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Although prolonged exposure (PE) has been identified as a first-line treatment for posttraumatic stress disorder (PTSD), research has found that military service members and veterans have smaller reductions in symptom severity compared to civilians. The nature of trauma in a deployed combat setting and the unique complexities of military culture have been proposed as explanations for greater rates of PTSD and poorer treatment response to first-line psychotherapies in military and veteran populations. This paper presents a case study to highlight how a novel, intensive outpatient program utilizing prolonged exposure therapy (IOP-PE) may benefit military personnel with combat-related PTSD. The patient is a Caucasian man in his early 40s seeking treatment for PTSD after more than 10 years of enlisted, active duty military service across two branches and three combat deployments. The IOP-PE includes the standard PE components and eight, nonstandard treatment augmentations tailored for military personnel. In contrast to standard PE, which typically is delivered weekly over several months, IOP-PE consists of 15 daily, 90-minute PE sessions conducted over 3 weeks. The patient demonstrated large reductions on the Clinician-Administered PTSD Scale (28 points) and PTSD Checklist (48 points) by the 6-month posttreatment follow-up point. Findings provide support for conducting further research that determines whether IOP-PE is effective and tolerable in military and veteran populations.

Lay Summary In an analysis of over 260 million emergency department visits across the United States from 2007 to 2017, inflammatory bowel disease conferred >10-fold risk for suicide deaths, self-harm, substance use, and psychiatric disorders, though the overall self-harm rates were low (

Improved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD).To determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD.This randomized clinical trial was conducted among military personnel and veterans at 4 sites in Texas from 2017 to 2019. Assessors were blinded to conditions. Data were analyzed from November 2020 to October 2022.The interventions were massed-PE, which included 15 therapy sessions of 90 minutes each over 3 weeks, vs intensive outpatient program PE (IOP-PE), which included 15 full-day therapy sessions over 3 weeks with 8 treatment augmentations. The IOP-PE intervention was hypothesized to be superior to massed-PE.Coprimary outcomes included the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) administered at baseline and posttreatment follow-ups. Measures ranged from 0 to 80, with higher scores indicating greater severity. Diagnostic remission and reliable change were secondary outcomes.Among 319 military personnel and veterans screened, 234 were randomized (mean [SD] age, 39.20 [7.72] years; 182 [78%] male participants), with 117 participants randomized to IOP-PE and 117 participants randomized to massed-PE. A total of 61 participants (26%) were African American, 58 participants (25%) were Hispanic, and 102 participants (44%) were White; 151 participants (65%) were married. Linear mixed-effects models found that CAPS-5 scores decreased in both treatment groups at the 1-month follow-up (IOP-PE: mean difference, -13.85 [95% CI, -16.47 to -11.23]; P .001; massed-PE: mean difference, -14.13 [95% CI, -16.63 to -11.62]; P .001). CAPS-5 change scores differed from 1- to 6-month follow-ups (mean difference, 4.44 [95% CI, 0.89 to 8.01]; P = .02). PTSD symptoms increased in massed-PE participants during follow-up (mean difference, 3.21 [95% CI, 0.65 to 5.77]; P = .01), whereas IOP-PE participants maintained treatment gains (mean difference, 1.23 [95% CI, -3.72 to 1.27]; P = .33). PCL-5 scores decreased in both groups from baseline to 1-month follow-up (IOP-PE: mean difference, -21.81 [95% CI, -25.57 to -18.04]; P .001; massed-PE: mean difference, -19.96 [95% CI, -23.56 to -16.35]; P .001) and were maintained at 6 months (IOP-PE: mean change, -0.21 [95% CI, -3.47 to 3.06]; P = .90; massed-PE: mean change, 3.02 [95% CI, -0.36 to 6.40]; P = .08). Both groups had notable PTSD diagnostic remission at posttreatment (IOP-PE: 48% [95% CI, 36% to 61%] of participants; massed-PE: 62% [95% CI, 51% to 73%] of participants), which was maintained at 6 months (IOP-PE: 53% [95% CI, 40% to 66%] of participants; massed-PE: 52% [95% CI, 38% to 66%] of participants). Most participants demonstrated reliable change on the CAPS-5 (61% [95% CI, 52% to 69%] of participants) and the PCL-5 (74% [95% CI, 66% to 81%] of participants) at the 1-month follow-up.These findings suggest that PE can be adapted into compressed treatment formats that effectively reduce PTSD symptoms.ClinicalTrials.gov Identifier: NCT03529435.

Highlights • The impact of the COVID-19 pandemic may be especially potent for individuals with PTSD. • PE is a well-established and efficacious treatment for PTSD. • Clinical practice strategies aid in implementation of PE during the COVID-19 pandemic., The unprecedented effects and duration of the COVID-19 crisis are likely to elevate the population’s level of anxiety due to psychological stress, economic hardship, and social isolation. This effect may be especially potent for individuals with preexisting mental health conditions, such as posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) therapy is a highly effective treatment for PTSD across trauma-exposed populations, and has been implemented effectively via telehealth. Nevertheless, PE implementation via telehealth may require specific adaptations during the COVID-19 crisis due to public health mandates calling for sheltering in place and physical distancing. This paper discusses strategies for implementing PE for PTSD during the COVID-19 pandemic, which may also be applied to other situations in which physical distancing must be considered.

