4, p < .001, but did not demonstrate significant improvements when randomized to group CPT, d = 0.4, p = .060. For participants classified as HHI/CES, individual CPT was significantly superior to group CPT, d = 0.98, p = .003. Symptoms of depression improved following treatment, with no significant differences by treatment delivery format or HHI/CES status. The findings of this clinical trial subgroup study demonstrate evidence that group CPT is less effective than individual CPT for service members classified as HHI/CES. The results suggest that HHI/CES status may be important to consider in selecting patients for group or individual CPT; additional research is needed to confirm the clinical implications of these findings., (© 2022 International Society for Traumatic Stress Studies.)

Background: Smoking is a prevalent concern among Veterans, especially those with posttraumatic stress disorder (PTSD). Despite the availability of interventions for smoking cessation, these treatments have not been as effective among Veteran populations, particularly Veterans with PTSD. The present study seeks to describe the methods of a randomized clinical trial examining the efficacy of CPT-SMART, a multidimensional treatment combining cognitive processing therapy (CPT) for PTSD, smoking cessation counseling, pharmacotherapy, and contingency management (CM) compared to a yoked comparison group., Methods: One hundred twenty Veterans with PTSD who smoke cigarettes will be enrolled. All participants will receive CPT in addition to counseling and pharmacotherapy for smoking cessation. Participants will be randomized to the CPT-SMART condition, which includes monetary reinforcement that is contingent on bioverification of smoking abstinence (i.e., contingency management), or a yoked comparison with monetary reinforcement matched to the participant to whom they are yoked. The primary outcome is bioverified smoking abstinence at the 6-month follow-up appointment., Conclusion: If shown efficacious, a combined PTSD and smoking treatment plus incentive-based approach for smoking could be implemented into specialty PTSD programs. The positive public health impact of reducing smoking among Veterans with PTSD could be enormous as it would prevent significant smoking-related morbidity and mortality., (Copyright © 2022. Published by Elsevier Inc.)

Objective: Although fear of cancer recurrence (FCR) has been conceptualized as a multidimensional construct with emotional and cognitive components, little work has distinguished or assessed both components. Further, most existing research has not included intimate partners of cancer patients, although they also experience FCR. This study aimed to (1) determine whether FCR is better conceptualized as a singular or multidimensional construct at the within-person level over time and (2) model the corresponding trajectories in patients and their partners., Methods: Female early stage breast cancer patients and their partners (N = 78 couples) completed up to five assessments over the first year post-diagnosis tapping both emotional and cognitive elements of FCR. Multilevel confirmatory factor analysis was used to evaluate FCR's factor structure, and multivariate latent growth curve modeling was used to estimate trajectories of emotional and cognitive FCR., Results: FCR was best conceptualized as two distinct but related emotional and cognitive factors. In patients and partners, emotional FCR decreased over the first year post-diagnosis on average, while cognitive FCR did not change over time., Conclusions: Findings support the conceptualization of FCR as a multidimensional construct and underscore the potential importance of distinguishing emotional and cognitive components of FCR in future research., (© 2022 John Wiley & Sons Ltd.)

Posttraumatic stress disorder (PTSD) clinics in the Department of Veterans Affairs (VA) often provide psychoeducational or skill-building groups to prepare veterans for trauma-focused PTSD treatments. However, there has been limited evaluation of the effectiveness of this phase-based approach for treatment engagement and symptom reduction. Participants included 575 veterans seeking treatment for PTSD whose treatment outcomes were assessed in a VA outpatient PTSD clinic staffed by mental health professionals and trainees. Participants completed self-report measures of baseline characteristics and psychiatric symptoms as part of routine PTSD clinic treatment. We tested the association of preparatory group treatment with engagement in and treatment response to subsequent trauma-focused psychotherapies, cognitive processing therapy (CPT) and prolonged exposure therapy (PE), which are designated by VA as evidence-based psychotherapies (EBP). Following participation in preparatory treatments, 94/391 (24%) of veterans engaged in a subsequent trauma-focused EBP (CPT or PE). Relative to patients who had previously completed a preparatory group, patients initiating a trauma-focused EBP without having first attended preparatory PTSD treatment had similar rates of trauma-focused EBP completion and better treatment response, as measured by decreases on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders , fifth edition ( DSM-5 ; PCL-5), F (1, 3009) = 10.89, p = .001, and Patient Health Questionnaire 9 measure of depressive symptoms F (1, 3688) = 6.74, p = .010. Overall, veterans reported greater symptom reduction when engaging in trauma-focused EBP directly, without having previously attended a preparatory group. These data support veteran engagement in trauma-focused EBPs for PTSD without first being encouraged to complete psychoeducational or skill-building groups. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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., (Copyright © 2021. Published by Elsevier B.V.)

