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Electronic health records (EHRs) offer opportunities for research and improvements in patient care. However, challenges exist in using data from EHRs due to the volume of information existing within clinical notes, which can be labor intensive and costly to transform into usable data with existing strategies. This case report details the collaborative development and implementation of the postencounter form (PEF) system into the EHR at the Road Home Program at Rush University Medical Center in Chicago, IL to address these concerns with limited burden to clinical workflows. The PEF system proved to be an effective tool with over 98% of all clinical encounters including a completed PEF within 5 months of implementation. In addition, the system has generated over 325,188 unique, readily-accessible data points in under 4 years of use. The PEF system has since been deployed to other settings demonstrating that the system may have broader clinical utility.

IntroductionPoor sleep is prevalent among individuals with social anxiety disorder (SAD) and may negatively affect exposure therapy outcomes. Poor sleep may impair memory and learning, and thus compromise fear extinction learning thought to take place in exposure therapy. We examined poor sleep as a predictor of exposure therapy outcomes for SAD and the moderating role of d-cycloserine (DCS) on this relationship.MethodsParticipants were 152 individuals with a primary diagnosis of SAD. As part of a randomized clinical trial evaluating the efficacy of DCS for enhancing the effects of exposure therapy, they completed self-report baseline measure of sleep quality, and self-report sleep diaries assessing sleep duration (total sleep time [TST]) and sleep quality the nights before and after treatment sessions.ResultsPoorer baseline sleep quality was significantly associated with slower improvement over time and worse symptom outcomes at the end of treatment and follow-up after controlling for baseline symptoms of depression and social anxiety. Greater TST the night before treatment predicted lower SAD symptoms at the next session, after controlling for symptoms at the previous session. There was no relation between prior or subsequent night sleep quality on symptoms at the next session. No associations were moderated by DCS.ConclusionsWe replicated and extended findings indicating that poor sleep quality is associated with poorer exposure therapy outcomes for SAD. Assessing for sleep difficulties before treatment initiation and incorporating sleep interventions into treatment may enhance exposure therapy outcomes for SAD.

BackgroundIntensive treatment programmes (ITPs) have shown promise for reducing PTSD and depression symptoms. It is still unknown whether treatment gains are maintained following completion.ObjectiveThis study examined whether veterans were able to maintain treatment gains for up to 12 months after an ITP for PTSD and whether reductions in negative posttrauma cognitions predicted treatment gain maintenance.Methods209 veterans (62.7% male, mean age = 40.86 years) completed a 3-week, CPT-based ITP for PTSD. Participants' PTSD (PCL-5) and depression (PHQ-9) symptoms were assessed at pre-treatment, post-treatment, and at 3-, 6-, and 12-month follow-up timepoints.ResultsDespite small symptom increases from post-treatment to 3-month follow-up, significant and clinically meaningful reductions in PTSD and depression symptoms were reported from intake to 12 months follow-up (averaging >18 points on the PCL-5 and >6 points on the PHQ-9; d = 1.28, and d = 1.18, respectively). Greater reductions in negative posttrauma cognitions during treatment were associated with lower PTSD (p

Previous research has demonstrated that sleep disturbances show little improvement with evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, sleep improvements are associated with PTSD treatment outcomes. The goal of the current study was to evaluate changes in self-reported insomnia symptoms and the association between insomnia symptoms and treatment outcome during a 3-week intensive treatment program (ITP) for veterans with PTSD that integrated cognitive processing therapy (CPT), mindfulness, yoga, and other ancillary services. As part of standard clinical procedures, veterans (N = 165) completed self-report assessments of insomnia symptoms at pre- and posttreatment as well as self-report assessments of PTSD and depression symptoms approximately every other day during treatment. Most veterans reported at least moderate difficulties with insomnia at both pretreatment (83.0%-95.1%) and posttreatment (69.1-71.3%). Statistically significant reductions in self-reported insomnia severity occurred from pretreatment to posttreatment; however, the effect size was small, d = 0.33. Longitudinal mixed-effects models showed a significant interactive effect of Changes in Insomnia × Time in predicting PTSD and depression symptoms, indicating that patients with more improvements in insomnia had more positive treatment outcomes. These findings suggest that many veterans continued to struggle with sleep disruption after a 3-week ITP, and successful efforts to improve sleep could lead to better PTSD treatment outcomes. Further research is needed to establish how adjunctive sleep interventions can be used to maximize both sleep and PTSD outcomes.