To develop a patient-centered text message-based platform that promotes self-management of symptoms of interstitial cystitis/bladder pain syndrome (IC/BPS).Adult women with IC/BPS interested in initiating a first- or second-line treatments per American Urological Association guidelines (recategorized as "behavioral/non-pharmacologic treatments" and "oral medicines" in the 2022 version) participated in rapid cycle innovation consisting of iterative cycles of contextual inquiry, prototype design and development. We delivered treatment modules and supportive messages using an algorithm-driven interactive messaging prototype through a HIPAA-compliant texting platform. Patients provided feedback through narrative text messages and an exit interview. Feedback was analyzed qualitatively and used to iteratively revise the platform until engagement ≥ 85% and accuracy ≥ 80% were achieved. The final version consisted of four treatment module categories (patient education and behavioral modification, cognitive behavioral therapy, pelvic floor physical therapy, and guided mindfulness practices) and supportive messages delivered through an automated algorithm over 6 weeks.Thirty IC/BPS patients with moderate symptom bother (median IC Problem Index score 9, range 6-12) participated in five cycles of contextual inquiry. Qualitative analysis identified three overarching concepts that informed the development of the platform: preference for patient centered terms, desire to gain self-efficacy in managing symptoms, and need for provider support. Patients preferred the term "interstitial cystitis" to "bladder pain syndrome" which carried the stigma of chronic pain. Patients reported greater self-efficacy in managing symptoms through improved access to mind-body and behavioral treatment modules that helped them to gain insight into their motivations and behaviors. The concept of provider support was informed by shared decision making (patients could choose preferred treatment modules) and reduced sense of isolation (weekly check in messages to check on symptom bother).A patient centered text message-based platform may be clinically useful in the self-management of IC/BPS symptoms.

Fluctuations of endogenous estrogen modulates fear extinction, but the influence of exogenous estradiol is less studied. Moreover, little focus has been placed on the impact of estradiol on broad network connectivity beyond the fear extinction circuit. Here, we examined the effect of acute exogenous estradiol administration on fear extinction-induced brain activation, whole-brain functional connectivity (FC) during the fear extinction task and post-extinction resting-state. Ninety healthy women (57 using oral contraceptives [OC], 33 naturally cycling [NC]) were fear conditioned on day 1. They ingested an estradiol or placebo pill prior to extinction learning on day 2 (double-blind design). Extinction memory was assessed on day 3. Task-based functional MRI data were ascertained on days 2 and 3 and resting-state data were collected post-extinction on day 2 and pre-recall on day 3. Estradiol administration significantly modulated the neural signature associated with fear extinction learning and memory, consistent with prior studies. Importantly, estradiol administration induced significant changes in FC within multiple networks, including the default mode and somatomotor networks during extinction learning, post-extinction, and during extinction memory recall. Exploratory analyses revealed that estradiol impacted ventromedial prefrontal cortex (vmPFC) activation and FC differently in the NC and OC women. The data implicate a more diffused and significant effect of acute estradiol administration on multiple networks. Such an effect might be beneficial to modulating attention and conscious processes in addition to engaging neural processes associated with emotional learning and memory consolidation.

Background COVID-19 pandemic has major ramifications for global health and economy, with growing concerns about economic recession and implications for mental health. Here we investigated the associations between pandemic-related income loss with financial strain and mental health trajectories over a 1-month course, in two independent cohorts. Methods Two independent studies were conducted in the U.S and in Israel at the beginning of the outbreak (March-April 2020, T1; study I: N = 2904, study II: N = 1267) and at a 1-month follow-up (T2; study I: N = 1318, study II: N = 241). Mixed-effects models were applied to assess associations among COVID-19-related income loss, financial strain, and pandemic-related worries about health, with anxiety and depression, controlling for multiple covariates including pre-COVID-19 income. Results In both studies, income loss and financial strain were associated with greater depressive symptoms at T1, above and beyond T1 anxiety, worries about health, and pre-COVID-19 income. Worsening of income loss was associated with exacerbation of depression at T2 in both studies. Worsening of subjective financial strain was associated with exacerbation of depression at T2 in one study (US). Conclusions Income loss and financial strain were uniquely associated with depressive symptoms and their exacerbation over time, above and beyond pandemic-related anxiety. In times when a myriad of stressors are affecting mental health worldwide, our findings reveal specific links between the economic impact of COVID-19 and psychiatric outcomes.

Based on feedback received during post-training consultation within a Prolonged Exposure (PE) implementation initiative, additional assessment training was added to help community providers identify patients who met criteria for posttraumatic stress disorder (PTSD) symptom severity and were considered appropriate for PTSD treatment. The current study investigated the rates of trauma exposure and PTSD in the community sample, as well as the percentage of individuals deemed “appropriate” for PE by community therapists. Clinicians involved in the PE Initiative administered the Post-traumatic Diagnostic Scale for DSM-5 (PDS-5) to 10,260 individuals across 13 community agencies. Clinicians were also asked to report whether patients were perceived as appropriate for PE. Consistent with our hypothesis, the rates of potential PTSD in Philadelphia community mental health (58.2% of our total sample) far exceeded national averages (8.3%). Contrary to our hypothesis, 100% of patients who scored above the clinical cutoff for PTSD were considered appropriate for PE by their community clinician. The results of this study emphasize the high prevalence of PTSD among individuals presenting for treatment to community mental health centers. Despite common misconceptions that patients are often perceived as ineligible or not appropriate for PE, 100% of patients in the PE Initiative who scored above the clinical cutoff for PTSD were considered good candidates for treatment according to their clinicians. This suggests that with sufficient training and post-training consultation, as provided in this community initiative, community clinicians may be more likely to perceive PE as an appropriate treatment option.

Prolonged Exposure (PE) is a highly effective treatment for posttraumatic stress disorder (PTSD) across a variety of delivery formats and samples. However, for military service members, the treatment tends to be less effective than for civilians. One explanation for the reduced response to PE in military service members is the frequency, intensity, and heterogeneity of combat trauma. Combat trauma may yield a variety of posttraumatic responses, including moral injury, or the psychosocial-spiritual suffering consequent of exposure to moral injurious events. Despite rapidly increasing research on combat-related moral injury, little clinical guidance exists on how or if moral injury may be addressed via trauma-focused treatments such as PE. This case report describes the facilitation of moral healing for a U.S. Army soldier with combat-related PTSD in a 3-week intensive outpatient PE program. While PTSD symptoms were reduced from pre- to posttreatment, even more substantial treatment gains were observed in the soldier’s functional changes, engagement with values-based activities, and his reported willingness to embrace moral pain. Although not explicit in the PE manual, targeting these latter outcomes in PE can facilitate moral healing in service members with PTSD. This case report provides a detailed description of how PE procedures were targeted to address moral injury and where theory-driven augmentations were included to facilitate moral healing.