Cognitive processing therapy (CPT) is a gold-standard treatment for adults with posttraumatic stress disorder (PTSD). However, adolescents may also benefit from CPT, particularly when existing evidence-based treatments for adolescents are unavailable or not a good fit. In this program evaluation study, community-based therapists participating in training delivered a modular version of CPT to 32 adolescents (age range: 14-17 years) and 174 adults recruited at their sites (overall sample: 81.1% female, 59.7% White, 31.6% Black, 21.6% Hispanic, 2.9% American Indian/Alaskan Native, 1.9% Asian, and 9.7% other race). The same protocol was used for adolescents as adults. Treatment outcomes, including treatment completion status, number of sessions needed, and PTSD and depression symptom change, were compared between groups. In total, 47.1% of adults versus 71.9% of adolescents completed treatment. Among completers, there was no between-group difference in the number of attended sessions, RR = 1.04, 95% CI [0.88, 1.23], p = .576. Overall, in the full intent-to-treat sample (i.e., completers and noncompleters), large symptom reductions were observed for PTSD, b = -3.27, SE = 0.17, p < .001, d = 1.22; and depression, b = -0.82, SE = 0.07, p < .001, d = 0.84. There were no differences in the rate of change for adolescents versus adults regarding PTSD, b = -0.15, SE = 0.48, p = .759; or depression, b = -0.20, SE = 0.14, p = .181. These findings suggest that CPT is a viable treatment option for adolescents, who benefited from treatment and completed treatment at a high rate., (© 2021 International Society for Traumatic Stress Studies.)

Suicidal ideation (SI) is a prevalent issue in the veteran population. A number of factors have been identified as risk factors for suicidal ideation (SI) in veterans, including suicide attempts, depression, posttraumatic stress disorder (PTSD), and drug use. However, clinicians' ability to predict suicide is poor, particularly given the interplay between various factors such as previous suicide attempts. As such, there is a gap in our knowledge of which factors most saliently predict suicide risk and which should be targets for interventions designed to lower SI. Network analysis, a method allowing for an examination of how variables relate within the context of a network of factors, may bridge this gap by simultaneously evaluating the interrelationships between risk factors for suicide in veterans. Current study used network analysis and data from 2268 Iraq/Afghanistan-era military veterans to examine the relationships between suicidal ideation and several factors related to suicide risk, such as past suicide attempts, PTSD symptoms, depression, drug use, trauma exposure. Partial correlation network results showed suicidal ideation to be strongly related to depression, with smaller connections to past suicide attempts and anger. Additionally, past suicide attempts was strongly related to history of childhood trauma and weakly related to problematic drug use and PTSD symptoms. These results offer valuable information for both predicting suicide risk and differentiating targets for interventions lowering suicide risk in veterans., (Published by Elsevier Ltd.)