UNSTRUCTURED Electronic health records (EHRs) offer opportunities for research and improvements in patient care. However, challenges exist in using data from EHRs due to the volume of information existing within clinical notes, which can be labor intensive and costly to transform into usable data with existing strategies. This case report details the collaborative development and implementation of the postencounter form (PEF) system into the EHR at the Road Home Program at Rush University Medical Center in Chicago, IL to address these concerns with limited burden to clinical workflows. The PEF system proved to be an effective tool with over 98% of all clinical encounters including a completed PEF within 5 months of implementation. In addition, the system has generated over 325,188 unique, readily-accessible data points in under 4 years of use. The PEF system has since been deployed to other settings demonstrating that the system may have broader clinical utility.

ObjectiveThe purpose of the present study was to detail the patient flow and establish the feasibility of a brief 3-week intensive treatment program (ITP) for veterans with posttraumatic stress disorder (PTSD).MethodThe present study examined data from 648 veterans referred to a non-Veterans Affairs ITP for PTSD from January 2016 to February 2018 to determine the flow of patients into and through the ITP and evaluate individuals' satisfaction with treatment.ResultsOn average, 25.9 individuals contacted the ITP each month expressing interest in the program. A large proportion of individuals who completed an intake evaluation were accepted (72.2%) into the ITP. Of those accepted, 70.6% ultimately attended the ITP, and the vast majority of veterans who attended the ITP completed treatment (91.6%). Logistic regression results suggested that among veterans who were accepted to the program, those who were legally separated or divorced had significantly greater odds of attending the program compared to single veterans. Veterans were highly satisfied with the 3-week ITP and rated cognitive processing therapy components as the most helpful part of the program.ConclusionsThe present study demonstrates that ITP formats for PTSD are of interest and acceptable to veterans, and this format allows individuals to receive high doses of evidence-based treatments in a short amount of time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Although evidence-based treatments for posttraumatic stress disorder (PTSD), such as Cognitive Processing Therapy (CPT), have been developed and widely disseminated, the rate of veterans engaging in and completing these therapies is low. Alternative methods of delivery may be needed to help overcome key barriers to treatment. Delivering evidence-based therapies intensively may address practical barriers to treatment attendance as well as problems with avoidance. This report details the case of a combat veteran who received 10 sessions of Cognitive Processing Therapy delivered twice per day over a single, five-day work week (CPT-5). Post-treatment, the veteran reported large and clinically meaningful decreases in PTSD and depression symptom severity as well as in guilt cognitions, which is a purported mechanism of successful treatment. These effects persisted six weeks after treatment ended. Despite the intensive nature of the treatment, the veteran found CPT-5 tolerable and could cite many benefits to completing therapy in one work week. In conclusion, CPT-5 holds promise as a way to efficiently deliver an evidence-based therapy that is both clinically effective and acceptable to patients, although more rigorous clinical trials are needed to test this treatment delivery format.

BackgroundThe experience of Military Sexual Trauma (MST) in the form of sexual assault and sexual harassment is common during service in the U.S. Armed Forces and often leads to adverse health outcomes including posttraumatic stress disorder (PTSD). Improving treatment of MST-related PTSD across settings is important to optimize treatment for survivors. The delivery of Cognitive Processing Therapy (CPT) in an intensive treatment program (ITP) shows promise for rapid reduction of PTSD symptoms for veterans and service members (veterans). However, a recent outcome study suggested that this modality is significantly less effective in reducing symptoms of PTSD for survivors of MST compared to veterans recovering from combat trauma.Methods-The current study examines the utility of modifications made to a CPT-based ITP designed to treat PTSD secondary to MST in a mixedgender sample (N = 285). Treatment modifications included the introduction of skills-based groups in emotion regulation and interpersonal domains. Individual skills-consultation sessions were also offered to participants on an as-needed basis. Further, training was provided to both clinical and non-clinical staff to increase understanding of the unique experiences and needs of MST survivors.ResultsProgram changes proved beneficial, resulting in PTSD treatment outcomes that were comparable for survivors of MST and combat traumas.LimitationsFurther research is needed to determine which of these specific program changes were most impactful in improving symptom outcomes.ConclusionsOur findings suggest that short-term, intensive PTSD treatment for MST survivors may be improved by integrating present-focused, skills-based therapies and staff sensitivity training.