The aim of this study was to determine the relationship between opioid prescriptions and number of chronic pain conditions in women with interstitial cystitis (IC).This was a cross-sectional study. Women diagnosed with IC based on International Classification of Diseases, Ninth Revision/Tenth Revision codes over an 11-year period (2010-2020) were identified from electronic medical records. Data on comorbidities and ambulatory opioid prescriptions were also extracted. Univariable and multivariable logistic regressions were used to assess the relationship between opioid prescriptions and the number and type of coexisting chronic pain conditions.Of the 1,219 women with IC, 207 (17%) had received at least 1 opioid prescription. The proportions of women with opioid prescriptions for no, 1, 2, and 3 or more coexisting chronic pain conditions were 13%, 20%, 28%, and 32%, respectively. On univariable analysis, factors significantly associated with opioid use were higher body mass index ( P0.001), depression ( P0.001), sleep disorder ( P0.001), endometriosis ( P0.05), chronic pelvic pain ( P0.001), fibromyalgia ( P0.05), joint pain ( P0.001), and number of coexisting chronic pain diagnoses ( P0.001). On multivariable analysis, opioid prescriptions remained significantly associated with the number of coexisting chronic pain diagnoses: 1 diagnosis (adjusted odds ratio [aOR], 1.8; 95% confidence interval [CI], 1.3-2.7), 2 diagnoses (aOR, 2.6; 95% CI, 1.6-4.3), 3 or more diagnoses (aOR, 2.5; 95% CI, 1.1-5.5), diagnosis of chronic pelvic pain (aOR, 2.1; 95% CI, 1.3-3.5), endometriosis (aOR, 2.4; 95% CI, 1.4-4.3), chronic joint pain (aOR, 1.8; 95% CI, 1.1-2.9), and sleep disorders (aOR, 2.4; 95% CI, 1.6-3.6).The likelihood of opioid prescriptions in women with IC increases with the number and type of coexisting chronic pain conditions and sleep disorders.

Background Suicide is the tenth leading cause of death in the United States. Several studies have leveraged electronic health record (EHR) data to predict suicide risk in veteran and military samples; however, few studies have investigated suicide risk factors in a large-scale community health population. Methods Clinical data was queried for 9,811 patients from the Penn Medicine Health System who had completed a Patient Health Questionnaire-9 (PHQ-9) documented in the EHR between January 2017 and June 2019. Patient demographics, PHQ-9 scores, and psychiatric comorbidities were extracted from the EHR. Univariate and multivariable logistic regressions were applied to determine significant risk factors associated with suicide ideation responses from the PHQ-9. Results One-quarter (25.8%% of patients endorsed suicide ideation. Univariate analysis found 22 risk factors of suicide ideation. Multivariable logistic regression found significant positive associations (Odds Ratio, (95% Confidence Interval)) with the following: younger ages less than 18 years: 2.1, (1.69, 2.60) and 19-24 years: 1.55, (1.29, 1.87)), single marital status (1.22, (1.08, 1.38)), African American (1.22, (1.08, 1.38)), non-commercial insurance (1.16, (1.03, 1.31)), multiple comorbidities (1 comorbidity (1.65, (1.32, 2.07); 2 comorbidities (2.07, (1.61, 2.64)), 3+ comorbidities (2.49, (1.87, 3.33))), bipolar disorders (Type I: 1.38, (1.14, 1.67) and Type II: 1.94, (1.52, 2.49)), depressive disorders (1.70, (1.49, 1.94)), obsessive compulsive disorder (OCD) (1.43, (1.08, 1.90)), and stress disorders (1.53, (1.33, 1.76)). Conclusion Community EHR information can be used to predict suicidal ideation. This information can be used to design tools for identifying patients at risk for suicide in real-time.

Mental health courts offer access to community-based care for defendants with psychiatric disorders, including posttraumatic stress disorder (PTSD). However, limited information is available on how judges make treatment decisions about evidence-based practices. In this qualitative study, we interviewed mental health court judges to evaluate: (1) perspectives toward the role of PTSD in criminal behavior; (2) knowledge about evidence-based practice for PTSD; (3) treatment decisions for defendants with PTSD; and (4) treatment decisions for defendants at risk for suicide, a common comorbidity with PTSD. We hypothesized that mental health court judges would report low familiarity with evidence-based practices for PTSD despite wide recognition of the impact of trauma on criminal behavior. Methods: Mental health court judges ( N = 11, 60% women, 60% between 50–59 years) were recruited from 7 states in the US and completed a demographics questionnaire and semi-structured qualitative interview that was transcribed and double-coded. Results: Judges in mental health court unanimously agreed that PTSD is highly prevalent among their defendants, but that they had not having received formal education about evidence-based practices for PTSD. They reported relying on their team members to provide recommendations for treatment planning and viewed their role as the enforcer of the treatment teams’ suggestions. Finally, judges also reported that suicide prevention is an important consideration and that there is a need for universal suicide risk assessments. Conclusions: These findings have implications for continuing education among judges in mental health court, and we recommend mandated training to increase awareness of evidence-based practices for PTSD and suicide prevention.