Cognitive Processing Therapy (CPT) is an evidence-based therapy recommended for posttraumatic stress disorder (PTSD). However, rates of improvement and remission are lower in veterans and active duty military compared to civilians. Although CPT was developed as a 12-session therapy, varying the number of sessions based on patient response has improved outcomes in a civilian study. This paper describes outcomes of a clinical trial of variable-length CPT among an active duty sample. Aims were to determine if service members would benefit from varying the dose of treatment and identify predictors of treatment length needed to reach good end-state (PTSD Checklist-5 ≤ 19). This was a within-subjects trial in which all participants received CPT (N = 127). Predictor variables included demographic, symptom, and trauma-related variables; internalizing/externalizing personality traits; and readiness for change. Varying treatment length resulted in more patients achieving good end-state. Best predictors of nonresponse or needing longer treatment were pretreatment depression and PTSD severity, internalizing temperament, being in precontemplation stage of readiness for change, and African American race. Controlling for differences in demographics and initial PTSD symptom severity, the outcomes using a variable-length CPT protocol were superior to the outcomes of a prior study using a fixed, 12-session CPT protocol. CLINICALTRIALS.GOV IDENTIFIER: NCT023818., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: Many clinicians question whether patients with a history of childhood trauma will benefit from trauma-focused treatment. In this secondary analysis, we examined whether reports of childhood abuse moderated the efficacy of cognitive processing therapy (CPT) for active-duty military with posttraumatic stress disorder (PTSD). Methods: Service members ( N = 254, mean age 33.11 years, 91% male, 41% Caucasian) were randomized to receive individual or group CPT ( n = 106 endorsing and n = 148 not endorsing history of childhood abuse). Outcomes included baseline cognitive-emotional characteristics [Posttraumatic Cognitions Inventory (PTCI), Trauma-Related Guilt Inventory (TRGI), Cognitive Emotion Regulation Questionnaire-Short Form (CERQ)], treatment completion, and symptom outcome (PTSD Checklist, Beck Depression Inventory-II). We predicted participants endorsing childhood abuse would have higher scores on the PTCI, TRGI, and CERQ at baseline, but be noninferior on treatment completion and change in PTSD and depression symptoms. We also predicted those endorsing childhood abuse would do better in individual CPT than those not endorsing abuse. Results: Those endorsing childhood abuse primarily experienced physical abuse. There were no baseline differences between service members with and without a history of childhood abuse (all p ≥ .07). Collapsed across treatment arms, treatment completion and symptom reduction were within the noninferiority margins for those endorsing versus not endorsing childhood abuse. History of abuse did not moderate response to individual versus group CPT. Conclusions: In this primarily male, primarily physically abused sample, active-duty military personnel with PTSD who endorsed childhood abuse benefitted as much as those who did not endorse abuse. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background: Withholding cancer-related concerns from one's partner (protective buffering) and feeling that one's partner is inaccessible or unresponsive to such disclosure (social constraints) are two interpersonal interaction patterns that separately have been linked to poorer adjustment to cancer., Purpose: Guided by the Social-Cognitive Processing Model, we examined the joint effects of social constraints and protective buffering on fear of cancer recurrence (FCR) in survivors and spouses. Social constraints and protective buffering were hypothesized to emerge as independent predictors of higher FCR., Methods: Early-stage breast cancer survivors and spouses (N = 79 couples; 158 paired individuals) completed up to five repeated measures of FCR, social constraints, protective buffering, and relationship quality during the year postdiagnosis. A second-order growth curve model was estimated and extended to test the time-varying, within-person effects of social constraints and protective buffering on a latent FCR variable, controlling for relationship quality., Results: As hypothesized, greater social constraints and protective buffering significantly (p < .05) predicted higher concurrent FCR at the within-person level, controlling for global relationship quality and change in FCR over time. The fixed effects were found to be similar for both survivors and spouses., Conclusions: Findings suggest that interaction patterns resulting in inhibited disclosure are associated with greater FCR for both survivors and spouses, consistent with the Social-Cognitive Processing Model. This work adds to the growing body of research highlighting the social context of FCR., (© Society of Behavioral Medicine 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Veterans have high rates of suicide, and nonsuicidal self-injury (NSSI) is one of the strongest predictors of suicide risk; however, there is presently little known about antecedents of NSSI that might inform intervention efforts. Accumulating research suggests that anger and hostility play an important role in NSSI, but whether these emotions precede and predict NSSI is currently unknown. The aim of the current study was to examine the temporal relationships between anger/hostility and NSSI urges and behavior among veterans diagnosed with NSSI disorder. Our hypothesis was that angry/hostile affect would predict subsequent NSSI urge and engagement, but not vice versa. Forty veterans with NSSI disorder completed a 28-day ecological momentary assessment study with three daily prompts to report on their affect and NSSI urges and engagement. Multilevel cross-lagged path modeling was used to determine the direction of effects between angry/hostile affect and NSSI urges and engagement over time. Consistent with our hypothesis, results indicated that the lagged effects of angry/hostile affect on subsequent NSSI urge and engagement were significant, whereas the lagged effects of NSSI urge and engagement on angry/hostile affect were not significant. Findings highlight the importance of assessing and treating anger among veterans who engage in NSSI., (Published by Elsevier Ltd.)