BackgroundSleep disturbance is a core feature of post-traumatic stress disorder (PTSD). Given the relationship between sleep disturbance and PTSD, there has been a relative paucity of studies examining the potential therapeutic impact of using pharmacotherapy to target sleep disturbance in patients with PTSD. Eszopiclone (ESZ) is a non-benzodiazepine y-aminobutyric acid-A receptor agonist indicated for the treatment of sleep and may affect sleep in patients with PTSD.AimTo evaluate the efficacy of ESZ vs placebo (PBO) for patients with PTSD and insomnia.MethodsThe study was a 12-wk, double blind, randomized controlled trial with 3 mg of ESZ (n = 13) or PBO (n = 12).ResultsPatients in both arms experienced significant improvement in PTSD symptoms as assessed by the Clinician-Administered PTSD Scale for DSM-IV (CAPS): ESZ (t11 = -3.12, P = 0.005) and PBO (t11 = -3.5, P = 0.002) and by self-report with the Short PTSD Rating Interview (ESZ t11 = -3.38, P = 0.003 and PBO t11 = -4.48, P = 0.0005). There were no significant differences between treatments on the CAPS (t22 = -0.13, P = 0.70) or the Short PTSD Rating Interview (t22 = -0.58, P = 0.56). Similarly, both treated groups improved on sleep measures as assessed by the Pittsburgh Sleep Quality Index with PTSD Addendum (PSQI) and on total sleep time (TST) and sleep latency assessed by actigraphy with no significant differences between groups (PSQI t22 = -0.24, P = 0.81; total sleep time t10 = 0.13, P = 0.90 and sleep latency t10 = 0.68, P = 0.50). There was a significant correlation between improvement in sleep and overall improvement in PTSD as measured by change scores on the PSQI and CAPS, r(8) = 0.79, P = 0.01 for ESZ treated subjects, but not for those treated with PBO r(9) = 0.16, P = 0.69. Adverse events of ESZ were consistent with the known profile of the medication including dysgeusia (30%, mild), sedation (20%, mild) and headache (20%, moderate to severe).ConclusionResults do not support the hypothesis of a specific positive effect of ESZ compared to PBO for measures of PTSD and associated sleep disturbance.

BackgroundEvidence-based treatments for post-traumatic stress disorder (PTSD) have poor uptake and remission rates, suggesting that alternative treatments are needed. Morning bright light may be an effective treatment for PTSD given its established effects on mood and sleep, however, there are no published trials.MethodsWe conducted a placebo-controlled pilot trial of a wearable light device, the Re-timer®, for individuals with probable PTSD. Individuals were randomly assigned to the active Re-timer® (n = 9) or a placebo Re-timer® dimmed with neutral density filters (n = 6). Participants self-administered the treatment at home 1 hr each morning over 4 weeks. PTSD and depression symptoms were assessed at pre- and post-treatment.ResultsThe Re-timer® was well tolerated and the perceived benefit was high, though treatment adherence was only moderate. Those in the active group were more likely to achieve a minimal clinically important change in PTSD and depression symptoms and had larger symptom reductions than those in the placebo group CONCLUSIONS: A wearable morning light treatment was acceptable and feasible for patients with probable PTSD. This study provides initial proof-of-concept that light treatment can improve PTSD. A larger trial is warranted to establish treatment efficacy. NCT#: 03513848.