The coronavirus disease 2019 (COVID-19) pandemic resulted in significant increases in insomnia, with up to 60% of people reporting increased insomnia. However, it is unclear whether exposure to risk factors for the virus or worries about COVID-19 are more strongly associated with insomnia. Using a three-part survey over the course of the first 6 months of the pandemic, we evaluated associations between COVID-19 exposures, COVID-19 worries, and insomnia. We hypothesised that COVID-19-related worries and exposure to risk of COVID-19 would predict increases in insomnia. Participants (N = 3,560) completed a survey at three time-points indicating their exposures to COVID-19 risk factors, COVID-19-related worries, and insomnia. COVID-19 worry variables were consistently associated with greater insomnia severity, whereas COVID-19 exposure variables were not. COVID-19 worries decreased significantly over time, and there were significant interactions between change in COVID-19 worries and change in insomnia severity over time. Individuals who experienced increases in COVID-19 worries also experienced increases in insomnia severity. Changes in worry during the COVID-19 pandemic were associated with changes in insomnia; worries about COVID-19 were a more consistent predictor of insomnia than COVID-19 exposures. Evidence-based treatments targeting virus-related worries may improve insomnia during this and future calamities.

Objective To evaluate the psychometric and predictive performance of the Columbia-Suicide Severity Rating Scale (C-SSRS) in emergency department (ED) patients with suicidal ideation or attempts (SI/SA). Methods Participants (n = 1,376, mean age 36.8, 55% female, 76.8% white) completed the C-SSRS during the ED visit and were followed for one year. Reliability analyses, exploratory structural equation modeling, and prediction of future SA were explored. Results Reliability of the Suicidal Ideation subscale was adequate, but was poor for the Intensity of Ideation and Suicidal Behavior subscales. Three empirically derived factors characterized the C-SSRS. Only Factor 1 (Suicidal Ideation and Attempts) was a reliable predictor of subsequent SA, though odds ratios were small (ORs: 1.09-1.10, CI95% : 1.04, 1.15). The original C-SSRS Suicidal Ideation and Suicidal Behavior subscales and the C-SSRS ED screen predicted subsequent SA, again with small odds ratios (ORs: 1.07-1.19, CI95% : 1.01, 1.29). In participants without a SA history, no C-SSRS subscale predicted subsequent SA. History of any SA (OR: 1.98, CI95% : 1.43, 2.75) was the strongest predictor of subsequent SA. Conclusions The psychometric evidence for the C-SSRS was mixed. History of a prior SA, as measured by the C-SSRS, provided the most parsimonious and powerful assessment for predicting future SA.

Problem Statement: There is a need to increase diversity among both researchers and participants in the area of HIV scholarship. The Mid-Atlantic Center for AIDS Research Consortium (MACC) Scholars Program was developed to promote diversity among HIV-related researchers and participants. Approach: Four Scholars were provided with mentorship from senior investigators at Johns Hopkins University, George Washington University, and the University of Pennsylvania. Each Scholar was awarded a grant to develop a pilot study on a topic related to HIV-prevention, treatment, or care. The paper will describe the benefits of the program, challenges that Scholars faced in their projects, and areas for growth of the program from the perspective of the Scholars. Findings: The Scholars unanimously agreed that the program was essential for gathering pilot data and for receiving practical training in grantsmanship and writing. For challenges, each Scholar encountered unanticipated delays in regulatory approval, resulting in a lag of project start-up. As an indication of the success of the program, Scholars reported on their productivity for grantsmanship, scientific publications, and grantsmanship over the first year of the program. Finally, the Scholars offered several suggestions for continuing to improve the MACC Program for future cohorts. Conclusion: The Scholars perceived the inaugural year of the MACC Scholars Program as extremely helpful and productive. Ongoing efforts should be made to continue to promote the development of diverse junior scientists in HIV research.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with significant cognitive impairment and increased risk for mental health comorbidities. This study aimed to identify specific associations between cognitive impairment, self-reported disruptions in memory, and psychiatric symptoms including depression, anxiety, posttraumatic stress disorder (PTSD), and perceived sleep concerns.Data collected from all consecutive patients with Post-Acute Sequelae of SARS-CoV-2 infection (PASC) who presented to a dedicated Post-COVID Clinic were used to evaluate whether certain psychiatric symptoms were more strongly associated with cognitive impairment and self-reported memory disturbances.Univariate and multivariable analyses revealed that depression symptom severity was significantly associated with the severity of cognitive impairment among patients with PASC. This association was driven primarily by lower performance on verbal fluency, attention, and delayed recall tasks among patients with higher depression symptoms severity. Perceived sleep concerns were an important predictor of self-reported memory disturbances. Conversely, neither PTSD symptom severity nor anxiety symptom severity were significant predictors of cognitive impairment or self-reported memory disturbances.These findings have important clinical implications for justifying the need for screening patients with PASC for both depression and cognitive impairment.

BackgroundThe COVID-19 pandemic is a rapidly evolving stressor with significant mental health consequences. We aimed to delineate distinct anxiety-response trajectories during the early stages of the pandemic and to identify baseline risk and resilience factors as predictors of anxiety responses.MethodsUsing a crowdsourcing website, we enrolled 1,362 participants, primarily from the United States (n = 1064) and Israel (n = 222) over three time-points from April-September 2020. We used latent growth mixture modeling to identify anxiety trajectories over time. Group comparison and multivariate regression models were used to examine demographic and risk and resilience factors associated with class membership.ResultsA four-class model provided the best fit. The resilient trajectory (stable low anxiety) was the most common (n = 961, 75.08%), followed by chronic anxiety (n = 149, 11.64%), recovery (n = 96, 7.50%) and delayed anxiety (n = 74, 5.78%). While COVID-19 stressors did not differ between trajectories, resilient participants were more likely to be older, living with another person and to report higher income, more education, fewer COVID-19 worries, better sleep quality, and more dispositional resilience factors at baseline. Multivariate analyses suggested that baseline emotion regulation capabilities and low conflictual relationships uniquely distinguished participants in distinct trajectories.ConclusionsConsistent with prior resilience research following major adversities, a majority of individuals showed stable low levels of low anxiety in response to the COVID-19 pandemic. Knowledge about dispositional resilience factors may prospectively inform mental health trajectories early in the course of ongoing adversity.