Posttraumatic stress disorder (PTSD) has been associated with accelerated progression of coronary heart disease (CHD). However, the underlying pathophysiological pathway has remained elusive and it is unclear whether there is a direct link between PTSD and CHD risk. This paper describes the methods of a randomized controlled trial developed to examine how changes in PTSD symptoms affect CHD disease pathways. One hundred twenty participants with current PTSD and who are free of known CHD will be randomized to receive either an evidence-based treatment for PTSD (Cognitive Processing Therapy; CPT) or a waitlist control (WL). Before and after CPT/WL, participants undergo assessment of CHD risk biomarkers reflecting autonomic nervous system dysregulation, systemic inflammation, and vascular endothelial dysfunction. The primary hypothesis is that individuals who show improvement in PTSD symptoms will show improvement in CHD risk biomarkers, whereas individuals who fail to improve or show worsening PTSD symptoms will have no change or worsening in CHD biomarkers. This study is expected to provide knowledge of the role of both the direct impact of PTSD symptoms on CHD risk pathways and the role of these systems as candidate mechanisms underlying the relationship between PTSD and CHD risk. Further, results will provide guidance on the utility of cognitive therapy as a tool to mitigate the accelerated progression of CHD in PTSD. Clinical Trials Registration: https://clinicaltrials.gov/ct2/show/NCT02736929; Unique identifier: NCT02736929., (Copyright © 2021 Elsevier Inc. All rights reserved.)

In response to COVID-19, continued workforce training is essential to ensure that evidence-based treatments are available on the frontline to meet communities' ongoing and emerging mental health needs. However, training during a pandemic imposes many new challenges. This paper describes a multisite training and implementation pilot program, facets of which allowed for continued training despite the onset of the COVID-19 pandemic and subsequent social distancing guidelines. This virtual facilitated learning collaborative in Written Exposure Therapy, an evidence-based treatment for posttraumatic stress disorder, included virtual workshop training, phone-based clinical consultation, implementation-focused video calls for program leadership, and program evaluation. Data are presented about program enrollees and patient impact following the onset of COVID-19-related social distancing restrictions. Challenges, successes, and practical guidance are discussed to inform the field regarding training strategies likely to be durable in an uncertain, dynamic healthcare landscape., (Published 2020. This article is a U.S. Government work and is in the public domain in the USA.)

The global outbreak of COVID-19 has required mental health providers to rapidly rethink and adapt how they provide care. Cognitive processing therapy (CPT) is a trauma-focused, evidence-based treatment for posttraumatic stress disorder that is effective when delivered in-person or via telehealth. Given current limitations on the provision of in-person mental health treatment during the COVID-19 pandemic, this article presents guidelines and treatment considerations when implementing CPT via telehealth. Based on lessons learned from prior studies and clinical delivery of CPT via telehealth, recommendations are made with regard to overall strategies for adapting CPT to a telehealth format, including how to conduct routine assessments and ensure treatment fidelity., (© 2020 International Society for Traumatic Stress Studies.)

Both negative posttraumatic cognitions and posttraumatic stress disorder (PTSD) symptoms decrease over the course of cognitive-behavior therapy for PTSD; however, further research is needed to determine whether cognitive change precedes and predicts symptom change. The present study examined whether weekly changes in blame predicted subsequent changes in PTSD symptoms over the course of cognitive processing therapy (CPT). Participants consisted of 321 active duty U.S. Army soldiers with PTSD who received CPT in one of two clinical trials. Symptoms of PTSD and blame were assessed at baseline and weekly throughout treatment. Bivariate latent difference score modeling was used to examine temporal sequential dependencies between the constructs. Results indicated that changes in self-blame and PTSD symptoms were dynamically linked: When examining cross-construct predictors, changes in PTSD symptoms were predicted by prior changes in self-blame, but changes in self-blame were also predicted by both prior levels of and prior changes in PTSD. Changes in other-blame were predicted by prior levels of PTSD, but changes in other-blame did not predict changes in PTSD symptoms. Findings highlight the dynamic relationship between self-blame and PTSD symptoms during treatment in this active military sample., (Copyright © 2019. Published by Elsevier Ltd.)

Background: The purpose of this study was to examine demographic, psychological, military, and deployment variables that might predict posttraumatic stress disorder (PTSD) symptom improvement in a sample of active duty service members who received either group or individual cognitive processing therapy (CPT)., Methods: Data were analyzed from 165 active duty service members with pre- and posttreatment data participating in a randomized controlled trial comparing group with individual CPT. Pretreatment variables were examined as predictors of change in PTSD severity from baseline to posttreatment, assessed using the PTSD Symptom Scale-Interview Version (PSS-I). Predictors of PSS-I change were first evaluated using Pearson correlations, followed by partial and multiple correlations to clarify which associations remained when effects of other predictors were controlled. Multiple regression analyses were used to test for interactions between pretreatment variables and treatment format., Results: Only age was a significant predictor of PTSD symptom change after controlling for other variables and statisitically correcting for testing multiple variables. There was also an interaction between age and treatment format., Conclusions: Younger participants had greater symptom improvement, particularly if they received individual treatment. Other pretreatment variables did not predict outcome. CPT appears to be robust across most pretreatment variables, such that comorbid disorders, baseline symptom severity, and suicidal ideation do not interfere with application of CPT. However, individual CPT may be a better option particularly for younger service members.