ObjectiveMoral injury is a nascent construct intended to capture reactions to events that violate deeply held beliefs and moral values. Although a model of moral injury has been proposed, many of the theoretical propositions of this model have yet to be systematically studied.MethodWe conducted semistructured interviews with eight veterans who reported experiencing morally injurious events during war zone deployments.ResultsUsing narrative thematic analysis, five main themes and associated subthemes emerged from the data. The main themes capture the timing of the event, contextual factors that affected the decision-making process during the morally injurious event, reactions to the moral injurious event, search for purpose and meaning, and opening up.ConclusionThe findings from the present study supported an existing model of moral injury, while extending it in several important ways. Preliminary clinical recommendations and directions for future research are discussed based on the study findings. These include directly exploring the context surrounding the morally injurious event, examining the veterans' moral appraisals, and helping them assume appropriate responsibility for their actions to reduce excessive self-blame. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Morningness-Eveningness Questionnaire (MEQ) and Munich ChronoType Questionnaire (MCTQ) are sometimes used to estimate circadian timing. However, it remains unclear if they can reflect a change in circadian timing after a light treatment. In this study, 31 participants (25-68 years) completed both questionnaires before and after a 13-28 day morning light treatment. The dim light melatonin onset (DLMO), a physiological marker of circadian timing, was also assessed in a subsample of 16 participants. The DLMO phase advanced on average by 47 minutes (p

BackgroundIntensive delivery of evidence-based treatment for posttraumatic stress disorder (PTSD) is becoming increasingly popular for overcoming barriers to treatment for veterans. Understanding how and for whom these intensive treatments work is critical for optimizing their dissemination. The goals of the current study were to evaluate patterns of PTSD and depression symptom change over the course of a 3-week cohort-based intensive outpatient program (IOP) for veterans with PTSD, examine changes in posttraumatic cognitions as a predictor of treatment response, and determine whether patterns of treatment outcome or predictors of treatment outcome differed by sex and cohort type (combat versus military sexual trauma [MST]).MethodOne-hundred ninety-one veterans (19 cohorts: 12 combat-PTSD cohorts, 7 MST-PTSD cohorts) completed a 3-week intensive outpatient program for PTSD comprised of daily group and individual Cognitive Processing Therapy (CPT), mindfulness, yoga, and psychoeducation. Measures of PTSD symptoms, depression symptoms, and posttraumatic cognitions were collected before the intervention, after the intervention, and approximately every other day during the intervention.ResultsPre-post analyses for completers (N = 176; 92.1% of sample) revealed large reductions in PTSD (d = 1.12 for past month symptoms and d = 1.40 for past week symptoms) and depression symptoms (d = 1.04 for past 2 weeks). Combat cohorts saw a greater reduction in PTSD symptoms over time relative to MST cohorts. Reduction in posttraumatic cognitions over time significantly predicted decreases in PTSD and depression symptom scores, which remained robust to adjustment for autocorrelation.ConclusionIntensive treatment programs are a promising approach for delivering evidence-based interventions to produce rapid treatment response and high rates of retention. Reductions in posttraumatic cognitions appear to be an important predictor of response to intensive treatment. Further research is needed to explore differences in intensive treatment response for veterans with combat exposure versus MST.

With approximately 20 veteran suicide deaths per day, suicidal ideation (SI) among veterans is an important concern. Posttraumatic stress disorder (PTSD) is associated with SI among veterans, yet mechanisms of this relationship remain unclear. Negative posttraumatic cognitions contribute to the development and maintenance of PTSD, yet no studies have prospectively examined the relationship between posttraumatic cognitions and SI. Veterans (N = 177; 66% Male) participating in a 3-week intensive outpatient program for PTSD completed assessments of PTSD severity, depressive symptoms, SI, and posttraumatic cognitions. Negative posttraumatic cognitions about the self significantly predicted SI at posttreatment, controlling for pretreatment levels of SI, depression, and PTSD symptom severity. Self-blame and negative posttraumatic cognitions about others/world did not predict SI prospectively. Negative posttraumatic cognitions about the self appear to be an important factor in the manifestation of SI among veterans with PTSD and should be monitored as a potential indicator of suicide risk.

