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Although the COVID-19 pandemic has been shown to be detrimental to mental health, it may hold a parallel potential for positive change. Little is known about posttraumatic growth (PTG) as a potential outcome for individuals with lived experience of psychiatric disorders following trauma exposure, especially in the context of the COVID-19 pandemic. Participants were 1,424 adults with lived experience of a psychiatric disorder who took part in a longitudinal study of mental health during the COVID-19 pandemic conducted by the National Centre for Mental Health. PTG was measured using the Posttraumatic Growth Inventory-Short Form (PTGI-SF). Factors hypothesized to be associated with PTG were investigated using linear regression. The mean participant PTGI score was 12.64 (SD = 11.01). On average, participants reported the highest scores on items related to appreciation of life and lowest on those related to spiritual change subscale. We found the strongest evidence of associations between higher levels of PTG and higher scores on assessment items related to perceived social support, B = 2.86; perceptions of the pandemic as traumatic, B = 4.89; and higher psychological well-being, B = 0.40. Taken together, we did not observe evidence of widespread PTG related to the COVID-19 pandemic among individuals with lived experiences of psychiatric disorders.

Background\ud Prevalence estimates of COVID-19-related posttraumatic stress disorder (PTSD) have ranged from 1% to over 60% in the general population. Individuals with lived experience of a psychiatric disorder may be particularly vulnerable to COVID-19-related PTSD but this has received inadequate attention.\ud \ud Methods\ud Participants were 1571 adults with lived experience of psychiatric disorder who took part in a longitudinal study of mental health during the COVID-19 pandemic. PTSD was assessed by the International Trauma Questionnaire (ITQ) anchored to the participant's most troubling COVID-19-related experiencevent. Factors hypothesised to be associated with traumatic stress symptoms were investigated by linear regression.\ud \ud Results\ud 40.10% of participants perceived some aspect of the pandemic as traumatic. 5.28% reported an ICD-11 PTSD qualifying COVID-19 related traumatic exposure and 0.83% met criteria for probable ICD-11 COVID-19-related PTSD. Traumatic stress symptoms were associated with younger age, lower income, lower social support, and financial worries, and lived experience of PTSD/complex PTSD. Depression and anxiety measured in June 2020 predicted traumatic stress symptoms at follow-up approximately 20 weeks later in November 2020.\ud \ud Conclusions\ud We did not find evidence of widespread COVID-19-related PTSD among individuals with lived experience of a psychiatric disorder. There is a need for future research to derive valid prevalence estimates of COVID-19-related PTSD.

First responders are exposed to repetitive work-related trauma and, thus, are at risk of developing posttraumatic stress disorder (PTSD). Eye-movement desensitization and reprocessing (EMDR) is a psychotherapy intervention designed to treat symptoms of posttraumatic stress. We conducted a systematic review to examine the viability of EMDR among first responders. The primary aim of this review was to identify studies that have trialed EMDR among first responders and evaluate its effectiveness in reducing trauma-related symptoms; a secondary aim was to identify whether EMDR has been used as an early intervention for this cohort and determine its effectiveness as such. Four databases were searched. Studies were included if they evaluated the extent to which EMDR was effective in alleviating symptoms stemming from work-related trauma exposure among first responders. The findings from each study were reported descriptively, and eight studies that evaluated the efficacy of EMDR in this population were included. There was substantial variation in how EMDR was implemented, particularly in the type, duration, frequency, and timing. The findings suggest that EMDR can alleviate symptoms of work-related trauma exposure among first responders; however, findings regarding early intervention were inconclusive, and a methodological quality assessment revealed that all studies were classified as being of either weak or medium quality. Although this review provides preliminary insights into the effectiveness of EMDR for first responders, the conclusions that can be drawn from the literature are limited, and the findings highlight several gaps in the literature.

Residential out-of-home care (OoHC) staff regularly experience workplace-related trauma. This may contribute to the future development of a trauma- or stressor-related disorder. Eye movement desensitization and reprocessing (EMDR) is an effective treatment for stress disorders but is largely unstudied in OoHC staff. The objective of the current study was to determine if EMDR, provided early within 3 months of an incident, reduced trauma symptom severity in OoHC staff.During a 3-year pilot study (2018-2020), a trained clinician delivered the Recent Traumatic Episode Protocol (R-TEP) and Group Traumatic Episode Protocol (G-TEP) EMDR to OoHC staff from one community service organization in Victoria, Australia. Retrospective data from the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) were deidentified and analyzed using descriptive statistics and analysis of variance. Due to the COVID-19 pandemic, individual EMDR (R-TEP) was provided via telehealth in 2020 in comparison with face-to-face sessions during 2018-2019.Overall, a significant decrease in PCL-5 scores was seen from baseline to follow up, and staff who received R-TEP or G-TEP experienced reductions in symptoms. Both face-to-face and online modalities showed significant reductions in PCL-5 scores. No significant differences were found between the online or face-to-face modes of delivery, suggesting both options are effective. No adverse reactions were reported among the 144 staff who participated.This study provides evidence for the efficacy of EMDR in reducing traumatic stress symptom severity for residential OoHC staff. A larger, prospective research study is needed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychological first aid (PFA) is a framework to address the psychosocial needs of individuals and communities in the acute aftermath of trauma. It is an evidence-informed set of principles that provides immediate support to affected individuals, with the aim of reducing distress, promoting adaptive functioning, enhancing resiliency, and mitigating the negative psychological sequalae of trauma. This chapter aims to introduce PFA and outline the core facets of the approach. The evolution of PFA will be considered alongside a summary of the research findings on which it is based. Widely used PFA frameworks will be described and discussed. Finally, the evidence base for PFA will be explored and recommendations for future research will be presented.

