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The purpose of this study was to examine differences between military veterans and service members with and without a psychiatric assistance dog (PAD) who were receiving cognitive behavioral therapy (CBT) for post-traumatic stress disorder (PTSD). Six hundred eighty-two military veterans presented at a 2-week intensive, outpatient CBT program for PTSD from February 2016 to February 2020. Self-reports of symptoms and rates of treatment completion by PAD ownership were assessed. Patients with PADs ( n = 93) reported higher scores on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) ( P = .04; Cohen's d = 0.23) and Neurobehavioral Symptom Inventory ( P < .01; Cohen's d = 0.34) at baseline. PTSD symptom change was comparable between participants with and without PADs ( P > .05). Dropout was higher among owners of PADs, but this difference was not significant ( P = .11). Among military populations, those with PADs may experience more severe PTSD and neuro-cognitive symptoms, but having a PAD was not associated with treatment outcome in intensive CBT. [ Psychiatr Ann . 2022;52(5):191–198.]

Accelerated models of care may be one solution to the problem of underutilization of mental health treatment in veterans. We report on a novel implementation of prolonged exposure (PE) therapy in a four-day, weekend-based intensive outpatient treatment program. Seventeen military veterans and service members (Mage = 45.23, SDage = 10.18; 76.47% male) completed the program. Symptoms of posttraumatic stress disorder (PTSD) and depression were targeted in five separate cohorts. Given that this was an uncontrolled pilot study, we assessed patient satisfaction and treatment completion. In a completers analysis, PTSD and depression symptoms decreased significantly from pre- to posttreatment (p's

OBJECTIVE While the comparative efficacy of prolonged exposure (PE) and cognitive processing therapy (CPT) has been examined in outpatient settings, there is a dearth of literature on the relative effectiveness of these interventions when adapted for an intensive treatment format. In an expanded secondary analysis of a previous study, we sought to examine the comparative effectiveness of PE and CPT delivered in the naturalistic setting of an intensive treatment format including maintenance of outcomes through a 6-month follow-up period. METHOD A sample of 296 veterans with posttraumatic stress disorder (PTSD) received either PE (n = 186) or CPT (n = 90), alongside other trauma-informed interventions, in a 2-week intensive clinical program. Treatment selection was determined collaboratively between patient and therapist. Our primary outcome was self-reported PTSD symptom severity (i.e., PTSD Checklist for DSM-5, PCL-5); secondarily, we examined self-reported depression (i.e., Patient Health Questionnaire) symptom severity outcomes. RESULTS A mixed-model regression controlling for age and gender revealed a significant effect of time from baseline to endpoint (p .05; model: Wald's χ² = 232.38, p < .001). Results were similar for depression outcomes. Attrition at posttreatment was not significantly different between groups: 7.2% for CPT and 6.5% PE (z score = 0.22). CONCLUSIONS Both PE and CPT are associated with comparable improvements when delivered as part of a 2-week intensive outpatient program. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Of troops returning from Iraq and Afghanistan, approximately 5–20% have PTSD, and another 11–23% have traumatic brain injury (TBI). Cognitive-behavioral therapies (CBTs) are empirically validated treatment strategies for PTSD. However, cognitive limitations may interfere with the ability to adhere to, and benefit from, CBTs. Co-morbid TBI has not been systematically taken into consideration in PTSD outcome research or in treatment planning guidance. We hypothesized that poorer pre-treatment cognitive abilities would be associated with poorer treatment outcomes from CBTs for PTSD. The present study was a naturalistic examination of “treatment as usual” in an outpatient clinic that provides manualized CBTs for PTSD to military service members and veterans. Participants were 23 veterans aged 18–50 years with combat-related PTSD and symptom duration more than 1 year; 16 of whom had mild TBI. Our predictor variables were well-normed objective tests of cognitive ability measured at baseline; our outcome variables were: a) individual slopes of change of the PTSD Checklist 5 (PCL-5) and the Clinician Assessment of PTSD Scale (CAPS-5) over weeks of treatment; and b) pre- to post-treatment change (Δ) in PCL-5 and CAPS-5. Contrary to our prediction, neither pre-treatment cognitive performance, nor the presence of co-morbid mild TBI, predicted poorer response to CBTs for PTSD. Our results discourage any notion of excluding PTSD patients with poorer cognitive ability from CBTs. Study limitations include a naturalistic treatment design, which did not allow for control of confounders, and an inability to completely rule out type II error because of small sample size.

BACKGROUND Complicated grief (CG) is a bereavement-specific syndrome distinct from but commonly comorbid with posttraumatic stress disorder (PTSD). While bereavement is common among military personnel (Simon et al., 2018), there is little research on the impact of CG comorbidity on PTSD treatment outcomes. METHODS To evaluate the impact of comorbid CG on PTSD treatment outcomes we analyzed data from a randomized trial comparing prolonged exposure, sertraline, and their combination in veterans with a primary diagnosis of combat-related PTSD (n = 194). Assessment of PTSD, trauma-related guilt, functional impairment, and suicidal ideation and behavior occurred at baseline and weeks 6, 12, and 24 during the 24-week trial. RESULTS CG was associated with lower PTSD treatment response (odds ratio (OR) = 0.29, 95% confidence interval (CI) [0.12, 0.69], p = 0.005) and remission (OR = 0.28, 95% CI [0.11, 0.71], p = 0.007). Those with CG had greater severity of PTSD (p = 0.005) and trauma-related guilt (