BackgroundUnique aspects of military sexual trauma (MST) may result in specific maladaptive cognitions among survivors. Understanding which posttraumatic cognitions are particularly strong among MST survivors could help clinicians target and improve treatment for these individuals. This study explored the impact of experiencing MST on posttraumatic cognitions among veterans with posttraumatic stress disorder (PTSD).MethodsVeterans enrolled in an Intensive Outpatient Program for PTSD (N = 226) were assessed for MST, PTSD severity, depression severity, and posttraumatic cognitions as part of a standard clinical intake. Multivariate analyses examined differences in posttraumatic cognitions between veterans who did and did not experience MST.ResultsMST survivors (n = 88) endorsed significantly stronger posttraumatic cognitions related to self-blame compared to non-MST counterparts (n = 138), even when accounting for current symptom severity. Specifically, MST predicted the following cognitions: "The event happened to me because of the sort of person I am," "Somebody else would have stopped the event from happening," "Somebody else would not have gotten into this situation," and "There is something about me that made the event happen," after controlling for severity of PTSD and depression.LimitationsStudy population was a treatment-seeking sample of veterans diagnosed with PTSD from a non-VA clinic. Veterans in MST group endorsed either sexual harassment, sexual assault, or both. Sample size of males who endorsed MST (n = 21) may be too small to generalize to all males.ConclusionsBeliefs related to self-blame may be important treatment targets for MST survivors.

ObjectiveThe purpose of the present research was to examine the demographic and mental health characteristics of veterans and service members who endorsed having caused harm, injury, or death to another person on deployment, while taking these individuals' total number of other lifetime traumas into account.MethodData for the present study were collected as part of the standard clinical evaluation for 228 treatment-seeking veterans and service members.ResultsThose who reported having caused harm, injury, or death to another person on deployment (22.4%) were more likely to be male, to have served in the Marines, to have served post 9/11, and to endorse other traumas commonly reported on deployment than those who did not endorse causing harm, injury, or death. Those who endorsed causing harm on deployment were less likely to have served in the Air Force, and to have experienced sexual assault than those who did not cause harm. Causing harm, injury, or death was associated with higher levels of posttraumatic stress disorder (PTSD), drug use, and expressive anger at the bivariate level, but was no longer associated with mental health problems after accounting for the number of other lifetime traumas.ConclusionsExamining the role of causing harm in isolation may lead to false conclusions. Clinicians and researchers should assess for veterans' and service members' entire trauma histories. (PsycINFO Database Record

This study aimed to examine: (1) the relationship between parental psychopathology and child psychopathology in military families and (2) parenting sense of competence as a mediator of the relationship between veteran psychopathology and child psychopathology. As part of their standard clinical evaluations, 215 treatment-seeking veterans who reported having a child between the ages of 4 and 17 were assessed for psychopathology (posttraumatic stress disorder, depression, anxiety, and stress), their sense of competence as a parent, and their child's psychopathology (internalizing, externalizing, and attentional symptoms). A path analysis model examining parenting sense of competence as a mediator of the relationship between veteran psychopathology and child psychopathology showed significant indirect effects of veteran depression on all child psychopathology outcomes via parenting sense of competence. Parental sense of competence may be a critical mechanism linking veteran depression and child psychopathology, and may therefore be an important target for intervention.

Exposure to potentially morally injurious events has been shown to be associated with posttraumatic stress disorder (PTSD) and depression symptoms in military personnel. Few studies have examined factors that help to explain how potentially morally injurious events may contribute to the development of trauma-related psychopathology. Negative posttrauma cognitions are thought to play a role in the etiology of PTSD and depression following trauma; however, it is unclear whether more global beliefs about the self, others, and world play a role in the development of PTSD and depression due to morally injurious events. Using structural equation modeling, we tested whether morally injurious experiences were indirectly related to trauma-related psychopathology (PTSD and depression) through negative posttrauma cognitions in a sample of veterans seeking treatment for PTSD. An indirect effects only model best fit the data and showed that morally injurious experiences, specifically perceived transgressions by oneself and perceived betrayal, were indirectly associated with trauma-related psychopathology through negative posttrauma cognitions, β = .17; 95% CI [.04, .31] and β = .25; 95% CI [.11, .41], respectively. Our findings suggest that negative posttrauma cognitions may be an important mechanism linking exposure to morally injurious events and trauma-related psychopathology.

Moral injury refers to a set of reactions to acts of perpetration or commission that violate an individual's deeply held beliefs and moral values. Although there is consensus that military service increases exposure to morally injurious events, there is no clear definition on what events do and do not constitute moral injury, which makes drawing firm conclusions regarding the prevalence of moral injury among military populations difficult. Exposure to morally injurious events places individuals at a greater risk for a range of poor mental health outcomes, which may be mediated by negative posttraumatic cognitions. Therefore, treatments that emphasize restructuring such cognitions are likely to be effective in treating the effects of moral injury, though data are lacking. In this article, we provide an overview of the key scientific findings regarding moral injury and highlight areas where future research is needed. Potential challenges in treating the negative sequelae of moral injury are also discussed.