Funding Information: This work was supported by the National Institute of Mental Health/U.S. Army Medical Research and Development Command (Grant No. R01MH106595 [to CMN, MBS, KJRe, and KCK]), and National Institutes of Health (Grant No. 5U01MH109539 [to the Psychiatric Genomics Consortium] and Grant No. U19 MH069056 [to BWD])). Financial support for the PTSD PGC was provided by the Cohen Veterans Bioscience, Stanley Center for Psychiatric Research at the Broad Institute, and One Mind. Genotyping of samples was provided in part through the Stanley Center for Psychiatric Genetics at the Broad Institute supported by Cohen Veterans Bioscience Statistical analyses were carried out on the LISA/Genetic Cluster Computer ( https://userinfo.surfsara.nl/systems/lisa ) hosted by SURFsara. This research has been conducted using the UK Biobank resource (Application No. 41209). Posttraumatic stress disorder (PTSD) is a heritable (h2 = 24–71%) psychiatric illness. Copy number variation (CNV) is a form of rare genetic variation that has been implicated in the etiology of psychiatric disorders, but no large-scale investigation of CNV in PTSD has been performed. We present an association study of CNV burden and PTSD symptoms in a sample of 114,383 participants (13,036 cases and 101,347 controls) of European ancestry. CNVs were called using two calling algorithms and intersected to a consensus set. Quality control was performed to remove strong outlier samples. CNVs were examined for association with PTSD within each cohort using linear or logistic regression analysis adjusted for population structure and CNV quality metrics, then inverse variance weighted meta-analyzed across cohorts. We examined the genome-wide total span of CNVs, enrichment of CNVs within specified gene-sets, and CNVs overlapping individual genes and implicated neurodevelopmental regions. The total distance covered by deletions crossing over known neurodevelopmental CNV regions was significant (beta = 0.029, SE = 0.005, P = 6.3 × 10−8). The genome-wide neurodevelopmental CNV burden identified explains 0.034% of the variation in PTSD symptoms. The 15q11.2 BP1-BP2 microdeletion region was significantly associated with PTSD (beta = 0.0206, SE = 0.0056, P = 0.0002). No individual significant genes interrupted by CNV were identified. 22 gene pathways related to the function of the nervous system and brain were significant in pathway analysis (FDR q < 0.05), but these associations were not significant once NDD regions were removed. A larger sample size, better detection methods, and annotated resources of CNV are needed to explore this relationship further. publishersversion published

BackgroundThere is evidence that the COVID-19 pandemic has negatively affected mental health, but most studies have been conducted in the general population.AimsTo identify factors associated with mental health during the COVID-19 pandemic in individuals with pre-existing mental illness.MethodParticipants (N = 2869, 78% women, ages 18–94 years) from a UK cohort (the National Centre for Mental Health) with a history of mental illness completed a cross-sectional online survey in June to August 2020. Mental health assessments were the GAD-7 (anxiety), PHQ-9 (depression) and WHO-5 (well-being) questionnaires, and a self-report question on whether their mental health had changed during the pandemic. Regressions examined associations between mental health outcomes and hypothesised risk factors. Secondary analyses examined associations between specific mental health diagnoses and mental health.ResultsA total of 60% of participants reported that mental health had worsened during the pandemic. Younger age, difficulty accessing mental health services, low income, income affected by COVID-19, worry about COVID-19, reduced sleep and increased alcohol/drug use were associated with increased depression and anxiety symptoms and reduced well-being. Feeling socially supported by friends/family/services was associated with better mental health and well-being. Participants with a history of anxiety, depression, post-traumatic stress disorder or eating disorder were more likely to report that mental health had worsened during the pandemic than individuals without a history of these diagnoses.ConclusionsWe identified factors associated with worse mental health during the COVID-19 pandemic in individuals with pre-existing mental illness, in addition to specific groups potentially at elevated risk of poor mental health during the pandemic.

Self-stigma refers to the internalisation of negative societal views and stereotypes. Self-stigma has been well-characterised in the context of mental disorders such as schizophrenia but has received little attention in relation to post-traumatic stress disorder (PTSD). This work aimed to determine the prevalence of self-stigma in a sample of adults with PTSD and to establish factors associated with the internalisation of stigma in this population. Participants were 194 adults (mean age 46.07 (SD = 12.39); 64.4% female; 96.6% white Caucasian; residing in the UK), who self-reported a diagnosis of PTSD and currently screened positive for the disorder according to the PTSD Checklist for DSM-5 (PCL-5). Structured interviews and validated self-report questionnaires were used to ascertain clinical and sociodemographic information for analysis. The prevalence of self-stigma measured by the Internalized Stigma of Mental Illness Scale (ISMIS) was 41.2% (95% CI 34.24–48.22). There was no evidence of an association between self-stigma and gender (β = −2.975 (95% CI −7.046–1.097) p = .151), age (β = 0.007 (95% CI −0.152–0.165) p = .953), sexual trauma (β = 0.904 (95% CI −3.668–5.476) p = .697), military trauma (β = −0.571 (95% CI −4.027–7.287) p = .571). Self-stigma was associated with lower income and higher levels of anxiety (β = 5.722 (95% CI 2.922–8.522) p = β = 6.937 (95% CI 4.287–9.588) p = β = 3.880 (95% CI 1.401–6.359) p = .002). The results indicate that self-stigma may be a significant issue among people with a diagnosis of PTSD. Further work is needed to understand the long-term impact and to develop interventions to address the internalisation of stigma in this population. The prevalence of self-stigma among a sample of participants with PTSD was 41.2%.There was no evidence of an association between self-stigma and gender, age or sexual / military trauma.Self-stigma was associated with lower income and higher levels of anxiety, depression, and traumatic stress symptoms. The prevalence of self-stigma among a sample of participants with PTSD was 41.2%. There was no evidence of an association between self-stigma and gender, age or sexual / military trauma. Self-stigma was associated with lower income and higher levels of anxiety, depression, and traumatic stress symptoms.