Repeated, extended deployments in support of OEF/OIF/OND have important implications for not only veterans, but also their family members. While this topic is beginning to garner more attention, more research is needed on the relationship between symptoms of posttraumatic stress disorder (PTSD), parenting factors, and family functioning among OEF/OIF/OND veterans. The present study aimed to: (1) examine the relationship between specific PTSD symptom clusters and family functioning among a sample of N = 191 treatment-seeking veteran parents who served after September 11, 2001; and (2) examine the mediating role of parenting sense of competence in this relationship. Participants completed the PTSD Check List (PCL), the Parenting Sense of Competence Scale (PSOC), and the Family Assessment Device (FAD) as part of their initial evaluation in an outpatient mental health clinic. Numbing and avoidance symptoms of PTSD (Criterion C; PCL_c) were associated with more problematic family functioning (r = .164, p

Two pilot studies (N = 11; N = 15) assessed the feasibility and efficacy of a weekly 6-session ACT group videoconferencing intervention for public speaking anxiety with participants in separate physical locations. Both studies found significant improvements in self-reported social anxiety symptoms from pre-treatment to follow-up, with high levels of patient satisfaction. Results provide support for group videoconferencing as a viable format for delivering behavioral treatments including acceptance-based interventions. The second study also found significant improvements in behavioral performance and supported the feasibility and utility of videotaped virtual audiences for homework exposure exercises. No significant differences in anxiety levels were experienced during in vivo homework exposures compared to virtual homework exposures. Practically, clinicians are encouraged to pay particular attention to optimizing physiological arousal during exposures and to consider technological and ethical factors of these formats.

Many returning military service members and veterans who were deployed following the September 11, 2001, terrorist attacks (9/11) suffer from posttraumatic stress disorder (PTSD) and insomnia. Although intensive treatment programs for PTSD have shown promise in the treatment of PTSD symptoms, recent research has demonstrated that sleep disturbance shows little improvement following intensive trauma-focused treatment. The aim of the present study was to evaluate changes in self-reported insomnia symptoms among veterans and service members following participation in a 2-week intensive program for PTSD. We further aimed to investigate if residual PTSD symptoms, specifically hyperarousal, were associated with residual insomnia symptoms. Participants (N = 326) completed self-report assessments of insomnia, PTSD symptoms, and depressive symptoms at pre- and posttreatment. At pretreatment, 73.9% of participants (n = 241) met the criteria for moderate or severe insomnia, whereas at posttreatment 67.7% of participants (n = 203) met the criteria. Results of paired t tests demonstrated statistically significant differences between pre- and posttreatment Insomnia Severity Index scores; however, the effect size was small, d = 0.34. Analyses revealed that posttreatment hyperarousal symptoms were associated with posttreatment insomnia. These findings suggest that although an intensive program for service members and veterans with PTSD may significantly reduce insomnia symptoms, clinically meaningful residual insomnia symptoms remain. Further research is warranted to elucidate the association between residual hyperarousal and insomnia symptoms following intensive trauma-focused treatment.

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) commonly co-occur in combat veterans, and this comorbidity has been associated with higher levels of distress and more social and economic costs compared to one disorder alone. In a secondary analysis of a multisite randomized controlled trial of a sample of veterans with combat-related PTSD, we examined the associations among pre-, peri-, and postdeployment adversity, social support, and clinician-diagnosed comorbid MDD. Participants completed the Deployment Risk and Resilience Inventory and the Beck Depression Inventory–II as well as structured clinical interviews for diagnostic status. Among 223 U.S. veterans of the military operations in Iraq and Afghanistan (86.9% male) with primary combat-related PTSD, 69.5% had current comorbid MDD. After adjustment for sex, a linear regression model indicated that more concerns about family disruptions during deployment, f(2) = 0.065; more harassment during deployment, f(2) = 0.020; and lower ratings of postdeployment social support, f(2) = 0.154, were associated with more severe self-reported depression symptoms. Interventions that enhance social support as well as societal efforts to foster successful postdeployment reintegration are critical for reducing the mental health burden associated with this highly prevalent comorbidity in veterans with combat-related PTSD.

Exposure therapy for social anxiety disorder (SAD) utilizes fear extinction, a memory process enhanced by sleep. We investigated whether naps following exposure sessions might improve symptoms and biomarkers in response to social stress in adults undergoing 5-week exposure-based group SAD therapy. Thirty-two participants aged 18–39 (18 females) with SAD were randomized. Before and after treatment, participants completed the Liebowitz Social Anxiety Scale (LSAS) and underwent a Trier Social Stress Test with psychophysiological monitoring (mpTSST) that included skin conductance (SCL), electromyographic (EMG) and electrocardiographic recording, and an auditory startle procedure while anticipating the social stressor. At sessions 3 and 4, exposure was followed by either a 120-min polysomnographically monitored sleep opportunity (Nap, N = 17) or wakefulness (Wake, N = 15). Primary hypotheses about SAD symptom change (LSAS) and EMG blink-startle response failed to differ with naps, despite significant symptom improvement (LSAS) with therapy. Some secondary biomarkers, however, provided preliminary support for enhanced extinction learning with naps, with trend-level Time (pre-, post-treatment) × Arm interactions and significant reduction from pre- to post treatment in the Nap arm alone for mpTSST SCL and salivary cortisol rise. Because of the small sample size and limited sleep duration, additional well-powered studies with more robust sleep interventions are indicated.