Since September 11, 2001, more than two million U.S. service members have deployed to Iraq or Afghanistan, many returning home with posttraumatic stress disorder (PTSD) and additional psychological and general medical complaints. Nonetheless, many do not seek care or may not respond to traditional outpatient approaches, warranting innovative, multidisciplinary treatment approaches. To help address these complex needs, the Wounded Warrior Project has funded four academic medical centers to develop a care network across the nation. As part of this Warrior Care Network, the Emory Healthcare Veterans Program in Atlanta; the Home Base Program at Massachusetts General Hospital, in collaboration with the Red Sox Foundation, in Boston; Road Home at Rush Medical Center in Chicago; and Operation Mend at the University of California, Los Angeles, have each developed innovative, intensive programs to treat PTSD among post-9/11 veterans and service members. The programs offer two- to three-week intensive PTSD treatment programs with evidence-based approaches embedded in a broader program. To date, 328 post-9/11 veterans and active-duty service members have received care in these intensive outpatient programs. The average completion rate is approximately 95%, which demonstrates the acceptability of this brief but intensive care model for a complex population who can be challenging to engage or retain in care.

This pilot study evaluated the feasibility, acceptability, and preliminary effectiveness of tailored cognitive-behavioral resilience training (TCBRT) for trauma-exposed individuals with a variety of subsyndromal psychological symptoms. TCBRT is a brief, flexible intervention that allows individuals to select the areas they wish to target using common cognitive-behavioral change principles. There were 14 individuals (78.6% female) who were recruited from a major medical center and enrolled in the 5-session intervention. There were 12 (85.7%) who completed all TCBRT sessions, and 2 (14.3%) who dropped out after 3 sessions. All participants reported that they received benefit from, were engaged in, and were satisfied with the intervention. Of the 12 with postintervention data, 5 of the participants demonstrated reliable increases in resilience and 6 demonstrated reliable decreases in anxiety. These improvements appeared to be maintained at 2-month follow-up; of the 11 participants with follow-up data, 5 demonstrated reliable increases in resilience and 6 demonstrated reliable decreases in anxiety. Our findings suggested that TCRBT was acceptable to trauma-exposed individuals with varying types of subthreshold distress.

BackgroundSleep quality may be an important, yet relatively neglected, predictor of treatment outcome in cognitive-behavioral therapy (CBT) for anxiety disorders. Specifically, poor sleep quality may impair memory consolidation of in-session extinction learning. We therefore examined sleep quality as a predictor of treatment outcome in CBT for social anxiety disorder and the impact of d-cycloserine (DCS) on this relationship.MethodsOne hundred sixty-nine participants with a primary diagnosis of DSM-IV generalized social anxiety disorder were recruited across three sites. Participants were enrolled in 12 weeks of group CBT. Participants randomly received 50 mg of DCS (n = 87) or pill placebo (n = 82) 1 hr prior to sessions 3-7. Participants completed a baseline measure of self-reported sleep quality and daily diaries recording subjective feelings of being rested upon wakening. Outcome measures including social anxiety symptoms and global severity scores were assessed at each session.ResultsPoorer baseline sleep quality was associated with slower improvement and higher posttreatment social anxiety symptom and severity scores. Moreover, patients who felt more "rested" after sleeping the night following a treatment session had lower levels of symptoms and global severity at the next session, controlling for their symptoms and severity scores the previous session. Neither of these effects were moderated by DCS condition.ConclusionsOur findings suggest that poor sleep quality diminishes the effects of CBT for social anxiety disorder and this relation is not attenuated by DCS administration. Therapeutic attention to sleep quality prior to initiation of CBT and during the acute treatment phase may be clinically indicated.