To describe the characteristics of individuals receiving outpatient rehabilitation for post-acute sequelae of SARS-CoV-2 infection (PASC). Further, to examine factors associated with variation in their psychological and cognitive functioning and health-related quality of life.Observational study.Outpatient COVID-19 recovery clinic at a large, tertiary, urban health system in the US.COVID-19 survivors with persistent sequelae (N=324).Not applicable.Multivariable logistic and linear regression models were used to examine factors associated with COVID survivors' experience of severe anxiety, severe depression, post-traumatic stress disorder (PTSD), cognitive impairment, and self-reported health-related quality of life.About 38% of survivors seeking care for their persistent COVID symptoms suffered from severe anxiety, 31.8% from severe depression, 43% experiencing moderate to severe PTSD symptomology, and 17.5% had cognitive impairment. Their health-related quality of life was substantially lower than that of the general population (-26%) and of persons with other chronic conditions. Poor and African American/Black individuals experienced worse psychological and cognitive sequelae after COVID19 infection, even after controlling for age, sex, initial severity of the acute infection, and time since diagnosis.Evidence of consistent disparities in outcomes by the patients' race and socioeconomic status, even among those with access to post-acute COVID rehabilitation care, are concerning and have significant implications for PASC policy and program development.

OBJECTIVE: Failing to account for temporal dynamics can hinder our understanding of suicidal ideation and the potential mechanisms underlying increased risk for suicide death and suicide attempts associated with posttraumatic stress disorder (PTSD). To address these limitations, this study used an analytic approach based on Dynamical Systems Theory to describe temporal patterns associated with multiple dimensions of suicidal ideation in a treatment-seeking sample of military personnel diagnosed with PTSD. METHOD: We performed a secondary analysis of archived data from 742 active duty military personnel (90% male, 57% white, mean age = 33 ± 7.4 years) enrolled in three clinical trials to examine the dimensional measurement properties of the first 5 items of the Scale for Suicidal Ideation (SSI). RESULTS: Findings indicated two change dynamics for suicidal ideation: homeostatic (i.e., the tendency for suicidal ideation to return to a stable point) and cyclical (i.e., the tendency for suicidal ideation to switch back and forth between higher and lower values). Cycling was the dominant dynamic, and was related to variables other from suicidal ideation. CONCLUSION: The cyclic nature of suicidal ideation suggests that assessment timing and context could influence observed associations with other variables. Analytic approaches and clinical methods that do not account for the temporal dynamics of suicide risk could miss these properties, thereby hindering efforts to identify mechanisms underlying the relationship between PTSD and suicidal thoughts and behaviors, and limiting opportunities for proactive and timely intervention. CLINICAL IMPACT STATEMENT: Suicidal ideation is multidimensional, with each dimension following different time courses. Cycling of suicidal ideation is pronounced among military personnel receiving treatment for PTSD. Recognizing these patterns could improve assessment and treatment by identifying critical periods of time during treatment that warrant suicide-focused interventions.

There is a relative lack of data regarding how patients weigh various factors when choosing a treatment strategy for interstitial cystitis/bladder pain syndrome (IC/BPS). Our aim is to describe patient experience with their current and prior treatments and discuss factors they consider when choosing a treatment. Twenty-one women with IC/BPS participated in five focus groups moderated by a psychologist. Focus groups were conducted until thematic saturation was reached. Group discussions were transcribed and independently coded by two reviewers. Emergent themes and concepts were identified using grounded theory methodology. Data on symptoms and beliefs regarding medications were collected using validated questionnaires: Interstitial Cystitis Symptom and Problem Index (ICSI and ICPI) and Beliefs in Medications Questionnaire-Specific (BMQ-S). The median age of participants was 42 years, and all had some college education. Median score (range) for the ICSI was 12 (4, 20) and for the ICPI was 10 (3, 16), indicating moderate symptom burden. Most patients had tried only first- or second-line treatments. The median BMQ-S score was 2, indicating a neutral attitude toward medication. Several themes were identified. Patients expressed interest in self-management of symptoms using a structured care plan that incorporates guided self-care practices and care that can be delivered virtually. Patients desired to minimize treatment side effects by reducing prescription medications and avoiding surgical procedures. Finally, patients had considerable interest in alternative treatments; however, they wanted these treatments to be evidence-based. Women with IC/BPS have a strong interest in guided programs that teach self-care practices and deliver alternative treatments through remote platforms.

The efficacy of prolonged exposure (PE) on suicide ideation (SI) as a secondary outcome among individuals with posttraumatic stress disorder (PTSD) is unclear. The purpose of this study was to compare the efficacy of PE in two formats (spaced, S-PE, 10 sessions over 8 weeks, and massed, M-PE, 10 sessions over 2 weeks) to Present Centered Therapy (PCT) and minimal contact control (MCC) on SI exacerbation among patients without suicide intent or plans. Active duty military personnel (n = 335) were randomized to: (1) S-PE vs. PCT and (2) M-PE vs. MCC. All participants completed the Beck Scale for Suicide Ideation and the Beck Depression Inventory (Suicide item) at baseline, posttreatment, and follow-ups. S-PE and PCT had significant and comparable reductions in SI during treatment. M-PE had significantly steeper reductions in SI during treatment compared to MCC. Specifically, more participants in M-PE compared to MCC had reliable improvement versus reliable exacerbation. Reduction in PTSD symptoms was significantly associated with reduction of SI. PE was associated with significant reductions in SI over time that were comparable to PCT and superior to MCC. These findings suggest that both trauma- and non-trauma-focused treatments are associated with reductions in SI, and that trauma-focused treatments improve SI relative to waitlist.