Underutilization of mental health care is a significant problem among veterans. Offering peer support may improve mental health care engagement. This observational pilot study was conducted using an institutional review board-approved data repository to preliminarily evaluate the association and potential impact of a clinic-based veteran peer outreach strategy on treatment engagement and dropout. Veteran peer outreach coordinators (VPOCs) provided systematic contact (a) within 1 week after clinical evaluation and (b) 1 month after the patient's first treatment session to patients entering treatment at a specialty mental health clinic that provides military-informed mental health care to post-9/11 veterans and service members. Individuals were 102 consecutive Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veteran psychotherapy referrals seen at an outpatient clinic. At 6 months, participants who received both contacts from VPOC had more psychotherapy sessions (M = 10.85, SD = 8.25) compared with those who had received no contact (M = 5.47, SD = 6.41) from VPOCs, t = 2.56, p < .05. The dropout rate was also significantly lower for those who received both peer outreach contacts (17.39%) compared with those who received only 1 VPOC contact (51.11%) or no VPOC contact (43.75%), χ2 = 7.27, p < .05. Veteran peer outreach may be associated with better engagement in mental health treatment and lower dropout. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Only two trials have compared acceptance and commitment therapy (ACT) and traditional cognitive behavior therapy (tCBT) in the treatment of social anxiety disorder (SAD), with both finding no significant differences. These trials did not examine effects on observer-rated behavioral outcomes and did not explicitly quantify the dose of exposure therapy within each treatment. In a replication trial, one hundred and two individuals with SAD (per DSM-IV criteria) were randomized to 12 sessions of ACT (n = 49) or tCBT (n = 53) controlling for exposure dose and assessing behavioral outcomes. Assessments were completed at pre- and post-treatment using clinician-rated and self-report measures of social anxiety, quality of life, and overall functioning. Observer-rated behavioral measures of social performance were completed for a subsample of participants. Results indicated that participants across conditions received equivalent doses of exposure. Those who received tCBT evidenced greater improvements in self-reported social anxiety symptoms and overall functioning, which contrasts with prior studies finding no differences between tCBT and ACT in the treatment of social anxiety. Medium effect sizes, while not statistically significant, indicate that ACT participants may have had greater improvements in observer-rated social behavior than tCBT participants. The discrepancy between these symptom and behavioral outcomes, building upon prior literature, calls for more research to assess the differences between tCBT and ACT treatments in behavioral domains.

Knowledge about what psychological characteristics underlie complicated grief (CG) is limited. The current study examined the five-factor personality traits in 81 bereaved adults with (n = 51) and without (n = 30) CG. A trained doctoral-level clinician evaluated participants using a structured, diagnostic psychiatric interview, and they completed self-report measures of grief and personality. A multiple regression model indicated that higher levels of neuroticism were associated with greater CG symptom severity, implicating neuroticism in the development of CG. Future prospective studies confirming it as a risk factor for the development of CG are warranted.

Objective Nonspecific factors, such as treatment outcome expectancy and working alliance, can influence treatment outcome. No studies to date have examined the role of expectancy and alliance on pharmacotherapy outcomes in individuals with complicated grief (CG). Method This secondary analysis of a larger randomized, control trial (RCT) examined the relationship between pharmacotherapy expectancy and alliance on treatment outcome in adults with CG who were participating in a multisite, double-blind, RCT examining the efficacy of citalopram and complicated grief treatment (CGT). Participants (n = 202) were randomized to one of four treatment conditions: citalopram (CIT), placebo (PBO), CGT + citalopram (CGT + CIT), or CGT + placebo (CGT + PBO). Results Pharmacotherapy outcome expectancy and working alliance were higher among individuals randomized to CGT + CIT and CGT + PBO compared with CIT or PBO without CGT. Pharmacotherapy outcome expectancy was higher at Week 2 among individuals who ultimately responded to treatment compared with those who did not and among those who remained in treatment compared with those who dropped out. In contrast, working alliance did not correlate with dropout or treatment outcomes in pharmacotherapy. Conclusions Expectancy for medication was higher among individuals randomized to receive CGT. Clinicians should assess symptoms and expectancies in the first weeks of treatment because these could be early markers of drop out and treatment response. (PsycINFO Database Record

Minimal research is available on the prevalence and impact of complicated grief (CG) in military service members and veterans, despite high reported rates of loss in this population. The present study aimed to examine prevalence rates of CG in a sample of treatment-seeking military service and members and veterans who served after September 11, 2001. Additionally, the study aimed to examine characteristics associated with CG as well as the association between CG and quality of life. In a sample of 622 military service members and veterans who served after September 11, 2001, 502 reported a significant loss (80.7%). Usable data were available for a total of 468 participants. Of these 468 participants, 30.3% (n = 142) met diagnostic criteria for CG, as defined by a score of 30 or more on the Inventory of Complicated Grief (ICG; Prigerson et al., 1995). We conducted a series of t tests and chi-square tests to examine the differences between individuals who met criteria for CG and those who did not. The presence of CG was associated with worse PTSD, d = 0.68, p < .001; depression, d = -1.10, p < .001; anxiety, d = -1.02, p < .001; stress, d = 0.99, p < .001; and quality of life, d = 0.76, p < .001. Multiple regression analyses examined the independent impact of CG on quality of life. Complicated grief was associated with poorer quality of life above and beyond PTSD, β = -.12, p = .017. In addition, in a separate regression, CG was associated with poorer quality of life above and beyond depression, β = -.13, p < .001. Overall, our findings highlight the impact of CG on this population, and have implications for assessment and treatment.