We recently applied untargeted metabolomic profiling on the plasma obtained from consecutive attenders referred for conventional Level 3 home-sleep studies with excessive daytime somnolence, comparing 17 OSAHS patients (AHI≥15, Epworth Score 13.5±4.5) with 16 age, gender, and BMI matched sleepy subjects (sleepy snorers (SS)) with negative home polysomnography tests (AHI We reported 6 biologically plausible plasma metabolites that can differentiate OSAHS from SS of similar phenotype with an AUC of 0.982 (95% CI: 0.9-1.0) (figure 1), with these key metabolites being essential lipids involved in protein synthesis and the formation of antioxidative, antiglycating, and free radical scavenging dipeptides. We now report early changes in these biomarkers following CPAP in those with OSAHS. 11 OSAHS patients with AHI≥15 (63.6% male, Age 54.4±6.9, BMI 34.2±4.0, AHI 47.6±25.6, Epworth 13.7±4.8) were commenced on standard auto-adjustment CPAP devices (Phillips DreamStation set at 4 to 18 cm H2O). Mean use of CPAP was 6.6±1.4 hours and average residual AHI was 6.9±6.0. Plasma was sampled pre and post treatment (42-70 days treatment), and metabolomically assessed using the Q Exactive Hybrid Quadrupole-Orbitrap mass spectrometry platform. 16 sleepy snorers with AHI Our previously reported biomarkers associated with processes such as oxidative stress, inflammation, and dysregulation of energy homeostasis improve with short-term treatment with CPAP towards the level of sleepy snorers of similar age, phenotype, and no OSAHS (figure 2). We feel these metabolites have significant potential in the future care pathways of OSAHS, and could reflect the cardiometabolic risk associated with OSAHS better than current diagnostic modalities. Reference O’Rourke, et al. Plasma metabolomics identifies OSAHS. ERS Congress 2021.

To explore in-depth the views on Internet-based psychological therapies and their implementation from the perspective of National Health Service (NHS) commissioners and managers.Qualitative interview study.Ten NHS commissioners and managers participated in a semi-structured, co-produced interview. Each transcribed interview was double-coded and thematically analysed using The Framework Method.Interviews generated three main themes. (1) Capacity issues across psychological therapy services create barriers to face-to-face therapies, and Internet-based interventions offer a solution. (2) Despite reservations, there is growing acceptance of Internet-based therapies. Different ways of connecting with patients are required, and Internet-based treatments are accessible and empowering treatment options, with guided self-help (GSH) preferred. Internet-based interventions may however exclude some individuals and be a threat to the therapeutic relationship between patient and practitioner. (3) Successful roll-out of Internet-based interventions would be facilitated by a strong empirical- or practice-based evidence, a national coordinated approach and timely training and supervision. Barriers to the roll-out include digital intervention set-up costs and delays due to NHS inflexibility.The study highlights factors influencing access to Internet-based therapies, important given the rapid evolution of e-therapies, and particularly timely given increasing use of remote therapies due to COVID-19 restrictions. Interviewees were open to Internet-based approaches, particularly GSH interventions, so long as they do not compromise on therapy quality. Interviewees acknowledged implementation may be challenging, and recommendations were offered.There is a shift in practice and increasingly positive views from NHS staff around remote psychological therapies and different ways of connecting with patients, particularly since the COVID-19 pandemic. There is a strong preference for Internet-based psychological interventions that are guided and that include built-in outcome measures co-produced with service users. There is a need to raise awareness of the growing evidence base for Internet-based psychological therapies, including research examining therapeutic alliance across Internet-based and face-to-face therapies. Challenges implementing Internet-based psychological therapies include therapist resistance to changing working practices in general, and inflexibility of the NHS, and national, coordinated implementation efforts are encouraged.

Bipolar disorder (BD) is a heritable mental illness with complex etiology. We performed a genome-wide association study (GWAS) of 41,917 BD cases and 371,549 controls of European ancestry, which identified 64 associated genomic loci. BD risk alleles were enriched in genes in synaptic signaling pathways and brain-expressed genes, particularly those with high specificity of expression in neurons of the prefrontal cortex and hippocampus. Significant signal enrichment was found in genes encoding targets of antipsychotics, calcium channel blockers, antiepileptics and anesthetics. Integrating eQTL data implicated 15 genes robustly linked to BD via gene expression, including druggable genes such as HTR6, MCHR1, DCLK3 and FURIN. This GWAS provides the best-powered BD polygenic scores to date, when applied in both European and diverse ancestry samples. Analyses of BD subtypes indicated high but imperfect genetic correlation between BD type I and II and identified additional associated loci. Together, these results advance our understanding of the biological etiology of BD, identify novel therapeutic leads and prioritize genes for functional follow-up studies.

Bipolar disorder is a heritable mental illness with complex etiology. We performed a genome-wide association study of 41,917 bipolar disorder cases and 371,549 controls of European ancestry, which identified 64 associated genomic loci. Bipolar disorder risk alleles were enriched in genes in synaptic signaling pathways and brain-expressed genes, particularly those with high specificity of expression in neurons of the prefrontal cortex and hippocampus. Significant signal enrichment was found in genes encoding targets of antipsychotics, calcium channel blockers, antiepileptics and anesthetics. Integrating expression quantitative trait locus data implicated 15 genes robustly linked to bipolar disorder via gene expression, encoding druggable targets such as HTR6, MCHR1, DCLK3 and FURIN. Analyses of bipolar disorder subtypes indicated high but imperfect genetic correlation between bipolar disorder type I and II and identified additional associated loci. Together, these results advance our understanding of the biological etiology of bipolar disorder, identify novel therapeutic leads and prioritize genes for functional follow-up studies.