Background Obsessive compulsive disorder (OCD) is associated with elevated suicide risk, but the directionality of the association between OCD severity and suicidal ideation has not been established, which was the goal of this study. Methods Participants (n = 325) were adults with either a current or past diagnosis of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) OCD who were assessed annually for suicidal ideation and OCD symptom severity for six years. Cross-lagged panel analyses statistically compared unidirectional and bidirectional models over time. Serious suicide-related adverse events were reported. Results The best-fitting and most parsimonious model included paths predicting suicidal ideation from OCD symptom severity, but not vice versa. These results were confirmed by comparing a model with cross-lagged paths constrained equal to a freely estimated model. Higher OCD symptom severity in a given year was associated with a higher suicidal ideation severity in the subsequent year. Five suicide-related adverse events were reported throughout the duration of the study, including two suicide deaths and three suicide attempts. Limitations The study relied on a single-item, annual measure of suicidal ideation in adults, with substantial variability in severity of suicide risk, and missing data increased with later observations in the study. Discussion OCD symptom severity predicted next year suicidal ideation severity. In contrast, suicidal ideation severity in a given year did not predict next-year OCD symptom severity in this OCD sample. Thus, rather than waiting for suicidal ideation to resolve, clinicians should consider providing empirically supported treatments for OCD.

Background Posttraumatic stress disorder (PTSD) is associated with suicidal ideation and behavior. However, less is known about how the PTSD symptom clusters, namely alterations in arousal and reactivity (AAR), negative alterations in cognitions and mood (NACM), avoidance, and intrusion, uniquely relate to suicidal ideation. This study aimed to characterize the associations among suicidal ideation and these symptom clusters. Methods Study 1 (n = 346) and Study 2 (n = 194) included community members and treatment-seeking adults at an anxiety specialty clinic, respectively. Participants completed measures of trauma exposure, PTSD symptoms, and suicidal ideation. Results In both studies, suicidal ideation significantly and positively correlated with all PTSD factors. In Study 1, Wald tests of parameter constraints indicated that NACM and AAR had the strongest associations with suicidal ideation, followed by intrusion and avoidance. Results were replicated when restricting the sample to individuals with probable PTSD. In Study 2, suicidal ideation significantly and positively correlated with all PTSD factors; there were no differences in the strength of the suicidal ideation-PTSD factors relations. Limitations The studies were cross-sectional and relied on a single-item measure of suicidal ideation. Discussion All PTSD factors significantly and positively correlated with suicidal ideation, and the NACM and AAR PTSD clusters were most strongly associated with suicidal ideation in Study 1. Therefore, clinicians should be cautious to thoroughly screen patients with elevations on these PTSD cluster scores for suicide risk.

Background Opioid use disorders are associated with increased risk of suicide thoughts, attempts, and death. We explored key variables from two theories of the development of suicidal thoughts and attempts (the interpersonal and three-step theories of suicide) to understand possible mechanisms underlying the association between opioid use and suicide risk. We hypothesized that interpersonal connections, variables reflecting psychological and physical pain, and variables that reduce fear of death (prior overdoses and risk-taking behaviors) would be associated with increased risk of thoughts of suicide. Methods Participants (N = 141) were opioid users recruited from an epicenter of the opioid crisis in Philadelphia using a mobile research center and completed an interview to assess substance use, depression, medical comorbidities, and suicidal thoughts among other variables. Results Univariate analyses showed that prior history of overdose, diagnosis of depression, older age, homelessness, and interpersonal connection were each associated with increased likelihood of endorsing thoughts of death/suicide. Multivariable analyses revealed prior history of overdose and depression were the variables most strongly associated with risk for thoughts of suicide. Conclusions Consistent with two theories of the development of suicidal thoughts and attempts, exposure to variables that reduce fear of death (e.g., overdoses) were associated with suicidal thoughts. In contrast, other risk-taking behaviors, medical comorbidities, and substance use were not key predictors of suicidal thoughts in this sample. Implications for targeted risk assessment among clinicians are discussed.

Based on feedback received during post-training consultation within a Prolonged Exposure (PE) implementation initiative, additional assessment training was added to help community providers identify patients who met criteria for posttraumatic stress disorder (PTSD) symptom severity and were considered appropriate for PTSD treatment. The current study investigated the rates of trauma exposure and PTSD in the community sample, as well as the percentage of individuals deemed "appropriate" for PE by community therapists.Clinicians involved in the PE Initiative administered the Post-traumatic Diagnostic Scale for DSM-5 (PDS-5) to 10,260 individuals across 13 community agencies. Clinicians were also asked to report whether patients were perceived as appropriate for PE.Consistent with our hypothesis, the rates of potential PTSD in Philadelphia community mental health (58.2% of our total sample) far exceeded national averages (8.3%). Contrary to our hypothesis, 100% of patients who scored above the clinical cutoff for PTSD were considered appropriate for PE by their community clinician.The results of this study emphasize the high prevalence of PTSD among individuals presenting for treatment to community mental health centers. Despite common misconceptions that patients are often perceived as ineligible or not appropriate for PE, 100% of patients in the PE Initiative who scored above the clinical cutoff for PTSD were considered good candidates for treatment according to their clinicians. This suggests that with sufficient training and post-training consultation, as provided in this community initiative, community clinicians may be more likely to perceive PE as an appropriate treatment option.