Objectives: Given that veterans are significantly more likely to suffer from post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), depression, and anxiety than civilians, yet current...

Anxiety disorders are highly pervasive and debilitating. Despite the prevalence of these disorders, many people with anxiety disorders are unable to access care, and even fewer have access to evidence-based treatments. Online (or Internet-mediated) interventions may be effective in reducing barriers to care for people with anxiety. Internet-mediated mental health interventions have become increasingly utilized and studied in parallel with advancements in technology. With foundations in evidence-based therapy methods, such treatments have been adapted for a variety of disorders, including anxiety disorders. Results from a variety of studies suggest promising but mixed findings on feasibility, efficacy, and treatment engagement. There remain several important challenges to and considerations for the use of digital tools to treat anxiety disorders, including treatment dropout, negative attitudes toward Internet-mediated technologies, low technological literacy, and lack of access to technology.

OBJECTIVE Extensive research supports the use of prolonged exposure (PE) and cognitive processing therapy (CPT), for posttraumatic stress disorder (PTSD) in veterans and service members. PE and CPT have been disseminated nationally across the Department of Veterans Affairs (VA) facilities. Many service members and veterans receive care outside the VA where access to these gold standard psychotherapies can be limited. This paper presents a novel program developed to train community providers in the use of PE and CPT and their application to veterans with PTSD through the use of a medium-touch approach to consultation. METHOD Four 2-day trainings (2 in PE, 2 in CPT) were delivered to a total of 170 participants over an 8-month period. A subset of approximately 10 providers per training (n = 42) received 6 months of weekly, group phone consultation following the 2-day training. All providers were assessed pre- and posttraining, as well as 3 and 6 months after their training. Outcomes for the training workshop alone and the training plus 6 months of consultation were compared. RESULTS While participant knowledge, t = -22.57, p < .001 and comfort (χ² = 74.00, p < .001) with PE and CPT significantly increased immediately following the 2-day training, those who received consultation were more likely to implement (χ² = 20.88, p < .001) and either complete or be close to completing PE or CPT with patients (χ² = 20.57, p < .001) 6 months following training. CONCLUSIONS Despite some limitations, these preliminary data support that consultation is an important component to include in PTSD therapy training and implementation in the community. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The current study examined Veterans' attitudes about the potential use of telepsychiatry for mental health treatment in routine clinical settings. Data were collected from Veteran outpatients ( N = 253) who completed a series of self-report screening measures as part of their initial evaluation at an outpatient clinic providing care to Veterans with deployment-related mental health problems. Using a de-identified data repository, symptoms of post-traumatic stress disorder (PTSD), depression, anxiety, and stress, as well as attitudes and level of comfort with receiving treatment through telehealth were assessed. Overall interest in telepsychiatry was mixed, with 25.7% of patients being “not at all comfortable” and 13.4% being “extremely comfortable” using telepsychiatry from home. Approximately one third (32.8%) of participants indicated a clear preference for telepsychiatry compared to in-person mental health visits. There were no differences in telepsychiatry preferences by symptom severity, demographic variables, rural versus urban location, or endorsed barriers to care. Although telepsychiatry may be a viable means of increasing access, patient preference should be considered, as a substantial percentage of Veterans in this study preferred in-person visits. [ Journal of Psychosocial Nursing and Mental Health Services, 57 (9), 38–43.]

Few studies have examined potential differences between social anxiety disorder (SAD) and generalised anxiety disorder (GAD) in the sensitivity to detect emotional expressions. The present study aims to compare the detection of emotional expressions in SAD and GAD. Participants with a primary diagnosis of GAD (n = 46), SAD (n = 70), and controls (n = 118) completed a morph movies task. The task presented faces expressing increasing degrees of emotional intensity, slowly changing from a neutral to a full-intensity happy, sad, or angry expressions. Participants used a slide bar to view the movie frames from left to right, and to stop at the first frame where they perceived an emotion. The frame selected thus indicated the intensity of emotion required to identify the facial expression. Participants with GAD detected the onset of facial emotions at lower intensity of emotion than participants with SAD (p = 0.002) and controls (p = 0.039). In a multiple regression analysis controlling for age, race, and depressive symptom severity, lower frame at which the emotion was detected was independently associated and GAD diagnosis (B = -5.73, SE = 1.74, p

A significant number of veterans of the conflicts in Iraq and Afghanistan have posttraumatic stress disorder (PTSD), yet underutilization of mental health treatment remains a significant problem. The purpose of this review was to summarize rates of dropout from outpatient, psychosocial PTSD interventions provided to U.S. Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) veterans with combat-related PTSD. There were 788 articles that were identified which yielded 20 studies involving 1,191 individuals eligible for the review. The dropout rates in individual studies ranged from 5.0% to 78.2%, and the overall pooled dropout rate was 36%, 95% CI [26.20, 43.90]. The dropout rate differed marginally by study type (routine clinical care settings had higher dropout rates than clinical trials) and treatment format (group treatment had higher dropout rates than individual treatment), but not by whether comorbid substance dependence was excluded, by treatment modality (telemedicine vs. in-person treatment), or treatment type (exposure therapy vs. nonexposure therapy). Dropout is a critical aspect of the problem of underutilization of care among OEF/OIF/OND veterans with combat-related PTSD. Innovative strategies to enhance treatment retention are needed.