Post-traumatic stress disorder (PTSD) is a common mental health condition that requires exposure to a traumatic event. This provides unique opportunities for prevention that are not available for other disorders. The aim of this review was to undertake a systematic review and evaluation of randomized controlled trials (RCTs) of interventions designed to prevent PTSD in adults. Searches involving Cochrane, Embase, Medline, PsycINFO, PILOTS and Pubmed databases were undertaken to identify RCTs of pre-incident preparedness and post-incident interventions until May 2019. Six pre-incident and 69 post-incident trials were identified that could be included in meta-analyses. The overall quality of the evidence was low. There was emerging evidence that some interventions may be helpful but an absence of evidence for any intervention that can be strongly recommended for universal, selected or indicated prevention before or within the first three months of a traumatic event. The strongest results were found for cognitive-behavioural therapy with a trauma focus (CBT-T) in individuals with a diagnosis of acute stress disorder which supports calls to detect and treat individuals with significant symptoms rather than providing blanket preventative interventions. Further research is required to optimally configure existing interventions with some evidence of effect and to develop novel interventions to address this major public health issue.

Post-traumatic stress disorder (PTSD) is a common mental disorder associated with significant distress and reduced functioning. Its occurrence after a severe traumatic event and association with characteristic neurobiological changes make PTSD a good candidate for pharmacological prevention and early treatment. The primary aim for this systematic review and meta-analysis was to assess whether pharmacological interventions when compared to placebo, or other pharmacological/psychosocial interventions resulted in a clinically significant reduction or prevention of symptoms, improved functioning or quality of life, presence of disorder, or adverse effects. A systematic search was undertaken to identify RCTs, which used early pharmacotherapy (within three months of a traumatic event) to prevent and treat PTSD and acute stress disorder (ASD) in children and adults. Using Cochrane Collaboration methodology, RCTs were identified and rated for risk of bias. Available data was pooled to calculate risk ratios (RR) for PTSD prevalence and standardised mean differences (SMD) for PTSD severity. 19 RCTs met the inclusion criteria; 16 studies with adult participants and three with children. The methodological quality of most trials was low. Only hydrocortisone in adults was found to be superior to placebo (3 studies, n = 88, RR: 0.21 (CI 0.05 to 0.89)) although this was in populations with severe physical illness, raising concerns about generalisability. No significant effects were found for the other pharmacotherapies investigated (propranolol, oxytocin, gabapentin, fish oil (1470 mg DHA/147 mg EPA), fish oil (224 mg DHA/22.4 mg EPA), dexamethasone, escitalopram, imipramine and chloral hydrate). Hydrocortisone shows the most promise, of pharmacotherapies subjected to RCTs, as an emerging intervention in the prevention of PTSD within three months after trauma and should be a target for further investigation. The limited evidence for hydrocortisone and its adverse effects mean it cannot be recommended for routine use, but, it could be considered as a preventative intervention for people with severe physical illness or injury, shortly after a traumatic event, as long as there are no contraindications. More research is needed using larger, high quality RCTs to establish the most efficacious use of hydrocortisone in different populations and optimal dosing, dosing window and route. There is currently a lack of evidence to suggest that other pharmacological agents are likely to be effective.

Impaired social function is a core feature of many psychiatric illnesses. Adverse experiences during childhood increase risk for mental illness, however it is currently unclear whether stress early in life plays a direct role in the development of social difficulties. Using an animal model of pre-pubertal stress (PPS), we investigated effects on social behaviour, oxytocin and arginine vasopressin (AVP). We also explored social performance and AVP expression in participants with borderline personality disorder (BPD) who experienced a high incidence of childhood stress. Social behaviour was impaired and AVP expression increased in animals experiencing PPS and participants with BPD. Behavioural deficits in animals were rescued through administration of the AVP receptor 1a antagonist Relcovaptan (SR49059). AVP levels and recognition of negative emotions were significantly correlated in BPD participants only. In conclusion, early life stress plays a profound role in the precipitation of social dysfunction, and AVP mediates at least part of this effect.

Background: Post-traumatic stress disorder (PTSD) is a major cause of morbidity amongst active duty and ex-serving military personnel. In recent years increasing efforts have been made to develop more effective treatments.\ud\udObjective: To determine which psychological therapies are efficacious in treating active duty and ex-serving military personnel with post-traumatic stress disorder (PTSD).\ud\udMethod: A systematic review was undertaken according to Cochrane Collaboration Guidelines. The primary outcome measure was reduction in PTSD symptoms and the secondary outcome dropout.\ud\udResults: Twenty-four studies with 2386 participants were included. Evidence demonstrated that CBT with a trauma focus (CBT-TF) was associated with the largest evidence of effect when compared to waitlist/usual care in reducing PTSD symptoms post treatment (10 studies; n = 524; SMD −1.22, −1.78 to −0.66). Group CBT-TF was less effective when compared to individual CBT-TF at reducing PTSD symptoms post treatment (1 study; n = 268; SMD −0.35, −0.11 to −0.59). Eye Movement Desensitization and Reprocessing (EMDR) therapy was not effective when compared to waitlist/usual care at reducing PTSD symptoms post treatment (4 studies; n = 92; SMD −0.83, −1.75 to 0.10). There was evidence of greater dropout from CBT-TF therapies compared to waitlist and Present Centred Therapy. Conclusions: The evidence, albeit limited, supports individual CBT-TF as the first-line psychological treatment of PTSD in active duty and ex-serving personnel. There is evidence for Group CBT-TF, but this is not as strong as for individual CBT-TF. EMDR cannot be recommended as a first line therapy at present and urgently requires further evaluation. Lower effect sizes than for other populations with PTSD and high levels of drop-out suggest that CBT-TF in its current formats is not optimally acceptable and further research is required to develop and evaluate more effective treatments for PTSD and complex PTSD in active duty and ex-serving military personnel.