BackgroundThe COVID-19 pandemic has major ramifications for global health and the economy, with growing concerns about economic recession and implications for mental health. Here we investigated the associations between COVID-19 pandemic-related income loss with financial strain and mental health trajectories over a 1-month course.MethodsTwo independent studies were conducted in the U.S and in Israel at the beginning of the outbreak (March-April 2020, T1; N = 4 171) and at a 1-month follow-up (T2; N = 1 559). Mixed-effects models were applied to assess associations among COVID-19-related income loss, financial strain, and pandemic-related worries about health, with anxiety and depression, controlling for multiple covariates including pre-COVID-19 income.FindingsIn both studies, income loss and financial strain were associated with greater depressive symptoms at T1, above and beyond T1 anxiety, worries about health, and pre-COVID-19 income. Worsening of income loss was associated with exacerbation of depression at T2 in both studies. Worsening of subjective financial strain was associated with exacerbation of depression at T2 in one study (US).InterpretationIncome loss and financial strain were uniquely associated with depressive symptoms and the exacerbation of symptoms over time, above and beyond pandemic-related anxiety. Considering the painful dilemma of lockdown versus reopening, with the tradeoff between public health and economic wellbeing, our findings provide evidence that the economic impact of COVID-19 has negative implications for mental health.FundingThis study was supported by grants from the National Institute of Mental Health, the US-Israel Binational Science Foundation, Foundation Dora and Kirsh Foundation.

BackgroundProlonged exposure therapy (PE) is an evidence-based treatment for posttraumatic stress disorder (PTSD) that is underutilized in the military health system. Standard workshop training in PE may not be sufficient to alter provider behavior, but post-workshop consultation requires significant resources. Therefore, it is important to determine the incremental utility of post-workshop consultation.MethodsThis study used a hybrid type III randomized implementation trial at 3 US Army installations. Providers were randomized to receive a 4-day prolonged exposure workshop (Standard training condition,n= 60), or the prolonged exposure workshop followed by 6–8 months of post-workshop expert case consultation (Extended training condition,n= 43). The effects training condition were examined on provider attitudes (self-efficacy in delivering PE, expectations for patient improvement, and beliefs about PE), use of PE and PE components, and clinical outcomes of patients with PTSD (using the Clinician-Administered PTSD Scale (CAPS-5)).ResultsExtended condition providers reported greater improvements in self-efficacy,b= .83, 95% CI [.38, 1.27],t(79) = 3.71,p= .001, andd= .63. A greater proportion of patients in the Extended condition (44%) than in the Standard condition (27%) received at least 1 PE session,b= .76,t(233) = 2.53,p= .012, and OR = 2.13. Extended condition providers used more PE components (M= .9/session) than did Standard condition providers (M= .5/session),b= .54, 95% CI [.15, .93],t(68) = 2.70,p= .007, andd= .68. Finally, decrease in patients’ PTSD symptoms was faster for patients of Extended condition providers than for patients of Standard condition providers,b= − 1.81, 95% CI [− 3.57, − .04],t(263) = − 2.02,p= .045, andd= .66, and their symptoms were lower at the second assessment,b= − 5.47, 95% CI [− 9.30, − 1.63],t(210) = − 2.81,p= .005, andd= .66.ConclusionsPost-workshop consultation improved self-efficacy for delivering PE, greater use of PE, faster PTSD reduction, and lower PTSD severity at the second assessment. To our knowledge, this is the first demonstration that post-workshop case consultation for PE improves patient outcomes.Trial registrationClinicaltrials.gov,NCT02982538. Registered December 5, 2016; retrospectively registered

COVID-19 pandemic is a global calamity posing an unprecedented opportunity to study resilience. We developed a brief resilience survey probing self-reliance, emotion-regulation, interpersonal-relationship patterns and neighborhood-environment, and applied it online during the acute COVID-19 outbreak (April 6–15, 2020), on a crowdsourcing research website (www.covid19resilience.org) advertised through social media. We evaluated level of stress (worries) regarding COVID-19: (1) contracting, (2) dying from, (3) currently having, (4) family member contracting, (5) unknowingly infecting others with (6) experiencing significant financial burden following. Anxiety (GAD7) and depression (PHQ2) were measured. Totally, 3042 participants (n = 1964 females, age range 18–79, mean age = 39) completed the resilience and COVID-19-related stress survey and 1350 of them (mean age = 41, SD = 13; n = 997 females) completed GAD7 and PHQ2. Participants significantly endorsed more distress about family contracting COVID-19 (48.5%) and unknowingly infecting others (36%), than getting COVID-19 themselves (19.9%), p 10, 22.2%) and depression (PHQ2 > 2, 16.1%) did not differ between healthcare providers and non-healthcare providers. Higher resilience scores were associated with lower COVID-19 related worries (main effect F1,3054 = 134.9; p

OBJECTIVE Machine learning algorithms in electronic medical records can classify patients by suicide risk, but no research has explored clinicians' perceptions of suicide risk flags generated by these algorithms, which may affect algorithm implementation. The objective of this study was to evaluate clinician perceptions of suicide risk flags. METHODS Participants (n = 139; 68 with complete data) were mental health clinicians recruited to complete online surveys from October 2018 to April 2019. RESULTS Most participants preferred to know which features resulted in a patient receiving a suicide flag (94.12%) and reported that knowing those features would influence their treatment (88.24%). Clinicians were more likely to report that some algorithm features (increased thoughts of suicide) would alter their clinical decisions more than others (age, physical health conditions; χ² = 270.84, P < .001). Clinicians were more likely to report that they would create a safety/crisis response plan in response to a suicide risk flag compared to other interventions (χ² = 227.02, P < .001), and 21% reported that they would complete a no-suicide contract following a suicide risk flag. CONCLUSIONS Clinicians overwhelmingly reported that suicide risk flags in electronic medical records would alter their clinical decision making. However, clinicians' likelihood of acting in response to a suicide risk flag was tied to which features were highlighted rather than the presence of the risk flag alone. Thus, the utility of a suicide risk algorithm will be reduced if clinical features underlying the algorithm are hidden from clinicians or if clinicians do not view the clinical features as intuitively meaningful predictors of suicide risk.