Individuals with complicated grief are at elevated risk of suicidal thoughts. Anxiety sensitivity has recently emerged as a risk factor of suicide. This study aimed to investigate a possible association between anxiety sensitivity and a wish to die in individuals with complicated grief. Participants were evaluated for participation in a treatment study and completed an ancillary questionnaire-based study. Participants were 51 bereaved adults evaluated (age: mean, 54 [SD, 13.6] years; 78% [n = 40] women). Logistic regression was used to examine the relationship between anxiety sensitivity and a wish to die. Overall, anxiety sensitivity was associated with a wish to die at the level of a medium effect size, although it did not reach statistical significance. The anxiety sensitivity social concerns subscale was significantly associated with a wish to die. These findings add to a growing literature implicating anxiety sensitivity in reporting a wish to die.

Complicated grief (CG) is a persistent, impairing response to the death of the loved one. CG affects approximately 7% of bereaved individuals and is distinct from other disorders including major depressive disorder and post-traumatic stress disorder. Several theories attempt to explain the phenomenology of CG and underscore the role of maladaptive cognitions about the death, avoidance behavior, insufficient integration of the death into one’s autobiographical memory, poor coping response, and disruption of biobehavioral attachment systems. This chapter will review two evidence-based treatments—cognitive behavior therapy and complicated grief treatment—found effective for the treatment of CG.

Grief-related avoidance is a significant component of complicated grief, yet has rarely been formally measured in a validated fashion. Further, more work is needed to understand the impact of grief-related avoidance on symptom severity and functional impairment among individuals with complicated grief (CG). The Grief-Related Avoidance Questionnaire (GRAQ; Shear, Monk et al. 2007) was created to assess grief-related avoidance and the present analysis aimed to further develop this measure and construct by confirming the GRAQ’s psychometric properties and examining loss-related predictors of avoidance. In a sample of 393 adults with CG, we found the GRAQ had high internal consistency, with a Cronbach’s alpha of 0.89 and good convergent validity. While the EFA results suggest that the GRAQ may be unidimensional, a 3-factor model generally corresponded with the findings by (Shear, Monk et al. 2007), which suggested the presence of 3 subscales. Loss-related variables age, relationship to the deceased, a...

Bereavement is a potent and highly prevalent stressor among service members and veterans. However, the psychological consequences of bereavement, including complicated grief (CG), have been minimally examined. Loss was assessed in 204 post-9/11, when service members and veterans with combat-related posttraumatic stress disorder (PTSD) took part in a multicenter treatment study. Those who reported the loss of an important person completed the inventory of complicated grief (ICG; n = 160). Over three quarters (79.41%) of the sample reported an important lifetime loss, with close to half (47.06%) reporting the loss of a fellow service member (FSM). The prevalence of CG was 24.75% overall, and nearly one third (31.25%) among the bereaved. CG was more prevalent among veterans who lost a fellow service member (FSM) (41.05%, n = 39) compared to those bereaved who did not (16.92%, n = 11; OR = 3.41, 95% CI: 1.59, 7.36). CG was associated with significantly greater PTSD severity, functional impairment, trauma-related guilt, and lifetime suicide attempts. Complicated grief was prevalent and associated with adverse psychosocial outcomes in veterans and service members with combat-related PTSD. Clinicians working with this population should inquire about bereavement, including loss of a FSM, and screen for CG. Additional research examining CG in this population is needed.

The increased popularity and functionality of mobile devices has a number of implications for the delivery of mental health services. Effective use of mobile applications has the potential to (a) increase access to evidence-based care; (b) better inform consumers of care and more actively engage them in treatment; (c) increase the use of evidence-based practices; and (d) enhance care after formal treatment has concluded. The current paper presents an overview of the many potential uses of mobile applications as a means to facilitate ongoing care at various stages of treatment. Examples of current mobileapplicationsinbehaviouraltreatmentandresearcharedescribed,andtheimplicationsofsuchuses are discussed. Finally, we provide recommendations for methods to include mobile applications into current treatment and outline future directions for evaluation. Copyright © 2013 John Wiley & Sons, Ltd. Key Practitioner Message:  Mobile devices are becoming increasingly common among the adult population and have tremendous potential to advance clinical care.  Mobile applications have the potential to enhance clinical care at stages of treatment—from engaging patients in clinical care to facilitating adherence to practices and in maintaining treatment gains.  Research is needed to validate the efficacy and effectiveness of mobile applications in clinical practice.  Research on such devices must incorporate assessments of usability and adherence in addition to their incremental benefit to treatment.

Exposure and ritual prevention (ERP) has been shown to be effective for treating obsessive–compulsive disorder (OCD), but many people with OCD are not able to access this specialized, evidence-based mental health treatment. Internet-mediated technologies, e.g., videoconferencing, represent a way to increase the availability of evidence-based treatments such as ERP, but given that OCD is a complex disorder requiring a nuanced treatment approach, clinicians attempting to implement ERP remotely should appreciate not only the advantages but also the challenges associated with treating OCD from a distance. Using a case example, we describe this treatment method and discuss relevant clinical considerations.