Background: Internet-delivered Cognitive Behavioural Therapy (i-CBT) offers potential as an alternative, accessible, clinically and cost-effective treatment for post-traumatic stress disorder (PTSD), but little is known about its acceptability.\ud \ud Objective: To review the available evidence to understand the acceptability of i-CBT for PTSD.\ud \ud Method: We undertook a mixed-methods systematic review according to Cochrane Collaboration Guidelines, of randomised controlled trials (RCTs) of i-CBT for adults with PTSD. We examined included studies for measures of acceptability, and possible proxy indicators of acceptability, including dropout rates, which were meta-analysed as risk ratios (RRs).\ud \ud Results: Ten studies with 720 participants were included. We found i-CBT to be acceptable according to specific acceptability measures, and suggestions for acceptability according to some proxy measures of i-CBT programme usage. There was, however, evidence of greater dropout from i-CBT than waitlist (RR 1.39, CI 1.03–1.88; 8 studies; participants = 585) and no evidence of a difference in dropout between i-CBT and i-non-CBT (RR 2.14, CI 0.97–4.73; participants = 132; 2 studies).\ud \ud Conclusion: i-CBT appears a potentially acceptable intervention for adults with PTSD. We identified clinical and research questions, including the status of proxy indicators, and call for standardised, consistent treatment acceptability measurement.

Over the last two decades, treatment guidelines have become major aids in the delivery of evidence-based care and improvement of clinical outcomes. The International Society for Traumatic Stress Studies (ISTSS) produced the first guidelines for the prevention and treatment of posttraumatic stress disorder (PTSD) in 2000 and published its latest recommendations, along with position papers on complex PTSD (CPTSD), in November 2018. A rigorous methodology was developed and followed; scoping questions were posed, systematic reviews were undertaken, and 361 randomized controlled trials were included according to the a priori agreed inclusion criteria. In total, 208 meta-analyses were conducted and used to generate 125 recommendations (101 for adults and 24 for children and adolescents) for specific prevention and treatment interventions, using an agreed definition of clinical importance and recommendation setting algorithm. There were eight strong, eight standard, five low effect, 26 emerging evidence, and 78 insufficient evidence to recommend recommendations. The inclusion of separate scoping questions on treatments for complex presentations of PTSD was considered but decided against due to definitional issues and the virtual absence of studies specifically designed to clearly answer possible scoping questions in this area. Narrative reviews were undertaken and position papers prepared (one for adults and one for children and adolescents) to consider the current issues around CPTSD and make recommendations to facilitate further research. This paper describes the methodology and results of the ISTSS Guideline process and considers the interpretation and implementation of the recommendations.Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Nuevas guías para la prevención y el tratamiento del trastorno de estrés postraumático de la Sociedad Internacional de Estudios de Estrés Traumático: metodología y proceso de desarrollo GUIAS DE LA ISTSS PARA EL TEPT En las últimas dos décadas, las guías de tratamiento se han convertido en una ayuda importante para la prestación de atención basada en la evidencia y la mejora de los resultados clínicos. La Sociedad Internacional de Estudios de Estrés Traumático (ISTSS en sus siglas en inglés) produjo las primeras guías para la prevención y tratamiento del trastorno de estrés postraumático (TEPT) en 2000 y publicó sus últimas recomendaciones, junto con los documentos de posición sobre el TEPT complejo (TEPT-C), en noviembre de 2018. Se desarrolló y siguió una metodología rigurosa; se plantearon preguntas de alcance, se realizaron revisiones sistemáticas y se incluyeron 361 ensayos controlados aleatorizados de acuerdo con los criterios de inclusión acordados a priori. En total, se realizaron 208 metanálisis y fueron utilizados para generar 125 recomendaciones (101 para adultos y 24 para niños y adolescentes) para intervenciones específicas de prevención y tratamiento, utilizando una definición acordada de la importancia clínica y un algoritmo de configuración de recomendaciones. Hubo ocho estudios con pruebas sólidas, ocho como estándar, cinco con bajo efecto, 26 con evidencia emergente y 78 fueron evaluados como con evidencia insuficiente para ser recomendados en las recomendaciones. Se consideró la inclusión de preguntas de alcance separadas sobre tratamientos para presentaciones complejas de TEPT, pero se decidió en contra debido a cuestiones de definición y ausencia virtual de estudios diseñados específicamente para responder con claridad las posibles preguntas de alcance en esta área. Se realizaron revisiones narrativas y se prepararon documentos de posición (uno para adultos y otro para niños y adolescentes) para considerar los problemas actuales en torno al TEPT-C y hacer recomendaciones para facilitar la investigación adicional. Este documento describe la metodología y los resultados del proceso de la Guía de la ISTSS y considera la interpretación y la implementación de las recomendaciones.Traditional and Simplified Chinese Abstracts by the Asian Society for Traumatic Stress Studies (AsianSTSS) 簡體及繁體中文撮要由亞洲創傷心理研究學會翻譯 The International Society for Traumatic Stress Studies New Guidelines for the Prevention and Treatment of PTSD: Methodology and Development Process Traditional Chinese 標題: 國際創傷壓力研究協會就PTSD預防和治療提供的新指引:方法學與發展過程 撮要: 過去二十年來, 治療指引成為了提供實證為本治療和改善臨床療效的主要輔助工具。國際創傷壓力研究協會(ISTSS)於2000年推出了首個創傷後壓力症(PTSD)預防和治療指引, 並於2018年11月發表最新的建議, 及對於複雜性PTSD (CPTSD)的意見書。過程中發展出嚴謹的方法學、基於觀察提出問題, 並作出了系統性審核。我們基於先驗地同意的包含準則, 找出361項隨機對照試驗;共進行了208項元分析, 採用對臨床重要性一致同意的定義, 以及一致同意產生建議的演算法, 從而得出125項特殊的預防建議及干預治療建議(101 項關於成人;24 項關於兒童及青少年)。讓我們作出建議的試驗研究當中, 8個具有力證據、8個為標準、5個低效、26個有新證據、78個證據不足。我們曾考慮包含對PTSD複雜情況的個別治療觀察問題, 但因為在定義方面仍存有問題, 而且欠缺能清楚解答那些潛在觀察問題的實質研究, 所以最後取消該考慮。我們亦進行了敘述評估, 及就當前有關CPTSD的疑問撰寫意見書(一份關於成人, 一份關於兒童及青少年), 並對未來研究作出建議。本文描述ISTSS提供指引過程的方法學和結果, 並探討建議的詮釋和運用。 Simplified Chinese 标题: 国际创伤压力研究协会就PTSD预防和治疗提供的新指引:方法学与发展过程 撮要: 过去二十年来, 治疗指引成为了提供实证为本治疗和改善临床疗效的主要辅助工具。国际创伤压力研究协会(ISTSS)于2000年推出了首个创伤后压力症(PTSD)预防和治疗指引, 并于2018年11月发表最新的建议, 及对于复杂性PTSD (CPTSD)的意见书。过程中发展出严谨的方法学、基于观察提出问题, 并作出了系统性审核。我们基于先验地同意的包含准则, 找出361项随机对照试验;共进行了208项元分析, 采用对临床重要性一致同意的定义, 以及一致同意产生建议的算法, 从而得出125项特殊的预防建议及干预治疗建议(101 项关于成人;24 项关于儿童及青少年)。让我们作出建议的试验研究当中, 8个具有力证据、8个为标准、5个低效、26个有新证据、78个证据不足。我们曾考虑包含对PTSD复杂情况的个别治疗观察问题, 但因为在定义方面仍存有问题, 而且欠缺能清楚解答那些潜在观察问题的实质研究, 所以最后取消该考虑。我们亦进行了叙述评估, 及就当前有关CPTSD的疑问撰写意见书(一份关于成人, 一份关于儿童及青少年), 并对未来研究作出建议。本文描述ISTSS提供指引过程的方法学和结果, 并探讨建议的诠释和运用。.