Study Objectives To examine sleep disorder symptom reports at baseline and posttreatment in a sample of active duty U.S. Army Soldiers receiving treatment for posttraumatic stress disorder (PTSD). Explore sleep-related predictors of outcomes. Methods Sleep was evaluated in 128 participants in a parent randomized clinical trial comparing Spaced formats of Prolonged Exposure (PE) or Present Centered Therapy and a Massed format of PE. In the current study, Spaced formats were combined and evaluated separately from Massed. Results At baseline, the average sleep duration was < 5 h per night on weekdays/workdays and < 6 h per night on weekends/off days. The majority of participants reported clinically significant insomnia, clinically significant nightmares, and probable sleep apnea and approximately half reported excessive daytime sleepiness at baseline. Insomnia and nightmares improved significantly from baseline to posttreatment in all groups, but many patients reported clinically significant insomnia (>70%) and nightmares (>38%) posttreatment. Excessive daytime sleepiness significantly improved only in the Massed group, but 40% continued to report clinically significant levels at posttreatment. Short sleep (Spaced only), clinically significant insomnia and nightmares, excessive daytime sleepiness, and probable sleep apnea (Massed only) at baseline predicted higher PTSD symptoms across treatment course. Short weekends/off days sleep predicted lower PTSD symptom improvement in the Spaced treatments. Conclusions Various sleep disorder symptoms were high at baseline, were largely unchanged with PTSD treatment, and were related to worse PTSD treatment outcomes. Studies are needed with objective sleep assessments and targeted sleep disorders treatments in PTSD patients. Clinical Trial Registration NCT01049516.

Chronic pain and opioid use are associated with increased risk for suicidal ideation and behaviors (SIB) in cross-sectional studies, particularly among individuals who catastrophize about their pain. This study examined the longitudinal association between two styles of pain coping, catastrophizing and hoping/praying, as predictors of subsequent SIB, as well as possible mediators of this association among patients with chronic pain receiving long-term opioid therapy. Participants (n = 496) were adults with chronic nonmalignant pain on long-term opioid therapy who did not develop an opioid use disorder. Participants were assessed for pain coping, suicidal ideation, depression, social support and pain interference at baseline, and were reassessed for SI, depression, and pain interference at 6- and 12-month follow-ups. Catastrophizing was a significant predictor of increased subsequent SIB, whereas hoping/praying did not protect against future SIB. The relationship between catastrophizing and future SIB was mediated by depression, but not social support or pain interference. In conclusion, catastrophizing was an important predictor of subsequent SIB due to its effect on increasing depression among patients with chronic nonmalignant pain receiving long-term opioid therapy. Future research should explore the extent to which targeting catastrophizing reduces subsequent depression and suicide risk.

While psychiatric disorder prevalence is higher among patients living with HIV (PLWH), there are no prior studies on rates of psychiatric diagnosis documentation in electronic medical records (EMRs) of PLWH, which was the goal of this study. Participants (n = 2,336) were enrolled in the Center for AIDS Research (CFAR) Longitudinal Database study. Diagnostic codes were extracted to assess the prevalence rates of depressive, alcohol/substance use, PTSD, sleep, and adjustment disorders. Prevalence rates for psychiatric disorders were extracted from national epidemiological studies for comparison. Rates of Major Depressive Disorder in the EMR were comparable to prior epidemiological reports in PLWH. In contrast, rates of PTSD, substance use, alcohol use, adjustment, and insomnia disorders were all markedly lower compared to epidemiological studies. While clinicians appropriately documented depression, other psychiatric comorbidities were largely overlooked. This indicates a potential bias in the detection or documentation of psychiatric disorders in PLWH.

Suicide rates among youths in foster care are among the highest in the United States. Despite this fact, many foster-care agencies do not perform universal suicide-risk assessments as part of routine care. This commentary includes an argument for the importance of implementing universal suicide-risk assessments for youths in foster care. Important contextual information that prevents behavioral-health clinicians from implementing universal suicide screenings of youths in foster care is discussed. Several possible strategies for implementing universal suicide-risk assessments are offered; the pros and cons of each strategy are discussed. The perspectives of multiple stakeholders should be included in the consideration of universal suicide screening for youths in foster care, including behavioral-health providers, primary-care doctors, supervisors, directors of agencies, foster parents, and case managers. Although each of these stakeholders can improve suicide prevention, youths in foster care may not have regular access to each stakeholder. Case managers may be the optimal stakeholders for implementing universal suicide screening because of their frequent access to youths in foster care; therefore, case managers should receive training in suicide-risk assessment and prevention strategies.

BackgroundFew studies have investigated the patterns of posttraumatic stress disorder (PTSD) symptom change in prolonged exposure (PE) therapy. In this study, we aimed to understand the patterns of PTSD symptom change in both PE and present-centered therapy (PCT).MethodsParticipants were active duty military personnel (N = 326, 89.3% male, 61.2% white, 32.5 years old) randomized to spaced-PE (S-PE; 10 sessions over 8 weeks), PCT (10 sessions over 8 weeks), or massed-PE (M-PE; 10 sessions over 2 weeks). Using latent profile analysis, we determined the optimal number of PTSD symptom change classes over time and analyzed whether baseline and follow-up variables were associated with class membership.ResultsFive classes, namely rapid responder (7–17%), steep linear responder (14–22%), gradual responder (30–34%), non-responder (27–33%), and symptom exacerbation (7–13%) classes, characterized each treatment. No baseline clinical characteristics predicted class membership for S-PE and M-PE; in PCT, more negative baseline trauma cognitions predicted membership in the non-responder v. gradual responder class. Class membership was robustly associated with PTSD, trauma cognitions, and depression up to 6 months after treatment for both S-PE and M-PE but not for PCT.ConclusionsDistinct profiles of treatment response emerged that were similar across interventions. By and large, no baseline variables predicted responder class. Responder status was a strong predictor of future symptom severity for PE, whereas response to PCT was not as strongly associated with future symptoms.