Minimal research is available on the prevalence and impact of complicated grief (CG) in military service members and veterans, despite high reported rates of loss in this population. The present study aimed to examine prevalence rates of CG in a sample of treatment-seeking military service and members and veterans who served after September 11, 2001. Additionally, the study aimed to examine characteristics associated with CG as well as the association between CG and quality of life. In a sample of 622 military service members and veterans who served after September 11, 2001, 502 reported a significant loss (80.7%). Usable data were available for a total of 468 participants. Of these 468 participants, 30.3% (n = 142) met diagnostic criteria for CG, as defined by a score of 30 or more on the Inventory of Complicated Grief (ICG; Prigerson et al., 1995). We conducted a series of t tests and chi-square tests to examine the differences between individuals who met criteria for CG and those who did not. The presence of CG was associated with worse PTSD, d = 0.68, p.001; depression, d = -1.10, p.001; anxiety, d = -1.02, p.001; stress, d = 0.99, p.001; and quality of life, d = 0.76, p.001. Multiple regression analyses examined the independent impact of CG on quality of life. Complicated grief was associated with poorer quality of life above and beyond PTSD, β = -.12, p = .017. In addition, in a separate regression, CG was associated with poorer quality of life above and beyond depression, β = -.13, p.001. Overall, our findings highlight the impact of CG on this population, and have implications for assessment and treatment.

Defusion, the ability to achieve psychological distance from internal experiences such as thoughts and feelings, is considered to be a key mechanism of cognitive behavior therapy and is particularly emphasized in certain acceptance-based behavior therapies like mindfulness-based cognitive therapy and acceptance and commitment therapy (ACT). Unlike other treatment components such as cognitive restructuring, however, defusion has been less well studied as a potential mediator of change. One reason for this lack of attention is the absence of a well-validated measure of defusion. Current measures confound defusion with other related, yet distinct, constructs such as psychological acceptance or mindful awareness. One challenge in measuring defusion is that the meaning of the construct is not readily apparent to respondents. The current study reports on a new measure, the Drexel defusion scale (DDS), by providing information about its development, reliability, and validity. Results from several samples indicate that the measure is unidimensional, with good internal consistency. The DDS is highly correlated with measures of acceptance and decentering, suggesting high convergent validity. Higher scores on the DDS are also associated with less psychopathology and a higher quality of life, even after controlling for measures of similar constructs, indicating that the DDS provides incremental validity beyond existing measures. Additionally, among a treatment-seeking sample, increases in the DDS were associated with improvements in psychological functioning, for both those receiving ACT and CT treatment. The DDS appears to be a reliable and valid measure of defusion.

Debate continues about the extent to which postulated mechanisms of action of cognitive behavior therapies (CBT), including standard CBT (i.e., Beckian cognitive therapy [CT]) and acceptance and commitment therapy (ACT) are supported by mediational analyses. Moreover, the distinctiveness of CT and ACT has been called into question. One contributor to ongoing uncertainty in this arena is the lack of time-varying process data. In this study, 174 patients presenting to a university clinic with anxiety or depression who had been randomly assigned to receive either ACT or CT completed an assessment of theorized mediators and outcomes before each session. Hierarchical linear modeling of session-by-session data revealed that increased utilization of cognitive and affective change strategies relative to utilization of psychological acceptance strategies mediated outcome for CT, whereas for ACT the mediation effect was in the opposite direction. Decreases in self-reported dysfunctional thinking, cognitive "defusion" (the ability to see one's thoughts as mental events rather than necessarily as representations of reality), and willingness to engage in behavioral activity despite unpleasant thoughts or emotions were equivalent mediators across treatments. These results have potential implications for the theoretical arguments behind, and distinctiveness of, CT and ACT.

The use of technology to provide remote psychological assessment and intervention services is growing rapidly. Remote assessment, treatment, training, and consultation options, particularly those provided via the Internet (e.g., videoconferencing, self-help Web sites, handheld devices), have the potential to increase access to high-quality psychological services. Despite the promise of these technologies, a variety of clinical, ethical, and logistical challenges accompany the remote delivery of such services. Among these challenges are issues involving security, competence, the therapeutic alliance, usability, and technical difficulties. We elucidate some of the challenges posed by these technologies and suggest preliminary recommendations for psychologists considering their use.

The gold-standard treatment for OCD is exposure and ritual prevention (ERP), yet despite its well-established efficacy, only a small percentage of OCD patients have access to this treatment. Remote treatments (e.g., videoconferencing) are becoming increasingly popular avenues for treatment delivery and show promise in increasing patient access to evidence-based mental health care. The current pilot study utilized an open trial to examine the feasibility and preliminary efficacy of videoconference-mediated, twice weekly, ERP for adults (n=15) with OCD. Results revealed that ERP was associated with significant improvements in OCD symptoms and large within-group effect sizes. Among the 10 individuals who completed a 3-month follow-up assessment, 30% of participants no longer met DSM-IV-TR criteria for OCD and 80% of participants were rated as very much or much improved on the CGI. This study adds to the growing body of literature suggesting that videoconference-based interventions are viable alternatives to face-to-face treatment.