Background Therapist-delivered trauma-focused psychological therapies are an effective treatment for post-traumatic stress disorder (PTSD). These have become the accepted first-line treatments for the disorder. Despite the established evidence-base for these therapies, they are not always widely available or accessible. Many barriers limit treatment uptake, such as the limited number of qualified therapists to deliver the interventions, cost, and compliance issues, such as time off work, childcare, and transportation, associated with the need to attend weekly appointments. Delivering cognitive behavioural therapy (CBT) on the Internet is an effective and acceptable alternative to therapist-delivered treatments for anxiety and depression. However, fewer Internet-based therapies have been developed and evaluated for PTSD, and uncertainty surrounds the efficacy of Internet-based cognitive and behavioural therapy (I-C/BT) for PTSD. Objectives To assess the effects of I-C/BT for PTSD in adults. Search methods We searched the Cochrane Common Mental Disorders Group's Specialised Register (CCMDCTR) to June 2016 and identified four studies meeting the inclusion criteria. The CCMDCTR includes relevant randomised controlled trials (RCT) from MEDLINE, Embase, and PsycINFO. We also searched online clinical trial registries and reference lists of included studies, and contacted researchers in the field to identify additional and ongoing studies. We ran an update search on 1 March 2018, and identified four additional completed studies, which we added to the analyses along with two that were previously awaiting classification. Selection criteria We searched for RCTs of I-C/BT compared to face-to-face or Internet-based psychological treatment, psychoeducation, wait list or care as usual. We included studies of adults (aged over 16 years or over), in which at least 70% of the participants met the diagnostic criteria for PTSD, according to the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD). Data collection and analysis We entered data into Review Manager 5 software. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data with a fixed-effect meta-analysis, except where heterogeneity was present, in which case we used a random-effects model. Two review authors independently assessed the included studies for risk of bias; any conflicts were discussed with a third author, with the aim of reaching a unanimous decision. Main results We included 10 studies with 720 participants in the review. Eight of the studies compared I-C/BT delivered with therapist guidance to a wait list control. Two studies compared guided I-C/BT with I-non-C/BT. There was considerable heterogeneity among the included studies.Very low-quality evidence showed that, compared with wait list, I-C/BT may be associated with a clinically important reduction in PTSD post-treatment (SMD -0.60, 95% CI -0.97 to -0.24; studies = 8, participants = 560). However, there was no evidence of a difference in PTSD symptoms when follow-up was less than six months (SMD -0.43, 95% CI -1.41 to 0.56; studies = 3, participants = 146). There may be little or no difference in dropout rates between the I-C/BT and wait list groups (RR 1.39, 95% CI 1.03 to 1.88; studies = 8, participants = 585; low-quality evidence). I-C/BT was no more effective than wait list at reducing the risk of a diagnosis of PTSD after treatment (RR 0.53, 95% CI 0.28 to 1.00; studies = 1, participants = 62; very low-quality evidence). I-C/BT may be associated with a clinically important reduction in symptoms of depression both post-treatment (SMD -0.61, 95% CI -1.17 to -0.05; studies = 5, participants = 425; very low-quality evidence). Very low-quality evidence also suggested that I-C/BT may be associated with a clinically important reduction in symptoms of anxiety post-treatment (SMD -0.67, 95% CI -0.98 to -0.36; studies = 4, participants = 305), and at follow-up less than six months (MD -12.59, 95% CI -20.74 to -4.44; studies = 1, participants = 42; very low-quality evidence). The effects of I-C/BT on quality of life were uncertain (SMD 0.60, 95% CI 0.08 to 1.12; studies = 2, participants = 221; very low-quality evidence).Two studies found no difference in PTSD symptoms between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD -0.08, 95% CI -0.52 to 0.35; studies = 2, participants = 82; very low-quality evidence), or when follow-up was less than six months (SMD 0.08, 95% CI -0.41 to 0.57; studies = 2, participants = 65; very low-quality evidence). However, those who received I-C/BT reported their PTSD symptoms were better at six- to 12-month follow-up (MD -8.83, 95% CI -17.32 to -0.34; studies = 1, participants = 18; very low-quality evidence). Two studies found no difference in depressive symptoms between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD -0.12, 95% CI -0.78 to 0.54; studies = 2, participants = 84; very low-quality evidence) or when follow-up was less than six months (SMD 0.20, 95% CI -0.31 to 0.71; studies = 2, participants = 61; very low-quality evidence). However, those who received I-C/BT reported their depressive symptoms were better at six- to 12-month follow-up (MD -8.34, 95% CI -15.83 to -0.85; studies = 1, participants = 18; very low-quality evidence). Two studies found no difference in symptoms of anxiety between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD 0.08, 95% CI -0.78 to 0.95; studies = 2, participants = 74; very low-quality evidence) or when follow-up was less than six months (SMD -0.16, 95% CI -0.67 to 0.35; studies = 2, participants = 60; very low-quality evidence). However, those who received I-C/BT reported their symptoms of anxiety were better at six- to 12-month follow-up (MD -8.05, 95% CI -15.20 to -0.90; studies = 1, participants = 18; very low-quality evidence).None of the included studies reported on cost-effectiveness or adverse events. Authors' conclusions While the review found some beneficial effects of I-C/BT for PTSD, the quality of the evidence was very low due to the small number of included trials. Further work is required to: establish non-inferiority to current first-line interventions, explore mechanisms of change, establish optimal levels of guidance, explore cost-effectiveness, measure adverse events, and determine predictors of efficacy and dropout.