Military-affiliated individuals (i.e., active duty personnel and veterans) exhibit high rates of posttraumatic stress disorder (PTSD). Although existing evidence-based treatments for PTSD, such as cognitive processing therapy (CPT), have demonstrated effectiveness with military-affiliated patients, there is evidence to suggest these individuals do not benefit as much as civilians. However, few studies have directly compared the effects of PTSD treatment between civilian and military-affiliated participants. The current study compared treatment outcomes of military-affiliated and civilian patients receiving CPT. Participants with PTSD who were either civilians (n = 136) or military-affiliated (n = 63) received CPT from community-based providers in training for CPT. Results indicated that military-affiliated participants were equally likely to complete treatment, Log odds ratio (OR) = 0.14, p = .648. Although military-affiliated participants exhibited reductions in PTSD, B = -2.53, p < .001; and depression symptoms, B = -0.65, p < .001, they experienced smaller reductions in symptoms relative to civilians: B = 1.15, p = .015 for PTSD symptoms and B = 0.29, p = .029 for depression symptoms. Furthermore, variability estimates indicated there was more variability in providers' treatment of military-affiliated versus civilian participants (i.e., completion rates and symptom reduction). These findings suggest that military-affiliated patients can be successfully retained in trauma-focused treatment in the community at the same rate as civilian patients, and they significantly improve in PTSD and depression symptoms although not as much as civilians. These findings also highlight community providers' variability in treatment of military-affiliated patients, providing support for more military-cultural training., (© 2019 International Society for Traumatic Stress Studies.)

Background: Suicidal ideation is a problem that disproportionately affects veterans. Moreover, veterans with posttraumatic stress disorder (PTSD) appear to be at particularly high risk for suicide., Objective: The purpose of the present research was to examine whether shame mediates the association between PTSD and suicidal ideation., Methods: Secondary analyses were conducted in a sample of 201 veterans with PTSD seeking care through an outpatient Veterans Affairs specialty PTSD clinic., Results: Path analysis revealed that shame fully accounted for the effects of PTSD on suicidal ideation, suggesting that shame may represent a key link between PTSD and suicidal ideation among veterans., Limitations: Although the reverse mediation effect was also examined, the present sample was cross-sectional and predominantly male., Conclusions: The present findings suggest that shame may be an effective point of treatment intervention to reduce suicidal ideation among veterans with PTSD; however, additional prospective research is still needed to delineate the precise nature of these associations over time., (Published by Elsevier B.V.)

Although effective treatments for posttraumatic stress disorder exist, their use in community settings is disappointingly low. Training alone does not necessarily lead to adoption. To address this problem, we trained community clinicians in cognitive processing therapy, an evidence-based treatment for posttraumatic stress disorder, using a Learning Collaborative, an intensive training methodology focused on both clinical training and developing sustainability. Sixty clinicians within 18 agencies began the year-long, team-based Learning Collaborative. Clinicians attended three in-person Learning Sessions, received weekly consultation, and submitted audio-recorded sessions to be rated for fidelity. Clinicians were rostered as approved treatment providers if they completed all training requirements. Additionally, we engaged leadership from each agency to build a sustainable practice. Clinicians trained through the Learning Collaborative demonstrated a high degree of fidelity to the treatment (average competence ratings "satisfactory" to "good"), and most (68%) were rostered as approved treatment providers. Patients treated by clinician trainees exhibited significant symptom reductions (d = 1.68 and 1.28 for posttraumatic stress and depression symptoms, respectively, among treatment completers). At a 6-month follow-up, 95% of rostered clinicians and 100% of agencies with rostered clinicians were still providing the treatment. These results suggest that the Learning Collaborative model is a promising approach for the dissemination and implementation of evidence-based treatments for adult posttraumatic stress disorder., (Copyright © 2018. Published by Elsevier Ltd.)