Many university students suffer from test anxiety that is severe enough to impair performance. Given mixed efficacy results of previous cognitive-behavior therapy (CBT) trials and a theoretically driven rationale, an acceptance-based behavior therapy (ABBT) approach was compared to traditional CBT (i.e., Beckian cognitive therapy; CT) for the treatment of test anxiety. In this pilot study, 16 university students with test anxiety were randomly assigned to receive either a CT or ABBT 2-hr group workshop. The two treatments produced markedly different effects on test performance (measured by exam scores), with those receiving ABBT experiencing improvements in performance, whereas those receiving CT exhibited reduced performance. In addition, there was a suggestion that ABBT might have been more effective at reducing subjectively experienced test anxiety (i.e., a nonsignificant but medium-sized group by time interaction effect). Implications of these results for the treatment of test anxiety and for theoretical notions related to cognitive change strategies are discussed.

Anxiety Sensitivity (AS) has been associated with sleep difficulties in certain anxiety disorder populations, but no studies have examined cross-diagnostically the role of anxiety sensitivity in sleep dysfunction. Three hundred one participants with generalized anxiety disorder (GAD), social anxiety disorder (SAD), and panic disorder (PD) completed an ancillary questionnaire-based study. Linear regression was used to examine AS and sleep dysfunction, and mediation analyses were used to examine whether AS was a mediator of the effect of primary diagnosis on sleep. AS was associated with increased sleep dysfunction across anxiety disorders, and primary anxiety disorder diagnosis was significantly associated with sleep dysfunction. However, after controlling for AS, primary diagnosis was no longer significant. AS significantly mediated the effects of PD versus SAD and of PD versus GAD on sleep dysfunction, but did not significantly mediate the effect of GAD versus SAD on sleep dysfunction. Taken together, AS appears to be a more important predictor of sleep dysfunction overall, emphasizing the cross-diagnostic nature of AS and bolstering the RDoC initiative approach for treating psychological dysfunction.

Despite high rates of physical and mental health difficulties, veterans have low rates of health service utilization. Among other barriers to accessing needed treatment, stigma is associated with poorer quality of healthcare and lower intentions to seek treatment for health concerns. Healthcare-related stigma is prevalent among veterans and includes privacy concerns and a variety of personal beliefs regarding mental illness and treatment that deter them from seeking services. Despite efforts targeted toward reducing stigma, progress in this area has been limited, and increasing access to needed physical and mental healthcare among veterans and service members remains a persistent concern. This chapter explores the various stigma faced by today’s veterans, synthesizes the extant research on stigma-reducing strategies, and provides our recommendations for future directions. Avenues for future work include the development of prospective research designs to more completely examine the impact of stigma on service use, the development of novel approaches to interventions that expand upon existing models, and a focus on normalizing health and treatment seeking in military settings.

Posttraumatic stress disorder (PTSD) can develop after exposure to trauma and is associated with intrusions of the trauma memory, arousal, reactivity, and avoidance symptoms, along with negative alterations in cognitions and mood. PTSD is a debilitating, and often chronic, disorder responsible for significant individual and societal costs. The gold standard treatment for PTSD is cognitive behavioral therapy (CBT) which includes four primary components: (a) psychoeducation, (b) anxiety management, (c) exposure, and (d) cognitive restructuring. Two specific interventions, prolonged exposure (PE) and cognitive processing therapy (CPT), have the most research support and can dramatically reduce PTSD symptoms, ameliorate the impact of comorbid mental health problems, and improve quality of life. Although CBT is the first-line treatment for PTSD, psychopharmacological interventions, particularly serotonin-targeting medications, are also helpful as adjunctive treatments for PTSD. The efficacy of CBT is well established, yet many individuals fail to access or complete these treatments. Given the impact of PTSD and its associated disability and cost, continued efforts are needed to ensure that these treatments are disseminated to individuals in need and to maximize engagement in these treatments.

A significant number of veterans of the conflicts in Iraq and Afghanistan have posttraumatic stress disorder (PTSD), yet underutilization of mental health treatment remains a significant problem. The purpose of this review was to summarize rates of dropout from outpatient, psychosocial PTSD interventions provided to U.S. Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) veterans with combat-related PTSD. There were 788 articles that were identified which yielded 20 studies involving 1,191 individuals eligible for the review. The dropout rates in individual studies ranged from 5.0% to 78.2%, and the overall pooled dropout rate was 36%, 95% CI [26.20, 43.90]. The dropout rate differed marginally by study type (routine clinical care settings had higher dropout rates than clinical trials) and treatment format (group treatment had higher dropout rates than individual treatment), but not by whether comorbid substance dependence was excluded, by treatment modality (telemedicine vs. in-person treatment), or treatment type (exposure therapy vs. nonexposure therapy). Dropout is a critical aspect of the problem of underutilization of care among OEF/OIF/OND veterans with combat-related PTSD. Innovative strategies to enhance treatment retention are needed.