Post-traumatic stress disorder (PTSD) is a common and debilitating disorder. The risk of PTSD following trauma is heritable, but robust common variants have yet to be identified by genome-wide association studies (GWAS). We have collected a multi-ethnic cohort including over 30,000 PTSD cases and 170,000 controls. We first demonstrate significant genetic correlations across 60 PTSD cohorts to evaluate the comparability of these phenotypically heterogeneous studies. In this largest GWAS meta-analysis of PTSD to date we identify a total of 6 genome-wide significant loci, 4 in European and 2 in African-ancestry analyses. Follow-up analyses incorporated local ancestry and sex-specific effects, and functional studies. Along with other novel genes, a non-coding RNA (ncRNA) and a Parkinson’s Disease gene,PARK2, were associated with PTSD. Consistent with previous reports, SNP-based heritability estimates for PTSD range between 10-20%. Despite a significant shared liability between PTSD and major depressive disorder, we show evidence that some of our loci may be specific to PTSD. These results demonstrate the role of genetic variation contributing to the biology of differential risk for PTSD and the necessity of expanding GWAS beyond European ancestry.

Background: Trauma exposure and posttraumatic stress disorder (PTSD) are common among individuals with a mental disorder, but symptoms often go undetected and untreated. Methods: The aim of this study was to determine the prevalence of PTSD among a large sample of adults with psychiatric diagnoses and to establish factors associated with symptoms going undetected. Participants were 1,946 adults recruited by the National Centre for Mental Health. Structured interviews and validated self-report questionnaires were used to ascertain clinical and demographic information for analysis. Results: The prevalence of participants screening positive for PTSD that had not been detected by clinical services was 13.9% [12.4–15.5%, 95% confidence interval]). Factors associated with undetected PTSD were female gender, younger age of first contact with psychiatric services, and lower household income. Especially, poor rates of detection were observed after traumatic events, such as child abuse and sexual assault. Conclusions: Our findings demonstrate the need for routine assessment of trauma histories and symptoms of PTSD among individuals with anymental disorder.