BackgroundMore data are needed to guide next-step interventions for panic disorder refractory to initial intervention.MethodThis 24-week randomized clinical trial (RCT) enrolled 46 patients with DSM-IV-defined panic disorder from November 2000 to April 2005 and consisted of 3 phases. Patients who failed to meet remission criteria were eligible for randomization in the next treatment phase. Phase 1 was a 6-week lead-in with open-label sertraline flexibly dosed to 100 mg (or escitalopram equivalent) to prospectively define treatment refractoriness (lack of remission). Phase 2 was a 6-week double-blind RCT of (1) increased-dose selective serotonin reuptake inhibitor (SSRI) versus (2) continued SSRI plus placebo. Phase 3 was a 12-week RCT of added cognitive-behavioral therapy (CBT) compared to "medication optimization" with SSRI plus clonazepam. Primary endpoints were remission and change in Panic Disorder Severity Scale (PDSS) score in the intent-to-treat sample in each phase.ResultsIn phase 1, 20.5% (8/39) of the patients achieved remission, and only baseline severity predicted endpoint PDSS score (beta [SE] = 1.04 [0.15], t = 6.76, P < .001). In phase 2, increasing the SSRI dose did not result in greater improvement or remission rates (placebo 15% [n = 2] vs increased dose 9% [n = 1]: Fisher exact test P = NS). In phase 3, remission was minimal (medication optimization = 11% [n = 1]; CBT = 10% [n = 1]), with a lack of group difference in PDSS score reduction (t(17) = 0.51, P > .60) consistent with a small effect size (d = 0.24).ConclusionsAlthough power was limited and larger studies are needed, we failed to find evidence for greater benefit of increased SSRI dose versus continuation of current dose for panic disorder symptomatic after 6 weeks at moderate dose. Further, augmentation with CBT or medication optimization with clonazepam augmentation in nonremitted panic after 12 weeks of an SSRI did not differ, suggesting that both are reasonable next-step options. However, low overall remission rates in this comorbid refractory population suggest that better predictors of response to specific treatments over time and additional interventions are needed.Trial registrationclinicaltrials.gov Identifier: NCT00118417.

Pharmacotherapy is an effective treatment for generalized anxiety disorder (GAD), but few studies have examined the nature of decline of anxiety and depression during pharmacotherapy for GAD and even fewer studies have examined predictors of symptom decline. This study examined the decline in symptoms of anxiety and depression in patients with GAD during a 6-week open trial of fluoxetine. Growth curve analyses indicated that pharmacotherapy with fluoxetine led to significant declines in symptoms of anxiety and depression over the 6 weeks of treatment. However, the decay slope observed for anxiety symptoms was significantly greater than that for depressive symptoms. Further analyses revealed that the decline in anxiety remained significant after accounting for the changes in symptoms of depression. However, the effect of treatment on depression was no longer significant after controlling for the reduction in anxiety symptoms. Overall anxiety sensitivity (AS) did not moderate the level of reduction in symptoms of anxiety or depression during pharmacotherapy. However, AS specific to physical concerns demonstated a marginal negative association with decline in anxiety and depression. AS specific to social concerns also demonstrated a marginal negative association with decline in anxiety symptoms. These findings suggest that the decline in anxiety symptoms is independent of the decline in symptoms of depression during pharmacotherapy for GAD and specific AS dimensions may predict symptom change in GAD.

For Vietnamese refugees, we describe (a) how headache- and orthostasis-focused panic attacks are generated, (b) a culturally sensitive treatment for PTSD with comorbid headache- and orthostasis-focused panic attacks, and (c) the outcome of a treatment series. In a multiple-baseline, across-subjects design (N = 3), all patients demonstrated treatment-related improvement of headache- and orthostasis-associated panic attacks; and in the repeated-measures, within-subjects design, all patients greatly improved across treatment on measures of psychopathology. One treatment case is presented. (Contains 4 figures.)

Consecutive Cambodian refugees (N = 100) attending a psychiatric clinic were assessed for the presence and severity of current orthostatic panic (OP), which is defined as panic triggered by standing up. The patients with current OP (n = 36) had significantly greater psychopathology than patients without current OP. During OP, trauma associations and catastrophic cognitions were common. Negative affectivity's impact on OP severity was significantly mediated (Sobel test; Baron & Kenny, 1986) by orthostasis-associated flashbacks and catastrophic cognitions. In the care of traumatized Cambodian refugees, OP--including associated flashbacks and catastrophic cognitions--should be specifically assessed and treated.