Purpose: The purpose of this study was to determine whether fear of cancer recurrence (FCR) is associated with greater health care utilization (HCU) in early-stage breast cancer survivors., Methods: Three hundred early-stage breast cancer survivors diagnosed within the past 7 years reported on FCR as well as calls and visits to oncology providers and primary care providers during the preceding 3 months. Participants also reported on use of mental health services and psychotropic medications since diagnosis. Structural equation modeling was used to create a latent FCR factor and evaluate this factor as a predictor of various HCU outcomes controlling for age at diagnosis, years since diagnosis, generalized anxiety, objective risk of recurrence, and number of comorbidities., Results: FCR predicted more visits to both oncology providers (RR = 1.53, p = .002) and primary care providers (RR = 1.31, p = .013), as well as more phone calls to oncology providers (RR = 2.08, p = .007). FCR was not a significant predictor of phone calls to primary care providers (RR = 1.39, p = .054), utilization of mental health treatment (OR = 1.27, p = .362), or use of psychotropic medications (OR = 1.37, p = .178)., Conclusions: FCR was associated with increases in some types of HCU, which may reflect excessive medical reassurance-seeking and lead to unnecessary medical costs., Implications for Cancer Survivors: FCR is a serious concern that warrants greater attention to reduce distress-related health care utilization. Utilization of mental health services to address FCR may represent higher-value health care.

Objective: Fear of cancer recurrence (FCR) is a top concern of breast cancer (BC) survivors and their spouses. FCR often occurs within an interpersonal context, yet there has been little research on relationship processes that may influence FCR in patients and spouses. It was hypothesized that the inhibition of disclosure of cancer-related concerns, thoughts, and feelings because of perceived partner disinterest or avoidance (termed social constraints) would predict greater FCR in BC patients and their spouses both globally and in the context of everyday life., Method: Two studies, 1 cross-sectional (N = 46 couples) and 1 daily diary (21 days; N = 72 couples), were conducted to examine the between-person and within-person associations between social constraints and FCR in early stage BC patients and their spouses. Assessments were conducted about 6 months after BC surgery., Results: Global social constraints predicted greater global FCR in patients and spouses at the cross-sectional level, controlling for anxiety symptoms, relationship quality, and patient age, physical impairment, and BC stage. At the within-person level, results indicated that on days when more social constraints were reported, both partners were more likely to report greater FCR, controlling for momentary negative affect and relationship quality., Conclusions: This study is the first to examine the within-person association between social constraints and FCR. These findings suggest relationship processes, particularly inhibition of disclosure, can uniquely influence the experience of FCR for both BC patients and their spouses, pointing to an important consideration for future research and possible intervention development. (PsycINFO Database Record, ((c) 2018 APA, all rights reserved).)

Background: Suicidal ideation (SI) is a serious issue affecting U.S. veterans, and those with posttraumatic stress disorder (PTSD) are at an especially high risk of SI. Guilt has been associated with both PTSD and SI and may therefore be an important link between these constructs., Methods: The present study compared models of trauma-related guilt and used path analysis to examine the direct and indirect effects of PTSD and trauma-related guilt on SI among a sample of 988 veterans receiving outpatient PTSD treatment at a Veterans Affairs (VA) specialty clinic., Results: Results showed that a model of trauma-related guilt including guilt-cognitions and global guilt (but not distress) provided the best model fit for the data. PTSD and trauma-related guilt had direct effects on SI, and PTSD exhibited indirect effects on SI via trauma-related guilt., Limitations: The use of cross-sectional data limits the ability to make causal inferences. A treatment-seeking sample composed primarily of Vietnam veterans limits generalizability to other populations., Conclusions: Trauma-related guilt, particularly guilt cognitions, may be an effective point of intervention to help reduce SI among veterans with PTSD. This is an important area of inquiry, and suggestions for future research are discussed., (Published by Elsevier B.V.)

Cognitive content and processes are central to theories of post-traumatic stress disorder (PTSD). In this paper, we highlight recent findings on cognitive factors in PTSD. Evidence for the role of negative post-traumatic cognitions in PTSD has continued to mount, with cognitions mediating PTSD symptoms and predicting PTSD over and above other key variables. Researchers have also continued to implicate cognitive processes like rumination in the development and maintenance of PTSD. Finally, we review how cognitive-behavioral therapies interrupt dysfunctional cognitive processes in PTSD and highlight research supporting the theory that changes in cognitions are the mechanism of these treatments., (Copyright © 2016 Elsevier Ltd. All rights reserved.)