Background There is a shortage of suitably qualified therapists able to deliver evidence-based treatment for posttraumatic stress disorder (PTSD), precluding timely access to intervention. This work aimed to develop an optimally effective, feasible, and acceptable guided self-help (GSH) program for treatment of the disorder. Methods The study followed Medical Research Council (MRC) guidance for the development of a complex intervention. A prototype GSH program was developed through an initial modeling phase. Systematic reviews of the literature informed a portfolio of up-to-date information for key stakeholders to consider and discuss in a series of focus groups and semistructured interviews, which included 10 mental health professionals with expertise in the fields of GSH and/or PTSD, and seven former PTSD sufferers. Data were analyzed through a process of Inductive Thematic Analysis and used to inform the content, delivery, and guidance of a GSH program for PTSD. The prototype was piloted with 19 PTSD sufferers in two pilot studies, and refined on the basis of their quantitative results and qualitative feedback. Results The final version was available online and in hardcopy. It included 11 modules, some being mandatory and others optional, allowing tailoring of the intervention to meet an individual's specific needs. Qualitative and quantitative results of the pilot studies supported its efficacy in terms of reducing traumatic stress symptoms and its acceptability to PTSD sufferers. Conclusions

Aims and methodThe effectiveness of official support provided following a disaster has not been fully evaluated. This study aimed to ascertain whether there was an association between perceived support shortly after the 2004 Indian Ocean tsunami and later mental health symptoms in those affected, and to explore the factors associated with this. A survey, semi-structured interviews and focus group were used to explore the experiences and perceptions of 116 individuals severely affected by the tsunami.ResultsAgency or official support was perceived as poor overall. Perceived ineffectiveness of support available within a few days after the tsunami was associated with increased symptoms of post-traumatic stress disorder 15–19 months later. The strongest themes that emerged from our study were that support provided in a humane manner was perceived as effective and that uncoordinated support, poor communication and limited accessibility to support and information were perceived as ineffective.Clinical implicationsImproved planning of coordinated, flexible, multi-agency responses to traumatic events before they occur is required.

There is a shortage of suitably qualified therapists able to deliver evidence-based treatment for posttraumatic stress disorder (PTSD), precluding timely access to intervention. This work aimed to develop an optimally effective, feasible, and acceptable guided self-help (GSH) program for treatment of the disorder.The study followed Medical Research Council (MRC) guidance for the development of a complex intervention. A prototype GSH program was developed through an initial modeling phase. Systematic reviews of the literature informed a portfolio of up-to-date information for key stakeholders to consider and discuss in a series of focus groups and semistructured interviews, which included 10 mental health professionals with expertise in the fields of GSH and/or PTSD, and seven former PTSD sufferers. Data were analyzed through a process of Inductive Thematic Analysis and used to inform the content, delivery, and guidance of a GSH program for PTSD. The prototype was piloted with 19 PTSD sufferers in two pilot studies, and refined on the basis of their quantitative results and qualitative feedback.The final version was available online and in hardcopy. It included 11 modules, some being mandatory and others optional, allowing tailoring of the intervention to meet an individual's specific needs. Qualitative and quantitative results of the pilot studies supported its efficacy in terms of reducing traumatic stress symptoms and its acceptability to PTSD sufferers.Delivering psychological treatment in a GSH format shows promise as an effective and acceptable way of treating mild-to-moderate PTSD.

Objective\ud \ud To examine the impact of adverse childhood experiences (ACEs) and support on self-reported work inability of adults reporting disability.\ud \ud Participants\ud \ud Adults (ages 18–64) who participated in the Behavioral Risk Factor Surveillance System in 2009 or 2010 and who reported having a disability (n = 13,009).\ud \ud Design and Main Outcome Measures\ud \ud The study used a retrospective cohort design with work inability as the main outcome. ACE categories included abuse (sexual, physical, emotional) and family dysfunction (domestic violence, incarceration, mental illness, substance abuse, divorce). Support included functional (perceived emotional/social support) and structural (living with another adult) support. Logistic regression was used to adjust for potential confounders (age, sex and race) and to evaluate whether there was an independent effect of ACEs on work inability after adding other important predictors (support, education, health) to the model.\ud \ud Results\ud \ud ACEs were highly prevalent with almost 75% of the sample reporting at least one ACE category and over 25% having a high ACE burden (4 or more categories). ACEs were strongly associated with functional support. Participants experiencing a high ACE burden had a higher adjusted odds ratio (OR) [95% confidence interval] of 1.9 [1.5–2.4] of work inability (reference: zero ACEs). Good functional support (adjusted OR 0.52 [0.42–0.63]) and structural support (adjusted OR 0.48 [0.41–0.56]) were protective against work inability. After adding education and health to the model, ACEs no longer appeared to have an independent effect. Structural support remained highly protective, but functional support only appeared to be protective in those with good physical health.\ud \ud Conclusions\ud \ud ACEs are highly prevalent in working-age US adults with a disability, particularly young adults. ACEs are associated with decreased support, lower educational attainment and worse adult health. Health care providers are encouraged to screen for ACEs. Addressing the effects of ACEs on health and support, in addition to education and retraining, may increase ability to work in those with a disability.

BackgroundSelf-help interventions for psychiatric disorders represent an increasingly popular alternative to therapist-administered psychological therapies, offering the potential of increased access to cost-effective treatment.AimsTo determine the efficacy, cost-effectiveness and acceptability of self-help interventions for anxiety disorders.MethodRandomised controlled trials (RCTs) of self-help interventions for anxiety disorders were identified by searching nine online databases. Studies were grouped according to disorder and meta-analyses were conducted where sufficient data were available. Overall meta-analyses of self-helpv.waiting list and therapist-administered treatment were also undertaken. Methodological quality was assessed independently by two researchers according to criteria set out by the Cochrane Collaboration.ResultsThirty-one RCTs met inclusion criteria for the review. Results of the overall meta-analysis comparing self-help with waiting list gave a significant effect size of 0.84 in favour of self-help. Comparison of self-help with therapist-administered treatments revealed a significant difference in favour of the latter with an effect size of 0.34. The addition of guidance and the presentation of multimedia or web-based self-help materials improved treatment outcome.ConclusionsSelf-help interventions appear to be an effective way of treating individuals diagnosed with social phobia and panic disorder. Further research is required to evaluate the cost-effectiveness and acceptability of these interventions.