We sought to examine psychological mechanisms of treatment outcomes of a mindfulness meditation intervention for Generalized Anxiety Disorder (GAD).We examined mindfulness and decentering as two potential therapeutic mechanisms of action of generalized anxiety disorder (GAD) symptom reduction in patients randomized to receive either mindfulness-based stress reduction (MBSR) or an attention control class (N=38). Multiple mediation analyses were conducted using a non-parametric cross product of the coefficients approach that employs bootstrapping.Analyses revealed that change in decentering and change in mindfulness significantly mediated the effect of MBSR on anxiety. When both mediators were included in the model, the multiple mediation analysis revealed a significant indirect effect through increases in decentering, but not mindfulness. Furthermore, the direct effect of MBSR on decrease in anxiety was not significant, suggesting that decentering fully mediated the relationship. Results also suggested that MBSR reduces worry through an increase in mindfulness, specifically by increases in awareness and nonreactivity.Improvements in GAD symptoms resulting from MBSR are in part explained by increased levels of decentering.

The increased popularity and functionality of mobile devices has a number of implications for the delivery of mental health services. Effective use of mobile applications has the potential to (a) increase access to evidence-based care; (b) better inform consumers of care and more actively engage them in treatment; (c) increase the use of evidence-based practices; and (d) enhance care after formal treatment has concluded. The current paper presents an overview of the many potential uses of mobile applications as a means to facilitate ongoing care at various stages of treatment. Examples of current mobile applications in behavioural treatment and research are described, and the implications of such uses are discussed. Finally, we provide recommendations for methods to include mobile applications into current treatment and outline future directions for evaluation.Mobile devices are becoming increasingly common among the adult population and have tremendous potential to advance clinical care. Mobile applications have the potential to enhance clinical care at stages of treatment-from engaging patients in clinical care to facilitating adherence to practices and in maintaining treatment gains. Research is needed to validate the efficacy and effectiveness of mobile applications in clinical practice. Research on such devices must incorporate assessments of usability and adherence in addition to their incremental benefit to treatment.

Most individuals with social anxiety disorder (SAD) do not receive any type of treatment. Reasons include logistical barriers (e.g., geographic location, travel time), fear of stigmatization, and fear of the social interactions associated with seeking treatment. Videoconferencing technology holds great promise in the widespread delivery of evidence-based treatments to those who would otherwise not receive treatment. This pilot study assessed the feasibility, acceptability, and initial efficacy of an acceptance-based behavioral intervention using Skype videoconferencing to treat adults with generalized SAD. Twenty-four participants received 12 sessions of weekly therapy and were assessed at pre-treatment, mid-treatment, post-treatment, and 3-month follow-up. Participants and therapists rated the intervention as acceptable and feasible. Analyses revealed significant pre-treatment to follow-up improvements in social anxiety, depression, disability, quality of life, and experiential avoidance, with effect sizes comparable to or larger than previously published results of studies delivering in-person CBT for SAD. Implications and future directions are discussed.

A meta-analysis was conducted to summarize and integrate the literature on the cognitive functioning of older adults with posttraumatic stress disorder (PTSD). We hypothesized that those with PTSD would exhibit worse performance in each of the cognitive domains studied when compared to older adults without PTSD. Major databases were queried and eleven articles met criteria for review. As predicted, there was evidence of worse performance across cognitive measures in older adult samples with PTSD relative to older samples without PTSD. The strongest effect across samples was found for lower test scores in the broad domain of memory among older adults with PTSD, and there was evidence that trauma exposure is uniquely associated with worse performance on tests specific to learning. We outline factors thought to contribute to the interactions among PTSD, cognitive deficits, and the aging process. These findings highlight the need for thorough evaluation of cognitive functioning in older adults with PTSD, particularly in the areas of processing speed, learning, memory, and executive functioning.

Over 80% of people with social anxiety disorder (SAD) do not receive any type of treatment, despite the existence of effective evidence-based treatments. Barriers to treatment include lack of trained therapists (particularly in nonmetropolitan areas), logistical difficulties (e.g., cost, time, transportation), concerns regarding social stigma, and fear of negative evaluation from health care providers. Interventions conducted through electronic communication media, such as the Internet, have the potential to reach individuals who otherwise would not have access to evidence-based treatments. Second Life is an online virtual world that holds great promise in the widespread delivery of evidence-based treatments. We assessed the feasibility, acceptability, and initial efficacy of an acceptance-based behavior therapy in Second Life to treat adults with generalized SAD. Participants (n=14) received 12 sessions of weekly therapy and were assessed at pretreatment, midtreatment, posttreatment, and follow-up. Participants and therapists rated the treatment program as acceptable and feasible, despite frequently encountered technical difficulties. Analyses showed significant pretreatment to follow-up improvements in social anxiety symptoms, depression, disability, and quality of life, with effect sizes comparable to previously published results of studies delivering in-person cognitive behavior therapy for SAD. Implications and future directions are discussed.

The present study represents one of the first comparisons of the long-term effectiveness of traditional cognitive behavior therapy (i.e., Beckian cognitive therapy; CT) and acceptance and commitment therapy (ACT). One hundred thirty-two anxious or depressed outpatients were randomly assigned to receive either CT or ACT, and were assessed at posttreatment (n=90) and at 1.5-year (n=91) follow-up. As previously reported, the two treatments were equivalently effective at posttreatment according to measures of depression, anxiety, overall (social/occupational/symptom-related) functioning, and quality of life. However, current results suggest that treatment gains were better maintained at follow-up in the CT condition. Clinical significance analyses revealed that, at follow-up, one-third more CT patients were in the clinically normative range in terms of depressive symptoms and more than twice as many CT patients were in the normative range in terms of functioning levels. The possible long-term advantage of CT relative to ACT in this population is discussed.